**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure 1 (R127) of 1 Residents who did not have fully signed DNR (do not resuscitate) documents was provided with CPR (Cardiopulmonary Resuscitation). R127 returned from the hospital on 4/6/23. Upon return there is a verbal consent obtained on 4/6/23 from the POA (power of attorney)/daughter on the (CPR) Cardiopulmonary resuscitation consent form & Emergency Care Do Not Resuscitate Order (DNR). Facility staff did not follow up on having R127's POA/daughter sign these forms and the physician did not sign the Emergency Care Do Not Resuscitate Order (DNR). The Facility therefore did not have a valid DNR order. On 4/10/23 R127 experienced a choking episode, became unresponsive was not breathing & pulseless. Facility staff did not administer CPR as they thought R127 was a DNR. Failure to have a fully signed document for DNR and provide CPR in the absence of a signed DNR created a finding of Immediate Jeopardy (IJ), which began on 4/10/23. NHA (Nursing Home Administrator)-A , DON (Director of Nursing)-B and [NAME] President of Success-C were notified of the immediate jeopardy on 3/27/24 at 12:40 p.m. The immediate jeopardy was removed on 3/27/23. However, the deficient practice continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: The Cardiopulmonary Resuscitation (CPR) policy last reviewed/revised 6/30/23 under policy documents It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Under policy explanation and compliance guidelines documents 1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and; a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation transection, or decomposition). R127's diagnoses includes diabetes mellitus, congestive heart failure, Atrial Fibrillation, kidney disease, peripheral vascular disease, right below knee amputation, dysphagia and dementia. R127 was originally admitted to the facility on [DATE], was discharged to the hospital on 3/22/23 and readmitted on [DATE]. R127's POA (power of attorney) for healthcare was activated on 6/7/22. The physician order dated 3/1/23 documents full code. The (CPR) Cardiopulmonary resuscitation consent form is checked for resuscitation and is signed by R127's POA on 3/2/23. The Resident has an advanced directive in place care plan initiated 3/2/23 documents an intervention also dated 3/2/23 of Follow advanced directive per MD (medical doctor) orders. The admission MDS (minimum data set) with an assessment reference date of 3/7/23 has a BIMS (brief interview mental status) score of 10 which indicates moderate cognitive impairment. The eInteract SBAR (situation, background, assessment, and recommendation) dated 3/22/23 at 18:08 (6:08 p.m.) under Nursing observations, evaluation, and recommendations are: Lab results came and creatinine was high; resident had difficulty breathing (used accessory muscles to breath). Under Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: Updated MD (Medical Doctor) [Name] from [Name of Medical Group] about the resident changed of condition and suggested to sent resident in the E.R. (emergency room) and MD [Name] approved it. This SBAR note was written by LPN (Licensed Practical Nurse)-S. R127 was hospitalized from [DATE] to 4/6/23. The hospital Discharge summary dated [DATE] documents Advanced Directives/Goals of Care: Patient is decisional: No. Power of Attorney designee/healthcare agent - Activated: Code Status: Selective treatment/DNR - no CPR/no intubation/no cardioversion. The (CPR) Cardiopulmonary resuscitation consent form is checked for No resuscitation (no cardiopulmonary resuscitation or external defibrillation). Refer to State approved DNR form if required. There is a handwritten notation at the bottom on this consent form which documents Verbal obtained 4/6/23 [Name] POA/daughter. There is no staff signature on this form and the Resident's authorization representative signature & date are blank. The Emergency Care Do Not Resuscitate Order (DNR) is checked for male, with R127's name and date of birth . There is a handwritten notation on the bottom of this consent form which documents verbal DNR obtained 4/6/23 [Name] POA/daughter. The signature for Patient or legal guardian or health care agent of an incapacitated patient & date are blank along with the signature & date of attending health care professional. The above signatures and dates are required for this order to be valid and its intent carried out. The nurses note dated 4/6/23 at 16:57 (4:57 p.m.) documents spoke with [Name], daughter/POA, regarding return to facility, reviewed wounds, wishes to continue DNR, discussed hospice care, is interested will have SW (social worker) follow up. Aware of Amitriptyline, Olanzapine, & Hydroxyzine need for consent, obtained verbal, will be in on Sat (Saturday) 4/8/23 to sign. This nurses note was written by RN (Registered Nurse) Manager-M. The nurses note dated 4/6/23 at 19:13 (7:13 p.m.) documents Resident is 82 Y.O. (year old) male with mild cognitive impairment. DNR (do not resuscitate) and POA [Name] daughter. Alert but confused, able to make needs known. VSS (vital signs stable), afebrile; SOB (shortness of breath) occurs when lying flat and exertion. Eats in room tonight; feeds self, and appetite good. Swallows good and take pills whole. Used urinal and emptied 200 mL; per report from hospital([hospital initials) had BM (bowel movement) this morning. Currently in bed in high fowler's watching TV. Bed is in low position, and call light and urinal within reach. Resident c/o (complained of) pain of 5/10; Tylenol is given as ordered, and was effective per resident upon reassessment. This nurses note was written by LPN-S. The telephone order dated 4/7/23 documents DNR. Surveyor noted this is not a valid DNR order as R127's POA & physician did not sign the required DNR forms. APNP (Advance Practice Nurse Prescriber)-Y initial visit note dated 4/7/23 for code status documents Full Code/Allow Resuscitation. APNP (Advanced Practice Nurse Prescriber)-Y note dated 4/10/23 under code status documents Full Code/Allow Resuscitation. Under subjective documents Patient is seen lying in bed this afternoon. He has had an increase in behaviors and confusion since yesterday. He has been tearful, irritable, restless, positive fall. He now has a black left eye. Staff has had a difficult time redirecting. SW (Social Worker) did reach out to family regarding hospice/palliative care options. Currently awaiting callback from family. ROS (review of systems) questions or not quite as appropriately responsive as the prior day, however he states he is currently comfortable while lying in bed. We will continue close monitoring, plan of care would be ideal to transition to hospice. Warfarin will be discontinued due to multiple repeated falls since admission. The nurses note dated 4/10/23 at 20:31 (8:31 p.m.) documents Around 2030ish, (8:30 p.m.) Resident requested some snacks and was given Peanut Butter and Jelly, and Oatmeal Creme Pie. Then set him up on the table by the lounge by nurses' station with a cup water while watching TV. Approximately 2044 (8:44 p.m.); Nurse one, witnessed in wheelchair ambulating away from TV; resident was looking at something on the wall, nurse witnessed this and asked what are you up to [R127's first name]?. Then resident's head tilted to the