**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 4 out of 13 sampled residents, that the facility failed to ensure that the residents environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical attention. Additionally, 3 other residents received and/or consumed meals that were not mechanically altered per the physician orders. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1, 5, 6, and 14. NOTICE On 8/23/23 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce the hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that residents who were evaluated for and prescribed a mechanically altered diet had those diet modifications implemented to reduce the hazard(s) and risk(s); were monitored to ensure the effectiveness of those interventions; were supervised for the appropriate preparation and delivery of the prescribed modified diet texture to reduce or eliminate the hazard(s) and risk(s); and were monitored and modified when necessary in accordance with current professional standards of practice. Notice of IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON), the Corporate Resource Nurse (CRN) 2, and the Regional Administrator. On 8/23/23 at 10:01 PM, the facility provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 8/24/23 at 2:00 PM. IJ Abatement Plan For F805 and F689 at Alpine Meadow Rehabilitation and Nursing 8/23/2023 Immediate Actions Taken to Correct Deficient Practices Administrator has hired a Certified Dietary Manager who is competently trained and educated on therapeutic/mechanically altered diets and the menu system who will take on the role of dietary manager effective 8/24/23 at 0600 [6:00 AM]. On 8/23/23, a Diet and Tray Card audit was completed by the regional nurse consultant to ensure that correct physician prescribed diet orders in PointClickCare match the meal tickets in Nutrition Management. Beginning on 8/23/23 at lunch meal, regional nurse consultant implemented a Therapeutic Diet audit to be completed for all residents with mechanically altered diet textures at all meals by the regional nurse consultant or appropriately trained and competent designee to ensure correct physician prescribed diet orders are followed to prevent further harm to any residents. Measures to Ensure the Deficient Practice Does Not Recur Regional nurse consultant will complete an inservice on 8/24/23 by 2 PM with all nursing, dietary, activity and social service staff on requirements for their respective departments regarding resident diet orders and meal tray delivery to residents, including the different types of diets offered at the facility and how to recognize and verify each type of diet before serving the diet to each resident. Administrator will print and laminate visual aids with information on all diet types offered at the facility that will be placed at each nursing station, aide station, on each meal cart and in the kitchen for ease of reference by nursing, dietary, activity and social service staff. To be completed 8/24/23 by 2 PM. Speech language pathologist (SLP) will complete a screen and/or evaluation as indicated with all residents on mechanically altered diets to verify that each resident has the correct physician prescribed diet type in place. Any recommendations for diet type changes will be referred to the Medical Director for approval before the diet order is changed. To be completed 8/24/23 by 2 PM. Beginning 8/23/23, regional nurse consultant or appropriately trained and competent designee will complete a Therapeutic Diet audit for all residents with mechanically altered diet textures at all meals daily x [times] 2 weeks then at one meal daily Monday through Friday x 2 weeks to ensure correct physician prescribed diet orders are followed to prevent further harm to any residents. Beginning 8/24/23, Human Resources Director (HR) will complete a New Hire audit for all newly hired employees daily Monday through Friday x 4 weeks in the nursing, dietary, social service and activity department and verify that the appropriate competency checklist is completed before the end of the on-boarding process. Measures to Monitor and Ensure Corrective Action is Achieved and Sustained QAA [Quality Assurance Assessment] committee under the direction of the administrator will review the findings from the Therapeutic Diet audit and New Hire audit monthly until a lesser frequency is determined to be appropriate. Any ongoing problems with residents of the facility receiving the correct physician prescribed diet order or the facility's training process for new staff regarding resident diet orders and meal tray delivery to residents will be addressed with modifications to the plan of correction implemented at the direction of the QAA committee. Findings included: IMMEDIATE JEOPARDY 1. Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of paranoid schizophrenia, dysphagia, anorexia, adult failure to thrive, and pneumonitis. On 7/28/23, the Annual Minimum Data Set (MDS) assessment of resident 1 documented a Brief Interview for Mental Status (BIMS) score of 1/15, which would indicate a severe cognitive impairment. Facility staff assessed resident 1 as having hallucinations. Facility staff assessed that resident 1 required supervision with set up help only for eating. The assessment documented that resident 1 had a swallowing disorder with loss of liquids from the mouth when eating or drinking, holding food in mouth or cheek or residual food in mouth after meals, and coughing or choking during meals or when swallowing medication. Review of resident 1's physician orders revealed a diet order for a pureed texture diet that was initiated on 5/30/23. On 8/11/23, resident 1's diet order was changed to a pureed texture diet with honey thick liquids. Review of resident 1's progress notes revealed the following: a. On 5/1/23 at 10:26 AM, the progress note documented that resident 1 returned from a dental appointment after having 6 teeth extracted without complications. The note documented that the dentist recommended cool soft foods today. b. On 5/23/23 at 10:26 AM, the progress note documented, Resident has multiple teeth extracted on 5/1/23. He has been offered a soft or puree diet as a result of dental extractions, which the resident has refused. he is very particular about the food he will accept. c. On 5/23/23 at 11:00 AM, the progress note documented, SLP completed initial observation/evaluation of resident yesterday. SLP reports resident drank thin water and ate a cup of pudding without any overt s/s [signs and symptoms] difficulty swallowing. Resident was impulsive during the eval and did not follow prompts or cues to take single sips of water when given. He reported, 'I am,' demonstrating a lack of insight or cognitive ability to process the instructions. He also reported to SLP that he couldn't eat pudding after finishing the cup of pudding and did not demonstrate understanding or insight when SLP drew his attention to the fact that he had just eaten a cup of pudding. It remains unclear if resident's inability to eat is related to lack of dentition and unwillingness to eat a downgraded diet texture or if there is an element of dysphagia as well. An MBS [modified barium swallow] has been scheduled for Friday for further evaluation. SLP plans to observe resident eat lunch today and will keep facility staff apprised of any recommended changes to resident's plan of care. d. On 5/23/23 at 11:52 AM, the progress note documented, Notified MD [Medical Director] and RD [Registered Dietician] of resident's weight loss and refusal of mechanical soft