**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that:The facility failed to ensure Resident #1, who ambulated with the help of a walker, received adequate supervision to prevent him from exiting the facility with a busy highway at the front, undetected on 06/09/25. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/09/25 and ended on 06/11/25. The facility corrected the non-compliance before the investigation began on 06/25/25. This failure could place the residents with exit seeking behaviors at risk for injury or death.The findings included:Record review of Resident #1's face sheet dated 06/25/25 reflected a [AGE] year-old male admitted to the facility on [DATE] . His diagnoses included heart failure, lack of coordination, unsteadiness on feet, hypertension, muscle wasting and atrophy, difficulty in walking, pain, incontinence, and dementia. Record review of Resident #1's initial MDS assessment dated [DATE] reflected a BIMS score of 09, indicating Resident #1's cognition was moderately impaired. The MDS stated he had no indication of psychosis or behavioral issues. Record review of Resident #1's care plan dated 04/29/25 reflected Resident #1 had elopement risk and a history of attempts to leave the facility unattended with poor safety awareness. The relevant intervention was, place him in a secured unit for personal safety. Other interventions were, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books or any other activities that resident prefers. On 6/9/25 an additional intervention of notifying the ADM/DON if resident was out of cigarettes, was added as Resident #1 appeared stressful when he did not have cigarettes. Record review of Resident #1's elopement evaluation dated 06/09/25 reflected Resident #1 had a score of 6 out of 7 indicating he was at high risk for elopement. The initial elopement assessment conducted by DON on 04/29/25 next day after his admission indicated Resident #1 was at high risk of elopement with history of attempts when he was at the previous facility. Record review of a FRI dated 06/10/25 reflected, on 06/09/25 at about 7:41am the facility first learned about the elopement of Resident #1. On 06/09/25 CNA A noted resident in his bedroom asleep at about 5:45 am. CNA B went to check on him at about 7:00am to help him prepare for breakfast and at that time it was realized that he was not in his room. The facility building and grounds were searched for locating him. By 7:41am it was confirmed that resident was not in the premises of the facility. It was believed Resident #1 escaped through a window, as during the search the staff noticed a broken window in the dining area of the memory care unit with the screen pushed out. The resident was located approximately a mile away from the facility and staff brought him back to the facility. During an interview on 06/27/25 at 4:10pm CNA A stated on 06/09/25 she arrived at the facility at about 5:29am as usual for her shift. CNA A stated she had seen Resident #1 in his room at about 5:45 am sound asleep. She said at about 7:00 am another staff member who went into Resident #1's room stated he was not in his room. CNA A stated she began to look in the dining area and noticed Resident #1's walker by the back table and the window was broken with its screen off. She said an immediate search was initiated and resident was not found on the premises. The DON and AD began to search outside the memory care unit and outside of the facility building. She stated she was told later Resident #1 was located by the park about a mile away from the facility and staff brought him back to the facility. CNA A stated she received an in service on elopement on 06/09/25 and elopement drill and Inservice on the missing person policy and procedure on 06/10/25. During a phone interview on 06/25/25 at 4:20pm CNA B stated on 06/09/25 she was working on the 6:00pm to 6:00am shift. She said when Resident #1 went missing in the morning she searched for him in the bathroom, resting areas and out in the courtyard of the memory care unit. CNA B stated generally Resident #1 was quiet and calm however there were moments he would be aggravated. CNA B stated while Resident #1 was on constant observation by a staff , he made another attempt to break the window in the next day after the incident of elopement occurred. She stated later he was relaxed and appeared settled down without any further attempts. CNA B stated she received an in service on elopement on 06/09/25 and elopement drill and Inservice on the missing person policy and procedure on 06/10/25. During a phone interview on 06/25/25 at 4:45pm CNA C stated she worked at the facility's memory care unit in the 6:00pm to 6:00am shift. She stated she knew Resident #1 was at high risk of elopement however never made any attempt since his admission until 06/09/25. She stated she did not know the triggering factor for his elopement. CNA C stated when she came to know Resident #1 was missing, she let the nurse in charge and others know about it and started searching everywhere. CNA C stated she received an in service on elopement on 06/09/25 and elopement drill and Inservice on the missing person policy and procedure on 06/10/25. During an interview on 06/25/25 at 11:30am the AD stated she came into the facility on [DATE] as usual at about 5:30 am to work. She said at about 7:30am the staff let her know that Resident #1 was missing from memory care. She stated she with the help of the floor plan of the facility and checked everywhere inside the facility. The AD stated when she could not find Resident #1 on the facility