right. Nurse attempted to wake resident. Resident didn't respond. Nurse called out for second nurse. Second nurse attempted to arouse resident. Resident stopped breathing and Heimlich maneuver started. Oral sweep attempted but teeth clamped down initially. More abdominal thrusts performed. Approximately 2046 (8:46 p.m.), 911 called. Oral sweep performed, suctioning started, followed by Oxygen therapy. Around 2050ish (8:50 p.m.) EMT (emergency medical technicians) arrived CPR (cardiopulmonary resuscitation) initiated. Approximately 2130 (9:30 a.m.), Resident declared departed by EMT. This nurses note was written by LPN-S. The nurses note dated 4/10/23 at 20:58 (8:58 p.m.) POA (Power of Attorney) updated changing conditions and CPR was initiated by EMT's, POA then request that resident be sent to hospital. At 2132 (9:32 p.m.), [Name] - POA updated that resident departed. Approx 2150 (9:50 p.m.), POA arrived at facility; updated that resident will be sent to [Name of County] Medical Examiner. This note was written by LPN-S. The nurses note dated 4/10/23 at 22:00 (10:00 p.m.) documents At 2045 (8:45 p.m.) writer heard commotion coming for around the corner on the North unit and went to investigate. Observed resident slumped in w/c (wheel chair). LPN was attempting to arouse resident and then performed Heimlich. Informed by LPN that resident was eating immediately prior to event. Resident assessed for respirations, none were apparent Resident was pale/ ashen gray. Writer performed 6 to 7 thrusts from behind the w/c, on one knee reaching around to front of resident and gaining good leverage. These were unsuccessful. Staff instructed to call 911. LPN attempted oral suction. EMTs arrived within minutes and took over care of resident. This note was written by RN (Registered Nurse)-II. The nurses note dated 4/10/23 at 23:04 (11:04 p.m.) documents Medical examiner will send unit to pick up the deceased . This nurses note was written by RN-II. The nurses note dated 4/10/23 at 23:41 (11:41 p.m.) documents Resident transported by [Name of County] Medical Examiner team to Medical Exam Office. [telephone number]. This nurses note was written by LPN-R. The Fire Department patient care report documents unit dispatched on 4/10/23 at 20:49:17 (8:49:17 p.m.) on scene on 4/10/23 at 20:50:49 (8:50:49 p.m.) and at patient on 4/10/23 at 20:50:50 (8:50:50 p.m.) Primary impression documents Respiratory-Foreign Body Airway. Secondary Impression: CV - Cardiac Arrest. Assessment summary on 4/10/23 at 20:50:50 for mental status documents Unresponsive, for chest/lungs documents Breath sounds absent right, breath sounds absent left. Under section chief complaint for complaint type documents Chief (Primary), for Complaint documents pulseless not breathing, for Duration of Complaint documents 10, and for Time Units of Duration of Complaint documents Minutes. Under Narrative documents [Fire Department initials] was dispatched to an assisted living facility for someone choking. Upon arrival a nurse came up to ems (emergency medical services) staff and stated they tried a Heimlich maneuver once they found the patient choking but soon after the pt did not have a pulse. The nurse stated they were going to assist the patient to the ground since he was in a wheel chair but they assumed the patient was a DNR (do not resuscitate). [Fire Department initials] stated they need a properly signed document with a doctor's signature and many of the workers went to the computers to try to get one. [Fire Department initials] found the [AGE] year old male patient in his wheel chair. There was a half eaten sandwich in the room near the patient. The workers stated they thought the pt choked on his peanut butter sandwich. The pt was found by ems crew to not have a pulse and was quickly assisted to the ground with CPR (cardiopulmonary resuscitation) being initiated with a lucas device. The pt's rhythm started in asystole. [Fire Department initials] obtained IO (intraosseous) access in the left leg. [Fire Department initials] cleared the pt's airway by suctioning big chunks of what appeared to be a sandwich. [Fire Department initials] was able to place a green LMA (laryngeal mask airway) in the pt's airway with positive equal breath sounds bilaterally with proper chest rise and fall. [Fire Department initials] administered a total of five epinephrine's during CPR. About the half way marker of the code [Fire Department initials] called for a doctor for further instructions. Doctor 0179 came on and told [Fire Department initials] to continue with ACLS (advanced cardiovascular life support). Doctor 0179 advised [Fire Department initials] to administer 3 grams of calcium and to hold off on epi's after the 5th administration. The pt switched into a wide complex PEA (pulseless electrical activity) rhythm but later switched back to asystole rhythm. ETCO2 (end tital carbon dioxide) remain 60-70 throughout the incident. [Fire Department] initials administered one liter of normal saline via IO throughout the code. No proper paperwork was given to [Fire Department initials] during the code even though the staff continually stated that pt has a DNR. At 2130 (9:30 p.m.) hours doctor 0179 stated to do a thirty second pause check. [Fire Department initials] had no signs of life with an asystole rhythm. Doctor 0179 then called for a 1099 at 2130 hours. Medical examiner was called by [Fire Department initials] with the body being released back to the nursing facility care. On 3/25/24 at 3:13 p.m. Surveyor asked RN (Registered Nurse)-II what staff should do when a resident is choking. RN-II informed Surveyor ask if the resident can cough, speak or breath if not begin Heimlich maneuver. Surveyor asked RN-II if he remembers R127 and if he could tell Surveyor what happened on 4/10/23 when R127 had a choking incident. RN-II informed Surveyor he was passing pills at the end of the hall and heard noise, just the commotion, hurried voices like in distress. RN-II explained R127's unit was around the corner from his unit. Surveyor asked RN-II what he saw. RN-II informed Surveyor the patient was in a wheelchair in front of the nurses station, had been in the lounge area. RN-II informed Surveyor the lounge is across from the nurses station and the nurses station is kind of between the two units. RN-II indicated there were two staff trying to arouse R127. RN-II informed Surveyor he didn't know if they had performed thrusts already but he got behind the chair and gave several thrusts. LPN-R said we have to do CPR, we put him on the floor, I think we began CPR and he had already told staff to call 911. Surveyor asked RN-II did you see staff performing CPR. RN-II replied I can't remember if they had just started or EMT. Surveyor asked RN-II if there is a choking episode is there normally a page. RN-II replied yes but didn't know if there was one but there were 3 of the 4 nurses there. On 3/26/24 at 9:04 a.m. Surveyor spoke with CNA (Certified Nursing Assistant)-T. Surveyor asked CNA-T if R127 could feed himself. CNA- informed Surveyor he could eat himself but he was suppose to be supervised at the time. CNA-T informed Surveyor at the time of the incident, she grabbed the crash cart, stated I wasn't part of the next steps. Surveyor inquired if 911 was called CNA-T informed Surveyor they called 