**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and a policy review, the facility failed to ensure care and services to prevent accidents for 3 of 9 sampled residents reviewed for nutrition and falls, as evidenced by the failure to provide supervision while eating for Resident #37; failure to implement preventative measures to prevent a fall related injury for Resident #14; and failure to complete a post fall investigation to determine the cause of the fall for Resident #20.On 06/24/25 it was determined the facility failed to ensure adequate supervision for Resident #37, a resident with diagnoses of Cerebral Infarction (Stroke) and Dysphagia (difficulty swallowing), to prevent the likelihood of choking, aspiration (the accidental ingestion of food particles or fluids into the lungs), and/or death. Resident #37, who was ordered to have a mechanically altered diet, was not supervised during meals as per her current care plan and was subsequently provided with a whole hot dog that she consumed. The resident had a history of being served potato chips, Goldfish crackers by facility staff members. The likelihood of Resident #37 choking on the hot dog with the potential of aspiration or death was determined and the Administrator was informed of the Immediate Jeopardy on 06/27/25 at 10:50 AM. The Immediate Jeopardy was identified on 06/24/25 and was removed on 06/27/25. The scope and severity were decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 06/27/25 and verified by interview, observation and record review on 06/27/25. Although, the facility submitted an acceptable removal plan, the potential for more than minimal harm remains without the implementation of a plan of correction and monitoring of the corrective actions.Cross Reference - F805. The findings included:A Review of the policy titled, Meal Supervision and Assistance revised on 11/29/22 documented that the resident will be prepared for a well-balanced meal in a calm environment, with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This included identifying hazards and risks. The listed guidelines for compliance included checking the meal tray before serving it to the resident to make sure that it was the correct diet ordered and that the food texture was appropriate for the resident's ability to chew and swallow. Photographic Evidence Obtained.A record review revealed that Resident #37 was admitted to the facility on [DATE]. Her diagnoses included Cerebral Infarction (Stroke) due to Embolism of the Left Carotid Artery (lack of blood flow to the brain caused by a blood clot), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction Affecting the Right Dominant Side, Aphasia (impaired ability to speak) Following Cerebral Infarction, Dysphagia (swallowing difficulty) Following Cerebral Infarction, and Muscle Weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented this resident's Brief Interview of Mental Status (BIMS) score equaled 5, which indicated that Resident #37 had severe cognitive impairment.A record review of Resident #37's care plan, last revised on 02/13/25, revealed that Resident #37 was at risk for malnutrition due to her medical history which included Dysphagia, Aphasia, Anxiety, and Cerebrovascular Accident (stroke). Since 12/02/22, the interventions listed in the care plan included providing the diet as ordered, and monitoring for signs and symptoms of aspiration such as coughing, choking, pocketing of foods, spitting out food, wet vocal quality, and wet lungs. If symptoms of aspiration or choking were found, the physician and the Speech Language Pathologist were to be notified. An intervention since 12/02/22 specified to set-up the trays, supervise, cue, and assist the resident as needed with meals. It specified to allow adequate time to consume food/fluids provided. Record review of the medical record Listing of Tasks for Eating showed no checkmarks under the column that denoted the provision of supervision from 06/13/25 through 06/26/25. The eating task in the electronic medical record was used by Certified Nursing Assistants (CNAs) to document how much a resident ate or drank, and how much assistance was provided by the CNA.Record review revealed the physician ordered diet for Resident #37, dated 06/01/25, documented a Regular Diet, with mechanical soft texture foods, and thin consistency fluids. The diet listed in the Meal Tracker (meal ticket software program) was Regular - Mechanical Altered/Ground. The diets in the electronic medical record documented (mechanical soft), and the meal ticket software program documented (ground). Both were mechanically altered diets that were used for residents with swallowing difficulties. Photographic evidence of the meal ticket was obtained.During an observation of Resident #37's dinner meal, on 06/24/25 at 5:26 PM, Resident #37 refused her meal. The meal ticket on her tray specified that she was on a Regular-Mechanical Altered/Ground diet. Staff A, Certified Nursing Assistant (CNA), offered the resident several food options including grilled cheese, a peanut butter and jelly sandwich, and an egg salad sandwich. Resident #37 communicated