**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow Doctor's Orders for 2 out of 3 residents reviewed (Resident #2 and Resident #3). Resident #2 had an order for a mechanical soft diet with ground meat. Resident #2 received cut up sausage links instead of ground up sausage for breakfast. Resident #2 had a coughing/choking spell and five days later they admitted to the hospital with aspiration pneumonia. Resident #3 had an order for cut up meat. The kitchen staff prepared to serve Resident #3 a cheeseburger without cutting the meat cut up, as ordered by the Doctor. The facility reported a census of 34 residents.Findings include:1. Resident #2's Minimum Date Sheet (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS), score of 7, indicating severely impaired cognition. Resident #2 ate independently. The MDS included a diagnosis of heart failure. The MDS reflected Resident #2 had a mechanically altered diet (required change in texture of food or liquids). The Care Plan Problem reviewed 7/7/25 indicated Resident #2 had difficulty chewing and swallowing related to dysphagia (swallowing difficulties), having 2 teeth pulled, and unable to wear his lower denture. The Care Plan included the following approaches:a. 3/25/25: Mechanical soft diet with ground meats. b. 6/26/25: Nectar thickened liquids. A Progress Note authored by Staff A, Licensed Practical Nurse (LPN), dated 6/12/25 at 8:55 AM, documented Staff A in the dining room giving a resident their medication at approximately 7:55 AM and overheard a kitchen aide ask Resident #2 if he was okay. Staff A turned and noted he had a red face, he couldn't speak, he didn't make the universal choking signal with his hands but attempted to cough up food. Resident #2 had some air exchange and continued to attempt to cough. He had a small emesis (vomit) of undigested food and liquid into the garbage at table. The staff assisted Resident #2 back to his room. While in his room, noted redness left his face, and he became pale. Once in his room Resident #2 had a more effective cough and had a moderate emesis of undigested food and liquid. He continued to cough and threw up 2 cut chunks of sausage. Resident #2 spit up phlegm but could talk to the nurse and to the Assistant Director of Nursing (ADON) with clear and appropriate speech. No staff intervention beyond forward positioning and patting on his back to promote coughing required. Resident #2 stated that never happened before and reported being fine. The nurse obtained the following vital signs (VS):a. Blood Pressure (BP) 170/72 (Measuring standard 120/80)b. Temperature (T) 97.1 Fahrenheit (F) (Measuring standard 98.6)c. Oxygen saturation (PO2) 96% on room air (RA) (Measuring standard greater than 90%)d. Pulse (P) 64 (Measuring standard 60 - 100)e. Respirations (R) 18 (Measuring standard 12 - 20)Resident #2 told the nurse as he winked, they are reason his blood pressure is up. The assessment revealed lung sounds (LS) with course crackles (short popping noises in the lungs) and wheezes (high pitched lung sounds) throughout all anterior (front) et posterior (back) lung fields. The nurse provided him with an as needed (PRN) nebulizer (delivers medicine through a mist to the lungs) was given at this time. At 8:15 AM, this writer returned to resident's room following the nebulizer treatment et noted resident had some audible wheezes (could hear without a stethoscope), LS assessed and noted no course crackles, but he did have occasional expiratory (breathe out) wheezes to posterior bases (bottom of the lungs). His VS measured the following:a. BP 132/62,b. P 55c. R 18d. T 97.5 F e. PO2 94% RA. At 8:25 AM, the nurse placed a telephone call (TC) to the Primary Care Provider (PCP)'s office, spoke with receptionist and reported they needed to speak with the PCP's nurse. The receptionist transferred the facility nurse to the PCP nurse's voicemail. The facility nurse left a message regarding the incident that morning and Resident #2's condition since the incident. The nurse asked about a new order from the PCP for emergency room (ER) evaluation or STAT (without delay) portable x-ray. The nurse requested a TC back as soon as possible. The facility expected the PCP for rounds that afternoon. At 8:50 AM, the nurse made a TC to Resident #2's son and updated him on the incident that morning and his condition since. The nurse reported she waited for a TC back from PCP and they expected the PCP to come to the facility for rounds that afternoon. He asked how Resident #2 did the previous night and noted he didn't have notes in the nurses' notes. He reported his brother got a phone call from Resident #2 and told him This is the end. The nurse reported Resident #2 didn't make any no statements like that that morning, and other than the incident he appeared in a pleasant mood. The nurse reported she would continue to assess Resident #2 and notify his son of any new orders from the PCP or if he had any change in condition. He verbalized understanding and satisfaction with the plan of care.A Progress Note dated 6/17/25 at 6:44 PM, documented that at 5:10 PM a CNA called the nurse into Resident #2's room, due to him being pale with respirations of 22. The note described Resident #2 as hard to wake and with audible (heard without a stethoscope) wheezes. The nurse's assessment revealed Resident #2's lungs as very coarse throughout. At 5:17 PM, the nurse called Resident #2's son who gave the okay to send his father to the ER. At 5:29 PM, the nurse got an order from the Doctor to send Resident #2 to the ER. At 5:45 PM, the transportation specialist arrived to take Resident #2 to the ER. The nurse notified the son, who said he would meet them there. At 5:50 PM, called ER to give nurse to nurse report.An ED General/Miscellaneous Note dated 6/17/25 at 6:20 PM, reflected Resident #2's chief complaint as shortness of breath. Resident #2 didn't provide much information personally. The facility reported he choked. The note included a diagnosis of aspiration pneumonia. An impression from a Radiology final report interpretation for a 1 view chest x-ray dated 6/17/25 at 6:22 PM, Resident #2 had pneumonia in his medial (middle) left lung base and directed to follow up to ensure clearing. The findings included patchy opacities (white patches on x-ray) of the medial left lung base.The Progress Note dated 6/17/25 at 8:35 PM, reflected the nurse called the ER. The hospital staff reported they planned to admit Resident #2 for a few days with antibiotics due to pneumonia. The nurse called and notified the DON.The Progress Note dated 6/19/25 at 10:27 AM, the nurse received a call from the hospital. They reported the Speech Therapist would evaluate Resident #2 that day, and he would likely discharge the next day. The Progress Note dated 6/20/25 at 10:44 AM, the nurse received a call from the hospital's Social Worker (SW). They reported Resident #2 would stay another night due to increase in BNP (blood test that indicates heart failure when elevated), and he had a swallow study that day at 1 PM. The Progress Note dated 6/22/25 at 10:29 AM, indicated the facility nurse spoke to the hospital Registered Nurse (RN) about an update on Resident #2. They wanted to watch Resident #2's lab work for another night. They planned to discharge Resident #2 back to the facility for skilled care the next day. The Progress Note dated 6/23/25 at 10:23 AM, identified the nurse received a call from the hospital's SW. Resident #2 had blood in his stool and they would keep another day for monitoring.The Progress Note dated 6/24/25 at 10:00 AM, reflected the nurse received a call from a hospital RN with report. Resident #2 had a nectar thickened, mechanical soft diet. He had an order to use the incentive spirometry (technique used using a handheld device to improve lung function during recovery from lung illness) usage 2500 (level reached by the resident). He had crackles in his left lower base. They obtained his weight and took him to lunch. Resident #2 had a new order for nectar thick liquids. He returned to the facility on a skilled care level for aspiration pneumonia (a bacterial infection in your lungs caused by inhaling something other than air) and exacerbation (worsening) of CHF (Congestive Heart Failure). He would work with PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy). The nurse notified the staff to monitor and record his output every shift, do daily weights, and give him thickened liquids. On 7/7/25 at 3:40 PM, a pleasant Resident #2 stated he remembered the morning he started coughing. He reported he had a sausage that morning, but he didn't feel the pieces were too big. He thought it was just a weird coughing episode. He acknowledged he went to the hospital a few days later and was treated for pneumonia. On 7/7/25 at 3:02 PM, Staff B, Cook, stated that morning went by pretty quickly as they were a little behind on passing out drinks. Staff B stood by the steam table, and she noticed Resident #2 turning red. Staff B saw Staff A get up out of her chair and went to Resident #2. Staff B directed to grab a garbage, and then Resident #2 threw up some. Staff A saw the pieces of sausage that were on his plate which he didn't eat and weren't very ground up. Staff B reported Staff C as the cook that day. Staff B stated she usually didn't give the residents on mechanical soft diets hot dogs or sausages as they don't grind up very well, in her opinion. They asked Staff B to write a statement, so she didn't talk with Staff C right away. They had the steam table out in the dining room by the bird cage with Staff C and Staff B both serving food. Staff B stated she didn't remember giving Resident #2 his food as she focused on passing out the drinks because the residents