Health inspection·November 1, 2024

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the physician-prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) for one of four sampled residents (Resident 1) when, during lunch on 11/1/24, Resident 1, who has physician prescribed No Added Salt (NAS) diet Mechanical Soft texture, was served a piece of uncut country-fried steak. This failure had the potential to result in a choking episode and further compromise the nutritional and medical status of Resident 1. Findings: During a review of Resident 1's admission Record (AR), dated 11/1/24, the AR indicated, Resident 1 was admitted to the facility on [DATE] and had a diagnosis which included Anemia (a condition where the body does not have enough healthy red blood cells), Muscle Weakness, Heart Failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Hypertension (high blood pressure), Syncope (fainting), Hypothyroidism (a medical condition that can make someone feel tired, gain weight and be unable to tolerate cold temperatures) and Fracture of First Cervical Vertebra (bone that supports the skull at the base of the neck). During a review of the Resident 1 ' s Order Summary Report (OSR), dated 11/1/24, the OSR indicated, . No Added Salt (NAS) diet Mechanical Soft Texture, Regular Consistency . During a concurrent observation and interview on 11/1/24, at 1:100 p.m., with Resident 1, at Resident 1 ' s room, Resident 1 stated, They served me a whole country-fried steak for lunch. I cut it myself. It was tough cutting the meat. I only ate half of it. Resident stated she prefers soft and small pieces of meat. During a concurrent observation and interview on 11/1/24, at 1:06 p.m., with Licensed Vocational (LVN) 1, at Resident 1 ' s room, LVN 1 stated Resident 1 was served the wrong diet texture. LVN 1 stated Resident 1 was served a whole piece of country-fried steak and the diet order was mechanical soft texture. LVN 1 stated Resident 1 could have a choking episode from eating large pieces of meat. LVN 1 stated dietary and nursing staff were responsible in ensuring Resident 1 receive the appropriate meal texture and consistency and it was not done. During an interview on 11/1/24 at 1:25 p.m., with the Certified Dietary Manager (CDM), the CDM stated the facility failed to follow Resident 1 ' s physician ordered diet. The CDM stated Resident 1 could experience a choking episode from eating big pieces of meat. The CDM stated the correct diet Page 1 of 3 055410 055410 11/01/2024 Brighton Post Acute 361 E. Grangeville Blvd Hanford, CA 93230

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few should be prepared by the dietary staff and licensed nurses should verify the meal tray upon arrival to the unit. The CDM stated the dietary and nursing department failed to follow the Policy and Procedure (P&P) on Diet Orders. During an interview on 11/1/24 at 1:46 p.m., with the Director of Nursing (DON), the DON stated the standard of practice was for the dietary staff to verify the diet order during meal plating and for the licensed nurses to verify the contents of the meal tray upon arrival to the unit or prior to serving to the residents. The DON stated inappropriate food texture could potentially result to choking or aspiration pneumonia (a lung infection that occurs when food or liquid is inhaled into the lungs instead of swallowed). During a review of the facility ' s P&P titled, Tray-Cards/Diet Orders, undated, the P&P indicated, . 2. Tray cards should list the resident ' s preferred name, room number, diet order, location of meal service, food allergies, intolerances and preferences . 3. If permanent tray cards are used, before each meal service, Nutrition Services staff will check the tray cards against the physician prescribed diet orders . 5. The tray card should remain with resident ' s plate/tray until nursing staff has recorded the percentage of food consumed . Based on observation, interview, and record review, the facility failed to provide the physician-prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) for one of four sampled residents (Resident 1) when, during lunch on 11/1/24, Resident 1, who has physician prescribed No Added Salt (NAS) diet Mechanical Soft texture, was served a piece of uncut country-fried steak. This failure had the potential to result in a choking episode and further compromise the nutritional and medical status of Resident 1. Findings: During a review of Resident 1's admission Record (AR), dated 11/1/24, the AR indicated, Resident 1 was admitted to the facility on [DATE] and had a diagnosis which included Anemia (a condition where the body does not have enough healthy red blood cells), Muscle Weakness, Heart Failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), Hypertension (high blood pressure), Syncope (fainting), Hypothyroidism (a medical condition that can make someone feel tired, gain weight and be unable to tolerate cold temperatures) and Fracture of First Cervical Vertebra (bone that supports the skull at the base of the neck). During a review of the Resident 1's Order Summary Report (OSR), dated 11/1/24, the OSR indicated, . No Added Salt (NAS) diet Mechanical Soft Texture, Regular Consistency . During a concurrent observation and interview on 11/1/24, at 1:100 p.m., with Resident 1, at Resident 1's room, Resident 1 stated, They served me a whole country-fried steak for lunch. I cut it myself. It was tough cutting the meat. I only ate half of it. Resident stated she prefers soft and small pieces of meat. During a concurrent observation and interview on 11/1/24, at 1:06 p.m., with Licensed Vocational (LVN) 1, at Resident 1's room, LVN 1 stated Resident 1 was served the wrong diet texture. LVN 1 stated Resident 1 was served a whole piece of country-fried steak and the diet order was mechanical soft texture. LVN 1 stated Resident 1 could have a choking episode from eating large pieces of meat. LVN 1 stated dietary and nursing staff were responsible in ensuring Resident 1 receive the appropriate meal texture and consistency and it was not done. 055410 Page 2 of 3 055410 11/01/2024 Brighton Post Acute 361 E. Grangeville Blvd Hanford, CA 93230

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/1/24 at 1:25 p.m., with the Certified Dietary Manager (CDM), the CDM stated the facility failed to follow Resident 1's physician ordered diet. The CDM stated Resident 1 could experience a choking episode from eating big pieces of meat. The CDM stated the correct diet should be prepared by the dietary staff and licensed nurses should verify the meal tray upon arrival to the unit. The CDM stated the dietary and nursing department failed to follow the Policy and Procedure (P&P) on Diet Orders. During an interview on 11/1/24 at 1:46 p.m., with the Director of Nursing (DON), the DON stated the standard of practice was for the dietary staff to verify the diet order during meal plating and for the licensed nurses to verify the contents of the meal tray upon arrival to the unit or prior to serving to the residents. The DON stated inappropriate food texture could potentially result to choking or aspiration pneumonia (a lung infection that occurs when food or liquid is inhaled into the lungs instead of swallowed). During a review of the facility's P&P titled, Tray-Cards/Diet Orders, undated, the P&P indicated, . 2. Tray cards should list the resident's preferred name, room number, diet order, location of meal service, food allergies, intolerances and preferences . 3. If permanent tray cards are used, before each meal service, Nutrition Services staff will check the tray cards against the physician prescribed diet orders . 5. The tray card should remain with resident's plate/tray until nursing staff has recorded the percentage of food consumed . 055410 Page 3 of 3