**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the correct texture of diets to at least 6 residents (Resident #4, #9, #24, #27, #35 and #91) for an extended amount of time. The facility had all residents evaluated by a Speech Therapist (ST) for the IDDSI (International Dysphagia Diet Standardization Initiative 2019) framework of diets in April and May of 2023. Residents diets were changed and ordered per the ST's recommendations. These 6 residents were evaluated and were to receive either a Diet Texture 5 Minced & Moist or a Diet Texture 6 Soft & Bite Sized and were to have their food altered according to their designated diets. The Certified Dietary Manager (CDM) stated they were not following the diets as she was told to follow the mechanical soft diet model (from the National Dysphagia Diet (NDD)), which is a more liberal diet that included soft breads. Residents #4, #9 and #24 were to be given pureed bread sticks for lunch service on 10/17/23. They were given whole breadsticks. Resident #27 was to be given pureed pears on 9/17/23 and was given sliced pears. Documentation revealed that she had a choking episode. Resident #35, who was on Diet Texture 5 was given a Honey Bun, without it being approved by a Speech Therapist. Resident #91's documentation revealed that he was to have a level 6 diet soft and bite sized per ST's evaluation on 4/12/23. On 5/11/23 it was documented that this resident had recent coughing episodes and was to be on a soft and bite sized diet. On 5/24/23, the CDM documented that Resident #91 was on a general diet with mechanical soft texture. The facility reported a census of 38 residents. On 10/18/23 at 11:30 AM, the Iowa Department of Inspections and Appeals and Licensing staff contacted the facility staff to notify them the Department staff determined an Immediate Jeopardy situation existed at the facility. This Immediate Jeopardy situation started on 9/17/23, the day Resident #27 was documented as having a choking episode. The facility staff removed the immediacy on 10/18/23 and decreased the scope to D, after the facility staff completed the following: Corrective Action: a. Success Center Course IDDSI training will be completed for all cooks and dietary aids by end of today 10/18/23 or by next shift. CDM will complete training on dietary spreadsheets with all cooks prior to next shift. A competency quiz will be issued to all cooks and dietary aids to validate understanding. b. Dietary Spreadsheets will be updated and match diet cards, care plans will be updated and match physician orders and diet cards by end of today 10/18/23. c. Nursing assessments will be completed on residents #4, #9, #24 and #27 by end of day today 10/18/23. Any concerns will be immediately communicated to physician. Family and physician will be notified by facility regarding resident #27's coughing episode by end of day today 10/18/23. d. QAPI meeting will be held today 10/18 to review current action plan. Identification of Others: e. All residents with altered diet orders medical records will be audited today (10/18/23) to ensure all diets are correct. Any discrepancies found will be immediately corrected. CDM or designee will monitor all meals x 7 days to monitor and ensure proper diet texture is provided to residents. Process/Systemic Change: f. Success Center IDDSI training course will be issued for all new dietary hires and completed annually. g. Facility will follow Policy & Procedure utilizing dietary spreadsheets for validation of correct texture. h. All new or changed diet orders will be reviewed weekly during weekly IDT meeting to ensure accuracy of diet textures. Monitoring: i. CDM or designee, will monitor meal services and validation of correct texture at meal service per spreadsheet every meal x 7 days, if no concerns noted will continue audits weekly x 4 and monthly x 2. Findings will be shared during QAPI x 3 months for further review and recommendations. Further auditing will be determined by QAPI committee. Completion Date: j. Please consider this IJ abatement plan as the facility action to address the immediate concerns of noncompliance. This plan will be implemented and completed on October 18th, 2023, by end of day. Findings Include: The following is information that is included in handouts from IDDSI dated January 2019: Level 5 Minced & Moist Food for Adults -Soft and moist, but with no liquid leaking/dripping from the food -Biting is not required -Minimal chewing required -Lumps of 4mm (millimeter) in size -Lumps can be mashed with the tongue -Food can be