started coming out to the dining room and They didn't have their drinks yet. Resident #2 had the rest of the food almost gone off of his plate and everything else on that plate would have fit in with his diet. Staff C got quiet after that incident that day and she didn't really talk to Staff B after that. Staff B stated everyone in the kitchen knows Resident #2 is on a mechanically soft diet with ground meats. Staff C had served him ground meat before this happened, so Staff B knew that Staff C knew (Resident #2's diet) too. When asked what size the chunks of sausage were, she showed a distance between her thumb and index finger. When asked if the pieces of sausage she saw were appropriate sized for ground meat, she said no. It appeared that the size she indicated as about the size of a star on a small decorative flag on the table. She nodded and said that the star was about the right size. The star measured on the ruler application on a cell phone, as 0.56 centimeters (cm). On 7/8/25 at 10:57 AM, Staff A stated that morning their floor nurse called in, so between Staff A and the ADON they covered the floor. Staff A gave medications to another resident who sat in the dining room. Staff A thought Staff B stated Resident #2 was coughing. Staff A stated Resident #2 did have an ineffective cough and had a small emesis. Staff A pushed Resident #2 down to his room in his wheelchair where he proceeded to have another emesis and continued coughing. He brought up 2 pieces of sausage. When asked if the sausage pieces were ground Staff A said no. Staff A stated she didn't see what he had on his plate in the dining room. They served sausage links that morning. She only saw the pieces of sausage he vomited. Staff A described it as the full diameter of the link; she indicated with her thumb and index finger (approximately 1 1/2 cm) but the width of the sausage piece as maybe the width of the white stripe on the flag. The white stripe on the flag measured 0.58 cm. Staff A added the ADON came in the room as well. Staff A described Resident #2's color as red during the coughing episode and then became pale after that, but then his color returned. He did have some audible wheezing, but had clear speech and he acted normal. Staff A and the ADON discussed the diet compared to the piece of sausage Staff A saw. Staff A didn't know if the ADON looked at the sausage at that time. They looked into Resident #2's diet order. Staff A stated the pieces of sausage she saw Resident #2 cough up were too big for his mechanical soft diet with ground meat. The ADON went to talk with the cook and Staff A called the PCP and Resident #2's family. On 7/8/25 at 11:13 AM, the ADON, Licensed Practical Nurse (LPN), stated Staff A asked her over the walkie talkie to go to Resident #2's room. When she got there Resident #2 had pretty much coughed everything up. The ADON said Resident #2 could talk but had his face a little flushed. This ADON stated she didn't see the sausage. She did see some phlegm come up, but she didn't see the sausage. The ADON stated talked with Staff C but didn't remember Staff C's response. The ADON reported she knew Staff C said Resident #1 had sausage that morning but couldn't remember if Staff C said it was ground or not. On 7/8/25 at 11:30 AM, lunch service began, observed the CDM stood next to the steam table, and Staff C plated the food. Staff C served Resident #2 first with a loose meat hamburger on a bun with cheese, 4 cheesy tater tots, and a small bowl of salad. The CDM described the lettuce as shredded and tater tots soft because they had cheese in them, making them appropriate for a mechanical soft diet. On 7/8/25 at 12:09 PM, the Certified Dietary Manager (CDM), stated she worked at the facility since 2013. She worked as a cook for the majority of her time and then became the Dietary Manager about 3 years ago. The CDM stated she arrived at the facility a few minutes after it happened. She stated her shift started at 8:00 AM. She stated right when she got in to work, they told her what happened. The CDM stated she didn't see the food left on Resident #2's plate. Another staff member told her Staff C threw it away. The CDM stated that when she asked Staff C about it, they didn't remember throwing his food away. When the CDM asked Staff C if she ground up the sausage, the cook said she finely chopped the sausage. The CDM found out she didn't grind any meat that morning for the breakfast buffet. The CDM said only 1 other resident at that time had a diet order for ground meat and that resident didn't like breakfast meats.On 7/8/25 at 12:45 PM, Staff C stated she didn't have any ground sausage on the breakfast buffet that morning, and Resident #2 wanted bacon. She stated she wouldn't serve Resident #2 bacon, so Staff C took a piece of sausage link and cut it up into fine pieces. Staff C stated she normally