Health inspection·March 4, 2026

§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. Cal. Code Regs., tit. 22. § 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. Cal. Code Regs., tit 22, §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: Cal. Code Regs., tit. 22, § 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. Cal. Code Regs., tit. 22, § 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, (c) Each facility shall establish and implement policies and procedures, including but not limited to: (4) Dietary services policies and procedures which include: (A) Provision for safe, nutritious food preparation and service. On 1/12/2026, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual health recertification survey. The facility failed to prepare food in a form designed to meet individual needs (requirements for a person’s well-being, such as food) of Resident 14, Resident 96, and Resident 24) who were prescribed a pureed diet (a texture modified diet that consists of smooth, pudding-like consistencies that are easy to swallow). The facility failed to follow the recipe for pureed oatmeal and in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks) when on 1/13/2026, Resident 14, Resident 96, and Resident 24 were served regular oatmeal with lumps, grains, and was not pureed. As a result, Resident 14, Resident 96, and Resident 24 were placed at risk of being unable to safely consume their food, choke (when food gets stuck in your airway, blocking the flow of the air to the lungs) and aspirate (when food or liquid enters your airway and lungs instead of your stomach) on their food, difficulty breathing, and death. A review of the facility’s menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, “Fall 2025,” dated 1/13/2026, indicated that residents on a pureed diet in accordance with IDDSI Level 4 were to receive the following on the meal tray: * Apple juice 4 ounces (oz – a unit of measure for volume) * Puree oatmeal 4 oz * Puree sausage patty 1/3 cup (c – a unit of measure for volume) * Puree pancakes ½ c * Milk 2% 8 oz * Coffee 8 oz * Margarine 1 each * Syrup 1 oz During an observation on 1/13/2026 at 6:50 a.m. of the food at the steamtable (kitchen appliance that keeps food warm at a safe temperature for serving), observed no pureed oatmeal on the steamtable. During an interview on 1/13/2026 at 7:16 a.m. with the Dietary Supervisor (DS), the DS stated that no food substitutions (replacing one food ingredient or item with another to accommodate dietary restrictions and adjust nutritional intake) were made for breakfast prepared on 1/13/2026. During a subsequent observation on 1/13/2026 at 7:22 a.m., at the start of breakfast meal service, observed no separate pureed oatmeal on the steamtable. During an interview on 1/13/2026 at 7:35 a.m., with Cook 1, Cook 1 stated she (Cook 1) prepared regular oatmeal, but stated it could not be served to all residents because residents on pureed diets required pureed oatmeal, and residents on fortified diets (adding additional high calorie [a unit of measurement for energy], high protein [essential nutrients that aid for building and repairing body tissue] food to the meal) required oatmeal prepared with added butter as an ingredient to increase calorie and protein content. 1. A review of Resident 14’s Admission Record indicated the facility originally admitted Resident 14 on 4/18/2023 and readmitted the resident on 12/22/2025 with diagnoses including dysphagia (difficulty swallowing) oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and adult failure to thrive (syndrome [a group of symptoms which consistently occur together] 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]). A review of Resident 14’s Minimum Data Set (MDS - a resident assessment tool), dated 10/31/2025, indicated Resident 14 usually made self-understood and understood others. The MDS indicated Resident 14 required supervision and touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes the activity). The MDS further indicated Resident 14 had mechanically altered diet (food texture that is intended to be safe and easy to swallow) within the last 7 days as a resident in the facility. A review of Resident 14’s History and Physical (H&P - a comprehensive assessment of a resident’s medical condition), dated 11/20/2025, indicated Resident 14 was able to understand and make decisions. A review of Resident 14’s Care Plan titled, “[Resident 14] has a swallowing problem,” initiated on 12/22/2025, indicated goals for the resident’s risk for injury related to aspiration will be minimized through the review date with the interventions including diet to be followed as ordered and monitor, document and report as needed for any signs and symptoms of dysphagia: pocketing (holding food in the