that she didn't want any of those alternatives. Staff A mentioned she would look at the menu to see what other alternatives were available. Staff A saw that a hot dog was listed on the menu as an available option, and asked Resident #37 if she wanted a hot dog. Resident #37 said, yes. During an interview on 06/24/25 at 5:38 PM, while in the hallway in front of the dining room, Staff A, CNA, stated she had given Resident #37 a hot dog and she ate it. Upon receiving this information, the surveyor returned to the resident's room, Resident #37 held a quarter of the hot dog bun while still sitting on her bed. The hot dog was not visible and it appeared the resident had consumed the hotdog.During an interview on 06/24/25 at 5:42 PM with Staff A, when asked if the hot dog was whole or cut-up into small pieces, the CNA stated she served Resident #37 a whole hot dog that was not cut-up. When asked if the kitchen staff knew it was for Resident #37, Staff A said that she told the kitchen it was for Resident #37. Staff A confirmed that Resident #37 ate 100% of the hot dog.During an interview on 06/24/25 at 5:52 PM, the Certified Dietary Manager (CDM) stated that she didn't know who the hot dog was for. She reported, Resident #37 wouldn't be given a whole (intact) hot dog because of her diet; it would be mechanically ground. The CDM stated that the kitchen staff would have been able to grind it for her. The surveyor asked to see the food processor that was used for grinding up foods, and the CDM showed the surveyor a clean food processor. The surveyor asked the CDM if the kitchen staff prepared any ground hot dogs on 06/24/25, and the CDM said that they did not. She explained that no one on a ground diet ordered a hot dog that day.During an observation of the dinner meal on 06/26/25 at 5:50 PM, Resident #37 was in bed and a tray of food was on her tray table. The food on the tray included, ground beef, mashed potatoes, and vegetables were on the main dinner plate. There appeared to be warm ground chicken salad was on a separate small plate covered with plastic wrap. The resident moved the plate onto her lap and peeled back the plastic wrap. She used her fingers to pick up and taste the chicken salad. She shook her head from left to right and waved her hands back and forth. She said no ., no ., and she placed the plate back on the meal tray. She did not eat any more chicken salad. There was no staff from the facility present in Resident #37's room when she tasted the chicken salad. The surveyor continued to observe Resident #37 in her room. No staff members provided supervision for Resident #37 during the dinner meal from 5:50 PM through 6:05 PM. 2) Review of the record revealed Resident #14 was admitted to the facility on [DATE] and was sent out to the emergency room (ER) on 02/26/25 and 03/01/25, with a return to the facility those same days. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 1, on a 0 to 15 scale, indicating severe cognitive impairment. This MDS documented Resident #14 had a fall with injury since the prior assessment of 12/24/24.Review of the current care plan initiated on 01/21/22 documented Resident #14 was at risk for falls and fall related injury related to cognitive loss, stroke, non-ambulatory status, impaired mobility, weakness, medication use, fall history, osteopenia (small bones), and bilateral knee contractures. An intervention included providing a mat on the floor to the left side of the bed as of 11/07/23. A second intervention initiated on 12/04/23 documented the use of bilateral wedges to sides of bed for safety and fall risk prevention.Review of the current physician orders documented the need for a floor mat to the left side of the bed for safety since 11/07/23. A current order dated 06/23/25 documented the use of bed bolsters to bilateral sides of bed.Review of a change in condition form dated 02/26/25 documented Resident #14 had a fall with no apparent injury and was sent out to the hospital.Review of progress notes documented, in part, the following:a) On 02/26/25 at 4:25 PM, Resident #14 suffered an unwitnessed fall at about 3:45 PM, and was sent to the ER.b) On 02/26/25 at 10:22 PM the nursing staff received information from the ER (Emergency Room) that the resident was being returned back to the facility. A CT (Computed Tomography) of the brain and cervical spine (upper part) indicated no fractures or injuries.c) On 03/01/25 at 10:18 AM and 10:52 AM the resident's brother insisted Resident #14 return to the ER due to increased back pain and to get additional studies. The resident was sent back to the ER.d) On 03/01/25 at 8:06 PM the resident returned to the facility with diagnoses to include a closed wedge compression fracture of T10 (thoracic or mid back) vertebra and a closed compression fracture of L3 lumbar (lower back) vertebra. The resident was medicated with Dilaudid (an opioid/narcotic pain medication), Toradol (an anti-inflammatory medication), and Zofran (a medication for nausea) at 1:53 PM. He returned to the facility with orders for Percocet (an opioid/narcotic pain medication) as needed.Review of the radiology studies