**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were served appropriate thickened liquid consistency for 2 of 7 residents, Residents #46 and #71, with physician orders for thickened liquids.On 6/1/2025, Resident #46 was ordered to have thickened liquids. On 8/19/2025, Resident #71 was ordered to have thickened liquids. On 8/27/2025 at 5:42 PM, Resident #71 was served apple juice on ice at a thin consistency. Resident #71 took sips of the apple juice, resulting in the resident coughing. Staff C, Scheduling Manager, served coffee at thin consistency to Resident #71. On 8/27/2025 at 6:01 PM, Resident #46 was served a cup that had a straw in it and contained ice and a clear thin liquid on the meal tray. Resident #46 took a sip from the cup which contained the clear thin liquid. There was a cup that had a plastic lid labeled NA (Nectar Apple). When the lid was removed the apple juice was observed to be at a thin consistency.The facility's failure to provide liquids in a form to meet the needs of Residents #46 and #71 and failure to identify the machined used to prepare and serve thickened liquids was not functioning properly led to the determination of Immediate Jeopardy at a scope and severity of isolated (J). The facility's actions placed Residents #46 and #71 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Immediate Jeopardy began on August 27, 2025.The Administrator was notified of the Immediate Jeopardy on August 29, 2025 at 1:49 PM. Findings include:Review of Resident #71's health record showed the resident was admitted on [DATE] with diagnoses including metabolic encephalopathy (a condition where the brain's metabolism is disrupted, leading to altered brain function), heart failure, unspecified, chronic obstructive pulmonary disease, unspecified, atherosclerotic (hardening of the arteries from plaque building up gradually inside them) heart disease of native coronary artery without angina pectoris (chest pain), hypertensive heart disease with heart failure, hypo-osmolality (a condition where the overall concentration of dissolved substances in the blood is lower than normal) and hyponatremia (a condition where the sodium concentration in the blood serum is below normal); non-ST elevation (Nstemi) myocardial infarction, cognitive communication deficit, and altered mental status, unspecified.Review of Resident #71's physician order dated 8/19/2025 read, Regular diet, dysphagia mechanical soft texture, nectar thickened fluids consistency.Review of Resident #71's care plan initiated on 8/4/2025 read, Focus. The resident has a swallowing problem r/t [related to] unable to tolerate thin liquids. Interventions Speech screen performed to determine diet.Review of Resident #71's Speech Therapy Treatment Encounter Note dated 8/19/2025 read, Precautions: Precautions = Precautions are as follows: Precautions Details: mech alt/nectar diet [mechanical altered/nectar thick liquids], edentulous. Patient was seen for skilled ST [Speech Therapy] interventions services to address dysphagia management services. Per Nursing report, Pt [Patient] has demonstrated s/s [signs/symptoms] of dysphagia and aspiration. Pt was seen via telehealth services with assistance provided from rehab staff. Upon arrival to Pt [Physical Therapy], she displayed consecutive coughing/sneezing. Pt initially consumed nectar via cup x 1 [one time] and displayed delayed cough. Pt consumed honey-thick via cup sips WFL [Within Functional Limit]. Pt consumed nectar small sips via cup across trials WFL. Pt consumed puree snack WFL. Pt consumed mech alt snack WFL. Pt consumed thin liquid X3 [three times] and displayed mild cough. ST recommends patient consume a mech alt/nectar diet at this time as it is determined to be the safest diet for the patient to consume at this time. ST will continue to follow up with Pt.Review of Resident #71's Speech Therapy Discharge Summary read, Dates of Service 08/06/25 - 08/21/25. Skilled Interventions Provided: Patient was seen for skilled ST intervention services to address dysphagia management services to determine the safest diet for the patient to consume. Patient Progress: Progress & Response to Treatment: Patient participates well during services; however, Pt displayed s/s of aspiration concerns and required liquid diet change to nectar thick.During an observation on 8/27/2025 at 5:30 PM of the tray line service, Staff B, Dietary Aide, was verifying resident tray accuracy after the Certified Dietary Manager placed items on the trays.During an observation on 8/27/2025 at 5:42 PM, Resident #71 was sitting in a wheelchair in the room with the bedside table in front of the resident. On the bedside table, there was a cup with a straw. The cup contained apple juice of thin consistency with ice. Staff D, Certified Nursing Assistant (CNA), delivered a meal tray to Resident #71. Staff D assisted Resident #71 with the meal set up and exited the room. Resident #71's meal tray consisted of a ground fish sandwich, boiled broccoli, and dessert. No other liquids were observed on the tray. Resident #71 took a sip from the thin consistency apple juice and coughed afterwards. Staff C, Scheduling Manager, was walking in front of Resident #71's room and the resident requested coffee. Staff C asked what kind of coffee and if she would like cream and sugar. Resident #71 took a sip of the thin consistency apple juice and coughed again. Staff C returned to the room and donned personal protective equipment to enter Resident #71's room to deliver thin consistency coffee.During an interview on 8/27/2025 at 5:52 PM, Staff C, Scheduling Manager, stated, The coffee is decaf coffee. It's the regular coffee that all residents get on the floor. When asked about Resident #71's diet, Staff C reviewed the resident's meal ticket and stated, [Resident #71's name] has a nectar thickened diet. She is not able to drink thin liquids. She shouldn't have the juice or the coffee.During an interview on 8/27/2025 at 5:57 PM, the Director of Nursing (DON) stated, [Resident #71's name] was delivered thin consistency juice and coffee. The resident is nectar thickened [liquid] and should not be given thin liquids.Review of Resident #71's assessment dated [DATE] read, Change in Condition (SBAR) [Situation, Background, Assessment, and Recommendation]. Type: cough. The change in condition, symptoms, or signs observed and evaluated is/are: Pt. was coughing while drinking thin liquids. This started on 08/27/2025. Recommendation: Chest X-ray.During an interview on 8/28/2025 at 8:50 AM, Staff E, CNA, stated, We are supposed to check in the [name of software program for medical records] to see what the diet is. With meal process, we look at their ticket and look at [name of software program for medical records] first thing in the morning. Look at the ticket and see the diet or ask the nurse if not sure. The drinks come out first. On the drink cart, there is a notebook that includes the diets for the residents, and you check there. I didn't check the book before delivering the coffee to [Resident #71's name]. I went to ask [Staff G, CNA's name] who was the CNA running the drink cart. I mentioned the room and the bed, and I got distracted by someone else, so I am not sure if she checked the book. The nectar thickened drinks should come from the kitchen on their trays. Sometimes, you have to go back to the kitchen and request the thickened liquids because they don't come on the meal tray. The resident can choke if they have the wrong consistency. They can cough and lose their breath, and turn red in the face.During an interview on 8/28/2025 at 9:54 AM, Staff D, CNA, stated, I did not give [Resident #71's name] the coffee but, I did give her thin liquid juice. I did not give her thickened liquids because those normally come on the tray. There is a list on the beverage cart that tells us the liquid consistency for each resident. I delivered the drink myself. I did not check the list. I just knew it