easily mashed with just a little pressure from a fork -Should be able to scoop food onto a fork, with no liquid dripping and no crumbles falling off the fork Examples of Level 5 Minced & Moist Food for Adults included: -Fruit served finely mashed or chopped to 4 mm lump size pieces (drain any excess liquid) -NO REGULAR DRY BREAD due to high choking risk! Level 6 Soft & Bite-Sized for Adults -Soft, tender and moist, but with no thin liquid leaking/dripping from food -Ability to 'bite off' a piece of food is not required -Ability to chew 'bite sized' pieces so that they are safe to swallow is required -Bite-sized pieces no bigger than 1.5 X 1.5 cm (centimeter) in size -Food can be mashed/broken down with pressure from fork -A knife is not required to cut this food EXAMPLES of Level 6 Soft & Bite-Sized Food for Adults included: NO REGULAR DRY BREAD due to high choking risk! 1. A Minimum Data Set (MDS) dated [DATE], documented Resident #4's diagnoses included dysphagia of the oral phase (the tongue collects the food or liquid and moves it around the mouth so it can be chewed) and oropharyngeal phase (the tongue moves the food or liquid toward the back of the mouth). A Brief Interview for Mental Status (BIMS), for Resident #4 revealed a score of 9 out of 15, which indicated moderately impaired cognition. This resident was independent with set up help only for eating. A Care Plan for Resident #4 with a Focus Area dated as revised on 9/1/22, documented that this resident had a potential nutritional problem related to history of weight loss, difficulty chewing (missing dentures) and vision impairment. Interventions directed staff that this resident received a general diet with soft & bite size texture, regular fluid consistency. It directed that she needed to be supervised at meal intakes at this time. A Therapy Daily/PRN (as needed) Documentation Note dated 4/18/23 at 9:48 a.m., documented that Staff A, Speech Therapist (ST), completed a speech screen on 4/12/23 for transition to IDDSI Diet Recommendation: Food Level:#6 (Soft & Bite Size). Liquid Level:0 (thin). Eat with Supervision. Dietary updated. A Doctor's Order for Resident #4 dated 4/28/23, directed that Resident #4 was to receive a regular diet #6 Soft & Bite-Sized texture. 2. A MDS dated [DATE], documented that Resident #9's diagnoses included non-Alzheimer's dementia, dysphagia (difficulty with chewing) and anorexia . A BIMS for Resident #9 revealed a score of 3 out of 15, which indicated severely impaired cognition. This resident required extensive assist of 1 for eating. A Care Plan for Resident #9 with a Focus Area revised on 11/10/22, documented that this resident had a potential nutritional problem related to obesity, CHF (congested heart failure), self-feeding difficulty, inappropriate food choices, and need for a mechanically altered diet. An undated intervention, directed staff that this resident had an order for a texture modified diet. General, soft & bite size. A Therapy Daily/PRN (as needed) Documentation Note dated 4/18/23 at 9:48 a.m., documented that Staff A, ST, completed a speech screen on 4/12/23 for transition to IDDSI Diet Recommendation: Food Level:#6 (Soft & Bite Size). Liquid Level:0 (thin). Eat with Supervision and tray set up. Encourage small bites, take small bites/sips, medications crushed. Dietary updated. A Doctor's Order for Resident #9 dated 4/28/23 and revised on 8/24/23, directed that this resident was on a #6 diet Soft & Bite Sized texture. Directions were to offer finger foods as appropriate. Do not give condiments on plate. Staff to supervise and provide cues as well as assist with condiments. 3. A MDS dated [DATE], documented that diagnoses for Resident #24 included non-Alzheimer's dementia. A BIMS for Resident #24 revealed a score of 7 out of 15, which indicated severely impaired cognition. This MDS documented that this resident was independent with set up help only for eating. A Care Plan for Resident #24 with a Focus Area dated as revised on 8/17/23, documented that this resident had a potential nutritional problem with decreased oral intake possibly related to complaint of mouth pain and/or medication side effect. She had a recent history of bowel impaction and carried diagnoses of obesity and diabetes mellitus. Intervention directed staff that resident had an order for a minced and moist diet with thin liquids-she was to be supervised with meal intakes. A Doctor's Order dated 5/22/23 and revised on 8/24/23, directed that Resident #24 was on a regular diet, #5 Minced & Moist with transitional foods