**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility after a visitor utilized the exit code then held the door open for the resident to walk out on 04/18/25 around 9:52 PM. The temperature outside was a high of 91 degrees and a low of 68. The resident was found over three hours later. She was taken to the hospital for evaluation after 1:30 AM. The noncompliance was identified as PNC. The IJ began on 04/18/24 and ended on 04/21/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for elopements resulting in falls, injuries, dehydration, and hospitalization. Findings included: Review of Resident #1's face sheet, printed 05/07/25, reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on 04/19/25. Her diagnoses included cerebral infarction due to occlusion or stenosis of small artery (stroke), hypertension (high blood pressure), aphasia following unspecified cerebrovascular disease (difficulty speaking), expressive language disorder (difficulty speaking), and difficulty in walking. Review of Resident #1's admission MDS assessment, dated 04/19/25, Section C (Cognitive Patterns) reflected a BIMS assessment was not completed, nor did staff assess her short-term memory. Section GG (Functional Abilities) reflected she was independent with ADLs including transfers and walking 150 feet. Review of Resident #1's admission assessment and baseline care plan, initiated 04/11/25, reflected the resident was not an elopement risk but was at risk for falls. Review of Resident #1's Elopement Risk Assessment, dated 04/11/25, reflected a 1 which indicated no risk for elopement. Review of Resident #1's psychosocial assessment completed 04/15/25, reflected resident was not very verbal at this time and did not answer many of the questions. Review of Resident #1's progress note, dated 04/19/25 at 2:15 AM, documented by the DON, reflected the following: During a routine round by floor nurse, a resident was reported missing from their room. All staff on duty conducted a thorough search of the entire building but were unable to locate the resident. The DON and Administrator were then called to the building to review the footage and discovered that the resident had been let out of the front door by a family member of another resident. The resident has a local address and several local family friends as emergency contacts. The Administrator contacted the resident's (family member), who resides out of state, to inform her of our findings. The (family member) stated that the resident had informed her that she was visiting a family friend in town. Multiple attempts were made to contact the family friend at their local physical address and via cellular phone. The (city) Police Department was notified for assistance. The DON, Dietary Manager, Administrator, and the (city) Police Department searched various areas, including the facility and the resident's housing address. The resident was located a block away from her home. Due to the resident's disease process, she is occasionally unable to verbally express her needs but can respond to yes or no questions and is aware of her surroundings. The resident was adamant about returning to her home rather than the facility. Once the resident was in the presence of her front door, the DON and Dietary Manager assessed her for any injuries or complications. The resident reported experiencing shortness of breath and consented to allow EMS to conduct a further evaluation. The (city) Police Department requested backup from EMS, and the resident was transported to a hospital for medical attention . Review of Resident #1' progress noted, dated 04/19/25 at 11:39 AM, documented by the DON, reflected the following: During a routine round, a resident was reported missing from their room around 2115. Floor nurse reports that she last time she saw her resting in bed with eyes open around 2015, All staff on duty conducted a thorough search of the entire building but were unable to locate the resident. Around 2251 The DON and Administrator were notified and arrived to building shortly after. They were able to review the camera footage and discovered that the resident had been let out of the front door by a family member of another resident around 2153. Family was notified by the Administrator. Report from floor nurse (name), LVN F. [sic] Review of the facility's investigation reflected the as followed: During routine rounds staff noticed the resident was missing. Staff initiated a search and verified all other residents were accounted for. When staff were unable to locate the resident, facility management were notified at 12:30 AM. Management went to the facility and assisted in the search. The administrator viewed the surveillance video and saw a visitor use a code to open the door, hold the door, and the resident walked out of the building. Family was notified and provided phone numbers and local addresses. The MD was notified. The local police were notified and assisted in the search. The codes to the doors were changed. Staff were interviewed. Staff were in-serviced on elopement, assessing risk of elopement, and codes for the exit alarms. An observation on 05/07/25 at 9:16 AM, revealed a neon pink sign on the inside of the entrance/exit door. The sign reflected, DO NOT ASSIST ANYONE OUT OF FACILITY. The sign was printed in large black font and was posted at eye level. The door had a keypad and required a code to exit the door. Observations on 05/07/25 between 9:16 AM and 3:50 PM, revealed staff entering the code to allow visitors in or out of the facility at the main entrance. The buzzer sounded each time the door was opened. No observations of visitors entering the door code was made. Observations of other entrance doors revealed keypads in place and DO NOT ASSIST ANYONE OUT OF FACILITY signs displayed. An observation on 05/07/25 at 10:00 AM, of the video surveillance from 04/18/25, revealed footage labeled Hall 400. Resident #1 opened her room door and looked into the hallway. She looked to the right, the left, back to the right, then back to the left. She stepped out into the hall and walked out of view of the camera. The resident was wearing long pants and a long-sleeved top. The next camera view was labeled Front Lobby. A person, identified as a family member, not related to Resident #1, was seen walking through the lobby to the front door. Resident #1 was observed as she entered the lobby. She adjusted the strap of her purse over her shoulder. She walked toward the front door. The family member was observed as she entered the code to open the front door. The family member exited the door, turned, and saw Resident #1 walking toward the door. The family member held the door open, and Resident #1 walked out. The next camera view was labeled, Parking Lot. Resident #1 was observed as she walked across the parking lot away from the facility. The time stamp reflected 04/18/25 at 9:52 PM. The video ended when the resident reached the end of the parking lot. A voice message was left 05/07/25 at 10:45 AM, which requested a return call from Resident #1's family member. A return call was not received prior to exit from the facility. During a telephone interview on 05/07/25 at 11:10 AM, an officer from the (city) Police Department provided the location where Resident #1 was picked up by EMS on the morning of 04/19 /25 at 1:45 AM. A mapping website reflected the location was 1.6 miles from the facility. The officer stated he did not participate in the search for the resident because it happened on the night shift. He stated he was able to review the report from the officer who participated in the search. During an interview on 05/07/25 at 1:16 PM, LVN A stated she had received training on elopement recently. The training included identifying risk and preventing elopement. She did not remember the exact date but knew it was after the recent elopement. She stated she did not work the day the resident eloped, and she did not recall any residents with exit-seeking behaviors. She stated if a resident was missing, staff would immediately initiate a search, complete a head count, and notify management immediately. LVN A reported recent training on ANE and named the ADM as the Abuse Coordinator. During an interview on 05/07/25 at 1:19 PM, MA