or puree diet. RD recommended to offer house supplement and ice cream as much as he'll accept, and to offer foods that are soft and tolerable. e. On 5/23/23 at 4:14 PM, the progress note documented, [Medical Director] requests that an appointment be made with resident's mental health provider at the [hospital name omitted]. It is suspected that there may be a mental health component associated with resident's recent change in thought processes around foods that he can or cannot tolerate. Even foods that he has previously tolerated well, such as med pass, pudding, cereal, etc., he will no longer eat. Transportation coordinator will make an appointment for the soonest the [hospital name] can accommodate. f. On 5/30/23 at 3:35 PM, the MD progress note documented, [Resident 1] is a [AGE] year old male with paranoid schizophrenia who was admitted to the [name of hospital omitted] 5/25 due to failure to thrive. He had been losing weight due to poor oral intake. Teeth had been removed but he had healed and no swallowing issues were identified. He had a fixed delusion that he could not swallow because of his missing teeth. At the [hospital] he was started on a pureed diet. They reported he at [sic] this well. g. On 6/5/23 at 5:40 PM, the progress note documented, Resident is not eating meals despite puree texture. Resident has c/o [complaints of] that he cannot chew food. Resident will drink fluids, he gulps liquids and must be reminded to slow down and to breath. Used a straw and that seamed to help. h. On 6/29/23 at 1:19 PM, the progress note documented, Residents STAT CXR [immediate chest x-ray] results came back, Impression: RIGHT LOWER LOBE INTERSTITIAL PNEUMONIA. IS NEW COMPARED TO CXR DONE ON 12/17/22. RN [Registered Nurse] informed in house MD of results. MD wondered if resident may have aspirated and questioned if he had his swallow study completed by ST [Speech Therapist]. When resident was refusing foods last month speech therapy saw him. Resident wasn't compliant enough to get a thorough assessment done; they then planned to do a MBS but was then sent out to the hospital a day before MBS was suppose to be done. MD requested we pursue that route again; DON stated that ST will see him. i. On 7/4/23 at 9:20 AM, the progress note documented, Resident is still having episodes of coughing w/ [with] phlegm. Resident is unable to voice to RN if he is able to clear secretions properly. j. On 8/6/23 at 6:32 PM, the progress note documented, CNA [Certified Nurse Assistant] asked if RN would come into the room and assist her. RN went to assess what had happened. RN walked in and saw drops of blood on the floor, RN saw resident on his knees on the floor and with his head on head on the bed. Resident lifted his head up and RN saw a string of clotted blood. RN went to get supplies to clean wound. Resident took off his glasses, RN asked resident what had happened. Resident sat himself up and sat himself on his bed. RN asked CNA to obtain another CNA for assistance. Other CNA came in; RN noticed resident started to cough. RN noticed food in his mouth; resident pulled out pork from dinner out of his mouth, resident started coughing more. RN asked resident if he was able to breathe; resident kept coughing and unable to answer RN. RN started the Heimlich, CNA took over and RN called 911. Resident was going in and out of consciousness; CNA assessed pulse and CNA informed RN that pulse was not present, CNA started CPR, CNA did break ribs. Resident came out of consciousness, RN an CNA's [sic] were back blowing, RN during this time is getting instructions from 911 operator. At one point 911 operator was instructing RN to apply AED [automated external defibrillator] pads, RN informed 911 operator that resident was in and out of consciousness and didn't want to apply it; RN assessed residents pulse, resident had a pulse, resident was breathing, residents eyes were open. Paramedics arrived and take over. Paramedics took resident to ER; RN gave face sheet and med list. RN called and informed MD. k. On 8/6/23 at 9:57 PM, the progress note documented, At approximately 9:50 pm I called [local hospital] to get an update on patient. RN reported patient is currently stable, they did a food extraction just above his epiglottis with mild sedation. Patient is stable and will be admitted for pneumonia. l. On 8/8/23 at 11:00 PM, the progress noted for the date of service of 8/9/23 documented, Resident has returned from the hospital on palliative care. We will continue to monitor. We will likely order comfort meds to have available should the patient need them. He is having difficulty swallowing is still a high aspiration risk. On 5/22/23, the SLP evaluation documented that resident 1 had a recent onset of difficulty with chewing due to recent loss of some teeth. Resident 1 attributed all swallowing difficulty to decreased ability to chew and that resident 1 endorsed he could not chew complex texture foods and had been declining in overall oral intake. The oral peripheral exam documented impairments to the mandibular range of motion (ROM), mandibular strength/tone and mandibular coordination. The exam documented an impairment to the lingual sensation/function. The exam documented that the laryngeal/pharyngeal performance was impaired with the reflexive cough strangled and wet and the volitional throat clearance as strangled. The clinical bedside assessment of swallowing documented, Pt [patient] p/w [presented with] clinical s/s of aspiration during thin liquid PO [by mouth] trials via sequential straw sip. Pt noted to be impulsive, continue to drink thin liquid while simultaneously coughing. Pt with persistent cough following PO intake of thins, with pt endorsing choking on thin liquids. The assessment further documented, Pt p/w delayed cough following sequential PO intake of puree (pudding) consistencies. Pt with strong hyolarygeal elevation w/ [with] PO intake, however, pt with wet vocal quality and delayed cough. The assessment summary documented, Patient presents with moderate oropharyngeal dysphagia characterized by decreased mandibular ROM/strength, decreased lingual ROM/strength, decreased safety awareness w/PO intake, decreased overall PO intake which necessitates skilled SLP services for dysphagia to analyze pharyngeal function, analyze oral function, assess/evaluate for safest level of oral intake, develop and instruct in compensatory strategies, maximize nutrition/hydration with oral motor facilitation and minimize risk of weight loss with swallow analysis in order to improve ability to decrease risk of malnutrition/weight loss, safely consume highest level of oral intake and safely swallow without signs/symptoms of aspiration. On 5/26/23, resident 1's SLP Discharge summary documented that resident 1 was discharged to the hospital and they were unable to complete the modified barium swallow study on site. On 8/6/23, the menu documented country style pork ribs, potato salad, mixed vegetables, peach jello, and a salad were scheduled. On 8/9/23, the hospital discharge summary documented that resident 1 was given the wrong plate of food at dinner in the facility. He was given a regular consistency instead of a pureed diet. The summary documented resident 1 ' s diagnosis as aspiration pneumonia secondary to foreign body aspiration of his dinner. The History of Present Illness documented that the facility DON reported that resident 1 had an order for a pureed diet but was served the wrong plate of food at dinner this evening. The resident aspirated the food, lost consciousness and a staff