**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure resident environments remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one resident (Resident #1) of 3 residents reviewed for 2-person mechanical lift transfers. The facility failed to ensure CNA A transferred Resident #1 on 01/19/2025 with a mechanical lift per her [NAME] (Notes for CNAs to access in PCC to provide a quick overview of the resident's needs) and her comprehensive plan of care plan. CNA A transferred Resident #1 with a gait belt by herself which resulted in a displaced fracture of her right humeral neck (bone at top of arm that connects to ligament (tough fibrous connective tissue) of shoulder). An Immediate Jeopardy was identified as past noncompliance on 5/21/2025. The IJ began on 1/19/25 and ended on 1/20/25. The facility had corrected the noncompliance before the survey began. This failure could put residents at risk of accidents, and could result in serious injury, harm, impairment, and death. The findings included: Record review of Resident #1's face sheet dated 5/20/25 revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] with readmission on [DATE]. The resident's diagnoses included senile degeneration of brain (mental deterioration associated with old age), dementia (a syndrome characterized by a decline in cognitive abilities, affecting memory, thinking, behavior, and the ability to perform everyday activities), chronic kidney disease (long-term condition characterized by the gradual loss of kidney function and leads to the body's inability to filter waste, toxins and excess water from the blood), displaced fracture of surgical neck of right humerus (bone fractures moved around during the fracture causing a gap around the fracture at the top of the right arm near the shoulder), muscle weakness (condition where muscles do not generate enough strength for normal activities), cognitive communication deficit (refers to communication difficulties that arise from cognitive impairments rather than primary language or speech issues) and other abnormalities of gait and mobility (unusual walking patterns or deviations from normal walking, affecting balance, coordination, and consistency in walking). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was dependent on staff for ADLs and required two or more persons to transfer her from the chair to her bed or bed to her chair. Record review of Resident #1's significant change MDS assessment dated 01/24/'2025 reflected the resident scored a 9 out of 15 on her BIMS which indicated the resident had moderate cognitive impairment and could understand others and be understood. The resident used a used a manual wheelchair for mobility. She was dependent on staff for ADLs and required two or more persons to transfer her from chair to bed or bed to chair. Record review of Resident #1's [NAME] dated 01/2025 reflected TRANSFERS: Requires maximum assistance of 2 staff with mechanical lift. Record review of Resident #1's Active Orders As of: 05/20/2025 reflected she had 3 orders of narcotic pain medications prior to the fracture of her right humerus which she was prescribed by hospice on 02/02/2024 listed as the following: 1.Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 2 hours as needed for mild pain/dyspnea. Phone Active 02/02/2024 2. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.5 ml by mouth. every 2 hours as needed for moderate pain/dyspnea. Phone Active 02/02/2024 3. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every. 2 hours as needed for severe pain/dyspnea. Phone Active 02/02/2024 Record review of the facility PIR dated 01/23/25 reflected on 01/19/2025 during a transfer from wheelchair to bed (Resident #1), CNA A heard a pop sound. LVN B (Charge Nurse on the unit) assessed, and Resident #1 told the nurse her right arm hurt. An assessment done by hospice RN C reflected she called the family, and the family did not want Resident #1 to go to the ER. The family requested she have an orthopedic appointment and to keep her comfortable. A sling was applied to stabilize her right arm and routine hospice pain medications were given. The Administrator spoke with Resident #1 and her family in Resident #1's room on 01/20/2025 at 10:00 am. Resident #1 stated she was not in pain, and she was comfortable. Treatment was provided in house and the resident stated she felt safe. CNA A was suspended pending investigation. Staff member stated she did not touch Resident #1's arm during the transfer. CNA A stated she did not use a mechanical lift and did not check the [NAME]. X-ray results were positive for a fracture the same day and Resident #1's family refused the orthopedic appointment later. Record review of Resident #1's progress note dated 01/19/2025 at 3:30 am written by LVN B reflected; resident was climbing out of bed earlier in the shift. CNA A got Resident #1 up in a wheelchair and brought her to the dining room for snacks. CNA A transferred Resident #1 back to bed and came and told him (LVN B) Resident #1's arm popped during transfer. LVN B entered the room and found Resident #1 lying in bed with a gait belt on and she complained of pain in her right arm. He wrote he did not see any obvious deformity and Resident #1 stated she would not move her arm. LVN B notified hospice, her vital signs were within normal limits and he did not attempt ROM. LVN B medicated Resident #1 with morphine sulfate, .5 ml sublingually (under the tongue) and he wrote the resident was calm. Record review of progress note written by RN C dated 01/19/2025 at 10:00 am reflected Hospice nurse came in to evaluate Resident #1 due to possible injury. Right shoulder is clearly swollen, and Resident #1 has pain to the touch. Unable to move arm without it hurting. X-ray completed. Record review of the Radiology Results Report dated 01/19/2024 at 9:55 am reflected Findings: Displaced humeral neck fracture of the right shoulder. Record review of Resident #1's progress note dated 01/20/25 written by the FNP reflected the family had 3 options: 1. send the resident to the ER. 2. call orthopedic office on Monday for further recommendation. 3. Keep the resident on hospice and control pain. The FNP's assessment of Resident #1 included: she was not in pain, had a sling in place, required maximum assistance and was mostly bed bound. Record review of Resident #1's progress note dated 01/21/25 at 2:25 pm written by RN C reflected hospice talked with orthopedic office and discussed with family who decided to keep Resident #1 in the facility and comfortable. A new order for morphine Contin 15 mg bid was provided. No pain currently. Record review of progress note written by RN C dated 01/19/2025 at 10:00 am reflected Hospice nurse came in to evaluate Resident #1 due to possible injury. Right shoulder is clearly swollen, and Resident #1 has pain to the touch. Unable to move arm without it hurting. X-ray completed. Record review of the Radiology Results Report dated 01/19/2024 at 9:55 am reflected Findings: Displaced humeral neck fracture of the right shoulder. Record review of Resident #1's progress note dated 01/20/25 written by the FNP reflected the family had 3 options: 1. send the resident to the ER. 2. call orthopedic office on Monday for further recommendation. 3. Keep the resident on hospice and control pain. The FNP's assessment of Resident #1 included: she was not in pain, had a sling in place, required maximum assistance and was mostly bed bound. Record review of Resident #1's progress note dated 01/21/25 at 2:25 pm written by RN C reflected hospice talked with orthopedic office and discussed with family who decided to keep Resident #1 in the facility and comfortable. A new order for morphine Contin 15 mg bid was provided. No pain currently. In an observation and interview on 05/20/25 at 08:45 a.m. Resident #1 was lying in bed. Resident #1 was on a low bed with a fall mat beside the bed on the floor. She stated she had a small amount of pain in her right arm but was provided pain medication. In an interview on 05/20/2025 at 08:47 am with LVN E who was Resident #1's charge nurse, she who stated Resident #1 required a mechanical lift transfer with 2 people. In an interview on 05/20/2025 at 08:50 am with CNA F who was assigned to work with Resident #1, he stated he had been at the facility for over a year and Resident #1 had always required a mechanical lift and 2 people for transfer. In an interview on 05/20/2025 at 3:00 pm with LVN B, he who stated Resident #1 was climbing out of bed and he asked CNA A to go get her up in a wheelchair and take her to the dining room for some snacks. He stated he knew how to check the [NAME], and he said Resident #1 never got up on the nightshift. He said he realized when CNA A told him Resident #1's arm popped during transfer something was wrong. He stated he entered Resident #1's room and she complained of pain, and he assessed her, medicated her, and notified the hospice of the potential injury. He stated he was accountable as the charge nurse and nursing staff received training right after that on abuse and neglect and checking the [NAME]. In an interview on 05/21/2025 at 03:09 pm with CNA A, she who stated Resident #1 did not usually get up on nightshift. She said Resident #1 had a low bed with a mat but had a fall a few nights prior and seemed to be restless, so LVN B asked her to get Resident #1 up and give her some snacks. She admitted she never had to get Resident #1 up prior to 01/19/2025. She stated she saw a gait belt sitting in a wheelchair in the resident's room and assumed she was a one-person transfer. She stated getting the resident up was no problem, but when she went to put Resident #1 back to bed, the resident jerked back, and she heard a crack or popping sound from Resident #1's right shoulder. She stated she was trained during on-boarding to check the [NAME] in PCC or to ask the nurse what type of transfer