from before. I had always considered her to be thin liquids. She was sitting up, talking, and drinking. I always thought she was thin liquid. I don't know when her order changed. Speech therapy does the orders for that. It is very important to give the correct consistency because of aspiration. If they are coughing or not making any noise. We always should check the list. I was educated on to look at the orders and slow down.During an interview via phone on 8/28/2025 at 10:10 AM, Staff G, CNA, stated, I was not responsible for the beverage cart. All the staff help and pass out the drinks. I was not approached by any staff member asking for coffee for [Resident #71'name]. They could get the coffee themselves because they are staff members.During an interview on 8/28/2025 at 11:17 AM, the Nurse Practitioner (NP) #1, stated, If she [Resident #71] actually aspirated, she could develop aspiration pneumonia. The hospital evaluates them and puts them [residents] on thickened liquids if patients have a history of stroke and dysphagia. They are evaluated in the hospital for swallowing. If there was a concern, they initiate thickened [liquids] until they have ruled out any medical concerns. When speech therapy evaluates a patient and they downgrade or establish their liquid consistency as thickened, until the diet is changed. I expect the staff to provide the ordered diet and fluids.Review of Resident #46's health record showed the resident was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation (a type of irregular heartbeat that comes and goes on its own within seven days) (admitting diagnosis), dysphagia (difficulty swallowing food or liquids), oral phase, speech and language deficits following cerebral infarction, personal history of transient ischemic attack (TIA), gastro-esophageal reflux disease without esophagitis, constipation, essential hypertension, and anemia.Review of Resident #46's physician order dated 6/5/2025 read, Regular diet, dysphagia puree texture, nectar thicken fluids consistency.Review of Resident #46's care plan did not provide for documentation of a focus related to the resident's requiring of thickened liquids.Review of Resident #46's physician progress note dated 6/19/2025 read, PMH [past medical history] of dysphagia, oral phase; other speech and language deficits following cerebral infarction. Nurse staff reports patient has had a mild intermittent dry cough. Continue with diet medication for dysphagia. Continue current treatment plan.Review of Resident #46's Pulmonary Progress Note dated 8/20/2025 read, Chief Complaint: assessment regarding cough and dysphagia. Assessment/Plan: thickened liquid to reduce any risk of aspiration.During an observation on 8/27/2025 at 6:01 PM, Resident #46 was in bed with a meal tray in front of her. There was a cup with a straw that contained ice and clear thin liquid on the meal tray. There was a cup with apple juice with a plastic lid on the cup with NA (Nectar Apple) written on top of the cup. When the lid was removed the apple juice was observed to be of a thin consistency. Resident #46 was observed taking a sip from the cup which contained clear thin liquid.During an interview on 8/27/2025 at 6:03 PM, the DON stated, [Resident #46's name] should not have thin liquids. When the DON removed the lid of the cup labeled NA of apple juice, the DON stated, This is not thickened. This cup comes from the kitchen, but it is not thickened.During an observation on 8/27/25 at 6:03 PM, the DON removed both cups with thin liquids from Resident #46's room.During an interview on 8/28/2025 at 1:53 PM, the DON stated, Yesterday, when I saw the nectar thick apple juice coming from the kitchen was not the right consistency, I had it removed and had a staff get her [Resident #46] something else to drink. I went back to the office, and I saw you guys walking down. I did not see the resident cough, and nobody came back to tell me anything else, and I called the nurse practitioner, and we did a change in condition. I did not tell the kitchen in regard to anything.During an observation on 8/27/2025 at approximately 6:10 PM, the Food Service Manager (FSM) removed the lid labeled NA (Nectar Apple) from a cup that was removed from a bin with ice on the kitchen tray line counter that was being served to the residents on thickened liquids. The FSM poured thickened water into a cup and poured the nectar thick apple juice into another cup and the consistency was not the same thickened consistency.During an interview on 8/27/2025 at approximately 6:11 PM, the FSM stated, I do not know what to call this consistency [referring to the nectar thick apple juice cup removed from the bin in the kitchen]. I don't know if it's the machine is not working or if the ice is melting and getting into the cups.During an observation on 8/27/2025 at approximately 6:14 PM, the Certified Dietary Manager (CDM) and the FSM, the CDM poured the nectar thick apple juice in a cup and also poured the honey thickened juice from the draft machine.During an interview on 8/27/2025 at approximately 6:14 PM, the CDM stated, The apple thickened fluids are not as thick as the water. It could be more thickened. The honey thickened is not thickened. The machine might not be calibrating correctly. I would have to call the company and have them come out. The machine is to be checked every three months [by the vendor] or as needed.During an interview on 8/28/2025 at 9:35 AM, the Registered Speech Therapist stated, If the patient is nectar or honey thick, the patient should get the ordered consistency liquids. If a patient who is on thickened liquids is provided thin liquids on a consistent basis, anything can happen; silent aspiration, dysphagia, it would depend on the patient.During an interview on 8/28/2025 at 1:00 PM, Staff B, Dietary Aide, stated, I think there are five cups on the tray line prepared. I thought they were already thickened. I was not aware that there is a problem with the machine. I was going to put them on the trays to be served.During an observation on 8/28/2025 at 1:14 PM, the FSM had an open cup of red thin liquid in front of her and was opening a Thick & Easy instant food and beverage thickening powder.During an interview on 8/28/2025 at 1:14 PM, the FSM stated, I was using the machine this morning and until now. I began to pour the thickening powder just now [into the red liquid]. I did not know we should not use the machine because you [referring to this writer] did not tell us we needed to shut it down yesterday. When asked when she and the CDM observed the fluids from the machine were not the appropriate thickened consistency why she had not stopped using the machine, the FSM did not respond. When asked who is responsible for the kitchen and the proper functioning of the kitchen equipment the FSM stated, I am.During an observation on 8/28/2025 at 1:20 PM in the kitchen, Staff B, Dietary Aide, was putting drinks and food on the resident's tray. The drinks that she had sitting on the tray line were covered with a lid. Drinks on the tray covered with a lid were designated as thickened drinks. The liquids were observed to be of a thin consistency.During an interview on 8/28/2025 at 1:22 PM, the FSM stated, I thought the drink machine was fine to use.During an interview on 8/28/2025 at 1:25 PM, the Administrator stated, I was not aware of the machine not working until just now. I thought last night that they had just given the resident a wrong cup with the wrong liquid consistency.During an interview on 8/28/2025 at 2:03 PM, Staff J, Licensed Practical Nurse/ Unit Manager (LPN/UM) for South, stated, I was in the dining room for dinner last night. I checked breakfast trays this morning and told them it [referring to thickened liquids] was too thin. Just with the juices we saw, we sent them back to the kitchen because they did not seem thick enough. [Residents #46 and #71's names] had cranberry juice on their trays and we had