**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 30 residents, which included seven residents who required a mechanically altered diet (foods that can be safely and successfully swallowed by being whipped, blended, ground, chopped or mashed). Based on observation, interview, and record review the facility failed to provide the appropriate mechanically altered diet to Resident (R) 82, who subsequently developed aspiration pneumonia (an inflammatory condition of the lungs caused by inhaling foreign material or vomit) and admitted to the hospital, requiring oxygen on 12/14/21 (after the noon meal) which she did not require prior to this incident. R82 underwent an esophagogastroduodenoscopy (EGD, a procedure to examine the throat, stomach and small intestine) to remove a piece of pork. This placed the resident in immediate jeopardy for choking and at risk for potential death or brain damage due to lack of oxygen through choking. Findings included: - Resident (R) 82's pertinent diagnoses from 11/23/21 Physician's Orders in the Electronic Medical Record (EMR) revealed unspecified non-displaced fracture of second cervical vertebrae (break of the second bone in the neck; required a neck brace to prevent movement). The 11/29/21 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R82 required limited one-person assistance with eating meals. R82 had no history of choking or swallowing issues. The Nutrition Care Area Assessment (CAA) dated 11/29/21 documented R82 received a pureed diet (a smooth, creamy substance made of liquidized or crushed food items) with thin liquids (normal consistency drinks). R82 required set up with her meals and preferred to eat in her room. The Physician Orders documented on 11/23/21, that R82 had a diet order for pureed foods. On 12/14/21 at 03:48 PM, the orders directed staff to discontinue the pureed diet. The 12/04/21 Care Plan documented R82 was on a dysphagia (difficulty swallowing) level 1 diet (pureed diet) due to the cervical fracture and Speech Therapy would evaluate her for swallow function. The Speech Language Pathologist Note written on 12/13/21 by Speech Therapist I documented R82 wanted to increase her diet consistency from pureed to the most appropriate diet consistency. R82 did not exhibit any deficits if her diet consistency was changed from pureed to mechanical soft. R82 had to wear her neck collar/brace but had no additional cautions for swallowing. The Therapy Communication Form written by Speech Therapist I on 12/13/21, recommended R82 be moved up to a mechanical soft diet with ground meat and extra gravy. Administrative Nurse J noted the form as seen on 12/14/21. The Lunch Menu for 12/14/21 documented pork chops, stewed tomatoes, rice, and cheesecake. Further investigation revealed for a dysphagia 1 diet, the dietary staff were expected to puree the pork chops, tomatoes, and cheesecake, and would not serve the rice. The Meal Ticket (used by dietary staff to identify the type of diet each resident had, with the resident's meal order) for R82 dated 12/15/21 documented R82 with a diet of pureed, but the word pureed was scratched out and ground was written in by hand. Observation of R82 on 12/14/21 at 04:00 PM found R82 coughing and spitting up clear phlegm (mucus coughed up from the lungs) into a basin. Licensed Nurse (LN) M was at the bedside to complete an assessment and inquired if R82 was ok. R82 denied pain and discomfort. The Nursing Progress Note written on 12/14/21 at 04:31 PM by LN M, documented R82 had no complaints of shortness of breath and was not using supplemental oxygen. R82 complained of a nasal drip and coughed up a lot of clear phlegm after lunch. The Nursing Progress Note written on 12/14/21 at 05:45 PM by LN M, documented R82 continued to cough up clear phlegm out of her nose and mouth with no complaints of shortness of breath. The staff notified R82's family of the lunch incident. LN M noted at approximately 05:00 PM, Occupational Therapist O notified her that R82 was vomiting a darker tinged color, out of her mouth and nose, and was unable to stop. LN M assessed R82 and noted the resident complained of shortness of breath, stated she felt like something was stuck at the top of her throat, had a headache, and she could not keep anything down. LN M notified Administrative Nurse B, notified R82's family, and received consent to send R82 to the emergency room for an evaluation. The facility's Investigation documented R82 admitted to the facility on [DATE] on a pureed diet. On 12/13/21 speech therapy evaluated R82 because she did not like her pureed diet. After the evaluation, speech therapy recommended R82 be moved up to a mechanical soft diet of ground meat and extra gravy. It was also recommended that R82 have ice in her liquids to help stimulate muscle action within the oral cavity and to help execute a safe swallow. The diet orders were changed after lunch on 12/14/21 to a mechanical soft diet of ground meat and extra gravy. R28 received a regular diet tray at lunch. R28 experienced a choking episode with lunch and did not report it to nursing staff right away, but later in the afternoon reported choking on the