the resident needed. She stated she was trained on how to do mechanical lift transfers and needed 2 people for the transfer. She said not checking the [NAME], or asking the nurse about the right type of transfer can result in injury or harm. In an interview on 05/22/2025 at 10:03 am with the DON, she shoshe stated CNA A made a mistake and was suspended pending investigation. She stated training of all staff started the very next day. She had the Physical Therapist train staff on transfers. She stated staff received an on-boarding training with one person and they demonstrate how to do everything, and checking a resident's [NAME] is one of the items they have training on. She stated the importance of knowing the right transfer of a resident provides safety for the resident and the staff or they could get hurt. She stated CNA A received 1:1 training by the Physical Therapist on transfers prior to being allowed to work. She stated CNA A was retrained on how to access and use PCC for the [NAME], but later she resigned for other reasons . Record review of Rehabilitation Training dated 01/20/2025 provided to CNA A by the Physical Therapist reflected she had remedial training on transfers. In an interview on 05/20/2025 at 04:23 pm with CNA D who was the facility trainer revealed when staff on-board, training included the CNA would sign into PCC, then click on their station and would be able to access a resident [NAME] to check their type of required transfer. She stated she trained CNA A, and the backup plan was to ask the nurse or herself. Record review of CNA As orientation training record titled Nurse Aide Floor On-Boarding dated 09/20/2024 reflected she was trained on How to identify residents transfer ability on PCC, and mechanical lift transfers. In an interview on 05/20/2025 at 1:12 p.m. with the ADM, she who stated she was the abuse and neglect prevention coordinator. She stated CNA A was suspended pending investigation. She stated residents must feel safe at the facility. She ADM stated staff were trained immediately after the incident and she made the report. She ADM stated she was accountable for quality of care at the facility. She stated the incident was discussed in QAPI and continued to be monitored. She ADM stated 9 residents in the facility required mechanical lift transfers. Record review of the facility policy titled Abuse Prevention/Neglect or Exploitation dated 03/16/2022 reflected It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident's property. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury of harm. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility policy and procedure titled No Lift Concept dated 10/23/13 reflected requires all employees to adopt a No Lift Concept. Employees are expected to use the aid of equipment when lifting objects or residents. An educational in-service relating to safety practices and lifting is required of all employees at least one time and/or as needed. Procedure: 2. Nursing staff are required to use mechanical lifts (Hoyer, Sit-To-Stand), gait/transfer belts, sliding boards, bed scales and bed repositioning devices on residents when appropriate after being trained in their use. It was determined the failure placed Resident #1 in an IJ situation on 05/21/25. The ADM was notified on 05/21/2025 at 03:26 pm, that a PNC IJ had been identified due to the above failure. The facility implemented the following interventions: 1. CNA A was suspended pending investigation and when she returned provided 1:1 instruction for transfer and re-educated on the [NAME] and use of [NAME] prior to resident care. She later resigned. 2. On 1/20/2025 MDS coordinators completed a full audit on all residents [NAME]'s to ensure accuracy of transfer information. 3. The DON in-serviced all staff on 1/20/25 for ANE, checking the [NAME] in PCC for transfer information on residents and staff were not allowed to work until training was completed. 4. Review of new nursing staff on-boarding reflected 100% were trained in checking the [NAME] in PCC and transfers. 5. All new nursing staff continue to be in-serviced during orientation with the on-boarding checklist. 6. An Ad hoc QAPI meeting was called at 09:00 am on 01/19/2025 to discuss the incident and plan of correction. The physician was called at 6 am and the hospice RN on call was notified at 4 am. It will be discussed in quarterly QAPI meeting with the Medical Director on 05/28/2025. Observation on 05/21/2025 at 10:18 am of CNA F and CNA I perform a mechanical lift transfer for Resident #3 revealed no issues with safety and no issues with CNA F signing into PCC to check the residents [NAME]. Record review of Resident #2 and #3's MDS's, Care Plans and [NAME]'s reflected they were mechanical lift 2 person transfers. Observation on 05/21/2025 at 10:25 am of CNA J and LVN K perform a mechanical lift transfer for Resident #2 revealed no issues with safety and no issues with CNA J signing into PCC to check the residents [NAME]. Record review of training titled Checking [NAME] and Resident Transfers dated 01/20/2025 reflected 64 staff signatures. Signatures were compared to a nurse staff roster for 01/19/2025 and 100% were highlighted as had training. Record review of a notarized statement dated 05/21/25 which reflected On 01/20/2025 MDS coordinators completed a full audit on all residents [NAME]'s to ensure accuracy of transfer information. MDS coordinators continue ongoing auditing by reviewing each resident's [NAME] with every MDS completed. Signed by MDS L and MDS M. Record review of AD HOC QAPI sign in sheet dated 01/19/2025 reflected the ADM, DON, MDS M, Director of Therapy and the ADON attended. Interviews on 05/21/2025 from 10:00 am to 1:45 pm with 12-day shift nursing staff and 9-night shift nursing staff to total 20 out of 88 nursing staff employed revealed they received training after the incident on abuse and neglect, checking the [NAME] in PCC and resident transfers. In an interview on 05/21/2025 at 12:27 pm with MDS L (Day Shift), she who stated training occurred after Resident #1's incident. Staff were trained on abuse and neglect, checking the [NAME] and making sure the resident is transferred safely. In an interview on 05/21/2025 at 1:24 pm with CNA N (Night Shift), she who stated she was recently trained on abuse and neglect, checking the [NAME] in PCC for transfers, and she was trained when she on-boarded. In an interview on 05/21/2025 at 1:29 pm with CNA O (Night Shift), she who stated the ADM was the abuse and neglect coordinator. She was recently trained on abuse and neglect and checking the [NAME] for resident information. In an interview on 05/21/2025 at 1:32 pm with CNA P (Night Shift), she who stated she was recently trained to check the [NAME] for type of care a resident required. She was also trained on abuse and neglect prevention. She stated if staff was unsure of type of transfer for a resident, to check with the nurse. In an interview on 05/21/2025 at 1:35 pm with LVN Q (Night Shift) she who stated she had training on abuse and neglect. How to check [NAME] on PCC and what transfer the resident required and to ask the Charge Nurse. In an interview on 05/21/2025 at 1:38 pm with CNA S (Night Shift), she who stated in January they had training on how to access PCC and to check the [NAME] and see what type of transfer a resident needed. She stated she had training on abuse and neglect, to report an incident immediately and the ADM was the abuse and neglect prevention coordinator. In an interview on 05/21/2025 at 1:40 pm with CNA T (Day Shift), she who stated training on abuse and neglect was scheduled and on-going as needed. She stated the abuse and neglect prevention coordinator was the ADM and to report any incident immediately. She stated she had training in January on how to access the [NAME] in PCC to find out what type of transfer a resident required or to ask the nurse. In an interview on 05/21/2025 at 1:42 pm with LVN U (Day Shift), she who stated staff had recent training on checking PCC for the [NAME] which gives information on a resident such as how to transfer a resident from bed to chair. She stated as a charge nurse she needed to make sure residents are transferred safely and provided quality care. She monitored the care provided by CNAs assigned to her unit. In an interview on 05/21/2025 at 1:43 pm with RN V (Day Shift), she who stated she was one of the MDS nurses and was responsible for keeping [NAME]'s current. She stated staff were trained after the incident with Resident #1 on how to check the [NAME]. Training on abuse and neglect was provided. She stated staff were informed to report an incident right away. In an interview on 05/21/2025 at 1:44 pm with CNA W (Day Shift), he who stated he received training on how to access the [NAME] in PCC to check on a resident's care required such as transfers. He stated training was provided on abuse and neglect, and it was ongoing and as needed. In an interview on 05/21/2025 at 1:45 pm with the ADON (Day Shift), she who stated training was provided in January 2025 on how to check PCC for a resident's care needs by looking at their [NAME]. She stated she had training on abuse and neglect and provided some of the training. She stated after the incident 100% of nursing staff were trained and new people receive training on PCC, [NAME] and abuse and neglect with on-boarding. In an interview on 05/21/2025 at 1:45 pm with CMA X (Day Shift), she who stated she was provided training on signing into PCC, referring to a resident [NAME] and checking what type of care they required such as transfers. She stated she had training on abuse and neglect. In an interview on 05/21/2025 at 1:45 pm with CNA F (Day Shift), he who stated he had the training in January 2025 after the incident with Resident #1 and how to check PCC for the [NAME]. He stated he would ask the nurse if he was unsure about a resident's care. He said training was ongoing and as needed on abuse and neglect. He CNA F said the abuse and neglect prevention coordinator was the ADM. In an interview on 05/21/2025 at 2:10 pm with RN Y (Day Shift), she stated training on abuse and neglect was ongoing and as needed. She stated after the incident with Resident #1 in January 2025, all nursing staff were trained on how to check PCC for a resident [NAME] and to find out the care required such as type of transfer. She stated as a charge nurse she monitored the CNAs and resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident the residents environment remained as free of accident hazards as was for 1 of 14 Residents (#16) reviewed for mechanical soft diet needs and supervision. 