from the ER visit on 03/01/25 documented both compression fractures as acute/subacute, indicating they could not tell if the fracture was recent or anytime within the past few months.Review of the facility provided fall investigation documented there were interventions/strategies in place from the care plan but lacked documentation of whether the fall mat and wedges/bolsters were in place. The Assigned CNA Statement Form and Registered Nurse (RN) Statement Form both lacked documentation as to whether the fall mat and wedges/bolsters were in place. Review of the Fall Root Cause Analysis documented, in part, there were no floor mats in place.During an interview on 06/27/25 at 8:44 AM, when asked about the investigation related to the care plan interventions at the time of the fall, the Administrator, who was also the Risk Manager, did not comment, while the Director of Nursing (DON) explained the resident would play with the bed remote and had raised the bed up and rolled out of bed. The DON further stated the fall mat was in place. When asked to locate evidence of this on the fall investigation and was also notified the root cause analysis documented a lack of the fall mat, the DON stated, I'm sure I saw it but agreed to the conflicted information in the investigation.During an interview on 06/27/25 at 11:23 AM, when asked about the radiological report documentation of acute/subacute fracture, the Medical Director stated that more than likely, because of the minimal 10% height loss, the fractures were chronic. When asked about the resident's increased yelling/pain with movement, the Medical Director reviewed the full radiological report and stated the bulging disk may have been affected with the fall and caused the pain.3) Review of the record revealed Resident #20 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, indicating the resident was cognitively intact.Review of a change in condition form dated 11/02/24 documented Resident #20 slipped out of the shower chair with no open injuries.During an interview on 06/23/25 at 4:08 PM, when asked about his fall in the bathroom, Resident #20 stated he was being assisted with a shower in his bathroom, was seated in the rolling shower chair, and further stated, Apparently the wheels were not locked as it went out from under me. The resident denied any fracture, but stated it happened about three months ago, that he had fallen on his bottom and had twisted his shoulder, and it took him a couple of months to recover.On 06/25/25 at 11:21 AM, the DON was asked to locate and provide evidence of the fall investigation for Resident #20 from 11/02/24. At 12:47 PM the DON provided a folder labeled with the name of Resident #20, stated, I wasn't here when it (the fall for Resident #20 in November 2024) happened and I couldn't find any investigation, so I printed out the information that I could find in PCC (Point Click Care, the facility's electronic medical record (EMR)) and filled out the Fall Investigation Form. I wanted you to have something. There aren't any statements or anything else.Review of the folder revealed the Fall Investigation Form with only page one filled out with information the DON had obtained from the EMR. The possibility of an equipment issue was not addressed in any of the documents. The Fall Investigation Form documented the fall was unwitnessed whereas the nursing post fall evaluation documented the fall as being witnessed.During a phone interview on 06/27/25 at 11:36 AM, when asked if she recalled the fall in the shower for Resident #20, Staff M, CNA, stated she did as she was present during the fall. When asked what happened, the CNA stated she really wasn't sure, but I always lock the wheels (of the shower chair). The CNA further explained the resident fell as he was trying to pull himself up with the grab bar when the chair slipped back.During an interview on 06/27/25 at 8:40 AM, the DON confirmed she had not found an investigation for the fall of Resident #20 on 11/02/24 but had found a statement. At 9:59 AM the DON returned with a statement and Fall Hand Off form. Review of the statement revealed Staff M, CNA, documented the resident was trying to stand up to dry off and the shower chair slid back, and he fell on his bottom. The Fall Hand Off form lacked any information regarding the actual fall but was an instruction sheet for the nursing staff. The DON confirmed there was no root cause analysis or evidence the event was investigated. The DON also agreed to the lack of any information related to the shower chair. The facility's Immediate Jeopardy removal plan dated 06/27/25 included the following, which was also verified:On 06/24/25 Resident #37 was immediately assessed. A speech referral was submitted to assess diet appropriateness. A chest x-ray was ordered to rule out aspiration. Respiratory assessments were initiated every shift for 72 hours for signs and symptoms of aspiration. The resident's diet order, care plan, and Kardex were reviewed and updated as indicated for accuracy. The physician and responsible party were notified. On 06/25/25 a speech evaluation was ordered for Resident #37.On 