**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 1 resident reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 15 minutes from 6:00 PM to 6:15 PM on 10/07/24 before a 3rd party called to notify the facility that Resident #1 was walking through a field adjacent to the facility. On 10/18/24 at 2:27 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/19/24 at 1:25 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's continuing to monitor the implementation and evaluate the effectiveness of their Plan of Removal. This failure could place residents requiring supervision at risk for injury and accidents with potential for more than minimal harm. Findings included: Record review of Resident #1's face sheet revealed an [AGE] year-old male with an original admission date of 10/15/22 and a current admission date of 05/28/24. Pertinent diagnoses included Alzheimer's disease, Dementia, and Unsteadiness on Feet. Record review of Resident #1's Comprehensive MDS assessment section C, cognitive patterns, dated 10/01/24 revealed a BIMS score of 3 (severe impairment). Record review of Resident #1's care plan revealed the focus Resident is at risk for falls D/T CONFUSION initiated on 10/15/22 and revised on 10/17/22. Interventions listed for this focus included: Assist with ADLs as needed initiated on 10/15/22. Call light within reach initiated on 10/15/22. Complete fall risk assessment initiated on 10/15/22. Orient resident to room initiated on 10/15/22. Provide adaptive equipment or devices as needed initiated on 10/17/22. Pt evaluate and treat as ordered or PRN initiated on 10/17/22. SIDE RAILS: quarter rails up as ordered initiated on 10/17/22 and revised on 10/17/22 Further record review of Resident #1's care plan revealed the focus The resident has had an actual fall with no injury, d/t poor balance initiated on 05/18/24 and revised on 05/20/24. Interventions listed for this focus included: For no apparent acute injury, determine and address causative factors of the fall initiated on 05/18/24 and revised on 05/20/24. Neuro-checks as per protocol initiated on 05/18/24 and revised on 05/20/24. Observe/report PRN x 72h to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation initiated on 05/18/24 and revised on 05/20/24. Physician ordered UA&C/S for resident initiated on 05/18/24. Resident education on using his cane for support initiated on 05/18/24 and revised on 05/20/24. Record review revealed Resident #1's elopement risk assessment dated [DATE] indicated he was not a risk for elopement at that time. Further record review revealed Resident #1's elopement risk assessment dated [DATE] indicated he was a risk for elopement at that time. Record review of the provider investigation report dated 10/11/24 revealed the following narrative: Resident was seen by charge nurse a few minutes before 6pm walking from dining room down the hallway. At 615pm Charge nurse received a call from a woman stating there was an elderly man looking like a patient of ours walking in the back field towards the fire station all in brown and was he ours? Charge nurse [LVN K] asked the 2nd charge nurse if she was missing anyone and both nurses started looking at their residents. As the staff kept looking [LVN K] quickly got in her car and drove down the street and a fireman and the lady were sitting with the resident unharmed and he stated that he was looking for his work. [LVN K] brought him safely back. Resident was in the facility at 643pm. [QAPI] and CP updated for Elopement. Elopement audit for all residents. Code change for doors and ambulance door change to lobby door. 1x1 [one to one monitoring of the resident by facility staff]. Further review of the provider investigation report revealed a witness statement written as follows by LVN C on 10/08/24: 330pm- [Resident #1] came to nurses station to ask for coffee, we told him it was not ready yet and he left the nursing area. Approx 615pm- I was coming up from the 300hall and [LVN K] told me a lady just called and said she saw a man wearing brown walking through the grassy area by our building. Went down my hall to look for all my residents, I looked out the back door and I did not see anything. Spoke with [CNA L] and he stated the alarm had sounded but he did not notice anything unusual, thought it was a family member. I went back to nurses station and saw [Unknown CNA] come back from the dining room and then we went to go look outside the facility at this time. We did not notice any residents in the surrounding area. I came back in and notified [LVN K] I did not have any missing residents and I didn't see anyone outside. Further review of the provider investigation report revealed a witness statement written as follows by LVN K on 10/08/24: Approx 6pm I saw [Resident #1] coming up 400 hall. Approx 615pm I answered the phone and it was a lady stating she saw an older gentlemen walking through the grassy area by our building wearing brown. We started checking the building for any missing residents. I took off in my vehicle to go drive around and look for him. I found him down [local road] with some fire fighters right passed the fire station. Resident was placed back in my vehicle and returned to facility. I assessed the resident from head to toe and notified all proper channels. Further review of the provider investigation report revealed in-services covering Missing Residents/Actual Elopement Event were conducted for 65 staff members between 10/07/24 and 10/09/24 by the ADON. In an interview with the DON on 10/27/24 at 2:25 PM, the DON stated Resident #1 had no history of exit seeking behavior prior to the elopement incident. The DON stated Resident #1 did not typically go outside. The DON stated Resident #1 was not allowed to go outside unsupervised. The DON stated LVN K called her after she had already found Resident #1 by the first station. The DON stated she did not know which exit Resident #1 used to leave the facility but was most likely the 100 hall exit door. The DON stated the alarm sounded on the 100 hall exit door around the time of the elopement. The DON stated she did not know who called the facility to report the elopement. The DON stated nobody in the facility was aware Resident #1 was missing until the facility was notified by the caller. The DON stated all exit doors in the facility had an electronic lock that required a code to exit. The DON stated since the incident the staff had been told not to use any of the exit doors at the rend of any residential halls. The DON stated they had an elopement drill on 10/08/24 at around 10:00 AM and they will continue to do them weekly for the next 4 weeks. The DON stated the emergency code for a missing resident was purple. The DON stated if purple was called, the charge nurse split up the staff with half of them searching outside the facility and the other half searching inside. The DON stated if they did not find the resident in a timely manner, they would notify the police. The DON stated all staff take part in the search for the missing resident. The DON stated there would be 25 to 30 staff members at the facility during the day and about 6 at night. The DON stated only staff should know the codes to the exit doors. The DON stated the last fall risk assessment performed on Resident #1 before the elopement was on 10/07/24 and received a score of 16. The DON stated a score of 10 or higher meant interventions should be initiated for the resident related to falls. During an observation on 10/17/24 at 3:00 PM, this state surveyor walked from the 100 hall exit door to the local fire station where the missing resident was located. The distance across the field just outside the 100 hall was approximately 650 feet to a residential road, and then another 350 feet after crossing the road to the fire station. In an interview with LVN C on 10/17/24 at 3:36 PM, LVN C stated the emergency color code for a missing