1.The facility failed to follow the Speech Language Pathologist's (SLP) recommendations to grind meat for Resident #16's mechanical soft diet, served Resident #16 a ham sandwich, with 2 slices of ham lunch meat, each doubled in half; Resident was found shortly after unresponsive, received Cardio Pulmonary Resuscitation (CPR), was sent to the hospital via Emergency Medical Services (EMS) where she died due to a Difficult airway with lots of debris as quoted by the physician. An Immediate Jeopardy (IJ) was identified on 06/23/2024. While the IJ was removed on 06/27/2024, the facility remained out of compliance at a scope of isolated with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for harm, up to and including death, by not providing residents with their correct diet textures. The findings include: 1. A record review of Resident #16's admission record dated 06/22/2024, revealed an admission date of 07/10/2023 with diagnoses which included muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass), dysphasia (difficulty swallowing), dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #16's significant change MDS assessment dated [DATE] revealed Resident #16 was a [AGE] year-old female admitted for long term care, assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #16 could be understood with clear speech and could understand others. Resident #16 had adequate hearing and had a need for corrective glasses. Resident #16 used a wheelchair. A review of the Functional Abilities and Goals section revealed Resident #16 was assessed for eating, Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently . A record review of Resident #16's care plan dated 06/22/2024 revealed, NUTRITION (Resident #16) is at risk for malnutrition DT (due to) DX (diagnosis) Muscular Dystrophy, Dysphagia, .vascular Dementia, decreased independence, age, wc (wheelchair) bound, requires assist, mechanical soft diet, .Provide diet as ordered: .Mechanical Soft Texture, Thin Liquids .Monitor for signs/symptoms of dysphagia (swallowing problems) and report to nurse/MD .(Resident #16) has GERD (gastro esophageal reflux disease) r/t (related to) hyperacidity .Monitor / document / report PRN (as needed) s/sx (signs and symptoms) of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, N/V (nausea vomiting), Indigestion, Regurgitation, increased salivation, swallowing problems, bitter taste in mouth, Dysphagia, substernal chest pain, increased gag response A record review of Resident #16's Speech Therapy Plan of Care (Evaluation Only) dated 07/12/2023, revealed, Reason for referral: this [AGE] year-old female presents for speech language pathology evaluation of cognitive communication and swallow status following hospitalization for syncope (fainting) episodes. Patient has (a) history of dysphagia (swallowing difficulties) due to C P Bar (the failure of the muscle at the top of the throat which closes and prevents food from coming back up) and complicated by myotonic muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass) .will continue on mechanical soft solids at this time due to narrowing (throat) .Precautions: fall risk, full code (staff perform CPR), cardiac / mechanical soft (grind meats) / thin liquids, aspiration precautions. Discharge Plans: patient will remain at this facility with full time caregiver support A record review of Resident #16's physicians orders dated 06/22/2024, revealed on 08/22/2023 the physician ordered for Resident #16 to be served a mechanical soft diet texture. A record review of Resident #16's PT - Therapist Progress & Updated Plan of Care dated 05/14/2024, was reviewed and signed by the physician on 05/30/2024 which read, precautions: fall risk, full code, cardiac / mechanical soft (grind meat) / thin liquids, aspiration precautions. Able to self monitor and correct. A record review of Resident #16's meal ticket, Thursday - June 20,2024 .please select menu choices .ham and cheese sand .mechanical soft .eats in room. During an interview and observation on 06/22/2024 at 01:07 PM the Assistant Food Service Manager (AFSM) stated the kitchen prepares and serves residents with a need for mechanical soft diet textures ham and cheese sandwiches. The AFSM provided a recipe for the ham and cheese sandwich, and the Alternate Menu Spreads document. The AFSM stated the Alternate Menu was reviewed and approved by the facility's registered dietician. The AFSM stated the alternate menu specified a Resident with a need for a mechanical soft diet could be served a ham sandwich. The AFSM demonstrated a ham sandwich which was prepared and available to be served to a Resident with a mechanical soft diet. The sandwich was wrapped in a clear plastic wrap. The AFSM unwrapped the sandwich and demonstrated the sandwich on a plate by removing the top slice of bread which revealed 2 slices of ham doubled in half and laid side by side on the bottom half of the sandwich. A record review of the undated alternative menu spreads revealed a ham sandwich was listed as yes / thin slices under the column for mechanical. A record review of the facility's Ham and Cheese Sandwich recipe dated 05/15/2024 revealed, .Smoked boneless pork ham, sliced thin, 2 oz., cheese, American, sliced, 0.5 oz., bread, white, slice .layer 2 oz. of ham and ½ oz. cheese on 1 slice of bread. Top with other slice During an interview on 06/22/2024 at 02:28 PM the Food Service Manager FSM stated the kitchen used an alternative menu spread which listed a ham and cheese sandwich has compatible with mechanical soft diet textures and could be served to residents who have a need for mechanical soft diet textures. The FSM stated the alternative menu spread was reviewed and approved by the RD on 11/13/2023. A record review of the facility's nursing schedule dated 06/20/2024 revealed CNA A, RN B, and Medication Aide C (MA C) worked Resident #16's hall from 07:00 AM to 07:00 PM. During an interview on 06/22/2024 at 11:00 AM with CNA A stated he has worked at the facility since 10/23/2023. CNA A stated Resident #16 was cool - she was calm, nice, and she liked coffee and hot tea .she could not walk, she was bed bound, she was recovering from a fractured leg, and she lived on the second floor. CNA A stated he worked Thursday 06/20/2024 from 07:00 AM to 07:00 PM, it was a normal day . at dinner time, around 06:00 PM, MA C and I helped serve residents their meals .I did not serve Resident #16 . I was in the room across from Resident #16 .I heard a call light and came out and saw (Resident #16's) call light, I went in, and I saw Resident #16 seated in her wheelchair with a distressed look on her face, gasping for air. I called and yelled for RN B, I swept Resident #16's mouth and discovered some food, it looked like bread. RN B arrived; we repositioned Resident #16 on the floor. RN B called out for help, and we continued to sweep Resident #16's mouth, we were finding pieces of food, bread .MA C came in the room and RN B told her to bring the crash cart (a cart supplied with CPR supplies) and call 911, we began CPR with RN B performing chest compressions. MA C returned with the crash cart, and we began using the AED (automatic external defibrillator) and the suction machine to suck out food from Resident #16's mouth / throat; we continued CPR with RN B doing chest compressions and I provided rescue breathing with the bag, we took turns about 2x each when EMS arrived and took over. During an interview on 06/22/2024 at 11:15 AM MA C stated she has worked at the facility 13 years. MA C stated Resident #16 was nice and sweet .she took her pills whole .she had a wheelchair. MA C stated she served residents their meals. MA C stated the kitchen prepared and delivered the residents' meals to the unit in a meal cart. MA C stated on 6/20/2024, she retrieved Resident #16's dinner from the cart and served Resident #16 her dinner, which consisted of a ham sandwich and then proceeded to serve other residents. MA C stated Resident #16 ate in her room. MA C stated she was alerted to Resident #16's room where she saw RN B and CNA A providing CPR to Resident #16 on the floor. MA C stated RN B called for MA C to bring the crash cart and call 911. MA C stated she returned with the crash cart. MA C stated she called 911 on her cell phone at 06:37 PM, and then made the path clear for EMS. MA C stated she went to the front door to guide EMS to Resident #16 once they arrived. During an interview on 06/22/2024 at 01:27 PM RN B stated Resident #16 would prefer to eat in her room. RN B stated Resident #16 had a need for a mechanical soft diet but would often refuse her diet texture, for example she would eat bacon for breakfast. RN B stated on 06/20/2024 at dinner time, around 06:00 PM, she was assisting and providing care for another Resident. RN B stated she had not reviewed residents' dinner meal trays for safety and CNA A and MA C were serving residents their dinner meals. RN B stated had she reviewed Resident #16's sandwich she may not have seen the ham was sliced and not ground per mechanical soft diet texture protocol due to the sandwiches are wrapped and she did not routinely unwrap sandwiches. RN B stated she believed the