member performed the Heimlich maneuver that was unsuccessful. They also performed CPR and when EMS [emergency medical services] arrived the patient was found to be hypoxic but with a pulse. In the ER [emergency room] patient was given ketamine and the food was retrieved from his trachea. ER physician reports he had stridorous respirations off and on and there was a high suspicion that there is still material in the lower trachea. The director of nursing reported the patient had multiple teeth extracted earlier this year and ever since then has had dysphagia and was treated for aspiration pneumonia on June 26th. It was determined in May of this year that he needed a feeding tube but he refused .Also noted that patient has excessive secretions the oropharynx and is likely chronically aspirating his secretions. The discharge summary documented that on 8/8/23 resident 1 underwent a barium swallow and failed the test. He was explained that he needs a feeding tube to prevent further aspiration events. Patient does not believe he has aspirated, does not believe he has pneumonia He says he absolutely refuses to have a feeding tube placed. He wants to eat and go home. Representative from his facility came to see patient. They discussed hospice and he decided he wants to go home on hospice. He wants abx [antibiotics] and o2 [oxygen] discontinued and asked code status to be changed to DNR [Do Not Resuscitate]. On 9/29/21, resident 1 had a care plan for at risk for nutritional status initiated. Interventions identified included to monitor/document/report any signs and symptoms of dysphagia such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; Registered Dietician to evaluate and make diet change recommendations; and staff to provide supervision and encouragement with meals as needed. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses which consisted of, but were not limited to, type 2 diabetes mellitus, pain, dementia, pulmonary hypertension, nonrheumatic aortic valve stenosis, orthostatic hypotension, atrial fibrillation, presence of cardiac pacemaker, hypertension, and mild cognitive impairment. On 6/16/23, resident 6's Quarterly MDS Assessment documented a BIMS score of 15 which would indicate that the resident was cognitively intact. The assessment documented that resident 6 required supervision with set-up help for eating, and that resident 6 had a swallowing disorder with symptoms of holding food in the mouth/cheeks or residual food in the mouth after meals. Review of resident 6's physician orders revealed a diet order for a regular diet mechanical soft texture, think liquids consistency that was initiated on 5/14/20. On 2/6/2020, resident 6 had a care plan for at risk for altered nutrition status due to edentulous status with mechanical altered texture required for ease of chewing initiated. Interventions identified included monitor/document/report any signs and symptoms of dysphagia such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses of dementia, emphysema, hypertension, alcohol abuse, and malignant neoplasm of pancreas. On 5/19/23, resident 5's Quarterly MDS Assessment documented a BIMS score of 5/15, which would indicate a severe cognitive impairment. The assessment documented that resident 5 required a one person physical assist with supervision for eating. The assessment documented that resident 5 had a swallowing disorder with symptoms of holding food in the mouth/cheeks or residual food in the mouth after meals. Review of resident 5's physician orders revealed a diet order for a regular diet chopped texture, thin liquids consistency that was initiated on 2/18/22. On 5/25/23, resident 5 had a physician order for SLP to evaluate for possible diet texture upgrade. No documentation could be found of the SLP evaluation. On 2/26/22, resident 5 had a care plan for at risk for altered nutrition status related to medical condition initiated. Interventions identified included monitor/document/report any signs and symptoms of chewing swallowing problems related to dysphagia or oral health problems such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. 4. Resident 14 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, benign paroxysmal vertigo, dementia, obstructive sleep apnea, and low back pain. On 6/21/23, resident 14's Quarterly MDS Assessment documented that a BIMS score was not obtained due to the resident was rarely/never understood. The assessment documented that resident 14 required a one person extensive physical assist for eating. The assessment documented that resident 14 had a swallowing disorder with symptoms of loss of liquids/solids from mouth when eating or drinking; holding food in mouth/cheeks or residual food in mouth after meals; and coughing or choking during meals or when swallowing medications. Review of resident 14's physician orders revealed a diet order for a regular diet minced and moist texture, thin liquids consistency that was initiated on 8/17/23. On 9/28/21, resident 14 had a care plan for at risk for malnutrition initiated. Interventions identified included monitor/document/report any signs and symptoms of chewing swallowing problems related to dysphagia or oral health problems such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; refer to SLP or dentist as indicated to address dysphagia; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. On 8/22/23 at 11:33 AM, an interview was conducted with the Dietary Manager (DM) 2. The DM 2 stated that the kitchen staff were responsible for plating resident meal trays, but nursing staff were responsible for delivering the trays to residents. On 8/22/23 at 12:15 PM, an interview was conducted with the hospitality aide. The hospitality aide was observed delivering food trays to residents in their rooms. The hospitality aide stated she passed out meal trays to residents often. The hospitality aide stated she would check the diet card on the resident ' s food tray for their preferences and put a drink on the resident ' s tray. Several cups of fluid were observed on top of the food cart. The hospitality aide further stated she does not look on the diet card to see if a resident was on thickened liquids or any special diet before giving the food tray to the resident and that she only looked at the resident ' s preferences. The hospitality aide stated the kitchen would know the diet and takes care of that. On 8/22/23 at 12:17 PM, an observation was made of CNA 1 delivering food to resident 6 ' s room. The resident diet ticket documented a mechanical soft diet with thin liquids. Resident 6 ' s meal was observed as shrimp tacos with refried pinto beans. The taco was made with a corn tortilla and a shredded cabbage topping. Resident 1 refused the meal and stated she did not like shrimp. On 8/22/23 at 12:17 PM, an observation was made of resident 5 sitting at a table in the dining room eating lunch. The dietary manager (DM 2) approached resident 5 and removed his plate. The plate had 2 whole corn tortillas and 1 uncut shrimp. An interview was conducted with DM 2 at 12:18 PM. DM 2 stated the uncut shrimp on resident 5 ' s plate was a regular texture diet. DM 2 stated a chopped diet would have no tortillas or shrimp. Resident 5 ' s meal ticket documented regular chopped thin liquids diet. On 8/22/23 at 12:39 PM, an observation was made of resident 1 ' s meal tray. Resident 1 ' s meal ticket documented a pureed diet texture with honey thick liquids. Resident 1 ' s meal was observed as a regular diet with shrimp tacos with shredded cabbage on a corn tortilla and refried beans. CNA 