**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents, who were on dysphagia (difficulty chewing and swallowing) minced and moist (mechanical-soft texture modified diet for difficulty chewing and swallowing) diet received food consistent with diet order and according to the minced and moist diet menu recipe for seven of eight sampled resident (Resident 10, 11, 50, 53, 62, 81, and 83). The facility failed to: 1. Ensure the Dietary Supervisor (DS), who was overseeing meal preparation, [NAME] (CK 1) who was preparing the residents' meals, and Licensed Vocational Nurse (LVN 4), who was validating the meal on residents' trays for diet appropriateness and food texture before meal was served to the residents, ensured Resident 10, 11, 50, 53, 62, 81, and 83 received correct food consistency per their prescribed diet. 2. Ensure Resident 10, 11, 50, 53, 62, 81, and 83 did not receive a ground pimento cheese salad sandwich (sandwich included two slices of regular [not minced] white bread, including the crust, with a scoop of ground pimento cheese in between slices of bread, and sliced in half) on their lunch trays 8/14/2024, which was not in accordance with the residents' physician order. 3. Ensure the dietary department followed the facility's policy and procedure (P&P) titled, Dietary Department- General, which indicated the dietary department was to prepare and provide nutritionally adequate, well-balanced meals that were consistent with physician's diet order. These deficient practices resulted in Resident 10, 11, 50, 53, 62, 81, and 83 receiving a lunch tray on 8/14/2024 that contained a ground pimento cheese salad sandwich on a regular soft white bread which placed Resident 10, 11, 50, 53, 62, 81, and 83 at high risk for aspiration (condition when food, liquid, or other material enters a person's airway [passageway for air] and eventually the lungs), choking (life threatening condition where an object such as food lodges in the throat blocking the flow of air), and possible death. On 8/15/2024 at 4:56 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Director of Nursing (DON) and the Administrator (ADM) due to the facility's failure to ensure Residents 10, 11, 50, 53, 62, 81, and 83 received food consistent with their therapeutic diet ( diet that controls the intake of a certain foods) texture of dysphagia minced and moist diet. On 8/16/2024 at 4:20 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 8/16/2024 at 4:32 p.m., in the presence of the DON and ADM. The IJPR included the following immediate actions: On 8/14/24 and 8/15/24, Resident 10 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet (dysphagia minced and moist diet) texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 11 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 50 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 53 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 62 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 81 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 83 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, the Registered Dietician (RD) provided an in-service (education) to DS, CK 1, and licensed nurses regarding validation of the residents' diet for appropriate texture based on the prescriber order before meal trays were delivered to the residents to ensure correct food consistency was being served. On 8/15/2024, the facility's new dietary menu system, (web-based menu program) provided the missing recipes for Mechanical Soft Minced and Moist diet. On 8/15/2024, the RD provided a one to one (1:1) in-service to the DS regarding food preparation in accordance with the menu recipe for the prescribed diet. Findings: 1. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was admitted to the facility 9/13/2023 with diagnoses including dysphagia, unspecified dementia (loss of memory, language, problem-solving and other thinking abilities), and major depressive disorder (a mental disorder that causes a persistent low mood and loss of interest in activities that are normally enjoyable). During a review of Resident 10's care plan titled, Nutritional Problem initiated on 9/15/2023, the care plan indicated the goal for Resident 10 was to maintain adequate nutritional status as evidenced by maintaining the resident weight within five percent (%) of current weight and to have no signs or symptoms (s/s) of malnutrition (lack of proper nutrition, caused by not having enough to eat or not eating enough). The care plan interventions included monitoring, documenting, and reporting any s/s of dysphagia: food pocketing (a common term for when people with dementia keep food in their cheeks or the back of their mouth instead of swallowing it), choking, coughing, drooling, and several attempts at swallowing