**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to provide basic life support to a resident requiring emergency care. Resident #1 was found unresponsive at meal time on 7/9/22 around 12:15 p.m., staff initiated chest compressions but failed to access the emergency cart which contained emergency equipment including a suction machine and Ambu bag to provide rescue breathing. Upon arrival of emergency medical services (EMS) after 20 minutes unresponsive, suction produced removal of a large food bolus. EMS intubated and transported to hospital where resident later expired due to asphyxiation. This failure posed an Immediate Jeopardy to the residents health and safety. The facility reported a census of 108 residents and 31 residents who requested cardiopulmonary resuscitation (CPR). The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 9, 2022 on December 8, 2022 at 3:15 p.m the facility staff removed the immediate Jeopardy on December 9, 2022 through the following actions: * Staff re-educated on the CPR policy, where to locate the emergency equipment and provide rescue breathing when providing CPR (Education initiated and ongoing). *All supply areas have signs placed on doors to state emergency storage supply *Director of Nursing of designee will conduct three interview to three licensed nurses to validate CPR process by responding to the four processes identified on the audit sheet weekly for four weeks. The scope lowered from a K to a E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a resident census of 108. Findings include: A Policy and Procedure with revised date 4/13/22, documented the Emergency Procedure-Cardiopulmonary Resuscitation (CPR) stated: It is the policy of the facility to respond to medical emergencies for residents, staff and visitors. Policy Explanation and Compliance Guidelines: *The employee who first witnesses or is first on the site of a medical emergency, that are trained, will initiate immediate action, including CPR as appropriate basic first aid and summon for assistance. *A nurse will assess the situation and determine the severity of the emergency, stay with the resident, designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed. *All available staff will respond to the emergency accordingly. *Charge Nurse will designate a staff member to obtain emergency cart and bring to the code site, ensure accurate documentation of the event and delegate any other duties or tasks as needed. *this will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS. *If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services. An admission Minimum Data Set (MDS) assessment tool, dated 6/28/22, documented Resident #1 with a Brief Interview for Mental Status (BIMS) score of 12, for which indicates moderately impaired with decision making abilities. The MDS revealed the resident required staff assistance for bed mobility and dressing, and independent with set up for eating, and functional limited range of motion in the lower extremities (hip, knee, ankle, foot). The MDS revealed the resident's diagnoses included thyroid disorder, hip fractures, non-Alzheimer dementia, hemiplegia or hemiparesis, seizure disorder, epilepsy and bipolar disorder. An Iowa Physicians Orders for Scope of Treatment (IPOST) signed by family (Durable Power of Attorney for Health Care) on 6/29/22 at 1:39 p.m., identified the request for CPR for Resident #1. Record review revealed Progress Notes documented: * (late entry) dated 7/9/22 at 1:43 p.m., documented when the emergency medical technician (EMT) asked for a portable suction, I retrieved it and I hooked it up, but the emergency medical technician were the ones who used it. *on 7/9/22 at 1:53 p.m., Daughter called out to nurse that resident needs help, that she does not look good. Nurse immediately went into resident's room. Noted resident unresponsive, pale with food in front of her. ? resident choked on food. Did the Heimlich , no food noted in resident's mouth. Instructed the other nurse for us to put resident on the floor to start cardiopulmonary resuscitation (CPR). CPR was started but, still no pulse. I and other nurse took turn doing chest compressions until paramedics arrived and took over. *on 7/9/22 4:18 p.m., I was in the room giving the res her scheduled Norco at 12:32 p.m., and res was eating and talking at that time. Then I went down to C hall to give insulin's. I gave my last insulin about 12:50 p.m., and was putting the insulin back in the cart when I heard the resident's daughter say she needed a nurse in her room, that she did not look good. I rushed to her room, upon entering the other nurse was doing the Heimlich maneuver. She said let's get the resident on the floor and me and the med aid lifted the resident to the floor and started doing CPR. We told the medication aid to call 