**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 out of 4 sampled residents (R1) by failing to serve R1 the correct diet and failing to administer first aid (Heimlich Maneuver) timely when R1 experienced a choking episode. R1 experienced a choking episode that required the Heimlich maneuver to clear R1's airway. The facility did not complete all assessments of Vital Signs (VS) and respirations over the next 24 hours. At supper the following day, the facility did not ensure that R1 received the proper downgraded diet of bite sized and soft food items. R1's meal card indicated R1 could be served a dinner roll, which was served. R1's new downgraded diet does not allow dinner rolls. R1 experienced another choking episode prior to leaving the dining room from supper. First aid (Heimlich maneuver) was not administered immediately and R1 expired. The facility's failure to complete frequent and thorough assessments, failure to provide the proper diet, and failure to administer first aid immediately created a finding of immediate jeopardy that began on 6/24/25. INHA A (Interim Nursing Home Administrator) and INHA B were notified of the immediate jeopardy on 7/9/25 at 3:35 PM. The immediate jeopardy was removed on 7/21/25, however, the deficient practice continues at a scope severity of a D (Potential for more than minimal harm/isolated) as the facility continues to implement its action plan.Findings include: According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.The International Dysphagia Diet Standardization Initiative (IDDSI) website's (https://www.iddsi.org/) IDDSI Framework and Detailed Level Definitions, dated July 2019, states, in part: 6 Soft and Bite-Sized Description/characteristics.soft, tender and moist throughout but with no separate thin liquid.Food Specific or Other Examples: .Bread No regular dry bread, sandwiches, or toast of any kind. The website's Frequently Asked Questions page, (USIRGFAQExceptionsBreadsMixedConsistencyJan2025.pdf), dated January 2025, states, in part: . Part 1: Bread.Soft and Bite-Size, Level 6 and Minced and Moist, Level 5 do not include regular dry bread, sandwiches, or toast of any kind, even if they are cut-up to the appropriate size indicated for each diet level. Use pre-gelled soaked breads that are very moist and gelled through the entire product. The facility's Life Support Certifications and Course Requirements policy, dated 2/17/25, states, in part: .The purpose of this document is to establish and outline standards for facility's American Heart Association (AHA) Training Center and facility life support requirement. This policy is complimentary to the AHA Center standards. 3.1 Managing Certifications a. Certifications in BLS (Basic Life Support) .are recognized solely from the AHA.The facility's first aid training, Basic Life Support Provider Manual eBook, undated, states, in part: Choking Relief in a Responsive Adult or Child: Abdominal Thrusts Use abdominal thrusts to relieve choking in a responsive adult or child.Choking Relief in an Unresponsive Adult or Child. A choking victim's condition may worsen, and the victim may become unresponsive. If you are aware that a foreign-body airway obstruction is causing the victim's condition, you will know to look for a foreign body in the throat. To relieve choking in an unresponsive adult or child, follow these steps: 1. Shout for help. If someone is available, send that person to activate the emergency response system. 2. Gently lower the victim to the ground if you see that they are becoming unresponsive. 3. Being CPR, starting with chest compressions. Do not check for a pulse. Each time you open the airway to give breaths, open the victim's mouth wide. Look for the object. A. if you see an object that looks easy to remove, remove it with your fingers. B. If you do not see an object, continue CPR. 4. After about 5 cycles or 2 minutes of CPR, activate the emergency response system if someone has not already done so.Heimlich Maneuver works by using the air in the lungs to push an object out of the airway, when performing abdominal thrusts, to restore normal breathing when an individual is choking. R1 was admitted to the facility on [DATE] with diagnoses that include, in part: unspecified dementia, severe, with mood disturbance (a condition with a decline in mental ability severe enough to interfere with daily life); unspecified dementia, severe, with anxiety; other persistent atrial fibrillation (a heart rhythm disorder which leads to the heart beating irregularly and rapidly); muscle weakness generalized.R1's admission Minimum Data Set (MDS), dated [DATE], indicates Self-Care Eating ability score of 5, indicating need for set up or clean up assist.R1's quarterly Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R1's physician orders include:*DNR (Do Not Resuscitate)*General Level 7 foods-regular-easy to chewR1's care plan includes:*3/20/25.Problem: Cognition: I am alert and oriented to self and family. I am able to communicate some of my needs and wants to staff.