as well as providing and serving the resident's diet as ordered by the physician. During a review of Resident 10's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/21/2024, the MDS indicated Resident 10 had severe impairment in cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 10 required setup or clean-up assistance while eating but was able to eat by herself. During a review of Resident 10's Speech Therapist ([ ST] a licensed professional aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) Evaluation and Plan of Treatment dated 6/27/2024, the ST Evaluation and Plan of Treatment indicated ST has seen Resident 10 for a clinical swallowing evaluation (procedure used to assess how well a person swallows) due to increased concerns of aspiration after an event of low tolerance of regular texture solid food diet when the resident was coughing and required oral suctioning (remove food and/ or liquid from mouth and throat with a suction machine). The ST Evaluation and Plan of Treatment indicated a recommendation for puree (blended) diet and thin liquids with strict adherence to swallowing precautions such as sitting up while eating, small bites, eating slowly, and alternating solids and liquids. ST Evaluation and Plan of Treatment indicated the goal for Resident 10 was to increase the ability to safely swallow a minced and moist consistency to facilitate transition to a more complex food consistency. During a review of Resident 10's Physician's Order Summary Report, the Physician's Order Summary Report dated 7/17/2024 indicated an order for a dysphagia mechanical soft texture, regular/ thin consistency liquids, ground (finely chopped) food. During a review of Resident 10's ST Treatment Encounter Note dated 7/23/2024, the ST Treatment Encounter Note indicated Resident 10 was seen for dysphagia and to continue with the mechanical soft, ground texture foods. 2. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including dementia and dysphagia., During a review of Resident 11's ST Evaluation and Plan of Treatment dated 10/17/2023, indicated Resident 11 was evaluated by ST to assess the resident's swallowing function and readiness to upgrade her diet from pureed foods. The ST Evaluation and Plan of Treatment indicated Resident 11 had a history of aspiration pneumonia (a lung infection that occurs when food, liquid, or other foreign objects are inhaled into the lungs instead of being swallowed). The ST recommendation was to continue with the pureed diet with goal for Resident 11 to safely swallow a minced and moist consistency diet. During a review of Resident 11's ST Treatment Encounter Note dated 11/21/2023, indicated Resident 11 was seen for dysphagia treatment and tolerated a mechanical soft ground texture (minced and moist) diet. During a review of Resident 11's care plan titled, At risk for aspiration- receiving a mechanical soft, ground food diet revised on 2/28/2024 indicated goal for Resident 11 not to have episodes of aspiration. The care plan interventions included for Resident 11 to receive therapeutic diet and diet texture modifications as ordered by the physician. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had severe impairment of cognitive skills for daily decision making. The MDS indicated Resident 11 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 11 complained of difficulty or pain while swallowing. During a review of resident 11's Physician's Order Summary Report, the Physician's Order Summary Report dated 7/17/2024 indicated an order for dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. On 7/18/2024 there was a physician's order to assist Resident 11 with feeding as needed. 3. During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (occurs when blood flow to the brain was blocked, causing brain tissue to die), dysphagia, type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly) and dementia. During a review of Resident 50's ST Evaluation and Plan of Treatment dated 11/20/2023, indicated the goal for Resident 50 was to reduce risk of choking or coughing events and to safely swallow a minced and moist consistency diet. The ST Evaluation and Plan of Treatment indicated ST recommended to continue with the pureed diet. During a review of Resident 50's care plan titled, At risk for Aspiration initiated on 11/24/2023, the care plan indicated the goal for the resident included to not have any s/s of aspiration and to maintain safe swallowing. The care plan interventions included to provide diet as ordered by the physician and if a difficulty swallowing occurred to notify ST. During a review of Resident 50's ST Treatment Encounter Note dated 12/14/2023, indicated Resident 50 was seen for dysphagia treatment and evaluation of the resident's diet. The ST Treatment Encounter Note indicated ST recommended for Resident 50 to tolerate the mechanical soft, ground diet (minced and moist). During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 50 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 50 complained of difficulty or pain while swallowing and was on a mechanically altered diet. During a review of Resident 50's Physician's Order Summary Report, the Physician's the Order Summary Report indicated an order dated 7/17/2024 for a consistent carbohydrate diet ([CCHO], a restrictive eating plan that helps people with diabetes manage their blood sugar levels) dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. 