issues with them being too thin. We got them replaced with water which was thick enough.During an interview on 8/28/2025 at 2:13 PM, Staff S, CNA, stated, When we did the cart trays for lunch, the drink was too thin for rooms [Residents #46 and #71's rooms]. I took them back to the kitchen and told the staff that the drink was too thin. For breakfast, the UM took them back when they were too thin. The CNAs check the list on the drink cart for residents who are on thickened liquids.During an interview on 8/28/2025 at 2:30 PM, the FSM stated, The tech [from the name of the draft machine, drink machine used to prepare and serve thickened liquids, service company] came in today and adjusted the flow of the juice and the thickened water by using a screwdriver to adjust the flow of the water and juice. We only sent out water this morning, I do not know how the residents needing thickened liquids got juice this morning. I was not made aware of juices being brought back to the kitchen this morning.During an interview on 8/28/2025 at 3:32 PM, the Draft Machine Service Company's Service Manager stated, The machine was delivered on June 10, 2025, and the facility has scheduled deliveries every week [thickened water and concentrate used in the machine]. The last delivery was on 8/21/2025. The driver will do the delivery and check if the machine is working. When asked if the delivery driver checks the machine with each delivery the Service Manager stated, That varies, the driver may check it out but not always. Most customers will mention if they have a problem and the driver checks into it and will fix it. It [the repair] would go on the computer document only if it's a service call and then the driver will just clear it. The machine has a water line and that mixes with the type of juice [concentrate] on the other line. The juice is not thickened; the water is thickened. The service call was that the thickened water was too thick. I see that the technician documented Brix [term used for adjusting the draft machine] the honey and nectar gun. Brix means that he [the technician] had to adjust the gun. The technician only adjusted the thickened water. The computer document reports what the customer reported. The machine never needs calibration.During an interview on 8/28/2025 at 4:01 PM, the FSM stated, I texted the sales rep [representative]. He misinterpreted my text message. I told him that the liquids were too thin. I sent him the message at 6:36 AM today [8/28/2025] to request someone to come out and take a look at the machine. During the last delivery [8/21/2025] the driver did not check the machine. They usually will check if we report an issue and I did not have anything to report. Review of text message sent on 8/28/2025 at 6:36 AM, from the FSM read, Good morning ([Name of the Draft Machine Service Company's Sales Representative's name], We seem to have an issue with the thickness of our thickened liquid. The waters are pouring correct, but the juice's are to thin. If this could be addressed asap [as soon as possible] that would be great. Unfortunately the state is in here and will be all day. They were the ones who brought it to my attention last evening. Let me know an approximate time so I can at least give them something. Thank you [the FSM].During an interview on 8/29/2025 at 8:31 AM, the DON stated, Speech and dietary would have the education and knowledge to be able to identify that thicken liquids are not at the right consistency. If the staff suspect it is not thick enough, they always go to speech [therapist] or dietary and they will confirm the consistency. I was aware that the nursing staff had to send back some of the consistencies. It occurred for breakfast and lunch, and the consistency had to be corrected. The inconsistency happened due to dietary having some concerns with their machine. As far as for me, I was not aware the machine was not in proper order. If I was aware, I would have given other directives. To me that was a follow up because I gave directives to the CNAs to correct the consistency and I was expecting that if they are not able to fix the inconsistency they should come back to me and report if it is a dietary problem. That was not reported to me. My responsibilities are to oversee the residents, that they are getting the care that we provide. Making sure that they are getting all the care they need, if any concern in any other department, that I am made aware it, so that it is fixed in a timely manner. When asked if it is her responsibility to safeguard the residents, the DON stated, I do. It is part of my responsibility to ensure of their safety.During an interview on 8/29/2025 at 8:58 AM, the Regional Director of Operations of Rehabilitation Services, stated, The speech therapist has the education and knowledge to identify the liquid consistency. I know that in the kitchen there is a machine and they have policies in the kitchen regarding that. Definitely, if a nurse has any questions, they can reach out to the ST. There are two modes of contact for the ST, some involve speech therapist occasionally in the building and worst case scenario telehealth. It is definitely better they see it [liquid consistency] in person, but during telehealth it is likely they would be able to identify it. The rehabilitation director has an OT [Occupational Therapy] background, but I would feel it would be best if ST be the one to determine. If they are using the packets to mix by hand, it would be to read the directions in the back of the packets. To my knowledge, they have not been to the facility to check on the consistency of the draft machine to verify it [liquids] is at the right consistency. When I say kitchen policies, I mean the settings of the machines for the consistency. I think that a speech therapist should come and give a more accurate assessment of the liquids. If there was an issue with the machine, I feel it should have been reverted to manually mixing and not utilizing the machine. We do in-services, I'm not sure when the last one happened. If a long-term resident is receiving [ST] services, at least quarterly, screens or change in status assessment is conducted whether it be a negative or positive change. If there is a risk of choking, aspiration and risk for pneumonia; if [a resident] is coughing after the meal, then that will elicit a speech therapy evaluation. The quarterly screen is a standard of practice.During an interview on 8/29/2025 at 9:21 AM, the CDM stated, Everyone in the kitchen has the education and knowledge to identify if liquids are not at the right consistency. Not all nurses are able to identify consistency. They are not trained but some are so used to seeing them [thickened liquids] that they are able to identify the consistency of a liquid. The nurses should always go to the kitchen and ask the staff for confirmation. After that night, [8/27/25, when the deficient practice was identified] we had called the company to come out to fix it [thickened liquid machine]. They [dietary] did not use the machine after I had left. The next day, I came in the afternoon around three. All the staff in the kitchen know any equipment that is broken should not be used. I told the staff before leaving that they should not use the machine until the company comes out to look at it since it was not working properly and instructed the staff to prepare the juices for breakfast manually. I don't know why they were using that [thickened liquid machine]. Normally, if the equipment is out of order, we need to put up a sign. There was not a sign posted before I left but [The FSM's name] knew she should put up a sign. As a CDM, I have to train all the new employees that come in. I do angel rounds, care plan meetings, food preferences, inventory and ordering, making sure that emergency storage is good for the hurricane season. I am just covering right now; I have been here every day since Monday [8/25/2025]. I go over