resident was pink. LVN C stated a code pink indicated the staff should start looking everywhere for the missing resident. LVN C stated she would go through the rooms to see who was there or not. LVN C stated one of the nurses would delegate some people to go outside and others to stay inside. LVN C stated she would notify the police immediately after the resident was missing. LVN C stated she had not been part of an elopement drill since she had been working at the facility for 2 years. LVN C stated it had been weeks since her last in-service on elopements. In an interview with HK L on 10/17/24 at 3:40 PM, HK L stated he had never taken from in an elopement drill at the facility. HK L stated he had an in-service 2 days ago covering elopement. HK L stated someone goes outside to look for the resident while others stay inside. HK L stated someone needed to notify the administrator and nurse. HK L stated the emergency color code for an elopement was silver. In an interview with CNA M on 10/17/24 at 3:43 PM, CNA M stated the emergency color code for a missing resident was grey. CNA M stated a code grey indicated to all staff they needed to start looking for a missing resident. CNA M stated she would look in the rooms in her hall first. CNA M stated the charge nurse would be in charge during the elopement. CNA M stated some staff would search inside while others searched outside. CNA M stated she received an in-service 2 or 3 days ago covering elopements. CNA M stated she took part in an elopement drill 3 days ago. In an interview with the AD on 10/17/24 at 3:43pm, the AD stated the code called overhead for a missing resident was Code Purple, and if it was called, all staff were to meet at the nurse's station where the DON or the ADM would let everyone know who they were looking for and assign tasks. The AD stated if the resident was not found within 25 minutes, the police department was to be called, and the resident reported missing. The AD stated the last drill and in-service were done last Thursday or Friday (10/10/24 or 10/11/24). The AD stated for the drill, the van driver went and hid, a code purple was called overhead, and everyone was assigned a task/area to look. The van driver was found outside hiding behind a bush. In an interview with the SW on 10/17/24 at 3:49 PM, the SW stated she had only had one elopement drill since she had been working at the facility starting on 12/01/10. The SW stated when it first occurred, someone would get over the intercom and call out a code purple. The SW stated someone would go out the door that alarmed and look for the resident. The SW stated the administrator and RP were to be notified. The SW stated all the door codes had recently been changed and staff were no longer to use the exit doors on the resident's halls. In an interview with RN N on 10/17/24 at 3:50, RN N stated the emergency color code for a missing resident was purple. RN N stated they would check outside while combing the patients inside and inform the DON. RN N stated whoever found out the resident was missing would be the one to take charge. RN N stated they would search inside and outside the facility at the same time. RN N stated if they could not find the resident within 10 minutes they would notify the police. RN N stated she received an elopement in-service 2 days ago. RN N stated it had been a few months since her last elopement drill. In an interview with the MS on 10/17/24 at 3:53 PM, the MS stated he had worked at the facility for 19 years and that he had always conducted an elopement drill once every 3 months. The MS stated he conducted an elopement drill on 10/08/24 with all staff who were present on shift at 10:35 AM. The MS stated he had no records of ever conducting an elopement drill during night shift. The MS stated he checked the door locks and alarms weekly on all exit doors. The MS stated during door checks he pressed on the push bar from the inside for 15 seconds to ensure the alarm sounded and that the door would open. The MS stated after the door opened, he closed it back and entered the code to shut off the alarm. The MS stated he did not check the door functionality from the outside. The MS stated he was aware the door could be held open indefinitely without the alarm sounding if no one touched the push bar after the code was input. In an interview with the ADM on 10/17/24 at 3:55 PM, the ADM stated they conducted an elopement in-service with 100% staff over the course of 10/07/24 and 10/08/24 right after the elopement occurred. The ADM stated she conducted another in-service with staff on 10/15/24. The ADM stated when an alarm went off, staff were supposed to go outside and check to make sure no residents went out. The ADM stated staff should notify the charge nurse the alarm went off to initiate a head count. The ADM stated she had the alarm codes changed after the incident, along with an elopement assessment conducted on every resident in the facility. The ADM stated the elopement assessment was changed to immediately notify them if it triggered. The ADM stated the most recent elopement drills were done on 10/08/24, 09/18/24 and 06/26/24. The ADM stated she did not know the last time night shift had an elopement drill. The ADM stated the emergency code for an elopement was purple. The ADM stated Resident #1 was put on a 1 to 1 a few months ago because he talked about wanted to leave for work. The ADM stated during that time Resident #1 never attempted to leave the facility or went near an exit door. The ADM stated it turned out Resident #1 had a urinary tract infection at that time, and once it was cleared up his behaviors improved and was taken off the 1 to 1. The ADM stated she did everything she could to prevent an immediate jeopardy situation. In an interview with LVN Y on 10/18/24 at 9:45 AM, LVN Y stated resident elopement assessments were completed on entry, re-entry, after an event, quarterly, and annually. LVN Y stated the charge nurse on the floor should conduct the elopement risk assessment. LVN Y stated if the resident was overdue for an elopement risk assessment the nurse would see it in their chart as red indicating it was overdue. In an interview with CNA L on 10/18/24 at 10:50 AM, CNA L stated he was in room [ROOM NUMBER] at the end of the hall when the alarm for the exit door on hall 100 sounded at approximately 6:00 PM on 10/07/24. CNA L stated he saw a family member at the other end of the hall and assumed they opened the door but came back inside. CNA L stated he did not recognize the visitor and never spoke to them. CNA L stated he did not look outside at that time. CNA L stated he received an in-service on elopements on 10/08/24. CNA L stated he did not know the emergency color code for a missing resident. CNA L stated he had not taken part in any elopement drills at the facility. CNA L stated the alarm was going off for about 10 minutes before he turned it off around 6:10 PM. CNA L stated he was not aware of anyone else checking on the alarm. CNA L stated LVN K saw him turn the alarm off. CNA L stated he did not know the elopement policy and he did not know Resident #1 was missing until LVN K had already brought him back in the building. In an interview with LVN K on 10/18/24 at 3:40 PM, LVN K stated she was sitting at her computer in the nurse's station when she saw Resident #1 walking towards his room on the 200 hall. LVN K stated she received a call from a lady driving by the facility that stated she saw a male wearing all brown walking in the field adjacent to the facility. LVN K stated she remembered the alarm going off on the 100 hall but could not remember the time it occurred. LVN K stated the alarm went off 5 to 10 minutes before she received the phone call. LVN K stated the alarm sounded for a 1 to 2 minutes at the most. LVN K stated she observed CNA L go towards the 100 hall exit door, turned off the alarm and looked out