4. During a review of Resident 53's admission Record, the admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, dysphagia, cerebral infarction, and dementia. During a review of Resident 53's ST Evaluation and Plan of Treatment dated 5/1/2024, the ST Evaluation and Plan of Treatment indicated Resident 53 was evaluated for swallowing function with the goal to reduce risk of choking or coughing events and to tolerate safest and least restrictive diet without signs of aspiration. The ST Evaluation and Plan of Treatment indicated ST recommended to continue with the pureed diet. During a review of Resident 53's care plan titled, Altered nutrition: on a Mechanically Altered, Therapeutic Diet and At Risk of Aspiration initiated 5/11/2024, indicated the goal for Resident 53 included not to have any signs of aspiration and Resident 53 will demonstrate correct eating techniques to maximize safe swallowing. The care plan interventions included serving the resident's diet and diet texture modifications as needed as ordered by the physician. During a review of Resident 53's Physician's Order Summary Report dated 7/11/2024, the Physician's Order Summary Report indicated an order for a CCHO diet, dysphagia mechanical soft texture, nectar thick (can be sipped from a cup but require effort if taken via a straw) consistency liquids, and ground food. During a review of Resident 53's MDS dated [DATE], the MDS indicated Resident 53 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 53 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 53 coughed or choked during meals and complained of difficulty or pain while swallowing. The MDS indicated Resident 53 was on a mechanically altered diet. During a review of Resident 53's ST Treatment Encounter Note dated 7/30/2024, the ST Treatment Encounter Note indicated Resident 53 was seen for dysphagia treatment and ST recommended to continue mechanical soft ground texture foods with mildly (nectar consistency) thick liquids. 5. During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was admitted to the facility 5/10/2023 with diagnoses including dysphagia, acute kidney failure (a sudden and often reversible decline in kidney function), muscle weakness, and atrial fibrillation (a rapid and irregular heartbeat). During a review of Resident 62's ST Treatment Encounter Note dated 2/1/2024, the ST Treatment Encounter Note indicated Resident 62 presented with mild oral dysphagia (difficulty swallowing) and ST recommended minced and moist foods, mechanical soft ground diet with thin liquids. During a review of Resident 62's MDS dated 5/13/ 2024, the MDS indicated Resident 62 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 62 required supervision or touching assistance (staff provides verbal cues/ and or steadying as the resident completes the activity) for eating. The MDS indicated Resident 62 was on a mechanically altered diet and complained of difficulty with swallowing. During a review of Resident 62's care plan titled, At risk for Aspiration initiated on 5/31/2023, the care plan indicated Resident 62's goal was not to have evidence of aspiration. The care plan interventions included to provide Resident 62 diet as and diet texture modifications per physician's order. During a review of Resident 62's Physician's Order Summary Report dated 7/17/2024, the Physician's Order Summary Report indicated an order for a regular diet, dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. During a review of Resident 62's Physician's Order Summary Report dated 8/23/2023 the Physician's Order Summary Report indicated to always assist Resident 62 with feeding. 6. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, muscle weakness, depressive episodes, and cognitive communication deficit. During a review of Resident 81's care plan titled, Nutritional problem or potential nutritional problem related to poor appetite initiated 7/11/2024, the care plan indicated Resident 81's goal was to provide Resident 81's diet as ordered by the physician and monitoring for any signs of dysphagia. During a review of Resident 81's MDS dated [DATE], the MDS indicated Resident 81 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 81 needed substantial/ maximal assistance (staff does more than half the effort) for eating. During a review of Resident 81's ST Evaluation and Plan of Treatment dated 7/25/2024, the ST Evaluation and Plan of Treatment indicated Resident 81 was evaluated due to communication deficits and dysphagia with residue remaining in the oral cavity (mouth) while eating. The ST Evaluation and Plan of Treatment indicated ST recommended to downgrade the resident's diet to a minced and moist diet for dysphagia and swallow precautions (steps taken to ensure safe swallowing and prevent aspiration). During a review of Resident 81's Physician's Order Report, dated 8/2/2024, the Physician's Order Report, indicated and order for a mechanical soft texture, regular/ thin consistency liquids, for mechanical soft ground foods. During a review of Resident 81's ST Treatment Encounter Note dated 8/12/2024, the ST Treatment Encounter Note indicated Resident 81 was seen to address swallowing safety and swallowing dysfunction and ST recommended a minced moist diet. 7. During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted to the facility 7/17/2024 with diagnoses including dysphagia, autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). During a review of Resident 83's MDS dated [DATE], the MDS indicated Resident 83 was rarely or never understood. The MDS indicated eating was not attempted during the MDS review. The MDS indicated Resident 83 was dependent (staff does all the effort) on staff for eating. The MDS indicated Resident 83 was on a mechanically altered diet and complained of difficulty or pain with swallowing. During a review of Resident 83's care plan titled, At risk for Aspiration dated 7/30/2024 indicated the resident was started on a dysphagia mechanical soft texture, regular/ thin consistency liquids, ground texture. The care plan goal for Resident 83 included to demonstrate correct eating technique to maximize swallowing and Resident 83 would not show any signs of aspiration. The care plan interventions included to provide Resident 83 with the diet per physician's order and to monitor the resident for signs and symptoms of aspiration. During a review of Resident 83's Physician's Order Summary Report, the Physician's Order Summary Report indicated an order dated 7/30/2024 for a dysphagia mechanical soft texture, with regular/ thin consistency liquids, ground texture diet and observe the resident for alertness, food pocketing, coughing per swallowing protocol (guidelines or procedures used to assess and manage residents with swallowing difficulties). During a review of Resident 83's ST Treatment Encounter Note dated 8/1/2024, the ST Treatment Encounter Note indicated Resident 83 was seen for dysphagia treatment and ST recommended for Resident 83 to continue mechanical soft ground texture foods (minced and moist) and thin liquids. During a review of the facility's Diet Spreadsheet for Wednesday 8/14/2024, the Diet Spreadsheet indicated a grilled cheese sandwich was to be served for residents on a regular diet and a pimiento cheese sandwich to be served to residents on a therapeutic diet (a modification of a regular diet). The Diet Spreadsheet indicated a ground pimento cheese sandwich was to be served to residents on a dysphagia minced and moist diet ([MM5] the diet code for minced and moist diet). During a review of the facility's ground pimento cheese salad sandwich MM5 recipe, the MM5 recipe indicated bread was to be minced and assembled into a sandwich as follows: 1. For each sandwich: place two slices of bread into a washed and sanitized food processor and pulse grind for 4-6 seconds to create a minced, bread crumb consistency. 2. Placed minced bread into a bowl and spray with a vegetable pan spray or spritz with water or an appropriately prepared broth to moisten the bread (not soaked or wet). 3. Divide the moistened minced breadcrumbs in half or portion the minced and moistened bread on a plate or in a sandwich mold. 4. Portion and spread the ground/minced pimento cheese salad with thick sauce or gravy over the bottom layer of minced bread and then top with the other portion of minced bread. During an observation of the kitchen tray line (a system of food preparation, in which trays move along an assembly line) on 8/14/2024 at 11:39 a.m., under the supervision of the DS and RD, a dietary aide (DA 1) was observed calling out the diets from a resident meal ticket (resident diet and food preference) and CK 1 was plating (arrangement of food on a plate) the lunch meal. CK 1 was observed plating the pimento cheese sandwich for the meal tickets when DA 1 was calling out for dysphagia minced and moist diet and the mechanical chopped diets (a