B stated she did not recall ever seeing Resident #1 standing near exit doors or trying to get out of the facility. She stated she had training on ANE and Elopement a few weeks ago. She stated since that training, the door codes had changed, and they were not allowed to give the new code to family members. She stated the family members were understanding once the reason for the change had been explained to them. MA B stated if a resident was missing, they conducted a search, completed a head count, and notified the charge nurse immediately. MA B was able to describe types of abuse and the need to report any abuse immediately. During an interview on 05/07/25 at 1:26 PM, a visiting FM stated staff open the door for her when she entered and exited the facility. She stated she had not been given the code for the doors. She stated it had not been a problem as staff had been available to assist her at each visit. During an interview on 05/07/25 at 1:28 PM, LVN C stated she had recent training on elopement and not giving the door code to visitors. She stated they in-service included training on completing the elopement assessment on admission, frequent rounding, watching for residents exit-seeking, and not giving out the code for the doors. She stated staff assisted family and other visitors in and out of the building. She stated she had received frequent in-services on ANE, spoke to the policy, and named the ADM as the abuse coordinator. During an interview on 05/07/25 at 1:31 PM, the DON stated Resident #1 had been assessed on admission and she was not an elopement risk. She stated the resident was admitted for short term therapy to gain strength after her hospitalization. The DON stated she drove to the facility as soon as she was notified, around 12:30 AM, that the resident was missing . She stated the facility was thoroughly searched and a nurse had searched the perimeter. The administrative staff went out in teams and searched for the resident. She stated she and the dietary manager found Resident #1 near her home. She stated the Resident #1 allowed a partial assessment and the resident made it known that she did not want to return to the facility. The DON stated the resident agreed to go to the hospital to be evaluated after she reported some shortness of breath. She stated the police officer at the scene call for EMS who transported the resident to the hospital. During an interview on 05/07/25 at 2:26 PM, the ADM stated he expected residents were treated with dignity and respect. He stated they tried everything in their power to prevent elopements. He stated he was called just after midnight after the resident was missing. Staff told him they had searched the facility and ensured all other residents were present. He stated, once at the facility, he watched the video and saw the resident had been let out of the building by a visiting family member. He stated a family member of Resident #1 provided addresses for local friends and the resident. The police were notified and assisted in the search. The ADM stated the DON and DM had found the resident about a block from her house. He stated EMS took the resident to the hospital for evaluation. Upon return to the facility, he changed the codes to the doors and staff were instructed not to give the new code to family or visitors. He stated signs were created and placed at each exit. He stated they initiated in-service training on elopement, resident rights, and visitations. The ADM stated they did not have a locked unit and they did not use a Wander guard system. During an interview on 05/07/25 at 3:00 PM, CNA D stated she did not remember Resident #1. She stated she had been trained on Elopement and Resident Rights recently but did not remember the date of the training, about 3 weeks ago. She named the ADM as the abuse coordinator and stated any abuse must be reported immediately. She stated frequent rounding and knowing where the residents were was important to prevent elopement. She stated the door code was not to be given to visitors . Review of an in-service dated 04/19/25 and initiated by RN E then continued by the DON, ADON, and ADM, reflected staff were in-serviced on identifying high risk for elopement, understanding elopement, prevention of elopement, and adding to QAPI. Review of an in-service dated 04/19/25 and initiated by RN E then continued by the DON, ADON, and ADM, reflected staff were in-serviced on Resident Rights. Review of the Ad Hoc QAPI meeting agenda, dated 04/21/25, reflected the ADM, DON, SW, and MD participated. Review of eight resident medical records reflected Elopement Assessments were all current. Residents who had been in the facility more than 90 days had Elopement Assessments completed quarterly. Review of the facility's Elopement Policy, dated Qtr 3, 2018, reflected the following: Staff shall investigate and report all cases of missing residents. 4. If an employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.); d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Contact the Attending Physician and report findings and conditions of the resident; c. Notify the resident's legal representative (sponsor); d. Notify search teams that the resident has been located; e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. Review of the facility's Resident Rights Policy, revised February 2021, reflected the following: Employees shall treat all residents with kindness, respect, and dignity. l. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; e. self-determination; p. be informed of, and participate in, his or her care planning and treatment. The noncompliance was identified as PNC. The IJ began on 04/18/24 and ended on 04/21/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to meet the nutritional menu of a puree diet for 1 (Resident#1) of 4 residents resulting in a choking incident. The facility failed to verify and follow the dietary menu of 1 of 27 residents prescribed a modified textured diet. This failure could place residents identified as having mechanically altered diets at risk for potential death or brain damage due to lack of oxygen from choking. On 11/07/22 at 1:35 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 11/09/22 at 6:45 PM the facility remained out of compliance at the severity level of actual harm and scope of isolated due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, high blood pressure, anxiety, hyperlipidemia (increased cholesterol), arthritis, abnormalities of gait and mobility, salivary secretion, abnormal posture, muscle weakness(weak) dysphagia (difficulty swallowing), mild malnutrition, and major depressive disorder Review of Resident # 1's care plan undated revealed Resident #1 is at risk for diet alteration related to- regular diet, dysphagia level 1 puree texture, mildly thick (Nectar) 2 consistency diet and nectar thick liquids between meals three times daily. Review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS Score of 0 indicating severe cognitive impairment. Review of Resident #1's progress notes dated 10-29-2022 revealed resident was noted choking on food from the dinner tray. Agency LVN B was able to dislodge food from the mouth and stabilize it. Review of Resident #1's physician order dated 11-23-2021 revealed a regular diet, dysphagia level 1 puree texture, mildly thick (nectar) 2 consistency, fortified meals for all meals, and snacks in between meals. Interview on 11-5-2022 at 2:24 PM DON stated he was not in the facility when the choking incident occurred on 10-29-22 with Resident #1. DON stated that Agency LVN B (no longer contracted with the facility) was responsible for conducting an investigation of the incident and what caused the resident to receive the wrong textured diet. DON stated the facility incident investigation was not completed by Agency LVN B. DON stated it was Agency LVN B responsibility to ensure it was the incident report was completed. DON stated he failed to verify the incident report and the investigation was completed. Interview on 11-5-2022 at 2:45 PM, ADON stated she was not in the building when the incident with Resident #1 occurred. ADON stated she entered the progress notes regarding the incident. ADON stated when she was called by Agency LVN B, Agency