In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across West Virginia. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes.
Top Areas of Noncompliance
The most frequently cited IJ deficiencies in 2025 in West Virginia include:
- F689 Free of Accident/Hazards/Supervision/Devices
- F678 Cardiopulmonary Resuscitation (CPR)
However, today we are going to review two (2) IJ citations at that were cited at F805 – Food in Form to Meet Individual needs. One (1) was cited during the same Standard Survey as a CPR deficiency at a “K” scope/severity and the other was also a “K” scope/severity during the facility’s Standard Survey. The second nursing home had another IJ citation at a “K” scope/severity related to F698 Accidents, which in this instance was for hot water temperatures, but we are not covering that topic today.
F805 Food in Form to Meet Individual Needs
Here is how the F805s became IJ level deficiencies.
Citation Example 1 – F805 S/S: K
The first deficiency revolved around ten (10) residents all receiving the wrong consistency meal. One (1) resident was interviewed and stated she had difficulty chewing the food, especially meats, sometimes. The resident also reported difficulty swallowing and that sometimes the foods make her cough. So, what happened? The resident was eating lunch in her room and on observation, their tray ticket indicated the food consistency was to be chopped. What was on her tray? Breaded chicken cut into various size pieces which obviously didn’t match an order for Minced & Moist Meats only texture.
The standard scenario of checking the policy on therapeutic diet was completed and then things turned south. The surveyor also checked diet level descriptions, the Order Listing Report, etc. and followed these reviews with staff interviews.
- Dietary Aides on interview reported that they did not know about Dysphagia Advanced diets, Soft and Bite-Size and Minced and Moist diet level. One Dietary Aide shared that “some cards” are written up different and “normally” they just know it when they see who it is.
- The Certified Dietary Manager was questioned regarding the different diet levels on the Diet Order Listing Report and shared that they usually go by the extension manual.
- The dietitian, on interview, stated they do not recommend the textures of diets and sometimes they come from the hospital on different diets and that the SLP recommends the texture. The dietitian also gave descriptions of various diet textures.
- The SLP was not available for interview.
You have to know where this is going by now . . . to the next meal which was a “texture” nightmare. Nine (9) residents were all provided with the incorrect consistency of a meal with the focus on their hamburger on a bun. Findings ranged from the meal served not being chopped, one resident was served a hamburger cut in half, another resident had theirs cut in quarters and another was given a whole hamburger and vegetable were also incorrect as was the diet texture for another resident who was served a mixture of chopped and pureed items. Further investigation identified that all these meals were the incorrect consistency. The survey team made their thought clear on the wrong consistency being served – receiving food in the wrong consistency could result in choking, aspiration pneumonia which can lead to serious harm or death. None of us can actually disagree with that conclusion.
Citation Example 2 – F805 S/S:K
Moving on to IJ #2 for F805 . . . today’s topic related to residents not receiving a nourishing diet prepared in a form to meet their need to be served mechanical soft diets.
The sample size in this IJ citation was eleven (11). Findings from the lunch observation included four (4) residents being served whole meatballs and whole penne pasta. All observed residents were consuming their meals, and it was shared that staff are cutting the meatballs for them today as the dishwasher was broken and the residents only had plastic utensils and were experiencing difficulty with cutting the meatballs.
- The inevitable interview with the Dietary Manager in Training stated the kitchen or nursing staff can chop the food.
- The CDM shared that the meatballs should probably have been ground and fork tender. The CDM also stated meat for mechanical soft diets should be ground unless there is an order for regular, chopped meat.
- The policy for Swedish meatballs over noodles noted how a food processor was to be used to process the meat and noodles separately.
Oh, did I forget to mention the facility used penne pasta instead of the noodles that the recipe call for? Also, other recipes in the meal extension stated penne pasta should be chopped for a mechanical soft diet. The nursing assistant stated that they always chopped it but also confirmed that on that day, the residents on a mechanical soft diet received whole pasta.
Other concerns identified include a resident with a physician order for nectar-thickened liquids being served non-thickened chocolate milk and another resident being served spoon-thick chocolate milk and was trying to drink it – the milk was to be nectar-thick.
There were four (4) residents on physician-ordered mechanical soft diets being served French fries and then another four (4) served ground meat without gravy.
The investigation was thorough, and the citation included references from the policy for mechanical soft diets that included preparations for specific items served in the incorrect consistency. Another well-written deficiency citation “proving” the risk for choking for each resident cited.
Compliance Insights
After reading today’s IJ post, I am sure each of you has figured out a game plan for assessing the staff’s knowledge of your systems related to providing food in the correct form to meet a resident’s needs. Somehow, I think that your plan will include checking tray and meal ticket accuracy as well as a trip (or two) to the kitchen to look at food preparation concerns such as following meal extension recipes.