texture-modified diet that provides foods that are easy to swallow and require minimal chewing). During a concurrent observation and interview on 8/14/2024 at 12:20 p.m., with Certified Nursing Assistant (CNA 3), Resident 81 was observed receiving her meal tray in the room. CNA 3 delivered the meal tray to Resident 81 bedside. Resident 81's meal tray was observed containing the ground pimento cheese salad served on two slices of white bread (not minced and not moist), including the crust, with a scoop of ground pimento cheese in between the bread, sliced in half. Resident 81 meal ticket was observed on the tray and indicated Dysphagia minced and moist, mechanical soft diet. CNA 3 stated she was at the bedside to assist Resident 81 for eating. CNA 3 stated the bread served was not safe for Resident 81 to consume because the resident tends to pocket her food and she could choke. During a concurrent observation and interview on 8/14/2024 at 12:25 p.m., with DS in the kitchen, the DS was asked to check Resident 53's lunch tray before the meal cart (transportation method to bring meal trays to the residents) went out to the resident room. Resident 53's meal ticket, on the tray, indicated the resident was on dysphagia minced and moist diet. However, Resident 53's tray was observed containing a pimento cheese sandwich (ground pimento cheese salad in between two white breads with crust, sliced in half). The DS stated, this sandwich was appropriate for Resident 53 based on the dietary spreadsheet and the tray with sandwich was observed sent out for delivery to Resident 53. During an interview on 8/14/2024 at 12:35 p.m., the RD stated the type of sandwich with ground pimento cheese salad in between two non-minced and not moist two pieces of white bread with crust, sliced in half served to the residents on dysphagia minced and moist diet was appropriate based on the facility's Diet Spreadsheet. The RD stated, we must follow what corporate (umbrella company) wanted and this Diet spread Sheet was what they sent/approved. During a concurrent interview and record review on 8/14/2024 at 2:33 p.m., the RD stated she spoke with CK 1 who informed her (RD) that she (CK 1) was not provided with the MM5 diet recipe for the ground pimento cheese salad sandwich when she was preparing these kinds of sandwiches for lunch on 8/14/2024. CK 1 stated she made a mistake of looking at the spread sheet and preparing the MM5 diet the same as the mechanical soft diet (did not call for mincing bread). The RD stated the purpose of the dysphagia minced and moist diet was to eliminate the need for a lot of chewing to promote easy swallowing. The RD stated bread was soft so the residents would be able to eat it. Concurrently during an interview on 8/14/2024 at 2:33 p.m., the RD reviewed facility's Diet Manual (DiningRD.com 2022 edition) under dysphagia minced and moist diet (MM5) and stated the manual indicated foods to avoid for the dysphagia minced and moist diet included soft bread and rolls. The RD stated the potential outcome of giving residents on MM5 diet foods that were supposed to be avoided placed the residents at the risk for choking, aspiration, and respiratory distress (stop breathing). The RD stated it was not appropriate to serve the ground pimento cheese salad sandwich on a regular slice of soft that was not minced and was not moist white bread with crust to Resident 10, 11, 50, 53, 62, 81, and 83, who were on the dysphagia minced and moist diet. During an interview on 8/14/2024 at 2:55 p.m., CK 1 stated when she was preparing food for lunch on 8/14/2024, she was looking at the Dietary Spreadsheet and read the dysphagia minced and moist diet the same as the mechanical soft diet. CK 1 stated for dysphagia minced and moist diet whole sandwich should be ground up, but it was overlooked, and CK 1 was not paying attention. CK 1 did not provide an answer as to why the dysphagia minced and moist menu was not followed and stated, I do not know what happened. CK 1 stated all residents, including Resident 10, 11, 50, 53, 62, 81, and 83 who were on dysphagia minced and moist diet, received the ground pimento cheese salad sandwich for lunch on 8/14/2024 served on bread that was not minced but on a regular slice of soft white bread. During an interview on 8/14/2024 at 3:05 p.m., ST 1 stated bread with crust was a high choking risk. The ST 1 stated serving food that did not meet dietary standards for a dysphagia diet was a safety risk and the whole sandwich should have been ground up for a minced and moist diet. During an interview on 8/15/2024 at 9:49 a.m., DA 1 stated the usual presentation for a minced and moist diet looked like finely ground pieces and bread was usually soaked in a liquid. DA 1 stated she knew the bread did not look correct