LVN B told her Resident #1 was choking on food and she was able to dislodge food from her mouth and stabilize Resident #1. Interview on 11-5-2022 at 2:51 PM Agency CNA A stated he was in the dining room assisting with other residents when he was redirected by Agency LVN B and was called to assist Resident #1 with feeding. Agency CNA A stated Agency CNA H (no longer contracted with the facility) had already placed the food tray in Resident #1's room. Agency CNA A stated he did not verify the meal tray as he thought it was already verified by Agency CNA H. Agency CNA A stated the meal observed was a regular texture meal of fish and french fries. Agency CNA A stated he had fed the resident a couple of bites of the fish and fries when he noticed Resident #1's lips quivering. Agency CNA A stated he went into the hall to seek assistance and Agency LVN B came in and stuck her fingers in Resident #1 mouth to dislodge the food. Agency CNA A stated he was not provided training on facility-specific policies and procedures, for resident diet orders, and verifying meals and food textures. He stated he did not check Resident #1's closet door checklist for ADLs posted in her room. Agency CNA A stated he did not know the location of the facility policies and procedures for checking dietary orders and textures. Agency CNA A stated the facility's charge nurse would give assignments daily and if he had any questions, he would ask the charge nurse. Observation on 11-5-2022 at 3:00 PM revealed that Resident #1's closet door checklist reflected indicated a diet, puree texture. Interview on 11-5-2022 at 5:40 PM Agency CNA B stated that the facility had not provided training since her start date of employment at the facility on verifying textured diets. Agency CNA B stated the facility's training consisted of being provided with a facility-generalized nonspecific checklist that did not include texture diets and ADL care. Agency CNA B stated a facility checklist was not an effective training tool to care for residents. Agency CNA B stated the charge nurse would give out assignments daily and share information regarding the care of a resident. Agency CNA B stated if she had any questions regarding a resident, she would contact the charge nurse. CNA B stated the treatment of a resident was communicated through the charge nurse and the ADL checklist that included the diet texture was located on the inside door or each resident's closet. CNA B stated training is important for the knowledge of residents' needs and to prevent further illness or injuries. Interview on 11-6-2022 at 12:05 PM Agency CNA C stated the facility did not provide training on verifying textured diets. The only training received was to complete a checklist which she stated was not an effective training tool. Agency CNA C stated she did not know where to find the facility policies and procedures on menus and texture diets. Agency CNA stated the charge nurse would give out her assignment daily and if she had any questions, she would ask the charge nurse. Agency CNA stated there was a checklist of each Resident's ADL needs located inside their closet doors. The lack of training on verifying the residents' diet texture needs could interfere with residents' health and safety. Interview on 11-6-2022 at 12:08 PM Agency LVN A stated the facility did not provide training on verifying textured diets. Agency LVN a stated the charge nurse would make the assignments each shift and if she had any questions her charge nurse would answer them. LVN A stated there is a checklist of ADLs that included the diet texture for each resident. LVN A had no knowledge of the location of the facility's policy and, procedures on menus and verifying textured diets. Agency LVN A stated it was important to have the proper training on resident diets and verification of the texture of the food as it could eventually cause injury or death to a resident. Interview on 11-6-2022 at 12:15 PM Agency CNA D stated the facility did not provide training on verifying textured diets. Agency CNA D stated the nurse in charge would provide the assignment and answer any questions regarding her assignment. CNA D stated she did not know where the policies and procedures regarding resident diet and verification of textured meals were located. CNA D stated that there was a checklist inside each resident's closet door that had a list of ADLs that included the diet texture for each resident. CNA D stated without proper training regarding the verification of modified texture diets this could cause resident injuries or death. Interview on 11-6-2022 at 12:24 PM, Agency CNA E stated the facility did not provide training on verifying textured diets. Agency CNA E stated a checklist for a resident's ADLs to include diet texture was located inside the resident's closet doors. Agency CNA E stated she does not know the location of the facility policies regarding resident textured diets and the verification process. Agency CNA E stated the nurse in charge gives assignments daily and if there were any questions regarding her assignment, she would ask the charge nurse. Agency CNA E stated it was important to have training regarding diets and verification of meals to help in preventing accidents. Interview on 11-6-2022 at 1:00 PM DON stated there was no policy for a CNA-to-CNA tradeoff to share information on resident diet and texture of the meals. DON stated if agency staff had questions, they were directed to a charge nurse for the answers. DON stated there was no additional training when agency staff completed the agency orientation checklist upon hire. DON stated the closet door ADL checklist that includes the diet texture was acceptable for doing the job. DON stated when agency staff had questions, they could seek help from the nurse in charge. Interview on 11-6-2022 at 1:15 PM DON stated it was not clear if Resident #1 was given someone else's tray or if the tray was incorrectly made by kitchen staff. DON stated that an investigation report was not completed for the choking incident on Resident #1. Interview on 11-6-2022 at 1:20 PM DON stated it was the charge nurse's responsibility to start the investigation regarding the choking incident involving Resident #1. DON stated that Agency LVN B placed the incident report in another resident (unnamed) medical record. DON stated he was not able to find the choking incident report for Resident #1. DON stated he dropped the ball in verifying the incorrect charting of the choking incident as it was his job to make sure documentation was accurate. Interview on 11-6-2022 at 3:30 PM Administrator stated before an agency staff was hired, they had to complete basic training identified on their agency's website. Administrator stated these trainings included training on abuse /neglect, emergency evacuations, infection control, bill of rights, and change of conditions. Administrator stated the agency orientation checklist provided by the facility was sufficient training for the agency staff and no additional training was needed for resident ADL and diet texture needs. Interview on 11-6-2022 at 3:40 PM DON stated there was no additional training for agency staff and he believed the agency orientation checklist for agency staff was sufficient training for resident ADL and diet texture needs. Interview on 11-6-2022 at 5:30 PM CNA F stated there was no facility-instructed training provided to agency workers. CNA F stated the agency workers were given their daily assignments by the nurse in charge. CNA F stated if agency staff had any questions the agency staff would ask him or the nurse in charge. CNA F stated it was important to have training regarding verifying resident diet textures for the health and safety of residents. Interview on 11-6-2022 at 5:50 PM CNA G stated that agency staff was not provided additional training on resident diets and verifying meals. CNA G stated staff reported to the charge nurse for their assignment and asked the nursing staff any questions they may have. CNA G stated the agency orientation checklist was not an effective training tool for agency staff and for verifying resident textured diets. CNA G stated agency staff utilized the resident's closet door checklist to complete the resident