premises, she took her car and drove through the highway for about two miles looking for him. The AD said when she returned after 30 minutes unsuccessfully, there was police at the facility for searching Resident #1. The AD stated she received an in service on elopement on 06/10/25. During an interview on 06/25/25 at 10:55am the MM stated on 06/09/25 he was asked to change the broken window glass of one of the windows in the memory care dining hall. He stated he replaced it on 06/09/25 with flex glass that was not easily breakable. The MM stated he changed the code for both the exit doors of the memory care unit as well to make sure residents would not wander out of the memory care area unnoticed. During an interview on 06/25/25 at 10:45am CNA D stated she worked at the facility for 6 years and now she works in the memory care unit in the day shift . She stated she was not working on 06/09/25 at the facility when the incident occurred. CNA D stated Resident #1 was okay at the facility after the incident and was not exhibiting any exit seeking. She stated she had attended an Inservice on elopement after the incident, when she came to work. She stated she learned in the in service how to detect the early warning signs of elopement and how to conduct a search and report the incident to nurse in charge and the staff on duty . During an interview on 06/25/25 at 2:10pm CNA E stated he started working at the facility two weeks ago after the incident of Resident #1's elopement occurred. He stated Resident #1 was very quiet normally without any exit seeking behaviors. CNA E stated Resident #1 was a smoker who utilized all the smoking breaks . CNA E stated he had worked closer with Resident #1 as he was assigned 1:1 observation on Resident #1 most of the time to ensure that Resident #1 would not elope. He stated he received an in service on elopement on 06/25/25 in the morning. During an observation and interview on 06/25/25 at 4:45 pm Resident#1 was in the dining hall in the memory care unit. He was sitting at a table quietly and working on a puzzle. He stated he was okay at the facility though 'not over excited'. He said the current facility was better than any other facilities in the area, thus he was not unhappy. When the investigator asked about, how he had managed to escape on 06/09/25, he laughed and stated it was a top secret and could not be disclosed as he might use the same trick again. He said he loosened a pair of screws that held down the window glass and then lifted it easily and escaped through it to the back yard. When asked why he did break the window glass he stated it was easily breakable with a push however did not go through the hole created by it. He stated once he was out in the backyard, he jumped the fence without getting hurt, as there was a way to do it safely. He stated he used a walker while at the facility however 'managed' to walk in the street without it. When asked why he wanted to get out, he stated he was bored at the facility and wanted to go out to socialize with others in the community. He stated if you were out in the public, it would be easy to get cigarettes from members in the community, when you ran out of stock. Resident #1 stated he had no issue with cigarette stock and smokes every day. During an interview on 06/25/25 at 10:45am the DON stated the staff came to know Resident #1 was missing, at about 7:00am . He stated everyone was looking for him everywhere and meanwhile the staff called 911 for police help. He stated staff found Resident #1 about a mile away after about 2 hours. He added, considering Resident #1's condition he was not able to walk that far, and he was made to believe that he might have asked for a lift to a passenger for transportation. The DON stated the moment Resident #1 arrived back at the facility he did a head-to-toe assessment. The DON stated resident had no injuries, deformities, or any pain at that time or afterwards. He said Resident #1 was presented as calm and humorous after his return to the facility. The DON stated as per records Resident #1 made elopement attempts in the past while he was in another facility. He said Resident #1 had long history with TDC and this had taken into consideration while making decisions. He added Resident #1 was placed in the memory care unit as he was at high risk for elopement when he was initially admitted to the facility. The DON said Resident #1 was on 1:1 after the elopement on 06/09/25 and off from it only on 06/24/25 when the MDT team determined that he was safe. The DON stated Resident #1 might have eloped through one of the windows in the dining room in memory care as staff observed it was broken. He said, staff observed a chair in the backyard towards the fence and it was believed Resident #1 might have used the chair to climb up the fence. The DON stated the triggering factor for his elopement was not clear however it was observed that Resident #1 got stressed when his stock of cigarettes got depleted. The DON said recently he ran out of cigarettes due to issues with money from social security. He said the ADM decided to buy cigarettes for him out of pocket until he received money from social security, to keep Resident #1 free from the thoughts of elopement. DON stated he conducted an audit on all residents at the facility to make sure that an elopement risk assessment was conducted on all residents. During an interview on 06/25/25 at 1:35pm the ADM stated the resident was last seen at the memory care unit at 5:45am and the facility came to know about his elopement at about 7:00am. She said the police were informed