Health inspection·June 12, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review,and facility P&P review, the facility failed to ensure one of six sampled residents reviewed for dining (Resident 1) received food prepared in a form to meet the resident's individual dietary needs. * The facility failed to ensure Resident 1 was provided with the chopped vegetables as per the physician's diet order. This failure had the potential for Resident 1 not liking the food based on the dietary modification and could affect the resident's quality of life. Findings: Review of the facility's P&P titled Nutrition Management of Dysphagia dated 2023 showed in the section for dysphagia mechanical diet, all cooked vegetables should be chopped approximately half inch and cooked, soft to a mashable texture. Medical record review for Resident 1 was initiated on 6/12/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/25/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Speech Therapy Treatment Encounter Note dated 6/2/25, showed Resident 1 had mild oropharyngeal dysphagia caused by reduced mastication impacted by reduced dentition and delayed swallow initiation. The Speech Therapy's recommendations showed to continue the mechanical soft, chopped diet for ease of oral phase. Review of Resident 1's Physician Order Summary showed an order dated 6/7/25, for fortified, no added salt diet, mechanical soft texture, thin liquids consistency, chopped meats/veggies, Asian menu, and renal diet. Further review of the physician's order showed restriction to dairy products, tomatoes, bananas, oranges, cantaloupe, and honeydew. Review of Resident 1's admission Record dated 6/12/25, showed Resident 1 had diagnoses which included dysphagia oropharyngeal phase. Review of Resident 1's meal ticket for lunch dated 6/12/24,showed mechanical soft Asian menu, fortified, no added salt, and chopped meat/veggies. Page 1 of 2 055575 055575 06/12/2025 Pacific Haven Subacute and Healthcare Center 12072 Trask Ave. Garden Grove, CA 92843

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/12/25 at 1215 hours, Resident 1 was observed sitting in a wheelchair on the left side of her bed. Resident 1 was observed eating her lunch. Resident 1's food on the tray was a long piece of fish, cooked vegetable including napa cabbage, rice, four oz. of juice, hot ginger tea, and a red velvet cookie. Resident 1 was observed with long pieces of napa cabbage served on her lunch plate, approximately more than 1 inch in size. LVN 2 was called into the room and verified the above observation. LVN 2 verified the meal ticket showed chopped meats and veggies. LVN 2 verified the napa cabbage in Resident 1's lunch tray was big, approximately more than 1 inch and stated it should have been chopped more. LVN 2 stated she would let the dietary supervisor know. On 6/12/25 at 1227 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DSS. The DSS verified the above findings and acknowledged Resident 1 was not served chopped vegetables for her lunch as ordered by the physician. The DSS stated the fish was served soft and was scoopable and did not need to be chopped; however, the vegetables which included the napa cabbage should have been chopped to less than a half inch approximately the size of the thumb nail. The DSS stated she would make sure Resident 1 would be served chopped vegetables and meats. On 6/12/25 at 4:43 hours, a telephone interview was conducted with the Speech Therapist. The Speech Therapist stated chopped meats/vegetables meant the meats and the vegetables should be cut approximately to thumb nail size which was around a half inch. The Speech Therapist was informed of the above findings. The Speech Therapist stated the fish would be flaky in texture when cooked and it did not need to be chopped; however, the cooked vegetable such as cabbage should be chopped to the thumb nail size before serving to the resident. The Speech Therapist stated Resident 1 was able to swallow the regular food; however, for her ease of swallowing Resident 1 should have been served with chopped vegetables as she recommended and as ordered by the physician. On 6/12/25 at 1706 hours, the DON and Administrator were informed and acknowledged the above findings. 055575 Page 2 of 2