ADLs and check for their textured diets. CNA G stated without effective training on resident diets and the verification processes injuries or death could occur. Interview on 11-6-2022 at 6:00 PM RN A stated the agency orientation checklist was a guide but was not effective for resident care. RN A stated the agency staff was not getting hands-on training when they came onsite regarding resident diets and verification of meals. RN A stated there was no policy binder on-site, the facility policy was located online, and agency staff was not aware of where to find information specific to resident diets and verification of meals. RN A stated agency staff were given their assignments by the nurse in charge and that nurse gave a rundown on what was needed. RN A stated the resident closet door checklist gave a list of ADLs which included diet texture. RN A stated she had concerns with the agency staff having proper training and the lack of training regarding verifying textured diets could lead to injuries or possible death. Review of facility grievances dated 11-1-2022 revealed Resident #1's family member was concerned that her mother received the wrong food tray with the wrong textured meal. Review of the facility grievance dated 10-29-2022 revealed a written statement from Agency CNA A of Resident #1's choking incident due to wrong meal being provided. Review of the facility agency staff orientation checklist (undated) revealed a checklist for agency nurses to read and follow all treatments/orders as written. The checklist also indicated that agency staff were to complete a risk management report (incident report) for any unusual occurrence and communicate to oncoming nurses. Review of the facility tray identification policy revised in April 2007 revealed nursing staff shall check each food tray for the correct diet before serving the residents. Review of the facility choking policy dated the 3rd quarter of 2018 revealed to call for help but stay with the resident. Report other information in accordance with facility policy and professional standards of practice. No reference on where to find facility policy and professional standards of practice was noted. Review of policy for assisting with impaired resident within room meals policy dated 3rd quarter 2018 to check the tray before serving it to the resident to ensure that it is the correct diet ordered and the food consistency is appropriate to the resident's ability to chew and swallow. Review of the facility staff development program policy dated the 3rd quarter of 2018 revealed all personnel must participate in initial orientation and regularly scheduled in-service training classes. Review of the facility's on-the-job training policy dated January 2008 would be conducted when necessary to assist employees in performing their assigned tasks. Review of facility investigation and reporting policy dated 3rd Quarter 2018 revealed if an incident or suspected incident of resident neglect is reported the administrator will assign the investigation to an appropriate individual. A review of the facility orientation policy (undated) revealed the facility orientation program for newly hired employees, transfers, volunteers, and travel staff stated that an orientation program shall be conducted for all newly hired employees, transfers from other departments, and volunteers. Parkview Nursing and Rehabilitation POR Letter of Abatement for Removal of Immediate Jeopardy November 7, 2022 On 11/07/22 an abbreviated survey was initiated at Parkview Nursing and Rehab, 1501 S. Main, [NAME], TX 78644. On 11/07/22, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. Impact Statement: All residents were identified on 11/7/2022 to have the potential to be affected by this deficient practice. F803 - The facility failed to meet the nutritional menu of a puree diet for one resident resulting in a choking incident. Problem #1 The facility failed to follow the dietary needs of 1 of 4 residents reviewed for the puree diet. The facility failed to verify and follow the residents prescribed modified texture diet. Action Taken/Monitoring: DON/ Designee began in-service on 11/7/2022 in regard to tray distribution and identification to the appropriate resident for all staff including agency prior to the start of their next shift. This has been completed for all current building staff as of 11/8/2022, as well as ongoing for new staff including agency, by monitoring the staff roster in relation to the staff schedule. DON/Designee will ensure that all licensed nursing staff including agency staff have been in-serviced prior to the start of their next shift, by monitoring the staff roster in relation to the staff schedule, to verify that tray cards match the appropriate diet as ordered. This has been completed for all current staff including agency as of 11/8/2022, and ongoing for new staff including agency. DON/Designee will ensure that all staff including agency are in-serviced, started on 11/7/2022 and was completed by 11/8/2022, by monitoring the staff roster in relation to the staff schedule. on where to find the appropriate diet for all residents prior to the start of their next shift. This can be found in each resident's room posted to the inside of their closet door to include photo identification, a binder with the appropriate resident diet is also located in the dining room for staff to access to ensure the appropriate diet is served. Administrator initiated training on tray distribution and identification 11/7/2022 and will ensure that 100% of all staff including agency are in-serviced prior to the start of their next shift by monitoring the staff roster in relation to the staff schedule, to be ongoing with all new staff including agency regarding tray distribution and identification to the appropriate resident. This will be validated daily by monitoring for accuracy x7 days, weekly x3 weeks, then monthly x3 months. Administrator/Designee will ensure that the nursing staff is monitoring the accuracy of the trays to match the ordered diet per each resident by checking a minimum of 10 trays at meal service x7days, beginning 11/7/2022, then weekly x3 weeks, then monthly x 3months. The Administrator/Designee will monitor the training of tray card and identification x7 days, beginning 11/7/2022, then weekly x3 weeks, then monthly x3 months, or until all new staff including agency have been in-serviced. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on 11/8/2022. Problem #2 Interviews with agency staff revealed there is no additional training beyond the checklist provided. Action Taken/Monitoring: The Administrator/Designee will develop and implement an effective training program for all new staff including agency. This training program was developed and initiated beginning on 11/7/2022. This training has been completed for all agency staff as of 11/8/2022 or the start of their next shift whichever occurs first, and ongoing for new staff including agency by monitoring the staff roster in relation to the staff schedule. This training will include general orientation of the facility to include when and how to report Abuse and Neglect, documentation guidelines include resident identifiers, physician orders including dietary orders, when to complete risk management in regard to incident and accident reports, and abridged policy and procedures for primary care of residents. DON, Nurse Management/ IDT will ensure by monitoring staff roster versus the staff schedule for any new oncoming Agency staff have completed Agency orientation prior to their shift until no more agency is being utilized in facility. The administrator will ensure, by monitoring staff roster versus the staff schedule, that all new staff including agency are trained prior to the start of their next shift, beginning on 11/7/2022 by record review of agency training manual and signed affidavit of receiving a manual x7days, then weekly x3 weeks, then monthly x3 months, or substantial compliance is maintained. The administrator will monitor the training x7 days weekly beginning on 11/7/2022, x3 weeks, then monthly x3 months, or until all new staff have been in-serviced, by record review of agency training manual and signed affidavit of receiving a manual The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on 11/8/2022. Problem #3 No known knowledge of facility policies or the location of policies onsite. Action Taken/Monitoring: Director of Nursing/Designee will in-service and educate all staff including agency staff on where to locate and review policy and procedures prior to the start of their next shift. Policies and Procedures are located at the nursing station as well as in Point Click Care: Home-View All Links-Eduro Central [resident electronic records system], all policies and procedures can be found here by the nursing staff. Education on where to find policies and procedures for staff began on 11/7/2022 and was completed by 11/8/2022 for all current staff including agency. Training will be ongoing for new staff, including agency, to the facility. Don/Designee will monitor all new staff including agency, who come to the facility to ensure their knowledge of the location of the policies and procedures, by record review of agency training manual and signed affidavit of receiving a manual. This will be monitored by Administrator/DON/Designee daily x7days, beginning on 11/7/2022, then weekly x4 weeks, then monthly x3months. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on 11/8/2022. Problem #4 Record review revealed no incident report had been documented on Resident #1 choking incident. Action Taken/Monitoring: DON/Designee will in-service all staff prior to the start of their next shift beginning on appropriate completion of incident reports with identified risk to resident beginning on 11/7/2022, completed on 11/8/2022 or prior to their next scheduled shift whichever occurs first. All current staff including agency will be in-serviced prior to the start of their next shift and will be on-going for new staff including agency. Administrator/DON/Designee will review the accident/incident reports starting on 11/7/2022 and will be an ongoing process to ensure a thorough investigation is completed. Incident and accidents reports will be reviewed, and an investigation will be completed within 72 hours of the incident to include appropriate interventions. This will be reviewed daily during Risk Management Meeting, Monday-Friday. Administrator will ensure, through record review of agency training manual and signed affidavit of receiving a manual that 100% of staff including agency are in-serviced prior to the start of their next shift, beginning on 11/7/2022 and completed for all current staff as of 11/8/2022. Training will be on-going for new staff, including agency, daily x7days, weekly x3 weeks, then monthly x3 months. Don/Designee will monitor all new staff, including agency, who come to the facility to ensure their knowledge of how and when to complete an incident report by validating the staff roster versus the staff schedule. This will be monitored by Administrator/DON/Designee daily x7days, weekly x3 weeks, then monthly x3months until substantial compliance is achieved beginning on 11/7/2022. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on 11/8/2022. Involvement of Medical Director The Administrator notified the facility's Medical Directors, of the Immediate Jeopardy tag on 11/07/22. The Administrator in collaboration with the Inter-disciplinary team and Medical Director will review and validate the policies and procedures including Accidents and Incidents: Investigations and Reporting; Tray Distribution and Identification; Resident Rights; Emergency Procedure - Choking; Change in a Residents Status or Condition; Activities of Daily Living; Assistance with Meals; and Abuse and Neglect are being followed, as well as meet federal, state, and local regulations, during an ADHOC QAPI meeting held on 11/8/2022. Involvement of QA On 11/08/22 an Ad Hoc QAPI meeting will be held with the Medical Director, Administrator, Director of Nursing, and Dietary Director to review and validate the plan of removal. Administrator and Inter-Disciplinary team reviewed policies including: Accidents and Incidents: Investigations and Reporting; Tray Distribution and Identification; Resident Rights; Emergency Procedure - Choking; Change in a Residents Status or Condition; Activities of Daily Living; Assistance with Meals; and Abuse and Neglect of the residents on 11/7/2022, within the facility with appropriate corrections as indicated, and the policy and process to ensure practice is to act upon all allegations as if they are true and accurate until proven otherwise. Who is responsible for the implementation of the process? The Administrator will be responsible for implementation of ensuring the adequate process regarding meeting the nutritional needs of the residents within the facility. The new process/system was started on 11/07/22. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 11/07/22. The Surveyor monitored the Plan of Removal on 11/08/22 as follows: Observations on 11/08/22 from 12:14 PM - 2:50 PM revealed staff verifying meal tickets to meal trays prior to providing meals to residents. Interview on 11/08/22 at 2:00 PM ADON stated she verified all residents' diets with ST and all orders/care plans were updated in PCC [ resident electronic records system]. ADON stated she would be getting with Dietary to ensure all diets matched the orders that afternoon. ADON stated RD was scheduled to review all orders the following day. ADON stated she was responsible for diets from the nursing standpoint, and she would continue to work with ST and dietary to ensure orders were updated as needed. ADON stated one person from Administration must be at every meal, checking meal trays, after the nurse verifies meals. Observations on 11/09/22 between 5:00 PM - 5:15 PM revealed residents to be seated in the dining area waiting for dinner service. Kitchen and nursing staff were observed verifying meals to tickets and placing trays in dining carts. ADON was observed verifying all meals in carts prior to being sent out to resident halls. Interview on 11/09/22 at 5:05 PM with Agency CNA I, stated she was provided training the previous day by DON regarding policies and procedures related to abuse, neglect, choking, and verification of resident diets and ADLs. Agency CNA I stated she would check the resident's ADL chart posted in residents' closets and ask the charge nurse questions if she was unsure of anything. Interview and observation on 11/09/22 beginning at 5:20 PM revealed Agency RN to be setting up trays for residents in a resident's room and verifying the meal ticket prior to providing meal trays to residents. Agency RN stated she was in-serviced the previous day by the DON about policies and procedures regarding diets, abuse, neglect, accidents, hazards, and where to find policies and procedures. Interview on 11/09/22 at 5:25 PM Facility CNA G stated she received recent training from DON about abuse and neglect, policies and procedures related to ADLs, verifying meals, and choking incidents/ accidents. Observations on 11/09/22 at 5:30 PM revealed three signs posted in the dining room regarding choking, signs of, and procedures for choking. Staff was observed in hallways verifying meals as they pulled trays from meal carts and then brought them into resident rooms. Interview on 11/09/22 at 5:33 PM DON stated his expectations for verification of meals and procedures and provided an overview of topics covered during recent in-services provided to the staff since IJ was called. DON stated all staff are required to participate in an in-service prior to starting their shift. Review of the following in-services and assignment sheet dated 11/09/22 revealed all staff working the current shift and previous shift signed and dated in-services. The following in-services were reviewed: Abuse and Neglect dated 11/7/22 and 11/8/22, Resident Rights dated 11/7/22 and 11/8/22, Tray Distribution and Identification dated 11/7/22 and 11/8/22, Emergency Procedure (Choking) dated 11/7/22 and 11/8/22, Assistance and Meals dated 11/7/22 and 11/8/22, Activities of Daily Living dated 11/7/22 and 11/8/22. Agency Orientation Binder undated was reviewed and it was revealed to include the agency facility orientation checklist and the following facility policies: Tray Identification revised 2007, Abuse/Neglect updated 