Health inspection·November 27, 2024

F806 §483.60(d) Food and drink Each resident receives and the facility provides— §483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences § 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. (b) A current profile card shall be maintained for each patient, indicating diet order, likes, dislikes, allergies to foods, diagnosis and instructions or guidelines to be followed in the preparation and serving of food for the patient. 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 10/08/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual recertification survey. The facility failed to ensure Resident 135 was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when on 10/8/2024, Resident 135, who was allergic to onions, was served baked beans containing onions for lunch. As a result, Resident 135 was served baked beans containing onions which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]) and/or death for Resident 135. During a review of Resident 135's Admission Record, the Admission Record indicated the facility initially admitted Resident 135 on 10/1/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems), chronic viral hepatitis C (long term liver inflammation and infection), and essential hypertension (chronic elevation of blood pressure from an unknown cause). During a review of Resident 135's Minimum Data Sheet (MDS - a resident assessment tool) dated 10/5/2024, the MDS indicated Resident 135's cognition (ability to think and make decisions) was severely impaired. The MDS indicated Resident 135 needed set-up and clean-up assistance (helper sets up and cleans up, resident completes the activity) when eating. During a review of Resident 135's Physician Orders dated 10/1/2024, the Physician Orders indicated to provide mechanical soft (a texture-modified diet that consists of foods that are soft and easy to chew and swallow) chopped texture (a food texture that is intended to be safe and easy to swallow) diet. During a review of Resident 135's Allergy List dated 10/1/2024, the Allergy List indicated Resident 135 was allergic to onions. During a review of Resident 135's Care Plan (undated), the Care Plan indicated Resident 135 has an allergy to onions. The Care Plan goal was for Resident 135 not to be served with food containing onions at any time. Resident 135's Care Plan included the following interventions: - Inform staff or caregivers of resident's allergy. - Label the Physician's Order Sheet, Medication Administration Record (MAR - a document of the medications administered to a resident), treatment sheet, and face sheet of Resident 135's allergy. During a review of Resident 135's MAR dated 10/8/2024, the MAR indicated Resident 135 was allergic to onions. During a review of the facility's daily spreadsheet titled "Therapeutic Spreadsheet Cycle 4," dated 10/8/2024, the daily spreadsheet indicated residents on mechanical soft diet would include the following foods in the tray: - Ground barbecue pork (BBQ) three (3) ounces (oz, a unit of measurement) - Baked beans half (½) cup (c, a household measurement) - Finely chopped creamy coleslaw ½ c - Biscuit - Peach cobbler - Beverage eight (8) oz During an observation of the meal tray line process on 10/8/2024 at 11:53 a.m., the trays with utensils, condiments, and meal tray tickets (includes resident's diet, allergy, likes/dislikes, food preferences) were set in the meal carts (used to transport or deliver the meal trays). Dietary Aide 1 (DA 1) announced the resident's diet textures, likes, and dislikes then the allergies. Cook 1 and Cook 2 dished out (distributed) the foods from the steamtable (food-holding equipment designed to keep hot foods at a safe holding temperature) to the plates. DA 1 checked the accuracy and completeness of each tray. The DS checked the accuracy of the trays before the meal carts came out of the kitchen. During a review of Resident 135's meal tray ticket on 10/8/2024 at 12:25 p.m., Resident 135's meal tray ticket indicated Resident 135 was on mechanical soft diet, was allergic to onions, disliked salad and coleslaw, and preferred soup and juice. During a concurrent observation and interview on 10/8/2024 at 12:25 p.m., with the DS, in the kitchen, observed Resident 135's meal tray contained chopped pork with BBQ sauce, a bowl of beans with chopped onions, biscuit, cake, and juice. The DS stated Resident 135 did not get the soup as the dietary staff forgot to put the soup on the tray. The DS requested a vegetable soup from the dietary staff and placed the vegetable soup on Resident 135's tray. The DS stated Resident 135 was okay with cooked onions that was included in the vegetable soup. The SSA informed the DS that onions were listed as an allergy of Resident 135. The DS replaced the vegetable soup with clear broth for Resident 135. During an observation on 10/8/2024 at 12:29 p.m. in the kitchen hallway, LVN 