Health inspection·May 7, 2024

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 provide resident with an alternative meal, consistent with resident's identified food allergies, for 1 out of 5 residents (Resident 1). This failure could have negatively impacted Resident 1's health by consuming a food item they had an allergy to. Findings: On May 7, 2024, at 7:55 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On May 7, 2024, at 8:20 a.m., an interview was conducted with Resident 1, who stated, her food allergies are peanuts and tomatoes. Resident further stated, she requested a tuna sandwich from nursing staff, and nursing staff brought her a tuna sandwich with tomatoes on it. Resident 1 informed nursing staff she was allergic to tomatoes, and she could not eat it. Nursing staff returned resident's sandwich and brought her a new tuna sandwich with no tomatoes on it. A review of Resident 1's face sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of Pneumonitis (inflammation in the lungs) due to inhalation of food and vomit. Further review, indicated, Resident 1 had food allergies to peanuts and tomatoes. A review of Resident 1's Brief Interview for Mental Status ({BIMS} – an assessment tool used to identify cognitive conditions) indicated a score of 12 (moderate cognitive impairment). On May 7, 2024, at 11:10 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1, who stated, when a resident requests an alternative food item, such as a sandwich, the CNA will take resident's Diet Card (a card on residents meal trays that contains individualized diet information, including food allergies) off resident's meal tray, check resident's allergies and diet against their food request, give dietary staff residents diet card and food request, dietary staff checks resident's food allergy on diet card, then will give nursing staff resident's food item, if available per diet/food allergies. On May 7, 2024, at 1:00 p.m., an interview was conducted with facility [NAME] 1, who stated, when a resident requests an alternative food item, nursing staff provides resident diet card to dietary staff, dietary staff will check resident's diet card against resident's food allergies and request, if diet card is not available, [NAME] 1 will ask nursing staff to verify residents allergies from Page 1 of 2 056229 056229 05/07/2024 Palm Springs Healthcare & Rehabilitation Center 277 S Sunrise Way Palm Springs, CA 92262

F 0806 their medical records. Level of Harm - Minimal harm or potential for actual harm On May 7, 2024, at 1:23 p.m., and interview was conducted with the facility's Registered Dietician (RD), who stated, when a resident requests an alternative food item, dietary staff will ask nursing staff for the resident's diet card to check the resident's allergies and prescribed diet. If nursing staff is unable to provide the resident's diet card, dietary staff is to call the Dietary Supervisor (DS) to check resident's allergies/prescribed diet. If DS is not available, dietary staff will ask nursing staff to check resident's medical record to verify their allergies. Residents Affected - Few On May 7, 2024, at 1:41 p.m., an interview was conducted with DS, who verified, Resident 1 did receive a tuna sandwich with a tomato in it, although resident is allergic to tomatoes. DS stated, her expectations are for nursing staff to bring the resident's diet card to the kitchen with resident's food request; Dietary staff are to ask for the resident's diet card, and check resident allergies, prior to giving out an alternative meal. If resident's diet card is not available, dietary staff are to contact DS/or nursing staff, to verify resident allergies, prior to providing an alternative meal. A facility Policy & Procedure, titled, Diet (Tray) Card, OP3 0213.02, undated, indicated, .Purpose: The diet cards purpose is to inform the dietary staff how to assemble the resident's meal tray and to provide caregivers with mealtime information . Background: The diet (tray) card contains the resident's name . allergy information . Procedure: 2. Ensure that food items served are consistent with tray card information . 056229 Page 2 of 2