1 identified the incorrect diet order and returned the meal tray to the kitchen. On 8/22/23 at approximately 12:45 PM, an interview was conducted with the DON. The DON stated that after resident 1 ' s most recent hospitalization the hospital recommended a diet of NPO [nothing by mouth] with a feeding tube. The DON stated that resident 1 was found unresponsive and choking on food and that he had a history of chronic aspiration. The DON stated that resident 1 failed his swallow study in the hospital. The DON stated that resident 1 had aspiration pneumonia in March 2023 and after that illness was downgraded to a pureed diet. On 8/22/23 at 12:57 PM, an interview was conducted with CNA 1. CNA 1 stated that she had worked at the facility for a long time and she should have looked at the meal ticket to identify the diet before delivering the tray to resident 6. On 8/22/23 at 1:17 PM, a follow-up interview was conducted with the DON. The DON stated that resident 1 refused the feeding tube and all treatment during his last hospitalization and was now on palliative care. The DON stated that resident 1 was not compliant with the pureed diet. The DON stated that if the resident was noncompliant staff should notify the licensed nurse and the nurse should offer education to the resident. If the resident continued to refuse the therapeutic diet then the nurse should notify the Medical Director (MD). On 8/22/23 at 3:24 PM, a telephone interview was conducted with Licensed Nurse (LN) 1. LN 1 stated that on 8/6/23 resident 1 was found on the floor with his elbows on the bed. Resident 1 had dried blood on his forehead. LN 1 stated she obtained supplies to clean resident 1 ' s wound. Resident 1 was assisted to bed and was sitting up in bed when he started to cough. LN 1 stated that resident 1 was attempting to clear his airway. LN 1 stated that she observed pork inside resident 1 ' s mouth. LN 1 stated she asked resident 1 if he was choking and he did not respond. LN 1 stated that she performed the Heimlich maneuver and the aide took over while she called 911 and checked the resident ' s code status. LN 1 stated that they were also giving back blows to resident 1. LN 1 stated that the aide identified that resident 1 did not have a pulse, the resident was blue/gray in color and they began chest compressions. LN 1 stated that resident 1 became responsive and opened his eyes and CPR was stopped. LN 1 stated that EMT ' s [Emergency Medical Technicians] arrived and suctioned resident 1 ' s airway and transported him to the Emergency Room. LN 1 stated that the aide removed a piece of pork that was hanging out of resident 1 ' s lip. LN 1 stated that resident 1 was supposed to have a pureed diet texture and when she looked at the resident ' s meal tray it was a regular texture diet of pork and mashed potatoes. LN 1 stated that the kitchen had made resident 1 two dinner trays and when resident 1 saw the regular tray had told the CNA that he wanted to eat that one instead of the pureed diet. LN 1 stated that none of the aides had reported the diet change to her. LN 1 stated that the aides should know that resident 1 was to have a pureed diet because it was noted on his meal ticket. LN 1 stated that the aides should have notified her when resident 1 requested a regular diet. On 8/22/23 at 3:51 PM, an interview was conducted with the Registered Dietician (RD). The RD stated they put together a weekly extension of the meals that detailed the modified diet and this showed the kitchen staff what modifications should be made to the diet for the different textures. The RD stated that DM should be able to print off the menu system with the extensions. The RD stated that the DM 2 was new and she provided training to him last week on the menu and the extensions for different diet textures. The RD stated that as a consultant she was in the facility one time a week. The RD stated that the previous DM 1 was an assistant DM at a sister facility and she had interacted with him 2 or 3 times. The RD stated that she checked in on DM 1 to see how he was doing. The RD stated that DM 1 did not attend the nutrition at risk meetings but they encouraged the DM to attend them also. The RD stated that she did not recall having any concerns with DM 1 and did not address the diets and extensions for textures. The RD stated that her understanding was that DM 1 was familiar with the menu system, diets, and textures. The RD stated that she completed audits every 30 days unless deemed more frequently. The RD stated that she had been auditing more frequently due to reports that residents were requesting different diets from their speech therapy (ST) evaluation. The RD stated that she did not change the diet order and that the ST was to evaluate the resident to see what the appropriate diet would be. On 8/22/23 at 4:16 PM, an interview was conducted with the DM 2. DM 2 stated that he had been doing the online training and had been provided some education by the RD. DM 2 stated that he and the RD had gone over the mechanically altered diet textures and how to identify the differences. DM 2 stated that before meal service he separated the different textured diets into piles so that he could do all one texture at a time and could plate them according to the meal ticket. The DM 2 stated that either himself, the dietary aide (DA) 3, or the hospitality aide plated the food in the kitchen. DM 2 stated that the hospitality aide had her food handlers permit and was allowed to assist in the kitchen. DM 2 stated that at the time of plating he had the meal ticket under the heat lamp so that he could visualize the therapeutic meal texture. DM 2 stated that he was informed of one meal at lunch time that one meal was plated wrong and not according to the meal ticket and diet order. DM 2 stated that it was supposed to be a pureed diet plated was a chopped diet. DM 2 stated that he did not see the returned meal and could not recall which resident the meal was for. On 8/22/23 at 5:13 PM, an observation was conducted of resident 14 eating dinner in the dining room with the Corporate Resource Nurse (CRN) 1 assisting. Resident 14 was observed eating a baked roll that was dry and cut into bite-sized pieces, green beans, and ziti noodles with red sauce. Resident 14 ' s meal ticket indicated Minced & Moist MM5. On 8/23/23 at 7:57 AM, a telephone interview was conducted with a Speech Language Pathologist (SLP). The SLP stated that she evaluated the residents for a safe swallow by testing the cranial nerves and performing a bedside swallow exam. The SLP stated that she would evaluate the residents during a meal. The SLP stated that she would have the resident take a couple of bites of pudding, graham cracker, and water. The SLP stated that she would feel on the throat for hyolaryngeal excursion or movement of the epiglottis to ensure that it was inverting in the throat and covering the airway. Depending on the resident the SLP would ask if they were experiencing any pain or if they felt a globus sensation or something caught in the throat. The SLP stated that the e[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 4 out of 13 sampled residents, that the facility failed to ensure that the residents received food prepared in a form designed to meet their individual needs. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical attention. Additionally, 3 other residents received and/or consumed meals that were not mechanically altered per the physician orders. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1, 5, 6, and 14. NOTICE On 8/23/23 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to observe meals and food preparation to assure the food was prepared and appropriate to meet the resident's needs according to their assessment and care plan. Specifically, the facility failed to ensure that residents who were evaluated for and prescribed a mechanically altered diet had those diet modifications implemented; and were monitored and supervised to ensure the appropriate food preparation and delivery of the prescribed modified diet texture. Notice of IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON), the Corporate Resource Nurse (CRN) 2, and the Regional Administrator. On 8/23/23 at 10:01 PM, the facility provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 8/24/23 at 2:00 PM. IJ Abatement Plan For F805 and F689 at Alpine Meadow Rehabilitation and Nursing 8/23/2023 Immediate Actions Taken to Correct Deficient Practices Administrator has hired a Certified Dietary Manager who is competently trained and educated on therapeutic/mechanically altered diets and the menu system who will take on the role of dietary manager effective 8/24/23 at 0600 [6:00 AM]. On 8/23/23, a Diet and Tray Card audit was completed by the regional nurse consultant to ensure that correct physician prescribed diet orders in PointClickCare match the meal tickets in Nutrition Management. Beginning on 8/23/23 at lunch meal, regional nurse consultant implemented a Therapeutic Diet audit to be completed for all residents with mechanically altered diet textures at all meals by the regional nurse consultant or appropriately trained and competent designee to ensure correct physician prescribed diet orders are followed to prevent further harm to any residents. Measures to Ensure the Deficient Practice Does Not Recur Regional nurse consultant will complete an inservice on 8/24/23 by 2 PM with all nursing, dietary, activity and social service staff on requirements for their respective departments regarding resident diet orders and meal tray delivery to residents, including the different types of diets offered at the facility and how to recognize and verify each type of diet before serving the diet to each resident. Administrator will print and laminate visual aids with information on all diet types offered at the facility that will be placed at each nursing station, aide station, on each meal cart and in the kitchen for ease of reference by nursing, dietary, activity and social service staff. To be completed 8/24/23 by 2 PM. Speech language pathologist (SLP) will complete a screen and/or evaluation as indicated with all residents on mechanically altered diets to verify that each resident has the correct physician prescribed diet type in place. Any recommendations for diet type changes will be referred to the Medical Director for approval before the diet order is changed. To be completed 8/24/23 by 2 PM. Beginning 8/23/23, regional nurse consultant or appropriately trained and competent designee will complete a Therapeutic Diet audit for all residents with mechanically altered diet textures at all meals daily x [times] 2 weeks then at one meal daily Monday through Friday x 2 weeks to ensure correct physician prescribed diet orders are followed to prevent further harm to any residents. Beginning 8/24/23, Human Resources Director (HR) will complete a New Hire audit for all newly hired employees daily Monday through Friday x 4 weeks in the nursing, dietary, social service and activity department and verify that the appropriate competency checklist is completed before the end of the on-boarding process. Measures to Monitor and Ensure Corrective Action is Achieved and Sustained QAA [Quality Assurance Assessment] committee under the direction of the administrator will review the findings from the Therapeutic Diet audit and New Hire audit monthly until a lesser frequency is determined to be appropriate. Any ongoing problems with residents of the facility receiving the correct physician prescribed diet order or the facility's training process for new staff regarding resident diet orders and meal tray delivery to residents will be addressed with modifications to the plan of correction implemented at the direction of the QAA committee. Findings included: IMMEDIATE JEOPARDY 1. Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of paranoid schizophrenia, dysphagia, anorexia, adult failure to thrive, and pneumonitis. On 7/28/23, the Annual Minimum Data Set (MDS) assessment of resident 1 documented a Brief Interview for Mental Status (BIMS) score of 1/15, which would indicate a severe cognitive impairment. Facility staff assessed resident 1 as having hallucinations. Facility staff assessed that resident 1 required supervision with set up help only for eating. The assessment documented that resident 1 had a swallowing disorder with loss of liquids from the mouth when eating or drinking, holding food in mouth or cheek or residual food in mouth after meals, and coughing or choking during meals or when swallowing medication. Review of resident 1's physician orders revealed a diet order for a pureed texture diet that was initiated on 5/30/23. On 8/11/23, resident 1's diet order was changed to a pureed texture diet with honey thick liquids. Review of resident 1's progress notes revealed the following: a. On 5/23/23 at 11:00 AM, the progress note documented, SLP completed initial observation/evaluation of resident yesterday. SLP reports resident drank thin water and ate a cup of pudding without any overt s/s [signs and symptoms] difficulty swallowing. Resident was impulsive during the eval and did not follow prompts or cues to take single sips of water when given. He reported, 'I am,' demonstrating a lack of insight or cognitive ability to process the instructions. He also reported to SLP that he couldn't eat pudding after finishing the cup of pudding and did not demonstrate understanding or insight when SLP drew his attention to the fact that he had just eaten a cup of pudding. It remains unclear if resident's inability to eat is related to lack of dentition and unwillingness to eat a downgraded diet texture or if there is an element of dysphagia as well. An MBS [modified barium swallow] has been scheduled for Friday for further evaluation. SLP plans to observe resident eat lunch today and will keep facility staff apprised of any recommended changes to resident's plan of care. b. On 5/30/23 at 3:35 PM, the MD progress note documented, [Resident 1] is a [AGE] year old male with paranoid schizophrenia who was admitted to the [name of hospital omitted] 5/25 due to failure to thrive. He had been losing weight due to poor oral intake. Teeth had been removed but he had healed and no swallowing issues were identified. He had a fixed delusion that he could not swallow because of his missing teeth. At the [hospital] he was started on a pureed diet. They reported he at [sic] this well. c. On 8/6/23 at 6:32 PM, the progress note documented, CNA [Certified Nurse Assistant] asked if RN would come into the room and assist her. RN went to assess what had happened. RN walked in and saw drops of blood on the floor, RN saw resident on his knees on the floor and with his head on head on the bed. Resident lifted his head up and RN saw a string of clotted blood. RN went to get supplies to clean wound. Resident took off his glasses, RN asked resident what had happened. Resident sat himself up and sat himself on his bed. RN asked CNA to obtain another CNA for assistance. Other CNA came in; RN noticed resident started to cough. RN noticed food in his mouth; resident