911. Surveyor asked CNA-T if she remembers who called 911. CNA-T informed [name of] LPN-S but she wasn't 100% sure. Surveyor asked CNA-T if she knew who lowered R127 to the floor. CNA-T informed Surveyor she doesn't remember and wasn't sure if it was the ambulance. Surveyor asked CNA-T if she was in the area when the fire department arrived. CNA-T replied yes. Surveyor asked if she remembered when they did. CNA-T informed Surveyor they started chest compressions with the machines, doesn't know for how long but felt like it went on for 40 minutes. On 3/26/24 at 9:28 a.m. Surveyor asked DON (Director of Nursing)-B to show Surveyor where the AED (automated external defibrillator) is located. Surveyor observed there is an AED located in the small alcove opposite room [ROOM NUMBER]. Surveyor observed there is a sign on the defibrillator box stating extra AED pads located in the north nurses station medication room. The AED battery expires 6-2025. Surveyor noted this AED is located in the center hallway of R127's unit. On 3/26/24 at 9:52 a.m. Surveyor spoke with RN Manager-M. Surveyor asked RN Manager-M if codes are called at the Facility. RN Manager-M replied yes. Surveyor inquired what type of codes are there. RN Manager-M informed Surveyor they basically have code blue or stat for what ever the situation is. RN Manager-M the situation is through the phone system, the crash cart comes, and someone grabs the AED as there is one on each unit. Surveyor inquired when a code blue would be called. RN Manager-M informed Surveyor if someone is unresponsive, choking, sometimes if there is a fall with bleeding may call for extra help. Surveyor inquired if the page is overhead. RN Manager-M replied no it goes through all the phones. Surveyor asked if staff was not at the nurses station would they hear the page. RN Manager-M informed Surveyor if staff were in a resident's room they would not hear it and if the nurse was passing meds (medications) and was at the end of the hall they wouldn't hear it. On 3/26/24 a 10:09 a.m. Surveyor spoke with LPN-R on the telephone and asked LPN-R if he could explain to Surveyor what happened the night R127 died. LPN-R informed Surveyor he was coming from the center hall, went by the nurses station, looked to the left and saw R127 rolling towards the nurses station but facing the wall with the light switch. LPN-R informed Surveyor he knows R127 was a fall risk and asked R127 along the lines of what are you up to. LPN-R informed Surveyor R127 kind of looked like he heard him but R127 looked up at the wall, was looking at the wall and then his head tilted to the right then straight down. R127 became unresponsive, he did a sternal rub, saw LPN-S walking towards him and told her to come here. LPN-R informed Surveyor he checked for a pulse, had a faint pulse, and LPN-S pointed out she had just set up R127 with a sandwich. LPN-R informed Surveyor he did an oral sweep, initiated Heimlich maneuver which was not effective, got the suction machine tried to suction him, continued with the Heimlich, at some point R127 no longer had a pulse and no longer was breathing, and informed Surveyor he's not sure from there. LPN-R then informed Surveyor someone called to check the code status and 911 was called but wasn't sure who called 911. LPN-R informed Surveyor they (referring to the fire department) were pretty darn quick, thinks they started CPR compressions. Surveyor asked LPN-R if anyone at the Facility started CPR. LPN-R replied it was the EMT, he was DNR as far as I know. Surveyor asked if anyone brought the AED or crash cart. LPN-R replied crash cart yet, AED no in relation to him being a DNR. Surveyor asked LPN-R if a Resident was choking and became pulseless, not breathing would you start CPR on them. LPN-R replied no, he was not grabbing for his throat, can't say if breathing. Surveyor asked LPN-R how he knew R127 was a DNR. LPN-R replied I called out not sure who I spoke to remember saying pull chart want to see code status even if had a pulse want to know what the code status is. Surveyor asked LPN-R if R127 was his patient. LPN-R informed Surveyor no and he hadn't taken care of R127. On 3/26/24 at 11:12 a.m. Surveyor called [Name of County] medical examiners office and spoke with [Name]. Surveyor asked what R127's cause of death was. [Name] informed Surveyor accidental. The immediate cause is asphyxia due to choking. On 3/26/24 at 1:08 p.m. Surveyor asked RN Manager-M what the process is for obtaining CPR/DNR for a resident. RN Manager-M informed Surveyor on admission the admitting nurse will go over with the patient if they are their own person or if activated then get a determination one way or another. Surveyor asked what happens if a resident is readmitted . RN Manager-M informed Surveyor it gets readdressed each admission. Surveyor asked what happens if a verbal consent is received for CPR/DNR. RN Manager-M informed Surveyor if the POA says they will be in the next week she will leave it on the chart so it can be signed and if they are not local will ask if they want it sent to them. Surveyor inquired who follows up to ensure the POA has signed. RN Manager-M informed Surveyor she knows social service does audits or she would when she is doing a chart review. Surveyor asked how often chart reviews are done. RN Manager-M informed Surveyor on admission and then quarterly. Surveyor asked RN Manager-M if Surveyor was a resident at the Facility and had an activated POA and my POA said they would be in to sign the DNR form when would this be followed up on to make sure my POA came in. RN Manager-M replied depends on charting I would think within a week. Surveyor asked when does the doctor sign. RN Manager-M informed Surveyor they only sign for DNR not full code. Surveyor asked RN Manager-M if a DNR is valid without the POA & doctors signature. RN Manager-M replied that's a good question, I think it would be if a family member told me, would write verbal consent. RN Manager-M informed Surveyor once the family signs then they would have the doctor sign. Surveyor asked RN Manager-M what happens if there is a verbal consent, the signatures haven't been obtained and the resident stops breathing & is pulseless. RN Manager-M informed Surveyor she would call the family & asked what the wishes are. RN Manager-M informed Surveyor she doesn't know if she would start CPR and doesn't know if she's come across that situation. Surveyor asked RN Manager-M what the protocol is if a Resident is choking. RN Manager-M informed Surveyor if the resident is choking & breathing would try to get them to cough and do the Heimlich maneuver. If they are having trouble breathing call 911, we would still treat them. Surveyor asked if a resident was choking & stopped breathing would they start CPR. RN Manager-M informed Surveyor guess to error on the sign of caution would start CPR. If can't get a hold of family and CPR/DNR is not signed I don't know, would have to be clarified. On 3/26/24 at 1:48 p.m. Surveyor asked LPN-S how she knows if a Resident is DNR or CPR. LPN-S informed Surveyor it's in PCC (pointclickcare) and in their chart. LPN-S explained in PPC when you click profile you can see code status and in paper chart it's after profile. Surveyor asked LPN-S if she could explain to Surveyor what happened the night R127 