06/26/25 a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) bedside study was ordered.On 06/24/25 the CNA and dietary employee involved were removed from the floor and received one-on-one education by the Staff Development Coordinator and Dietary Manager on verifying diet slips with current orders, appropriate food textures for mechanical soft diets, how to address concerns regarding tray accuracy, possible consequences of serving inappropriate diets, and ensuring proper supervision of residents who require it during meals.On 06/25/25 the facility reviewed residents with mechanically altered diets to ensure current orders matched tray ticket diets. There were 18 current residents who were on mechanically altered diets at the time of the survey.On 06/24/25 through 06/26/25 current staff were educated on supervision of residents related to accidents and incidents specifically to proper supervision of residents who require it during meals, including alternate food options and snacks as requested. Newly hired staff will receive education on supervision of residents during meal consumption in their orientation. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.On 06/27/25 current staff were educated on how to respond to a choking resident. Education was done via the facility on-line portal, in person, and via telephone.On 06/27/25 the information in the facility's removal plan was verified. Observations of the lunch and dinner meals on 06/27/25 demonstrated a process to ensure physician ordered diets were being delivered to residents. A new diet communication manual was placed in the main dining room and on each tray cart. On 06/27/25 six staff, including Staff B, the CNA who provided Resident #37 with potato chips and permitted the resident to choose Gold Fish crackers were interviewed. Each staff member was able to verbalize the education provided during the week. They verbalized what needs to be done before providing an alternate food item or snack to a resident, the new process for meal tray delivery, and how residents are identified who need supervision. On 06/24/25 Resident #37 was immediately assessed by her assigned nurse. A speech referral was submitted to assess diet appropriateness. A chest x-ray was ordered to rule out aspiration and was refused by the resident. Respiratory assessments were initiated and documented every shift for 72 hours for signs and symptoms of aspiration. The resident's diet order, care plan, and Kardex were reviewed and updated as indicated for accuracy. The physician and responsible party were notified. On 06/24/25 Staff L, dietary cook and Staff A, CNA, were provided the one-on-one education.On 06/24/25 a total of 109 current staff, including all disciplines, received the education related to supervision.On 06/25/25 the speech evaluation was completed for Resident #37.On 06/25/25 an audit was completed confirming the meal textures in Meal Tracker (the dietary software used to print meal tickets) matched the physician's order for all current residents.On 06/26/25 a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) bedside study was conducted. The recommendations from this study were to advance the resident diet to a mechanically soft chopped diet.On 06/27/25 it was verified that all 27 licensed nurses had CPR (cardiopulmonary resuscitation)/Heimlich maneuver (procedure recommended for a choking resident) certifications in good standing.As of 06/27/25, 100% of staff received education on responding to a choking resident via their on-line portal. In addition, 30% of current staff were educated in person and 23% via telephone on how to respond to a choking resident. Staff who received this education via telephone will receive the in-person education upon their next working shift at the facility.An Ad Hoc/Quality Assurance Performance Improvement (QAPI) meeting was held on 06/25/25 with the Medical Director, the Administrator, the Director of Nursing, the Staff Development Coordinator, and the Dietary Manager. Supervision during meal consumption was discussed. A plan for continued monitoring and sustained compliance was reviewed. An additional Ad Hoc/QAPI meeting was held on 06/26/25 to evaluate the effectiveness of the education.The facility's Immediate Jeopardy was removed on 06/27/25 at 6:50 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, policy review, and review of professional standards of practice, the facility failed to prepare foods in a form to meet the individual needs for 4 of 5 sampled residents, Resident #37, Resident #10, Resident #15, and Resident #21, reviewed for nutritional concerns. This had the potential to affect 18 current residents who were on mechanically altered diets at the time of the survey.On 06/24/25 it was determined the facility failed to follow a physician ordered diet, that was mechanically altered, for Resident #37, a resident with diagnoses of dysphagia (difficulty swallowing), to prevent the likelihood of choking, aspiration (the accidental sucking in of food particles or fluids into the lungs), and or death. Resident #37, who was ordered to have a mechanically altered diet, was provided with a whole hot dog that she consumed.The likelihood of Resident #37 choking on the hot dog with the potential of aspiration or death was determined. The Administrator was informed of the Immediate Jeopardy on 06/27/25 at 10:22 AM.The Immediate Jeopardy was identified on 06/24/25, and was removed on 06/27/25. The scope and severity were decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy for F689 and F805. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 06/27/25 and verified by interview, observation and record review on 06/27/25. Although, the facility implemented corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and monitoring of the corrective actions.Cross Reference - F689.The findings included:A review of the facility's Policy titled, Nutritional Management last revised 04/27/22, documented examples of interventions for nutrition that were to be individualized to address the specific needs of each resident. One example that was listed was the mechanically altered-consistency diet that may be prescribed for a resident diagnosed with dysphagia or with chewing difficulties.The National Dysphagia Diet Task Force (2002) created the National Dysphagia Diet: Standardization for Optimal Care. It described the Level 2: Dysphagia Mechanically Altered (Dysphagia Ground) diet as foods that are moist, soft-textured, and easily formed into a bolus. Meats are ground or are minced no larger than one-quarter-inch pieces. They are still moist, with some cohesion. Hot dogs, peanut butter, potato chips, dry, coarse cakes and cookies, and bread that has not been pureed, gelled, or slurried to a moist texture, were listed as foods to avoid on the Dysphagia Ground diet.The Level 1: Dysphagia Pureed diet was described as pureed, homogenous, and cohesive foods. Foods should have a pudding-like texture.A review of information on the Mechanical Soft Diet (used by the University of Wisconsin-[NAME] integrated health system) and provided as a reference by the Corporate Certified Dietary Manager documented the Mechanical Soft diet was designed for people who had trouble chewing and swallowing. It included chopped, ground, and pureed foods, as well as foods that broke apart without a knife, (like fish). It specified that sausage, [NAME] (hot dogs), peanut butter, and chips were foods to avoid on the mechanical soft diet. 1) Record review revealed Resident #37 was admitted to the facility on [DATE]. Her diagnoses included Cerebral Infarction due to Embolism of the Left Carotid Artery (lack of blood flow to the brain caused by a blood clot), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction Affecting the Right Dominant Side, Aphasia (impaired ability to speak) Following Cerebral Infarction, Dysphagia (swallowing difficulty) Following Cerebral Infarction, and Muscle Weakness. Per the Minimum Data Set (MDS) assessment dated [DATE], this resident's BIMS score equaled 5, which indicated that Resident #37 had severe cognitive impairment. At the time of admission, Resident #37 received no foods or liquids by mouth. She was dependent on tube feeding for total nutrition. She started eating by mouth and was served meals from the kitchen as of 02/01/22.A record review of Resident #37's care plan, last revised on 02/13/25, revealed that Resident #37 was at risk for malnutrition because of her medical history which included Dysphagia, Aphasia, Anxiety, and a Cerebrovascular Accident (stroke). Since 12/02/22, the interventions listed in the care plan included providing the diet as ordered, and monitoring for signs and symptoms of aspiration such as coughing, choking, pocketing of foods, spitting out food, wet vocal quality, and wet lungs. If symptoms of aspiration or choking were found, the physician and the Speech Language Pathologist were to be notified.Record review revealed the physician ordered diet for Resident #37, dated 06/01/25, was for a regular diet, with mechanical soft texture foods, and thin consistency fluids. The diet listed in the Meal Tracker (meal ticket software program) was Regular - Mechanical Altered/Ground. The diets in the electronic medical record (mechanical soft), and the meal ticket software program (ground), were both mechanically altered diets that were used for residents with swallowing difficulties. The two diets were not identical. Photographic evidence of the meal ticket was obtained.During an observation of Resident #37's dinner meal, on 06/24/25 at 5:26 PM, Resident #37 refused her meal. The meal ticket on her tray specified that she was on a Regular-Mechanical Altered/Ground diet. Staff A, Certified Nursing Assistant (CNA), offered the resident several food options including grilled cheese, a peanut butter and jelly sandwich, and an egg salad sandwich. Resident #37 communicated that she didn't want any of those alternatives. Staff A mentioned she would look at the menu to see what other alternatives were available. Staff A saw that a hot dog was listed on the menu as an available option, and asked Resident #37 if she wanted a hot dog. Resident #37 said yes. During an interview on 06/24/25 at 5:38 PM, while in the hallway in front of the