to get help in the searching process and eventually staff located Resident #1 by a park about one mile away from the facility. The ADM stated Resident #1 said he was walking from the park to the store to cash in a lottery ticket. She stated Resident #1 was particular about having cigarettes consistently and due to some delayed social security payments, he ran out of cigarettes at the time of elopement . She said most likely this triggered him to get out of the facility to procure cigarettes by some other means. The ADM stated it was believed he might have escaped through a window by breaking the glass, stepped out and then by using an unsecured chair in the backyard jumped out of the fence. She stated immediately after Resident #1's return an assessment had been completed to make sure he was unhurt and safe. The ADM stated Resident #1 was under 1:1 observation until 06/17/25, he was referred to psychiatric service and a psych evaluation was completed. A QAPI meeting was conducted, and it was decided to help Resident #1 financially if he ran out of money to ensure an uninterrupted supply of cigarettes. She stated currently the chairs in the backyard were fastened with chains and soon will be anchored to the ground permanently with concrete. The ADM stated she was planning to change the glass panels of all the windows in memory care with non-shatter window glass for further protection from elopement by residents in the future and started collecting quotes for the work from contractors. During an observation on 06/25/25 at 11:30am of the window in memory care revealed that broken glass was replaced. An observation on 06/25/25 at 5:05pm of the backyard revealed the facility was enclosed by a fence. There were two gates on the fence that were locked with padlock. There were two chairs on the patio that were fastened with chains to the wall and not removable. Record review on 06/25/25 of the 1:1 observation check sheet revealed Resident #1 was on 1:1 on arrival back to the facility on [DATE] until 06/24/25. Record review of the Inservice revealed all the staff who worked in the memory care unit were in serviced on Elopement- How to avoid an elopement , What to do during an elopement Record review of the facility's policy Wandering and Elopement revised in 03/2019 reflected: Policy Statement The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation:1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.2. If an employee observes a resident leaving the premises, he/she should:a. attempt to prevent the resident from leaving in a courteous manner;b. get help from other staff members in the immediate vicinity, if necessary; andc. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.3. If a resident is missing, initiate the elopement/missing resident emergency procedure: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; andc. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.).4. 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; andf. document relevant information in the resident's medical record. Record review and verification on 06/25/25 of the corrective action implemented by the facility beginning on 06/09/2025 reflected: 1. An elopement risk reevaluation was completed on Resident #1 after the incident on 06/09/25 . Record review of Resident #1's Elopement Evaluation dated 06/09/25 reflected Resident #1 was at high risk for elopement. 2. Resident was on 1:1 until 06/17/25 in the memory care unit. Record review of the One to one Monitoring form revealed resident was on 1:1 began at 9:00am on 06/09/25 and discontinued on 06/17/25 by the MD. 3. A Psychiatric evaluation was completed.Record review of the psychiatric periodic evaluation dated 06/18/25 reflected a psychiatric evaluation conducted with Resident was referred to provider by DON for psychiatric evaluation and elopement as the chief complaint. 4. A QAPI meeting to discuss the elopement incident .Record review of QAPI Action Plan dated 06/09/25 revealed an Ad. Hoc QAPI meeting conducted on 06/09/25 with MD attended remotely. 5. The facility made arrangements to ensure Resident #1's stock of cigarettes would be replenished before finished. Record review of the care plan dated 06/09/25 revealed this arrangement was incorporated in the care plan. 6. The chairs in the backyard were secured permanently .An observation on 06/25/25 at 5:00pm revealed the two chairs outside at the smoking area were secured to the wall with chains and was not removable. 7. The codes to doors on the secured unit were changed by the maintenance person to ensure residents would not walk out by using the code.Observation and interview on 06/25/25 at 10:10am revealed MM changing the code. The MM stated he changed it every week to make sure no residents in memory care had access to it. 8. An elopement Inservice with all the staff on the memory care unit was completed on 06/10/25. Record review of the in-service record revealed on 06/09/25 and 06/10/25 an (on going) in service conducted on elopement -How to avoid an elopement what to do during an elopement with 71 staff members participated. 9. The Care plan of Resident #1 was updated on 06/09/25. Record review of careplan revealed the careplan updated on 06/09/25 with added intervention for elopement. 10. Auditing of all the residents' record was completed by 06/14/25 to ensure elopement risk assessment conducted on all residents. Record review on 06/25/25 in E H R of 17 sample residents revealed their elopement evaluations were updated/completed. 