texture. Directions included ground meat, per request. Provide cueing during meals. A Nutritional Status-Dietitian Assessment progress note dated 6/8/23 at 11:08 a.m., documented that Resident #24 was recently hospitalized with a bowel obstruction. This resident was followed by ST and now received a minced and moist diet without concern. A Nutritional Status-Dietitian assessment dated [DATE] at 10:22 a.m., documented that Resident #24 has had difficulty establishing bowel regularity since her bowel impaction last quarter. Resident reported constipation, following a documented period of loose watery stools. She complained of mouth pain due to a canker sore located on her right, lower gum, stating I can't chew or swallow anything without it hurting. She continues on minced & moist textures. Resident at nutritional risk with decreased oral food intake possibly related to bowel irregularity, medication side-effect, and/or mouth pain. Resident may benefit from oral exam to resolve oral discomfort and cueing with meals to help increase oral intake. 4. A MDS dated [DATE], documented that Resident #27's diagnoses included non-Alzheimer's dementia and malnutrition. Documentation for a BIMS read that it should not be conducted as resident rarely/never understood. This resident required extensive assist of 1 for eating. A Care Plan with a Focus Area dated as revised on 6/8/23, documented that this resident had potential for nutritional problems related to varied meal acceptance, self-feeding difficulty, and unintentional weight loss. An undated intervention directed staff that Resident #27 received a general diet with minced & moist textures and slightly thickened liquids. Doctor's orders for Resident #27 were ordered as follows: On 9/14/22, Regular diet, regular texture thin consistency. On 4/27 23, Regular diet #7 regular texture thin consistency. On 6/28/23, Regular diet #6 Soft & Bite-Sized texture thin consistency On 8/1/23, Regular diet #5 Minced & Moist texture, Slightly thick consistency. An Incident Progress Note dated 9/17/23 at 8:55 p.m., documented that Resident #27 choked in the dining room after eating a pear slice at approximately 6:00 p.m. This resident showed no signs of distress after this choking incident. Lung sounds clear at 7:30 p.m. An Incident Progress Note dated 9/18/23 at 3:16 a.m., documented that resident was resting quietly without any problems to note. The head of her bed is elevated some and call light is within reach. Skin was warm, dry and pink. There was no further documentation following/related to these 2 Incident Progress Notes until 10/18/23. A Health status Progress Note dated 10/18/23 at 1:19 p.m., documented the note was an addendum to the Incident Progress Note on 9/17/23 at 8:55 p.m. Resident had a coughing spell on 9/17/23 at approximately 6:00 p.m. following the consumption of pears. The staff assisting with the meal called this nurse (nurse documenting the entry) to come and assess the resident after the coughing spell. Resident was visually assessed and lungs assessed afterward to ensure no aspirating had occurred and lung sounds were clear. Lung sounds were re-assessed at 7:30 p.m., and remained clear. The previous Progress Note this writer incorrectly used the word choking for this coughing spell. Daughter notified of this coughing incident and physician notified as well. A Health Progress Note dated 10/18/23 at 1:27 p.m. documented the Provider's name and residents date of birth . It then documented that on 9/17/23 at approximately 6:00 p.m., during mealtime, resident had a coughing spell after consuming pears. Resident did not have any signs of distress after this and lung sounds were clear when checked immediately after and an hour and a half later when rechecked. 5. A MDS dated [DATE], documented that Resident #35's diagnoses included malnutrition. This resident's BIMS score was 12 out of 15, which indicated moderately impaired cognition. This resident was independent with set up help only for eating. A Care Plan with a Focus Area dated as revised on 9/22/23, documented that this resident was at nutritional risk with underweight status and unspecified protein-calorie malnutrition diagnoses. She had chewing difficulty likely related to acute illness with generalized weakness and potential for self-feeding difficulty with tender, swollen dominant hand. Interventions directed staff to monitor for weight loss, this resident was to eat a general diet with minced and moist textures, thin fluids. Doctor's Orders for Resident #35's diet were as follows: 9/12/23 Lactose Restricted diet, #5 Minced & Moist with Transitional Foods texture, thin consistency 10/19/23 Regular diet, #5 Minced & Moist texture thin consistency. 