the window. LVN K stated she did not speak to CNA L at that time. LVN K stated once she was informed that a resident was missing, CNA L and LVN C looked around the rooms while other staff started looking in common areas. LVN K stated no one went outside to look for Resident #1 at that time. LVN K stated since Resident #1 liked to wander into other resident's rooms they began looking for him there. LVN K stated Resident #1 had not been known to try to go outside or display exit seeking behaviors. LVN K stated after they could not find Resident #1 in the facility, she got in her personal vehicle and drove around the facility. LVN K stated she found the resident at a local fire station near the facility talking to firemen about trying to get to work. LVN K stated she thought someone might have let Resident #1 out a back door since family and visitors would use those exit doors on the halls. LVN K stated it took a while to get back to the facility because there was a lot of traffic at the time. LVN K stated she performed a head-to-toe assessment on Resident #1 once she got back to the facility and noted bruising to the left side of his head and bruising to his left elbow due to a fall earlier in the day. LVN K stated the bruising on Resident #1 did not look brand new. LVN K stated a code purple was not called during this incident because staff were around the nurse's station when the call came in and were aware Resident #1 was missing. LVN K stated she believed RN A did the assessment on Resident #1 after his fall earlier in the morning. LVN K stated she believed she had seen the bruise to Resident #1's head earlier in the day. In an interview with RN A on 10/18/24 at 3:54 PM, RN A stated he did the head-to-toe assessment on Resident #1 after his fall earlier in the day on 10/07/24. RN A stated he did not find any injuries on Resident #1 during his assessment. Record review of the facility policy Missing Resident/Actual Elopement Event revised on 04/05/23 and reviewed on 04/03/24 revealed the following: 1. A facility head count should be conducted whenever the following occurs; a. When a door alarm has sounded, but there was no witness to the reason for the sounding of the alarm. b. When the fire alarm goes into alarm to verify that all residents are accounted for. c. Anytime the alarm system for the doors is not operational 2. If during a facility head count a resident is unaccounted for, proceed to step 4 3. If staff cannon account for the whereabouts of a resident, during the course of the day proceed to step 4. 4. The sign out log should be reviewed to determine if the resident or resident representative has signed out of the facility. 5. The time and location the resident was last seen and the clothing the resident was wearing should be determined. 6. The Executive Director or representative and all department heads are notified that the resident cannot be located. The executive Director may need to initiate a facility lockdown if determined it is needed by the Executive Director. 7. The charge nurse will assign staff to begin a coordinated search of the facility and facility grounds. Search the facility's grounds for the resident. If necessary, distribute copies of the resident's photograph to the staff searching the grounds. Keep a record of the areas searched. 8. Staff will be assigned to remain on the unit(s) and to utilize the roster/census sheet to establish the unit census and confirm the whereabouts of all other residents. 9. If the resident cannot be located, the charge nurses or designee will notify law enforcement immediately. Law enforcement personnel will then coordinate the search efforts. 10. The charge nurse or designee will notify the responsible party, the physician, and the medical director that the resident is missing. Record review of the facility policy Unsafe Wandering and Elopement Prevention revised on 08/22/22 and reviewed on 09/25/24 revealed the following: 1. Accurate and thorough assessment of the resident is fundamental in determining indicators for unsafe wandering and elopement. Not all resident exhibit unsafe wandering behaviors or verbalize the desire to leave the facility unplanned. a. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. Record review of the undated facility policy Emergency Code Words revealed the following: Code Purple - Missing Resident An Immediate Jeopardy was identified on 10/18/24 at 2:27 PM. The IJ template was presented to the ADM, and a plan of removal was requested. This was determined to be an Immediate Jeopardy (IJ) on 10/18/24 at 2:27 PM. The Administrator was notified. The IJ template was presented to the ADM on 10/18/24 at 2:27 PM. The following Plan of Removal was submitted by the facility and was accepted on 10/18/24 at 4:27 PM. PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY Plan of Removal: Regarding: IJ 10/18/2024 F 689 Free of Accidents / Hazards / Supervision Failure: The facility failed to ensure the safety of Resident #1 by not providing supervision to prevent Resident #1 from eloping from the facility. On 10/7/2024 Resident #1 exited from the facility and was found near the fire department Corrective action for those found to be affected by the alleged deficient practice: o Identified resident was discharged to a secured unit on 10/9/2024. o Clinical assessment of the resident after return to the unit was completed. o Completed incident report within the PCC system o Notified Medical Director and family of event. o Ensured all residents are present and in the building o Completed/ updated elopement assessment for resident that exited facility and updated his care plan. Identification of others residents having the potential to be affected: o Elopement risk assessments were completed for all residents in the building. Measures/Systemic Changes to ensure the deficient practice does not recur: o Complete elopement assessments for all residents that reside in the facility today, quarterly, significant change and new admissions to the facility. o Elopement drill was completed on 10/8/202 and will be completed weekly. o Obtained statements from staff members that were present during the incident o The following in-services were completed for staff on 10/7/24, 10/8/2024 and 10/15/2024 -Residents at risk for elopement -What to do if a resident elopes -Door security-with alarms, how to ensure door alarms are in place, how often to monitor door alarms, ensuring alarms are turned back on after turning off and exiting and ensuring doors are secure. -Reporting guidelines with elopement -Completing elopement assessments and updating care plans o A list of residents with potential for elopement will be placed at the nurse's station and reception desk, pictures of residents and information will be placed in that book to identify who is at risk. This will be updated quarterly and PRN o AD-hoc QAPI completed by DON-ED and Medical Director o Check all exterior doors to ensure alarms are functioning properly and document. This will be complete weekly and as needed. o Elopement drill to be completed weekly to include all 3 shifts. o Complete elopement assessments for all residents that reside in the facility quarterly, significant change and new admissions to the facility. o Door codes were changed on all exit doors. o Doors at the end of hallways are no longer used. o Further education initiated on 10/18/2024 to include Policy on unsafe wandering and Elopement Prevention. o Elopement drill completed on night shift 10/17/2024. On going monitoring: o Elopement drills will be reviewed in monthly QAPI. o Elopement assessments will be reviewed 2-3 times per week in morning meeting. o All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial compliance has been achieved. Verification of Plan of Removal Interviews were conducted with RN O, CNA P, HK Q, CNA R, LVN J, RN A, RN S, CNA T, CNA U, CNA H, CNA G, CNA V, CNA W, DA X on 