Health inspection·June 13, 2024

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 interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for 1 (Resident #1) of 5 residents reviewed for meals. -The facility failed to ensure Resident #1's mechanical soft fish was free of small bones. This failure placed all residents, especially those with swallowing issues, at risk of aspirating or choking. Findings included: Record review of Resident #1's face sheet, dated 06/13/24, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (loss of memory and thinking), diverticulitis of intestine (small, inflamed pockets in intestine), type II diabetes, and dysphasia (difficulty swallowing). Record review of Resident #1's quarterly MDS assessment, dated 05/16/24, reflected her BIMS score was 14, which indicated cognition was intact. Further review reflected Resident #1 required a mechanically altered therapeutic diet . Record review of Resident #1's care plan, revised 03/05/24, reflected the resident could eat independently. Record review of Resident #1's consolidated physician orders, dated 06/13/24, reflected the resident had an active order for a mechanical soft diet starting on 02/15/24. In an interview on 06/12/24 at 6:45 PM, Resident #1 stated during dinner the night before, she was eating a fish sandwich and was stuck in the mouth by something sharp. Resident #1 stated she quickly spit out the fish and found tiny bones. Resident #1 stated her family was visiting at the time and placed the chewed food in a medicine cup and took it to the Administrator. Resident #1 stated she did not swallow any of the food. In an interview on 06/12/24 at 8:30 PM, the Administrator stated he was aware that Resident #1 had firm particles in her fish that appeared to be bones. He stated Resident #1 spit the food in a cup and provided it to him, so he was able to observe it himself. The Administrator stated he was going to start in-services with the kitchen staff on thoroughly inspecting food items for bones that should not be there. He stated the fish ordered from the supplier was boneless and it would have been Page 1 of 2 675811 675811 06/13/2024 Victoria Gardens of Frisco 10700 Rolater Dr Frisco, TX 75035

F 0805 difficult for the kitchen staff to know there were tiny bones left in some pieces. Level of Harm - Minimal harm or potential for actual harm In an interview on 06/13/24 at 11:00 AM, the Consultant RD stated the facility ordered boneless cod patties from the supplier to prepare the fish sandwiches that were served for dinner. She stated she was notified about the tiny bones found in Resident #1's fish and she was at the facility to in-service staff on checking meat for bones before preparing. The Consultant RD stated there were no other reports of residents having bones in their fish. She stated this was probably an error with the supplier having fileted fish with pieces of bone accidentally left inside and this was going to be addressed with the food supplier. The Consultant RD stated leaving tiny bones inside of fish could cause a choking hazard for the residents. Residents Affected - Few In an interview on 06/13/24 at 3:30 PM, the Dietary Manager stated she worked at the facility for 10 years but had been the dietary manager for 3 weeks. The DM stated they never had an issue with bones being found in fish. She stated they always ordered fileted fish and used cod patties for the fish sandwiches that were severed. She stated when preparing food for residents on therapeutic diets, the kitchen staff knew to pay close attention to textures and even when they served bone-in chicken, they use boneless chicken chunks for special diets to avoid any type of bones or hard particles being left inside. She stated it would have been difficult to see tiny bones accidentally left in the fish, especially when it was supposed to already be boneless; however, the staff would be even more thorough with checking the food during preparation or come up with an alternative food. The DM stated the risk of leaving particles and bones inside of meat prepared for therapeutic diets could be the residents choking. Review of Mechanical Soft Diet handout provided by the consulting RD revealed in part the following: A mechanical soft diet is a diet that has been mechanically altered (ground or mashed) to provide softer foods. It is helpful to people who have problems chewing and/or swallowing regular texture foods. 675811 Page 2 of 2