choked. LPN-S informed Surveyor she was at the desk. R127 wheeled himself next to her and asked for a snack, he wanted a sandwich. LPN-S informed Surveyor she asked if he wanted a peanut butter and jelly sandwich. LPN-S informed Surveyor she placed a bed side table side ways in the lounge area as R127 wanted to watch TV with the sandwich and water. LPN-S indicated she placed the bed side table so they could see R127. LPN-S informed Surveyor when R127 was eating she was doing charting or she had her check list of what she had done at the nurses station. LPN-S informed Surveyor there was a light on in a Resident's room, a CNA came and told her the resident wanted a boost. LPN-S informed Surveyor she yelled she was going to help the aide and went to the room. LPN-S informed Surveyor there was a CNA at the desk and LPN-R was on the other side. LPN-S informed Surveyor when she came out LPN-R called her name, R127 was facing the wall, his neck tilted to the right. LPN-R was rubbing R127's chest, R127 was not visibly breathing, LPN-S indicated she told LPN-R R127 was just eating and LPN-R jumped to the conclusion R127 was choking and started the Heimlich maneuver. LPN-S said she check R127's wrist and carotid for pulse. Surveyor asked if R127 had a pulse. LPN-S replied no and not visibly breathing. LPN-R attempted a oral sweep but the teeth were clamped down so did more Heimlich maneuver. LPN-R ask what kind of status he has. LPN-S told him DNR. LPN-R said we need to do suction, the other CNA got the crash cart and LPN-R tried to use suction. Surveyor inquired if LPN-R was able to remove any food. LPN-S replied no nothing, seems like a little bit of powder. We assumed bread. We used oxygen therapy and called 911. Surveyor asked LPN-S who called 911. LPN-S informed Surveyor she did. Surveyor asked LPN-S how long was it between when she went over to LPN-R until 911 was called. LPN-S stated think it was about 10 minutes then stated maybe 5. Surveyor asked LPN-S if she or LPN-R did CPR. LPN-S replied no we didn't do CPR we grabbed crash cart to use suction and oxygen therapy. LPN-S informed Surveyor when the EMT came they asked us about code status. I told them R127 was DNR. LPN-S informed Surveyor an EMT told her to call R127's POA. Surveyor asked LPN-S what she said to R127's POA. LPN-S informed Surveyor she asked the daughter if she was coming, your dad is not feel good right now, not breathing was eating a peanut butter and jelly sandwich. The daughter asked did you do CPR, did you save my dad, told her we couldn't do that because your dad is DNR. The daughter/POA told LPN-S she wants to change it wants us to save her dad. Surveyor asked LPN-S if the EMT's asked for any code status paperwork. LPN-S informed Surveyor there was paperwork for DNR but it was just verbal. Surveyor asked LPN-S if anyone paged a code. LPN-S replied no. Surveyor asked if she knew why a code wasn't called. LPN-S informed Surveyor it didn't cross her mind. Surveyor asked LPN-S why didn't she call 911 right away. LPN-S informed Surveyor they were checking R127's pulse, LPN-R was conversing with her, R127 was eating a sandwich after that need to do suction, it was going on so fast, we tried to provide basic needs best we can, tried to provide everything we can use then call 911. On 3/26/24 at 2:28 p.m. Surveyor asked DON-B for facility's choking policy and any investigation regarding R127 on 4/10/23 & any education provided. DON-B informed Surveyor the Facility does not have a choking policy. Surveyor was provided with an incident report dated 4/10/23, a handwritten statement from RN-II, staff statements obtained by Prior DON-NN from RN-II, LPN-S, & LPN-R, preliminary autopsy findings, and education provided to Social Service. Surveyor noted RN-II's handwritten statement dated 4/10/23 documents Heard nurses on north unit talking to one another. Hear CNA say who is supervisor? Should I get [RN-II's first name]. I walked over to unit and saw [LPN-R's first name] and [LPN-S's first name] with patient in w/c (wheelchair). [LPN-R's first name] attempted Heimlich on patient. [LPN-S first name] tried from front as [LPN-R's first name] applied O2 (oxygen)/attempted suctioning. I got down and wrapped arms around chair and patient attempting Heimlich. I wanted patient on the floor for CPR and 911 called since this started as choking. Nurses both said he was no code. 911 was called. [LPN-S first name] phone with daughter. Daughter wanted CPR continued. Fireman had started when thy got here until shown no code order. Patient was pronounced. Staff hoyered patient to bed. The facility's failure to ensure R127 had a fully signed DNR document and CPR not being performed led to a finding of immediate jeopardy. The immediate jeopardy was removed on 3/27/24 when the facility implemented the following action plan: * The DON initiated re-education of following resident choice for code status and ensuring medical record has a code status noted upon admission. This re-education will be completed with licensed nurses prior to next scheduled shift. * The DON initiated re-education with current floor staff on the facility's code response procedure. * The SW (Social Worker) or designee initiated an audit of in house resident to determine CPR wishes are on file and accurate. * Code drills were started once per shift for 48 hours and 3 per week, involving each shift for 4 weeks. * The Director of Nursing and Social Services completed an audit of current in house residents to assure code status form and order was in electronic medical record. Interdisciplinary team reviewed cardiopulmonary policy with Medical Director including an ad hoc QAPI meeting. * The Director of Nursing/designee to initiate interviews of 5 nurses per week x 4 weeks on various shifts using case studies and what if scenarios to validate understanding and expectations required during a choking or code situation. * DON/designee will audit new admissions and readmissions to ensure code status and orders are present x 8 weeks. Results of the above audits will be brought to the QAPI committee for further recommendations, if warranted. * An ad hoc QAPI completed with Executive Director, Medical Director, Social Worker, Director of Nursing, IDT (interdisciplinary team), and VPS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R45 was admitted to the facility on [DATE]. On 3/24/24 at 10:01 AM R45 was not in their room for screening for the recertification survey. R45 had a fall this morning and was sent out to the hospital. There were non-skid strips on the floor by the bed. R45's medical record was reviewed by Surveyor. R45 has an activated Power of Attorney for Healthcare. The Hospital Summary from 3/24/24 includes, on Eliquis (blood thinner) with known Right SDH (subdural hematoma) s/p (status post) Right [NAME] holes for evacuation (11/2023), Right craniotomy for SDH evacuation (01/09/24), and MMA (middle meningeal artery) embolization (01/14/24). R45 presented on 3/24/2024 after an unwitnessed fall with head injury. Imaging re-demonstrated known Right SDH with acute component. R45's Fall Assessments were reviewed with the following: On 11/25/24 at 7:15 AM R45 was observed on the floor next to their bed on their knees. R45 Just took their self to the toilet. R45 had gripper socks on their feet. There