6. A MDS dated [DATE], documented diagnoses for Resident #91 included dysphagia of the oral phase and the oropharyngeal phase. Documentation for a BIMS read that it should not be conducted as resident rarely/never understood. Resident required supervision with set up help only for eating. A Care Plan with a Focus Area dated as initiated on 1/18/23, documented that this resident was at nutritional risk with unintended weight loss related to end-stage disease process with inadequate oral food intake. This resident had a history of dysphagia, weight loss and altered nutrition related labs. Interventions directed that this resident had an order for regular, soft & bite size, with regular fluids. A Therapy Daily PRN Documentation Note Progress Note dated 4/18/23 at 9:52 a.m., documented that Staff A, ST contacted, completed a Speech Screen on 4/12/23 for transition to IDDSI Diet Recommendation: Food Level: #6 (Soft & Bite Sized). Liquid Level #0 (thin). Resident was to Eat with supervision with tray set up. Alternate liquids with solids. Small bites/sips, pause between bites/sips, medications crushed. Dietary was updated. A Doctor's Order dated 4/28/23, directed that this resident was on a regular diet #6 Soft & Bite-Sized texture. Thin consistency. A Nutritional Status-Dietitian Assessment Progress Note dated 5/11/23 at 10:13 a.m., documented that Resident #91 had recent coughing episodes at meals. He at this time was to receive a soft and bite sized diet order. He was accepting nourishment throughout the day from staff. A Care Conference Note Progress Note dated 5/24/23 at 2:28 p.m., was documented by the CDM. It documented that Resident #91 was on a general diet with regular fluids, mechanical soft texture. Progress Notes dated 8/20/23 documented that Resident #91 had passed away. On 10/17/23 at approximately 10:30 a.m., observed Staff C, [NAME] puree the food for lunch. Staff C had stated that they have 3 residents on a puree diet and she purees 4 portions to have extra. Observed Staff C puree 4 bread sticks with milk. On 10/17/23 at 11:30 a.m., observation of lunch service began. During this lunch service Resident #4, Resident #9, and Resident #24 received a full bread stick. The CDM was asked if it was okay that they received the breadsticks and she stated that it was. Resident #35 requested the cheesecake dessert. Staff B, Cook, stated that she could not have the dessert because Resident #35 was lactose intolerant. Staff B and the CDM agreed that she could have a Honey Bun. After the service was finished, these residents' trays were checked in the dining room. The bread sticks had all been eaten. The CDM verified that Residents' #4, #9 and #24 received and ate the full bread stick as well as the fact that Resident #35 received and ate a Honey Bun. The CDM stated they follow a mechanical soft diet not the IDDSI diet so these foods were safe to serve to the IDDSI level 5 and level 6 diets. The lunch service ended at 12:10 p.m. A test tray was tasted directly after service. It was noted that the bread stick was hard on both ends and the middle was chewy and not soft. A Fall/Winter-therapeutics menu documented the following: - 3rd week Tuesday, Lunch Day:3: documented that Goulash, 1 breadstick, and carrots had been written in for lunch regular diet and goulash pureed, breadstick pureed, and carrots pureed had been written in for the pureed diet. The typed menu had been whited out with the above written on the whited out area. Easy to Chew, Soft & Bite-Sized, and Minced & Moist diets had a dash (-) under them. This is the menu for the day of the lunch observation. The supper menu documented that the Regular diet was cheese pizza and for the Soft & Bite Sized and Minced and Moist diets the residents would be served Beef Rigatoni Casserole -3rd week Wednesday, Breakfast Day:4: Blueberry Muffin for Regular Diet, Blueberry Muffin slurried for Soft and Bite Sized diet, and Blueberry Muffin pureed for Minced and Moist Diet. Supper for this day had diced pears for Regular diet and pureed pears for Minced and Moist Diet. - 3rd week Saturday, Lunch Day:7: documented that a Garlic Buttered Breadstick was to be given for a Regular diet. It documented that the Garlic Buttered Breadstick was to be pureed for the Soft & Bite Sized Diet and for the Minced & Moist Diet. This day showed [NAME] Toast for Breakfast for the regular diet. For the Soft & Bite-Sized Diet and for the Minced & Moist Diet the residents on these diets were to receive pureed cinnamon white bread. On 10/17/23 at 2:29 p.m., Staff C, Dietitian, stated that the residents on a 5 (Minced and Moist) and 6 level diet (Soft & Bite Sized) should have had a pureed breadstick. She stated that technically speech therapy should assess and document the level of diet that each resident should be on. Staff C stated that she had just started at the facility in August. The decision for the diet level could have possibly been made by speech. Staff C stated that technically the facility should be following the diets. Staff C stated that she normally did not work with the IDDSI diet and this home has the diet. Staff C stated that she typically did not recommend a change in diet she would have speech therapy look at it if she thought a change was warranted. Staff C stated that she was new to the this corporation and the protocols are a little different then the homes she had been working at. Staff C was unable to access the records off site. She stated she did not recommend any diets at this facility. I would not have recommended any diets, I started beginning of August. Resident #35's name does sound familiar to me. Unable to access records. I don't remember recommending a diet for her. I typically would go with the diet that was recommended from the hospital if that was where she came from, or from Speech Therapy. Staff C stated that she had gone over diets with the CDM. She stated she did approve a change to goulash and bread sticks as there was a day with ham sandwiches on the menu and the residents do not like the ham sandwiches. On 10/17/23 at 1:19 p.m., the CDM, looked over the menu spreadsheet. The breadsticks for the meal for the upcoming Saturday menu were to be pureed for residents that were to be served 6 soft and bite sized diet textures and 5 minced and moist diet textures. This CDM stated that they should have served pureed bread sticks for the residents on these diets. Reviewed the residents on these diets and 3 out of 6 residents that received either the soft and bite-sized diet or the minced and moist diet received a bread stick (Residents #4, #9 and #24). One resident, Resident #35, who was on a minced and moist diet did not receive a bread stick but she was given a Honey Bun snack instead of cheesecake as she was lactose restricted. The CDM stated that Resident #35 should not have had a whole Honey Bun. This CDM stated that Residents #4, #9, and #24 should not have had whole breadsticks, the breadsticks should have been pureed. The CDM stated the residents were not going to be happy about this. When asked about the meal for this day being whited out and written over, she stated Staff C and the CDM went over the menus. Lunch for this day was to be a ham sandwich. The CDM stated the residents do not like the ham sandwich option, so the Dietitian and the CDM changed it to goulash, a bread stick and carrots. She said they changed it on the day the menu was dated by the dietitian. The CDM stated that there is a Corporate Dietitian and the company has changed to the SNOW program. She stated they follow the IDDSI diets now. She said that they used to be able to serve the bread sticks on a mechanical soft diet. On 10/17/23 at 2:08 p.m., reviewed diet cards for the residents who were on 5 or 6 level diets. No exceptions were on the diet cards (ie may have bread stick, may have honey bun), nor were there any exceptions written in their doctor's orders. On 10/17/23 at 2:20 p.m., Staff D, Certified Nurse Assistant (CNA), stated she assisted Resident #24 to dine at lunch. Staff D stated she had to hold the breadstick for Resident #24 and would put it up to this resident's mouth and then this resident would take a small bite of it. Staff D stated Resident #24 ate the whole bread stick, she ate all of her lunch. Staff D also stated that Resident #24 had toast at breakfast. Staff D stated she often cuts the crust off of the toast for Resident #24 as this resident tends to have a hard time chewing it. Staff D stated that she adds quite a bit of jelly to this resident's toast as she tends to swallow it better that way. Staff E, CNA stated she assisted Resident #9 at lunch. Staff E stated that she had broken off pieces of Resident #9's bread stick and then put it in her mouth. Staff D stated that the pieces were about 1 inch sized chunks. Staff E stated she did not assist Resident #9 at breakfast this morning. Staff E stated that Resident #9 seemed to do okay with eating the bread