911. When we switched doing chest compressions this nurse went out to call 911. I gave the 911 operator all the necessary info and I headed back to relieve the other nurse. We switched doing chest compressions until the EMT arrived to relieve us. I gave the EMT the info of what happened and stayed close the answer questions. At about 1:15 p.m., the EMT asked for portable suction; I retrieved the suction for them. *At about 1:30 p.m., the EMT said they had a rhythm on the resident and were going to transfer to the hospital. *at 4:31 p.m., On call physician notified of residents transfer to Methodist hospital. Phone call to daughter to follow up on the events that occurred this afternoon. Resident in critical care unit on life support at this time. During an interview 12/8/22 at 11:00 a.m., Staff B, Registered Nurse (RN) confirmed her involvement with participation in the CPR process with Staff A, Licensed Practical Nurse (LPN) . Staff B explained that when she entered the residents room, Staff A stated that they needed to lay the resident on the floor and begin CPR. Staff B explained that no mouth to mouth was given while she was in the residents room, only chest compressions until the ambulance arrived. Staff B was not able to determine how long chest compressions were being done, only it seemed like a long time. During an interview on 12/8/22 at 1:20 p.m., Staff C, certified medication aide (CMA) confirmed that he was in the residents room while Staff A and Staff B performed CPR on the resident. Staff C stated that he was in involved with the participation in the process of CPR. Staff C explained that while he was in the residents room only chest compressions were being performed on the resident and no mouth to mouth was performed. During an interview on 12/12/22 at 1:00 p.m., Staff A confirmed her involvement with participating in the CPR process with Staff B. Staff A confirmed that mouth to mouth was not performed and only chest compressions were performed on Resident #1. Staff A stated that she attempted the Heimlich maneuver on the resident but failed to check to see if anything was in Resident #1's airway. Staff A stated that the expectation of the nursing staff is to follow the policy and procedure for CPR. The Des Moines Fire Department patient record dated 7/9/22 documented at 1:11 p.m., responded to cardiac arrest patient at [NAME] Park nursing home. EMS given incorrect location from dispatch that was across the street from where patient resided. Police Officer arrived first at incorrect location. Delay resulted from incorrect location and the time it took to find the correct location through dispatch. Upon arrival at correct location, Lead and fire medic: brought [NAME] device, ambu bag, red bag, and monitor to patient room, Additional support brought stretcher and additional equipment when they arrived. Staff led EMS through nursing home (NH) to patient room on second floor. Patient was found unresponsive on floor of nursing home room with ineffective manual CPR being performed by NH staff. Patient had several family members in the room along with a roommate. It was unknown if arrest was witnessed. Patient's daughter stated that the patient had been in that state for at least 15 minutes. Patient's roommate stated that she was the last person to talk to the patient and that that was 30 min. prior td EMS arrival. The patient's daughter stated that she had POA and did not wish for her mother to be coded. When asked for documentation nursing home staff stated that patient did not have an advance directive and that the patient wished to be a full code to which daughter agreed. EMS had already placed patient on monitor with initial rhythm of Asystole (lack of cardiac activity). CPR was initiated, When advanced airway efforts were initiated, considerable amounts of food were found in the patient's airway. Intubation efforts were delayed to suction out the food and then the patient was intubated. No blood, bile or vomit were found in airway, Patient's rhythm during subsequent pulse checks. After administration of Epinephrine, return of spontaneous circulation was achieved with a strong pulse and normal sinus rhythm. CPR discontinued and RESQPOD ( a threshold device that attaches to the airway during CPR to enhance negative pressure and increase perfusion) was removed. Patient was moved onto a backboard and secured fully without issue. Patient lifted and placed on EMS stretcher without issue. Patient brought through nursing home to ambulance by stretcher. Phone report made to the hospital and transport initiated. Patient went back into cardiac arrest approximately 2 minutes prior to hospital arrival. At hospital, patient transferred to resuscitation room bed by backboard without issue. Patient care transferred to resuscitation team. During an interview