was no injury noted. -Neuro checks completed with assessment. -New intervention to offer toileting between 5-6 AM. -There was no prior falls. The new intervention for toileting between 5 -6 AM was added to R45's plan of care. R45's Fall Assessments were reviewed with the following: On 11/29/23 at 7:15 AM R45 was observed on the floor parallel to the bed. Had gripper socks on. -non-skid strips next to bed. -neuro checks started and was assessed. -There was no injury. The Fall Assessment did NOT include any information leading up to the fall. It did not include if the toileting intervention was followed. On 3/25/24 at 2:39 PM Surveyor spoke with (Licensed practical Nurse) LPN-O who completed the Fall Assessment Investigation. LPN-O indicated 1st shift starts at 6:00 AM. The staff statement was from the 1st shift certified nursing assistant. The Investigation Form indicates they were unaware of any toileting prior to the fall. LPN-O indicated R45 usually takes themselves, however needs assist. LPN-O did not know of any documentation prior to the fall occurrence. LPN-O indicates the Unit Manager gathers the information related to the fall. LPN-O could not recall any other details. On 3/25/24 at 2:50 PM LPN-O provided Surveyor with a Documentation Survey Report from November 2023. On 11/29/23 for the 3rd shift (10:00 PM - 6:00 AM) there is one entry that indicates toilet use. R45 is totally dependent with 1 assist and had toilet use at 5:40 AM. On 3/26/24 at 9:28 AM Surveyor spoke with (Registered Nurse/ Unit Manager) RN UM-M. R45's Fall Investigation information was reviewed at this time. The fall on 11/29/23 at 7:15 AM did not include any information from the 3rd shift. There was no documentation of events leading up to the fall occurrence. RN UM-M indicated they would gather information to determine if fall interventions were in place. This Fall Investigation does not contain information related to the fall. There was no injuries noted. There should have been information from the prior shift. On 3/26/24 at 3:42 PM at the facility Exit Meeting. Surveyor shared the concerns with R45's 11/29/23 fall assessment. No additional information was provided. Based on interview and record review the Facility did not ensure each Resident received adequate supervision and assistance devices to prevent accidents for 3 (R127, R63, & R45) of 8 Residents. R127 was readmitted to the facility on [DATE]. The hospital discharge summary for a discharge date of 4/6/23, under discharge recommendations documents 5. Diet: Diabetic (carb controlled) diet, low sodium; add protein supplements with meals (sugar free gelatin and low carb Glucerna). Per Speech Therapy: 1) Cont (continue) general solids, thin liquids; constant supervision/assist for all intake. 2) Meds (medication) whole in puree or with sips of liquid (minimum of 3 oz (ounce) liquid wash following same). 3) Small bites/sips, alternate solids/liquids consistently, slow pacing, stop intake if coughing increased, reflux precautions. The speech evaluation dated 4/7/23 documents R127 required supervision 91 to 100% of the time and food feeling of stuck. Swallowing strategies included alternation of liquids/solids, bolus size modifications, rate modification and general swallow techniques/precautions, along with the following maneuvers: upright posture during meals and upright posture for > (greater) 30 mins (minutes) after meals. Reflux precautions. R127's care plan was not revised to include supervision and swallowing strategies. On 4/10/23 R127 requested a snack and was provided with a peanut butter and jelly sandwich. R127 was given this sandwich with a glass of water on a bed side table in the lounge area with the TV located across the hallway from the nurses station. R127 was eating the sandwich approximately 20 feet from where staff were located behind the nurses station. LPN-S who provided R127 with the sandwich indicated she yelled to staff she was going to help a CNA boost another Resident and there was a CNA doing charting at the nurses station & LPN-R was on the other hall. LPN-R informed Surveyor he came from the center hall, turned left and looked to the left where he saw R127 who was a fall risk and asked R127 along the lines of what are you up to. LPN-R informed Surveyor R127 kind of looked like he heard him but R127 looked up at the wall, was looking at the wall and then his head tilted to the right then straight down. R127 became unresponsive and he did a sternal rub. LPN-R saw LPN-S walking towards him and told her to come here. LPN-R informed Surveyor he checked for a pulse, had a faint pulse, and LPN-S pointed out she had just set up R127 with a sandwich. LPN-R informed Surveyor he did an oral sweep, initiated Heimlich maneuver which was not effective, got the suction machine tried to suction him, continued with the Heimlich, at some point R127 no longer had a pulse and no longer was breathing. 911 was called. Upon arrival at 8:50 p.m. the Fire Department was informed by staff they tried a Heimlich maneuver once they found the patient choking but soon after the pt did not have a pulse. The fire department provided CPR to R127 and cleared the pt's airway by suctioning big chunks of what appeared to be a sandwich. Cardiopulmonary resuscitation care was provided to R127 until 9:30 p.m. when had no signs of life with an asystole rhythm and R127 was declared. Failure to provide adequate supervision when R127 was eating a peanut butter & jelly sandwich which led to a choking incident and subsequent death created a finding of Immediate Jeopardy (IJ), which began on 4/10/23. NHA (Nursing Home Administrator)-A , DON (Director of Nursing)-B and [NAME] President of Success-C were notified of the immediate jeopardy on 3/27/24 at 12:40 p.m. The immediate jeopardy was removed on 3/28/24. However, the deficient practice continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan & as evidenced by the following examples: * R63's falls on 4/4/23 & 7/9/23 were not thoroughly investigated and the root cause was not determined to help prevent further falls. * R45's fall on 11/29/23 was not thoroughly investigated and the root cause was not determined to help prevent further falls. Findings include: The NSG (nursing) Accident and Supervision policy revised 7/14/22 under policy documents: The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Under Policy Explanation and Compliance Guidelines documents: 2. Evaluation and Analysis: the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc. 4. Monitoring and Modification - Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions. c. Modifying or replacing interventions as needed. d. Evaluating the effectiveness of new interventions. 