The standards for nutritional care and support of patients in a skilled nursing facility (SNF) are firmly set by CMS (Medicare). Patients’ care must be supervised by an admitting physician, and include an admission assessment by a registered dietitian, with dietary needs set at this point. If swallowing problems are perceived, a speech therapist must be brought in to evaluate the extent. All information gathered on admission must be evaluated by the physician and a plan of care developed by him/her and the nursing staff. Nursing is then charged with preventative measures to be instituted, such as fall prevention, supervised meals, etc. Any difficulties with swallowing noted by the dietitian, the speech therapist, or nursing staff should be brought to the physician’s attention. A change in method of nutrition might follow. A failure to bring this patient problem to the physician’s attention and to address it proactively is a nursing breach of duty. I have served as a legal nurse consultant and expert since 2016 and have consulted on a similar case involving an SNF and its nursing staff’s failure to correctly observe and report a problem with a feeding tube.