on 12/7/22 at 1:45 p.m., the facility DON, confirmed and verified that the nurses are expected to follow the CPR policy and procedure and do mouth-mouth along with chest compressions and to obtain the crash cart. The State of Iowa Certificate of Death dated 7/18/22, documented the immediate cause of death-asphyxia (suffocation), due to choking on food bolus and description of injury -choked on food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, the facility failed to serve a resident a mechanical soft diet as ordered by the physician. During the noon meal service on 12/06/22, the ticket incorrectly directed staff to serve a regular diet to a resident who required a mechanical soft diet. During the process of serving the incorrect diet, this surveyor stopped the dietary staff from serving the meal. These circumstances posed an Immediate Jeopardy to the residents health and safety. (Resident #2). During closed record review the facility failed to serve the correct diets for 2 of 4 residents reviewed. (Resident #1 and Resident #3). The facility reported a census of 108 residents and identified 11 residents on a mechanical altered diet. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of on July 9, 2022 on December 5, 2022 at 4:15 p.m. The facility staff removed the Immediate Jeopardy on December 7, 2022 through the following actions: Provided the following education to all staff: *Dietary Orders; *Dietary communication form to be completed with resident name, room number, allergies, and adaptive equipment *Copy of original physician diet order to be attached to dietary communication form and delivered to dietary department (kitchen) *Dietary staff will review diet order and if any changes are needed to meet the approved diet orders for [NAME] Center the nurse will be notified to obtain new order from provider. *Cullinary Coordinatro has been given access to point click care and [NAME] Brothers guest card as a back up to Certified dietary manager * Review the entire building diet report, compare to actual orders in point click care and resident physical chart for accuracy *Review and update all meal tickets for the current residents The scope lowered from a K to E at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a resident census of 108. Findings include: 1. The 5 day Skilled Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 with diagnosis for which included anemia, malnutrition, adult failure to thrive, and underweight. The MDS documented the Brief Interview for Mental Status (BIMS) score of 14 for which indicated no impaired decision making abilities, required set up assistance for eating and extensive assistance of one for bed mobility. The MDS revealed a swallowing disorder for which signs/symptoms of possible swallowing disorders as coughing or choking during meals or when swallowing medications, and mechanically altered diet is required for which is require change in texture of foods or liquids (pureed food, thickened liquids). The MDS documented weight of 83 pounds. The Discharge ordered dated 11/7/22 from Unity Point Health instructed staff to give Dysphasia level 5 diet- minced and moist. The International Dysphagia Diet Standardization Initiative (IDDSI) dated 2019, showed a level 5 diet as regular with minced and moist meat. During an interview on 12/8/22 at 10:45 a.m., the dietary manager stated that the definition of soft and bite sized food is that texture includes foods that are soft, tender and moist throughout, they can be mashed or broken down with pressure from a fork, spoon or chopsticks. food piece sizes should be no larger than 1.5 cm by 1.5 cm (size of a thumbnail) to minimize choking risks. The Clinical Physician Orders dated 11/7/2022 at 11:32 a.m., instructed staff to serve a Regular diet, Mechanical Soft texture, Thin consistency. The plan of care documented a problem of Resident #2 has a nutritional problem relate to history of inadequate intake of food/fluid and weight loss. Interventions include: *Provide, serve regular diet with mechanical soft texture and thin liquids as ordered. *Set-up/assist as needed. *Encourage good intake at all meals. *Monitor intake of food/fluid and record every meal. The Data Base for Nutritional Assessment/Reassessment and Resident Progress Notes dated and signed by the dietician on 11/16/22, documented, Resident was hospitalized recently and returned on skilled care with diet changed to regular with mechanical soft texture and thin liquids. Resident is being treated by speech therapy and was noted to cough at meal times 3. Resident is at nutritional risk related to anemia and depression, need for mechanical soft texture with some swallowing difficulty noted. Problem on going with change to mechanical soft texture. The Diet Type Report dated 12/5/22 at 11:25 a.m., documented