*3/21/25.nurse aide.transfer me with 1 assist with EZ stand*3/31/25.nurse aide.monitor me for an increased difficulty with my chewing and/or swallowing abilityR1's progress notes include:*6/23/25 9:54am choking on whole fruit with Heimlich maneuver performed for removal.call received from hall indicating resident actively choking with Heimlich being performed. Upon arrival, writer confirmed code status and observed staff still actively and unsuccessfully attempting Heimlich maneuver. At that time, writer phoned 911 for assist and instructed staff to continue with firm Heimlich application. While on the phone with 911 operator, staff achieved successful removal of food item and resident breathing improved.*6/23/25 11:43 AM call received from ER (emergency room), ready for discharge; CXR (chest x-ray) completed and negative, VS (vital signs) have remained stable. Stay and work up unremarkable.*6/23/25 12:54 PM RN (Registered Nurse) was sitting at nurses' station helping another nurse when CNA (Certified Nursing Assistant) called out. Other nurse went to see what CNA needed in patient's room. CNA yelled that patient was choking. This nurse ran in room to assist. Nurse noted that patient was sitting in recliner, pallor was gray, lips and around eyes was turning blue and unable to speak. Patient was not breathing. When nurse asked CNA what happened CNA stated, her husband brought her fruit, and she was actively eating it when I walked into the room. She is choking on a piece of fruit. CNA was instructed to get behind patient to do the Heimlich maneuver. Instructed another nurse to call to upstairs unit to have other RN come down to assist. After approximately 10 thrusts, patient coughed out a piece of cantaloupe and was able to breathe. Patient started to respond and speak when EMS (Emergency Medical Services) arrived. Prepared transfer. Patient was sent to the ER for evaluation.R1's Emergency Department Provider Note, dated 6/23/25, states, in part: Patient presenting with complaints of choking episode that has since resolved after Heimlich. She does not have any signs of trauma. Nontender abdomen, lung sounds clear bilaterally. Plan for x-ray to rule out aspiration. Vitals normal. Low suspicion for rib fracture. Plan for DC (Discharge).Patient Instructions: You were seen in the ER after an aspiration event (the accidental inhalation of foreign material, like food, into the airway and lungs). You received an x-ray that did not show any signs of pneumonia or damage to the lung itself. Follow up with your primary care doctor within 1 week.On 7/7/25 at 10:33 AM, Surveyor interviewed FM Q (family member) and asked about events of 6/23/25. FM Q stated that while visiting R1, R1 was eating cantaloupe in R1's room and then R1 didn't talk. FM Q noted that R1 was digging in R1's mouth with R1's fingers and when FM Q asked what was wrong, R1 didn't say anything, but kept digging. FM Q stated FM Q went to alert staff as FM Q noted R1 was getting paler. FM Q stated 3 staff responded, they called 911 and were tapping resident on R1's back, but R1 didn't respond. FM Q stated that one of the aides crawled up in the resident's chair and got arms around R1 and performed thrusts. FM Q stated that one of the staff opened R1's mouth and pulled out a piece of cantaloupe. FM Q stated that when the EMTs arrived, R1 was breathing and had eyes open. FM Q stated they took R1 to the ER.On 7/7/25 at 11:11 AM, Surveyor interviewed CNA F regarding the incident on 6/23/25. CNA F stated that when walking down the hall, CNA F noted FM Q come into the hall and check the call light. CNA F indicated a feeling that something was needed by R1, and CNA F went into R1's room to ask. CNA F stated that FM Q stated, I think R1 is choking. CNA F stated that R1 was not breathing and was very gray in color. CNA