meat to physical therapy staff. R28 began experiencing vomiting and nasal drainage. The facility sent R28 to the emergency department for further evaluation. All diet cards were reviewed for correct consistency. All staff were educated on verifying meal served with diet card. All dietary staff were educated on serving correct diet and following diet cards. All residents on altered diets were evaluated for safety on eating further meals in their rooms. The 12/16/21 Emergency Department Record documented R82 was on a pureed diet for the last two weeks but was given a piece of [pork] at lunch and was unable to drink anything since that time. R82 felt that she had something stuck in her throat. R82 was given a small amount of water in the emergency room (ER) but could not swallow it. The ER staff called the on-call general surgeon to assess R82. The EGD found the [pork] stuck in R82's throat and removed it. The hospital kept R82 overnight in the hospital for observation. A Witness Statement dated 12/15/21 by Dietary Staff N documented R82 was missing a tray on the first meal pass. Dietary Staff N made a plate for R82 with pureed food and placed it on the cart to be delivered. Dietary Staff N documented that she told the [unnamed] nurse aide to ensure R82 received the correct tray as the trays did not have (meal) tickets on them. Interview on 12/20/21 at 08:27 AM with Certified Nurse Aide (CNA) O revealed she was behind that afternoon and had the [unnamed] Certified Medication Aide (CMA) take the lunch orders from each resident. CNA O was given R82's lunch tray to deliver to her room. When CNA O gave R82 the lunch tray, R82 looked over the food and said it looked right. CNA O stated that R82's name was on the meal ticket, but stated that she could not remember if the diet was written on the ticket or not. CNA O picked up R82's tray after lunch and noted that R82 was coughing a little bit. CNA O stated that R82 told her I did not swallow my food right and that she did not eat well because of this. CNA O offered R82 a drink of water which did not stop the coughing. CNA O stated that R82 did not appear to have difficulty breathing, was not short of breath and was not using supplemental oxygen. R82 requested to see the nurse, so CNA O notified the [unnamed] LN on duty. Interview on 12/15/21 at 09:40 AM with Executive Chef F revealed the dietary staff were not to plate any food other than what was documented on the diet ticket, even if the nurse told the dietary staff differently. He stated the only valid way to have a diet order changed was to have it in writing, signed by the physician, and faxed to the kitchen manager. He said, prior to 12/15/21, meal tickets were printed on a weekly basis, so all the meal tickets for R82 documented puree. Executive Chef F verified he had not received written confirmation from a physician that R82's diet changed, and dietary staff should have given R82 a pureed meal. He expected all dietary staff to verify each meal tray for accuracy before being given to the residents. Interview on 12/15/21 at 10:06 AM with LN E revealed dietary staff would plate all food for residents and then bring the trays to the nurses' station to be delivered to the residents who eat in their rooms. The CNAs would then deliver the meal trays to the residents in their rooms. LN E stated all CNAs should open the lid to ensure the food plated matched the meal ticket. If the food did not match the ticket, the LN would notify the kitchen, and have it corrected. To change a diet for a resident, the LN would obtain an order from the physician and then send the written order to the kitchen manager Just before LN E left at 02:00 PM on 12/14/21, R82 told LN E that it felt like something was stuck in her throat, but she did not complain of anything else. She said R82 then went to therapy. Interview on 12/15/21 at 02:30 PM with Occupational Therapist (OT) G stated she worked with R82 after lunch around 01:30 PM or 02:00 PM. R82 was coughing and OT G noticed a small basin filled with spit. R82 stated she did not eat much lunch because she choked on something. OT G notified [LN M] and LN M completed an assessment. R82 still wanted to work with OT G, so the two of them walked the hall a short distance before returning to R82's room. R82 was not in distress or short of breath, but R82 did sound wheezy. R82 complained of a headache and staff offered fluids. Interview on 12/15/21 at 03:30 PM with Administrative Nurse J revealed R82 requested to eat regular food the week prior because she did not like the pureed diet. Administrative Nurse J obtained an order from the physician for R82 to have a swallow evaluation completed by Speech Therapy. Speech Therapist I and Physical Therapist H completed the swallow evaluation on 12/13/21 via facetime on the phone Administrative Nurse J stated R82 passed the evaluation with no concerns by the therapy team. Speech Therapist I recommended R82 be advanced to a mechanical soft diet with ground meat and extra gravy. Administrative Nurse J received the Therapy Communication Form written by Speech Therapist I and faxed it to the physician, requesting a new diet