Resident #2 to receive a Regular Mechanical Soft diet. The Week at a Glance menu for week 2 documented that following noon meal: *Caprese chicken *Garlic and basil pasta *Green beans *Blueberry pie bar Observation on 12/6/22 at 11:30 a.m., revealed during the noon meal service at the Redwoods dining room. Staff D (dietary cook) was plating the room tray for Resident #2, Staff D proceeded to place a regular piece of chicken, pasta, and mixed vegetables on the plate. This surveyor observed the dietary ticket that Staff D was using to plate Resident #2 food, the dietary ticket read regular-regular. The diet roster from 12/5/22 documented regular-mechanical soft diet. This surveyor questioned Staff D on the diet that was served to Resident #2. Staff D explained that they just follow the dietary ticket that is printed for the dietary staff to use. This surveyor questioned the diet that was served. Staff E (culinary chef) went to double check on the computer system the diet that was ordered by the physician. Staff E came back to the dining room and confirmed and verified that Resident #2 diet is regular-mechanical soft and handed Staff D a diet order communication form verifying the diet order. Staff D proceeded to give Resident #2 a regular-mechanical soft diet for which consisted of ground chicken. Staff D and Staff E confirmed and verified that Resident #2 was going to receive a regular piece of chicken, not the mechanical soft diet that was ordered. During an interview on 12/6/22 at 1:15 p.m., Staff D, confirmed and verified that the dietary ticket read regular-regular and that Staff D follows the diet ticket that is printed. During an interview on 12/6/22 at 1:22 p.m., Staff E, confirmed and verified that Resident #2 was on a mechanical soft/ground diet per Dr orders and that Staff D was going to serve a regular diet. During an interview on 12/6/22 at 5:15 p.m., Resident #2 confirmed and verified that they have been receiving a regular diet and would of ate the piece of chicken that would of been served to her. During an interview on 12/6/22 at 4:00 p.m., the facility director of nursing confirmed and verified that the facility failed to serve Resident #2 the correct diet of regular-mechanical soft, and verified during the noon service that staff were going to serve a regular piece of chicken. During an interview on 12/7/22 at 1:15 p.m., the facility dietary manger confirmed and verified that the dietary staff need to follow the resident right diet per physicians orders. The Dietary Spreadsheets for Week 2, instructed staff to serve a mechanical diet that consisted of 3 ounces of ground caprese chicken. 2. An admission MDS assessment dated [DATE], documented Resident #1 with a BIMS score of 12, for which indicates moderately impaired with decision making abilities. The MDS revealed the resident required staff assistance for bed mobility and dressing, and independent with set up for eating, and functional limited range of motion in the lower extremities (hip, knee, ankle, foot). The MDS revealed the resident's diagnoses included thyroid disorder, hip fractures, non-Alzheimer dementia, hemiplegia or hemiparesis, seizure disorder, epilepsy and bipolar disorder. The MDS also documented no nutritional approaches. The plan of care had a problem for potential of nutritional problem related to dementia, depression and chronic pain diagnosis along with new admission. Interventions include: *Provide, serve regular diet with regular texture and thin liquids. *Foods should be soft/moist and bite size. *Monitor intake of food/fluid and record every meal. A Speech Therapy Progress Note dated 6/15/22 at 1:47 p.m., Patient seen for on going dysphagia intervention. Co-treatment occurred with Occupational Therapy, working on self-feeding. Patient was pleasant and cooperative, more interactive today. Patient was able to feed herself when food/cup placed in her hand with assistance. No anterior loss or spillage noted. Mastication was slightly prolonged but functional with good bolus control. No overt sign/symptoms of aspiration or penetration appreciated. Recommend patient remain on Level 7: easy to chew diet with Level 0: thin liquids but up grade to bite size eat. Assistance with feeding as needed, single drinks from straw, medications whole in puree. The After Visit Summary from Unity Point Health dated 6/22/22, documented discharge diet orders: *drink consistency-level 0 *thin and food texture- level 7, Easy to Chew, bite sized meat. The Clinical Physicians Orders dated 6/22/22, documented an order for regular diet, regular texture, thin consistency, soft and bite sized. The Week at a Glance for Week 5 had a menu of: *Bacon Wrapped Pork Loin *Baked Sweet Potato *Pickled Beets *Bread/Margarine *Cookie The Progress Notes dated 7/9/2022 at 1:43 p.m., documented Late