pulled out pork from dinner out of his mouth, resident started coughing more. RN asked resident if he was able to breathe; resident kept coughing and unable to answer RN. RN started the Heimlich, CNA took over and RN called 911. Resident was going in and out of consciousness; CNA assessed pulse and CNA informed RN that pulse was not present, CNA started CPR, CNA did break ribs. Resident came out of consciousness, RN an CNA's [sic] were back blowing, RN during this time is getting instructions from 911 operator. At one point 911 operator was instructing RN to apply AED [automated external defibrillator] pads, RN informed 911 operator that resident was in and out of consciousness and didn't want to apply it; RN assessed residents pulse, resident had a pulse, resident was breathing, residents eyes were open. Paramedics arrived and take over. Paramedics took resident to ER; RN gave face sheet and med list. RN called and informed MD. d. On 8/6/23 at 9:57 PM, the progress note documented, At approximately 9:50 pm I called [local hospital] to get an update on patient. RN reported patient is currently stable, they did a food extraction just above his epiglottis with mild sedation. Patient is stable and will be admitted for pneumonia. On 5/22/23, the SLP evaluation documented that resident 1 had a recent onset of difficulty with chewing due to recent loss of some teeth. Resident 1 attributed all swallowing difficulty to decreased ability to chew and that resident 1 endorsed he could not chew complex texture foods and had been declining in overall oral intake. The oral peripheral exam documented impairments to the mandibular range of motion (ROM), mandibular strength/tone and mandibular coordination. The exam documented an impairment to the lingual sensation/function. The exam documented that the laryngeal/pharyngeal performance was impaired with the reflexive cough strangled and wet and the volitional throat clearance as strangled. The clinical bedside assessment of swallowing documented, Pt [patient] p/w [presented with] clinical s/s of aspiration during thin liquid PO [by mouth] trials via sequential straw sip. Pt noted to be impulsive, continue to drink thin liquid while simultaneously coughing. Pt with persistent cough following PO intake of thins, with pt endorsing choking on thin liquids. The assessment further documented, Pt p/w delayed cough following sequential PO intake of puree (pudding) consistencies. Pt with strong hyolarygeal elevation w/ [with] PO intake, however, pt with wet vocal quality and delayed cough. The assessment summary documented, Patient presents with moderate oropharyngeal dysphagia characterized by decreased mandibular ROM/strength, decreased lingual ROM/strength, decreased safety awareness w/PO intake, decreased overall PO intake which necessitates skilled SLP services for dysphagia to analyze pharyngeal function, analyze oral function, assess/evaluate for safest level of oral intake, develop and instruct in compensatory strategies, maximize nutrition/hydration with oral motor facilitation and minimize risk of weight loss with swallow analysis in order to improve ability to decrease risk of malnutrition/weight loss, safely consume highest level of oral intake and safely swallow without signs/symptoms of aspiration. On 5/26/23, resident 1's SLP Discharge summary documented that resident 1 was discharged to the hospital and they were unable to complete the modified barium swallow study on site. On 8/6/23, the menu documented country style pork ribs, potato salad, mixed vegetables, peach jello, and a salad were scheduled. On 8/9/23, the hospital discharge summary documented that resident 1 was given the wrong plate of food at dinner in the facility. He was given a regular consistency instead of a pureed diet. The summary documented resident 1 ' s diagnosis as aspiration pneumonia secondary to foreign body aspiration of his dinner. The History of Present Illness documented that the facility DON reported that resident 1 had an order for a pureed diet but was served the wrong plate of food at dinner this evening. The resident aspirated the food, lost consciousness and a staff member performed the Heimlich maneuver that was unsuccessful. They also performed CPR and when EMS [emergency medical services] arrived the patient was found to be hypoxic but with a pulse. In the ER [emergency room] patient was given ketamine and the food was retrieved from his trachea. ER physician reports he had stridorous respirations off and on and there was a high suspicion that there is still material in the lower trachea. The director of nursing reported the patient had multiple teeth extracted earlier this year and ever since then has had dysphagia and was treated for aspiration pneumonia on June 26th. It was determined in May of this year that he needed a feeding tube but he refused .Also noted that patient has excessive secretions the oropharynx and is likely chronically aspirating his secretions. The discharge summary documented that on 8/8/23 resident 1 underwent a barium swallow and failed the test. He was explained that he needs a feeding tube to prevent further aspiration events. Patient does not believe he has aspirated, does not believe he has pneumonia He says he absolutely refuses to have a feeding tube placed. He wants to eat and go home. Representative from his facility came to see patient. They discussed hospice and he decided he wants to go home on hospice. He wants abx [antibiotics] and o2 [oxygen] discontinued and asked code status to be changed to DNR [Do Not Resuscitate]. On 9/29/21, resident 1 had a care plan for at risk for nutritional status initiated. Interventions identified included to monitor/document/report any signs and symptoms of dysphagia such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; Registered Dietician to evaluate and make diet change recommendations; and staff to provide supervision and encouragement with meals as needed. 2. Resident 6 was admitted to the facility on [DATE] with diagnoses which consisted of, but were not limited to, type 2 diabetes mellitus, pain, dementia, pulmonary hypertension, nonrheumatic aortic valve stenosis, orthostatic hypotension, atrial fibrillation, presence of cardiac pacemaker, hypertension, and mild cognitive impairment. On 6/16/23, resident 6's Quarterly MDS Assessment documented a BIMS score of 15 which would indicate that the resident was cognitively intact. The assessment documented that resident 6 required supervision with set-up help for eating, and that resident 6 had a swallowing disorder with symptoms of holding food in the mouth/cheeks or residual food in the mouth after meals. Review of resident 6's physician orders revealed a diet order for a regular diet mechanical soft texture, think liquids consistency that was initiated on 5/14/20. On 2/6/2020, resident 6 had a care plan for at risk for altered nutrition status due to edentulous status with mechanical altered texture required for ease of chewing initiated. Interventions identified included monitor/document/report any signs and symptoms of dysphagia such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses of dementia, emphysema, hypertension, alcohol abuse, and malignant neoplasm of pancreas. On 5/19/23, resident 5's Quarterly MDS Assessment documented a BIMS score of 5/15, which would indicate a severe cognitive impairment. The assessment documented that resident 5 required a one person physical assist with supervision for eating. The assessment documented that resident 5 had a swallowing disorder with symptoms of holding food in the mouth/cheeks or residual food in the mouth after meals. Review of resident 5's physician orders revealed a diet order for a regular diet chopped texture, thin liquids consistency that was initiated on 2/18/22. On 5/25/23, resident 5 had a physician order for SLP to evaluate for possible diet texture upgrade. No documentation could be found of the SLP evaluation. On 2/26/22, resident 5 had a care plan for at risk for altered nutrition status related to medical condition initiated. Interventions identified included monitor/document/report any signs and symptoms of chewing swallowing problems related to dysphagia or oral health problems such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. 