Health inspection·February 13, 2026

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. 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 12/29/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual Health Recertification Survey. Resident 56 has a diagnosis of dysphagia (swallowing difficulties), was at risk for aspiration, and was placed on a restorative dining program, which included requiring supervision and/or assistance during meals. The facility failed to ensure Resident 56, who had an order for modified liquid consistency (liquids that have been thickened [drinks such as water, juice, coffee, modified with powders or gels to be easier and safer to swallow] to a specific level to improve swallowing safety per the International Dysphagia Diet Standardization Initiative [IDDSI - framework that provides a common terminology to describe food textures and drink thickness]), was not provided thin (water-like) liquids. The facility failed to: 1. Provide Resident 56’s therapeutic diet as prescribed in the physician’s diet order, dated 10/10/2025, to provide liquids with nectar/mildly thick liquid consistency when facility staff served Resident 56 unthickened coffee with a straw during lunch, at approximately 12 p.m. on 12/29/2025. 2. Implement Resident 56’s Dysphagia care plan, dated 10/16/2025, which identified Resident 56 as at risk for aspiration and had an intervention to not use straws when consuming fluids, when on 12/29/2025 facility staff served Resident 56 the coffee with a straw. The facility also failed to implement Resident 56’s Nutrition care plan dated 10/14/2025, which identified Resident 56 as being at risk for aspiration, dehydration, malnutrition and included interventions to provide Resident 56 with the diet as ordered.  3. Serve therapeutic diets with supervision and to meet Resident 56’s needs when nursing staff responsible for monitoring and assisting residents in the activity/dining room, did not verify that Resident 56’s coffee was of the correct liquid consistency. 4. Implement the facility’s policy and procedure (P&P) titled, “Thickened Liquids,” last reviewed on 8/23/2025, which indicated that thickened liquids are to be served at the appropriate consistency as ordered by the physician and that hot beverages are to be mixed on tray line or by nursing staff. The facility also failed to implement the P&P titled, “Restorative Dining Program,” last reviewed on 8/23/2025 indicated the Restorative Nursing Assistance (RNA) dining program to be performed as ordered and care planned to allow residents to safely and effectively consume food and fluids. As a result, Resident 56 was observed coughing while drinking unthickened coffee through a straw. Resident 56 was placed at risk for life threatening complications such as choking and aspiration pneumonia (a lung infection from inhaling foreign substances like food into the lungs), which could result in hospitalization and or death.  A review of Resident 56’s Admission Record indicated the facility admitted Resident 56 on 10/10/2025 with diagnoses including dysphagia following cerebral infarction (known as stroke, loss of blood flow to a part of the brain), aphasia (a language disorder caused by brain damage [often from stroke or injury] that impairs the ability to communicate) and gastro-esophageal reflux disease (GERD). A review of Resident 56’s History and Physical (H&P – a comprehensive assessment of a resident’s medical condition), dated 10/13/2025 indicated that Resident 56 had dysphagia requiring aspiration precautions and follow up with a Speech Therapist (ST- a person qualified to treat people with conditions that affect the production of speech, communication and swallowing problems). A review of Resident 56’s Minimum Data Set (MDS – a resident assessment tool), dated 10/16/2025 indicated Resident 56 was able to make herself understood and could understand others. The MDS further indicated Resident 56 required supervision during meals and substantial assistance from facility staff for activities of daily living (ADLs- essential self-care tasks for daily functioning such as bathing, dressing and toileting). The MDS indicated Resident 56 had a swallowing disorder as evidenced by coughing or choking during meals.    A review of Resident 56’s Physician’s Order dated 10/10/2025 indicated a diet order for no added salt (NAS), pureed (to crush, grind, or blend food into a?smooth, thick, pudding-like consistency, free of lumps, requiring no chewing and easy to swallow) texture; nectar/mildly thick liquid consistency.   A review of Resident 56’s Nutrition Care Plan (CP) dated 10/14/2025 included a focus on dietary concerns and problems, as well as the resident’s therapeutic diet (a specialized meal plan, prescribed by a doctor and planned by a dietitian, that modifies a normal diet to treat a medical condition and manage symptoms) and mechanically altered textures. The CP indicated that Resident 56 was at risk for aspiration and included an intervention to ensure that Resident 56’s diet was administered and served according to the Physician’s Order.   