kitchen prepared sandwiches for mechanical soft diet textures with ground lunch meats, like ham salad. RN B stated she was assisting another Resident in their room when she heard CNA A calling for her in Resident #16's room. RN B stated she immediately went to the room and discovered CNA A and Resident #16 in her wheelchair. Resident #16 was not breathing and was distressed. RN B stated she and CNA A began sweeping Resident #16's mouth and removed food debris. RN B stated she called out for help and MA C arrived, I told her to bring the crash cart and call 911. RN B stated MA C returned with the crash cart and she and CNA A used the suction machine and continued to remove food debris. RN B stated Resident #16 became unresponsive without a pulse and breath. RN B stated she and CNA A repositioned Resident #16 to the floor and began CPR with the use of the AED. RN B stated she and CNA A took turns and turned over CPR to the EMS paramedics when they arrived. A record review of Resident #16's hospital history and physical record, dated 06/20/2024 revealed Resident #16 was admitted to the emergency room at the local hospital at 09:11 PM, Patient admission date: 06/20/2024 at 21:11 (09:11 PM) BIBEMS (brought in by EMS), from nursing home after choking episode and cardiopulmonary arrest. EMS obtained ROSC (return of spontaneous circulation) after 20 minutes of CPR / ACLS (cardiopulmonary resuscitation / advanced cardiac life support). Difficult airway with lots of debris thus LMA (Laryngeal Mask Airway, a tube inserted down the throat to facilitate the airway) used until definitive airway obtained at (hospital) emergency room by emergency room physician using [NAME] ([NAME], a guide for an airway tube to be inserted). Patient hypotensive (very low blood pressure) .Reportedly mental status notable for repetitive twitching motion. During my exam flaccid after RSI (rapid sequence induction) drugs with pupils 4mm appeared fixed. Significantly hypoxic (severe low blood oxygen) with bilateral multifocal infiltrates (both the left and the right have widespread debris) on x-ray. Requiring aggressive pulmonary toilet by respiratory therapist (suctioning the airway to remove debris and mucus) irrigation and suction frequently currently requiring 100% oxygen) A record review of Resident #16's hospital Discharge Summary record, dated 06/20/2024 revealed Resident #16's physician pronounced Resident #16's death at 11:06 PM, During nursing care assessment (of) patient rhythm converted to asystole (also known as flatline, a state of standstill for the heart) and patient noted pulseless. CPR per ACLS initiated and code blue called .discussion initiated with (family representative) in waiting room current status and plan for proceeding. Informed suspicion for anoxic brain injury (severe brain cell death resulting in permanent cognition loss) given information that patient (was) found down arrested (unresponsive) and ROSC after 20 minutes (brain injury can begin after 4 minutes) .(family member) was offered and requested to witness active resuscitation efforts and at that time surrogate decision was made by (family member) to terminate efforts .time of death called at 23:06 (11:06 PM) . preliminary cause of death: choking / severe aspiration (when food and or drink are sucked into the airway and lungs). During an interview on 06/22/2024 at 11:38 AM the DON stated she believed the ham sandwich with thinly sliced ham was compatible for residents who required mechanical soft diets. The DON stated the plan was developed by the RD to support residents with the need for mechanical soft diets. During an interview on 06/22/2024 at 01:30 PM the RD stated she had reviewed and approved the facility's alternative menu spreads to include the compatibility of a ham sandwich with thinly sliced ham with the needs of residents who required mechanical soft diets. The RD stated her research and use of professional standard resources supported the compatibility of a ham sandwich with thinly sliced ham with the needs of residents who required mechanical soft diets. The RD stated the rationale was to improve residents' compliance with their diet textures and thereby improve nutritional intake and over all mitigate weight loss and malnutrition. During an interview on 06/22/2024 at 05:00 PM the SLP stated Resident #16 had a difficult swallow response due to the muscle atop of her throat was not functioning well. The muscle referred to as the CP was weak and would allow food to come back up reflux and could enter the airway. The SLP referred to the situation as a CP bar and was complicated by Resident #16's muscular dystrophy and history of strokes. The SLP stated she had evaluated Resident #16 and had recommended Resident #16 to be served a mechanical soft diet specific for ground meats. The SLP stated her definition of mechanical soft would be like the International Dysphagia Diet Standardization Initiative's level 5. The SLP stated her expectation for mechanical soft would include foods which were soft and moist, with no liquid leaking / dripping from the food, where biting is not required, minimal chewing was required, lumps of 4mm in size, lumps can be mashed with the tongue, food could be easily mashed with just a little pressure from a fork, food should be able to be scooped onto a fork, with no liquid dripping and no crumbles falling off the fork. The SLP stated she did not believe a ham sandwich met those requirements. The SLP stated she believed the meats should be ground for a mechanical soft diet and stated a ham sandwich could be served as a ham salad sandwich for residents who required a mechanical soft diet. The SLP stated Resident #16's risk for not receiving mechanical soft foods was choking and aspiration. During an interview on 06/22/2024 at 05:50 PM the Administrator stated she believed the ham sandwich with thinly sliced ham was appropriate for residents who required mechanical soft diets. The Administrator stated she stated she had confidence in the professional guidance from the RD was to support residents with a mechanical soft diet with the lunchmeat sandwiches made with thinly sliced meat. During an interview on 06/23/2024 at 06:10 PM NP L stated she had conferenced with the Medical Director and at this time could not offer opinions on the compatibility for a ham sandwich as prepared and served by the facility for the remaining residents at the facility who were ordered a mechanical soft diet. During an interview on 06/23/2024 at 07:04 PM NP L stated she was the NP for Resident #16. NP L stated she and the Medical Director reviewed Resident #16's medical record and believed a ham sandwich with thinly shaved ham could have been safe for Resident #16 to consume per her mechanical soft diet. Record review of policies for Resident Food Services with the subject Diet Orders and Other Resident Information (policy #C203, date issued- 5/95; revised date 01/24) on 6/25/2024 at 4:26PM revealed the policy stated: Diet orders should be determined with the resident or responsible party and in accordance with his/her informed choices, goals, and preferences. The responsible physician or designee or qualified dietician/other clinically qualified nutrition professional per state regulations, must order the diet in writing. The community may delegate the task of writing diet orders to a Registered Dietician who is acting within the scope of practice as defined by state law and is under the supervision of a physician. Nursing is responsible for communicating all nutrition related information to the Food and Nutrition department per community protocol. A record review of the International Dysphagia Diet Standardization Initiative's website, https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/5_Minced_Moist_Adults_consumer_handout_30Jan2019.pdf Accessed 06/23/2024, Revealed, Minced and Moist, level 5, minced and moist food for adults; what is this food texture level? Level 5 - minced and moist foods: Soft and moist, but with no liquid leaking / dripping from the food. Biting is not required. minimal chewing required. lumps of 4mm in size. food can be easily managed with just a little pressure from a fork. should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork. Why is this food texture level used for adults? Level 5 minced and moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food but are not able to chew it down into little pieces that are safe to swallow. Minced and moist foods only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It is important that minced and moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or fork . Examples of level 5 minced and moist foods for adults, meat served finely minced or chopped to 4mm lump size served in a thick smooth, non-pouring sauce or gravy .no regular dry bread due to high choking risk! Missing The facility's Administrator was notified and presented with a IJ template on 06/23/2024 at 07:00 PM, a Plan of Removal was requested from the facility. The following Plan of Removal submitted by the facility was accepted on 06/27/2024. Plan of Removal IJ Immediacy Removal Plan F 805 Facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs 06/23/2024. 1. All thin sliced meat options designated for mechanical soft diets were removed from all SNF units, (Unit 1), (unit 2), and (memory care). 6-23-24 2. Dietary Policy, Dietary Spread Sheets, and Dietary Menus were revised to show that all thin sliced meat options designated for Mechanical Soft Diets were removed and appropriate alternates noted. 6-23-24 3. All Staff working in facility were in-serviced by noon on 6-25-24 on Policy #C203 and #C219 , Titled Diet Orders and Other Resident Information and Snacks. The changes removed sandwiches with thinly sliced meats from all documents. In addition, Nursing Unit Stock Item List was updated, Seasonal Menu and Spreadsheets were updated to also reflect removal of thinly sliced meat as an option for mechanical soft diets. These policies will be available for reference by staff located in the Food Service Office, the Facility shared drive and presented as a visual for in-services. 