Health inspection·February 14, 2025

F805 §483.60(d) Food and drink Each resident receives and the facility provides— §483.60(d)(3) Food prepared in a form designed to meet individual needs. § 72333. Dietetic Service -General. “Dietetic service” means a service organized, staffed and equipped to assure that food service to patients is safe, appetizing and provides for their nutritional needs. § 72335. Dietetic Service -Food Service. (a) The dietetic service shall provide food of the quality and quantity to meet each patient's needs in accordance with the physicians' orders and to meet “The Recommended Daily Dietary Allowance,” the most current edition, adopted by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, and the following: (7) Recipes for all items that are prepared for regular and therapeutic diets shall be available and used to prepare attractive and palatable meals, in which nutritive values, flavor and appearance are conserved. Food shall be served attractively, at appropriate temperatures with appropriate eating utensils and in a form to meet individual needs. § 72339. Dietetic Service -Therapeutic Diets. Therapeutic diets shall be provided for each patient as prescribed and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary. 22 CCR §72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. § 72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 12/28/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual recertification survey. The facility failed to prepare food in a form designed to meet individual needs (requirements that a person has in order to be well such as food) for Resident 214, who was on puree diet (a texture modified diet that consists of smooth, moist foods that are easy to swallow) by not following the recipes for puree oatmeal, puree scrambled eggs, and puree wheat breads and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Four (Level 4 - pureed foods and extremely thick drinks) Standards. As a result, Resident 214 was served bread soaked in milk, oatmeal with lumps, and scrambled eggs that were not smooth and not pureed on 12/29/2024 which had the potential to cause Resident 214 to not be able to eat food and/or choke (when food gets stuck in your airway, blocking the flow of air to your lungs) on the food. A review of Resident 214's Admission Record indicated the facility originally admitted Resident 214 on 9/27/2024 and readmitted Resident 214 on 11/18/2024 with diagnoses including dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), end stage renal disease (final and permanent stage of kidney disease where kidney function has declined to the point that the kidneys can no longer function on their own), low cholesterol (level of fatty substance in the blood is low), and adult failure to thrive (syndrome of weight loss, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration [when body loses more water than it takes in and could disrupt normal bodily function], depressive symptoms [refer to feelings and behaviors that may include sadness, loss of interest in usual daily activities, changes in appetite, and sleep issues], and impaired immune function [body's defense system is not working well as it should, making it harder for the body to fight off infection and illness]. A review of Resident 214's Minimum Data Set (MDS - a resident assessment tool), dated 11/6/2024, indicated Resident 214 usually made self understood and understand others. The MDS further indicated Resident 214 required moderate assistance with eating and had complaints of difficulty or pain when swallowing. The MDS further indicated Resident 214 had mechanically altered diet (food texture that is intended to be safe and easy to swallow). A review of Resident 214's History and Physical (H&P), dated 11/9/2024, indicated the resident can make needs known but cannot make medical decisions. A review of Resident 214's Order Summary Report, dated 11/18/2024, indicated a physician's order for fortified diet (a food that has extra nutrients added to it), pureed texture, thin liquids consistency (no restriction), fortified for lunch. A review of Resident's 214's Nutritional Risk Assessment, dated 12/2/2024, indicated Resident 214 had chewing or swallowing problems and was unable to communicate needs. A review of Resident 214's Care Plan titled "[Resident 214] has decreased swallow safety and skills," last revised on 11/19/2024, indicated interventions including assessing the diet, providing compensatory strategies (actions used to offset difficulties and improve performance in specific areas of limitation, physical disability, and health condition), and providing resident and caregiver education. A review of Resident 214's Speech Therapy Evaluation and Plan of Treatment, dated 10/21/2024, indicated Resident 214 presented with mild oropharyngeal dysphagia. The Speech Therapy Evaluation and Plan of Treatment also indicated for Resident 214 to be on puree diet consistencies and thin liquid. A review of the facility's daily cook's spreadsheet titled "Winter Menus," dated 12/29/2024, indicated residents on puree diet in accordance with IDDSI Level 4 would include the following in the meal tray: o Orange juice four (4) fluid ounces (oz, a unit of measurement) o Puree oatmeal three-fourth (3/4) cup (c, household measurement) o Puree western omelet one third (1/3) c o Puree coffee cake 1/3 c o Margarine one (1) teaspoon (tsp, household measurement) o Parsley sprig garnish: no o Milk eight (8) oz During a concurrent observation of the food at the steamtable (kitchen appliance that keeps food warm at a safe temperature for serving) and interview on 12/29/2024 at 7:13 a.m. with Cook 1, Cook 1 stated she prepared the bread soaked in milk and plain scrambled eggs for residents on puree diet. Cook 1 stated she made a pot of oatmeal to be used for residents on regular (diet with no restriction) diet and residents on puree diet. During an observation on 12/29/2024 at 7:14 a.m. of puree food in trayline (an area where foods were assembled) inside the kitchen, observed Cook 1 plated bread soaked in milk that had whole chunks of bread, scrambled eggs that were not smooth and pureed, and oatmeal with lumps from the steamtable to the residents' plates on puree diets. During an interview on 12/29/2024 at 7:31 a.m. with the Dietary Supervisor (DS), the DS stated Cook 1 did not follow the recipe for puree omelet when Cook 1 prepared