dining room, Staff A, CNA, stated she had given Resident #37 a hot dog and she ate it. Upon immediate return to the resident's room, Resident #37 held a quarter of the hot dog bun while still seated in her bed. The hot dog was not visible.During an interview on 06/24/25 at 5:42 PM, when asked if the hot dog she provided was whole or cut-up into small pieces, Staff A stated she served Resident #37 a whole hot dog that was not cut-up. When asked if the kitchen staff knew it was for Resident #37, Staff A said that she told the kitchen it was for Resident #37. Staff A confirmed that Resident #37 ate 100% of the hot dog. During an interview on 06/24/25 at 5:52 PM, the Certified Dietary Manager (CDM) stated that she didn't know who the hot dog was for. She said Resident #37 wouldn't be given a whole (intact) hot dog because of her diet; it would be mechanically ground. The CDM stated that the kitchen staff would have been able to grind it for her. The surveyor asked to see the food processor that was used for grinding up foods, and the CDM showed the surveyor a clean food processor. The surveyor asked the CDM if the kitchen staff prepared any ground hot dogs on 06/24/25, and the CDM said that they did not. She explained that no one on a ground diet ordered a hot dog that day. The menu for the dinner meal on 06/24/25 was reviewed. It included a Ground Hot Dog (no bun) as an alternate entrée for residents on the mechanical altered/ground diet.During an observation on 06/24/25 at 4:45 PM, Resident #37 pointed to the picture of the place setting (plate with fork, spoon, and knife), with the word Hungry above the picture on her communication board. Photographic Evidence Obtained. During an interview with a Staff B, CNA, on 06/24/25 at 4:45 PM, when asked what she thought Resident #37 meant when she pointed to that picture, Staff B said that either she was hungry, or she didn't like her food. Staff B said Resident #37 wanted to know when dinner was ready. She said she offered Resident #37 a peanut butter and jelly sandwich that she didn't want it. When asked if snacks were available, Staff B identified a snack basket that was kept at the nurse's station. It contained graham crackers, Goldfish crackers, and soft/pliable chocolate cookies. Staff B said that she normally took the snack basket to Resident #37 and let her choose a snack from the basket. She also said that normally she gave Resident #37 potato chips. When asked how frequently she gave the resident potato chips, Staff B said that in the past 3 weeks she provided Resident #37 with potato chips two times. The CNA brought the basket of snacks to the resident. The Resident picked a bag of Goldfish crackers from the basket. The surveyor asked Staff B why Resident #37 was on a soft foods diet, and Staff B responded, I don't know, her meal ticket says regular. Then she said that Resident #37 had no problem swallowing foods and that she ate Goldfish crackers with ease. She also reported that in the past Resident #37 was also served hamburgers and fries.An observation on 06/25/25 at 8:49 AM revealed that Resident #37's meal tray had been removed from her room and placed into the meal cart. Staff C, CNA was asked to identify Resident #37's meal tray. The CNA located the tray and the resident's breakfast meal ticket. The tray was placed back onto the resident's tray table. Resident #37's tray was observed to have, a large plate with a crumpled up light-yellow biscuit that appeared to be dry. The plate and the muffin were garnished with parsley flakes. There was no sausage gravy as listed on the menu; there was no moisture providing sauce or syrup on it. During an interview on 06/25/25 at 9:52 AM, the CDM explained that sandwiches were not allowed on Resident #37's diet.An interview was conducted with the Speech Language Pathologist (SLP, expert on swallowing disorders) on 06/25/25 at 5:34 PM. When asked if the diets in the electronic medical record and the diets on the meal tickets were supposed to be identical, the SLP answered, yes. She said they should be the same. When the SLP was told that Resident #37's diet on the meal ticket documented she was on a Regular - Mechanical Altered/Ground diet, the SLP confirmed that was the diet she wanted for Resident #37. The physician's diet order in the electronic medical record was documented as Regular diet, Mechanical Soft texture, Thin consistency.During the continued interview on 06/25/25 at 5:34 PM with the SLP about the possible consequences of non-compliance with the diet texture, the SLP said that the big concerns were aspiration and choking. She explained that both Aspiration Pneumonia and choking could be fatal. When asked about Resident #37's request for a hot dog, the SLP said that it should have been ground. The SLP said that on her diet she can have soft sandwiches. When the SLP was asked about the potato chip and Goldfish crackers items, she said that hard and crunchy foods can be problematic. She said that potato chips and Goldfish crackers can be difficult to swallow because they are dry.During an interview with the SLP on 06/26/25 at 2:21 PM, when asked what the