consistency with staff and there is also a flyer, and the recipe book [for thickened liquids]. I feel that all the staff in the kitchen working right now is able to identify the consistency correctly of the liquids. [The FSM's name] texted the Administrator to let him know [the thickened liquid machine]. I feel that as the CDM, I am responsible for safeguarding the residents in the building. Whoever is the aide assigned to drinks on the schedule. The aide should be responsible for verifying the consistency when they are pouring. She should have stopped and addressed it with me and [the FSM's name]. I would have called the company right away and checked the storage and if not go get it from the supplier [boxes of thickened liquids]. They [dietary aides] need to notify use of any problem and that is also part of the job description to notify as immediately and I am available 24/7 every day.During an interview conducted on 8/29/2025 at 9:41 AM, the Dietary, Housekeeping and Laundry District Manager stated, My regional would be over the CDM. The previous CDM was bouncing between two accounts, and we were getting lots of complaints from another account. So, we had to terminate her. The issues in this kitchen were not part of her termination. I can assume it was happening here as well because I see a trend. The first line of defense is the dietary aide. This should not have happened. I was not made aware that the machine was not working properly. I would have gone out and even bought another machine. The staff in the kitchen, this is part of their daily equipment check and they have to not use it and find a way to continue the operation. It should have been reported from the aide.During an interview conducted on 8/29/2025 at 10:00 AM, the Administrator stated, The speech therapist is who we go to if there are any questions regarding consistency. The kitchen staff also have the education and the knowledge to determine the right consistency. That is why we have the system for check points to prevent things like that [residents being served inappropriate thickened liquid beverage] from happening. They notified me yesterday. I don't remember what time, but as soon as they told me, I got on the phone with the company and told them it was urgent. It was a busy day. I don't recall if I received a text from the FSM regarding the machine that evening when the machine was identified as not properly working. I oversee the day-to-day operations. For the kitchen my responsibly is to have the tools that they need to get their jobs done. They are vendors, so they do the hire and education. We are responsible for the food. The vendor would be responsible for fixing the equipment. Everyone that works here is responsible for safeguarding the residents. I feel that the break in the system was the machine and as soon as I was aware I called to get it fixed.During an interview on 8/29/2025 at 10:36 AM, the Medical Director stated, I was aware that the [Brand name of the draft/thickened liquid machine] had malfunctioned on Wednesday and I told them to call the company and have them fix the machine and come and fix it by Thursday. They [Residents requiring thickened liquids] have a possibility of aspiration pneumonia and fatal consequences as well. The staff should not use the machine until it is fixed by the company. I recommended not to use the device until fixed. I don't recall what time on Wednesday [8/27/2025] and the DON was the one to notify me. I make sure patient safety is first, and they get the care that they need. The policies are implemented. Today we were supposed to have a meeting, but I am going out of town, and I am going on a trip since it's a long weekend.Review of an article on 8/29/2025 from the library of [NAME], one of the largest nonprofit academic medical centers in the US, titled Aspiration from Dysphagia under the heading, What are possible complications of aspiration from dysphagia? read, A major complication of aspiration is harm to the lungs. When food, drink, or stomach contents make their way into your lungs, they can damage the tissues there. The damage can sometimes be severe. Aspiration also increases your risk of pneumonia. This is an infection of the lungs that causes fluid to build up in the lungs. Pneumonia needs to be treated with antibiotics. In some cases, it may cause death. Article located at [NAME]-[NAME].org/health-library/diseases-and-conditions/a/aspiration-from-dysphagia.htmlReview of [Name of the Draft Machine Service Company] Invoice dated 8/28/2025 read, Problem Reported: Soda X [Name of the FSM] Texted a request for calibration of her nectar thick gun juices. She said nectar juices coming out too thick. Resolution: Brix honey & [and] nectar gun.Review of the document titled [Name of the Draft Machine Service Company] Fountain-Dispensed Beverage Solutions with an effective date of 5/5/2025 read, Purpose: This agreement is submitted to above Care Facility for the purpose of becoming the sole supplier of all dispensed beverage products. [Name of draft machine service company] will install the needed equipment, service specified equipment, and deliver specified products. Equipment: [Name of draft machine service company] will install a customized dispensing systems consisting of the following equipment: [no equipment was marked]. A. This equipment will be installed in the facilities, and be of the highest quality and subject to weekly inspection and maintenance, as well as periodic preventive maintenance. This equipment will remain the property of [Name of draft machine service company]. Service and Delivery: [Name of draft machine service company] will provide regular maintenance of all equipment and product replenishment as required by the system. There will be no cost to the above facility for these services. Emergency Service will also be available at no additional cost. Notification: The facility agrees to notify [Name of draft machine service company] of any defects of failure of the equipment that does not receive proper service by its service technician.Review of the Invoice Summary: Dated 8/29/2025 from [name of the Draft Machine Service Company] Invoice #737596, Problem reported: History soda X needs a tech ASAP [As Soon As Possible]. Machine is still not working right. Beverage Dispenser giving trouble. The Juicer needs recalibration. [Name and Phone Number of Service Provider] Urgent!!!Resolution: HIST [History] exchanged thickened water dispensing gun and recalibrated.Review of Cook/Kitchen Staff Competency assessment dated [DATE] for Staff B, Dietary Aide, read, Administrative Functions. Inspect diet trays to assure that the correct diet is served to the resident. Ensure that all food procedures are followed in accordance with established facility policies, and Assist in serving meals as necessary and on a timely basis. The required functions of the job were marked as In service Needed. Signed by the FSM.During an interview on 8/28/2025 at 10:24 AM, the Certified Dietary Manager stated, She [Staff B] was supposed to put chilled desserts, salads and modified drinks on the trays on 8/27/25 for the dinner meal trays. The Competency Assessment for [Staff B's Name] was conducted on 5/27/25 with several functions listed as In-service needed. I cannot find any in-services provided to [Staff B's Name]. I was not made aware of this assessment [the training not being completed] until today.Review of the policy and procedure titled Thickened Liquids reviewed on 1/29/2025 read, Policy: thickened liquids will be provided for residents according to physician's orders. Purpose: to ensure sufficient fluid intake for residents with reduced swallowing capabilities. Guidelines: 1. Residents with reduced swallowing capabilities will be provided with liquids thickened to mildly thick (level 2), moderately thick (Level 3), or extremely thick (level 4) based on their individual tolerance as determined by the speech therapist and as ordered by the physician. 