cheeks), choking (a life-threatening event where food, liquid or another object becomes lodged in a resident’s airway obstructing their ability to breathe), coughing, drooling, holding food in mouth, several attempts at swallowing and refusing to eat. A review of Resident 14’s Speech Therapy Evaluation and Plan of treatment, dated 1/9/2025, indicated Resident 14 presented with moderate oropharyngeal phase dysphagia (difficulty moving food and liquids from the mouth into the throat and towards the esophagus [the food pipe connecting the throat to the stomach]). The Speech Therapy Evaluation and Plan of Treatment also indicated for Resident 14 to be on pureed diet texture and consistency with thin liquids. A review of Resident 14’s Food and Nutrition- IDDSI Nutritional Assessment and Care Area Assessment (CAA) dated 1/6/2026, indicated Resident 14 had chewing and swallowing problems and a pureed texture diet was ordered. A review of Resident 14’s Order Summary Report dated 12/22/2025, indicated a physician’s order for Consistent Carbohydrate Diet (CCHO - a diet with the same amount of carbohydrate in each meal for blood sugar management), No Added Salt (NAS - no salt packet on the tray), Pureed Level 4, and thin liquid consistency with no restrictions. During an observation on 1/13/2026 at 8:19 a.m. of the breakfast meal service in Station 4 observed Licensed Vocational Nurse 1 (LVN 1) 1 and Licensed Vocational Nurse 2 (LVN 2) checked meal cart 2 trays against the diet list and opened the cover of the plate but did not open the lid of the oatmeal to verify its consistency. During an observation on 1/13/2026 at 8:21 a.m. of the meal cart checking process at Station 4, observed LVN 1 and LVN 2 complete the tray-checking process, after which the Certified Nursing Assistants (CNA) began delivering breakfast trays to the residents. LVN 1 and LVN 2 did not open the oatmeal lids verify its consistency. During an observation on 1/13/2026 at 8:26 a.m. of passing of trays, observed Certified Nurse Assistant 2 (CNA 2) delivering Resident 14’s tray to the resident’s bedside (place next to a resident’s bed). During a concurrent observation and interview on 1/13/2026 at 8:38 a.m. of Resident 14’s breakfast meal, with CNA 2, observed CNA 2 assisting Resident 14 with breakfast and feeding Resident 14 five (5) teaspoons (tsp - a household measurement) of regular oatmeal. CNA 2 stated that Resident 14’s tray contained regular oatmeal, even though Resident 14 was ordered to have a pureed diet. CNA 2 stated Resident 14’s oatmeal was lumpy, which is not appropriate for a pureed diet. During an interview on 1/13/2025 at 10:44 a.m., with CNA 2, CNA 2 stated she (CNA 2) checks the ticket on residents’ trays however, the LVNs already check the trays to ensure the trays are safe to pass and deliver to the residents for consumption. CNA 2 stated that other residents received oatmeal that appeared more solid, while Resident 14 received watery oatmeal. The pureed oatmeal could be slightly watery but should not be overly thin and should be blended without specks (tiny spots). She (CNA 2) did not identify any issues with Resident 14’s tray because the LVNs had already checked the trays and Resident 14 would always receive watery oatmeal with specks. CNA 2 stated she fed Resident 14 the regular oatmeal on the tray. During a concurrent interview and record review on 1/13/2026 at 1:58 p.m. with the Speech Therapist (ST - a person qualified to treat people with conditions that affect the production of speech, communication and swallowing problems), Resident 14’s Speech Therapy Evaluation and Plan of Treatment, dated 1/9/2026, was reviewed. The Speech Therapy Evaluation and Plan of Treatment indicated Resident 14 presented with moderate oropharyngeal phase dysphagia. Resident 14 has a complex medical history with frequent hospitalizations and is currently on pureed diet due to impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and senses). Upgrading Resident 14’s diet would not be safe and Resident 14 requires feeding assistance. Resident 14 cannot tolerate any foods other than pureed and thin liquids because Resident 14 has some level of oropharyngeal dysfunction, as well as weakened and delayed swallowing. During an interview on 1/13/2026 at 2:35 p.m., with the ST, the ST stated serving regular oatmeal to Resident 14 was not appropriate because regular oatmeal does not meet IDDSI standards for a smooth, pudding-like consistency. Consuming regular oatmeal could place the residents at risk for aspiration or choking During an interview on 1/13/2026 at 3 p.m., with Certified Nurse Assistant 3 (CNA 3), CNA 3 stated she (CNA 3) saw Resident 14 was served oatmeal that was not pureed. She (CNA 3) did not stop Resident 14 from eating because Resident 14 stated she (Resident 14) eats regular oatmeal at home. During an interview on 1/13/2026 at 3:06 p.m., with the Registered Dietitian (RN), the Registered Dietitian (RD) stated that he (RD) assessed Resident 14 on 1/6/2026 and that Resident 14 was ordered CCHO, NAS, Pureed Diet, and thin liquid consistency due to a medical diagnosis of dysphagia. The RD stated that continuing the pureed diet for Resident 14 was appropriate. 