5. Supervision - Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment. R127's diagnoses includes diabetes mellitus, congestive heart failure, Atrial Fibrillation, kidney disease, peripheral vascular disease, right below knee amputation, dysphagia and dementia. R127 was originally admitted to the facility on [DATE], was discharged to the hospital on 3/22/23 and readmitted on [DATE]. R127's POA (power of attorney) for healthcare was activated on 6/7/22. The increased nutrient needs care plan initiated 3/1/23 documents the following interventions: * Eating - (SPECIFY: independent, assist of 1, setup, supervision). Initiated 3/1/23. * Provide diet as ordered - Consistent carbohydrate, low sodium diet; regular texture Initiated 3/1/23. * Administer medications as ordered. Initiated 3/3/23. * Administer vitamin/mineral supplements as ordered. Initiated 3/3/23. * Fluid restriction as ordered. Initiated 3/3/23. * Honor advanced directives r/t (related to) nutritional/hydration support. Initiated 3/3/23. * Honor food preferences. Initiated 3/3/23. * Obtain labs as ordered and notify MD of results. Initiated 3/3/23. * Provide supplements as ordered. Initiated 3/3/23. * Record weight per facility protocol/MD orders. Initiated 3/3/23. * Review weights and notify RD (Registered Dietitian), MD and responsible party of significant weight change. Initiated 3/3/23. * Document % (percentage) of meals consumed. Initiated 3/13/23. * Monitor status of skin integrity per nursing report/WAR (weekly at risk); f/u (follow up) with rec (recommendations) prn (as needed) and per pt (patient) preference. Initiated 3/13/23. * Nutrition edu (education) prn/as welcomed by pt. Initiated 3/13/23. The admission MDS (minimum data set) with an assessment reference date of 3/7/23 has a BIMS (brief interview mental status) score of 10 which indicates moderate cognitive impairment. R127 is assessed as not having any behavior, is independent with set up help for eating, and does not have any signs or symptoms of possible swallowing disorder or dental concerns. The physician orders dated 3/1/23 documents Consistent Carbohydrate diet Regular texture, Regular/Thin consistency, 2000 cc (cubic centimeters) fluid restriction. This order was discontinued when R127 was discharged to the hospital. The nutrition assessment note dated 3/13/23 by Dietitian-W documents Diet order: Consistent Carb (carbohydrate) diet. 2000 mL (milliliter) FR (fluid restriction) Average meal intake: 75-100% with snacks. Eating ability: Independent. Current weight: W 186.2 lb pounds - 3/9/2023 12:59 Scale: Wheelchair scale. BMI (body mass index): 33. Weight stable. Skin condition: Pressure injury Other. No edema present. Summary: Current diet order remains appropriate for management of resident Resident appears to be tolerating diet texture/consistency. Resident is consuming adequate calories to maintain weight. Current diet order/oral nutritional supplement(s) order provides adequate calories/protein to meet estimate nutritional needs. Resident is receiving diet of choice. Weight remains stable without significant variances. Resident has potential for weight fluctuation r/t (related to) fluid shifts. No new recommendations needed at this time. Will continue to monitor. PCC (pointclickcare) BMI adjusted to account for right BKA (below knee amputation). Continue current nutrition plan of care. The eInteract SBAR (situation, background, assessment, and recommendation) dated 3/22/23 at 18:08 (6:08 p.m.) under Nursing observations, evaluation, and recommendations are: Lab results came and creatinine was high; resident had difficulty breathing (used accessory muscles to breath). Under Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: Updated MD (Medical Doctor) [Name] from [Name of Medical Group] about the resident changed of condition and suggested to sent resident in the E.R. (emergency room) and MD [Name] approved it. This SBAR note was written by LPN (Licensed Practical Nurse)-S. R127 was hospitalized from [DATE] to 4/6/23. The hospital discharge summary for discharge date of 4/6/23 under discharge recommendations documents 5. Diet: Diabetic (carb controlled) diet, low sodium; add protein supplements with meals (sugar free gelatin and low carb Glucerna). Per Speech Therapy: 1) Cont (continue) general solids, thin liquids; constant supervision/assist for all intake. 2) Meds (medication) whole in puree or with sips of liquid (minimum of 3 oz (ounce) liquid wash following same). 3) Small bites/sips, alternate solids/liquids consistently, slow pacing, stop intake if coughing increased, reflux precautions. R127's nutrition care plan was not revised to include hospital speech therapy recommendations from the Discharge summary dated [DATE] of Small bites/sips, alternate solids/liquids consistently, slow pacing, stop intake if coughing increased, reflux precautions. The physician orders dated 4/6/23 documents May follow dietitian's recommendations and document fluid intake from meals. On 2000 cc fluid restriction. The nurses note dated 4/6/23 documents Resident is 82 Y.O. (year old) male with mild cognitive impairment. DNR (do not resuscitate) and POA [Name] daughter. Alert but confused, able to make needs known. VSS (vital signs stable), afebrile; SOB (shortness of breath) occurs when lying flat and exertion. Eats in room tonight; feeds self, and appetite good. Swallows good and take pills whole. Used urinal and emptied 200 mL; per report from hospital([hospital initials) had BM (bowel movement) this morning. Currently in bed in high fowler's watching TV. Bed is in low position, and call light and urinal within reach. Resident c/o (complained of) pain of 5/10; Tylenol is given as ordered, and was effective per resident upon reassessment. This nurses note was written by LPN-S. The speech evaluation and plan of treatment dated 4/7/23 under the section Clinical Bedside Assessment of Swallowing for Solids Assessed documents Solids Assessed = Unable to assess at this time (Attempted to grab snack for assessment - unable to find a snack in multiple locations at facility). For Thin Liquids documents Thin Liquids = Mild, Clinical S/S (signs/symptoms) Dysphagia: Slight wet vocal quality noted after the swallow on single and sequential sips. For Oral Containment documents How often does patient exhibit difficulty with oral containment/secretion management? = 0-25% of the time. For Supervision documents How often does patient require supervision/assistance at mealtime d/t (due to) swallow safety? = 91-100% of the time. For Esophageal Phase documents Esophageal: Patient/medical record indicates: Foods feeling stuck. Pt reports infrequent heartburn. Under the section Recommendations for Recommended documents Liquids = Thin liquids. Solids = Regular textures. For Swallow Strategies documents Compensatory Strategies/Positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: alternation of liquids/solids, bolus size modifications, rate modification and general swallow techniques/precautions, along with the following maneuvers: upright posture during meals and upright posture for > (greater) 30 mins (minutes) after meals. Reflux precautions. The Medicare 5 day MDS with an assessment reference date of 4/10/23 did not assess R127's cognition. R127 is assessed as having physical, verbal, other, and refusal of care for one to three days. Is independent with eating, and does not have swallowing disorder. No is checked for mechanically altered diet and yes for therapeutic diet. R127 does not have any dental concerns. APNP (Advanced Practice Nurse Prescriber)-Y note dated 4/10/23 under subjective documents Patient is seen lying in bed this afternoon. He has had an increase in behaviors and confusion since yesterday. He has been tearful, irritable, restless, positive fall. He now has a black left eye. Staff has had a difficult time redirecting. SW (Social Worker) did reach out to family regarding