order and placed a copy of the form in R82's chart. Administrative Nurse J also placed a copy of the form on the dietary manager's desk and emailed him as well as the Dietician. LN M notified Administrative Nurse J that [LN M] had concerns about R82's swallowing. Administrative Nurse J told LN M to notify Administrative Nurse B of the concern and that R82 received the wrong tray at lunch. Administrative Nurse J spoke with Kitchen Manager P about the incorrect plate served to R82 and Kitchen Manager P stated R82 was never changed off the pureed diet and should have received the puree diet tray for lunch. Interview on 12/15/21 at 05:23 PM with Physical Therapist (PT) H revealed that she assisted Speech Therapist I on 12/13/21 with a swallow evaluation via facetime. PT H stated she and Speech Therapist I told R82 that she would be upgraded to a mechanical soft diet with ground meat and extra gravy. PT H stated that the mechanical soft diet with ground meat and extra gravy should start on 12/15/21 with the evening meal and that R82 should have received a pureed meal for both breakfast and lunch on 12/15/21. On 12/15/21, she worked with R82 between 04:00 PM and 05:00 PM. R82 stated she felt like something was stuck in her throat and started vomiting. R82 vomited a total of three times before PT H was able to get nursing assistance. R82 vomited again once the [unnamed] LN came into the room. PT H stated that the vomit was pink-tinged and coming out of her mouth and nose, and that Administrative Nurse B came to the room. R82 vomited for the fifth time and pointed to her throat with the collar in place. PT H stated that R82 was not on oxygen and did not appear to be short of breath, but that R82 did have a gurgling sound coming from her throat. Administrative Nurse B left the room and told [unnamed LN] to call Emergency Medical Services (EMS). R82 was then sent to the ER. Interview on 12/16/21 at 02:59 PM with Speech Therapist I revealed R82 did not like the pureed diet and requested to be placed on a regular diet with real food. PT H assisted with the swallow evaluation of R82, which R82 passed. Speech Therapist I recommended that R82 be elevated to a mechanical soft diet with ground meat and extra gravy to prevent choking. Speech Therapist I and PT H discussed the meaning of the new diet with R82, which R82 responded she understood. Speech Therapist I stated that PT H brought the Therapy Communication Form to Administrative Nurse J and presented the information at the morning meeting on 12/14/21. Speech Therapist I stated that once she made a diet recommendation, it needed to be approved by the physician before the resident could have that diet. R82 was to receive the pureed diet until her physician approved the elevated diet of ground meat. Interview on 12/15/21 at 11:30 AM with Administrative Nurse B and Administrative Nurse D revealed they completed one-on-one education with both kitchen/dietary staff and nursing staff about following diet orders. They also discovered CNA O was the staff member who delivered the lunch meal tray to R82. They stated all resident orders were checked and verified with the most current order from the physician and all meals would be supervised by a member of the management team to ensure the meal order was being read and plated correctly. They further stated, only the cook would plate the food, the dietary aides would verify the tray with the supervisor and serve to the residents in the dining room or place the meal tray on the cart to be delivered. The nursing staff would be serving to the residents in their rooms and would be expected to verify the tray prior to delivery. The 03/2020 Meal Identification policy documented a meal ticket would be used to identify each resident's meal to ensure the resident received the correct meal. The meal ticket would include the resident name, room/location, and diet order as prescribed by the physician in the medical records. The facility failed to provide the appropriate mechanically altered diet to R82, who subsequently developed aspiration pneumonia and admitted to the hospital, requiring oxygen on 12/14/21 (after the noon meal) and she did not require oxygen prior to this incident. R82 underwent an EGD to remove a piece of pork. This placed the resident in immediate jeopardy for choking and at risk for potential death or brain damage due to lack of oxygen through choking. On 12/15/21 at 05:09 PM, the facility provided an acceptable plan for removal of the immediate jeopardy, when the facility implemented the following: 1. The facility immediately identified the event and the need for staff education for accurate diet textures served to residents. 2. The facility completed an audit of diet orders. 3. An audit of diets for all residents at mealtimes by dietary and nursing and audits were taken to morning meeting to follow up with any other clinical/dietary needs. 4. Supervising all meals being plated during meal times. The surveyor verified the implementation of the removal of the immediacy onsite on 12/16/21. The deficient practice remained at a G scope and severity following removal of the immediate jeopardy.