F stated that CNA F started hitting R1 on the back with an open hand and yelled for the nurse. CNA F stated that LPN E (Licensed Practical Nurse) came to the door and LPN E yelled for RN R (Registered Nurse). CNA F stated that RN R arrived and instructed to start the Heimlich. CNA F stated that CNA F positioned self behind R1 in R1's recliner and started the Heimlich. CNA F stated that CNA F would do the Heimlich a couple times, then look to see if R1 would respond, then RN R would do back blows, then alternate. CNA F stated there were about 2 cycles of this alternation before RN U arrived and stated to just continue the Heimlich. Surveyor asked if R1 had a history of swallowing issues. CNA F stated no.On 7/7/25 at 12:56 PM, Surveyor interviewed RN U and asked about the 6/23/25 incident. RN U stated that LPN E called about a dire situation. RN U stated that on arrival, RN U noted R1 slumped over in recliner, color pale, with staff performing Heimlich. RN U indicated verifying R1's code status in the chart and calling 911. Surveyor asked about treatment for choking. RN U stated perform the Heimlich immediately. RN U stated that back blows are not typically performed on an adult.On 7/8/25 at 10:56 AM, Surveyor interviewed RN R. RN R indicated being at nurses' station with LPN E and hearing CNA F yell from R1's room. RN R stated that LPN E went to R1's room and RN R heard CNA F yell that R1 was choking. RN R stated that RN R ran to R1's room and saw R1 blue around lips, drooling, and R1's eyes were fixed. RN R stated R1 was choking and unresponsive. RN R indicated instructing CNA F to perform the Heimlich and RN R did alternating back blows. RN R indicated instructing LPN E to contact RN U to call EMS. RN R stated that R1 coughed up a piece of cantaloupe and her skin started to pink and R1 was coming back around. RN R stated that when R1 left for the ER, RN R requested that R1 be in a common room or with staff for eating until a swallowing evaluation was done. Surveyor asked RN R about treatment for choking. RN R indicated that if person is responsive the Heimlich is performed, if unresponsive back blows and Heimlich. R1's Therapy Screen notes include:*6/23/25 1:39 PM Therapy Screen request: please screen episode of choking on piece of fruit provided by family required Heimlich intervention. Currently on regular diet.*6/24/25 10:12 AM Therapy Screen response: 6/24/25-Requested orders. Thank you. Diet downgrade to IDDSI-Level 6. Soft and bite sized solids.R1's Physician Orders state:*6/23/25.Nutritional Problem.Diet Order: General Level 6 foods- soft and bite sized. An (International Dysphagia Diet Standardization Initiative) (IDDSI) framework provides a standardized system for describing food and drink consistencies for individuals with swallowing difficulties (dysphagia). (Soft Bite-sized level 6 - soft bite sized food which is a level 6 on IDDSI framework).*6/23/25.meal assist: Partial assistOn 7/8/25 at 9:19 AM, Surveyor interviewed SLP I (Speech Language Pathologist) who indicated R1 was independent with eating, ate meals in the dining room, and was on a general diet until R1's episode on 6/23/25. SLP I indicated after the first choking episode SLP I conducted a screen on R1. SLP I indicated R1's screen showed R1 needed to have a swallow study completed so SLP I contacted R1's Medical Doctor to obtain an order for a swallow study. While waiting for the swallow study, SLP I downgraded R1's diet to an IDDSI level 6 diet.R1's meal ticket, undated, is printed with the following:*Starter: 1 chocolate milk 240cc (cubic centimeters); 1 2% milk; 2 Skim Milk 240cc*Hot Prep: blank*Cold Prep: 1 Dinner Roll ea (each)*HSM (Hillside Manor) IDDSI SB6R1's progress notes include:6/23/25 3:14 PM spoke with POA (Power of Attorney) regarding patient's visit to ER. Informed POA that it would be preferred for patient to be in the common area/dining room for meals and snacks for precautions. POA also informed that patient was placed on 24-hour monitoring for VS (vital signs) and respirations.6/23/25 5:27 PM respirations normal lung sounds clear diminished.Important to note: there are no vital signs documented with 6/23/25 5:27 PM respiratory assessment.6/24/25 4:36 AM respirations: normal lung sounds: upon auscultation clear Blood Pressure 116/56 Pulse 71 temperature 95.9 respirations 16 O2 (oxygen) saturation 98% on room airImportant to note: there are no vital signs or