Health inspection·April 24, 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. Based on clinical record review, facility dietary manual review, observations, and staff interviews, it was determined that the facility failed to provide a meal that was designed to meet the needs of residents requiring a mechanical soft meal, and failed to provide a pureed meal for one of three residents reviewed (Resident 1). Findings include: Review of the facility's dietary manual, section titled, Menus, revealed the facility's policy stated, .Menus are implemented by the Dietary Manager in conjunction with the Dietician . Further, review of subsection titled, Mechanical Soft Diet, stated, Purpose: The mechanical diet is modified in consistency to reduce the amount of chewing required to consume food. Review of the planned menu for April 22, 2025, lunch meal, revealed the mechanical soft lunch was to include ground chicken enchilada casserole and ground black beans. Review of the recipe for the chicken enchilada casserole revealed it included the instructions of, Mechanical Soft Steps: Remove desired number of servings to chop for the mechanical soft diets. Use a knife/fork or processor to chop foods to the desired consistency. Observation of the lunch meal service on April 22, 2025, revealed mechanical soft meals were served a chicken enchilada with chopped meat inside of a flour tortilla. The flour tortilla was served whole; not cut or chopped. Observations of the black beans served revealed they were served whole, not ground. During a staff interview on April 24, 2025, at approximately 2:30 PM, the Nursing Home Administrator (NHA) confirmed that the planned menu textures should have been followed as identified on the menu. Review of Resident 1's clinical record revealed diagnoses that included diabetes type II (decreased ability of the body to produce and utilize insulin) and essential hypertension (elevated/high blood pressure). Review of Resident 1's interdisciplinary progress notes revealed a note dated April 22, 2025, at 1:01 PM, by Employee 1 (Social Services), that stated, .[Resident 1] has been downgraded to puree texture [sic] [due to] difficulty swallowing pills . Review of Resident 1's physician orders revealed a diet order entered by Employee 4 (Registered Page 1 of 2 395347 395347 04/24/2025 Oak Hill Center for Rehabilitation and Nursing 1020 North Union Street Middletown, PA 17057

F 0805 Nurse) on April 22, 2025 at 8:01, for Liberalized Renal diet, Puree texture, Thin Liquids consistency. Level of Harm - Minimal harm or potential for actual harm Review of meal tickets (paper utilized by dietary staff to identify a residents' dietary needs, ordered texture, likes, dislikes, and other dietary requests) provided by Employee 2 (Director of Food Services) revealed the meal tickets were printed on April 22, 2025. Residents Affected - Few Review of Resident 1's meal ticket revealed it identified Resident 1's diet as Pureed, Liberalized Renal. Observation of lunch meal tray-line service on April 22, 2025, at approximately 11:30 AM, revealed the dietary slip for Resident 1 was dated (printed) on April 19, 2025. Observation of the dietary slip revealed it had Resident 1's diet listed as Regular, which was crossed out with, MS (mechanical soft) written above. Subsequent observation of tray-line service revealed that the tray prepared for Resident 1 was a mechanical-soft texture diet. Observation of meal tray delivery on April 22, 2025, at approximately 12:00 PM, revealed Resident 1 was served the mechanical soft diet in the presence of Employee 3 (Speech Therapist). During a staff interview at approximately 12:05 PM, Employee 3 revealed that Resident 1 was being observed by Employee 3 for the lunch meal to observe how Resident 1 tolerated consuming the puree diet. During the interview, Employee 3 revealed she was the staff that initiated the change to Resident 1's diet texture due to Resident 1 having difficulty swallowing food and Resident 1 not fully clearing food from her mouth as she was eating. Employee 3 stated that Resident 1 should have received a puree diet. At approximately 12:20 PM, Resident 1's meal tray was replaced with a puree texture meal tray. During a staff interview at that time, Employee 3 stated that, based on her professional judgement, Resident 1 was not able to safely consume the mechanical-soft texture meal. During the staff interview, Employee 3 stated that once the change to Resident 1's dietary order was made, a Dietary Communication Form, was completed and copies were provided to the unit licensed nurse, the dietary department, and the Director of Rehabilitation. During a staff interview on April 22, 2025, at approximately 1:15 PM, Employee 2 stated that the meal tickets are typically printed at the beginning of the week and used for duration of the week. During the interview, Employee 2 stated that changes to diets are typically made on the meal tickets as they are received by dietary. During a staff interview on April 22, 2025, at approximately 2:30 PM, the NHA confirmed that Resident 1 should have received a puree textured. 28 Pa code 201.18(b)(1)(3) Management 28 Pa code 211.6(a) Dietary services 395347 Page 2 of 2