difference was between a mechanical soft and a mechanically altered ground diet, the SLP said that it depends on the specific facility and their dietary policy. She added that in her experience the mechanical soft diet also warranted ground meats. The SLP stated that having the word Regular in the diet can be confusing and easy to misinterpret. She explained that the term Regular diet meant that he was not on a therapeutic diet like a Renal diet, or a diet for hypertension or diabetes.During the continued interview with the SLP on 06/26/25 at 2:21 PM, the SLP revealed a Speech Therapy treatment encounter note dated 03/01/2022 that listed the resident's response to treatment. She stated Resident #37 was on Speech Therapy from 01/04/22 through 03/02/22. The treatment encounter note documented the SLP's recommendation was for Current Foods/Solids to be Minced + Moist Foods MM5. This terminology was documented under a note that clarified the diet as per The International Dysphagia Diet Standardization Initiative 2016. The SLP said that Resident #37 had been on a mechanical soft diet for a long time. She equated the Mechanical Soft Ground diet with the Minced and Moist diet.2) Record review revealed Resident #10 was admitted to the facility on [DATE]. Her diagnoses included Barrett's esophagus without dysplasia (changes to the lining of the esophagus without precancerous changes to the cells), Encounter for Attention to Gastrostomy (feeding tube), Moderate Protein Calorie Malnutrition, Muscle Wasting and Atrophy, and Muscle Weakness. Her diet orders since 06/10/25 included provision of 4 cartons (237 milliliters each) of Osmolite 1.5 Cal (calorie) tube feeding daily, and a regular diet, with puree texture foods, and thin consistency fluids.A record review revealed Resident #10's Brief Interview for Mental Status (BIMS) score, per the Minimum Data Set (MDS) admissions assessment dated [DATE], was 15. This indicated that she was cognitively intact. The assessment also documented that she had swallowing problems within the 7-day lookback period prior to this assessment. The care area for nutrition noted that the doctor's order for the mechanically altered diet was related to swallowing problems.A record review of Resident #10's care plan dated 06/12/25 focused on the resident's risk for malnutrition. One of the interventions listed by the Registered Dietitian was to provide the diet as ordered.During an observation on 06/23/25 at 11:55 AM, Resident #10 was provided and ate her soup, while sitting at a table in the dining room. The soup had whole grains of white rice, and whole intact yellow kernels of corn in a light-yellow broth. This was the same soup that was served to residents who were on regular diets with no dietary restrictions. There were no meal tickets on the tables for any of the residents seated in the dining room at that time. During an observation of breakfast served to the residents in the Dining Room, on 06/25/25 at 8:29 AM, it was noted that the resident received portions of pureed sausage with gravy and a pureed biscuit on a plate. It was noted that there was a garnish on the plate that appeared to be chopped parsley. 3) A record review revealed that Resident #15 was admitted to the facility on [DATE]. His medical history included Moderate Protein-Calorie Malnutrition, Gastro-Esophageal Reflux Disease with Esophagitis (Inflammation of the Esophagus), Acute Respiratory Failure with Hypoxia (a lack or lowered amount of oxygen), and Metabolic Encephalopathy (metabolic derangements that affect brain function). Per the Minimum Data Set assessment dated [DATE], this resident's BIMS score equaled 3, which indicated he had severe cognitive impairment. The care plan initiated by the Registered Dietitian on 05/08/25 focused on Resident #15's risk for altered nutrition. A listed intervention was to provide the diet as ordered.A record review of Resident #15's diet order revealed that since 05/22/25, he was on a regular diet, with puree texture foods, and thin consistency fluids. The term Regular diet meant that he was not on a therapeutic diet like a Renal diet, or a diet for hypertension or diabetes.During an observation of lunch on 06/23/25, Resident #15 was served pureed breaded shrimp, pureed cabbage, pureed carrots, and mashed potatoes. The pureed shrimp and the pureed carrots were lumpy. There were distinct pieces of breaded shrimp and carrots visible. The scoops of food were not homogenous, pudding like textures. Photographic Evidence Obtained.During an observation in the kitchen on 06/25/25 at approximately 11:55 PM, the pureed baked ham with glazed honey was lumpy. An interview was conducted on 06/25/25 at 12:00 PM with Staff D, a cook. When asked how she knew how long to puree the foods, she answered that foods were pureed until they were smooth, and until they had no chunks and no separate particles at all. Concern for the lumpy appearance of the pureed foods was voiced to the CDM, and a trial plate of the lunch meal was requested. The CDM lifted a spoonful of the pureed baked ham with glazed honey, and it had small lumps of meat surrounded by a thinner substance. Two different textures were observed. Photographic Evidence Obtained. The CDM tasted the pureed ham and said it could have been smoother. A taste of the pureed ham revealed it contained small separate particles of ham.During an interview with the Staff D, cook, on 06/25/25 at 12:15 PM, she said that this morning the pureed ham was really smooth, and most likely when it was warmed up it got lumpy. 