hospice/palliative care options. Currently awaiting callback from family. ROS (review of systems) questions or not quite as appropriately responsive as the prior day, however he states he is currently comfortable while lying in bed. We will continue close monitoring, plan of care would be ideal to transition to hospice. Warfarin will be discontinued due to multiple repeated falls since admission. The nurses note dated 4/10/23 at 20:31 (8:31 p.m.) documents Around 2030ish, (8:30 p.m.) Resident requested some snacks and was given Peanut Butter and Jelly, and Oatmeal Creme Pie. Then set him up on the table by the lounge by nurses' station with a cup water while watching TV. Approximately 2044 (8:44 p.m.); Nurse one, witnessed in wheelchair ambulating away from TV; resident was looking at something on the wall, nurse witnessed this and asked what are you up to [R127's first name]?. Then resident's head tilted to the right. Nurse attempted to wake resident. Resident didn't respond. Nurse called out for second nurse. Second nurse attempted to arouse resident. Resident stopped breathing and Heimlich maneuver started. Oral sweep attempted but teeth clamped down initially. More abdominal thrusts performed. Approximately 2046 (8:46 p.m.), 911 called. Oral sweep performed, suctioning started, followed by Oxygen therapy. Around 2050ish (8:50 p.m.) EMT (emergency medical technicians) arrived CPR (cardiopulmonary resuscitation) initiated. Approximately 2130 (9:30 a.m.), Resident declared departed by EMT. This nurses note was written by LPN-S. The nurses note dated 4/10/23 at 20:58 (8:58 p.m.) POA (Power of Attorney) updated changing conditions and CPR was initiated by EMT's, POA then request that resident be sent to hospital. At 2132 (9:32 p.m.), [Name] - POA updated that resident departed. Approx 2150 (9:50 p.m.), POA arrived at facility; updated that resident will be sent to [Name of County] Medical Examiner. This note was written by LPN-S. The nurses note dated 4/10/23 at 22:00 (10:00 p.m.) documents At 2045 (8:45 p.m.) writer heard commotion coming for around the corner on the North unit and went to investigate. Observed resident slumped in w/c (wheel chair). LPN was attempting to arouse resident and then performed Heimlich. Informed by LPN that resident was eating immediately prior to event. Resident assessed for respirations, none were apparent Resident was pale/ ashen gray. Writer performed 6 to 7 thrusts from behind the w/c, on one knee reaching around to front of resident and gaining good leverage. These were unsuccessful. Staff instructed to call 911. LPN attempted oral suction. EMTs arrived within minutes and took over care of resident. This note was written by RN (Registered Nurse)-II. The nurses note dated 4/10/23 at 23:04 (11:04 p.m.) documents Medical examiner will send unit to pick up the deceased . This nurses note was written by RN-II. The nurses note dated 4/10/23 at 23:41 (11:41 p.m.) documents Resident transported by [Name of County] Medical Examiner team to Medical Exam Office. [telephone number]. This nurses note was written by LPN-R. The Fire Department patient care report documents unit dispatched on 4/10/23 at 20:49:17 (8:49:17 p.m.) on scene on 4/10/23 at 20:50:49 (8:50:49 p.m.) and at patient on 4/10/23 at 20:50:50 (8:50:50 p.m.) Primary impression documents Respiratory-Foreign Body Airway. Secondary Impression: CV - Cardiac Arrest. Assessment summary on 4/10/23 at 20:50:50 for mental status documents Unresponsive, for chest/lungs documents Breath sounds absent right, breath sounds absent left. Under section chief complaint for complaint type documents Chief (Primary), for Complaint documents pulseless not breathing, for Duration of Complaint documents 10, and for Time Units of Duration of Complaint documents Minutes. Under Narrative documents [Fire Department initials] was dispatched to an assisted living facility for someone choking. Upon arrival a nurse came up to ems (emergency medical services) staff and stated they tried a Heimlich maneuver once they found the patient choking but soon after the pt did not have a pulse. The nurse stated they were going to assist the patient to the ground since he was in a wheel chair but they assumed the patient was a DNR (do not resuscitate). [Fire Department initials] stated they need a properly signed document with a doctor's signature and many of the workers went to the computers to try to get one. (Cross-reference F678). [Fire Department initials] found the [AGE] year old male patient in his wheel chair. There was a half eaten sandwich in the room near the patient. The workers stated they thought the pt choked on his peanut butter sandwich. The pt was found by ems crew to not have a pulse and was quickly assisted to the ground with CPR (cardiopulmonary resuscitation) being initiated with a lucas device. The pt's rhythm started in asystole. [Fire Department initials] obtained IO (intraosseous) access in the left leg. [Fire Department initials] cleared the pt's airway by suctioning big chunks of what appeared to be a sandwich. [Fire Department initials] was able to place a green LMA (laryngeal mask airway) in the pt's airway with positive equal breath sounds bilaterally with proper chest rise and fall. [Fire Department initials] administered a total of five epinephrine's during CPR. About the half way marker of the code [Fire Department initials] called for a doctor for further instructions. Doctor 0179 came on and told [Fire Department initials] to continue with ACLS (advanced cardiovascular life support). Doctor 0179 advised [Fire Department initials] to administer 3 grams of calcium and to hold off on epi's after the 5th administration. The pt switched into a wide complex PEA (pulseless electrical activity) rhythm but later switched back to asystole rhythm. ETCO2 (end tital carbon dioxide) remain 60-70 throughout the incident. [Fire Department] initials administered one liter of normal saline via IO throughout the code. No proper paperwork was given to [Fire Department initials] during the code even though the staff continually stated that pt has a DNR. At 2130 (9:30 p.m.) hours doctor 0179 stated to do a thirty second pause check. [Fire Department initials] had no signs of life with an asystole rhythm. Doctor 0179 then called for a 1099 at 2130 hours. Medical examiner was called by [Fire Department initials] with the body being released back to the nursing facility care. On 3/26/24 at 8:14 a.m. Surveyor spoke with ST (Speech Therapist)-LL regarding R127. ST-LL informed Surveyor she was not the speech therapist when R127 was at the Facility. ST-LL looked at the Facility's speech therapy records and informed Surveyor R127 had a speech evaluation with one treatment. The Facility speech therapist at this time recommended solids with thin liquids and constant supervision. On 3/26/24 at 8:32 a.m. Surveyor asked Rehab Director-MM how nursing staff are aware of speech therapy's recommendations. Rehab Director-MM explained they have communication sheets which are given to dietary and nursing so they can be care planned and put on the Resident's diet slip. On 3/26/24 at 9:04 a.m. Surveyor spoke with CNA (Certified Nursing Assistant)-T. Surveyor asked CNA-T if R127 could feed himself. CNA- informed Surveyor he could eat himself but he was suppose to be