2. Upon receipt of the physician's order, pre-thickened products will be served by dietary.The Immediate Jeopardy (IJ) was removed onsite as of August 29, 2025 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. As verified by the survey team, on 8/27/2025, the facility assessed Residents #46 and #47 and audited and evaluated 8 of 8 residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to implement policy and procedures related to the provision of thickened liquids. The facility failed to ensure residents were served liquids to meet their needs. On 6/1/2025, Resident #46 was ordered to have thickened liquids. On 8/19/2025, Resident #71 was ordered to have thickened liquids. On 8/27/2025 at 5:42 PM, Resident #71 was served apple juice on ice at a thin consistency. Resident #71 took sips of the apple juice, resulting in the resident coughing. Resident #71 requested coffee and Staff C, Scheduling Manager, served coffee at thin consistency to Resident #71. On 8/27/2025 at 6:01 PM, Resident #46 was served a cup with a straw that contained ice and a clear thin liquid. Resident #46 took a sip from the cup of the clear thin liquid. On 8/27/2025, the Certified Dietary Manager identified the equipment used to prepare thickened liquids was malfunctioning. On 8/27/2025, the Director of Nursing did not notify the responsible kitchen staff of Resident #46 being served non-thickened apple juice. On 8/28/2025, Staff B, Dietary Aide, placed five cups of drinks that were designated as thickened drinks on a tray. The cups were covered with a lid. The liquids inside the cups were of a thin consistency.The facility's failure to provide liquids in a form to meet the needs of Residents #46 and #71 and failure to identify the machined used to prepare and serve thickened liquids was not functioning properly led to the determination of Immediate Jeopardy at a scope and severity of isolated (J). The facility's actions placed Residents #46 and #71 at a likelihood of serious harm, such as choking, aspiration (a condition in which foods, stomach contents, or fluids are breathed into the lungs through the windpipe) and/or death. The Immediate Jeopardy began on August 27, 2025.The Administrator was notified of the Immediate Jeopardy on August 29, 2025 at 1:49 PM.Findings include:Review of the Medical Director Agreement dated 7/1/2014 read, 1. Term. This Agreement shall be in full force and effect from the date hereof for a period of one (1) year and automatically renewed for additional one (1) year periods there after. This Agreement may be terminated by either party with or without cause upon thirty (30) days prior written notice to the other party. 2. Services. Physician agrees to provide such services as are set for in Exhibit A, attached hereto and incorporated herein by reference. Exhibit A: Physician shall: Provide services in accordance with any applicable requirements of federal, state or local laws, rule and/or regulations and third-party reimbursement sources. To abide by Facility's policies and procedures. To be responsible for the overall coordination of medical care at Facility; coordination of care means Physician shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident care policies and providing oversight and supervision of physician services and medical care of residents. Physician agrees to evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Physician identifies or about which Physician receives a report. To participate, as requested, in personnel evaluations and other quality monitoring programs established by Facility including attendance at the Facility's Quality Management Committee Meetings.Review of the job description titled Administrator read, Primary Purpose of this Position: The primary purpose of this position is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times. Duties and Responsibilities: Assume the administrative authority, responsibility and accountability for all programs in the facility. Ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas and/or improving services. Ensure that the food and nutrition services program meets the nutritional needs of the residents. Safety and Sanitation Functions: Ensure that a system for maintaining and improving buildings, grounds and equipment is planned, implemented and evaluated.Review of the job description titled Director of Nursing read, Primary Purpose of this position: The primary purpose of this position is to plan, organize, develop and direct the overall operation of the nursing services department in accordance with current federal, state, and local standards, guidelines and regulations that govern the facility and as directed by the Administrator and the Medical Director to ensure that the highest degree of quality care is maintained at all times. Duties and Responsibilities: Committee Functions: Participate in risk management and safety committee to mitigate risk factors for residents and staff.Review of the job description titled Speech-Language Pathologist read, Primary Purpose of this Position: Leads, guides and directs the delivery of speech language pathology and audiology services in the facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Duties and Responsibilities: Plans, develops, organizes, implements, evaluates and directs the delivery of speech language pathology and audiology services as well as its programs and activities, in accordance with current state and federal laws and regulations; and respective practice act (s) in the state. Promote safe work practices, safety rules, and accident prevention procedures to prevent resident/employee injury and illness.Review of job description titled Certified Dietary Manager read, Primary Purpose of this Position read, The primary purpose of this position is to plan, organize, develop and direct the operations of the food and nutrition services department in accordance with current federal, state, and local standards, guidelines and regulations and as directed by the Administrator. Duties and Responsibilities: Assist in planning, developing, organizing, implementing, evaluating and directing the food and nutrition services department, its programs and activities. Assume administrative authority, responsibility and accountability of supervising the food and nutrition services department. Review the food and nutrition requirements of each resident admitted to the facility as required and assist the attending physician in planning for the resident's prescribed diet plan. Assist in developing and implementing procedures for safe operation of all food and nutrition services equipment. Develop, implement and maintain written department policies; ensure staff is aware of and follows established facility policies. Assist in developing methods for determining quality and quantity of food served. Safety and Sanitation Functions: Ensure that all personnel operate food and nutrition services equipment in a safe manner, ensure that only trained and authorized personnel operate the department's equipment. Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. Miscellaneous Function: Be prepared to handle emergencies as they occur. Safety Requirement: Must maintain the care and use of supplies, equipment, etc , and maintain the appearance of food and nutrition service areas; must perform regular inspections of food and nutrition services areas for sanitation, order, safety and proper performance of assigned duties.Review of the job description titled Dietary Supervisor read, 1. Position Summary: The Dietary Supervisor is responsible for overseeing the daily operations of the dietary department, ensuring meals are planned, prepared and delivered in accordance with prescribed nutritional and therapeutic requirements. 