ground the sausage. They had their kitchen closed due to construction, so she would have had to run all the way down to the other end of the building to get him ground sausage. Staff C stated at that time they only had 1 resident had a diet order for ground meat. When asked if the facility had another resident with a mechanical soft diet with ground meats, Staff C said yes but that resident didn't like breakfast meats. Staff C stated she wouldn't give the resident any meat that morning, but then he asked for bacon, and she told him no bacon. When told the reported size of the sausage noted on his plate and what he vomited measured the full diameter of the sausage link and about 1/2 a cm thick. Staff C reported no way the sausage could measure that big of pieces. Staff C stated she normally cut the sausage links in half-length wise and then chopped it up so it couldn't have been the whole diameter of the link. Staff C stated the residents don't submit a breakfast menu as breakfast is always a buffet, so the resident wouldn't have choose which items they wanted like they do with lunch and supper. When asked why she didn't grind up some sausage for the buffet, Staff C stated that she guessed she didn't think about grinding up one portion of sausage that morning. Adding she forgot, otherwise she would have ground some. She then stated Resident #2 did like breakfast meats. She added Resident #2 had ground sausage for breakfast on the day of the interview. Staff C stated she heard Resident #2 ended up getting pneumonia. On 7/8/25 at 1:49 PM, The Registered Dietitian Consultant stated she knew of Resident #2 receiving cut up sausage links instead of ground sausage. When asked if it was okay to cut the sausage up instead, she stated that she would instruct staff to grind the meat even if staff stated they cut it into small pieces. She stated the staff should have ground the sausage. A Speech Therapy Treatment Encounter Note dated 7/8/25, documented Resident #2 had a diet order for a mechanically soft diet with nectar thick liquids. The note reflected therapy saw Resident #2 for ongoing dysphagia (difficulty in swallowing) intervention to promote safe swallow function. The Therapist saw Resident #2 in the dining room during the noon meal. Resident #2 tolerated the mechanical soft textures (shredded lettuce salad, ground meat cheeseburger, and cheesy tots) demonstrating adequate mastication (chewing), timely oral transit, timely swallow trigger, and no clinical signs/symptoms in 100% of trials. Speech Therapy recommended Resident #2 completed a follow-up video swallow study to assess any change in their swallowing function, specifically with liquids. Per the video swallow report from their hospital stay, Resident #2 previously had silent aspiration with thin liquids. The Therapist recommended to continue per their plan of care.On 7/9/25 at 9:57 AM, the Medical Director reported Resident #2 had an elevated BNP level, abnormal for their age. They explained Resident #2 likely had some left heart strain and they felt Resident #2 had some heart failure happening. They treated Resident #2 for both pneumonia and CHF (Congestive Heart Failure), as they happened at the same time. The Medical Director stated he thought the report the nurse gave the hospital colored the diagnosis of aspiration in the ER notes regarding a choking episode earlier in the week. He stated a 2-view x-ray of Resident #2's chest would be better to diagnosis them instead of the 1-view. 2. Resident #3's MDS assessment dated [DATE], identified a BIMS score of 99, indicating they rarely or never understood. The MDS indicated Resident #3 had severely impaired cognition for decision-making. The MDS listed Resident #3 as independent for eating. The MDS included a diagnosis of dysphagia.The Care Plan Problem start date 6/8/23 regarding Resident #3's nutritional status indicated they had difficulty swallowing as evidenced based on a diagnosis of dysphagia and their admission on a mechanically altered diet. The Approach dated 2/7/25, directed staff that Speech Therapy upgraded their diet from mechanical soft to general with cut meat. The approach included Resident #3 may need cueing to chew well, offer ground meat if he didn't eat the general cut meat. A goal with a long-term target date of 8/31/25, documented they would tolerate their diet without signs or symptoms of aspiration. A Speech Therapy Treatment Encounter Note dated 2/27/25, documented Therapy saw Resident #3for ongoing dysphagia intervention to promote safe swallow function and diet tolerance. They saw Resident #3 in the dining room and presented them with a regular texture snack. Resident #3 demonstrated adequate mastication (chewing), timely oral transit, timely swallow trigger, and no clinical signs/symptoms of aspiration in all trials, consuming entire packet (of shortbread cookies) without