2021, Emergency Choking 2018, Assistance with Meals revised 2017, and CPR revised 04/21. Orientation checklists were noted to be signed and dated by agency staff. Observations on 11/09/22 at 6:05 PM revealed DON, CNA I and Facility LVN A assisting residents in the dining room with pureed meals. Interview on 11/09/22 at 6:06 PM Facility LVN A stated it was her first day and was educated on the facility system, charting, how to find orders, and diets and was recently in-serviced by DON on the importance of and how to check meal tickets. Facility LVN A stated she was still getting the hang of things but felt the training was adequate at this point and felt comfortable seeking help, finding policies and procedures, and asking for more education regarding diet textures as needed. Interview on 11/09/22 at 6:13 PM Agency CMA stated she was recently in-serviced from DON on how to find resident information, how to check ADL information and diet texture posted in resident closets, policies, and choking signs and procedures. Interview and observation on 11/09/22 beginning at 6:15 PM revealed DON was providing training to Agency LVN C and using Agency Orientation Binder. Agency LVN C stated it was his first day working with the facility and so far, he felt the orientation being provided was easy to understand and understood how to check and verify ADLs and resident diet texture. Administrator, DON, and Corporate Nurse were informed on 11/09/2022 at 6:45 PM that the IJ was removed; however, the facility remained out of compliance at the severity level of actual harm and scope of isolated due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure agency staff were competent and trained in their job responsibilities. The facility failed to provide agency staff with the proper training to care for residents. This failure could place residents identified on a special texture diet at risk for potential harm or danger. On [DATE] at 1:35 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 6:45 PM the facility remained out of compliance at the severity level of actual harm and scope of pattern due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal. Findings include: Observation on 11-5-2022 at 3:00 PM revealed that Resident #1's closet door ADL checklist indicated a puree texture diet. Interview on 11-5-2022 at 2:51 PM Agency CNA A stated they did not receive training about diet textures and verification of meals at the facility. CNA A did not know the location of policies and procedures on diet textures and verification of meals or where they could be found. CNA A stated the charge nurse would provide assignments each day and would answer any questions about his assignment and resident ADL and diet needs. CNA A stated it was important to receive the proper training regarding ADL and diet needs to prevent a resident from serious injuries. Interview on 11-5-2022 at 5:40 PM Agency CNA B stated that the facility did not provide training regarding diet textures and verification of meals. Agency CNA B stated the facility provided a generalized orientation checklist for training and did not believe the facility orientation checklist was an effective training tool to care for residents' needs. Agency CNA B stated the charge nurse gave out assignments daily and would give resident-specific information regarding ADL care and dietary needs. Agency CNA B stated if she had any questions regarding a resident, she would contact the charge nurse. CNA B stated the treatment of a resident was communicated through the charge nurse and the ADL checklist was located inside the resident's closet. CNA B stated training regarding ADL care and dietary needs was important for the knowledge of residents' needs and to prevent further illness or injuries. Interview on 11-6-2022 at 12:05 PM Agency CNA C stated the facility did not provide any other training other than completing an orientation checklist, that did not include ADL care or dietary needs, and was not an effective training tool. Agency CNA A stated she did not know where she could find policies and procedures related to ADL care and diet textures. Agency CNA A stated the charge nurse gave out assignments daily and if she had questions, she would ask. Agency CNA A stated there was a checklist of the resident's ADLs inside their closet doors and this checklist would guide staff on the care needed for residents. Agency CNA C stated the lack of training regarding ADL care and dietary needs interfered with residents' health and safety. Interview on 11-6-2022 at 12:08 PM Agency LVN A stated that training regarding ADL care and diet textures was not provided to agency staff. Agency LVN A stated the charge nurse provided her with the daily assignments and if she had any questions, she would ask. Agency LVN A stated there was a checklist of ADLs inside the resident's closet doors to help aid in care. Agency LVN A stated he had no knowledge of the location of the policy of procedures regarding ADL care and dietary needs of residents or where to find them. Agency LVN A stated it was important to have the proper training regarding ADL care and dietary needs as it could eventually cause injury or death of a resident. Interview on 11-6-2022 at 12:15 PM Agency CNA D stated the facility did not provide training regarding ADL care and resident dietary needs since their hire date. Agency CNA D stated the nurse in charge provided the daily assignments and answered any questions. Agency CNA D stated they did not know where the policies and procedures regarding ADL care and dietary needs for residents were located. CNA D stated there was a checklist inside the resident's closet door that had a list of ADLs and diet textures for each resident. Agency CNA D stated lack of proper training regarding ADL care and dietary needs could cause further injuries or death. Interview on 11-6-2022 at 12:24 PM Agency CNA E stated the facility did not provide training regarding ADL care and diet textures. Agency CNA E stated a checklist for resident ADLs and dietary textures was located inside the resident closet doors. Agency CNA E stated they did not know the location of the facility policies regarding ADL care and dietary needs. Agency CNA E stated the nurse in charge gave assignments daily and if she had any questions, she would ask the charge nurse. Agency CNA E stated it is important to have training on ADLs and diet textures to help in preventing accidents and hazards. Interview on 11-6-2022 at 1:00 PM DON stated agency staff did not receive additional training regarding ADL care and dietary needs. DON stated if agency staff had questions, they were directed to a charge nurse for an answer. DON stated the agency orientation checklist was acceptable training and if staff needed assistance, they were able to ask the charge nurse. Interview on 11-6-2022 at 3:30 PM Administrator stated before agency staff were hired, they had to complete basic training that did not include ADL care and dietary needs, on their agency's website. Administrator stated the training included basic training of abuse /neglect, emergency evacuations, infection control, bill of rights, and change of conditions. Administrator stated the checklist provided by the facility was sufficient training for the agency and there was no additional training for agency staff regarding ADL care and resident dietary needs. Interview on 11-6-2022 at 3:40 PM DON stated there was no additional training for agency staff regarding ADL care and dietary needs, and the checklist for agency staff was sufficient training. Interview on 11-6-2022 at 5:30 PM Agency CNA F stated there was no facility-instructed training provided for agency workers regarding ADL care and dietary needs. Agency CNA F stated the agency workers were given their assignments by a nurse in charge and if the agency staff had any questions, they would ask him or the nurse in charge. Agency CNA F stated it was important to have training for the health and safety of residents. Interview on 11-6-2022 at 5:50 PM Agency CNA G stated that the agency staff did not get additional training. Agency CNA G stated they reported to the charge nurse for their assignments and would ask any questions they may have. Agency CNA G stated the