11. The MDT determined to review the situation weekly in QOC and Monthly in QAPI for compliance. During an interview on 06/25/25 at 4:15pm the ADM stated the situation was reviewed in the last two weekly QOC meetings and the QAPI is due next month. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/25/25 and ended on 06/25/25. The facility corrected the non-compliance before the investigation began on 06/25/25. The Past Non-Compliance form was sent to the Administrator on 06/25/25 at 5:30pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #1) reviewed for dietary services. The facility failed to follow Resident #1's altered diet when CS A gave Resident #1 a peanut butter sandwich on 08/15/2024. Resident #1 expired on 08/15/2024. An Immediate Jeopardy (IJ) situation was identified on 08/28/2024. While the IJ was removed on 08/29/2024, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving their proper diet to meet their individual needs, that can cause serious injury, hospitalization, or death. Findings Include: Record review of Resident #1's face sheet, dated 08/28/2024, reflected a [AGE] year-old-male, with a current admit date of 09/19/2014, a latest return admit date of 09/24/2021, and a discharge date of 08/15/2024. Resident #1's status was expired. Resident #1's had diagnoses which included lack of coordination, rheumatoid arthritis (autoimmune disorder that primarily affects joints), muscle wasting, paranoid schizophrenia (delusions of paranoia), dysphagia-oropharyngeal phase (swallowing disorder-disruption or delay in swallowing), cognitive communication deficit (challenges is communication that have underlying cause in cognitive deficit), unspecified dementia (syndrome associated with many neurodegenerative diseases, decline in cognition that affects the ability to perform everyday activities), and anxiety (panic disorder or phobias). Record review of Resident #1's Annual MDS (Minimum Data Set), dated 06/06/2024, reflected a BIMS summary score of 03, indicated a severely impaired cognitive skills for daily decision-making. Resident #1's speech clarity was a 1, which indicated unclear speech-slurred or mumbled words, and ability to understand others was a 2, which indicated sometimes understood-responded adequately to simple, direct communication only. Resident #1's was on a mechanically altered diet. Section GG-Functional Abilities and Goals reflected a score of 03 for Eating, which indicated Partial/Moderate assistance. Section I-Active Diagnoses reflected a code of 7, which indicated Other Neurological Conditions. Section K-Swallowing/Nutritional Status, K0520 reflected Mechanically altered diet-require change in texture of food or liquids, e.g., pureed food, thickened liquids. Record review of Resident #1's, undated, orders reflected an order description, mech (Mechanical) soft/thin liquids-fortified foods with meals, scoop/divided plate, foam cover for built up utensils all meals, and with special instructions, large portions at mealtime, no bread i.e. (that is) cakes, pancakes, sandwiches, rolls, biscuits, close supervision, with a start date: 04/29/2024 and an end date: Open Ended, DC 08/15/2024 reason is discharged . Record review of Resident #1's, undated, care plan, reflected: Problem start date 06/30/2022, category is ADLs Functional Status/Rehabilitation Potential, Resident (Resident #1) is slightly limited in ability to eat and drink AEB self-feeding (self-feeding), required setup/cues at times, goal is Resident (Resident #1) will eat 75-100% of meals and maintain hydration independently /with supervision/help, with an approach: - monitor and record intake of food/fluids and provide setup/supervision assistance during eating and drinking, disciplines responsible activities, CNA, Nursing. Problem, start date 04/01/2022, category is Nutritional Status, Potential for weight loss R/T : dysphasia (swallowing disorder) goal is nutritional status will be maintained AEB (As Evidenced By) no weight loss within 3 lbs of current weight over next 90 days, with an approach: - Serve diet per order, disciplines responsible Nursing Problem, start date 05/20/2021, category is Nutritional Status, high risk of aspiration (when something you swallow enters your airway or lungs), nutritional impairment and complications due to dysphasia (swallowing disorder), goal is (Resident #1) will remain free of aspiration, significant weight loss, s/sx, injury or complications related to dysphagia, with approaches: - Assess/record report to MD prn s/sx of aspiration or complications: choking/strangling on liquids, coughing during or after meals, respiratory difficulty or distress, fever, tachypnea (rapid shallow breathing), wheezes/crackles in lung field, and watery eyes, disciplines responsible Nursing. - Ensure resident is eating slowly and notify nurse ASAP if choking. Maintain upright position for 1 hour after eating, when possible, to reduce aspiration risk, disciplines responsible activities, CMA, CNA, dietary, Nursing. - Ensure that snacks and beverages offered at activities comply with diet and fluid consistency restrictions, disciplines responsible activities, CMA, CNA, dietary, Nursing. - serve diet as ordered, disciplines responsible activities, CMA, CNA, dietary, Nursing. Problem, start date 04/27/2024, category is Nutritional status, Resident (Resident #1) requires a mechanically altered diet, goal is Resident (Resident #1) will maintain current body weight of Blank pounds, with approaches: - Encourage oral intake of foods and fluids, disciplines responsible Nursing. - Monitor need to advance diet consistency, disciplines responsible Nursing. Record review of Resident #1's, undated, Meal Ticket