10/19/24 from 10:00 AM through 12:00 PM. All staff were able to identify the proper emergency color code for a missing resident. All staff stated the proper procedures if they responded to an elopement. All staff were knowledgeable on the changes implemented in the plan of removal. In an interview with the MS on 10/19/24 at 12:03 PM, the MS stated all shifts were getting elopement drills once a week until all staff were knowledgeable, and administration felt all staff were competent on elopement procedures. In an interview with the DON on 10/19/24 at 12:08 PM, the DON stated elopement drills were being conducted once per week for all 3 shifts. The DON stated elopement assessments were reviewed 2 to 3 times per week in the morning meetings to verify elopement drills were done and staff were knowledgeable on all elopement procedures. The DON stated the elopement procedures and implementation of training had been added to QAPI for review. Record review and verification of the accepted POR: Identified resident was discharged to a secured unit on 10/09/24 - Verified by record review through discharge list and interview with DON on 10/18/24. Clinical assessment of the resident after return to the unit was completed - Verified by record review of progress notes and nurse assessments on 10/18/24. Completed incident report within the PCC system - Verified by record review of incident reports on 10/18/24. Notified Medical Director and family of event - Verified by record review of progress notes and interview with DON on 10/18/24. Ensured all residents are present and, in the building - Verified by observation of all residents on a walkthrough of the facility on 10/18/24. Completed/updated elopement assessment for resident that exited facility and updated his care plan - Verified by record review of Resident #1's elopement assessment and interview with DON on 10/18/24. Identification of other residents having the potential to be affected - Verified by interview with DON on 10/18/24. Elopement risk assessments were completed for all residents in the building - Verified by interview with DON on 10/18/24. Measures/Systemic Changes to ensure the deficient practice does not recur - Verified by interview with DON on 10/18/24. Complete elopement assessments for all residents that reside in the facility today, quarterly, significant change and new admissions to the facility - Verified by interview with DON on 10/18/24. Elopement drill was completed on 10/18/24 and will be completed weekly - Verified by record review of elopement drill documentation sheet and interview with MS on 10/18/24. Obtained statements from staff members that were present during the incident - Verified by record review of provider investigation and interviews of relevant staff on 10/18/24. The following in-services were completed for staff on 10/7/24, 10/08/24, 10/15/24, and 10/18/24 - Verified by record review of in-service sign-in sheets and interviews with staff on 10/18/24 and 10/19/24: What to do if a Resident Elopes Door Security Reporting Guidelines with Elopement Complete Elopement Assessments and Updating Care Plans Employees given a quiz beginning on 10/18/24 on Elopement Procedures - Verified by record review of the quiz and interview with ADM on 10/19/24. A list of residents with potential for elopement will be placed at the nurse's station and reception desk, pictures of residents and information will be placed in that book to identify who is at risk. This will be updated quarterly, and PRN - Verified by observation of the new binder on 10/19/24. Emergency QAPI was completed with Medical Director - Verified by record review of the QAPI minutes on 10/19/24. Checking of all exterior doors to ensure alarms are functioning properly and document. This will be complete weekly and as needed - Verified by record review of the maintenance logs and interview with MS on 10/18/24 and 10/19/24. Elopement drills to be completed weekly to include all 3 shifts - Verified by interview with MS on 10/19/24. Complete elopement assessments for all residents that reside in the facility quarterly, significant change and new admissions to the facility - Verified by interview with DON on 10/18/24. Door codes were changed on all exit doors. Verified by observation of input of old door codes and interview with MS on 10/18/24. Doors at the end of hallways were no longer used. Verified by interviews with DON and ADM on 10/18/24. Elopement drill completed on night shift 10/17/24 - Verified by record review of elopement drill documentation sheet and interview with MS on 10/18/24. On going monitoring - Verified by interviews with DON and ADM on 10/19/24 Elopement drills will be reviewed monthly in QAPI - Verified by interview with DON on 10/19/24. Elopement assessments will be reviewed 2-3 times per week in morning meetings - Verified by interviews with DON and ADON on 10/18/24. All components of this plan of correction will be submitted to the facility QAPI committee meeting and additional recommendations will be made until substantial co[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #2) reviewed for NPO status. The facility failed to intervene timely and appropriately when Resident #2 obtainted food and began to choke. On 3/25/2024, during lunch service about 12:00 p.m., Resident #2 obtained access to Resident #1's food, staff did not provide timely interventions which led to Resident #2 choking and expiring. Resident #2 had a g-tube and was on NPO status. An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk of choking or death. Findings included: Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR. Record review of Resident #2's face sheet dated 3/26/24, revealed he was a [AGE] year-old male, admitted on [DATE]. Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24. Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression. Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident. During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m. During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall. During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. CNA A stated she is unsure how much time passed because it happened so quickly. During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. LVN B stated she is unsure how much time passed because it all happened so quickly. During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. Resident #2 did expire with the Hospice nurse in the room and the Hospice nurse pronounced time of expiration. During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair. Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status. This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice. Identification of other residents having the potential to be affected: o Audit completed of all residents' diets and NPO status. o The facility has a binder at the nurse's station that identifies residents that have an NPO status. o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm. Measures/Systemic Changes to ensure the deficient practice does not recur: All licensed staff will be re-educated on responding timely to emergent situations by DON and/or IP nurse. DON was reeducated by the Regional Director of Clinical Services on 3/26/2024. In-servicing by administrative nursing staff on Heimlich Maneuver per policy to be done facility wide. NPO book will be reviewed and updated as needed by DON and /or IP nurse Monday - Friday. In-servicing by administrative nursing staff (DON and/or IP nurse) on resident assessment and response to emergencies in a timely manner. Ongoing Monitoring: Daily rounding during mealtimes by administrative staff to ensure dining room supervision until compliance is achieved. All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, or designee are responsible for the corrections and continued monitoring. Completion date: 3-29-24 Verification of the facility's Plan of Removal Included: Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted. Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted. Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted. Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted. During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern. During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important. During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2 had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS) full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024. During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-serviced on the multiple topics yesterday, 03/29/2024. During an interview on 03/30/2024 at 4:21PM, (10PM-7A night shift) CNA M stated she was educated/in-serviced about if there was an incident, she must notify the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents receive adequate supervision to prevent accidents for 1 of 3 residents reviewed for NPO status. The facility failed to ensure Resident #1 was adequately supervised while eating lunch. On 3/25/2024, during lunch service about 12:00 p.m., CNA D did not ensure adequate supervision of Resident #1 while eating. Resident #2 obtained access to Resident #1's food, choked and died. Resident #2 had a g-tube and was on NPO status. An IJ was identified on 03/28/24. The IJ templates were provided to the facility on [DATE] at 5:30 PM. While the IJ was removed on 3/30/24 at 7:18PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk of choking or death. Findings included: Record review on 3/26/24 of self-reported incident report dated 3/25/24 revealed Resident #2 was up and wheeling around as normal. He saw another patient eating some pie at the table near the nursing station and grabbed it from him and put it in his mouth. CNA went to get it (the pie) and he started to have difficulty breathing. Director of Nursing took him to the room and suctioned, performed the Heimlich maneuver, and provided Oxygen. Family did not want him sent out but rather stay here since he was a DNR. Record review of Resident #2 face sheet revealed he was a [AGE] year-old male, admitted on [DATE], Resident #2 had a medical dx of OTHER SEQUELAE FOLLOWING NONTRAUMATIC SUBARACHNOID HEMORRHAGE (bleeding in the space between the brain and the tissue covering the brain), DYSPHAGIA (difficulty swallowing), COGNITIVE COMMUNICATION DEFICIT (difficulty thinking and how someone uses language), BIPOLAR DISORDER (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), SCHIZOPHRENIA (serious mental illness that affects how a person thinks, feels, and behaves), AND DEMENTIA (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #2's admission MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 which indicated Resident #2 was moderately cognitively impaired and needed help at times with indoor mobility. MDS indicates Resident #2 coughs and chokes during meals or when swallowing medication and has a feeding tube, Record review of Resident #2's care plan dated 3/26/24, stated Resident requires tube feeding with an initiated date of 2/16/24. Interventions for this tube feeding included anticipating Resident #2's needs, assisting Resident #2 to develop appropriate methods of coping and interacting. Encourage Resident #2 to express feelings appropriately. Record review of Resident #2's physician orders revealed an order for an NPO diet with an initiated date of 2/15/24. Record review of Resident #1's face sheet dated 3/26/24, revealed he was a [AGE] year old, admitted on [DATE] for Coronary Hear Disease, Hypertension, Dementia, Glaucoma, and Depression. Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 03 which indicated Resident #1 was severely cognitively impaired. Resident #1 was able to use suitable utensils to bring food and liquid to the mouth and swallow food/liquid once without assistance once the meal is placed before the resident. During an interview on 3/26/24 at 11:45a.m., the Administrator and the Director of Nursing stated, Resident #2 was seen at a table with another resident. Resident #2 was on NPO status. Resident #2 was seen with a pie plate with pie from the other resident at the table. CNA A removed the pie plate and informed the nurse at the nurse's station. LVN B (nurse at nurses' station) instructed CNA A to mov. Resident #2 from the table. CNA A was moving Resident #2 when she noticed he had changed in his demeanor and informed LVN B. LVN B then instructed CNA A to take Resident #2 to his room for an assessment. The Director of Nursing states I was called to Resident #2's room to assist LVN B with Resident #2. Resident #2 was unresponsive but still breathing when we transferred him to his bed. I did the Heimlich maneuver while sitting on the bed behind him. We did suction him with no residual. The Hospice nurse walked in while Resident #2 was being suctioned. Resident #2 did eventually expire, and the Hospice nurse called the time and date of 3/25/2024 at 12:38p.m. During an interview on 3/27/2024 at 11:45 a.m., with CNA D she stated she placed Resident #1 at a table in front of the nurse's station for monitoring of his food intake. CNA D stated she did not see anyone at the nurse's station at the moment she placed the tray of food in front of Resident #1 and left to pass the other trays for her hall. During a phone interview on 3/26/2024 at 1:18 p.m., with CNA A she stated she saw Resident #1 and Resident #2 sitting at a table together. CAN A stated Resident #2 was seen with a pie plate from Resident #1. CNA A stated He did have crumbs on his clothes CNA A stated the plate was removed from Resident #2 due to his NPO status. CNA A stated she informed LVN B of Resident #2 having wheeled himself to a table and getting a pie plate with pie. Resident #2 got the pie by being at the table while Resident #1 has his lunch tray and LVN B instructed CNA A to move Resident #2 away from the table. Immediately after informing LVN B of Resident #2 having the pie, CNA A stated she was moving Resident #1 and noticed he was pale in color and was not responding to her. CNA A stated after informing LVN B, LVN B instructed CNA A to take the Resident #2 to his room. During an Interview on 3/26/2024 at 12:53 p.m., LVN B stated she instructed CNA A to escort Resident #2 to his room for an assessment. LVN B stated she called out for RN to assist in Resident #2's room. During an interview on 3/26/2024 at 12:30 p.m., RN C stated she entered the room of Resident #2 and when he stopped breathing, she initiated the Heimlich maneuver and eventually suctioned Resident #2. LVN E stated she did see the suctioning process produce some residual particles of something. RN C stated Resident #2 was on Hospice and the family did not want emergency services called. During a phone interview on 3/28/24 at 5:34pm, the Hospice Nurse said, Resident #2 was lying in his bed with the head of the bed elevated upright to what appeared to be the highest position, there were four to five nurses surrounding patients' bed, patient is noted with the pulse ox monitor to his right hand and electronic blood pressure monitor to right arm. At this time the nurse (unknown which nurse) tells me the patient who has a dx of dysphagia grabbed a pie from another patient and ate it. Resident #2's skin is cyanotic, and eyes are partially open, patient had an oxygen mask on and one of the floor nurses was attempting to perform deep oral suction. I then grabbed my phone to attempt to call patients sister from my work phone but was unable to find her number at this time one of the nurses states she was going to call the patient's family member and inform her of the situation, I then called Nurses on wheels office to get the caregivers number but at this time the nurse reentered the room and stated that the patients sister did not want to revoke the Do Not Resuscitate order and refused to have patient sent to the hospital. I did see some particles in the suction machine canister. At 12:37pm - 12:38pm I attempted to obtain a manual BP reading. I was unable to auscultate a BP reading or an apical pulse. Pupils assessed and were fixed and dilated. I then waited 1 full minute to obtain a second set of vitals, upon second attempt no BP, no pulse and no respirations. I then pronounced Resident #2 at 12:38pm. During an interview on 3/30/2024 at 12:15 p.m., CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring at the facility and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. During an interview on 03/30/2024 at 12:31 p.m., RN C stated the facility has provided education on abuse and neglect, Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. During an interview on 3/30/2024 at 12:56 p.m., CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and stated Resident #2 would ask for food consistently in a form of hand gesture and this resident could self-propel his wheelchair. Record review of facility policy titled, Removing Foreign Body Airway Obstruction-Heimlich Maneuver and dated 07/07/20 included verbiage that stated, If severe airway obstruction develops, quick intervention is necessary to relieve the obstruction. Anoxia resulting from such obstruction may cause brain damage and death. There was no policy provided regarding residents on NPO status. Record review of facility dining, and meal service policy titled, Meal Service and Resident Dining Services dated 8/24/2023 and 4/26/2023 does not indicate monitoring or supervision of residents during mealtimes. This was determined to be an Immediate Jeopardy (IJ) on 03/28/24. The Administrator and the Director of Nursing were notified. The IJ template was provided to the facility on [DATE] at 5:30 PM. The following Plan of Removal submitted by the facility was accepted on 3/29/2024 at 6:27 p.m. The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the alleged issue of professional standards of practice. Identification of other residents having the potential to be affected: o DON updates NPO book in morning meeting which is shared with all staff. o This will be reviewed Monday - Friday and updates as needed. o Residents who are identified to be at risk for potential hazards related to NPO status will be monitored for potential risk of harm. Measures/Systemic Changes to ensure the deficient practice does not recur: Daily rounding during mealtimes by administrative staff to ensure adequate dining room supervision. Supervision will be done by nursing staff with direct over-sight while feeding assistants assist with feeding patients that will need it. In-services and education for all staff will be completed by 3-29-24 by Admin Nursing Staff to include, DON, , Infection Prevention, , , Regional Director of Clinical Services, , RN. In-service topics will include the following: Specialized Diets/NPO Binder Abuse and Neglect DON/ADON re-in serviced nursing staff of supervisory schedule of one dining room for all three meals on 3-28-24. Meal assignments Ongoing Monitoring: Department heads making dining room rounds ensuring supervision in dining area. All components of this plan of correction will be submitted to the facility QAPI committee meeting for three months and additional recommendations will be made until substantial compliance has been achieved. The Medical Director was notified and agrees with the plan of correction. The Admin Nursing Staff to include, Don, Infection Prevention Coordinator, Regional Director of Clinical Services, Executive Director, , LNFA, are responsible for the corrections and continue monitoring. Completion date: 3-29-24 Verification of the facility's Plan of Removal Included: Record review, the facility conducted 100% review of all residents identified with gastric tubes and NPO status, as well as reviewed all residents with modified/restrictive diets. Record review of Resident #1's physician dietary orders, audited on 03/29/2024, revealed order dated 2/22/2024 for Resident #1 to receive regular diet, easy to chew texture, thin consistency. There were no concerns noted. Record review of Resident #3's physician dietary orders, audited on 03/29/2024, revealed order dated 3/14/2024, enteral feeding documented Resident #3 to receive Glucerna 1.2, 55 ml/ hour for 22 hours. 100mL water flush Q4hr - There were no concerns noted. Record review of Resident #4's physician dietary orders, audited on 03/29/2024, order dated 07/25/2023, regarding enteral feeding documented Resident #4 to receive Fibersource at 70 ml/hour x 20 hours via pump, with 150mls water flush Q4 hours. There were no concerns noted. Record review of Resident #5's physician's dietary modification orders was audited on 03/29/2024, order dated 02/29/2024, documented Resident #5 to receive sodium restricted diet, regular texture, thin consistency. There were no concerns noted. During an observation and interview on 03/30/2024 at 4:47PM observed Resident #3's tube feeding. Resident #3 had Glucerna 1.2 infusing at 55mL/HR, with a scheduled 100ml water flush Q4hr. Resident #3 stated she did not have any concerns regarding her tube feedings. Resident #3 stated she knew why she was receiving tube feedings, and that the clinical staff attend to her needs when she requests assistance. During an observation on 03/30/2024 at 5:13PM Resident #1 was in the dining room eating his easy to chew meal which consisted of chicken, mashed potatoes, carrots, a slice of bread and tea. Resident #1 was able to ingest his food with no issues observed. No observable concern. During an observation on 03/30/2024 at 5:23PM, Resident #4 was receiving tube feeding. Resident #4 had Fiber source infusing at 70 ml/hour via pump with 150mL water flush Q4hr. Resident #4 did not exhibit any signs of distress. No concerns observed. During an interview on 03/30/2024 at 12:15PM, CNA C CNA C stated if she were to encounter a person with a change in color, she has been educated to call immediately for assistance, and will stay with patient until nurse arrives. CNA C stated if she were to experience a resident choking, she will initiate a Heimlich maneuver, and position her hands within the abdomen area and thrust upward. CNA C stated she has been also taught another way to alarm the nursing staff was to call for help loudly, to signify that a person was in distress and needs emergency assistance, that could potentially lead to death. CNA C stated the CNAs were usually supervising residents eating and observe how they eat and how much they eat and will report to the nurses any irregularities with eating/ eating behaviors. CNA C stated she has been instructed to set up a tray properly, which would involve cutting the proteins in bite size measurements, and will continue to observe residents eating, however if she must vacate area, she will return immediately to ensure the resident's safety, and will make sure the resident eats a good percentage of their meal. CNA C stated when she arrived yesterday (3/29/24), she was told of the choking event that led to Resident #2 expiring and stated that Resident #2 consistently would ask to eat food, however CNA C stated she would redirect Resident #2 to participate in activities during mealtimes. CNA C stated she has been educated on types of abuse which would encompass forcefully inflicting pain, and would report to the charge nurse, DON, and Administrator. CNA C stated she was last in-serviced about Code Blue, Heimlich Maneuvers, Abuse and Neglect, and Falls on 03/29/2024. During an interview on 03/30/2024 at 12:31PM, RN Charge Nurse; RN C stated the facility has provided education on abuse and neglect, and Heimlich maneuver, time management, and during emergent situations do not waste time and must immediately call 911. RN C stated for a full code blue, she has been educated on the proper procedures on how to conduct CPR and to always notify the chain of command. RN C stated Resident #2 was her patient on 03/25/2024 and she was on break when choking/expiration happened. RN C stated she was very sad about event. RN C stated Resident #2 was NPO due to dysphagia and had difficulty swallowing. RN C stated that Resident #2 was mobile via wheelchair and was able to wheel himself throughout the facility. RN C stated Resident #2 never requested food, and when she would ask if he was hungry, once the tube feeding was complete, he would state he was full. RN C stated Resident #2 was not impulse and enjoyed counting monopoly money. RN C said while she was on break, LVN A and the floor CNAs were the ones who were watching her residents. RN C stated Resident #2's behavior never made her believe that he would take something that was not his. RN C stated she administered Resident #2's gastric tube feed at 10AM on 03/25/2024. RN C stated once she returned Resident #2 had passed away. RN C stated family had already been notified. RN C stated she has been educated to initiate Heimlich maneuver immediately and call out for help, the helpers would be the ones contacting chain of command as well as calling for Emergency assistance, while she continues to attempt to dislodge any particles or foreign substances out of the resident's oral cavity. RN C stated that she will begin the Heimlich maneuver to ensure resident's safety followed by then assessing the oral cavity, all as preventative measure to maintain the resident's safety and wellbeing. RN C stated in her professional opinion, the treatment nurse was wrong, and should have acted immediately because time was very important. RN C stated privacy can be maintained later, life is what is important. During an interview on 03/30/2024 at 12:56PM, CNA D, CNA E, both stated they were in-serviced about abuse, neglect, when to report abuse and neglect, NPO definition, change in condition, and to report any immediate changes. Both stated they performed the Heimlich maneuver. Both stated to perform the Heimlich maneuver will situate hands under rib cage, and in an upward motion will thrust. Both stated they were comfortable with performing the Heimlich maneuver on heavier set people. CNA D stated she observed to her left Resident #1, crumbs on chest, thighs, and plate right in front of him. CNA D stated she knew that Resident #1 was NPO and there was nothing on the plate. CNA D notified the Treatment nurse, who instructed CNA D to take the plate away from him, and foot was caught in wheelchair and saw resident leaning to right side, and picked up his hat and his eyes were drifted to the right. The treatment nurse instructed CNA D to take to his room, and CNA D asked LVN A and Resident #1 was breathing lightly slow breathes, and while in front of an office and LVN A looked at him, then instructed to take Resident #1 into his room which was position 3 room down in 106A. CNA D stated the treatment nurse, LVN A, MDS Coordinator, and DON entered Resident #2's room. CNA D stated it could not be more than 2 minutes between the time she returned Resident #2 from the table to his room. CNA E stated that fall risk patients were positioned near the nurse's station to ensure there were people watching. CNA E stated she had worked with Resident #2 prior and saw a tube feeding pump and would monitor him and would ask for food consistently in a form of hand gesture. CNA E stated she was in his room on the day in question, and hospice nurse had just bathed Resident #2, and Resident #2 had wheeled himself out of his bedroom. Both stated they have been educated to stay with the patient and yell out for help from all clinical staff and have also been instructed to perform the Heimlich maneuver immediately. Both stated types of abuse they have been educated on were emotional, physical, and mental, if they notice a new bruise, abrasions, skin tears, and color will notify charge nurse and administrator if they suspect abuse. Both stated they attended in-services 03/29/2024- 03/30/2024. During an interview on 03/30/2024 at 1:28PM, CNA F, CNA G, CNA H, CNA I; all have stated they have been educated on Abuse and Neglect and NPO precautions, Heimlich maneuver. All stated NPO precautions were implemented for those residents that have gastric tubes that do not allow them to eat through their oral cavities. All stated they will advocate for a nurse to intervene by calling out for help and would initiate the Heimlich maneuver immediately if a resident was witnessed choking and knows that it may be due to eating/choking issue. All stated to position hands above the gastric tubes and as close to the rib cage/abdomen area and will conduct an upward thrust and will stay with the resident until the nurse arrives and will await their instructions. Resident #1was CNA I's resident and was able to eat by himself and was in the front so that there were more eyes to watch him. All stated Resident #2had dementia but was able to eat on his own and does not allow people to eat from his tray. All stated facility has implemented that all residents that need assistance to eat will be assisted in the dining room area, snack cart was now put behind nurses' station, as well as coffee station was now served only in dining area. CNA E stated she had seen Resident #2use a hand to mouth gesture that indicated he was hungry and wanted to eat. All stated, types of abuse they have been educated on were physiological, physical, sexual, verbal, abandonment, and misappropriation of property. All stated, signs and symptoms of abuse could be sad, crying, grimacing of pain, skin coloration, bruises, behavioral abnormalities, or resident verbalizes allegation. All stated if they do suspect abuse, they will report immediately to the charge nurse and administrator. During an interview on 03/30/2024 at 1:55PM, LVN A stated on 03/25/2024 around lunch time, she was at the nurse's station, on the phone getting a surgery date for another resident, when she was alerted by CNA D that help was needed. LVN A stated she then got her pulse oximeter and saw Resident #2 in distress in his room. LVN A stated she also saw the DON, MDS Coordinator, and CNA D. LVN A saw the DON performing the Heimlich maneuver. LVN A stated the treatment nurse was at the nurse's station conducting some form of documentation on the computer. LVN A stated she did not see anything going on, and once CNA D alerted her, she then reacted and went to Resident #2's room. LVN A stated she was focused on her trying to get her own resident a follow up appointment for surgery, she did not hear CNA D speak with the treatment nurse. LVN A stated it was no more than a minute from when LVN A was alerted to the time she entered Resident #2's room. LVN A stated, while the Director of Nursing was performing the Heimlich maneuver, saw some particles come out of Resident #2's mouth, but nothing else was coming up. LVN A stated the MDS Coordinator went to get a suction. LVN A stated she felt Resident #2's pulse and was gasping for air, and multiple times tried to get a blood pressure on Resident #2 but was not reading, and the pulse oximeter oxygen reading was in the 70's and administered oxygen through a simple mask, not a non-rebreather mas. LVN A stated the MDS Coordinator then returned and suctioned some particles with yanker and deeper suctioned, but nothing was working. LVN A stated they actively tried to suction and could hear Resident #2's heartbeat and was told by an unknown staff member that Resident #2's family member did not want to send Resident #2 into the hospital. LVN A stated she was positioned on the right side of Resident #2 and the hospice nurse was in the room standing to the further part of the room. LVN A stated she asked/told the hospice nurse to check pulse, and throughout the incident Resident #2's face would turn blue then return to normal skin color. LVN A stated Resident #2 was not exhibiting signs of choking. LVN A stated for sure the