respiratory assessment documented for 6/24/25 morning shift.6/24/25 6:51 PM This writer was paged to go to the 1st floor dining room to assist with resident. Upon arrival to dining room this writer observed several CNAs assisting resident, performing the Heimlich maneuver, resident pale, nonresponsive, without respirations, CNA G on phone with 911. Resident taken out of dining area, away from other residents, continuing Heimlich maneuver. Once in hallway this writer continued speaking with 911 operator, providing operator with pertinent resident information as CNAs transferred resident out of wheelchair onto floor as Heimlich maneuver not effective, chest compressions initiated at this time. NHA A (Nursing Home Administrator) and ADON D (Assistant Director of Nurse) arrived to assist, noted that resident had an active DNR (Do not Resuscitate) order, DNR bracelet on resident's left wrist, compressions stopped. ADON D and NHA A remained with resident and staff until EMTs (Emergency Medical Technicians) arrived.6/24/25 6:02 PM call placed to (POA) notified of resident passing due to witnessed choking episode-Heimlich unsuccessful and resident became unresponsive; resident is DNR (Do Not Resuscitate)-CPR (Cardiopulmonary Resuscitation) ceased per resident wishes. EMTs (Emergency Medical Technicians) arrived and verified DNR (Do Not Resuscitate) status and absence of VS (Vital Signs) at 1739 (5:30 PM) .On 7/7/25 at 1:29 PM, Surveyor interviewed CNA L about 6/24/25 incident. CNA L stated that CNA L was seated at the corner of the dining room table assisting residents to each side of CNA L to eat their supper. CNA L stated that R1 was next to one of those residents and R1 was self-feeding. CNA L stated that the resident between CNA L and R1 had finished with supper and left the dining room and that CNA L's partner, CNA J, was also gone from the dining room, leaving CNA L alone with the residents. CNA L indicated seeing little glimpses of R1 eating but concentrating attention on the resident that CNA L was feeding on the opposite side. CNA L indicated that R1 started to wheel away from the table, but CNA L wasn't observing her. CNA L stated that R1 wheeled behind CNA L. CNA L stated, I am only one person, and it is stressful in the dining room as there are quite a few feeders (residents that need to be assisted). CNA L stated that CNA J returned to the dining room and noted that R1 was blue. CNA L stated that the emergency was radioed (call for assistance), and other CNAs came to assist and one of them started the Heimlich. Surveyor asked if there was any intervention for R1 prior to the other CNAs arrival and starting the Heimlich. CNA L stated, I took the palm of my hand and patted her neck lightly, when we were waiting for help; it was just CNA J and me and R1 was bigger than us; we waited for help.On 7/7/25 at 1:50 PM, Surveyor interviewed RN M about 6/24/25 incident. RN M indicated hearing an alert regarding assist being needed in the dining room and went to assist. RN M stated R1 was slumped over and discolored, with a nurse checking pulse and a CNA on phone with 911. RN M stated an additional CNA was performing the Heimlich. RN M stated R1 was not breathing, and someone stated there was no pulse. RN M stated that RN M advised staff to move R1 into the hallway, away from the residents in the dining room. RN M stated that after moving R1 into hall, someone indicated to get ADON D and RN M went to do so. Surveyor asked about treatment for choking. RN M stated if they can talk/cough, call for help, no action; if they cannot talk/cough, call 911 and begin Heimlich and back blows. RN M stated continue until they clear, or they become unconscious. Surveyor asked what happens when they become unconscious. RN M stated check for pulse and make another decision; hopefully the RN is making the decision, it is not the CNAs call to make. I would keep doing the Heimlich until told by EMS not to.On 7/7/25 at 2:54 PM, Surveyor interviewed CNA G about 6/24/25 incident. CNA G indicated being on a resident unit when CNA J came to the unit and said R1 was purple and possibly choking. CNA G stated on arrival in the dining room, R1 was slumped over, purple, unresponsive and didn't appear to be breathing. CNA G stated, assuming R1 choked, CNA J got behind her, started doing the Heimlich, and said someone should call 911. CNA G stated CNA J dialed 911, then handed the phone to CNA G. CNA G