Entry: When the emergency medical technician (EMT) asked for a portable suction, I retrieved it and I hooked it up, but the EMTs were the ones who used it. The Progress Notes dated 7/9/2022 at 1:52 p.m., documented, Daughter called out to nurse that resident needs help, that she does not look good. Nurse immediately went into resident's room. Noted resident unresponsive, pale with food in front of her. Question if resident choked on food. Did the Heimlich, no food noted in resident's mouth. Instructed the other nurse for us to put resident on the floor to start CPR. CPR was started but, still no pulse. I and other nurse took turn doing chest compressions until paramedics arrived and took over. The Progress Notes dated 7/9/2022 at 4:18 p.m., documented, Incident Note Note: I was in the room giving the res her scheduled Norco at 12:32 p.m., and resident was eating and talking at that time. Then I went down to C hall to give insulin's. I gave my last insulin about 12:50 p.m., and was putting the insulin back in the cart when I heard the res's daughter say she needed a nurse in her room, that she did not look good. I rushed to her room, upon entering the other nurse was doing the Heimlich maneuver. She said let's get to res on the floor and me and the med aid lifted the res to the floor and started doing CPR. We told the med aid to call 911. When we switched doing chest compressions this nurse went out to call 911. I gave the 911 operator all the necessary information and I headed back to relieve the other nurse. We switched doing chest compressions until the EMT arrived to relieve us. I gave the EMT the info of what happened and stayed close the answer questions. At about 1:15 p.m.,the EMT asked for portable suction; I retrieved the suction for them. About 1:30 p.m., the EMT said they had a rhythm on the resident and were going to transfer to the hospital. The Progress Notes dated 7/9/2022 at 4:31 p.m., documented: On call physician notified of residents transfer to Methodist hospital. Phone call to daughter to follow up on the events that occurred this afternoon. Resident in critical care unit on life support at this time. The Progress Notes dated 7/9/2022 at 4:39 p.m.,documented late Entry: Res's family had asked the nursing staff to stop CPR, but because the resident was a full code we could not stop CPR until the EMTs were here. This was explained to the family. The Progress Notes dated 7/10/2022 at 10:56 a.m., documented Late Entry: This nurse spoke with the daughter, and her husband. They came to pick up all of the resident's belonging because they said they had decided to disconnect the life support and the resident had passed away that morning. This nurse offered a hug and condolences. The Des Moines Fire Department patient record dated 7/9/22 documented at 1:11 p.m., responded to cardiac arrest patient at [NAME] Park nursing home. EMS given incorrect location from dispatch that was across the street from where patient resided. Police Officer arrived first at incorrect location. Delay resulted from incorrect location and the time it took to find the correct location through dispatch. Upon arrival at correct location, Lead and fire medic: brought [NAME] device, ambu bag, red bag, and monitor to patient room, Additional support brought stretcher and additional equipment when they arrived. Staff led EMS through nursing home to patient room on second floor. Patient was found unresponsive on floor of nursing home room with ineffective manual CPR being performed by NH staff. Patient had several family members in the room along with a roommate. It was unknown if arrest was witnessed. Patient's daughter stated that the patient had been in that state for at least 15 minutes. Patient's roommate stated that she was the last person to talk to the patient and that that was 30 min. prior td EMS arrival. The patient's daughter stated that she had POA and did not wish for her mother to be coded. When asked for documentation nursing home staff stated that patient did not have an advance directive and that the patient wished to be a full code to which daughter agreed. EMS had already placed patient on monitor with initial rhythm of Asystote. CPR was initiated, When advanced airway efforts were initiated, considerable amounts of food were found in the patient's airway. Intubation efforts were delayed to suction out the food and then the patient was intubated. No blood, bile or vomit were found in airway, Patient's rhythm during subsequent pulse checks. After administration of Epinephrine, return of spontaneous circulation was achieved with a strong pulse and normal sinus rhythm. CPR discontinued and RESQPOD ( a threshold device that attaches to the airway during CPR to enhance negative pressure and increase perfusion) was removed. Patient was moved onto a backboard