2. Essential Functions: Supervised kitchen operations during assigned shift.Review of the job description titled Dietary Aide read, 1. Position Summary: Dietary aides assist with all aspects of food service operations, including food preparation, meal service, cleaning, maintenance of food service areas and equipment, and record keeping, as needed. Essential functions: prepare, serve, and assist with food selection in an efficient and pleasant manner.During an observation on 8/27/2025 at 5:30 PM of the tray line service, Staff B, Dietary Aide, was verifying resident tray accuracy after the Certified Dietary Manager placed items on the trays.Review of Resident #71's physician order dated 8/19/2025 read, Regular diet, dysphagia mechanical soft texture, nectar thickened fluids consistency.Review of Resident #71's Speech Therapy Discharge Summary read, Dates of Service 08/06/25 - 08/21/25. Skilled Interventions Provided: Patient was seen for skilled ST intervention services to address dysphagia management services to determine the safest diet for the patient to consume. Patient Progress: Progress & Response to Treatment: Patient participates well during services; however, Pt displayed s/s of aspiration concerns and required liquid diet change to nectar thick.During an observation on 8/27/2025 at 5:42 PM, Resident #71 was sitting in a wheelchair in the room with the bedside table in front of the resident. On the bedside table, there was a cup with a straw. The cup contained apple juice of thin consistency with ice. Staff D, Certified Nursing Assistant (CNA), delivered a meal tray to Resident #71. Staff D assisted Resident #71 with the meal set up and exited the room. Resident #71's meal tray consisted of a ground fish sandwich, boiled broccoli, and dessert. No other liquids were observed on the tray. Resident #71 took a sip from the thin consistency apple juice and coughed afterwards. Staff C, Scheduling Manager, was walking in front of Resident #71's room and the resident requested coffee. Staff C asked what kind of coffee and if she would like cream and sugar. Resident #71 took a sip of the thin consistency apple juice and coughed again. Staff C returned to the room and donned personal protective equipment to enter Resident #71's room to deliver thin consistency coffee.During an interview on 8/27/2025 at 5:52 PM, Staff C, Scheduling Manager, stated, The coffee is decaf coffee. It's the regular coffee that all residents get on the floor. When asked about Resident #71's diet, Staff C reviewed the resident's meal ticket and stated, [Resident #71's name] has a nectar thickened diet. She is not able to drink thin liquids. She shouldn't have the juice or the coffee.During an interview on 8/27/2025 at 5:57 PM, the Director of Nursing (DON) stated, [Resident #71's name] was delivered thin consistency juice and coffee. The resident is nectar thickened [liquid] and should not be given thin liquids.Review of Resident #71's assessment dated [DATE] read, Change in Condition (SBAR) [Situation, Background, Assessment, and Recommendation]. Type: cough. The change in condition, symptoms, or signs observed and evaluated is/are: Pt. was coughing while drinking thin liquids. This started on 08/27/2025. Recommendation: Chest X-ray.During an interview on 8/28/2025 at 9:54 AM, Staff D, CNA, stated, I did not give [Resident #71's name] the coffee but yeah, I did give her thin liquid juice. I did not give her thickened liquids because those normally come on the tray.Review of Resident #46's physician order dated 6/5/2025 read, Regular diet, dysphagia puree texture, nectar thicken fluids consistency.Review of Resident #46's physician progress note dated 6/19/2025 read, PMH [past medical history] of dysphagia, oral phase; other speech and language deficits following cerebral infarction. Nurse staff reports patient has had a mild intermittent dry cough. Continue with diet medication for dysphagia. Continue current treatment plan.Review of Resident #46's Pulmonary Progress Note dated 8/20/2025 read, Chief Complaint: assessment regarding cough and dysphagia. Assessment/Plan: thickened liquid to reduce any risk of aspiration.During an observation on 8/27/2025 at 6:01 PM, Resident #46 was in bed with a meal tray in front of her. There was a cup with a straw that contained ice and clear thin liquid on the meal tray. There was a cup with apple juice with a plastic lid on the cup with NA (Nectar Apple) written on top of the cup. When the lid was removed the apple juice was observed to be of a thin consistency. Resident #46 was observed taking a sip from the cup which contained clear thin liquid.During an interview on 8/27/2025 at 6:03 PM, the DON stated, [Resident #46's name] should not have thin liquids. When the DON removed the lid of the cup labeled NA of apple juice, the DON stated, This is not thickened. This cup comes from the kitchen, but it is not thickened.During an observation on 8/27/25 at 6:03 PM, the DON removed both cups with thin liquids from Resident #46's room.During an interview on 8/28/2025 at 1:53 PM, the DON stated, Yesterday, when I saw the nectar thick apple juice coming from the kitchen was not the right consistency, I had it removed and had a staff get her [Resident #46] something else to drink. I went back to the office, and I saw you guys walking down. I did not see the resident cough, and nobody came back to tell me anything else, and I called the nurse practitioner, and we did a change in condition. I did not tell the kitchen in regard to anything.During an observation on 8/27/2025 at approximately 6:10 PM, the Food Service Manager (FSM) removed the lid labeled NA (Nectar Apple) from a cup that was removed from a bin with ice on the kitchen tray line counter that was being served to the residents on thickened liquids. The FSM poured thickened water into a cup and poured the nectar thick apple juice into another cup and the consistency was not the same thickened consistency.During an interview on 8/27/2025 at approximately 6:11 PM, the FSM stated, I do not know what to call this consistency [referring to the nectar thick apple juice cup removed from the bin in the kitchen]. I don't know if it's the machine is not working or if the ice is melting and getting into the cups.During an observation on 8/27/2025 at approximately 6:14 PM, the Certified Dietary Manager (CDM) and the FSM, the CDM poured the nectar thick apple juice in a cup and also poured the honey thickened juice from the draft machine.During an interview on 8/27/2025 at approximately 6:14 PM, the CDM stated, The apple thickened fluids are not as thick as the water. It could be more thickened. The honey thickened is not thickened. The machine might not be calibrating correctly. I would have to call the company and have them come out. The machine is to be checked every three months [by the vendor] or as needed.During an interview on 8/28/2025 at 9:35 AM, the Registered Speech Therapist stated, If the patient is nectar or honey thick, the patient should get the ordered consistency liquids. If a patient who is on thickened liquids is provided thin liquids on a consistent basis, anything can happen; silent aspiration, dysphagia, it would depend on the patient.During an interview on 8/28/2025 at 1:00 PM, Staff B, Dietary Aide, stated, I think there are five cups on the tray line prepared. I thought they were already thickened. I was not aware that there is a problem with the machine. I was going to put them on the trays to be served.During an observation on 8/28/2025 at 1:14 PM, the FSM had an open cup of red thin liquid in front of her and was opening a Thick & Easy instant food and beverage thickening powder.During an interview on 8/28/2025 at 1:14 PM, the FSM stated, I was using the machine this morning and until now. I began to pour the thickening powder just now [into the red liquid]. I did not know we should not use the machine because you [referring to this writer] did not tell us we needed to shut it down yesterday. When asked when she and the CDM observed the fluids from the machine were not the appropriate thickened consistency why she had not stopped