4. Dietary Manager or Dietary Designees will monitor kitchen and all unit refrigerators routinely to ensure that appropriate sandwich options are available. 6-24-24 The Dietary Manager or Designee will be assigned to monitor tray line and sign off as to compliance of correct texture as ordered each meal for 14 days, then each meal twice a week for two weeks then three meal services once a week for 3 months. Administrator or Designee will follow up with meal tray monitor/audit twice a week for 3 months, at random meals to ensure tray line accuracy. Results to be reported to QAPI. 5. Nurse Practitioner and Medical Director were advised by Administrator and in agreement with plan. 6-23-24. Diet modifications orders will continue to be reviewed by nurse and translated to MD for approval. Diet modifications will be followed per SLP recommendations as approved by the MD. RD is notified via diet communication forms initiated by nursing staff once orders are confirmed. As with any orders or change in condition or treatment, will be further addressed in IDT mtg with DON, RD, Rehab Manager and other disciplines as appropriate. Diet spreadsheets 6-23-24 will be changed to ensure next available meal is accurately identified with up-to-date texture modifications for staff to follow. Care Plans will be updated per regulations. DON or designee will audit diet orders and associated care plans once every two weeks for three months to ensure compliance. Results will be reported to QAPI. An audit was conducted 6-24-24 by Dietary Manager and nursing for all residents with mechanical diet orders and no other residents were found to have been affected by this deficient practice. All thin sliced meat options previously designated for mechanical soft diets were removed from all SNF units. Diet modifications orders will continue to be reviewed by nurse and translated to MD for approval. Diet modifications will be followed per SLP recommendations as approved by the MD. RD is notified via diet communication forms initiated by nursing staff once orders are confirmed. DON or designee will audit diet orders and associated care plans once every two weeks for three months to ensure communication between RD and SLP is appropriate and timely. Results will be reported to QAPI Plan of Removal Verification IJ Immediacy Removal Plan F 805 Facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs 6-23-24. 1.All thin sliced meat options designated for mechanical soft diets were removed from all SNF units, (unit 1), (unit 2), and (memory care). 6-23-24 During observation of SNF Units- (1), (secured unit), (2), on 06/25/2024 at 04:40 PM, revealed all deli meat sandwiches, peanut butter and jelly sandwiches and peanut butter and jelly on crackers were removed from the refrigerators and replaced with egg salad sandwiches as a sandwich alternative for residents on mechanical soft diets. A list of approved alternative foods was also posted on the units. 2. Dietary Policy, Dietary Spread Sheets, and Dietary Menus were revised to show that all thin sliced meat options designated for Mechanical Soft Diets were removed and appropriate alternates noted. 06-23-24 During observation 06/25/2024 at 4:25 PM, a cork board had an Alternate Menu with deli meats, peanut butter and jelly sandwiches, and peanut butter and jelly crackers removed as an alternate for residents on mechanical soft diets and was approved by the RD. Review of the Alternate Menu Spreads revealed modified foods for all diets with mechanical soft foods with what foods were approved and what foods that were not approved. Seasonal Menus and Spreadsheet Review and Approval was also approved by the RD. 3. All Staff working in facility were in-serviced by noon on 6-25-24 on Policy #C203 and #C219, Titled Diet Orders and Other Resident Information and Snacks. The changes removed sandwiches with thinly sliced meats from all documents. In addition, Nursing Unit Stock Item List was updated, Seasonal Menu and Spreadsheets were updated to also reflect removal of thinly sliced meat as an option for mechanical soft diets. These policies will be available for reference by staff located in the Food Service Office, the Facility shared drive and presented as a visual for in-services. During an interview on 06/25/2024 at 01:05 PM Med Aide F stated she was in-serviced on receiving the diets that were ordered for the residents. She stated if it was a new resident what are the orders for the resident for example with medications, she would find out if the resident would get pudding or applesauce if they receive medications that are crushed. She stated as far as she knew, all the sliced meats were removed off the units. She stated she received the in-service in the morning yesterday. She stated if she saw someone with an incorrect diet, she would ask the resident if she could remove the plate and take it to the nurse. She stated the diet would be on the meal slip that would identify their diets . During an interview on 06/25/2024 at 01:15 PM CNA M (unit 1) stated he had been in-serviced on correct residents' diets yesterday 06/24/2024. He stated regular diets have no change to the texture and mechanical diets are ground meats. He stated if he saw someone with the incorrect diet, he would explain it to the resident about the diet not being safe and inform the nurse. He stated he would remove the tray from the table. He stated all sliced lunch meats have been removed from the unit. He stated an alternative would be soups, chicken salad, or baked potato/sweet potato. He stated the diet should be stated on the meal ticket. Sometimes with new residents, the ticket may not be printed, and he would ask the nurse what the diet order was for the newly admitted resident. During an interview on 06/25/2024 at 01:23 PM CNA X (unit 1- 35years ) stated she had the in-service about mechanical diets. She stated the sandwiches were removed from the unit. She stated she would look at the meal ticket or look at the resident's chart under dietary . She stated if someone had the wrong diet, she would not allow the resident to have the tray and explain why and then she would call the kitchen and notify the nurse. She stated other options would be egg salad, chicken, tuna, and ham salad- all soft and ground. She stated it was common sense to get something equal. During an interview on 06/25/2024 at 01:52 PM LVN V (unit 2- 2 years ) stated she had the in-service today before the start of her shift. She stated mechanical soft is moist ground meat, easy to chew. Egg salad, chicken salad, tuna salad had been brought to the unit and all other lunchmeats, peanut butter and jelly sandwiches and peanut butter and jelly crackers have been removed. She stated if someone received a wrong diet texture, she would immediately figure out what texture the resident should receive and switch out for the correct tray because they have extra pureed, mechanical soft and regular trays. If not, she would call the kitchen. She stated the process was, staff is notified that trays are delivered, and the nurses check the trays before they are handed to the aides that assist with passing out trays to the residents. She stated if someone stated they wanted to eat a regular sandwich she would not give it because of the dietary restriction. She stated she would educate them on the importance of why they are on a specific diet. If they say it was their right, she would offer them an alternative that is within their diet restriction. If that was not effective, she stated she would call the physician. During an interview on 06/25/2024 at 02:37 PM CNA G (memory care PRN 1 year ) stated the trays arrive, they look at tickets, check the food and check the diet and make sure they have what they are supposed to have, along with the nurse on the unit checking as well. She stated if she saw a tray with the wrong food or texture, she would inform the nurse. She stated she had an in-service yesterday about the sandwiches on the unit that they were no longer using lunchmeat only chicken, tuna, and egg salad as substitutes. She stated the sandwiches had been removed. She stated they had an in-service today about respect and dignity. She stated a mechanical soft meal, the meat would be ground to look like hamburger. She stated for some ground meat, they would add a gravy. During an interview on 06/25/2024 at 02:42 PM CNA/MED AIDE Z (Unit 2 and Training) stated she gave the in-service on the mechanical soft foods. She stated the crackers with peanut butter and lunchmeat sandwiches were removed from the units. She stated the alternatives were egg salad, tuna, chicken, and ham salad. She stated she would inform the nurse if the resident refused to accept the meat texture recommended for safety. She stated mechanical is chopped up or soft foods. She stated if the meat is chopped but dry, gravy would be added to make the meat moist. During an interview on 06/25/2024 at 03:07 PM CNA R (Unit 2- 6 months ) stated she had the in-service for sandwiches yesterday and the other in-service was abuse and neglect . She stated the sandwiches were to be used for alternatives for residents with mechanical soft diets for residents . She stated she would check the meal against the ticket and alert the nurse if the tray was incorrect. She stated trays are passed out by looking at the ticket, making sure diet is correct for the resident and making sure all the food on the ticket matches. She stated the nurse checks as well. She stated the lunchmeat sandwiches had been removed from the unit and replaced with chicken and tuna salad sandwiches. During an interview on 06/25/2024 at 03:12 PM CNA C (Unit 1- 16yrs ) stated she had the