supervised at the time. Surveyor asked CNA-T if she could explain to Surveyor what happened to R127 on 4/10/23 when R127 died. CNA-T informed Surveyor she was charting at the desk, basically in here to supervise him eating as R127 was given a little snack after dinner. Surveyor asked CNA-T what she means by supervising. CNA-T replied have to be in the vicinity of where he is, small bites and things like that. CNA-T informed Surveyor she and a nurse were at the nurses station and R127 was at a table, showing Surveyor the lounge R127 was in. Surveyor asked CNA-T if she was behind the desk when R127 was in the lounge. CNA-T replied yes charting. CNA-T informed Surveyor when R127 was finished he wheeled himself right by the garbage can, was messing with the light switch and [Name of] LPN-R, the other nurse saying hi to him, what are you doing buddy, R127 kind of had a blank stare, looking through LPN-R. R127 kind of nodded off unresponsive. CNA-T informed Surveyor what happened next is the fuzzy part. CNA-T informed Surveyor she grabbed the crash cart, stated I wasn't part of the next steps. On 3/26/24 at 9:52 a.m. Surveyor asked RN (Registered Nurse) Manager-M if a Resident requires constant supervision where should staff be in relationship to the Resident. RN Manager-M informed Surveyor the Resident would eat in the dining room or if the Resident eats in their room then staff should be in the room during the meal. Surveyor asked what if a Resident requests a snack would staff be in a room with the Resident. RN Manager-M informed Surveyor if they are in their room staff should be in the room or if in a common area in line of sight. Surveyor asked can staff be doing their charting while the Resident has their snack. RN Manager-M informed Surveyor if they are at the same table they could be. Surveyor asked if staff could be charting behind the nurses station when a Resident is having a snack in the lounge or in the hall. RN Manager-M informed Surveyor she would have the expectation they would be near to the resident. On 3/26/24 a 10:09 a.m. Surveyor spoke with LPN-R on the telephone and asked LPN-R if he could explain to Surveyor what happened the night R127 died. LPN-R informed Surveyor he was coming from the center hall, went by the nurses station, looked to the left and saw R127 rolling towards the nurses station but facing the wall with the light switch. LPN-R informed Surveyor he knows R127 was a fall risk and asked R127 along the lines of what are you up to. LPN-R informed Surveyor R127 kind of looked like he heard him but R127 looked up at the wall, was looking at the wall and then his head tilted to the right then straight down. R127 became unresponsive, he did a sternal rub, saw LPN-S walking towards him and told her to come here. LPN-R informed Surveyor he checked for a pulse, had a faint pulse, and LPN-S pointed out she had just set up R127 with a sandwich. LPN-R informed Surveyor he did an oral sweep, initiated Heimlich maneuver which was not effective, got the suction machine tried to suction him, continued with the Heimlich, at some point R127 no longer had a pulse and no longer was breathing, and informed Surveyor he's not sure from there. LPN-R then stated someone checked the code status and not sure who called 911. Surveyor asked LPN-R if R127 was his patient. LPN-R informed Surveyor no and he hadn't taken care of R127. Surveyor asked LPN-R if a Resident requires supervision while eating where would staff have to be. LPN-R replied within viewing distance, I suppose don't have to be on top of them. On 3/26/24 at 11:12 a.m. Surveyor called [Name of County] medical examiners office and spoke with [Name]. Surveyor asked what R127's cause of death was. [Name] informed Surveyor accidental. The immediate cause is asphyxia due to choking. On 3/26/24 at 1:27 p.m. a Surveyor asked DM (Dietary Manager)-JJ if peanut butter and jelly sandwiches are made in the kitchen or on the unit. DM-JJ informed Surveyor they make the sandwiches in the kitchen and the sandwiches are given to the nurses. Surveyor inquired what type of snacks are given to Residents. DM-JJ informed Surveyor they have peanut butter & jelly sandwiches, string cheese, crackers, fruit, oatmeal cream pie, chocolate pies, diabetic cookie. DM-JJ indicated they use wheat bread for their sandwiches. On 3/26/24 at 1:48 p.m. Surveyor spoke to LPN-S regarding R127. Surveyor asked LPN-S if R127 could feed himself. LPN-S informed Surveyor R127 could feed himself but part of their care plan was to supervise or watch him. Surveyor asked LPN-S why R127 had to be supervised. LPN-S informed Surveyor had a situation when came back from hospital R127 had swallowing problems. LPN-S informed Surveyor when R127 came back from the hospital they have to do supervision when he eats. Surveyor asked what supervision means. LPN-S informed when eating can see him. Surveyor asked when R127 was eating did he have to alternate liquids and solids. LPN-S informed Surveyor he could just eat normal foods. Surveyor then asked LPN-S if R127 took a bite of chicken would R127 then have to take a drink of a liquid after. LPN-S replied no. Surveyor asked LPN-S if she could explain to Surveyor what happened the night R127 choked. LPN-S informed Surveyor she was at the desk. R127 wheeled himself next to her and asked for a snack, he wanted a sandwich. LPN-S informed Surveyor she asked if he wanted a peanut butter and jelly sandwich. LPN-S informed Surveyor she placed a bed side table side ways in the lounge area as R127 wanted to watch TV with the sandwich and water. LPN-S indicated she placed the bed side table so they could see R127. LPN-S informed Surveyor when R127 was eating she was doing charting or she had her check list of what she had done at the nurses station. LPN-S informed Surveyor there was a light on in a Resident's room, a CNA came and told her the resident wanted a boost. LPN-S informed Surveyor she yelled she was going to help the aide and went to the room. LPN-S informed Surveyor there was a CNA at the desk and LPN-R was on the other side. LPN-S informed Surveyor when she came out LPN-R called her name, R127 was facing the wall, his neck tilted to the right. LPN-R was rubbing R127's chest, R127 was not visibly breathing, LPN-S indicated she told LPN-R R127 was just eating and LPN-R jumped to the conclusion R127 was choking and started the Heimlich maneuver. LPN-S said she checked R127's wrist and carotid for pulse. Surveyor asked if R127 had a pulse. LPN-S replied no and not visibly breathing. LPN-R attempted a oral sweep but the teeth were clamped down so did more Heimlich maneuver. LPN-R ask what kind of status he has. LPN-S told him DNR. LPN-R said we need to do suction, the other CNA got the crash cart and LPN-R tried to use suction. Surveyor inquired if LPN-R was able to remove any food. LPN-S replied no, nothing, seems like a little bit of powder. We assumed bread. We used oxygen therapy and called 911. On 3/26/24 at 2:18 p.m. Surveyor asked LPN-S to show Surveyor where in the lounge she placed R127 to eat the peanut butter and jelly sandwich. LPN-S showed Surveyor where she had placed R127. Surveyor noted R127 was approximately 20 feet away from the nurses station. On 3/26/24 at 4:07 p.m. Surveyor asked LPN-S if R127 usually asked for a peanut butter a[TRUNCATED]