for the dysphagia diet, but she did not question it because CK 1 prepared the food, and she (CK 1) was the cook. DA 1 stated she should have brought up her concern to the DS. DA 1 stated if a wrong diet was given to the residents they could choke. During an interview on 8/15/2024 at 1:36 p.m., LVN 4 stated she was checking the lunch meal carts on 8/14/2024 and pimiento cheese sandwiches were provided to the residents on bread that was not minced. LVN 4 stated she did not see anything wrong with the pimento cheese sandwiches served bread that was not minced served to the residents on the dysphagia minced and moist diet. During an interview on 8/15/2024 at 1:56 p.m., the Director of Rehab (DOR) stated it was important to follow closely the ST's recommendations because ST was the one evaluating the safety of the resident's swallowing. The DOR stated the resident's diet was based on the ST's clinical evaluation which was then reviewed by the physician following with a diet order. The DOR stated if the diet was not followed, there was a high risk for aspiration. During an interview on 8/15/2024 at 3:36 p.m., the DS stated he had not realized CK 1 did not have the recipe for pimiento cheese sandwich under MM5 diet. DS stated he assumed CK 1 prepared sandwiches based on the facility's recipe for the mechanical soft diet (makes food easy to chew) which was not the same as dysphagia minced and moist. The DS stated he was not concerned about the ground pimiento cheese salad sandwich being served to the dysphagia residents until the RD read in Diet Manual what foods to avoid. During an interview on 8/15/2024 at 4:24 p.m., the DON stated it was important to follow physician's diet orders. The DON stated residents were placed on a dysphagia diet due to having issues with swallowing or chewing. The DON stated it was important to follow the dysphagia minced and moist diet recipe to prevent choking. The DON stated residents on dysphagia minced and moist diet, should have little effort on chewing to consume the food. The DON stated the licensed nurses who were checking the meal trays with pimento cheese sandwiches served on bread that was not minced, should have returned the trays to the kitchen due to incorrect food texture posing a choking hazard. The DON stated CNAs should also recognize the proper diet consistencies and food texture and bring it to the licensed nurse's attention when serving trays. During a review of the facility's Long Term Care Diet Manual by DiningRD.com 2022 edition, the Diet Manual indicated the International Dysphagia Diet Standardization Initiative ([IDDSI] a global framework that provides standardized definitions and terminology for describing thickened liquids[ liquids that have been made thicker to help residents who have difficulty swallowing) and texture modified foods) level 5- Minced and Moist (MM5) dysphagia diet was designed for individuals with mild to moderate oral dysphagia. Foods will conform to this diet if they are ground, moist, and of the size that would fit between the tongs of a typical fork. The Diet Manual indicated to avoid breads such as soft bread, rolls, cake, and crackers unless the breads are modified to a fine, soft bread crumb texture and moistened. During a review of the facility's policy and procedure (P&P) titled Dining Program dated 1/1/2012, the P&P indicated licensed nurses were to check the Residents meals against the attending physician orders. The P&P indicated the CNAs were to check diet cards (meal tickets) against the meal served and notify the dietary department of any discrepancies. The P&P indicated the dietary staff was to check the tray cards (meal tickets) against the meal served at tray line and correct any discrepancies. During a review of the facility's P&P titled Dysphagia Diets and Thickened Liquids dated 1/1/2012, the P&P indicated the purpose of the policy was to provide appropriate food and fluid consistencies to residents with dysphagia or swallowing problems, to ensure adequate hydration and diminish the risk for asphyxiation (the process of being deprived of oxygen). During a review of the facility's P&P titled Dietary Department- General dated 6/1/2014, the P&P indicated the primary objective of the dietary department included preparation and provision of nutritionally adequate, well-balanced meals that are consistent with physician orders. During a review of the facility's P&P titled Standardized Recipes dated 7/1/2014, the P&P indicated the recipes would have adjustments or separate recipes for therapeutic and consistency modifications. The P&P indicated the Dietary Manager or designee would monitor and routinely verify the recipes used by the cooks. During a review of the facility's job description for Registered Dietician da[TRUNCATED]