4. Resident 14 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, benign paroxysmal vertigo, dementia, obstructive sleep apnea, and low back pain. On 6/21/23, resident 14's Quarterly MDS Assessment documented that a BIMS score was not obtained due to the resident was rarely/never understood. The assessment documented that resident 14 required a one person extensive physical assist for eating. The assessment documented that resident 14 had a swallowing disorder with symptoms of loss of liquids/solids from mouth when eating or drinking; holding food in mouth/cheeks or residual food in mouth after meals; and coughing or choking during meals or when swallowing medications. Review of resident 14's physician orders revealed a diet order for a regular diet minced and moist texture, thin liquids consistency that was initiated on 8/17/23. On 9/28/21, resident 14 had a care plan for at risk for malnutrition initiated. Interventions identified included monitor/document/report any signs and symptoms of chewing swallowing problems related to dysphagia or oral health problems such as Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing; refer to SLP or dentist as indicated to address dysphagia; to provide and serve the diet as ordered; and the Registered Dietician to evaluate and make diet change recommendations as needed. On 8/22/23 at 11:33 AM, an interview was conducted with the Dietary Manager (DM) 2. The DM 2 stated that the kitchen staff were responsible for plating resident meal trays, but nursing staff were responsible for delivering the trays to residents. On 8/22/23 at 12:15 PM, an interview was conducted with the hospitality aide. The hospitality aide was observed delivering food trays to residents in their rooms. The hospitality aide stated she passed out meal trays to residents often. The hospitality aide stated she would check the diet card on the resident's food tray for their preferences and put a drink on the resident's tray. Several cups of fluid were observed on top of the food cart. The hospitality aide further stated she does not look on the diet card to see if a resident was on thickened liquids or any special diet before giving the food tray to the resident and that she only looked at the resident's preferences. The hospitality aide stated the kitchen would know the diet and takes care of that. On 8/22/23 at 12:17 PM, an observation was made of CNA 1 delivering food to resident 6's room. The resident diet ticket documented a mechanical soft diet with thin liquids. Resident 6's meal was observed as shrimp tacos with refried pinto beans. The taco was made with a corn tortilla and a shredded cabbage topping. Resident 1 refused the meal and stated she did not like shrimp. On 8/22/23 at 12:17 PM, an observation was made of resident 5 sitting at a table in the dining room eating lunch. The dietary manager (DM 2) approached resident 5 and removed his plate. The plate had 2 whole corn tortillas and 1 uncut shrimp. An interview was conducted with DM 2 at 12:18 PM. DM 2 stated the uncut shrimp on resident 5's plate was a regular texture diet. DM 2 stated a chopped diet would have no tortillas or shrimp. Resident 5's meal ticket documented regular chopped thin liquids diet. On 8/22/23 at 12:39 PM, an observation was made of resident 1's meal tray. Resident 1's meal ticket documented a pureed diet texture with honey thick liquids. Resident 1's meal was observed as a regular diet with shrimp tacos with shredded cabbage on a corn tortilla and refried beans. CNA 1 identified the incorrect diet order and returned the meal tray to the kitchen. On 8/22/23 at 12:57 PM, an interview was conducted with CNA 1. CNA 1 stated that she had worked at the facility for a long time and she should have looked at the meal ticket to identify the diet before delivering the tray to resident 6. On 8/22/23 at 3:24 PM, a telephone interview was conducted with Licensed Nurse (LN) 1. LN 1 stated that on 8/6/23 resident 1 was found on the floor with his elbows on the bed. Resident 1 had dried blood on his forehead. LN 1 stated she obtained supplies to clean resident 1's wound. Resident 1 was assisted to bed and was sitting up in bed when he started to cough. LN 1 stated that resident 1 was attempting to clear his airway. LN 1 stated that she observed pork inside resident 1's mouth. LN 1 stated she asked resident 1 if he was choking and he did not respond. LN 1 stated that she performed the Heimlich maneuver and the aide took over while she called 911 and checked the resident's code status. LN 1 stated that they were also giving back blows to resident 1. LN 1 stated that the aide identified that resident 1 did not have a pulse, the resident was blue/gray in color and they began chest compressions. LN 1 stated that resident 1 became responsive and opened his eyes and CPR was stopped. LN 1 stated that EMTs [Emergency Medical Technicians] arrived and suctioned resident 1's airway and transported him to the Emergency Room. LN 1 stated that the aide removed a piece of pork that was hanging out of resident 1's lip. LN 1 stated that resident 1 was supposed to have a pureed diet texture and when she looked at the resident's meal tray it was a regular texture diet of pork and mashed potatoes. LN 1 stated that the kitchen had made resident 1 two dinner trays and when resident 1 saw the regular tray had told the CNA that he wanted to eat that one instead of the pureed diet. LN 1 stated that none of the aides had reported the diet change to her. LN 1 stated that the aides should know that resident 1 was to have a pureed diet because it was noted on his meal ticket. LN 1 stated that the aides should have notified her when resident 1 requested a regular diet. On 8/22/23 at 3:51 PM, an interview was conducted with the Registered Dietician (RD). The RD stated they put together a weekly extension of the meals that detailed the modified diet and this showed the kitchen staff what modifications should be made to the diet for the different textures. The RD stated that DM should be able to print off the menu system with the extensions. The RD stated that the DM 2 was new and she provided training to him last week on the menu and the extensions for different diet textures. The RD stated that as a consultant she was in the facility one time a week. The RD stated that the previous DM 1 was an assistant DM at a sister facility and she had interacted with him 2 or 3 times. The RD stated that she checked in on DM 1 to see how he was doing. The RD stated that DM 1 did not attend the nutrition at risk meetings but they encouraged the DM to attend them also. The RD stated that she did not recall having any concerns with DM 1 and did not address the diets and extensions for textures. The RD stated that her understanding was that DM 1 was familiar with the menu system, diets, and textures. The RD stated that she