stick. On 10/17/23 at 2:28 p.m., Resident #4, when asked how her lunch was today, stated it was good. When asked if she enjoyed the breadstick. She stated it was good and denied having any problems with chewing or swallowing. On 10/17/23 at 3:19 p.m., went over concerns of these residents receiving bread without it being pureed with the Director of Nursing (DON). The DON acknowledged concerns regarding the diets being changed. On 10/17/23 at 4:25 p.m., the Administrator stated she talked with their Head of Therapy. She stated that the Speech Therapist was busy and meeting with clients. The Administrator stated that the Head of Therapy said the IDDSI diets are liberal with bread and that it is one of the items that can be given with the different levels. She stated that the Speech Therapist saw all of their residents in April and May to evaluate them for the IDDSI diet. She stated that she and the CDM and a couple of other people went to training on the IDDSI diets as the corporation was going to this evaluation system. She stated the residents' diets were updated, however, the menus didn't start until a month or two ago when the facility changed over from their summer to fall menus. She repeated that she was happy to hear the Head of Therapy state that bread is one of those items that can be given whole with some of the levels in the IDDSI framework. The DON stated that Resident #35 was not evaluated by ST as she was admitted from the hospital and they used the diet order that the hospital had. The hospital also uses IDDSI diets. They both stated they would get the other ST evaluation that was requested of them along with the Corporate Dietitians phone #. A text was sent to the ST at this time requesting a time to talk in the a.m., as she was unavailable this afternoon/evening. On 10/17/23 at 4:53 PM, the CDM verified that tonight cheese pizza is on the menu but all residents who are to receive the 5 and 6 diets will not be getting pizza but will be getting the alternate of beef rigatoni. This CDM stated they will be following the #5 and #6 IDDSI diets as they are written on the menus from this point on. On 10/18/23 at 9:00 a.m., the CDM stated that the facility started the IDDSI diets in late September. She stated she does not keep the old diet spread sheets. She stated she would look for emails to see if she can find an old diet menu. This CDM stated that they used the the old diet spreadsheets up to late September when they started using the IDDSI spread sheets. The CDM stated the old spread sheets did not have the minced and moist or soft and bite-sized diet textures, it had the mechanical soft diet on it. The CDM stated that was where it gets gray. The minced and moist in her mind is pretty much the mechanical soft diet without the bread. This CDM stated the bread is the gray area. The IDDSI diets break down the bread differently and this also is in the gray area. When asked about breakfast that morning, the CDM stated they served slurried muffins to the residents with the soft and bite sized textured diets and they served pureed muffins to the residents with a minced and moist textured diets per the IDDSI menu. This CDM stated she had training on the IDDSI diets but nothing on how to implement the change over to them. She stated that they were told just to adjust the menus to what they knew. The CDM stated that they were serving bread without altering it and they were serving the old mechanical soft diets to the minced and moist diets. This CDM stated the mechanical soft diets were more liberal. She stated that the training was more about here is the information on the IDDSI diets. Not really an explanation on them. She said that Staff C and the CDM would just go over the menus and adjust what they needed to, because sometimes there would be 2 servings of vegetables for one meal service and then the next day they would have just spaghetti and meatballs or something like that without the vegetables. So, the dietitian and the CDM would adjust the daily menus but not necessarily to each specific texture of diet. On 10/18/23 at 9:35 a.m., the Corporate Dietitian, stated she was told that somebody was given a bread stick for a soft and bite sized diet and was asked if that was okay. She stated the resident should not have received the bread stick. The Corporate Dietitian stated that the bread stick would have been fine had the ST specified it would be okay. She stated that as a society (corporation) they went to the new diets. She stated that she was a bit baffled by why they didn't change