Health inspection·January 9, 2026

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, and record review, the facility failed to ensure one (Resident A) of three residents sampled, was receiving food and drink prepared in a form to meet the resident's needs.This failure had the potential to result in coughing and choking for Resident A. Findings:On December 5, 2024, at 4:15 p.m., an unannounced visit was conducted at the facility to investigate quality care issues. On December 8, 2025, at 12:00 p.m., a review of Resident A's, admission Record, was conducted, which indicated Resident A was admitted to the facility on [DATE], with diagnoses which included oropharyngeal dysphagia (difficulty swallowing) and Alzheimer's (progressive brain disorder) disease.A review of Resident A's Minimum Data Set (MDS-a standardized health assessment tool) indicated the following:- September 15, 2025, .Section GG- Functional Abilities.eating.supervision/touch assistance.; and - September 17, 2025, .Section K-Swallowing.Yes-cough/choke during meal.when swallowing medications.yes-pain when swallowing.mechanical altered diet.regular with change in texture of food/liquids.A review of Resident A's Order Recap Report, effective from October 1 to December 31, 2025, indicated, Regular diet Regular texture, Mildly Thick consistency, fortified food . Further review indicated the diet was ordered on November 6, 2025. A review of Resident A's Speech Therapy Treatment Encounter Notes indicated the following-December 03, 2025, .due to limitations in insight, safety awareness, new learning, oral motor strength and oral motor control.supervised the pt (patient) during PO (oral) intake. Pt (patient) presented with decreased safety awareness and coughs post swallow x (times) 5 (five) for the entire duration of the meal.; and -December 5, 2025, .precautions.confused.patient was also observed taking 4 (four) sips of nectar thick liquid via straw with congested coughing heard 7 (seven) times .mildly thick drinks MT2 (mildly thick level two) .Resident A's care plans reviewed and indicated:-Resident requires Speech Therapy (rehabilitation to help with swallowing) related to Dysphagia, initiated on September 14, 2025; and -Resident is at nutritional risk due to dementia, Bronchitis, Alzheimer's, hypertension, dysphagia, therapeutic diet and altered texture and consistency, initiated on November 6, 2025. The care plan further indicated interventions which included: Provide 1:1 assistance when needed, encourage 100% consumption of all fluids provided, and provide diet, as ordered.On December 8, 2025, at 12:30 p.m., an observation and interview were conducted with Resident A. Resident A was observed receiving his meal tray, drinking water that had been thickened. The nurse brought him (Resident A) another glass of water with thickener. However, when the resident took the drink, the thickener was observed to have settled at the bottom of the glass, leaving the water on top thinner. Resident A began coughing and choking. The resident was then assisted to sit up at a 90-degree angle and leaned forward. The nurse was called for assistance.On December 8, 2025, at 1:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated that the nursing staff is permitted to add thickener to the liquids for the residents. However, the process requires a few minutes for the water to achieve the desired consistency. If only a minute Page 1 of 2 056095 056095 01/09/2026 Devonshire Care Center 1350 East Devonshire Avenue Hemet, CA 92544

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had elapsed, it would not have been sufficient time for the water to thicken before Resident A attempted to drink it.On December 8, 2025, at 1:10 p.m., during an interview, the Licensed Nurse (LN) stated that she added thickener to Resident A's water, but she did not allow sufficient time for it to thicken properly before giving it to the resident, which could have prevented the resident from coughing and choking. A review of the facility's policy titled Therapeutic Diets, dated October 2017, indicated .therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals.a ‘therapeutic diet' is considered a diet ordered by a physician.as part of treatment for a disease or clinical condition to modify.or to alter the texture of a diet.the resident's response to his/her therapeutic diet in the resident's medical record.A review of the facility's Diet and Nutritional Care ManualGuidelines for Serving Thickened Liquids, dated 2021, indicated .identify and provide the appropriate fluid consistency.all liquids should be thickened to the proper consistency.the facility will determine whether nursing or food and nutrition services personnel will thicken the liquids.IDDSI (International Dysphagia Diet Standardizations Initiative) Level 2: Mildly Thick.commercial thickeners may be used to achieve mildly-thick consistency.a liquid consistency used when the tongue control is slightly reduced, provides liquids that flow at a slightly slower rate. Used when thin and slightly thin drinks flow too quickly for resident to swallow them safely. 056095 Page 2 of 2