stated CNA J said they should move R1 out of the dining room, away from the other residents. CNA G stated RN S arrived at some point while R1 was getting out of the dining room and took the phone from CNA G. When in the hall, R1 was transferred to the floor and CNA H started to do compressions. CNA G indicated being told to go downstairs to direct EMS to the correct location and on return with EMS, CPR had been stopped. Surveyor asked CNA G about treatment for choking. CNA G stated Heimlich maneuver, uncertain of any difference with unresponsive resident. Surveyor asked if R1 had previous concerns with swallowing. CNA G stated no problems until 6/23/25 when R1 choked on fruit.On 7/7/25 at 3:19 PM, Surveyor interviewed CNA H about 6/24/25 incident. CNA H stated the event was so traumatizing that only pieces are remembered. CNA H stated that someone radioed on the walkie talkie, but CNA H was unable to determine what was said. CNA H stated that CNA J came running to the unit and said that R1 was choking and turning blue. CNA H and CNA G ran to the dining room and attempted the Heimlich but didn't see anything come from her mouth. CNA H stated that someone said to remove R1 from the dining room and onto the floor and someone called 911. CNA H stated that 911 said to start CPR. CNA H stated that CNA H did one set of compressions, asked about a pulse, and was told that there was no pulse. Surveyor asked CNA H about treatment for choking. CNA H stated Heimlich maneuver, uncertain of any difference with unresponsive resident. On 7/8/25 at 9:30 AM, Surveyor interviewed CNA J about 6/24/25 incident. CNA J stated that CNA J had taken a resident away from the dining room and returned to the dining room in less than 5 minutes. Upon return to the dining room, CNA J noted R1 sitting behind CNA L with her head down further than normal and color appearing pale to purple. CNA J stated CNA J called R1's name and placed a hand on R1's shoulder to straighten R1 in the chair. CNA J stated there was mucous coming from R1's mouth and R1 was unresponsive. CNA J stated, I think R1 is choking. CNA J indicated leaving the dining room and running to the resident unit to find assist. CNA J indicated that CNA G and CNA H were at the nurses' station and the 2 CNAs started back to the dining room. CNA J stated that on the return to the dining room, CNA J used the walkie talkie to contact RN S to come assist with R1. CNA J stated that on return to the dining room, CNA L was standing next to R1, calling R1's name, CNA G started the Heimlich and said to call 911, and CNA J dialed the phone. Surveyor asked CNA J about length of time between finding R1 unresponsive and when CNA G started the Heimlich. CNA J said approximately 3 minutes. CNA J stated that CNA G did about 3 thrusts before CNA J gave CNA G the phone to speak with 911. CNA J reports starting to do the Heimlich. CNA J stated that RN M arrived and instructed to take R1 to the hallway. CNA J stated that in the hallway, R1 was moved to the floor and CNA H started compressions. CNA J stated that at some point RN S arrived and spoke with 911, then ADON D arrived and stated to stop compressions due to DNR status. On 7/8/25 at 1:27 PM during interview, CNA P (Certified Nursing Assistant) indicated CNA P was not sure what to do if CNA P suspected a resident had choked but is now unconscious. CNA P asked RN Educator M what to do. RN/Educator M indicated CNA P should keep trying to get more help while getting resident to the ground where she can begin abdominal thrusts and/or chest compressions on the unconscious person.On 7/8/25 at 2:27 PM, Surveyor interviewed ADON D (Assistant Director of Nursing) and asked if R1 had any swallowing concerns. ADON D indicated no recollection of R1 working with speech therapy prior to 6/24/25. Surveyor asked about care plan entry from 3/31/25 indicating need to monitor for difficulty with chewing and/or swallowing. ADON D stated this entry was made by the registered dietician (RD). Important to note: RD was out of office and unavailable for interview. Surveyor asked about interventions put into place for R1 following the choking incident on 6/23/25. ADON D stated that R1's diet was downgraded to IDDSI level 6, a speech screen was requested, R1 was changed to partial assist for meals (monitor from a distance-no need for 1 on 1), and respirations and vital signs were monitored for 24 hours. Surveyor asked how