Health inspection·November 19, 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 observation, interview, and record review, the facility failed to ensure food that accommodates resident allergies, intolerances, and preference for 1 (Resident #2) of 1 resident reviewed for food preferences. The facility failed to ensure Resident #2 was given a substitute food item. This failure could place residents at risk of not eating their meals, further resulting in weight loss, and poor quality of life.Findings included:Record review of Resident #2's face sheet, dated 09/23/2025, revealed a [AGE] year old female, admitted on [DATE] with primary diagnosis of chronic diastolic (congestive) heart failure and other diagnoses included history of transient ischemic attack (episode of stroke like symptoms) and cerebral infarction (stroke), spondylosis (degenerative change in the spine), gastro-esophageal reflux disease (chronic condition where stomach acid flows back into the esophagus), hypertension (high blood pressure), mild neurocognitive disorder (cognitive decline), hyperlipidemia (high levels of fat in the blood), anemia (low levels of iron in the blood), neuropathy (nerve damage), chronic respiratory failure (chronic condition where respiratory system cannot effectively remove carbon dioxide or take in enough oxygen), chronic obstructive pulmonary disease (lung condition caused by damage to the lungs that causes inflammation, limiting airflow), lack of coordination, and muscle weakness. Record review of Resident #2's MDS dated [DATE], reflected a BIMS (brief mental interview status - cognitive screening tool, scored on scale 0-15) score of 09, indicating moderate cognitive impairment. During an interview and observation on 09/23/2025 at 12:47 PM, Resident #2 said she did not eat much of her lunch. She said she was given rice, and she did not like rice. Observation at this time revealed Resident #2's meal tray had white rice on it. She had eaten less than 50% of her meal. Her meal ticket on the tray stated, Dislikes: .RICE, RICE BROWN, RICE WHITE, RICE WILD. During an interview on 09/23/2025 at 1:15 PM, the ADON stated meal tickets and trays were checked by dietary staff, then nurses, then CNAs. She stated staff were educated about checking meal tickets, especially since the kitchen switched hospitality companies. The ADON stated it was important to check meals tickets and trays so residents did not receive food they were allergic to, to make sure the consistency was correct, so residents do not choke, and to make sure residents were happy with food they received. During an interview on 09/23/2025 at 2:48 PM, the DM revealed the kitchen recently switched hospitality companies, but that did not stop them from doing their jobs. The DM said she was not present during the lunch meal and dietary aides were expected to check the tickets. She said the dislikes were on the tickets and she did not know how it was overlooked.; The DM said the ticket should have mashed potatoes written on it as the substitute food item. She explained nurses and CNAs looked at meal trays, but it fell on the kitchen, because the food came out of the kitchen. The DM stated it was important to match the trays with the meal tickets because the residents would not eat if they do not match, and they would lose weight and not stay healthy. During an interview on 09/23/2025 at 3:05 PM, the ADM stated the new Page 1 of 2 676405 676405 11/19/2025 Forum Parkway Health & Rehabilitation 2112 Forum Parkway Bedford, TX 76021

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospitality system was challenging for staff. He said he talked with nursing staff, and they checked most trays, and many were sent back during lunch. The ADM stated the DM trusts her dietary staff to (check meal tickets and trays and 99% of the time it was okay. The ADM said at the end of the day, the staff missed it (checking Resident #2's meal ticket and tray). He stated staff were being in-serviced and meals were being audited closer, a monthly food committee meeting was being set up, and staff would update resident food preferences. During an interview on 09/24/2025 at 1:03 PM, LVN A revealed she checked lunch meal trays on Resident #2's hall on 09/23/2025. LVN A explained she sent multiple trays back to the kitchen during lunch on 09/23/2025 (due to meal tickets and meal tray not matching). She stated she looked at meal tickets for diet types, like if it was a diabetic diet, the consistency like mechanical soft, allergies, dislikes, and compared the ticket with the foods. She explained it was important to check meal tickets for preferences, allergies, and texture to prevent residents from allergic reactions, choking, and losing weight if they received food they do not like. Record review of the facility's Resident Nutrition Services policy, revised July 2017, reflected: Policy StatementEach resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.Policy Interpretation and ImplementationThe multidisciplinary staff, including nursing staff, the Attending Physician and the Dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits. They will develop a resident care plan based on this assessment.Residents shall receive prompt meal service and appropriate feeding assistance. Reasonable efforts will be made to accommodate resident choices and preferences .4. Nursing personnel or feeding assistants will inspect food trays as they are delivered to ensure that the correct meal has been delivered, that the food appears palatable and attractive, and it is served at a safe and appetizing temperature.a. If an incorrect meal has been delivered, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. 676405 Page 2 of 2