Health inspection·March 7, 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. § 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 1/18/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual recertification survey. The facility failed to: 1. 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 1 on puree diet (a texture modified diet that consists of smooth foods with pudding-like consistency that are easy to swallow) by not following the recipes for puree bread and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks). 2. Ensure the ordered diet type was appropriate for Resident 32. The facility failed to utilize the General Acute Care Hospital 1 (GACH 1) Patient Discharge Instructions indicating a dietary restriction (a limitation on what food or ingredient a person eats) of mechanical soft finely chopped diet (a texture-modified diet that is prepared by finely chopping ingredients into small pieces, making it easier to chew and swallow for residents who have difficulty with regular food texture due to conditions like dysphagia [swallowing difficulties]), when obtaining the appropriate physician diet order for Resident 32 (upon re-admission to the facility), who had dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or throat). As a result, Resident 1 was served puree bread that was too sticky and did not fall during the spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) at lunch on 1/19/2025. Resident 32’s physician diet order (upon re-admission to the facility) indicated mechanical soft diet (a type of texture-modified diet for residents who have difficulty chewing and swallowing) instead of mechanical soft finely chopped diet. On 1/18/2025, Resident 32 was served biscuit at dinner. These had the potential to cause Residents 1 and 32 to not be able to eat the food, choke (when food gets stuck in your airway, blocking [obstructing] the flow of air to your lungs), and aspirate (when food or liquid enters your airway and lungs instead of your stomach) on the food. 1. A review of Resident 1’s Admission Record indicated the facility originally admitted Resident 1 on 2/27/2023 and readmitted Resident 1 on 1/17/2025 with diagnoses including dysphagia oropharyngeal phase, gastro-esophageal reflux disease (GERD- a condition in which the stomach contents move up into the esophagus [muscular tube that connects the mouth to the stomach]), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and sepsis (a serious condition in which the body responds improperly to an infection). A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool), dated 11/27/2024, indicated Resident 1 understood others and made self understood. The MDS indicated Resident 1 required supervision or touching assistance with eating (the ability to use suitable utensils to bring food/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident) and partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene. The MDS indicated Resident 1 required a mechanically altered (food texture that is intended to be safe and easy to swallow) diet. A review of Resident 1’s GACH 1 Patient Discharge Instructions, dated 1/17/2025, indicated dietary recommendations for puree and no added salt (NAS- no salt packet on the meal tray) diet. A review of Resident 1’s History and Physical (H&P), dated 1/18/2025, indicated Resident 1 does not have the capacity to make decisions. A review of Resident 1’s Speech Therapy (ST) Treatment Encounter Note, dated 1/18/2025, indicated swallow treatment that included alteration of textures and temperatures to facilitate sensation and bolus (a ball-like mixture of food and saliva that forms in the mouth during the process of chewing) clearance. The Speech Therapy Treatment Encounter Note indicated Resident 1’s current diet of puree consistencies and thin liquids. A review of Resident 1’s Speech Therapy: Speech Language Pathology (SLP – refers to the field of study and practice focused on assessing, diagnosing and treating communication disorders related to speech and swallowing issues) Evaluation and Plan of Treatment, with start of care date of 1/19/2025, indicated recommendations for puree consistencies, thin liquids, close supervision. The SLP Evaluation and Plan of Treatment also indicated Resident 1’s risk factors (variables or conditions that increase the likelihood of a specific adverse event or disease occurring) due to physical impairments and functional deficits, risk for aspiration (happens when food, liquid, or other material enters a person's airway and eventually the lungs) compromised general health, pneumonia (lung infection), and weight loss. A review of Resident 1’s Order Summary Report, dated 1/19/2025, indicated a physician’s order for regular, NAS, puree texture, thin consistency (no restrictions). A review of Resident 1’s Baseline Care Plan, dated 1/17/2025, indicated Resident 1 needed set-up help with eating and was on mechanically altered diet and puree, no added salt diet. The Baseline Care Plan indicated the resident’s dietary risks for weight loss as well as swallowing problems and chewing problems. A review of the facility’s menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled “Therapeutic Spreadsheet Cycle 4 2024,” dated 1/19/2025, indicated residents on puree diet in accordance with IDDSI Level 4 would include the following in the meal tray: • Puree baked ham number eight (#8) scoop (1/2) cup (c., a household measurement) • Puree baked sweet potato #12 scoop (1/3 c) • Puree seasonal zucchini #10 scoop (3.25 ounces [oz, a unit of measurement]) • Puree bread one (1) piece (pc, a household measurement) • Margarine one (1) pc • Applesauce ½ c • Water eight (8) oz During food preparation observation in the kitchen, on 1/19/2025 at 11:52 a.m. with Cook 1, observed Cook 1 prepared puree bread and poured thickener (a substance used to increase the viscosity [the measure of a fluid’s resistance to flow] of liquids to help support a safer swallow for residents) into the container without measuring the amount of the thickener. During a concurrent observation at Resident 1’s bedside (refers to the area at the side of a bed) and interview with Certified Nurse Assistant 5 (CNA 5), on 1/19/2025 at 12:45 p.m., observed Resident 1’s lunch tray ticket (a menu that lists the food items a resident will receive based on the resident’s diet, allergies, likes/dislikes, and food preferences) indicated soup of the day six (6) oz, baked ham, baked sweet potato, seasonal zucchini, one bread, one margarine, applesauce, fruit cup, water eight (8) oz, Lactaid (a non-dairy milk substitute) eight (8) oz, and no gravy. Observed CNA 5 assisting Resident 1 with feeding puree bread. CNA 5 stated the puree bread was a little sticky. During an interview with Cook 1 on 1/19/2025 at 1:02 p.m., Cook 1 stated puree food should be smooth and must maintain its shape on the plate. Cook 1 stated she did not measure the puree bread and the thickener when making the puree bread. Cook 1 then stated she just used her eyes and gradually mixed the thickener when making the puree bread. Cook 1 stated she would then know that the puree food was on its proper texture and consistency based on how she feels and based on her past experiences. Cook 1 stated she was taught (unable to recall who) how to perform the spoon tilt test. Cook 1 also stated that puree diet is for residents who could not swallow, and if the food served was not in the right texture and consistency, residents could be placed at high risk for choking (when a person can’t speak, cough, or breathe because something is blocking the airway). 