using the machine, the FSM did not respond. When asked who is responsible for the kitchen and the proper functioning of the kitchen equipment the FSM stated, I am.During an observation on 8/28/2025 at 1:20 PM in the kitchen, Staff B, Dietary Aide, was putting drinks and food on the resident's tray. The drinks that she had sitting on the tray line were covered with a lid. Drinks on the tray covered with a lid were designated as thickened drinks. The liquids were observed to be of a thin consistency.During an interview on 8/28/2025 at 1:22 PM, the FSM stated, I thought the drink machine was fine to use.During an interview on 8/28/2025 at 1:25 PM, the Administrator stated, I was not aware of the machine not working until just now. I thought last night that they had just given the resident a wrong cup with the wrong liquid consistency.During an interview on 8/28/2025 at 2:03 PM, Staff J, Licensed Practical Nurse/ Unit Manager (LPN/UM) for South, stated, I was in the dining room for dinner last night. I checked breakfast trays this morning and told them it [referring to thickened liquids] was too thin. Just with the juices we saw, we sent them back to the kitchen because they did not seem thick enough. [Residents #46 and #71's names] had cranberry juice on their trays and we had issues with them being too thin. We got them replaced with water which was thick enough.During an interview on 8/28/2025 at 2:13 PM, Staff S, CNA, stated, When we did the cart trays for lunch, the drink was too thin for rooms [Residents #46 and #71's rooms]. I took them back to the kitchen and told the staff that the drink was too thin. For breakfast, the UM took them back when they were too thin. The CNAs check the list on the drink cart for residents who are on thickened liquids.During an interview on 8/28/2025 at 2:30 PM, the FSM stated, The tech [from the name of the draft machine, drink machine used to prepare and serve thickened liquids, service company] came in today and adjusted the flow of the juice and the thickened water by using a screwdriver to adjust the flow of the water and juice. We only sent out water this morning, I do not know how the residents needing thickened liquids got juice this morning. I was not made aware of juices being brought back to the kitchen this morning.During an interview on 8/28/2025 at 3:32 PM, the Draft Machine Service Company's Service Manager stated, The last delivery was on 8/21/2025. The driver will do the delivery and check if the machine is working. When asked if the delivery driver checks the machine with each delivery the Service Manager stated, That varies, the driver may check it out but not always. Most customers will mention if they have a problem and the driver checks into it and will fix it. The service call was that the thickened water was too thick. I see that the technician documented Brix [term used for adjusting the draft machine] the honey and nectar gun. Brix means that he [the technician] had to adjust the gun. The technician only adjusted the thickened water. The computer document reports what the customer reported. The machine never needs calibration.During an interview on 8/28/2025 at 4:01 PM, the FSM stated, I texted the sales rep [representative]. He misinterpreted my text message. I told him that the liquids were too thin. I sent him the message at 6:36 AM today [8/28/2025] to request someone to come out and take a look at the machine. During the last delivery [8/21/2025] the driver did not check the machine. They usually will check if we report an issue and I did not have anything to report. Review of text message sent on 8/28/2025 at 6:36 AM, from the FSM read, Good morning ([Name of the Draft Machine Service Company's Sales Representative's name], We seem to have an issue with the thickness of our thickened liquid. The waters are pouring correct, but the juice's are to thin. If this could be addressed asap [as soon as possible] that would be great. Unfortunately the state is in here and will be all day. They were the ones who brought it to my attention last evening. Let me know an approximate time so I can at least give them something. Thank you [the FSM].During an interview on 8/29/2025 at 8:31 AM, the DON stated, Speech and dietary would have the education and knowledge to be able to identify that thicken liquids are not at the right consistency. If the staff suspect it is not thick enough, they always go to speech [therapist] or dietary and they will confirm the consistency. I was aware that the nursing staff had to send back some of the consistencies. It occurred for breakfast and lunch, and the consistency had to be corrected. The inconsistency happened due to dietary having some concerns with their machine. As far as for me, I was not aware the machine was not in proper order. If I was aware, I would have given other directives. To me that was a follow up because I gave directives to the CNAs to correct the consistency and I was expecting that if they are not able to fix the inconsistency they should come back to me and report if it is a dietary problem. That was not reported to me. My responsibilities are to oversee the residents, that they are getting the care that we provide. Making sure that they are getting all the care they need, if any concern in any other department, that I am made aware it, so that it is fixed in a timely manner. When asked if it is her responsibility to safeguard the residents, the DON stated, I do. It is part of my responsibility to ensure of their safety.During an interview on 8/29/2025 at 8:58 AM, the Regional Director of Operations of Rehabilitation Services, stated, The speech therapist has the education and knowledge to identify the liquid consistency. I know that in the kitchen there is a machine and they have policies in the kitchen regarding that. Definitely, if a nurse has any questions, they can reach out to the ST. There are two modes of contact for the ST, some involve speech therapist occasionally in the building and worst case scenario telehealth. It is definitely better they see it [liquid consistency] in person, but during telehealth it is likely they would be able to identify it. The rehabilitation director has an OT [Occupational Therapy] background, but I would feel it would be best if ST be the one to determine. If they are using the packets to mix by hand, it would be to read the directions in the back of the packets. To my knowledge, they have not been to the facility to check on the consistency of the draft machine to verify it [liquids] is at the right consistency. When I say kitchen policies, I mean the settings of the machines for the consistency. I think that a speech therapist should come and give a more accurate assessment of the liquids. If there was an issue with the machine, I feel it should have been reverted to manually mixing and not utilizing the machine. We do in-services, I'm not sure when the last one happened.During an interview on 8/29/2025 at 9:21 AM, the CDM stated, Everyone in the kitchen has the education and knowledge to identify if liquids are not at the right consistency. Not all nurses are able to identify consistency. They are not trained but some are so used to seeing them [thickened liquids] that they are able to identify the consistency of a liquid. The nurses should always go to the kitchen and ask the staff for confirmation. After that night, [8/27/25, when the deficient practice was identified] we had called the company to come out to fix it [thickened liquid machine]. They [dietary] did not use the machine after I had left. The next day, I came in the afternoon around three. All the staff in the kitchen know any equipment that is broken should not be used. I told the staff before leaving that they should not use the machine until the company comes out to look at it since it was not working properly and instructed the staff to prepare the juices for breakfast manually. I don't know why they were using that [thickened liquid machine]. Normally, if the equipment is out of order, we need to put up a sign. There was not a sign posted before I left but [The FSM's name] knew she should put up a sign. As a CDM, I have to train all the new employees that come in. I do angel rounds, care plan meetings, food preferences, inventory and ordering, making sure that emergency storage is good for the hurricane season. I am just covering right now; I have been here every day since Monday [8/25/2025]. I go over consistency with staff and there is also a flyer, and the recipe book [for thickened liquids]. I feel that all the staff in the kitchen working right now is able to identify the consistency correctly of the liquids. [The FSM's name] texted the Administrator to let him know [the thickened liquid machine]. I feel that as the CDM, I am responsible for safeguarding the residents in the building. Whoever is the aide assigned to drinks on the schedule. The aide should be responsible for verifying the consistency when they are pouring. She should have stopped and addressed it with me and [the FSM's name]. I would have called the company right away and checked the storage and if not go get it from the supplier [boxes of thickened liquids]. They [dietary aides] need to notify use of any problem and that is also part of the job description to notify as immediately and I am available 24/7 every day.During an interview conducted on 8/29/2025 at 9:41 AM, the Dietary, Housekeeping and Laundry District Manager stated, My regional would be over the CDM. The previous CDM was bouncing between two accounts, and we were getting lots of complaints from another account. So, we had to terminate her. The issues in this kitchen were not part of her termination. I can assume it was happening here as well because I see a trend. The first line of defense is the dietary aide. This should not have happened. I was not made aware that the machine was not working properly. I would have gone out and even bought another machine. The staff in the kitchen, this is part of their daily equipment check and they have to not use it and find a way to continue the operation. It should have been reported from the aide.During an interview conducted on 8/29/2025 at 10:00 AM, the Administrator stated, The speech therapist is who we go to if there are any questions regarding consistency. The kitchen staff also have the education and the knowledge to determine the right consistency. That is why we have the system for check points to prevent things like that [residents being served inappropriate thickened liquid beverage] from happening. They notified me yesterday. I don't remember what time, but as soon as they told me, I got on the phone with the company and told them it was urgent. It was a busy day. I don't recall if I received a text from the FSM regarding the machine that evening when the machine was identified as not properly working. I oversee the day-to-day operations. For the kitchen my responsibly is to have the tools that they need to get their jobs done. They are vendors, so they do the hire and education. We are responsible for the food. The vendor would be responsible for fixing the equipment. Everyone that works here is responsible for safeguarding the residents. I feel that the break in the system was the machine and as soon as I was aware I called to get it fixed.During an interview on 8/29/2025 at 10:36 AM, the Medical Director stated, I was aware that the [Brand name of the draft/thickened liquid machine] had malfunctioned on Wednesday and I told them to call the company and have them fix the machine and come and fix it by Thursday. They [Residents requiring thickened liquids] have a possibility of aspiration pneumonia and fatal consequences as well. The staff should not use the machine until it is fixed by the company. I recommended not to use the device until fixed. I don't recall what time on Wednesday [8/27/2025] and the DON was the one to notify me. I make sure patient safety is first, and they get the care that they need. The policies are implemented. Today we were supposed to have a meeting, but I am going out of town, and I am going on a trip since it's a long weekend.Review of [Name of draft machine service company] Invoice dated 8/28/2025 read, Problem Reported: Soda X [Name of Food Service Manager] Texted a request for calibration of her nectar thick gun juices. She said nectar juices coming out too thick. Resolution: Brix honey & [and] nectar gun.Review of the document titled [Name of the Draft Machine Service Company] Fountain-Dispensed Beverage Solutions with an effective date of 5/5/2025 read, Purpose: This agreement is submitted to above Care Facility for the purpose of becoming the sole supplier of all dispensed beverage products. [Name of draft machine service company] will install the needed equipment, service specified equipment, and deliver specified products. Equipment: [Name of draft machine service company] will install a customized dispensing systems consisting of the following equipment: [no equipment was marked]. A. This equipment will be installed in the facilities, and be of the highest quality and subject to weekly inspection and maintenance, as well as periodic preventive maintenance. This equipment will remain the property of [Name of draft machine service company]. Service and Delivery: [Name of draft machine service company] will provide regular maintenance of all equipment and product replenishment as required by the system. There will be no cost to the above facility for these services. Emergency Service will also be available at no additional cost. Notification: The facility agrees to notify [Name of draft machine service company] of any defects of failure of the equipment that does not receive proper service by its service technician.Review of Cook/Kitchen Staff Competency assessment dated [DATE] for Staff B, Dietary Aide, read, Administrative Functions. Inspect diet trays to assure that the correct diet is served to the resident. Ensure that all food procedures are followed in accordance with established facility policies, and Assist in serving meals as necessary and on a timely basis. The required functions of the job were marked as In service Needed. Signed by the FSM.During an interview on 8/28/2025 at 10:24 AM, the Certified Dietary Manager stated, She [Staff B] was supposed to put chilled desserts, salads and modified drinks on the trays on 8/27/25 for the dinner meal trays. The Competency Assessment for [Staff B's Name] was conducted on 5/27/25 with several functions listed as In-service needed. I cannot find any in-services provided to [Staff B's Name]. I was not made aware of this assessment [the training not being completed] until today.The Immediate Jeopardy (IJ) was removed onsite as of August 29, 2025 after the receipt of an acceptable IJ removal plan. The facility has completed the following steps to remove the immediate jeopardy. As verified by the survey team, on 8/28/2025, the facility administration conducted a QAPI meeting and root cause analysis related to consistency of liquids provided to the residents. On 8/28/2025, the Dietary Manager Received 1:1 (one on one) education on the importance of notifying the administration and dietary staff with equipment concerns and to post an out of order signage by the Administrator. On 8/29/2025, the Dietary Manager received 1:1 training on lock out/tag out. On 8/29/2025, the facility Administrator and the director of Nursing Services were reeducated by the Senior VP (Vice President) of Operations on the component of F835 to ensure the facility utilizes its resources effectively and efficiently to attain and maintain the highest physical well-being of each resident and implement procedures related to consistency of liquids by identifying equipment malfunction and notification responsible staff. On 8/29/2025, the Administrator received 1:1 training regarding equipment failure, c[TRUNCATED]