reflected Diet: Regular, Texture: mechanical soft, Other: large portions with meals, no bread cakes rolls biscuits, close supervision, Adap Equip Deep Divided Plate; Built up Spoon; Liq Consist thin. Record review of Resident #1's progress note, created and signed by LVN A, dated and timed 08/15/2024 at 08:38 PM, reflected. at approximately 6:20 PM called to secure unit per CNA About resident possibly choking this nurse immediate to dining room and noted resident on floor laying supine (on back) lips blue no respirations or pulse noted sternum rub performed resident gasped another nurse started the Heimlich some spit up food came from residents (Resident #1) mouth did gasp a few more breaths mouth swipe done and nothing noted still without pulse or respirations 911 was called at beginning of finding resident and in facility resident asystole (heart's electrical system fail causing heart to stop pumping, otherwise known as flat-line or flat-lining) noted on monitor RN DON pronounced at 1847 [06:47 p.m.] Family notified and thankful and stated Funeral Home is where he [Resident #1] is going called Cremation Provider due to they own postmortem care was provided and body released at 2015 [08:15 p.m.]. Interview on 08/28/2024 at 11:38 a.m., the ADON stated she worked on 08/15/2024 and was scheduled to be off at 06:00 p.m., although she had to stay because a nurse was coming in late. The ADON was in the middle of giving a report, then she overheard LVN A initially asking to prepare for a crash cart, the ADON obtained the crash cart, went to the locked unit, and observed it was Resident #1. The ADON stated Resident #1 was a DNR, the crash cart not used. The ADON recalled observed LVN A performed a sternal rub (method used when testing an unconscious person's responsiveness). The ADON stated she performed the Heimlich Maneuver as a precaution, due to possible choking. The ADON stated during the Heimlich maneuver (used to treat choking by foreign objects) she could not confirm if food was dislodged as she was behind Resident #1. The ADON stated during the commotion, staff was instructed to call EMS. The ADON stated she could not confirm the exact diet of Resident #1 during interview, but she was aware it was altered. The ADON stated when EMS arrived, they pronounced Resident #1 expired, and recalled there were no concerns brought to her attention by EMS. Interview on 08/28/2024 at 11:59 p.m., CS A stated she worked the night shift from 06:00 a.m. to 06:00 p.m., CS A stated she worked on 08/15/2024 and worked in the unit where Resident #1 resided. CS A stated Resident #1 was in distress, and went to get a nurse, CS A could not recall the nurse she got. CS A arrived back to the unit, and LVN A was present, CS A was instructed to call EMS and did. CS A stated during the commotion other staff arrived, unable to recall other staff, she attempted to assure other residents were watched during the incident. The CS A stated prior to the incident, during that time it was snack time for residents, I gave a snack to Resident #1, I [CS A] gave him a sandwich that day [08/15/2024], it was a peanut butter sandwich, Resident #1 liked his sandwiches. CS A knew Resident #1's dietary orders CS A stated, At the time, I didn't know what kind of diet he is on, I do now, I think it was soft or something, I [CS A] worked here for two plus years, most of the time that's what we fed Resident #1, I am part of the evening crew, I don't get in on the meals. CS A stated, yes I think its dangerous for anyone if they don't get the proper diet order. When asked where she obtained the sandwich and the details of when, CS A stated, sandwiches are pre-made by dietary staff, sandwiches are kept at front nurses' station [outside of the unit], they are together on a tray, and we take them to the residents when they want a snack. Interview on 08/28/2024 at 12:19 p.m., the DM stated meal tickets were important for staff to follow. The DM stated for mechanical soft diets, food was placed in a food processor and pulsed to have a chopped and soft texture. The DM stated Resident #1 had a mechanical soft diet, with no breads at all. The DM stated therapy recommended this diet because Resident #1 could not swallow properly, and he could choke. The DM stated at night the facility prepared snacks that included sandwiches, pudding for altered diets, and sometimes fruits. The DM stated Resident #1 should have gotten pudding for his snacks, and it would be dangerous for Resident #1 to eat bread. The DM stated breakfast, lunch, and dinner had meal tickets on food trays that were reviewed before passing it out to residents. The DM stated staff were knowledgeable because they were trained on dietary orders. Interview on 08/28/2024 at 12:31 p.m., the SLP stated she was also the Director of Rehabilitation, the SLP stated Resident #1 was on and off for rehabilitation services because he had difficulty self-feeding, toileting, sitting in an up-right position during meals times, his posture was poor, and he would hunch over. The SLP stated we would have therapy for Resident #1 with goals to correct his posture and sit up-right during meals, Resident #1 needed one on one interaction and constant redirection, he was very much non-compliant and ignored his therapy, but we kept trying to help him. The SLP stated Resident #1's cognition was poor. The SLP stated Resident #1's diet order was a mechanical soft diet with close supervision, with no breads or cakes. The SLP stated if Resident #1 had any bread, it was a dense material. The SLP described Resident #1 during therapy sessions, Resident #1 would tend to overstuff his mouth and continue to eat large portions and Resident #1 could not swallow the portions, she noticed Resident #1 would store the food on his inside cheek, and stated to staff he had swallowed the food, although when the SLP would check his mouth the SLP would see the food inside his mouth, inside his cheeks. The SLP added the training consisted of having Resident #1 learn how to eat smaller portions and learn how to swallow those portions, as the staff were hoping he could return to a full diet. The SLP stated his course was up and down, Resident #1 would have some advancements in therapy then he would decline from them. The SLP stated Resident #1 was not supposed to have dense, dry food, like cornbread. The SLP stated she communicated the needs for residents by communication forms, which informed the dietician, dietary aides, nursing, and she educated staff from different shifts. The SLP stated Resident #1's order was placed to reduce the risk of choking, if Resident #1 was left unsupervised and because his large intakes he had a high risk of choking on a peanut butter sandwich. Interview on 08/28/2024 at 01:31 p.m., the DON stated she worked on 08/15/2024 during the day, although she came back as she was informed Resident #1 expired. The DON stated she was informed Resident #1 was reading his bible in the dining area in the locked unit as this was his routine, and nurses were informed of Resident #1's condition and responded. The DON stated Resident #1 was on a mechanical soft diet. The DON stated the process of informing staff of diet orders was that nurses received a communication on orders, nurses would communicate with the CNAs, the orders were placed in EHR, it would transfer to the POC system, and CNAs could access care plans and orders in the tablets available. The DON stated the POC tablet in the locked unit was not working now, and in the process of getting that corrected. The DON stated she had not personally seen Resident #1 eat sandwiches, staff were educated, and all meals served during breakfast, lunch and dinner had meal tickets that were reviewed by nursing before trays were distributed. The DON stated she would agree Resident #1 would need a pudding or shake as a snack, not a peanut butter sandwich. The DON stated for the night shift, snacks were delivered by dietary staff to the front nurses' station (outside of the locked unit), staff would then be able to pick snacks on resident's needs. The DON's expectation was Resident #1 should have received a snack that met his orders, like a shake or pudding, and close supervision with meals would be always within eyesight. Interview on 08/28/2024 at 02:38 p.m., LVN A stated she worked the 06:00 p.m. to 06:00 a.m. shift, and further stated she worked the locked unit on 08/15/2024 and entered the building at approximately 06:00 p.m. LVN A recalled that evening on 08/15/2024, and stated at the start of her shift she received reports and reviewed them, a minute later CS A informed her Resident #1 did not look good and was possibly choking, he was on the floor blue and was observed with no respirations. LVN A performed a sternum rub, the crash cart was brought by the ADON but was not used as Resident #1 was a DNR. LVN A stated the ADON performed the Heimlich maneuver and a little spit came out. LVN A stated she performed a swipe method to Resident #1's mouth and noticed no food or and dislodged food. LVN A stated she did not believe there was any food in the premises, dinner was usually served at 05:00 p.m., and the dining area in the locked unit had already been cleaned, LVN A stated there were no signs of wrappers, sandwich wrappers, or indications of snacks. LVN A stated when she entered the building, snacks were not served yet, she did not see any at the front nurses' station, and snacks were passed around 08:00 p.m. When asked about the progress note she created and signed, LVN A stated, I did document what I saw, but I did not see actual food, I should have been more descriptive like writing the items I saw as particles or maybe I should have described it as green small pieces, in all happened so quickly. Interview on 08/28/2024 at 04:39 p.m., the ADM stated she was called that evening on 08/15/2024 and was informed Resident #1 expired due to a heart attack, and EMS stated on the report Resident #1 asystole (heart's electrical system fail causing heart to stop pumping, otherwise known as flat-line or flat-lining). The ADM stated she called the local EMS and asked for a report and was informed by local EMS since Resident #1 was not transferred to a hospital or another provider, there was no report. The ADM stated that residents, which included Resident #1, had dinner around 5 p.m. and snacks typically come out at 7 p.m. The ADM stated, when I called CS A to ask if she gave [Resident #1] a sandwich that night, [CS A] said no he [Resident #1] didn't get a sandwich, then she [CS A] later said yes I did give him [Resident #1] a sandwich, then later changed her [CS A] answer to no I didn't give him [Resident #1] a sandwich. On 08/28/2024 at 04:56 p.m., attempt made to contact the local EMS, no findings at this time as local EMS had not made any return calls. Interview on 08/29/2024 at 05:46 p.m., the RD stated there was a nutritional assessment completed around 04/2024, with orders in detail, and further stated, [Resident #1] has no bread, although I do not know if his orders were updated because I know that this particular resident (Resident #1) was not eating and all he wanted was a peanut butter and jelly sandwich, this is okay just as long as there is a one to one person sitting with him (Resident #1) while he eats, although that was just a conversation, to my understanding the last RD that is familiar with him (Resident #1) is on leave, from what I understand SLP allowed him to have sandwiches but with one on one supervision with small bites. The RD stated, if he (Resident #1) is on a mechanical soft diet there would more than likely be a choking. Record review of the facility's Food and Nutrition Services Policy, revised October 2017, reflected a Policy statement that Each resident is provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preference of each resident. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appear palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. This was determined to be an Immediate Jeopardy (IJ) on 08/28/2024 at 05:09 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 08/28/2024 at 6:26 p.m. The following Plan of Removal submitted by the facility was accepted on 08/29/2024 at 4:09 p.m.: Plan of Removal Immediate Jeopardy On 08/28/2024, an abbreviated survey was initiated the Facility. On 08/28/2024, at 6:30 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to provide Food prepared in a form designed to meet individual needs for Resident #1, who was provided a peanut butter and jelly sandwich and choked/passed away. ACTIONS Start Date: 8/28/2024. Completion Date: 8/28/2024 Responsible: Administrator/Director of Nursing Action: On 8/28/24, the regional nurse consultant, regional reimbursement consultant, the director of nursing, and the MDS audited all Matrix EHR orders to validate that they matched the RD Dining Meal ticket system and that they were on the Resident Profile so that the CNAs and other facility workers can identify the diet that the resident is on and any precautions that are in place. Any concerns or discrepancies were corrected immediately upon discovery. Snacks ordered for weight loss interventions were audited and all were correct. The director of nursing/designee in-serviced facility staff on where to find the diet information for a resident. Facility staff will receive the information before starting their next assigned shift. Agency staff will receive the information before starting their assigned shift. The CNA who fed the resident bread was individually re-educated by the administrator and the director of nursing on 8/28/24 regarding following the resident diet and where to find diet information. Start Date: 8/28/24 Completion Date: 8/29/24 Responsible: Administrator/Director of Nursing Action: On 8/28/24, the regional nurse consultant in-serviced the administrator and the director of nursing on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. New admission orders will be reviewed the next morning in the Interdisciplinary Team Meeting (IDT) and corrections made when needed. The RD Dining Meal Ticket system will also be checked at that time to validate that everything matches. The MDS will then develop a care plan for any dietary needs identified by day fourteen (14) or sooner, per the regulation. The RD recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting. Speech therapy recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders will be entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting. Start Date: 8/28/24 Completion Date: 8/28/24 Responsible: Administrator Action: An Ad Hoc QAPI meeting was held with the facility medical director to discuss the deficiency and actions put in place by the facility. The administrator will monitor the new orders for diets from the RD or the Speech Therapist, weekly for one (1) month and randomly thereafter by reviewing the facility activity report, actual food on meal trays, and documenting findings on a log created by the facility. Any concerns or trends will be brought to the monthly QAPI meeting for tracking and trending and new IDT recommendations. Monitoring of the POR included the following: Observation on 08/29/2024 from 03:22 p.m. to 05:19 p.m. revealed staff received in-service training from regional staff, ADM, DON, on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. Interview on 08/29/2024 at 03:31 p.m., the ADM stated she was in-serviced on 08/28/2024, last night, by the Regional Nurse Consultant on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the resident profile, also including topics of facility activity report review, new admission orders reviewed every morning to assure diet was completed and entered in EHR, the MDS coordinator would create dietary care plans or before day 14, the RD recommendations would be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders, new orders and concerns would be review in the weekly quality care meeting by the DON, and the new processed would be reviewed in the monthly QAPI meetings for three months. The ADM stated staff were in-serviced on topics of where to find the diet information, and CS A was individually re-educated and the DON on 8/28/24 regarding following the resident diet and where to find diet information. Interview on 08/29/2024 at 03:39 p.m., the DON stated the Regional Nurse Consultant in-serviced her the evening of 08/28/2024 on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. The DON stated all staff were in-serviced on topics of where to find the diet information, and CS A was individually re-educated by her and the ADM last night (08/28/2024) on topics of following the resident diet and where to find diet information in the POC tablets. The DON stated other topics the regional consultant trained her on was the facility