Based on observation, interview, and record review, the facility failed to ensure physician orders for a therapeutic diet were routinely followed for one (Resident #19) of two residents reviewed for nutrition resulting in the potential for adverse consequences including coughing, choking, and aspiration (process of food, liquid, or other material entering a person's airway or lungs instead of being swallowed). Findings include: Resident # 19 (R19) initially admitted to facility 11/11/22 with 2/2/23 facility readmission with diagnoses including hematemesis, aspiration pneumonia due to gastric secretions, esophagitis, and severe protein-calorie malnutrition. Review of Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/23 revealed that R19 was usually understood and understands with a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). Section G of MDS revealed that R19 required two-person extensive assist with bed mobility and transfers, one-person extensive assist with dressing, and supervision with eating after set up. Section K of same MDS revealed that R19 had no swallowing disorders but was on a mechanically altered diet (required change in texture of food or liquids) while a resident. In an observation and interview on 2/13/23 at 9:25 AM, Resident # 19 (R19) was observed laying in bed with head of bed elevated at an approximate 45-degree angle. A breakfast tray with an egg omelet, cornflakes with milk, and a glass of milk was observed to be positioned in front of resident on an over the bed table. A Styrofoam cup half full of water and small ice cubes was observed on the over the bed table, as well, with R19 observed to use a spoon to eat the ice cubes and water throughout the interview as stated, my mouth gets so dry. R19 stated that he would not be drinking the milk as It has some sort of slime in it. During the same observation and interview, a staff member was observed to enter room and provide R19 with a prepackaged orange jello cup which resident was noted to consume half of throughout interview prior to placing on over the bed table. In an observation and interview on 2/14/23 at 1:33 PM, R19 was observed laying in bed with head of bed at an approximate 30-degree angle. A Styrofoam cup, labeled 2/14/23 6:00 AM, with thickened yellow liquid observed on over the bed table with R19 stating that he thought it was water with some kind of flavoring and slime thickener in it. An opened bag of Fritos noted at bedside, as well, with R19 stating, I like the flavor, but they stick to my mouth. They are too dry. When R19 was questioned regarding the ice chips and water that he was observed to consume 2/13/23, R19 stated, I ask for them and sometimes they bring them to me and sometimes they don't. I take them whenever I can get them. Review of R19's medical record complete with the following findings noted: ST (Speech Therapy) Swallow Study dated 1/20/23 indicated within Summary/History section, .assessed at bedside for swallow skill and safety and to determine the least restrictive oral food and liquid consistency diet he is able to tolerate without risk of aspiration. Assessment section of same study indicated, .According to the portions of this test that I could adequately complete, this gentleman has a mild oral dysphagia due to nothing tastes good and a mild pharyngeal phase dysphagia with cough of liquids post swallow. The Dysphagia Recommendations section of report indicated, Diet Consistency: Easy to chew, Liquid Consistency: Nectar Thick (Mildly thickened liquids to the consistency of nectar), Swallowing Precautions: Small bites and sips, Eat/drink slowly. Hospitalist History and Physical with 1/30/2023 hospital admission date indicated within Assessment and plan section, Aspiration pneumonia due to gastric secretions acute in nature with Qualifiers indicated to be bilateral lower lobe of lung Pneumonitis due to inhalation of food and vomit with Hospital Discharge note dated 2/2/23 under Diet instructions noted to state, advance to usual diet. Facility readmission physician order dated 2/2/2023 stated, Regular Diet with indication within order under Diet Modifications which stated, Easy to Chew, Nectar Thickened. A Nurse Note dated 2/4/23 at 4:05 AM stated, .Accepted HS (bedtime) snack, ate 100% of applesauce and jello cup . and a note dated 2/5/23 at 2:24 AM stated, .Accepted HS snack, ate 100% of small applesauce and jello cup . Nutrition/Dietician note dated 2/9/23 at 2:48 PM stated, .Diet: Regular, easy to chew, nectar thick liquids. Nutrition risk care plan with 2/9/23 updated/reviewed date included within the problem, Potential nutrition concerns: Poor PO (by mouth) intake - varied intake; Dysphagia: had a swallow evaluation on 1/20/23 and is recommended a dysphagia diet . and a corresponding intervention with a 2/9/23 start date, Diet order: regular, easy to chew, nectar thick liquids. In an interview on 2/14/23 at 1:47 PM, Patient Care Technician (PCT) D confirmed familiarity with R19 and that she was his assigned PCT. Per PCT D, R19 was on a regular diet but that his liquids needed to be thickened and that to her knowledge he could not have ice chips or water. PCT D stated that R19 was able to feed himself but that staff were supposed to provide supervision while he was eating. In an interview on 2/14/23 at 1:55 PM, Nursing Home Administrator/Director of Nursing (NHA/DON) A confirmed that R19 was in the hospital most recently with a diagnosis of aspiration pneumonia and stated, upon referencing R19's medical record, that current order was for regular diet, easy to chew, with nectar thickened liquids. NHA/DON A stated that the last bedside swallow evaluation was complete by Speech Therapy on 1/20/23 with recommendations for regular, easy to chew diet, with nectar thickened liquids as was currently ordered for R19. NHA/DON A further stated that from what she could see from review of the medical records, that R19 was not currently receiving speech therapy and that no follow up speech evaluation had been complete since 1/20/23 nor after 2/2/23 facility readmission from hospital with diagnosis of aspiration pneumonia. When NHA/DON A was questioned regarding food and fluids that would be acceptable on an easy to chew diet with nectar thickened liquids, stated that she would not recommend Fritos as acknowledged that they would not be part of his diet order at this time, that water with ice chips would not be considered part of a nectar thick liquid diet, but that would have to refer to dietician as to whether jello was included in a nectar thick liquid diet In an interview on 2/14/23 at 2:19 PM, Registered Dietician (RD) C confirmed familiarity with R19 and stated current diet order to be regular, easy to chew with nectar thickened liquids. When questioned, RD C stated that Fritos could be considered part of an easy to chew diet, as they softened when mixed with saliva, but that they should not be left at R19's bedside to be consumed unsupervised, that nectar thick ice cubes could be made but that R19 should not have regular ice chips with water to be consumed with a spoon on a nectar thick liquid diet, and that jello was considered a thin liquid and therefore would not be part of a nectar thick liquid diet. In a follow up interview on 2/14/23 at 3:25 PM, NHA/DON A stated that a Physician Order had been received for a Speech Evaluation with a review of orders within R19's medical record noted to reflect an order dated 2/14/2023 at 2:39 PM which stated Consult to Speech Therapy Stat (immediately) with the Reason for consultation within order indicated to be bedside swallow. On 2/15/23 at 9:51 AM, notified by NHA/DON A that a follow up speech evaluation had been complete for R19. Review of ST (Speech Therapy) Swallow Study dated 2/15/23 indicated within section titled Assessment that The oral and pharyngeal phases of the swallow are within functional limits with Dysphagia Recommendations noted to indicate Diet Consistency: Easy to chew; Liquid Consistency: Thin ., however, prior to the completion of the 2/15/23 Speech Therapy Swallow Study, R19 was placed at risk as was provided with food and fluids that were not consistent with the diet order that was in place from 2/2/23 to 2/15/23 for a regular, easy to chew diet, with nectar thickened liquids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly install backflow protection devices, in two locations in the kitchen, resulting in the potential contamination of the domestic water supply. Findings include: On 2/13/23 at 9:30 AM, during an inspection of the kitchen, the atmospheric vacuum breaker (AVB) (a device commonly used in plumbing to prevent the backflow of contaminated liquids into the domestic water supply), at the waste disposal near the three-compartment sink, was observed to be plumbed in a position that makes the AVB functionally irrelevant. On 2/13/23 at 9:33 AM, the submerged inlet for the waste disposal, near the dish machine, was observed to not be provided with an AVB to prevent any contaminated liquid from entering the domestic water supply. At this time, Maintenance Supervisor E stated that they must have missed installing an AVB at the disposal. According to the 2017 FDA Food Code Section 5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under § 5-202.13 P; or (B) Installing an APPROVED backflow prevention device as specified under § 5-202.14. P