Health inspection·October 1, 2024

F656 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i)The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. On 8/13/2024 at 8 a.m., the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. The facility failed to ensure residents, who were on dysphagia (difficulty chewing and swallowing) minced and moist (mechanical-soft texture modified diet for difficulty chewing and swallowing) diet received food consistent with diet order and according to the minced and moist diet menu recipe for seven of eight sampled residents (Resident 10, 11, 50, 53, 62, 81, and 83). The facility failed to: 1. Ensure the Dietary Supervisor (DS), who was overseeing meal preparation, Cook (CK 1) who was preparing the residents' meals, and Licensed Vocational Nurse (LVN 4), who was validating the meal on residents' trays for diet appropriateness and food texture before meal was served to the residents, ensured Resident 10, 11, 50, 53, 62, 81, and 83 received correct food consistency per their prescribed diet. 2. Ensure Resident 10, 11, 50, 53, 62, 81, and 83 did not receive a ground (finely chopped by a meat grinder or a chopping knife) pimento cheese salad sandwich (sandwich included two slices of regular [not minced] white bread, including the crust, with a scoop of ground pimento cheese in between slices of bread, and sliced in half) on their lunch trays 8/14/2024, which was not in accordance with the residents' physician order. 3. Ensure the dietary department followed the facility's policy and procedure (P&P) titled, "Dietary Department- General," which indicated the dietary department was to prepare and provide nutritionally adequate, well-balanced meals that were consistent with physician's diet order. As a result Resident 10, 11, 50, 53, 62, 81, and 83 received a lunch tray on 8/14/2024 that contained a ground pimento cheese salad sandwich on a regular soft white bread placing Resident 10, 11, 50, 53, 62, 81, and 83 at high risk for aspiration (condition when food, liquid, or other material enters a person's airway [passageway for air] and eventually the lungs), choking (life threatening condition where an object such as food lodges in the throat blocking the flow of air), and possible death. 1. A review of Resident 10's Admission Record indicated Resident 10 was an 82-year-old female admitted to the facility 9/13/2023 with diagnoses including dysphagia, unspecified dementia (loss of memory, language, problem-solving and other thinking abilities), and major depressive disorder (a mental disorder that causes a persistent low mood and loss of interest in activities that are normally enjoyable). A review of Resident 10's care plan titled, "Nutritional Problem" initiated on 9/15/2023, indicated the goal for Resident 10 was to maintain adequate nutritional status as evidenced by maintaining the resident weight within five percent (%) of current weight and to have no signs or symptoms (s/s) of malnutrition (lack of proper nutrition, caused by not having enough to eat or not eating enough). The care plan interventions included monitoring, documenting, and reporting any s/s of dysphagia: food pocketing (a common term for when people with dementia keep food in their cheeks or the back of their mouth instead of swallowing it), choking, coughing, drooling, and several attempts at swallowing as well as providing and serving the resident's diet as ordered by the physician. A review of Resident 10's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/21/2024, indicated Resident 1 had severe impairment in cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 10 required setup or clean-up assistance while eating but was able to eat by herself. A review of Resident 10's Speech Therapist ([ ST] a licensed professional aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) Evaluation and Plan of Treatment dated 6/27/2024, indicated ST has seen Resident 10 for a clinical swallowing evaluation (procedure used to assess how well a person swallows) due to increased concerns of aspiration after an event of low tolerance of regular texture solid food diet when the resident was coughing and required oral suctioning (remove food and/ or liquid from mouth and throat with a suction machine). The ST Evaluation and Plan of Treatment indicated a recommendation for puree (blended) diet and thin liquids with strict adherence to swallowing precautions such as sitting up while eating, small bites, eating slowly, and alternating solids and liquids. ST Evaluation and Plan of Treatment indicated the goal for Resident 10 was to increase the ability to safely swallow a minced and moist consistency to facilitate transition to a more complex food consistency. A review of Resident 10's Physician's Order Summary Report dated 7/17/2024 indicated an order for a dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food (soft, moist food). A review of Resident 10's ST Treatment Encounter Note dated 7/23/2024, indicated Resident 10 was seen for dysphagia and to continue with the mechanical soft, ground texture foods. 