activity report review, new admission orders reviewed every morning to assure diet was completed and entered in the EHR, the MDS coordinator would create dietary care plans or before day 14, the RD recommendations would be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders, new orders and concerns would be reviewed in the weekly quality care meeting by the DON, and the new process would be reviewed in the monthly QAPI meetings for three months. Observation and interview on 08/29/2024 at 04:49 p.m., RN A stated she was also the MDS Coordinator and works the day shift, RN A stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. RN A stated she will create dietary care plans or before day 14. Observation of RN A revealed the use of the POC tablet to obtain information on resident diet orders, also including care plans and orders. Observation and interview on 08/29/2024 at 04:53 p.m., the ADON stated in-service training on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. ADON stated all staff were in-serviced on topics of where to find the diet information, and CS A was individually re-educated by the DON and the ADM on (08/28/2024) on topics of following the resident diet and where to find diet information in the POC tablets. Observation of ADON revealed the use of POC tablet to obtain information on resident diet orders, also including care plans and orders. The ADON stated new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. The ADON stated QAPI was conducted on the evening of 08/28/2024 to discuss the IJ and plan of removal. Interview on 08/29/2024 at 05:01 p.m., LVN B stated she works the day shift. LVN B stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. LVN B further stated CNAs were instructed to come to nursing if they had questions on dietary orders or any orders. Observation on 08/29/2024 at 05:09 p.m., revealed dinner service, trays had meal tickets, nursing reviewed meal tickets before distribution, and staff reviewed meal tickets before serving meals to residents. Interview on 08/29/2024 at 05:11 p.m., CNA A stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. CNA A stated staff were further trained and instructed to monitor snacks they gave to all residents to assure the proper diet order. CNA A stated and explained the process to confirm orders and care plans, ADL needs with the use of POC tablet. Observation and Interview on 08/29/2024 at 05:21 p.m., CMA A stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. CMA A stated staff must always confirm all orders which included dietary orders. CMA A stated she had access to POC on her medication cart as she used this for her duties in medication administration. Observation of CMA A revealed the use of POC to obtain information on resident diet orders, also including care plans and orders. Observation on 08/29/2024 at 05:26 p.m., revealed dinner service in the locked unit, trays had meal tickets, nursing reviewed meal tickets before distribution, and staff reviewed meal tickets before serving meals to residents. Phone interview on 08/29/2024 at 05:40 p.m., CS A stated in-service training on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. CS A stated she was re-trained on the use the facility's POC tablet, accessing diet orders, reviewing residents' profile for diet order and other orders. CS A stated, I took the in-service last night (08/28/2024) before I started, if I have any concerns, I am going to check with the nurse to confirm orders, and that I want to avoid and prevent any choking or risks of resident eating fast because that is serious. CS A stated, I have been schooled on the tablet and I am aware of the risks, I come in at the tail end of the shift after everything is said and done, and we want to make sure residents get snacks and I know the risk of giving something they aren't supposed to eat, a resident can choke and that is a very serious matter. Phone interview on 08/29/2024 at 05:51 p.m., LVN A stated she works the night shift. LVN A was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, to check with charge nurse prior to giving resident(s) an altered diet texture. Phone Interview on 08/29/2024 at 05:56 p.m., CNA B stated in-service completed on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. CNA B observed the use of POC to obtain information on resident diet orders, also including care plans and orders. CNA B stated she was aware of the risks of resident noncompliance of dietary orders, further stating, if we don't follow orders, it is dangerous for residents this could be from choking to food allergies, also I'm fully aware that I can always go to a nurse to confirm any orders or care for my residents. Interview on 08/29/2024 at 05:58 p.m., NA A stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. NA A stated. We must follow all orders, this is how we provide care for our residents, all orders, dietary, everything, if we don't, we could cause harm to residents. Interview on 08/29/2024 at 06:11 p.m., the DM stated she completed in-service training on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture, and there was a process of orders to confirm they matched the RD Dining Meal ticket system, and they were on the Resident Profile. Record review of in-services for ADM and DON on 08/28/2024 on topics of new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. Record review of in-service from 08/28/2024 to 08/29/2024 on topics of where to find the diet information for a resident completed, Subject: Resident Profile-how to pull up Resident Profile to review-Diets-Diagnosis-Ca[TRUNCATED]