orientation checklist was not an effective training tool for agency staff regarding ADL care and resident dietary needs. Agency CNA G stated the agency staff utilized the resident ADL closet door checklist posted in resident rooms. Agency CNA G stated without effective training regarding ADL care and dietary needs, residents could have injuries or die. Interview on 11-6-2022 at 6:00 PM RN A stated the agency orientation checklist was a guide but was not an effective training tool for resident ADL care and diet textures. RN A stated agency staff was not getting hands-on training regarding ADL care and diet textures when they start working at facility. RN A stated the facility policy was located online and agency staff was not aware of how to access it. RN A stated the agency staff were given their assignments by the nurse in charge and the nurse would give a rundown on what was needed regarding resident-specific needs. RN A stated the resident closet door ADL checklist provided resident-specific information. RN A stated she had concerns with the agency staff having proper training and the stated lack of training regarding ADL care and diet textures could lead to injuries or possible death. Review of the facility on-the-job training policy dated [DATE] revealed training will be conducted when necessary to assist employees in performing their assigned tasks. Review of the facility orientation policy (undated) revealed the orientation program for newly hired employees, transfers, volunteers, and travel staff stated that an orientation program shall be conducted for all newly hired employees, transfers from other departments, and volunteers. Review of the facility policy regarding on-the-job training dated [DATE] revealed that training will be conducted when necessary to assist employees in performing their assigned tasks. Parkview Nursing and Rehabilitation POR Letter of Abatement for Removal of Immediate Jeopardy [DATE] On [DATE] an abbreviated survey was initiated at Parkview Nursing and Rehab, 1501 S. Main, [NAME], TX 78644. On [DATE], a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. Impact Statement: All residents were identified on [DATE] to have the potential to be affected by this deficient practice. F726 - The facility failed to provide agency staff with the proper training to care for residents. Problem #1 The facility failed to follow the dietary needs of 1 of 4 residents reviewed for the puree diet. The facility failed to verify and follow the residents prescribed modified texture diet. Action Taken/Monitoring: DON/ Designee began in-service on [DATE] in regard to tray distribution and identification to the appropriate resident for all staff including agency prior to the start of their next shift. This has been completed for all current building staff as of [DATE], as well as ongoing for new staff including agency, by monitoring the staff roster in relation to the staff schedule. DON/Designee will ensure that all licensed nursing staff including agency staff have been in-serviced prior to the start of their next shift, by monitoring the staff roster in relation to the staff schedule, to verify that tray cards match the appropriate diet as ordered. This has been completed for all current staff including agency as of [DATE], and ongoing for new staff including agency. DON/Designee will ensure that all staff including agency are in-serviced, started on [DATE] and was completed by [DATE], by monitoring the staff roster in relation to the staff schedule. on where to find the appropriate diet for all residents prior to the start of their next shift. This can be found in each resident's room posted to the inside of their closet door to include photo identification, a binder with the appropriate resident diet is also located in the dining room for staff to access to ensure the appropriate diet is served. Administrator initiated training on tray distribution and identification [DATE] and will ensure that 100% of all staff including agency are in-serviced prior to the start of their next shift by monitoring the staff roster in relation to the staff schedule, to be ongoing with all new staff including agency regarding tray distribution and identification to the appropriate resident. This will be validated daily by monitoring for accuracy x7 days, weekly x3 weeks, then monthly x3 months. Administrator/Designee will ensure that the nursing staff is monitoring the accuracy of the trays to match the ordered diet per each resident by checking a minimum of 10 trays at meal service x7days, beginning [DATE], then weekly x3 weeks, then monthly x 3months. The Administrator/Designee will monitor the training of tray card and identification x7 days, beginning [DATE], then weekly x3 weeks, then monthly x3 months, or until all new staff including agency have been in-serviced. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #2 Interviews with agency staff revealed there is no additional training beyond the checklist provided. Action Taken/Monitoring: The Administrator/Designee will develop and implement an effective training program for all new staff including agency. This training program was developed and initiated beginning on [DATE]. This training has been completed for all agency staff as of [DATE] or the start of their next shift whichever occurs first, and ongoing for new staff including agency by monitoring the staff roster in relation to the staff schedule. This training will include general orientation of the facility to include when and how to report Abuse and Neglect, documentation guidelines include resident identifiers, physician orders including dietary orders, when to complete risk management in regard to incident and accident reports, and abridged policy and procedures for primary care of residents. DON, Nurse Management/ IDT will ensure by monitoring staff roster versus the staff schedule for any new oncoming Agency staff have completed Agency orientation prior to their shift until no more agency is being utilized in facility. The administrator will ensure, by monitoring staff roster versus the staff schedule, that all new staff including agency are trained prior to the start of their next shift, beginning on [DATE] by record review of agency training manual and signed affidavit of receiving a manual x7days, then weekly x3 weeks, then monthly x3 months, or substantial compliance is maintained. The administrator will monitor the training x7 days weekly beginning on [DATE], x3 weeks, then monthly x3 months, or until all new staff have been in-serviced, by record review of agency training manual and signed affidavit of receiving a manual The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #3 No known knowledge of facility policies or the location of policies onsite. Action Taken/Monitoring: Director of Nursing/Designee will in-service and educate all staff including agency staff on where to locate and review policy and procedures prior to the start of their next shift. Policies and Procedures are located at the nursing station as well as in Point Click Care: Home-View All Links-Eduro Central [resident electronic records system], all policies and procedures can be found here by the nursing staff. Education on where to find policies and procedures for staff began on [DATE] and was completed by [DATE] for all current staff including agency. Training will be ongoing for new staff, including agency, to the facility. Don/Designee will monitor all new staff including agency, who come to the facility to ensure their knowledge of the location of the policies and procedures, by record review of agency training manual and signed affidavit of receiving a manual. This will be monitored by Administrator/DON/Designee daily x7days, beginning on [DATE], then weekly x4 weeks, then monthly x3months. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Problem #4 Record review revealed no incident report had been documented on Resident #1 choking incident. Action Taken/Monitoring: DON/Designee will in-service all staff prior to the start of their next shift beginning on appropriate completion of incident reports with identified risk to resident beginning on [DATE], completed on [DATE] or prior to their next scheduled shift whichever occurs first. All current staff including agency will be in-serviced prior to the start of their next shift and will be on-going for new staff including agency. Administrator/DON/Designee will review the accident/incident reports starting on [DATE] and will be an ongoing process to ensure a thorough investigation is completed. Incident and accidents reports will be reviewed, and an investigation will be completed within 72 hours of the incident to include appropriate interventions. This will be reviewed daily during Risk Management Meeting, Monday-Friday. Administrator will ensure, through record review of agency training manual and signed affidavit of receiving a manual that 100% of staff including agency are in-serviced prior to the start of their next shift, beginning on [DATE] and completed for all current staff as of [DATE]. Training will be on-going for new staff, including agency, daily x7days, weekly x3 weeks, then monthly x3 months. Don/Designee will monitor all new staff, including agency, who come to the facility to ensure their knowledge of how and when to complete an incident report by validating the staff roster versus the staff schedule. This will be monitored by Administrator/DON/Designee daily x7days, weekly x3 weeks, then monthly x3months until substantial compliance is achieved beginning on [DATE]. The Administrator/Designee will report any identified concerns to the Quality Assurance Committee during an ADHOC QAPI meeting held on [DATE]. Involvement of Medical Director The Administrator notified the facility's Medical Directors, of the Immediate Jeopardy tag on [DATE]. The Administrator in collaboration with the Inter-disciplinary team and Medical Director will review and validate the policies and procedures including Accidents and Incidents: Investigations and Reporting; Tray Distribution and Identification; Resident Rights; Emergency Procedure - Choking; Change in a Residents Status or Condition; Activities of Daily Living; Assistance with Meals; and Abuse and Neglect are being followed, as well as meet federal, state, and local regulations, during an ADHOC QAPI meeting held on [DATE]. Involvement of QA On [DATE] an Ad Hoc QAPI meeting will be held with the Medical Director, Administrator, Director of Nursing, and Dietary Director to review and validate the plan of removal. Administrator and Inter-Disciplinary team reviewed policies including: Accidents and Incidents: Investigations and Reporting; Tray Distribution and Identification; Resident Rights; Emergency Procedure - Choking; Change in a Residents Status or Condition; Activities of Daily Living; Assistance with Meals; and Abuse and Neglect of the residents on [DATE], within the facility with appropriate corrections as indicated, and the policy and process to ensure practice is to act upon all allegations as if they are true and accurate until proven otherwise. Who is responsible for the implementation of the process? The Administrator will be responsible for implementation of ensuring the adequate process regarding meeting the nutritional needs of the residents within the facility. The new process/system was started on [DATE]. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on [DATE]. The Surveyor monitored the Plan of Removal on [DATE] as follows: Observations on [DATE] from 12:14 PM - 2:50 PM revealed staff verifying meal tickets to meal trays prior to providing meals to residents. Interview on [DATE] at 2:00 PM ADON stated she verified all residents' diets with ST and all orders/care plans were updated in PCC [ resident electronic records system]. ADON stated she would be getting with Dietary to ensure all diets matched the orders that afternoon. ADON stated RD was scheduled to review all orders the following day. ADON stated she was responsible for diets from the nursing standpoint, and she would continue to work with ST and dietary to ensure orders were updated as needed. ADON stated one person from Administration must be at every meal, checking meal trays, after the nurse verifies meals. Observations on [DATE] between 5:00 PM - 5:15 PM revealed residents to be seated in the dining area waiting for dinner service. Kitchen and nursing staff were observed verifying meals to tickets and placing trays in dining carts. ADON was observed verifying all meals in carts prior to being sent out to resident halls. Interview on [DATE] at 5:05 PM with Agency CNA I, stated she was provided training the previous day by DON regarding policies and procedures related to abuse, neglect, choking, and verification of resident diets and ADLs. Agency CNA I stated she would check the resident's ADL chart posted in residents' closets and ask the charge nurse questions if she was unsure of anything. Interview and observation on [DATE] beginning at 5:20 PM revealed Agency RN to be setting up trays for residents in a resident's room and verifying the meal ticket prior to providing meal trays to residents. Agency RN stated she was in-serviced the previous day by the DON about policies and procedures regarding diets, abuse, neglect, accidents, hazards, and where to find policies and procedures. Interview on [DATE] at 5:25 PM Facility CNA G stated she received recent training from DON about abuse and neglect, policies and procedures related to ADLs, verifying meals, and choking incidents/ accidents. Observations on [DATE] at 5:30 PM revealed three signs posted in the dining room regarding choking, signs of, and procedures for choking. Staff was observed in hallways verifying meals as they pulled trays from meal carts and then brought them into resident rooms. Interview on [DATE] at 5:33 PM DON stated his expectations for verification of meals and procedures and provided an overview of topics covered during recent in-services provided to the staff since IJ was called. DON stated all staff are required to participate in an in-service prior to starting their shift. Review of the following in-services and assignment sheet dated [DATE] revealed all staff working the current shift and previous shift signed and dated in-services. The following in-services were reviewed: Abuse and Neglect dated [DATE] and [DATE], Resident Rights dated [DATE] and [DATE], Tray Distribution and Identification dated [DATE] and [DATE], Emergency Procedure (Choking) dated [DATE] and [DATE], Assistance and Meals dated [DATE] and [DATE], Activities of Daily Living dated [DATE] and [DATE]. Agency Orientation Binder undated was reviewed and it was revealed to include the agency facility orientation checklist and the following facility policies: Tray Identification revised 2007, Abuse/Neglect updated 2021, Emergency Choking 2018, Assistance with Meals revised 2017, and CPR revised 04/21. Orientation checklists were noted to be signed and dated by agency staff. Observations on [DATE] at 6:05 PM revealed DON, CNA I and Facility LVN A assisting residents in the dining room with pureed meals. Interview on [DATE] at 6:06 PM Facility LVN A stated it was her first day and was educated on the facility system, charting, how to find orders, and diets and was recently in-serviced by DON on the importance of and how to check meal tickets. Facility LVN A stated she was still getting the hang of things but felt the training was adequate at this point and felt comfortable seeking help, finding policies and procedures, and asking for more education regarding diet textures as needed. Interview on [DATE] at 6:13 PM Agency CMA stated she was recently in-serviced from DON on how to find resident information, how to check ADL information and diet texture posted in resident closets, policies, and choking signs and procedures. Interview and observation on [DATE] beginning at 6:15 PM revealed DON was providing training to Agency LVN C and using Agency Orientation Binder. Agency LVN C stated it was his first day working with the facility and so far, he felt the orientation being provided was easy to understand and understood how to check and verify ADLs and resident diet texture. Administrator, DON, and Corporate Nurse were informed on [DATE] at 6:45 PM that the IJ was removed; however, the facility remained out of compliance at the severity level of actual harm and scope of pattern due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal.