**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a system to provide the correct physician ordered diet texture for 1 of 3 residents (R1) who was at risk for choking and had a history of dysphagia. This resulted in an Immediate Jeopardy (IJ) for R1 and had the likelihood to effect current and future residents who required changes to textured diets to prevent choking/aspiration. Additionally, the facility failed to include on the diet slip the complete dietary allergies for 1 of 1 residents (R3) who had a severe peanut allergy. The IJ began on 3/19/25, when R1 was served an International Dysphagia Diet Standard Initiative (IDDSI) Level 7 regular textured diet for breakfast instead of the recommended IDDSI Level 6. The Administrator and director of nursing (DON) were notified of the PNC IJ on 3/27/25 at 3:22 p.m. The facility had implemented corrective action on 3/24/25 to prevent recurrence, so the IJ was issued at past non-compliance. Findings include: IDDSI Level 5 Minced and Moist Diet tool dated January 2019, identified foods that are soft and moist but with no liquid leaking/dripping from the food, biting is not required, minimal chewing is required, lumps of 4 millimeters (mm) in size, lumps can be mashed with tongue, foods can easily be mashed with just a little pressure from the fork, and should be able to scoop food onto the fork with no liquid dripping and no crumbles falling off the fork .may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food but are not able to chew it down into little pieces that are safe to swallow. Minced and Moist foods only need a small amount of chewing and for the tongue to 'collect' the food into a ball and bring it to the back of the mouth for swallowing. It is important that Minced and Moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or a fork. IDDSI Level 6 Soft and Bite-Sized Diet tool dated January 2019, identified Level 6 Soft and Bite-Sized food may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft and Bite-Sized foods need a moderate amount of chewing, for the tongue to 'collect' the food into a ball and bring it to the back of the mouth for swallowing. The pieces are 'bite-sized' to reduce choking risk. Soft and Bite-Sized foods are eaten using a fork, spoon, or chopsticks. NO regular dry bread due to high choking risk. Foods that are soft, tender, and moist, but with no thin liquid leaking/dripping from the 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 are no bigger than 1.5 centimeter (cm) x 1.5 cm in size. Food can be mashed/broken down with pressure from a fork. A knife is not required to cut this food. IDDSI Level 7 Regular: meant for individuals who do not have issues chewing or swallowing. R1's face sheet dated 3/26/25, identified R1 admitted 2/2025. Diagnoses included left sided hemiplegia (paralysis on the left side of the body due to a stroke), hypoxemia (low levels of oxygen in the blood), dyspnea (shortness of breath), and dysphagia (difficulty swallowing). R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had no cognitive deficits. R1 was able to use suitable utensils to bring food and/or liquid to mouth and swallow food and/or liquid once the meal was placed. R1 was able to insert and remove dentures into and from the mouth. R1 had no identified swallowing disorders, and required a mechanically altered diet. R1 had no broken or loose dentures, no mouth or facial pain, and no discomfort or difficulty with chewing. R1's hospital Discharge summary dated [DATE], identified R1 required a diet of minced and moist textured foods, mildly thick liquids via spoon, no straws, and a recommendation of direct supervision assistance anytime R1 was ingesting something by mouth. R1's nursing care plan dated 2/28/25, identified R1 was able to feed himself with staff supervision. R1's speech therapy evaluation and treatment plan dated 3/3/25, identified R1 reported swallowing difficulty with meat and some breads, some coughing with liquids along with trouble swallowing for the past four years. Trialed thin and mildly thick liquids. Had a significant coughing episode with coleslaw (IDDSI level 7), no overt signs or symptoms of aspiration with IDDSI level 6 Soft and Bite-Sized textures. Needed occasional cues to use swallow strategies and required line of sight supervision. R1 had full upper dentures and partial lower. R1's diet notification form dated 3/3/25, completed by the speech therapist indicated R1 required IDDSI level 6 Soft and Bite-Sized diet texture, thin fluid consistency, line of sight supervision, no straws. R1's dietary care plan dated 3/3/25, identified R1 started a trial of IDDS 6 soft and bite sized food with extra moisture and food cut into small pieces. No coleslaw or breads. No straws. R1 had choking/aspiration (when something swallowed enters the airway or lungs) precautions which included: small bites, one bite at a time, chew thoroughly, eat slowly, and line of sight supervision. On 3/6/25, advance to thin liquids. R1's diet tray slips (used to ensure correct diet/food is plated and delivered to residents) dated 3/4/25 through 3/19/25, identified diet texture changed from Minced and Moist to Soft and Bite-Sized. The diet slip did not include, no coleslaw, no breads, no straws, and line site supervision according to SLP recommendation. R1's speech therapy treatment encounter note dated 3/19/25, identified speech language pathologist (SLP)-A witnessed R1 in the dining room towards the end of the meal. R1 had a sausage patty, and toast with butter and jelly. R1 had already eaten half of sausage patty, all of eggs and half of his toast. R1 did not have dentures in mouth. (Speech therapist) Grabbed dentures and was about to put in R1's mouth when R1 stated he still felt something there. The note indicated even after SLP-A provided swallowing cues and interventions, R1 regurgitated food and continued to have difficulty so SLP-A notified nursing. Nursing provided a breathing nebulizer treatment and identified R1's oxygen saturations were in 80's (normal is 95-100%) so oxygen was applied at 3 liters via nasal cannula. R1 was then sent to the emergency room for further evaluation. R1's progress notes dated 3/19/25, identified SLP-A observed R1 not wearing dentures while eating. SLP-A went to R1's room and retrieved dentures and when coming back to dining room seen R1 was coughing. R1 stated something feels like it is stuck in his throat. R1 vomited up food and mucous/saliva. Nurse called to room and evaluated. Oxygen decreased to low 80's and R1 complained of chest pain/tightness and shortness of breath. Supplemental oxygen applied and increased to 3 liters per minute to get saturations to 90%. R1 continued to complain of chest pain/tightness and was being sent to the emergency room after a possible aspiration at breakfast. R1's hospital Discharge summary dated [DATE], identified R1 had a hospital stay from 3/19/25-3/21/25 with diagnoses of hypoxia, dysphagia, and aspiration event. Active issues that required follow-up were dysphagia resulting in aspiration event and recommendation of IDDSI level 5 Minced and Moist texture with thin liquids. R1 was started on IV antibiotics for suspected aspiration pneumonia but discontinued by admitting physician. Discharge diet included IDDSI level 5 Minced and Moist diet. R1's diet notification form dated 3/21/25, informed R1 required IDDSI level 5 Minced and Moist diet texture, thin liquids, line of sight supervision, no straws. R1's dietary care plan dated 3/21/25, included IDDS 5 minced and moist textured foods, thin consistency for liquids. The facility Focus Audit, dated 3/22/35, identified licensed practical nurse (LPN)-A completed an audit of a meal for R1. The question was the resident receiving the correct diet per physician orders was marked as NO. The diet slip was marked as being correct. During an interview on 3/27/25 at 8:45 a.m., LPN-A explained she audited R1 at supper on 3/22/25. The cook provided R1 with a regular grilled cheese sandwich. That is what triggered LPN-A when she looked at the diet slip and it said no bread. LPN-A removed the meal prior to R1 consuming it and provided immediate education to the cook and dietary aide. Notification was made to DON, Administrator, and FNS-A of the error. During an interview on 3/26/25 at 8:39 a.m., R1 was leaned back in a recliner with a blanket on in his room. R1 indicated he had been working with SLP-A for his swallowing difficulty. R1 explained on 3/19/25, he was just eating, and the food went down the wrong pipe. R1 recalled he ate the sausage but could not remember if he had the toast. It was a little different diet, It just would not go down. When he took a sip of fluids it wanted to come back up. R1 wore dentures normally but could not recall if he had them in on 3/19/25, they hurt his mouth, but he has worn them all the time now since he returned from the hospital. During a phone interview on 3/26/25 at 10:33 a.m., cook (C)-A stated on 3/19/25, R1's diet slip had Soft and Bite-Sized food with no special instruction or restrictions so she plated and served R1 a regular meal of sausage patty, eggs, and toast. C-A explained his tray card should have addressed no bread and salads but it was missed. After the incident R1's diet slip was updated. C-A explained the diet slips were completed by the Supervisor of Food and Nutrition Services (FNS)-A. They contain pertinent information such as how the residents eat and drink, and if the residents need supervision at meals. FNS-A was the only one that had access to the software to update the diet slips so if anything changed after the diet slips were printed, the cook would have to manually write on them and put the information in their communication book. During a phone interview on 3/26/25 at 10:53 a.m., dietary aide (DA)-A stated on 3/19/25 he worked with C-A. C-A passed out the meals and DA-A passed out the drinks. DA-A did not notice that C-A provided R1 with the wrong diet. Any changes to meals would be on the diet slips. During an interview on 3/26/25 at 9:02 a.m., SLP-A stated R1 began speech therapy on 3/3/25. On 3/3/25, SLP-A evaluated R1 at lunch with a variety of textured foods; R1 had significant coughing toward the end of the evaluation which SLP-A attributed to the coleslaw. SLP-A upgraded R1 to IDDSI level 6 Soft and Bite-Sized diet texture with no bread and no coleslaw and advance to thin liquids with no straws and line of sight supervision. On 3/19/25, breakfast time, R1 was in the dining room, food was at the table and R1 was already eating. There were no staff members present. R1 had on his plate half a slice of toast and a sausage patty that was not cut up and was on his fork approximately half gone. This was not Soft and Bite-Sized, it was IDDSI level 7 regular textured food. SLP-A noticed that R1 did not have his upper denture or his bottom partial in his mouth and went to his room and got them and brought them to him. SLP-A returned to the dining room and noted that R1 had finished the sausage patty. R1 began coughing. R1 stated he felt something was stuck in his throat. SLP-A indicated she had provided verbal cues for swallowing, however R1 continued to cough and regurgitated thicker mucous mixed with small pieces of sausage. R1 stated it still felt like something was stuck and was feeling lightheaded. R1 kept having intermittent coughing so SLP-A notified nursing staff to assess R1. During a follow-up phone interview on 3/27/25 at 9:33 a.m., SLP-A indicated R1 required a modified diet and was at risk for choking and aspiration. SLP-A expected the staff to provide the diet as ordered. SLP-A explained if a resident was given the wrong textured diet they have an increased risk of choking, and aspiration. During a phone interview on 3/26/25 at 10:59 a.m., registered nurse (RN)-A stated she was R1's nurse on 3/19/25. RN-A went to R1's room to assess R1 after the incident on 3/19/25. R1 was sitting in his wheelchair and was alert, orientated, and able to follow directions during the assessment. R1 told RN-A that he was having a hard time breathing and did not feel good. R1's upper lung sounds were okay but lower lung sounds were so diminished, and he could not take a deep breath. RN-A gave a nebulizer treatment, and R1's oxygen was not at an acceptable level so oxygen was provided at 3 liters per minute via nasal cannula. The physician was notified of the changes of R1. RN-A was not aware at the time that R1 consumed a regular textured food but was made aware after talking with SLP-A. During an interview on 3/26/25 at 9:37 a.m., FNS-A explained when residents got dietary orders, he was responsible to update the diet slip and care plan, review the information with dietary staff, and write a progress note. The information was also added to the white board on the wall in the kitchen and put in the dietary communication book. FNS-A stated on 3/3/25, R1's diet order changed to Soft and Bite-Sized and thin liquids with no coleslaw, no breads, and no straws. FNS-A did not work on 3/19/24, but became aware of the incident. FNS-A indicated he should have updated the diet slip on 3/3/25 per the SLP-A's recommendations. During an interview on 3/27/25 at 9:08 a.m., DA-A stated they only put the diet slips on the plates or trays that are not given to a resident so the nursing staff can identify the meals. During an interview on 3/26/25 at 4:23 p.m., DA-B stated all pertinent dining information for residents were on the diet slips and that is what she would look at to confirm the correct diet was served. During an interview on 3/26/25 at 12:42 p.m., DA-C stated resident diets were listed on the diet slips. The only other way dietary staff would know pertinent information would be if it was written in the communication book. FNS-A made changes to the diet slips and would print them in advance. If FNS-A was not at work the information would go in the communication book. During an interview on 3/26/25 at 12:36 p.m., C-B stated R1 did not have no bread, no coleslaw, or that he required supervision on his diet slip on 3/19/25. During an interview on 3/27/25 at 9:57 a.m., RN-B stated she was familiar with the residents and aware of what resident diets were. RN-B assumed the dietary staff would provide the residents with the correct meals. If a resident was served a wrong diet it could cause choking and aspiration. If a resident started choking the Heimlich may need to be done which would probably scare other residents. During an interview on 3/27/25 at 8:33 a.m., RN-C stated if a resident received the wrong diet texture they could aspirate and lots of other things could go wrong. Line of sight supervision means that someone needs to be able to see the residents when they are eating. This can be done by nursing. During an interview on 3/27/25 at 10:19 a.m., DON stated if a resident was given the wrong textured food or beverage the person could aspirate, choke, experience unpleasant meal times, dignity issues, but ultimately it could lead to death. Any resident that has specific supervision requirements by speech language pathologist should be implemented. It was the expectation that residents were served the meals prescribed to them, and diet slips are completed accurately. The past non-compliance IJ began on 3/19/25. the IJ was removed, and the deficient practice corrected by 3/24/25, after the facility implemented a systemic plan that included the following actions: -completed a dining assessment on all residents who had not had one in the last quarter. Those that had one completed in the last quarter were reviewed for accuracy. This was completed on 3/24/25. -education that someone from nursing had to always be in the dining room during meal service. This was completed on 3/20/25 and 3/21/25. -dietary staff have been educated on diet slips, re-educated on process of how diets are communicated. This was completed on 3/22/35. -all kitchenettes have a binder with all of the IDDSI diets that any staff can reference and know appropriate foods that can be served to the resident/s. This was completed on 3/24/25. -DON and nurse managers will work daily with the interdisciplinary team to review new diet changes and updating the diet slips. -auditing of all process began on 3/20/25 and continue. R3 R3's face sheet dated 3/27/25, identified personal history of anaphylaxis (serious life-threatening allergic reaction that involves hives, swelling, sudden drop in blood pressure, and sometimes shock) reaction. Allergies included peanuts. R3's quarterly MDS dated [DATE], identified no cognitive deficits. R3's care plan dated 11/3/24, identified an allergy to peanuts. During an interview on 3/26/25 at 11:44 a.m., R3 stated she had a horrible peanut allergy and just smelling it could put her in anaphylactic shock. For a long time R3 did not go to the dining room because she was afraid peanut butter would be served. R3 had signs on her room and bathroom doors taped up that said peanut allergy. During an interview on 3/26/25 at 12:36 p.m., C-B stated R3 had an allergy to peanuts. C-B observed R3's diet slip and verified peanut allergy was not listed under the allergies. During an interview on 3/26/25 at 12:42 p.m., DA-C stated R3 had a peanut allergy and it was not listed on the diet slip. We just do not serve her anything with peanuts or peanut butter. During an interview on 3/26/25 at 12:52 p.m., FNS-A stated R3 had peanut allergies. It is posted in the kitchen and if cooking with peanuts it would be done separately. Staff alert R3 when something with peanuts will be served and R3 usually chose to eat in her room for those meals. FNS-A verified that peanut allergy was not listed on R3's diet slip and at 3:30 p.m. it was corrected. During an interview on 3/27/25 at 10:19 a.m., DON stated if a resident was given the wrong diet could affect them significantly. It was the expectation that residents were served the meals prescribed to them, and diet slips are completed accurately. The [NAME] job description reviewed 2/23/23, identified the cook should have accuracy and attention to detail, ability to provide, prepare and serve meals, supplements, and menu selection services. The Food Service Assistant job description reviewed 2/23/23, identified ability to distribute meals in a safe and timely manner consistent with prescribed diets.