in-service about no more peanut butter crackers, instead tuna salad sandwiches yesterday. Puree is like baby food consistency, and mechanical soft is ground with gravy. She stated when food trays are passed, they make sure the trays are accurate according to the resident's diet. She stated to make sure the resident's diet is accurate on the tray and meal ticket, she would look in the chart and ask the nurse if she was not sure. She stated she would let the nurse know immediately if a tray was incorrect and call the kitchen. She stated if she saw someone with the wrong tray in front of them, she would inform the resident that the tray was incorrect and switch it with the correct tray. She said she would allow the resident to keep what is soft to eat like a pudding and let the nurse know as well. She stated she was told the sandwiches were removed from the unit, but she had not checked yet. During an interview on 06/25/2024 at 03:20 PM CNA Q (floats to other units) stated she had the in-service about peanut butter crackers and no deli meat sandwiches and they were substituting egg salad and tuna salad sandwiches yesterday. She stated mechanical soft includes ground meats, sometimes fruit is ground, and sometimes the residents would get gelatin instead of a salad. She stated the deli sandwiches had been removed and replaced with egg and tuna sandwiches. She stated if she saw someone with the wrong tray,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 14 of 16 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #16) reviewed for mechanical soft diet needs. 1. The facility failed to follow the Speech Language Pathologist's (SLP) recommendations to grind meat for Resident #16's mechanical soft diet, served Resident #16 a ham sandwich, with 2 slices of ham lunch meat, each doubled in half; Resident was found shortly after unresponsive, received Cardio Pulmonary Resuscitation (CPR), was sent to the hospital via Emergency Medical Services (EMS) where she died due to a Difficult airway with lots of debris as quoted by the physician. 2. The facility assessed residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 with the need for a mechanical soft diet and prepared with the intent to serve to them ham sandwiches with sliced ham lunch meat, not ground. An Immediate Jeopardy (IJ) was identified on 06/23/2024. While the IJ was removed on 06/27/2024, the facility remained out of compliance at a scope of pattern with risk for harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. These failures could place residents at risk for harm, up to and including death, by not providing residents with their correct diet textures. The findings include: 1. A record review of Resident #16's admission record dated 06/22/2024, revealed an admission date of 07/10/2023 with diagnoses which included muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass), dysphasia (difficulty swallowing), dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #16's significant change MDS assessment dated [DATE] revealed Resident #16 was a [AGE] year-old female admitted for long term care, assessed with a BIMS score of 13 out of a possible 15 which indicated intact cognition. Resident #16 could be understood with clear speech and could understand others. Resident #16 had adequate hearing and had a need for corrective glasses. Resident #16 used a wheelchair. A review of the Functional Abilities and Goals section revealed Resident #16 was assessed for eating, Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently . A record review of Resident #16's care plan dated 06/22/2024 revealed, NUTRITION (Resident #16) is at risk for malnutrition DT (due to) DX (diagnosis) Muscular Dystrophy, Dysphagia, .vascular Dementia, decreased independence, age, wc (wheelchair) bound, requires assist, mechanical soft diet, .Provide diet as ordered: .Mechanical Soft Texture, Thin Liquids .Monitor for signs/symptoms of dysphagia (swallowing problems) and report to nurse/MD .(Resident #16) has GERD (gastro esophageal reflux disease) r/t (related to) hyperacidity .Monitor / document / report PRN (as needed) s/sx (signs and symptoms) of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, N/V (nausea vomiting), Indigestion, Regurgitation, increased salivation, swallowing problems, bitter taste in mouth, Dysphagia, substernal chest pain, increased gag response A record review of Resident #16's Speech Therapy Plan of Care (Evaluation Only) dated 07/12/2023, revealed, Reason for referral: this [AGE] year-old female presents for speech language pathology evaluation of cognitive communication and swallow status following hospitalization for syncope (fainting) episodes. Patient has (a) history of dysphagia (swallowing difficulties) due to C P Bar (the failure of the muscle at the top of the throat which closes and prevents food from coming back up) and complicated by myotonic muscular dystrophy (a group of diseases that cause progressive weakness and loss of muscle mass) .will continue on mechanical soft solids at this time due to narrowing (throat) .Precautions: fall risk, full code (staff perform CPR), cardiac / mechanical soft (grind meats) / thin liquids, aspiration precautions. Discharge Plans: patient will remain at this facility with full time caregiver support A record review of Resident #16's physicians orders dated 06/22/2024, revealed on 08/22/2023 the physician ordered for Resident #16 to be served a mechanical soft diet texture. A record review of Resident #16's PT - Therapist Progress & Updated Plan of Care dated 05/14/2024, was reviewed and signed by the physician on 05/30/2024 which read, precautions: fall risk, full code, cardiac / mechanical soft (grind meat) / thin liquids, aspiration precautions. Able to self monitor and correct. A record review of Resident #16's meal ticket, Thursday - June 20,2024 .please select menu choices .ham and cheese sand .mechanical soft .eats in room. During an interview and observation on 06/22/2024 at 01:07 PM the Assistant Food Service Manager (AFSM) stated the kitchen prepares and serves residents with a need for mechanical soft diet textures ham and cheese sandwiches. The AFSM provided a recipe for the ham and cheese sandwich, and the Alternate Menu Spreads document. The AFSM stated the Alternate Menu was reviewed and approved by the facility's registered dietician. The AFSM stated the alternate menu specified a Resident with a need for a mechanical soft diet could be served a ham sandwich. The AFSM demonstrated a ham sandwich which was prepared and available to be served to a Resident with a mechanical soft diet. The sandwich was wrapped in a clear plastic wrap. The AFSM unwrapped the sandwich and demonstrated the sandwich on a plate by removing the top slice of bread which revealed 2 slices of ham doubled in half and laid side by side on the bottom half of the sandwich. A record review of the undated alternative menu spreads revealed a ham sandwich was listed as yes / thin slices under the column for mechanical. A record review of the facility's Ham and Cheese Sandwich recipe dated 05/15/2024 revealed, .Smoked boneless pork ham, sliced thin, 2 oz., cheese, American, sliced, 0.5 oz., bread, white, slice .layer 2 oz. of ham and ½ oz. cheese on 1 slice of bread. Top with other slice During an interview on 06/22/2024 at 02:28 PM the Food Service Manager FSM stated the kitchen used an alternative menu spread which listed a ham and cheese sandwich has compatible with mechanical soft diet textures and could be served to residents who have a need for mechanical soft diet textures. The FSM stated the alternative menu spread was reviewed and approved by the RD on 11/13/2023. A record review of the facility's nursing schedule dated 06/20/2024 revealed CNA A, RN B, and Medication Aide C (MA C) worked Resident #16's hall from 07:00 AM to 07:00 PM. During an interview on 06/22/2024 at 11:00 AM with CNA A stated he has worked at the facility since 10/23/2023. CNA A stated Resident #16 was cool - she was calm, nice, and she liked coffee and hot tea .she could not walk, she was bed bound, she was recovering from a fractured leg, and she lived on the second floor. CNA A stated he worked Thursday 06/20/2024 from 07:00 AM to 07:00 PM, it was a normal day . at dinner time, around 06:00 PM, MA C and I helped serve residents their meals .I did not serve Resident #16 . I was in the room across from Resident #16 .I heard a call light and came out and saw (Resident #16's) call light, I went in, and I saw Resident #16 seated in her wheelchair with a distressed look on her face, gasping for air. I called and yelled for RN B, I swept Resident #16's mouth and discovered some food, it looked like bread. RN B arrived; we repositioned Resident #16 on the floor. RN B called out for help, and we continued to sweep Resident #16's mouth, we were finding pieces of food, bread .MA C came in the room and RN B told her to bring the crash cart (a cart supplied with CPR supplies) and call 911, we began CPR with RN B performing chest compressions. MA C returned with the crash cart, and we began using the AED (automatic external defibrillator) and the suction machine to suck out food from Resident #16's mouth / throat; we continued CPR with RN B doing chest compressions and I provided rescue breathing with the bag, we took turns about 2x each when EMS arrived and took over. During an interview on 06/22/2024 at 11:15 AM MA C stated she has worked at the facility 13 years. MA C stated Resident #16 was nice and sweet .she took her pills whole .she had a wheelchair. MA C stated she served residents their meals. MA C stated the kitchen prepared and delivered the residents' meals to the unit in a meal cart. MA C stated on 6/20/2024, she retrieved Resident #16's dinner from the cart and served Resident #16 her dinner, which consisted of a ham sandwich and then proceeded to serve other residents. MA C stated Resident #16 ate in her room. MA C stated she was alerted to Resident #16's room where she saw RN B and CNA A providing CPR to Resident #16 on the floor. MA C stated RN B called for MA C to bring the crash cart and call 911. MA C stated she returned with the crash cart. MA C stated she called 911 on her cell phone at 06:37 PM, and then made the path clear for EMS. MA C stated she went to the front door to guide EMS to Resident #16 once they arrived. During an interview on 06/22/2024 at 01:27 PM RN B stated Resident #16 would prefer to eat in her room. RN B stated Resident #16 had a need for a mechanical soft diet but would often refuse her diet texture, for example she would eat bacon for breakfast. RN B stated on 06/20/2024 at dinner time, around 06:00 PM, she was assisting and providing care for another Resident. RN B stated she had not reviewed residents' dinner meal trays for safety and CNA A and MA C were serving residents their dinner meals. RN B stated had she reviewed Resident #16's sandwich she may not have seen the ham was sliced and not ground per mechanical soft diet texture protocol due to the sandwiches are wrapped and she did not routinely unwrap sandwiches. RN B stated she believed the kitchen prepared sandwiches for mechanical soft diet textures with ground lunch meats, like ham salad. RN B stated she was assisting another Resident in their room when she heard CNA A calling for her in Resident #16's room. RN B stated she immediately went to the room and discovered CNA A and Resident #16 in her wheelchair. Resident #16 was not breathing and was distressed. RN B stated she and CNA A began sweeping Resident #16's mouth and removed food debris. RN B stated she called out for help and MA C arrived, I told her to bring the crash cart and call 911. RN B stated MA C returned with the crash cart and she and CNA A used the suction machine and continued to remove food debris. RN B stated Resident #16 became unresponsive without a pulse and breath. RN B stated she and CNA A repositioned Resident #16 to the floor and began CPR with the use of the AED. RN B stated she and CNA A took turns and turned over CPR to the EMS paramedics when they arrived. A record review of Resident #16's hospital history and physical record, dated 06/20/2024 revealed Resident #16 was admitted to the emergency room at the local hospital at 09:11 PM, Patient admission date: 06/20/2024 at 21:11 (09:11 PM) BIBEMS (brought in by EMS), from nursing home after choking episode and cardiopulmonary arrest. EMS obtained ROSC (return of spontaneous circulation) after 20 minutes of CPR / ACLS (cardiopulmonary resuscitation / advanced cardiac life support). Difficult airway with lots of debris thus LMA (Laryngeal Mask Airway, a tube inserted down the throat to facilitate the airway) used until definitive airway obtained at (hospital) emergency room by emergency room physician using [NAME] ([NAME], a guide for an airway tube to be inserted). Patient hypotensive (very low blood pressure) .Reportedly mental status notable for repetitive twitching motion. During my exam flaccid after RSI (rapid sequence induction) drugs with pupils 4mm appeared fixed. Significantly hypoxic (severe low blood oxygen) with bilateral multifocal infiltrates (both the left and the right have widespread debris) on x-ray. Requiring aggressive pulmonary toilet by respiratory therapist (suctioning the airway to remove debris and mucus) irrigation and suction frequently currently requiring 100% oxygen) A record review of Resident #16's hospital Discharge Summary record, dated 06/20/2024 revealed Resident #16's physician pronounced Resident #16's death at 11:06 PM, During nursing care assessment (of) patient rhythm converted to asystole (also known as flatline, a state of standstill for the heart) and patient noted pulseless. CPR per ACLS initiated and code blue called .discussion initiated with (family representative) in waiting room current status and plan for proceeding. Informed suspicion for anoxic brain injury (severe brain cell death resulting in permanent cognition loss) given information that patient (was) found down arrested (unresponsive) and ROSC after 20 minutes (brain injury can begin after 4 minutes) .(family member) was offered and requested to witness active resuscitation efforts and at that time surrogate decision was made by (family member) to terminate efforts .time of death called at 23:06 (11:06 PM) . preliminary cause of death: choking / severe aspiration (when food and or drink are sucked into the airway and lungs). During an interview on 06/22/2024 at 11:38 AM the DON stated she believed the ham sandwich with thinly sliced ham was compatible for residents who required mechanical soft diets. The DON stated the plan was developed by the RD to support residents with the need for mechanical soft diets. During an interview on 06/22/2024 at 01:30 PM the RD stated she had reviewed and approved the facility's alternative menu spreads to include the compatibility of a ham sandwich with thinly sliced ham with the needs of residents who required mechanical soft diets. The RD stated her research and use of professional standard resources supported the compatibility of a ham sandwich with thinly sliced ham with the needs of residents who required mechanical soft diets. The RD stated the rationale was to improve residents' compliance with their diet textures and thereby improve nutritional intake and over all mitigate weight loss and malnutrition. During an interview on 06/22/2024 at 05:00 PM the SLP stated Resident #16 had a difficult swallow response due to the muscle atop of her throat was not functioning well. The muscle referred to as the CP was weak and would allow food to come back up reflux and could enter the airway. The SLP referred to the situation as a CP bar and was complicated by Resident #16's muscular dystrophy and history of strokes. The SLP stated she had evaluated Resident #16 and had recommended Resident #16 to be served a mechanical soft diet specific for ground meats. The SLP stated her definition of mechanical soft would be like the International Dysphagia Diet Standardization Initiative's level 5. The SLP stated her expectation for mechanical soft would include foods which were soft and moist, with no liquid leaking / dripping from the food, where biting is not required, minimal chewing was required, lumps of 4mm in size, lumps can be mashed with the tongue, food could be easily mashed with just a little pressure from a fork, food should be able to be scooped onto a fork, with no liquid dripping and no crumbles falling off the fork. The SLP stated she did not believe a ham sandwich met those requirements. The SLP stated she believed the meats should be ground for a mechanical soft diet and stated a ham sandwich could be served as a ham salad sandwich for residents who required a mechanical soft diet. The SLP stated Resident #16's risk for not receiving mechanical soft foods was choking and aspiration. During an interview on 06/22/2024 at 05:50 PM the Administrator stated she believed the ham sandwich with thinly sliced ham was appropriate for residents who required mechanical soft diets. The Administrator stated she stated she had confidence in the professional guidance from the RD was to support residents with a mechanical soft diet with the lunchmeat sandwiches made with thinly sliced meat. During an interview on 06/23/2024 at 06:10 PM NP L stated she had conferenced with the Medical Director and at this time could not offer opinions on the compatibility for a ham sandwich as prepared and served by the facility for the remaining residents at the facility who were ordered a mechanical soft diet. During an interview on 06/23/2024 at 07:04 PM NP L stated she was the NP for Resident #16. NP L stated she and the Medical Director reviewed Resident #16's medical record and believed a ham sandwich with thinly shaved ham could have been safe for Resident #16 to consume per her mechanical soft diet. 2. A record review of the facility's diet type report dated 06/22/2024 revealed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were identified as in need of a mechanical soft diet texture. A record review of Resident #1's admission record dated 06/27/2024 revealed an admission date of 04/20/2020 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #1's ST - Therapist Progress & Discharge Summary dated 03/07/2024 revealed the SLP recommended Resident #1 was to receive a mechanical soft diet texture. A record review of Resident #1's care plan dated 06/27/2024 revealed Resident #1 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #2's admission record dated 06/27/2024 revealed an admission date of 08/05/2022 with diagnoses which included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior) and dysphagia (difficulty swallowing). Further review revealed Resident #2 was an [AGE] year-old female. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 had a need for a mechanical altered diet. A record review of Resident #2's physician's orders dated 06/27/2024 revealed Resident #2 was ordered on 09/28/2023 to receive a mechanical soft diet texture. A record review of Resident #2's care plan dated 06/27/2024 revealed, provide diet as ordered .mechanical soft texture A record review of Resident #3's admission record revealed an admission date of 10/01/2021 with diagnoses which included dementia (affects memory, thinking, and behavior) and dysphagia (difficulty swallowing). Further review revealed Resident #3 was a [AGE] year-old female. A record review of Resident #3's quarterly MDS assessment dated [DATE] revealed Resident #3 had a need for a mechanical altered diet. A record review of Resident #3's physician's orders dated 06/27/2024 revealed Resident #3 was ordered on 09/05/2023 to receive a mechanical soft diet texture. A record review of Resident #3's care plan dated 06/27/2024 revealed, provide diet as ordered .mechanical soft texture A record review of Resident #4's admission record revealed an admission date of 12/30/2016 with diagnoses which included dementia (affects memory, thinking, and behavior) and dysphagia (difficulty swallowing). Further review revealed Resident #4 was a [AGE] year-old male. A record review of Resident #4's physician's orders dated 06/27/2024 revealed Resident #4 was ordered on 08/14/2023 to receive a mechanical soft diet texture. A record review of Resident #4's care plan dated 06/27/2024 revealed, provide diet as ordered .mechanical soft texture A record review of Resident #5's admission record revealed an admission date of 03/23/2022 with diagnoses which included Alzheimer's disease (a type of dementia which affects memory, thinking, and behavior) and dysphagia (difficulty swallowing). Further review revealed Resident #5 was an [AGE] year-old female. A record review of Resident #5's quarterly MDS assessment dated [DATE] revealed Resident #5 had a need for a mechanical altered diet. A record review of Resident #5's ST - Therapist Progress & Discharge Summary dated 09/05/2023 revealed the SLP recommended Resident #5 was to receive a mechanical soft diet texture. A record review of Resident #5's care plan dated 06/27/2024 revealed, provide diet as ordered .mechanical soft texture A record review of Resident #6's admission record dated 06/27/2024 revealed an admission date of 02/01/2024 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 was an [AGE] year-old male admitted for care requiring a mechanical soft diet texture. A record review of Resident #6's physician's orders dated 06/27/2024 revealed Resident #6 was ordered on 02/01/2024 to receive a mechanical soft diet texture. A record review of Resident #6's care plan dated 06/27/2024 revealed Resident #6 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #7's admission record dated 06/27/2024 revealed an admission date of 03/07/2024 with diagnoses which included dysphagia (difficulty swallowing). A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was an [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #7's physician's orders dated 06/27/2024 revealed Resident #7 was ordered on 03/21/2024 to receive a mechanical soft diet texture. A record review of Resident #7's care plan dated 06/27/2024 revealed Resident #7 required a mechanical soft diet texture. A record review of Resident #8's admission record dated 06/27/2024 revealed an admission date of 10/22/2020 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #8's quarterly MDS assessment dated [DATE] revealed Resident #8 was an [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #8's physician's orders dated 06/27/2024 revealed Resident #8 was ordered on 06/17/2024 to receive a mechanical soft diet texture. A record review of Resident #8's care plan dated 06/27/2024 revealed Resident #8 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #9's admission record dated 06/27/2024 revealed an admission date of 05/26/2023 with diagnoses which included dysphagia (difficulty swallowing). A record review of Resident #9's quarterly MDS assessment dated [DATE] revealed Resident #9 was an [AGE] year-old male admitted for care requiring a mechanical soft diet texture. A record review of Resident #9's physician's orders dated 06/27/2024 revealed Resident #9 was ordered on 08/14/2023 to receive a mechanical soft diet texture. A record review of Resident #9's care plan dated 06/27/2024 revealed Resident #9 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #10's admission record dated 06/27/2024 revealed an admission date of 09/10/2016 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #10's quarterly MDS assessment dated [DATE] revealed Resident #10 was a [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #10's physician's orders dated 06/27/2024 revealed Resident #10 was ordered on 08/14/2023 to receive a mechanical soft diet texture. A record review of Resident #10's care plan dated 06/27/2024 revealed Resident #10 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #11's admission record dated 06/27/2024 revealed an admission date of 01/06/2021 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #11's quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #11's physician's orders dated 06/27/2024 revealed Resident #11 was ordered on 12/15/2023 to receive a mechanical soft diet texture. A record review of Resident #11's care plan dated 06/27/2024 revealed Resident #11 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #12's admission record dated 06/27/2024 revealed an admission date of 12/23/2023 with diagnoses which included Myopathy (a disease of the muscle in which the muscle fibers do not function properly. Myopathy means muscle disease) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #12's quarterly MDS assessment dated [DATE] revealed Resident #12 was a [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #12's physician's orders dated 06/27/2024 revealed Resident #12 was ordered on 01/02/2024 to receive a mechanical soft diet texture. A record review of Resident #12's care plan dated 06/27/2024 revealed Resident #12 resided in the memory care unit and required a mechanical soft diet texture. A record review of Resident #13's admission record dated 06/27/2024 revealed an admission date of 02/23/2019 with diagnoses which included dysphagia (difficulty swallowing) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). A record review of Resident #13's quarterly MDS assessment dated [DATE] revealed Resident #13 was a [AGE] year-old female admitted for care requiring a mechanical soft diet texture. A record review of Resident #13's physician's orders dated 06/27/2024 revealed Resident #13 was ordered on 09/04/2023 to receive a mechanical soft diet texture. A record review of Resident #13's care plan dated 06/27/2024 revealed Resident #13 resided in the memory care unit and required a mechanical soft diet texture. Record review of policies for Resident Food Services with the subject Diet Orders and Other Resident Information (policy #C203, date issued- 5/95; revised date 01/24) on 6/25/2024 at 4:26PM revealed the policy stated: Diet orders should be determined with the resident or responsible party and in accordance with his/her informed choices, goals, and preferences. The responsible physician or designee or qualified dietician/other clinically qualified nutrition professional per state regulations, must order the diet in writing. The community may delegate the task of writing diet orders to a Registered Dietician who is acting within the scope of practice as defined by state law and is under the supervision of a physician. Nursing is responsible for communicating all nutrition related information to the Food and Nutrition department per community protocol. A record review of the International Dysphagia Diet Standardization Initiative's website, https://iddsi.org/IDDSI/media/images/ConsumerHandoutsAdult/5_Minced_Moist_Adults_consumer_handout_30Jan2019.pdf Accessed 06/23/2024, Revealed, Minced and Moist, level 5, minced and moist food for adults; what is this food texture level? Level 5 - minced and moist foods: Soft and moist, but with no liquid leaking / dripping from the food. Biting is not required. minimal chewing required. lumps of 4mm in size. food can be easily managed with just a little pressure from a fork. should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork. Why is this food texture level used for adults? Level 5 minced and moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food but are not able to chew it down into little pieces that are safe to swallow. Minced and moist foods only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It is important that minced and moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or fork . Examples of level 5 minced and moist foods for adults, meat served finely minced or chopped to 4mm lump size served in a thick smooth, non-pouring sauce or gravy .no regular dry bread due to high choking risk! Missing The facility's Administrator was notified and presented with a IJ template on 06/23/2024 at 07:00 PM, a Plan of Removal was requested from the facility. The following Plan of Removal submitted by the facility was accepted on 06/27/2024. Plan of Removal IJ Immediacy Removal Plan F 805 Facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs 06/23/2024. 1. All thin sliced meat options designated for mechanical soft diets were removed from all SNF units, (Unit 1), (unit 2), and (memory care). 6-23-24 2. Dietary Policy, Dietary Spread Sheets, and Dietary Menus were revised to show that all thin sliced meat options designated for Mechanical Soft Diets were removed and appropriate alternates noted. 6-23-24 3. All Staff working in facility were in-serviced by noon on 6-25-24 on Policy #C203 and #C219 , Titled Diet Orders and Other Resident Information and Snacks. The changes removed sandwiches with thinly sliced meats from all documents. In addition, Nursing Unit Stock Item List was updated, Seasonal Menu and Spreadsheets were updated to also reflect removal of thinly sliced meat as an option for mechanical soft diets. These policies will be available for reference by staff located in the Food Service Office, the Facility shared drive and presented as a visual for in-services. 4. Dietary Manager or Dietary Designees will monitor kitchen and all unit refrigerators routinely to ensure that appropriate sandwich options are available. 6-24-24 The Dietary Manager or Designee will be assigned to monitor tray line and sign off as to compliance of correct texture as ordered each meal for 14 days, then each meal twice a week for two weeks then three meal services once a week for 3 months. Administrator or Designee will follow up with meal tray monitor/audit twice a week for 3 months, at random meals to ensure tray line accuracy. Results to be reported to QAPI.