2 and LVN 3 checked the meal trays for Station 2's meal cart where Resident's 135 lunch tray was placed. LVN 3 read the diet list (a list of residents with diet, allergies, likes, and dislikes) and LVN 2 checked the meal tray and meal tray ticket for Resident 135's tray accuracy. LVN 2 and LVN 3 stated the meal trays for Station 2 residents were okay to distribute to Station 2. Resident 135's meal tray was served and was set on Resident 135's bedside table. During an observation on 10/8/2024 at 12:39 p.m., in Resident 135's room, observed Resident 135's meal tray at bedside. Resident 135's meal tray had chopped pork with BBQ sauce, beans in a bowl with pieces of chopped onions, biscuit, clear broth, cake, and juice. During an interview and a record review of the facility's recipe titled "Baked Beans #2" on 10/8/2024 at 12:56 p.m. with Cook 1 and the Assistant Dietary Supervisor (ADS), Cook 1 stated with ADS interpreting in Cook 1's language that she (Cook 1) used only the recipe titled "Baked Beans #2" for the baked beans. The Baked Beans #2 recipe indicated the following ingredients: pork and beans, light brown sugar, chopped onions, ketchup, and yellow mustard. Cook 1 stated she did not use the pork and beans and used the pinto beans from scratch instead. Cook 1 stated she then added ketchup, onions, brown sugar, and mustard. Cook 1 stated she did not prepare a separate recipe for any resident. During an interview on 10/8/2024 at 12:59 p.m. with the DS, the DS stated that if Resident 135 consumed the food item with onions, he (Resident 135) would have food reactions such as rash (an area of the skin that has changes in texture or color and may look inflamed or irritated) and other allergic reactions. During an interview on 10/8/2024 at 1:08 p.m. with Resident 135, Resident 135 stated he did not eat the beans on his meal tray because he was afraid that the beans had onions. Resident 135 stated the staff (unable to recall who) told him that the baked beans may have contained onions, and the meal tray was taken away from him by the staff (unable to recall who). Resident 135 stated his throat will swell up and close if he consumes onions. During an interview on 10/9/2024 at 9:52 a.m. with DA 1, DA 1 stated his role in meal tray line was to announce the allergy and check the meal trays for accuracy with what the meal tray ticket indicated. DA 1 stated he did not know that the baked beans had onions as it was not specified on the spreadsheet or the menu. DA 1 stated it was important for the meal tray to be allergen-free for residents with food allergies because they (residents) could be in danger and could potentially cause death. During an interview on 10/9/2024 at 11 a.m. with LVN 2 and LVN 3, LVN 2 stated they (LVN 2 and LVN 3) checked all the trays for accuracy, food dislikes, allergies, and diet types on 10/8/2024 for lunch meal. LVN 2 stated she checked the tray, meal tray tickets, and food on the meal tray and LVN 3 read and checked the diet list. LVN 2 stated they checked all the trays from Station 1 to Station 4. LVN 3 stated she (LVN 3) did not see any onions in any of the food served for Resident 135 and there was no way that they could know if onion was an ingredient in the baked beans. During an interview on 10/10/2024 at 10:56 a.m. with the ADM, the ADM stated that he (ADM) needed to verify with Cook 1's interpreter (ADS) about the ingredient that she (Cook 1) used in cooking the baked beans as he (ADM) was told that Cook 1 stated she used onion powder. During a review of the ADM's email on 10/10/2024 at 1:48 p.m., the ADM email indicated that he confirmed with the ADS who interpreted during Cook 1's interview on 10/8/2024, that Cook 1 stated she (Cook 1) used onion powder in the baked bean dish. During an interview on 10/10/2024 at 2:09 a.m. with the RD, the RD stated the dietary staff should not serve any food items, derivatives, flavoring, powder, and all products containing a particular allergen. The RD stated residents with onion allergies should not get onions, onion derivatives, onion powder, onion flavor, and all onion products on their meal trays. The RD stated residents could have the same anaphylactic reactions (anaphylactic shock) if they (residents) consumed food and food products containing the food allergen. During a concurrent interview and record review on 10/10/2024 at 2:34 p.m. with Cook 1 and the RD with the Interpreter's (translating Cook 1's language via phone) assistance, the facility's undated recipe titled "Baked Beans #2" was reviewed. Baked Beans #2 had an ingredient of pork and beans, light brown sugar, chopped onions, and mustard. Cook 1 stated she did not use the pork and beans and used pinto beans for the baked bean dish. Cook 1 stated she used the ketchup, light brown sugar, and yellow mustard but did not use chopped onions. Cook 1 stated she used onion powder instead of chopped onions