4). Resident #21 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, an Annual MDS, with a reference date of 06/15/25, Resident #21 had a BIMS score of 12, indicating the resident was cognitively intact. Resident #21's diagnoses at the time of the assessment included: Anemia, Malnutrition, COPD, Dysphagia. Resident #21's diet orders included: Regular diet, Pureed texture, Nectar consistency - 06/13/25During an observation of breakfast served to the residents in the Dining Room, on 06/24/25 at 8:24 AM, Resident #21 was served pureed French toast and pureed sausage. It was noted that there was a garnish sprinkled about the plate and on the foods that appeared to be chopped parsley. The facility's Immediate Jeopardy removal plan dated 06/27/25 included the following, which was also verified:On 06/24/25 Resident #37 was immediately assessed. A speech referral was submitted to assess diet appropriateness. A chest x-ray was ordered to rule out aspiration. Respiratory assessments were initiated every shift for 72 hours for signs and symptoms of aspiration. The resident's diet order, care plan, and Kardex were reviewed and updated as indicated for accuracy. The physician and responsible party were notified. On 06/25/25 the speech evaluation was ordered for Resident #37.On 06/26/25 a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) bedside study was ordered.On 06/24/25 the CNA and dietary employee involved were removed from the floor and received one-on-one education by the Staff Development Coordinator and Dietary Manager on verifying diet slips with current orders, appropriate food textures for mechanical soft diets, how to address concerns regarding tray accuracy, possible consequences of serving inappropriate diets, and ensuring proper supervision of residents who require it during meals.On 06/25/25 the facility reviewed residents with mechanically altered diets to ensure current orders matched tray ticket diets. There were 18 current residents who were on mechanically altered diets at the time of the survey.On 06/24/25 through 06/26/25 current nursing and dietary staff were educated on verifying diet orders with current physician orders and consequences of serving inappropriate diets, to include regular meals, alternate options and snacks. Newly hired staff will receive education on these matters. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.On 06/27/25 the information in the facility's removal plan was verified. Observations of the lunch and dinner meals on 06/27/25 demonstrated a process to ensure physician ordered diets were being delivered to residents. A new diet communication manual was placed in the main dining room and on each tray cart. On 06/27/25 six staff, including Staff B, the CNA, who provided Resident #37 with potato chips and permitted the resident to choose Goldfish crackers, were interviewed. Each staff member was able to verbalize the training provided during the week. They verbalized what needed to be done before providing an alternate food item or snack to a resident, and the new process for meal tray delivery.On 06/24/25 Resident #37 was immediately assessed by her assigned nurse. A speech referral was submitted to assess diet appropriateness. A chest x-ray was ordered to rule out aspiration and was refused by the resident. Respiratory assessments were initiated and documented every shift for 72 hours for signs and symptoms of aspiration. The resident's diet order, care plan, and Kardex were reviewed and updated as indicated for accuracy. The physician and responsible party were notified. On 06/24/25 Staff L, dietary cook and Staff A, CNA, were provided the one-on-one education.On 06/25/25 the speech evaluation was completed for Resident #37.On 06/25/25 an audit was completed confirming the meal textures in Meal Tracker (the dietary software used to print meal tickets) matched the physician's order for all current residents.By 06/26/25 a total of 79 nursing and dietary staff, to encompass 100%, received the above-mentioned education.On 06/26/25 a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) bedside study was conducted. The recommendations from this study were to advance the resident diet to a mechanically soft chopped diet.An Ad Hoc/Quality Assurance Performance Improvement (QAPI) meeting was held on 06/25/25 with the Medical Director, the Administrator, the Director of Nursing, the Staff Development Coordinator, and the Dietary Manager. Supervision during meal consumption was discussed. A plan for continued monitoring and sustained compliance was reviewed. An additional Ad Hoc/QAPI meeting was held on 06/26/25 to evaluate the effectiveness of the education.The facility's Immediate Jeopardy was removed on 06/27/25 at 6:50 PM.