difficulty. Patient tolerated thin liquids without signs or symptoms aspiration. Speech Therapy to discharge on regular diet with cut up meats and thin liquids.The facility provided an untitled list with residents' names and diets dated 7/8/25. The observation used the list during lunch service observation. On 7/8/25 at 11:30 AM, lunch service began, observed the CDM stood next to the steam table, and Staff C plated the food. At 11:35 AM, the staff served the third resident, Resident #3. Staff C prepared a plate with a hamburger patty on a bun with cheese, tater tots, a small lettuce salad, and handed it to the CDM to deliver to Resident #3. The CDM turned to hand it to staff to take it to Resident #3. When asked if he needed his meat cut up, the CDM said yes, when asked if they planned to serve him the whole sandwich (without the meat being cut up), the CDM said yes. The CDM handed the plate back to Staff C and the CDM stated Resident #3 needed to have his meat cut up and directed Staff C to cut up the hamburger patty. At 11:48 PM, Staff C served a whole hamburger to another resident, the CDM stopped her and reminded her the resident needed their meat cut up. The CDM reminded the [NAME] again when she tried to serve a full hamburger on a bun to another resident with an order for cut up meat. The CDM stated all of the resident at that table have an order for cut up meat. She repeated this as the cook prepared another resident's hamburger.At 12:02 PM, the CDM whispered to Staff C. Staff C cut up another resident's hamburger. At 12:05 PM, the CDM whispered to Staff C again. Staff C cut up another resident's hamburger. The Resident Diet Order List included 9 residents with direction to cut meat. Of these 9 residents, 6 of them received hamburgers (not the alternative of chef salad). The CDM had to remind Staff C to cut the meat for all 6 of the residents served hamburgers with cut meat direction on the diet sheet. On 7/8/25 at 12:09 PM, the CDM confirmed Staff C wasn't going to cut up any of the hamburgers that day. After the first one, she needed to remind her for each resident who required cut up meat. She reported it as frustrating, as the cooks have all of the residents' names and their orders right there to look at, so they know what to serve. On 7/8/25 at 12:45 PM, Staff C stated because they had hamburger that day for lunch, she didn't think she had to cut it up. Staff C stated if it were a pork chop, Swiss steak, chicken, turkey, roast beef, pork loin, or anything like that she would have cut the meat. Staff C added she cut everybody's meat. Staff C stated nobody ever told her she needed to cut up hamburger, she stated she never knew that. On 7/8/25 at 1:49 PM, when asked about the meal that day that Staff C didn't cut up the cheeseburgers for residents with orders to cut up meat as written on the diet sheet, the Registered Dietitian Consultant responded it depended on if they needed the cut meat for a set up assist or if Speech Therapy recommended, they needed all meat cut up. The Registered Dietitian received a list of the residents observed that day that Staff C gave a whole hamburger with instruction to cut up meat on the diet list provided by the CDM. She stated she would look over the residents and call back. The list included Resident #3. On 7/8/25 at 2:14 PM, the Registered Dietitian stated she viewed the notes. She reported the list included Resident #3 as the only resident with a ST recommendation. She explained they needed to cut up Resident #3's meats due to swallowing difficulties/dysphagia. The Dietitian reported the other residents on the list, had orders as they needed set up assistance as they have difficulty cutting their food. She stated they should have cut up Resident #3's hamburger. On 7/8/25 at 4:15 PM, the Director of Nursing and the Administrator acknowledged the concern with Resident #2 receiving the wrong diet, choking, and required going to the hospital a few days later. They acknowledged the concern of Resident #3 planned to be served a hamburger patty not cut up. They stated they understood the Registered Dietitian stated Resident #2 should have received ground sausage, not cut up sausage, and someone should have cut up Resident #3's hamburger cut up per his diet order as he had swallowing difficulties/dysphagia. They acknowledged the CDM did give the plate back to Staff C after being questioned if the meat needed to be cut up and acknowledged the CDM admitted they were going to serve Resident #3 the whole hamburger without cutting it up. An undated Dietary Services policy directed the facility provide residents nutrition within the diets as ordered by their physician. The policy instructed to plan and follow menus to meet the nutritional needs of residents according to their physicians' orders. In addition, provide diets as directed by the consultant dietician.