2. A review of Resident 11's Admission Record indicated Resident 11 was a 92-year-old female admitted to the facility on 7/6/2023 with diagnoses including dementia and dysphagia. A review of Resident 11's ST Evaluation and Plan of Treatment dated 10/17/2023, indicated Resident 11 was evaluated by ST to assess the resident's swallowing function and readiness to upgrade her diet from pureed foods. The ST Evaluation and Plan of Treatment indicated Resident 11 had a history of aspiration pneumonia (a lung infection that occurs when food, liquid, or other foreign objects are inhaled into the lungs instead of being swallowed). The ST recommendation was to continue with the pureed diet with goal for it to safely swallow a minced and moist consistency diet. A review of Resident 11's ST Treatment Encounter Note dated 11/21/2023, indicated Resident 11 was seen for dysphagia treatment and tolerated a mechanical soft ground texture (minced and moist) diet. A review of Resident 11's care plan titled, "At risk for aspiration- receiving a mechanical soft, ground food diet" revised on 2/28/2024, indicated goal for Resident 11 not to have episodes of aspiration. The care plan interventions included for Resident 11 to receive therapeutic diet and diet texture modifications as ordered by the physician. A review of Resident 11's MDS dated 7/9/2024, indicated Resident 11 had severe impairment of cognitive skills for daily decision making. The MDS indicated Resident 11 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 11 complained of difficulty or pain while swallowing. A review of Resident 11's Physician's Order Summary Report, dated 7/17/2024 indicated an order for dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. On 7/18/2024 there was a physician's order to assist Resident 11 with feeding as needed. 3. A review of Resident 50's Admission Record, indicated Resident 50 was an 81-year-old female admitted to the facility on 9/30/2021 with diagnoses including cerebral infarction (occurs when blood flow to the brain was blocked, causing brain tissue to die), dysphagia, type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly) and dementia. A review of Resident 50's ST Evaluation and Plan of Treatment dated 11/20/2023, indicated the goal for Resident 50 was to reduce risk of choking or coughing events and to safely swallow a minced and moist consistency diet. The ST Evaluation and Plan of Treatment indicated ST recommended to continue with the pureed diet. A review of Resident 50's care plan titled, "At risk for Aspiration" initiated on 11/24/2023, the care plan indicated the goal for the resident included to not have any s/s of aspiration and to maintain safe swallowing. The care plan interventions included to provide diet as ordered by the physician and if a difficulty swallowing occurred to notify ST. A review of Resident 50's ST Treatment Encounter Note dated 12/14/2023, indicated Resident 50 was seen for dysphagia treatment and evaluation of the resident's diet. The ST Treatment Encounter Note indicated ST recommended for Resident 50 to "tolerate the mechanical soft, ground diet (minced and moist)." A review of Resident 50's MDS dated 7/11/2024, indicated Resident 50 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 50 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 50 complained of difficulty or pain while swallowing and was on a mechanically altered diet. A review of Resident 50's Physician's Order Summary Report, indicated an order dated 7/17/2024 for a consistent carbohydrate diet ([CCHO], a restrictive eating plan that helps people with diabetes manage their blood sugar levels) dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. 4. A review of Resident 53's Admission Record, indicated Resident 53 was an 89-year-old male, admitted to the facility on 4/29/2024 with diagnoses including type 2 diabetes, dysphagia, cerebral infarction, and dementia. A review of Resident 53's ST Evaluation and Plan of Treatment dated 5/1/2024, indicated Resident 53 was evaluated for swallowing function with the goal to reduce risk of choking or coughing events and to tolerate safest and least restrictive diet without signs of aspiration. The ST Evaluation and Plan of Treatment indicated ST recommended to continue with the pureed diet. A review of Resident 53's care plan titled, "Altered nutrition: on a Mechanically Altered, Therapeutic Diet and At Risk of Aspiration" initiated 5/11/2024, indicated the goal for Resident 53 