Health inspection·October 17, 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 review of resident clinical record, facility documentation and staff interviews, it was determined that the facility failed to provide food that accommodates resident allergies, one of two residents reviewed (Resident R1). Findings include: Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of Chronic Kidney Disease, Trisomy 21 (Down Syndrome) and Dementia. Further review of Resident R1's clinical record revealed that was Resident R1 was allergic to Apricots, Apricot Kernels and Corn. Review of copy of meal ticket dated October 7, 2024, revealed that the meal ticket was labelled with Resident R1's name. Further the meal ticket indicated: Allergies: Corn and Corn products. Under Main menu: chicken tenders with honey mustard sauce, Parslied Noodles, Honey Glazed Carrots, white roll. Further, in bold letter: No sub found for Apricots. At the bottom of the meal ticket, was written ALLERGY: Apricots, Corn. Interview with Regional Dietary Consultant, Employee E5, conducted on October 17, 2024, at 12:08 pm revealed that the facility use a computer program to generate the menu and identify resident food allergies based on food items and other information such as resident allergies entered by the dietary staff into the program's database. So any food items a resident is allergic to will not be generated in that resident's menu. The Kitchen staff then makes sure that any food items a resident is allergic to is not place on the resident's tray. Further, Employee E5 also revealed that the Seasoned Mixed Vegetables was one of the menu items entered in the computer program. Further Employee E5 also revealed that the individual ingredients of the Seasoned Mixed Vegetables was not taken into account when Seasoned Mixed Vegetables was entered into the computer program. So, the program was not able to identify Resident R1's allergies to corn when Seasoned Mixed Vegetables was generated as one of the items on Resident R1's menu on October 7, 2024. Further, interview with Employee E5 confirmed that on October 7, 2024, Resident R1 was served Seasoned Mixed Vegetables which contained corn. Page 1 of 2 395819 395819 10/17/2024 Caring Heart Rehabilitation and Nursing Center 6445 Germantown Avenue Philadelphia, PA 19119

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with Facility Administrator Employee E1 conducted on October 17, 2024 at 12:45 pm revealed that the facility had implemented a plan of correction on the identified deficient practice regarding provision of food to residents that accommodate their allergies. Further interview with Employee E1 revealed that on October 7, 2024 they initiated their plan of corrections which included modifying their process to prevent food allergens from being included in the menu, education of all dietary staff regarding changes in the process and facility conducted a QAPI (Quality Assurance Performance Improvement)on the identified deficient practice. Review of facility documents provided by the facility revealed that menu's were modified. Menus for residents with allergies had the word ALLERGIES written across the menu. Further, all food items the resident was allergic to was high lighted in yellow. Further, inservices including signatures, inservices attendance on all dietary personnel on the modification of the process to prevent food allergens from being included in the menu were also in place and QAPI on resident allergies has been initiated and on-going. 28 Pa. Code: 211.6(a)(c) Dietary service 28 Pa. Code 201.29(j) Resident rights 395819 Page 2 of 2