A review of Resident 56’s Dysphagia CP dated 10/16/2025, completed by the ST indicated Resident 56 had oropharyngeal dysphagia, and was at risk for aspiration, and required aspiration precautions, including an intervention not to use straws when consuming fluids. During a dining observation on 12/29/2025 at 12:15 p.m., in the activity/dining room, the surveyor observed Resident 56 seated at a table eating lunch with RNA 1, RNA 2 and Licensed Vocational Nurse 1 (LVN 1) present. On one side of the room, there was a coffee service cart and a meal tray cart for residents. On top of the coffee service cart was a burgundy cup with a plastic lid labeled “moderate thick milk,” containing a white powder. On 12/29/2025 at 12:22 p.m., Resident 56 was observed holding a coffee cup with a straw and coughing after drinking from that coffee cup through a straw. The liquid in the cup was light brown and had a thin, water-like consistency. Resident 56’s meal tray contained three cups: a clear liquid labeled mildly thickened water, a white liquid labeled mildly thickened milk, and a red liquid labeled mildly thickened juice. The food on the tray was pureed and consistent with the diet indicated on the meal ticket. Resident 56’s meal ticket indicated that Resident 56 was on a pureed diet with mildly thickened consistency liquids.     During a concurrent observation and interview on 12/29/2025 at 12:23 p.m., in the activity/dining room, with RNA 1, the surveyor observed Resident 56 holding a coffee cup with a straw. RNA 1 stated Resident 56 is on a pureed diet with thickened liquids and should not use a straw due to the risk of choking. RNA 1 further stated Resident 56 continuously requests a straw, and staff (did not specify) sometimes provide it. RNA 1 stated that upon looking inside Resident 56’s coffee cup, RNA 1 identified the light brown liquid as coffee and confirmed that Resident 56 should not have been given coffee with a thin, watery consistency and served with a straw.   During a concurrent observation and interview on 12/29/2025 at 12:45 p.m., in the activity/dining room, with the Dietary Supervisor (DS), the surveyor observed Resident 56 holding a coffee cup with a straw. The DS described the light brown liquid in Resident 56’s cup as thin, water-like coffee, and stated the liquid should have been mildly thick, nectar-like in consistency. The DS stated that it was dangerous for Resident 56 to receive thin coffee with a straw because her (Resident 56) diet order required mildly thick liquids, putting her (Resident 56) at risk for aspiration and choking. The DS further stated that whenever a resident with a thickened liquid diet requests coffee, the RNA or any licensed staff must go to the kitchen to request it. The DS stated only kitchen staff are authorized to prepare thickened liquids, and the cup containing the thickener should never have left the kitchen.     During an interview on 12/29/2025 at 12:55 p.m., RNA 1 stated that prior to lunch, a coffee service is provided, and while residents wait for their meal trays, she (RNA 1) and RNA 2 distribute coffee. RNA 1 stated the cup labeled “moderate thick milk” contained thickener, but she (RNA 1) did not know where the cup came from or who brought it into the dining room. RNA 1 stated she (RNA 1) was aware Resident 56 cannot drink with a straw, but sometimes she (RNA 1) and other RNAs (did not specify) provide a straw because the resident repeatedly requests for a straw.    During an interview on 12/29/2025 at 1:05 p.m., RNA 2 stated that she and RNA 1 typically work together in the dining room during coffee service and lunch. RNA 2 stated she (RNA 2) was handed the cup labeled “moderate thick milk,” by dietary staff (did not specify) in the kitchen but she (RNA 2) did not give Resident 56 the unthickened coffee and straw that day (12/29/2025). RNA 2 stated she did not know who provided the unthickened coffee with straw to Resident 56 during lunch on 12/29/2025.   During an interview on 12/29/2025 at 1:14 p.m., with LVN 1, LVN 1 stated his (LVN 1) role during lunch was to supervise residents. He (LVN 1) does not serve coffee to residents and that coffee is served by the RNAs. LVN 1 stated meals are checked by licensed staff once the trays leave the kitchen and are checked again upon arrival in the activity/dining room by verifying the trays against the meal tickets. He (LVN 1) did not observe who provided Resident 56 with the coffee or the straw.     