Health inspection·May 24, 2025

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the food allergies (abnormal response after a certain food is eaten) for one of four sampled residents (Resident 1) by serving Resident 1 fish, who was allergic to seafood. This deficient practice resulted in Resident 1 having an allergic reaction and had the potential to cause Resident 1 to have an anaphylactic shock (severe, potentially life-threatening allergic reaction) the reaction may include itchy skin, edema, collapsed blood vessels, fainting, difficulty in breathing, and death). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included Dysphagia (difficulty swallowing) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). The admission Record indicated Resident 1 was allergic to caffeine, cheese, citrus products, milk, seafood and white bread. During a review of Residents 1's Minimum Data Set (MDS – a resident assessment tool), dated 5/2/2025, the MDS indicated Resident 1 did not have cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 substantial/maximal assistance (staff does more than half the effort) for activities of daily living (ADLs) such as bed mobility (how resident moves from lying to turning side to side), upper body dressing and personal hygiene. During a review of Resident 1's Physician Orders dated 5/23/2025, the Physician's orders indicated to provide Resident 1 with a Regular, no added salt diet, pureed texture (soft, blended, semi solid foods with a smooth consistency that requires no chewing), thin consistency and no white bread, milk, citrus, cheese caffeine nor seafood. During a review of Resident 1's Change of Condition (COC) dated 5/23/2024, the COC indicated Resident 1 complained of itching on her head and neck after eating lunch. The COC indicated Resident 1 ate fish and had an allergy it. The COC indicated, the doctor was notified and ordered to administer diphenhydramine hydrochloride ([Benadryl] medication used to treat allergy symptoms), oral tablet 50 milligrams via gastrostomy tube every 8 hours as needed for allergic reactions. During an interview on 5/24/2025 at 8:06 a.m. with Resident 1, Resident 1 stated, she was allergic to all kinds of seafood. Resident 1 stated on 5/23/2025, staff (unidentified) brought her lunch tray Page 1 of 2 056220 056220 05/24/2025 Briarcrest Nursing Center 5648 East Gotham Street Bell Gardens, CA 90201

F 0806 Level of Harm - Minimal harm or potential for actual harm which had 3 small containers; one with green vegetables, one with peach puréed and another container with a food item that was white in color. Resident 1 stated, she thought the food item was chicken, so she tasted it. Resident 1 stated Certified Nurse Assistant (CNA)1 told her, the white food item was fish. Resident 1 stated she developed and allergic reaction to the fish, felt numbness to her lower lip and was administered Benadryl and medication for her stomach (not specified) with relief. Residents Affected - Few During an interview on 5/24/2025 at 9:00 a.m. with the Dietary Supervisor (DS), the DS stated during the tray line procedure (system where meals are prepared and assembled on trays and delivered to residents) the kitchen assistant (KA) would read the tray card (used to identify special diets and allergies of residents), and the cook would plate the food. The DS stated on 5/23/2025 Resident 1 received pureed fish by mistake. The DS stated Resident 1's tray card showed the resident's allergies, which included seafood, in small letters and was not written with a pen. During an interview on 5/24/2025 at 9:37 a.m. with KA, the KA stated tray card usually included resident's dislikes and food allergies written in pen with big to alert staff. The KA stated on 5/23/2025, Resident 1's tray card included the resident's allergy to seafood however was written in small letters and was not written with a pen, so she (KA) did not see it. The KA stated serving Resident 1 food, she was allergic to placed her in danger from an allergic reaction. During an interview on 5/24/2025 at 11:45 a.m. with Licensed Vocation Nurse (LVN) 1, LVN 1 stated when passing out food trays, two licensed nurses should check the trays before the CNAs pass them out to Residents. LVN 1 stated CNAs should also check for the diet, residents name and room number. LVN 1 stated on 5/23/2025, Resident 1 received a food tray with pureed fish which caused the resident to have redness to the forehead and chest and was given Benadryl. LVN 1 stated on 5/23/2025, she did not check Resident 1's food tray because she had to pass medications. LVN 1 stated it was very important to check the trays for any allergies to food. LVN 1 also stated, giving the wrong food to Resident 1 could cause the resident to have an anaphylactic shock which could lead to hospitalization. During an interview on 5/24/2025 at 1:10 p.m. with the Director of Nursing (DON) the DON stated staff should double check the food trays before they are served to residents to prevent the resident's from experiencing any allergic reactions which could lead to hospitalization. The DON sated It was very important to make sure residents received the correct tray and for staff to follow the allergies as indicated on the tray card. During a review of the facility's policy and procedures (P&P) titled, Tray card dated 2017, the P&P indicated tray cards should list residents' name, room number, diet order, location or meal services and food preferences. During a review of the facility's P&P titled, Food nutritional services aide dated 2017, the P&P indicated the Food and Nutrition Services Aide checks resident's trays for proper and accurate food items. 056220 Page 2 of 2