often vital signs and respirations were to be assessed. ADON D stated every shift. Surveyor reviewed documentation following 6/23/25 incident. ADON D indicated that there were no vital signs documented for the 6/23/25 5:27 PM assessment and there were no vital signs or respiratory assessment for 6/24/25 AM shift. ADON D stated that ADON D would have expected those assessments to be completed and documented. Surveyor asked ADON D about treatment for choking. ADON D stated all staff are trained in BLS (basic life support). The standard is to encourage coughing, summon assist, and if necessary, begin the Heimlich. Resident is removed from a common area for their dignity and to protect other residents from a traumatic event. Heimlich is performed until the object is expelled and the resident is breathing, or, if they become pulseless/non-breathing and they have a DNR, we stop; if they are a full code, we'd perform CPR. Surveyor asked if there was an investigation following the 6/24/25 incident. ADON D stated yes, all the CNAs and nurses were asked for statements. ADON D indicated that ADON D went to food/nutrition services to validate the meal served. Surveyor asked who served R1's meal. ADON D indicated no knowledge of who had served the meal. Surveyor asked how staff summon help in an emergency. ADON D stated via walkie talkie, phone, or voice/yelling. Surveyor asked when the CNA is expected to summons help. ADON stated immediately.On 7/8/25 at 3:21 PM during interview, SLP I indicated residents on a IDDSI level 6 diet cannot have a dinner roll. SLP I indicated there are exceptions made for certain residents on IDDSI level 6 diets. SLP I stated, I had not completed a formal evaluation for R1. Her order was for a level 6 diet with no exceptions. She could not eat bread.On 7/8/25 at 4:03 PM, Surveyor interviewed DME V (Deputy Medical Examiner) and asked about R1's autopsy. DME V stated there was evidence of choking; substance was hard to determine 100%, but it seemed to be a starchy substance, potentially mashed potato. Surveyor asked if DME V was aware that R1 had been served a dinner roll. DME V stated no, DME V had been told cod and mashed potatoes.On 7/8/25 at 4:34 PM, Surveyor interviewed ADON D and asked if residents receiving an IDDSI level 6 diet are to receive bread products. ADON D stated there is an allowance at times. Surveyor asked if R1 had an allowance and was to be served bread. ADON D stated no. On 7/8/25 at 5:10 PM, Surveyor interviewed NHA A and asked about the 6/23/25 incident. NHA A stated that all nursing staff present were asked to write a statement. Surveyor asked if CNA H, who performed compressions, was asked for a statement. NHA A indicated that NHA A did not realize that CNA H was present, and no statement had been requested. On 7/8/25 at 2:40 PM, DA K (Dietary Aide) stated to Surveyor, R1's meal ticket only had drinks and a dinner roll on it, but no food was ordered for her. It was blank. DA K also stated, I put butter on her roll and cut it into bite sized pieces. I had to go upstairs to get a tray that was mistakenly delivered up there. In the meantime, I don't know what happened. I came back and saw staff around R1 who looked pale. On 7/8/25 at 6:03 PM, Surveyor interviewed DA K (Dietary Aide) and asked if residents on IDDSI level 6 can have bread products. DA K indicated yes, they can with a waiver. Surveyor asked DA K if R1 had a waiver in place. DA K stated, No, I didn't make up the tray. I just served it. I was in dining room already when the trays came up. I gave R1 the tray. I cut cod up. I buttered the roll and cut it up. I only work there once a week and the week prior R1 was a general diet. I normally read the ticket and this time there was nothing on the meal ticket except for drinks and dinner roll. DA K indicated using the ticket to verify the food on the plate matches the food listed on the ticket, but DK A was unable to do that this time.On 7/9/25 at 9:16 AM, RN N (Registered Nurse) stated to Surveyor, When we get an order for a diet change, it gets changed in the care plan and in the orders. Then the system prints off a sheet that states the change. We fax this to dietary staff at the hospital. We are all responsible for making sure the cards are correct. We have diet sheets printed off in the dining room with all the diets on it and all staff, including dietary have access to these sheets.On 7/9/25 at 9:20 AM during