included not to have any signs of aspiration and Resident 53 will demonstrate correct eating techniques to maximize safe swallowing. The care plan interventions included serving the resident's diet and diet texture modifications as needed as ordered by the physician. A review of Resident 53's Physician's Order Summary Report dated 7/11/2024, indicated an order for a CCHO diet, dysphagia mechanical soft texture, nectar thick (can be sipped from a cup but require effort if taken via a straw) consistency liquids, and ground food. A review of Resident 53's MDS dated 7/19/2024, indicated Resident 53 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 53 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 53 coughed or choked during meals and complained of difficulty or pain while swallowing. The MDS indicated Resident 53 was on a mechanically altered diet. A review of Resident 53's ST Treatment Encounter Note dated 7/30/2024, indicated Resident 53 was seen for dysphagia treatment and ST recommended to continue mechanical soft ground texture foods with mildly (nectar consistency) thick liquids. 5. A review of Resident 62's Admission Record, indicated Resident 62 was a 92-year-old male admitted to the facility 5/10/2023 with diagnoses including dysphagia, acute kidney failure (a sudden and often reversible decline in kidney function), muscle weakness, and atrial fibrillation (a rapid and irregular heartbeat). A review of Resident 62's ST Treatment Encounter Note dated 2/1/2024, indicated Resident 62 presented with mild oral dysphagia (a swallowing disorder that affects the mouth, lips, and tongue, making it difficult to control food and liquids) and ST recommended minced and moist foods, and mechanical soft ground diet with thin liquids (regular liquid consistency). A review of Resident 62's MDS dated 5/13/ 2024, indicated Resident 62 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 62 required supervision or touching assistance (staff provides verbal cues/ and or steadying as the resident completes the activity) for eating. The MDS indicated Resident 62 was on a mechanically altered diet and complained of difficulty with swallowing. A review of Resident 62's care plan titled, "At risk for Aspiration" initiated on 5/31/2023, it indicated Resident 62's goal was not to have evidence of aspiration. The care plan interventions included to provide Resident 62 diet as and diet texture modifications per physician's order. A review of Resident 62's Physician's Order Summary Report dated 7/17/2024, indicated an order for a regular diet, dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. 6. A review of Resident 81's Admission Record, indicated Resident 81 was an 87-year-old female, admitted to the facility on 7/8/2024 with diagnoses including acute kidney failure, muscle weakness, depressive episodes, and cognitive communication deficit. A review of Resident 81's care plan titled, "Nutritional problem or potential nutritional problem related to poor appetite" initiated 7/11/2024, indicated Resident 81's goal was to provide Resident 81's diet as ordered by the physician and monitoring for any signs of dysphagia. A review of Resident 81's MDS dated 7/15/2024, indicated Resident 81 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 81 needed substantial/ maximal assistance (staff does more than half the effort) for eating. A review of Resident 81's ST Evaluation and Plan of Treatment dated 7/25/2024, indicated Resident 81 was evaluated due to communication deficits and dysphagia with residue remaining in the oral cavity (mouth) while eating. The ST Evaluation and Plan of Treatment indicated ST recommended to downgrade the resident's diet to a minced and moist diet for dysphagia and swallow precautions (steps taken to ensure safe swallowing and prevent aspiration). A review of Resident 81's Physician's Order Report, dated 8/2/2024, indicated and order for a mechanical soft texture, regular/ thin consistency liquids, for mechanical soft ground foods. A review of Resident 81's ST Treatment Encounter Note dated 8/12/2024, indicated Resident 81 was seen to address swallowing safety and swallowing dysfunction and ST recommended a minced moist diet. 7. A review of Resident 83's Admission Record, indicated Resident 83 a 44-year-old female, admitted to the facility 7/17/2024 with diagnoses including dysphagia, autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). A review of Resident 83's MDS dated 7/24/2024, indicated Resident 83 was rarely or never understood. The MDS indicated eating was not attempted during the MDS review. The MDS indicated Resident 83 was dependent (staff does all the effort) on staff for eating. The MDS indicated Resident 83 was on a mechanically altered diet and complained of difficulty