scrambled eggs that were not smooth and pureed instead of puree western omelet. During a concurrent observation of the test tray (a process of tasting, temping [measuring the temperature of food to ensure it is safe to eat] and evaluating the quality of food) and interview on 12/29/2024 at 7:43 a.m. with the DS, the DS stated puree diet contains food that are blended, moist, and not too runny, and was served for residents with chewing and swallowing difficulties. The DS stated the foods that Cook 1 prepared including the puree bread and oatmeal had lumps and the puree scrambled eggs were not smooth. The DS stated Cook 1 must follow the recipe, but she (Cook 1) did not follow it. The DS stated residents could have swallowing problems and would not be able to eat the food resulting to weight loss as a potential outcome of not following the recipe for puree foods. The DS stated she was not familiar with the spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together), but she will get an in-service right away. During an interview on 12/29/2024 at 10:31 a.m. with the Registered Dietician (RD), the RD stated puree diet in accordance with IDDSI Level 4 standards were used for residents with no teeth and with issues on swallowing and chewing. The RD stated puree diet in accordance with IDDSI Level 4 should be smooth, with no lumps or chunks, or any food that residents could choke on, and all food should not require chewing or swallowing like mashed potato and pudding. The RD stated bread that was soaked in milk would not pass as pureed diet and texture. The RD stated Resident 214 and other residents with dysphagia diagnosis on pureed diet who received foods not passing a puree texture could be harmed, as food could get stuck in their throat and the residents could aspirate (accidentally inhale a substance into the lungs). During an interview on 12/29/2024 at 10:45 a.m. with the Speech Language Pathologist (SLP - a health professional who evaluates and treats speech, language, and swallowing disorders), the SLP stated pureed diets included foods that are blended like baby food, with no chunks, or any textured food. The SLP stated Resident 214 and other residents with dysphagia diagnosis and pharyngeal (throat) impairments on puree diet could potentially choke food if the prepared food was in a form not designed to meet individual needs. The ST stated bread soaked in milk is not considered puree as it has mixed consistency of thin liquid and thickened food. The SLP stated Resident 214 and other residents with pharyngeal impairment and dysphagia diagnosis had more challenges with mixed consistency items, as they could choke on thin liquids. During an interview on 12/29/2024 at 11:45 a.m., Certified Nursing Assistant 1 (CNA 1) stated that on 12/29/2024, she (CNA 1) assisted Resident 214 with breakfast, and on Resident 214's meal tray, Resident 214 had oatmeal, eggs, tea, and bread that was soaked in milk. CNA 1 stated Resident 214 was on pureed diet. CNA 1 stated Resident 214 ate all the oatmeal and about half of the bread. During an interview on 12/29/2024 at 12:18 p.m. with the DS, the DS stated Cook 1 did not follow the recipe for puree diet and did not blend the foods. During an interview on 12/29/2024 at 2:02 p.m. with the DS, the DS stated there was no recipe for the bread soaked in milk. The DS stated Cook 1 should have followed the puree bread recipe, but she (Cook 1) did not. During an interview on 12/30/2024 at 7:05 a.m. with Cook 1, Cook 1 stated "Sorry, ma'am I forgot to blend the food yesterday." A review of the facility's policy and procedures (P&P) titled, "Menu Planning," dated 10/30/2024, indicated the menu service provides the seasonal menus with corresponding recipes. The P&P indicated the menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. The P&P indicated the menus are planned to consider texture and color of all foods in meals. The procedure indicated the facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. The P&P indicated menus are written for regular and therapeutic diets in compliance with the facility's diet manual and to refer to the diet manual as needed. The P&P indicated standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. A review of the facility's diet manual titled "Regular Pureed Diet/IDDSI Level 4," dated 10/30/2024, indicated "Description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep (when liquid separates out of a solid food). Detailed recipes and procedures for pureeing foods maybe found in Book #1, under the Food Safety/Miscellaneous Section. All foods are prepared in a food processor or blender, except for foods, which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potato." The diet manual further indicated foods avoided in the puree diet included lumpy cereal (oatmeal) dry cereal, unless pureed. IDDSI Testing Requirements: The finished pureed food items must pass IDDSI Level 4 testing requirements (like the fork drip, fork pressure, and spoon tilt tests.)" A review of the facility's recipe titled "Recipe: Pureed (IDDSI Level 4) Eggs" dated 10/30/2024, indicated "(5) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI Level 4 testing requirements." A review of the facility's recipe titled "Recipe: Pureed (IDDSI Level 4) Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products," dated 10/30/2024, indicated "(4) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI Level 4 testing requirements." A review of the facility's recipe titled "Recipe: Pureed (IDDSI Level 4) Hot Cereal," dated 10/30/2024, indicated "(4) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI Level 4 testing requirements." A review of the IDDSI guideline website titled "IDDSI," dated 7/2019, indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test (a test used to check the correct thickness and cohesiveness of food)." The facility failed to prepare food in a form designed to meet individual needs for Resident 214, who was on puree diet by not following the recipes for puree oatmeal, puree scrambled eggs, and puree wheat breads and in accordance with the IDDSI Level 4 Standards. As a result, Resident 214 was served bread soaked in milk, oatmeal with lumps, and scrambled eggs that were not smooth and not pureed on 12/29/2024 which had the potential to cause Resident 214 to not be able to eat food and/or choke on the food. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 214.