interview, ADON D (Assistant Director of Nursing) indicated it is all staffs' responsibility to make sure the meal tickets and the meal are accurate prior to serving the resident.On 7/9/25 at 9:36 AM during interview, Nutrition Services District Manager O indicated hospital staff realized there was a mistake made and began putting together a response plan. Nutrition Services District Manager O stated, We needed to make immediate changes and acted right away. Nutrition Services District Manager O indicated the hospital staff received training on IDDSI levels for food and drinks. They ordered red placemats for all high-risk meal trays and began using them right away when they arrived. Nutrition Services District Manager O indicated she does not know why the Nursing Home Administration team was not made aware of the mistake and she now plans to include the nursing home staff in the education regarding IDDSI levels and on the new system for making sure residents are served the correct food items.On 7/9/25, Surveyor asked NHA A (Nursing Home Administrator) if dietary staff were asked to give statements. NHA A indicated being unaware that dietary staff were passing meal trays and therefore dietary staff were not asked about the incident and should have been. Surveyor asked NHA A if R1 should have received the correct diet. NHA A stated that the correct diet is expected to be served.During the partial extended survey conducted on 7/21/25, facility staff were not able to identify food items that are appropriate in accordance with the International Dysphagia Diet Standardization Initiative despite receiving education as part of the facility's initial removal plan. Additionally, staff in the facility were working with residents without knowledge of emergency procedures for choking despite recent education provided as part of the facility's initial removal plan.On 7/21/25 at 9:19 AM, CNA W (Certified Nursing Assistant) indicated to Surveyor residents on IDDSI level 5, 6, and 7 diets can have bread products.On 7/21/25 at 9:31 AM, CNA Y indicated to Surveyor residents on level 6 and 7 diets can have bread products.On 7/21/25 at 9:55 AM, CNA P indicated to Surveyor she was unsure which diet levels can have bread products and which ones cannot.On 7/21/25 at 10:28 AM, CNA X indicated to Surveyor if she saw a resident actively choking in the dining room she would run and go get the nurse. CNA X indicated she would leave the resident while she retrieved a nurse.On 7/21/25 at 10:41 AM, LPN E (Licensed Practical Nurse) indicated to Surveyor she would expect a CNA who observes a resident to be choking to call a nurse for help, then she expects the nurse to perform an RN assessment, to call 911, and then to start the Heimlich maneuver. LPN E indicated an RN has to assess before a CNA initiates the Heimlich maneuver.On 7/21/25 at 11:21 AM, INHA B (Interim Nursing Home Administrator) and RN M (Registered Nurse) indicated to Surveyor all staff were educated related to providing emergency care to a choking resident and how to identify foods within all levels of the International Dysphagia Diet Standardization Initiative. INHA B and RN M indicated all staff are basic life support certified and should know what to do in the event of a resident choking and they should know who can and who can't have bread products according to their ordered diet.The failure to serve the correct diet to a resident, failure to complete frequent and thorough assessments, and failure to administer first aid (Heimlich Maneuver) immediately created a reasonable likelihood for serious harm which created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 7/21/25, however the deficient practice continues at a scope severity of a D (Potential for more than minimal harm/isolated) as the facility continues to implement the following action plan.All nursing and dietary staff will be educated prior to start of their next shift regarding the facility policy and procedure on diet changes and location of diet lists. New staff to be educated regarding this process during orientation. The IDT and dietary staff are to ensure all new orders and dietary changes are communicated to the dietary department by the nurse entering the dietary order. Nursing staff to relay new dietary orders during huddle and changes to the diet are posted in each wing daily. This process and education began on 7/21/2025 and ongoing.Dietary cards were