2. A review of Resident 96’s Admission Record, indicated the facility originally admitted Resident 96 on 4/27/2023 and readmitted the resident on 11/11/2025 with diagnoses including dysphagia, essential hypertension (HTN - high blood pressure) and hyperlipidemia (increase fats in the blood). A review of Resident 96’s MDS, dated 10/31/2025, indicated Resident 96 made self-understood and understand others. Resident 96 required supervision and touching assistance. Resident 96 had a mechanically altered diet within the last 7 days as a resident in the facility. A review of Resident 96’s H&P, dated 1/2/2026, indicated the resident can make needs known but cannot make medical decisions. A review of Resident 96’s Care Plan titled, “[Resident 96] has a swallowing problem…” initiated on 10/24/2025, indicated goals for the resident’s risk for choking episodes when eating and drinking and at risk for signs and symptoms of aspiration will be minimized through the review date. The Care Plan indicated interventions including diet to be followed as ordered. A review of Resident 96’s Care Plan titled, “[Resident 96] has a nutritional problem: Fortified Pureed texture level 4 with moderately thick level 3 liquid consistency (liquid can be drunk from a cup with moderate effort required to suck through a bore or wide bore straw),” last revised on 12/10/2025, indicated interventions to monitor, document and report as needed for any signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing and refusing to eat. A review of Resident 96’s Speech Therapy Evaluation and Plan of treatment, dated 10/20/2025, indicated Resident 96 presented with severe oropharyngeal dysphagia characterized by poor bolus control (refers to the tongue's ability to form, manipulate, and propel a food or liquid mass through the oral cavity), tongue pumping (refers to a repetitive, involuntary, forward-and-backward movement of the tongue) and unproductive cough yielding wet vocal quality post (after) swallow. The Speech Therapy Evaluation and Plan of Treatment also indicated for Resident 96 to be on pureed diet texture and consistency with thin liquids. A review of Resident 96’s Food and Nutrition-IDDSI Nutritional Assessment and CAA dated 11/18/2025, indicated Resident 96 had chewing and swallowing problems and a pureed texture diet was ordered. The document further indicated Resident 96 has inadequate oral intake related to dysphagia. A review of Resident 96’s Order Summary Report, dated 12/10/2025, indicated a physician’s order for Fortified Pureed Level 4, and moderately thick liquid level 3 consistency. During an observation on 1/13/2026 at 8:20 a.m. of Resident 96’s breakfast tray in Resident 96’s bedside, observed regular oatmeal with oatmeal particles and lumps on the tray. Observed Certified Nurse Assistant 1 (CNA 1) fed Resident 96 with regular oatmeal. Resident 96 consumed 3 tsp of regular oatmeal. During an interview on 1/13/2026 at 11:59 a.m. with CNA 1, CNA 1 stated she (CNA 1) did not notice that the oatmeal served that morning was not pureed. She (CNA 1) served regular oatmeal to Resident 96, however, Resident 96 did not consume all of it, stating she (Resident 96) did not like it. CNA 1 stated that had she (CNA 1) noticed that the oatmeal was not pureed, she (CNA 1) would have returned it to the kitchen to request cream of wheat or another appropriate substitute. She (CNA 1) was aware that Resident 96 is on a pureed diet and the oatmeal that Resident 96 consumed was clumpy and Resident 96 could choke on the oatmeal. During a concurrent interview and record review on 1/13/2026 at 2:13 p.m., with the ST, Resident 96’s Speech Therapy Evaluation and Plan of Treatment, dated 10/20/2025, was reviewed. The Speech Therapy Evaluation and Plan of Treatment indicated Resident 96 presented with severe oropharyngeal dysphagia. The ST stated she (ST) evaluated Resident 96 on 10/20/2025 and observed that Resident 96 was not managing her (Resident 96) saliva secretions (useful fluids, chemicals, or substances produced and released by cells, glands, or organs in the body) well. Resident 96 was ordered a Puree Level 4 diet with mildly thick liquids, which ST stated was an appropriate diet order for Resident 96. Resident 96 has cognitive impairment and inattention when swallowing, as she does not remember to swallow her own secretions. Resident 96 has oropharyngea