Heimlich maneuver should have been conducted as well as an assessment on scene, as opposed to having the resident taken to their room because maintaining the life of a patient was more important than maintaining their privacy for emergent situations. LVN A stated Resident #2 was sitting at the edge of bed and the DON performed Heimlich maneuver for approximately 5-10minutes, nothing substantial came out, followed by the staff member placing him back in bed with the head of the bed raised, eyes were not open, and body would sporadically jerk and when performing sternal rub Resident #2's body would jerk but then stop. LVN A stated Resident #2's breathing was light/labored breathing, then stop and then would twitch/jerk sporadically. LVN A stated she has been educated to perform an assessment immediately once it was known there was cause of an emergent situation as well as to begin a Heimlich maneuver immediately when a resident was choking. During an interview on 03/30/2024 at 2:36PM, Laundry Attendant A, Laundry Attendant B; Both stated that if they witness a resident actively choking and were standing up, they will immediately perform the Heimlich maneuver, or if they were in a wheelchair, they will call out for help from the clinical. Both stated they were in-serviced about abuse, neglect, reporting of abuse/neglect reporting, where the NPO book was located and the definition of NPO which means nothing by mouth. Both stated they were also in-serviced about the Heimlich maneuver and how to perform the Heimlich maneuver by placing both hands under the rib cage and thrusting in an upwards motion. During an interview on 03/30/2024 at 2:45P, CNA J, CNA K, CNA L, CNA M, all stated if they were to encounter a resident that was showing signs of pallor or change in condition they will call out for the nurses' help. All stated that they will immediately commence the Heimlich maneuver, would perform the Heimlich maneuver by placing their hands on the resident's abdomen and performing a forceful upward thrust. All stated, as a collaborative effort if a resident needed to be observed while eating, the CNAs were primarily the people to do the observation, and if they must leave for any reason the nurses will take over. All stated, those residents that need assistance eating were now located in the dining room area. All stated, the snack carts were located behind the nurse's station now, and coffee station was now behind the nurses' stations as well. All stated, those residents that were NPO were now updated according in the POC as well as inputted in the NPO book that was located at the nurse's station. All stated, they were in-serviced about NPO definition, abuse and neglect, Heimlich maneuver. All stated, the facility has instructed to be more observant of the NPO residents that were mobile. All stated, abuse and neglect, encompass verbal, mental, physical, isolation, and emotional abuse. All stated, if they suspect abuse, they will report suspicion to the charge nurse and administrator. All stated they were in-services from 03/27/2024-03/30/2024. During an interview on 03/30/2024 at 3:02PM, LVN B stated she was (8YEARS)full time: LVN B stated she worked the second shift (3-11PM) on 03/25/2024. LVN B stated Resident #2 was impulsive and would consistently ask to eat actual food and would also exhibit frustration when told he was not allowed to eat via oral cavity due to swallowing issues. LVN B stated Resident #2's mental compacity could have limited him in understanding why he could not eat through oral cavity. LVN B stated she has been educated that if she were to see a resident actively choking, she would immediately perform the Heimlich maneuver, and stated she would immediately assess the resident if the resident was exhibiting signs of distress, change in condition, or change in skin coloration. LVN B stated as a nurse, she will always prioritize the safety and well-being of a resident before maintaining their privacy because she believes, in her professional opinion, that keeping her residents' lives and thriving was the most important reason, the well-being of her residents come before maintaining their privacy because resident's lives were more important. LVN stated she was educated that a nurse needs to always stay in the dining room while residents were in the dining room, also on abuse, neglect, NPO definition (make sure no foods available to them for their safety), and Heimlich maneuver. LVN stated the facility has instructed the clinical staff to be more vigilant, LVN B caught Resident #1 walking and was very mobile and stressed that Resident #1 was impulsive. LVN stated Resident #2 was very determined. LVN stated there are all types of abuse including physical, sexual, verbal, monetary. LVN stated she was looking out for signs of symptoms of abuse by being observant of bruises, behavioral abnormalities, and family hostile dynamics, 3/27/2024 and 3/29/2024. During an interview on 03/30/2024 at 3:36PM, LVN C stated she worked here for8years; (3-11PM) LVN C stated that Resident #2 would state he was hungry all the time. LVN C stated Resident #2 was active and would administer bolus feeds 5 times a day. LVN C stated she worked on 03/25/2024 the evening shift (3-11PM). LVN C stated the facility implemented a new process of the medication aides will be observing residents eat/assisting residents to eat within the dining room area solely. LVN C stated that the event with Resident #2 on 03/25/2024 potentially was avoidable, and continued by stating the nursing staff should have reacted immediately to render aide to Resident #2, not remove Resident #2 from the table area, in front of the nurse's station, to his room. LVN C stated the time it took for Resident #2 to be transported to his room, the clinical staff could have assessed the resident and immediately started to perform the Heimlich maneuver. LVN C stated in NPO residents should be given multiple diverting activities during mealtimes as a preventative measure to keep them from being around others that were eating actual food. LVN C stated she would in her professional opinion, as a nurse, if she were to encounter a choking resident, she would immediately assess the residents, perform vital signs and begin an investigation immediately to advocate for the residents' health and well-being. LVN C stated that residents' lives were more important than maintaining a resident's privacy. LVN C stated she was educated/in-serviced about NPO definition, NPO book, abuse, neglect, Heimlich maneuver. LVN C stated all residents that need feeding assistance will be assisted in the dining room, and all snack carts will be positioned in the nursing station. During an interview on 03/30/2024 at 4:06PM, LVN D (11PM-7PM) LVN D stated he was educated on the importance of reporting abuse and neglect, reporting any allegation of abuse, completing incident reports, specialized diets, NPO status, and Heimlich maneuver. LVN D stated if resident was actively exhibiting signs of distress including choking, he would act upon the concern immediately. LVN D stated a resident's life was more important than maintaining privacy during an emergent situation. LVN D stated if he were to be notified of a resident's change of condition, he would immediately assess the resident, attain vital signs, and if it determined they are choking, he would immediately perform the Heimlich maneuver. LVN D stated the tables that were initially in the front of the nurses' station were used for residents to eat at when the dining room was overly loud and stimulating. LVN D stated the facility has now instructed the clinical staff that residents that need to be assisted to eat, will now be solely done in the dining room. LVN D stated the facility has implemented 1 nurse will be in the dining room during mealtimes and will stay till the last resident finishes. LVN D stated he was in-se[TRUNCATED]