completed audits every 30 days unless deemed more frequently. The RD stated that she had been auditing more frequently due to reports that residents were requesting different diets from their speech therapy (ST) evaluation. The RD stated that she did not change the diet order and that the ST was to evaluate the resident to see what the appropriate diet would be. On 8/22/23 at 4:16 PM, an interview was conducted with the DM 2. DM 2 stated that he had been doing the online training and had been provided some education by the RD. DM 2 stated that he and the RD had gone over the mechanically altered diet textures and how to identify the differences. DM 2 stated that before meal service he separated the different textured diets into piles so that he could do all one texture at a time and could plate them according to the meal ticket. The DM 2 stated that either himself, the dietary aide (DA) 3, or the hospitality aide plated the food in the kitchen. DM 2 stated that the hospitality aide had her food handlers permit and was allowed to assist in the kitchen. DM 2 stated that at the time of plating he had the meal ticket under the heat lamp so that he could visualize the therapeutic meal texture. DM 2 stated that he was informed of one meal at lunch time that one meal was plated wrong and not according to the meal ticket and diet order. DM 2 stated that it was supposed to be a pureed diet plated was a chopped diet. DM 2 stated that he did not see the returned meal and could not recall which resident the meal was for. On 8/22/23 at 5:13 PM, an observation was conducted of resident 14 eating dinner in the dining room with the Corporate Resource Nurse (CRN) 1 assisting. Resident 14 was observed eating a baked roll that was dry and cut into bite-sized pieces, green beans, and ziti noodles with red sauce. Resident 14's meal ticket indicated Minced & Moist MM5. On 8/23/23 at 7:57 AM, a telephone interview was conducted with a Speech Language Pathologist (SLP). The SLP stated that a corn tortilla, salad texture and whole shrimp was a regular diet texture. The SLP stated that a mechanical soft diet was like a sloppy joe, a minced and moist was chopped with a gravy over top to bring more moisture into the food, and a mechanical soft was chopped. The SLP stated that she did not conduct an evaluation for resident 5 and resident 6. On 8/23/23 at 8:35 PM, a follow-up interview was conducted with the DON. The DON stated that resident 6 had a diet order for a mechanical soft texture diet because of her teeth and difficulty with chewing. The DON stated that resident 6's dentures were being refitted currently. The DON stated that resident 6 had been on a mechanical soft diet since being admitted and she had issues with her shoulder so she could not cut her food independently. The DON stated that resident 5 had a stroke, did not have any teeth and did not want any dentures and that was the rationale for the chopped texture diet order. The DON stated that resident 5 had not been evaluated by the SLP for any swallowing difficulties. The DON stated that diets were reviewed in the Nutrition at Risk (NAR) meetings and recommendations for changes to the diet order could be referred to the MD for any changes to the diet orders. The DON stated that the DM could then make changes to the diet order in the electronic medical records, but that DM 1 did not have access to the risk management and was unable to put diet orders into the electronic medical records. The DON stated that on 8/6/23 resident 1 had received a regular meal tray with pork on it and the kitchen had prepared the incorrect diet order for the resident. The DON stated that she had argued with DM 1 several times because the residents were asking for different diet textures and he was providing the residents their requests, and that he had done this at his previous facility. The DON stated that she informed DM 1 that he needed to provide the residents with the diet that was ordered or else talk to her about any diet changes. The DON stated that she did not have any concerns with diet changes prior to the incident with resident 1. The DON stated that LN 1 had reported to her that DM 1 did not like LN 1 and DM 1 had told LN 1 that he could give the resident's whatever he wanted. The DON stated that DM 1 was let go because of the incident with resident 1 and she was not okay with him changing the diet orders especially since she had provided him with education regarding this prior to the incident with resident 1. The DON stated she instructed DM 1 to follow the meal ticket, and that they could have the resident evaluated by the SLP for a diet change and then notify the MD. The DON stated that DM 1 did not bring the subject back up with her because her instructions were very specific, you need to follow the diet orders. The DON stated that she had to depend on him to follow his training, but that DM 1 was not certified. The DON stated that the staff were educated on checking the meal ticket for the diet order and then checking the meal tray to verify that it was the correct diet per the orders. The DON stated that the staff were educated to know what a mechanical soft or chopped diet looked like and that this training was completed upon hire. The DON stated that after resident 1's choking incident she and the ADM, and DM 2 had training with the RD on how to put diet orders into the electronic medical records and how to verify and check those orders. The DON stated that the meal trays should not be coming out of the kitchen plated wrong against the diet orders now. On 8/23/23 at 9:55 AM, an interview was conducted with the ADM. The ADM stated that education on ITSY [International Dysphagia Standardization Initiative] was provided to the kitchen staff and should be provided to the CNA Coordinator. The ADM stated that it would be the CNA coordinator should go through the education with her staff. However, the ADM stated that he had been trying to hire a new CNA Coordinator for months now. The ADM stated that education was not provided to the CNA staff in the interim during the hiring process. The ADM stated that diet education was provided by the RD to the DON, ADON, Transportation staff, and himself. The ADM stated that DM 2 would provide education to the kitchen staff. The ADM stated that he was auditing the diets for the textures, and personally viewed every meal service for a week after the incident with resident 1. The ADM stated that he also worked with the RD to verify that all diet orders were correct. The ADM stated that he was initiating audits again today. On 8/23/23 at 11:00 AM, an interview was conducted with CNA 2. CNA 2 stated that she had been hired last Wednesday, August 16th 2023. CNA 2 stated that she had been trained on her first day to look at meal tickets when delivering meals to ensure that each resident received the correct meal. On 8/23/23 at 11:05 AM, an interview was conducted with CNA 1. CNA 1 stated that she had received training about delivering the correct diet order to residents prior to the beginning of the complaint survey on 8/22/23. CNA 1 stated that she was supposed to ensure meal tickets matched the meal tray delivered to each resident. CNA 1 also described the differences between a puree diet, a mechanical soft diet, and a regular diet. A puree diet was pureed, a mechanical soft diet was chopped up, and a regular diet was normal. On 8/23/23 at 11:14 AM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated that she had been working at the facility for three days. DA 1 listed the different [TRUNCATED]