and secured fully without issue. Patient lifted and placed on EMS stretcher without issue. Patient brought through nursing home to ambulance by stretcher. Phone report made to the hospital and transport initiated. Patient went back into cardiac arrest approximately 2 minutes prior to hospital arrival. At hospital, patient transferred to resuscitation room bed by backboard without issue. Patient care transferred to resuscitation team. The History and Physical from Unity Point Health dated 7/9/22 at 2:01 p.m., documented that patient presents with unresponsive episode-found unresponsive at [NAME] Park, brought in by Des Moines. Found food in mouth. Narrative note-Patient is a [AGE] year old female presenting to the Emergency Department by ambulance for unresponsive. Per EMS, the patient was found unresponsive at [NAME] Park. Upon arrival the patient did not have a pulse, she was then in asystole on the monitor. CPR was given as well as epinephrine and she was also intubated. Pulse returned about 20 minutes after CPR. EMS states that when they intubated the patient there was food in her throat so they suctioned and then there was successful placement of the tube. A Physician Discharge summary dated [DATE] at 8:35 p.m., documented, Patient is a [AGE] year old woman who is admitted to the Intensive Care Unit (ICU) today after cardiac arrest. Her family was visiting her today at the facility and upon walking into her room, notes that she was slumped over, blue, and agonallly breathing. She did look like she had been eating with food around her and in her lap. Her roommate said she had been speaking to her about 10 minutes prior. They checker her pulse and it was absent. They yelled for help and staff started CPR. EMS was called and arrived in about 20 minutes. They then took over CPR and it was another several minutes before ROSC was achieved. EMS intubated her and discovered some food in her mouth/airway upon doing this. She was previously admitted to the hospital about a month in June after a fall resulting in a hip fracture. During that stay, she did have an aspiration event with resulted in right lower lung collapse. Assessment/Plan- Acute hypoxic respiratory failure, now status post cardiac arrest-likely due to aspiration event. Shock, likely cardiogenic. Discussed with family about a prolonged cardiopulmonary resuscitation effort, her comorbidities, and age, her chances of a meaningful neurogenic recovery are extremely low. She is requiring significant support at this time. They have opted to not pursue any further aggressive measures. We will compassionately extubate and focus on comfort measures after additional family has had time to arrive. A physician note dated 7/9/22 at 9:39 p.m., documented, called to see patient for unresponsiveness. On exam the patient did not respond to verbal or physical stimuli. No heart of lung sounds were heard and the patient had no response to painful stimuli. Pupils were fixed and dilated. Patient pronounced dated at 5:54 p.m. Next of kin/family at bedside. Autopsy offered and declined. Direct cause of death was cardiopulmonary arrest which occurred as a result of likely aspiration event. A State of Iowa Certificate of Death dated 7/18/22, with a death date of 7/9/22 at 7:54 p.m., documented immediate cause of death-asphyxia due to choking on food bolus. During an interview on 12/7/22 at 1:15 p.m., the dietary manager commented that the prior chef was warned for putting resident diets into the [NAME] brothers system due to the chef not having the qualifications as needed. The dietary manager stated that the chef admitted to putting diet orders into the computer system. The dietary manager heard about the incident with Resident #1 on 7/11/22, the dietary manager was able to see that the chef put regular-regular diet into the [NAME] Brothers computer system and failed to add the moist, bite size. The dietary manager was not able to produce the diet ticket for Resident #1, said that normally after the resident get there food at meal times the tickets are thrown away. During an interview on 12/7/22 at 3:54 p.m., the family stated that they came to see their mom on 7/9/22 around noon and found mom slumped over in the recliner. The family member hollered for a nurse to come to the room. The family member stated that when they went into the room they noticed some meat on their mom shirt, they were not able to remember if the meat was bite size or not, only that it was a white meat. During an interview on 12/8/22 at 11:00 a.m., Staff B (registered nurse), explained that Resident #1 was sitting up in the recliner and had her noon meal on a tray table in front of her, Staff B was not able to remember what was on the room meal tray. During an interview on 12/8/22 at 1:20 p.m., Staff C (certified medication aide), explained