the menus to the IDDSI diets when they had the residents assessed and changed their individual diets to meet the IDDSI parameters. She stated the diets should have been transitioned to the IDDSI spread sheets (menus). She stated that the spread sheets/the SNOW program are their menus and their diet extensions including minced and moist and soft and bite sized. They include therapeutics as well. When told about the CDM stating she was using the mechanical soft diet guidelines for breads, the Corporate Dietitian stated that the CDM was right that a mechanical soft diet would allow bread. The Corporate Dietitian stated that if the facility was not ready to transition to the IDDSI diets then that would have been okay to wait until they were ready, but the problem was the facility went ahead and changed all the diets for the residents and then did not follow the diet orders. She stated other facilities did wait to start. On 10/18/23 at 9:50 a.m., Staff F, Speech Therapist, stated that it wasn't her that did the evaluations of the diets. She stated she was not really in the facility. This ST stated she didn't know the residents or their diets as she had not evaluated any residents at this facility. Staff F stated she would agree that bread sticks would have to be cleared through an evaluation by a Speech Therapist for a resident on a level 5 or 6 diet to have a bread stick. On 10/18/23 at 10:12 a.m., the Administrator and the CDM, both reported/concurred that the menus were changed to the IDDSI diets on 9/3/23. The Administrator stated the only issue was yesterday with the bread. Otherwise she had talked to others and they were following the diets. CDM stated they had been following the mechanical soft diets not the IDDSI diets. Administrator said they had the IDDSI diets though since April/May. CDM stated the IDDSI diets were on the diet spreadsheet but they were told not to follow them. They were to follow the mechanical soft diets. An explanation of the concern was given to the Administrator and the CDM. It was explained that the issue was that the residents were evaluated for the IDDSI diets with some of the residents having a diet change to Diet Texture 6 or 5 in April and May. These residents were not given the recommended food textures for these diets. They were given a more liberalized diet to include breads without a Speech Therapist determining that bread or any other item was okay for the individual residents that were evaluated and put on the Diet texture 5 and 6 diets. The CDM acknowledged that they had been giving them bread all along. The CDM and the Administrator were told about Resident #27 choking on sliced pears on September 17th. She was on a Diet Texture 5 minced and moist and per the week of diets provided by the facility at the beginning of the survey, pears are to be pureed for residents that receive Diet Texture 5. The Administrator stated she did not know about the choking episode and they should have done an incident report. When told they did do an incident progress note and on the incident progress note it documented that Resident #27 was given sliced pears. The Administrator stated she would have reviewed it then as she reviews all incident reports. The Administrator and the CDM agreed that breads for Diet Textures 5 and 6 were to be altered either by slurry or by pureeing depending on the type of bread and per the menu breakdown of diet texture types. On 10/18/23 at 11:20 a.m., the CDM provided spring/summer menus that she got off of the web site that they would have used for the spring and summer. She stated she is unable to give what dates that they actually used them. She also stated these were not the ones signed by the dietitian as she does not have a copy of those menus. She stated that she is still looking for the menu week that would have included 9/17/23. On 10/18/23 at 11:30 a.m., Staff A, Speech Therapist, stated that right now there was not a full time ST for this facility. Staff A stated that the reason she went up to the facility was to evaluate 9 residents for the International Diet (IDDSI). This ST stated she did these evaluations on 4/12/23. All 9 that she looked at were on modified diets already. Staff A stated the facility wanted her to look at these residents who were already on modified diets and evaluate them for the more restricted IDDSI diets. Staff A stated that the national level kind has more or less 3 different diets. The IDDSI has technically 4 solid levels. The big question for her to evaluate was the residents on the mech[TRUNCATED]