During a telephone interview on 12/29/2025, at 3:04 p.m., with facility’s Registered Dietitian (RD – an expert on diet and nutrition), the RD stated that it is extremely important to verify Resident 56’s diet order to ensure the resident receives the correct diet to meet nutritional needs. She (RD) has only observed the tray line and was not familiar with the coffee service process in the activity/dining room. The RD stated that in October (specific date not mentioned) of 2025, the facility transitioned to the IDDSI and that only dietary staff or licensed staff who have been trained are permitted to prepare thickened liquids. The RD further stated that not all licensed staff have currently received training on proper preparation of thickened liquids and that providing thin liquids to Resident 56 posed a danger due to the risk of aspiration. During a concurrent telephone interview and record review on 12/29/2025 at 4:01 p.m., with the ST, Resident 56’s Care Plans related to Nutrition from 10/16/2025 to 11/11/2025 and ST Evaluation notes from 10/16/2025 to 11/11/2025 were reviewed. The ST stated Resident 56 had a history of cerebrovascular accident (CVA – known as stroke) and upon evaluation on 10/16/2025, required a pureed diet with mildly thickened liquids, described as having a consistency similar to cooking oil or apricot juice. She (ST) recommended safe swallowing and aspiration precautions, including sitting upright, taking small bites and sips, consuming food and liquids of the correct consistency and texture, utilizing a chin tuck (gently moving your head and bringing your chin toward your chest), and not using straws. The ST stated that without these precautions, Resident 56 was at risk for aspiration and aspiration pneumonia. Resident 56 should not have been given thin liquids and a straw on 12/29/2025 during lunch. The ST stated she screened Resident 56 again on 12/11/2025 at the family’s request and determined Resident 56 was not ready for a diet upgrade to thin liquids due to continued coughing after consuming thin liquids. During an interview on 12/30/2025 at 11:22 a.m., with Nurse Practitioner 1 (NP 1), NP 1 stated she works directly with Resident 56’s physician. NP 1 stated Resident 56 has a history of CVA and has a physician order for mildly thickened liquids due to dysphagia. Resident 56 was not ready for thin/watery liquids due to risk for aspiration and that staff should follow all prescribed interventions and precautions. The ST evaluated Resident 56 on 12/30/2025, and although Resident 56 was able to clear her throat, she (Resident 56) continued to demonstrate a delayed cough and would require a Video Fluoroscopic Swallow Study (a test that shows what happens when you swallow food or liquid). NP 1 stated Resident 56 would continue on her current diet orders of no added salt, pureed texture, nectar/mildly thick liquid consistency. During an interview on 12/29/2025 at 6:10 p.m., with the Director of Nursing (DON), the DON stated that licensed and unlicensed nursing staff are not permitted to prepare thickened liquids because they have not yet been trained to do so. All thickened liquids must be prepared by kitchen staff only prior to being served to residents on thickened liquid diets. The DON also stated Resident 56 should not have been given unthickened liquids and a straw on 12/29/2025 during lunch, until cleared by the ST and determined to be safe.   During an interview on 12/30/2025 at 8:48 a.m., Cook 3 stated that cold liquids are pre-thickened, but hot liquids require preparation by adding thickener to achieve the appropriate consistency. It had been the kitchen’s practice to review residents’ diet orders, measure thickener using a measuring cup, and place the dry powder into a coffee cup for non-kitchen staff to mix and prepare the coffee. Cook 3 stated this had been their longstanding practice and that he (Cook 3) was not aware that only kitchen staff were permitted to mix or prepare thickened liquids.    During a concurrent interview and record review on 12/30/2025 at 9:45 a.m., with the DON, the facility’s P&P titled, “Thickened Liquids” last reviewed on 8/23/2025 was reviewed. The DON stated that none of the facility’s licensed nursing staff have been trained to prepare thickened liquids, despite the policy stating, “Exception: Hot beverages will be mixed on tray line or by nursing.” The DON further stated that only dietary/kitchen staff are permitted to prepare all thickened liquids.   A review of the facility’s P&P titled, “Healthcare Menus Direct, LLC. IDDSI Framework,” last reviewed on 8/23/2025 indicated level #2 Mildly Thick Liquids: flows off spoon; pours slower than drinks.     A review of the facility’s P&P titled, “Restorative Dining Program,” last reviewed on 8/23/2025 indicated the RNA dining program must be performed as ordered and care planned for with the purpose for residents to effectively and safely take in food and fluids.   A review of the facility’s P&P titled, “Diet Orders,” last reviewed on 8/23/2025 indicated diet orders prescri