because she did not like the flavor of the onion but likes the onion powder when making the baked beans. Cook 1 stated she used onion powder and added one spoon to the baked beans using estimation on how the food would taste as it (recipe) did not indicate the amounts. Cook 1 stated she said onion to ADS who was interpreting in Cook 1's language during the interview on 10/8/2024 and never mentioned onion powder because she (Cook 1) forgot to say powder. Cook 1 stated raw onions were available in the kitchen on 10/8/2024. The RD stated the staff (unable to recall who) notified her of the substitution of onions to onion powder after the IJ was called. The RD stated she did not agree with the substitution of using onion powder for onions based on how Cook 1 felt about the flavor as it was not a standard of practice. The RD stated the onion powder could have more ingredients that would contain more food allergens. The RD stated the recipe must be followed to ensure residents got the nutrients that they needed and so they could be aware of the ingredients for food allergies. During an interview on 10/11/2024 at 2:45 p.m. with the DS, the DS stated onion powder was a derivative of onion and residents could have same reaction if they were allergic to onions; hence, it (onion powder) should not be given on the meal tray. During a review of the facility's product ingredient titled "Ingredient Specification Onion" dated 9/15/2024, the facility's product specification indicated, "Description: Dehydrated onion (Allium cepa [common onion/bulb onion]) product prepared from fresh, sound, wholesome, first quality white onion." During a review of the facility's policies and procedures (P&P) titled "Food Allergies and Intolerances" dated 4/2024, the P&P indicated, "Residents with food allergies and/or intolerances are identified upon admission and offered food substitution of similar appeal and nutritional value. Steps are taken to prevent residents' exposure to the allergen. General Guidelines: 1. Food Allergies are immune system responses to allergens (food). Immunoglobulin E (IgE) antibodies (type of protein in the body that are part of the immune system and play a role in allergic reactions) to foods attach to mast (white blood cells that are part of the body's immune system and act as the body's alarm system) cells in body tissue (e.g.,skin, nose, throat, lungs, and gastrointestinal tract) and basophils (a type of white blood cell that help the body's immune system fight allergens) in blood. When allergens are eaten, the IgE antibodies attach to mast cells and basophils in certain sites and those cells produce histamine (chemical released by the body's immune system that causes many effects, including allergy symptoms), an inflammatory compound. Assessment and Interventions: - Residents are assessed for history of food allergies and intolerances upon admission and as part of the comprehensive assessment. - All residents reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan. - Meals for residents with severe food allergies are specifically prepared so that cross-contamination (the unintentional transfer of harmful bacteria or other microorganisms from one food, utensil, or surface to another) with allergens does not occur. - Residents with food intolerances and allergies are offered appropriate substitutions for food that they cannot eat." During a review of the facility's P&P titled "Allergies" dated 4/2024, the P&P indicated, "Procedure: (1) Upon admission to the community resident allergies will be identified. These will be noted on the nutritional assessment that is completed on admission. (4) The resident's menu will be modified to eliminate foods to which the resident is allergic." During a review of the facility's P&P titled "Accurate Diet Service" dated 4/2024, the P&P indicated "Policy: Each resident will receive the proper diet as prescribed by their physician or qualified designee. Procedure: (1) Before each meal service, a Food and Nutrition Services Department employee will check the meal tray cards with master list to assure the correct diet order, consistency order, and liquid consistency order on the card. (2) Prior to serving the tray, the nurse aide must check the diet cart to assure that the correct meal tray is being served to the resident. If there is doubt, the charge nurse should be notified, and the chart checked for the current physician's order." The facility failed to ensure Resident 135 was not given food containing allergens when on 10/8/2024, Resident 135, who was allergic to onions, was served baked beans containing onions for lunch. As a result, Resident 135 was served baked beans containing onions which had the potential to result in a life-threatening condition such as anaphylactic shock, severe tachycardia, cardiac arrest, and/or death for Resident 135. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 135.