that he saw her noon meal on the tray table and saw some white meat but was not able to remember what kind of food was on her room tray. During an interview on 12/12/22 at 1:00 p.m., Staff A (licensed practical nurse) confirmed and verified that Resident #1 was sitting in a recliner with table tray across her lap with noon meal on it. Staff A could not remember what was on the tray. Resident #1 was unresponsive so Staff A attempted to do the Heimlich maneuver, Staff B came into the room and resident was transferred to the floor and CPR was initiated. During an interview on 12/20/22 at 1:06 p.m., Staff G (certified nurse aide), stated that she remembers white meat on Resident #1 room tray. Staff G stated that the meat was not moist and no gravy present. Resident #1 eats independently in her room. During an interview on 12/14/22 at 5:15 p.m., Staff F (speech/language pathologist) explained that a moist, bite size pieces mean usually a 1.5 by 1.5 cm size of meat. Most facilities will go with a mechanical soft or ground meats with a level 7 diet that comes from the hospital. During an interview on 12/19/22 at 4:15 p.m., the dietary manager explained that when Resident #1 came to the facility it was ordered as a level 7 diet with moist bite size pieces for which should of been a mechanical soft/ground meet diet at the facility. The dietary manager acknowledged that the facility and clinical record lacked any documentation of diet communication forms for Resident #1. 3. A Quarterly MDS assessment dated [DATE], documented Resident #3 with diagnosis for include heart failure, renal insufficiency, renal failure, and diabetes mellitus. The MDS documented a BIMS of 13 for which no impaired decision making abilities, needs extensive assistance of two for bed mobility and is independent after set up for eating. Resident with weight loss that is not physician prescribed weight loss regimen. The plan of care with a revision date of 8/15/22, documented Resident #3 has a nutritional problem related to Diabetes, GERD, anemia, chronic renal failure and morbid obesity diagnosis along with increased nutritional needs for healing. Interventions include: *Resident is allergic to citrus foods. Staff will ensure that these foods are not served to her. *Provide, serve regular diet with regular texture and thin liquids as ordered. *She is to avoid high potassium and high sodium foods and fluids are limited to 1500 ml daily. *Encourage appropriate choices at meals and snacks. *Encourage protein intake. *Monitor intake of food/fluid and record every meal. The Unity Point Internal Medicine Discharge summary dated [DATE] at 10:28 a.m., documented diagnosis of Type 2 Diabetes Mellitus with hyperosmolar hyperglycemic state, with discharge diet orders of Diabetic Diet. The Medication Review Report signed and dated by the nurse practitioner on 6/7/22, documented a diet order of regular diet, regular texture, thin consistency with a start date of 6/2/22. A Resident Diet Order Communication form dated 6/2/22, documented a new admit, diet order-regular foods, regular texture, thin liquids. A physician consultation form with an encounter date 7/8/22 at 10:30 a.m., documented: I have ordered a low potassium diet at the care center- I understand this is challenging so I asked the patient to avoid high potassium foods. She is having labs completed every other week for close monitoring. Diabetes Mellitus- uncontrolled. A physician telephone orders dated 7/8/22 documented low potassium diet. A Resident Diet Order Communication form with no date, documented Resident #3 to receive a low potassium diet. A Data Base for Nutritional Assessment/Reassessment signed and dated by the dietician on 6/9/22, documented a regular diet with regular texture. The Resident Progress Notes dated and signed by the dietician on 6/9/22, documented Nutritional status triggered. Resident is eating well at most meals and is tolerating a regular diet with regular texture and thin liquids. She is allergic to citrus and staff will ensure that she is not served citrus foods. During an interview on 12/19/22 at 4:15 p.m., the dietary manger confirmed that the chef texted the manager on 7/15/22 with a diet order change. The diet order change was for Resident #3. The new diet order that came into the kitchen was a low potassium on the dietary communication for and the diet was entered into the [NAME] Brothers computer system as a renal diet for which the facility does not offer, so the dietary manager change the diet in the [NAME] brothers computer system to a regular diet, regular texture with thin liquids and low potassium food. The dietary manager confirmed and verified that the chef failed to enter the diet as ordered and failed to follow the standardized diets that the facility has to offer and placed the resident at risk.