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 with the DS on 1/19/2025 at 1:04 p.m., the DS stated the puree bread did not pass the puree spoon tilt test when she (DS) performed it. The DS stated the puree bread was too sticky. The DS stated there were recipes available for the staff to follow for puree and there were also scoops and measuring cups for the kitchen staff to use to ensure accuracy of the puree consistency. The DS stated Cook 1 should not be eyeballing the ingredients or the thickener. The DS stated Cook 1 was not following the recipe. The DS stated the puree bread did not fall when she (DS) performed the spoon-tilt test as it was sticky and could potentially cause residents to have difficulty swallowing leading to choking. During an interview with Speech Therapist 1 (ST 1) on 1/20/2025 at 10:04 a.m., ST 1 stated she recommends puree diet for residents who are weak, had impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and residents with dementia (a term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) for their safety. ST 1 stated puree diets are also recommended for residents who could not chew and had no teeth and those who had difficulty swallowing. ST 1 stated puree diet consisted of food that are smooth with no chunks or lumps and should not be watery. ST 1 stated the IDDSI standard used spoon tilt test and if the food did not fall off the spoon, it meant the food was too thick. ST 1 stated if food was too thick, there would be more bolus collection, and the food would be more difficult to swallow and harder for residents to get it down their throats. ST 1 stated Resident 1 and other residents with dysphagia diagnosis, on puree diet who received food not passing a puree texture could result to choking, aspiration, and weight loss as residents would not be able to eat as much food. During an interview with the RD on 1/20/2025 at 11:58 a.m., the RD stated she (RD) talked to the kitchen staff regarding puree diet and the spoon tilt test. The RD stated if the food did not pass the spoon tilt test, it could be too thick as the slurry (a mixture of fluid/liquid and thickener) was not done correctly. The RD stated if the puree food was too thick, Resident 1 and other residents could experience swallowing difficulties and choking hazards. During an interview with the Director of Staff Development (DSD) on 1/22/2025 at 6:32 a.m., the DSD stated CNAs should test the puree consistency for residents on puree diets. The DSD stated when the CNAs identify it is not the correct consistency, such as too thick, the CNAs should report to the charge nurse or can go to the dietary staff, cook, or to the DS, and request for food replacement as soon as possible. The DSD stated Resident 1 and other residents on puree diet who received thick puree consistency could have experienced choking and could have led to an emergency. During an interview with the Director of Nursing (DON) on 1/22/2025 at 1:16 p.m., the DON stated CNAs should check the consistency of food and that it should hold its shape and fork tender (refers to a food items, cooked to the point where it is soft enough to be easily pierced and shredded with a fork). The DON stated the puree food should be smooth, free of lumps, not watery, and holds it shape. The DON stated the puree food should pass the spoon-tilt test method. The DON stated if the puree food does not fall off the spoon, it did not pass the test. The DON stated if the puree food does not fall, and it is sticking on the spoon then it could be dry and could stick to the resident’s throat. The DON stated Resident 1 could choke and could affect Resident 1’s swallowing. A review of the facility’s policy and procedures (P&P) titled “Menus,” dated 7/30/2024, indicated, “Menus are developed and prepared to meet resident’s choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy.” A review of the facility’s P&P titled “Diet Manual,” dated 7/30/2024, indicated, “(4) The diet manual has been developed to provide explanation of the diets in the development of the menu program. The diets have been developed using current specific research, information from best practices, and recommendations from position papers of professional associations. (6) The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for the health and care personnel in following diet order.” A review of the facility’s diet manual titled “Dysphagia Diets Puree IDDSI Level 4,” dated 7/30/2024, indicated, “A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm, or sticky and holds its shape on a plate. The diet requires no biting and chewing. Any liquids must not separate from the food and the food fall off a spoon intact. The food is more easily swallowed and prevents aspiration. (3) Should not be sticky.” The diet manual indicated that all prepared puree recipes should be tested prior to service to ensure the texture meets the IDDSI guidelines and should pass the Fork Drip Test (a method used to determine the correct thickness of food and ability of the food to hold together) and Spoon Tilt Test. A review of the facility’s P&P titled “Standardized Recipes (a set of written instructions used to consistently prepare a known quantity and quality of food),” dated 7/30/2024, indicated standardized recipes shall be developed and used in the preparation of foods. The P&P indicated that only tested, standardized will be used to prepare foods and will be adjusted to the number of portions required for a meal. A review of the undated recipe titled “Bread Slice for Cycle 4 2024,” indicated, “it is recommended to serve puree or gelled bread for dysphagia diets, but if the Speech Language Pathologist of the facility signs and approves regular breads on an individual basis, chop regular portions. Make sure all particles are no more than 15 millimeters