Records reviewed established that R1 required a pureed diet and full assistance with eating. OMP and swallowing records further established that R1 had significant swallowing impairment and required precautions intended to reduce choking and aspiration risk. These precautions included puree texture, thickened liquids, supervision during feeding, upright positioning, slow feeding, small portions, and later an express instruction that food contain no chunks.

LPA identified multiple pieces of evidence showing that food provided to R1 did not consistently meet the required puree consistency.

Facility documentation dated January 16, 2025 recorded a food-consistency concern from January 15, 2025. The note reflected that an outside source and a caregiver observed visible solid pieces in food provided to R1 as a pureed meal. The concern was reported to facility staff and Dining Services at the time of the incident.

A second incident occurred on or about February 2, 2025, when a meal provided to R1 as pureed food contained a solid piece or chunk that had not been fully pureed. Information received during the investigation reflected that R1 was able to spit out the solid piece.

LPA reviewed photographs provided during the investigation. The photographs depicted visible solid food pieces or chunks in meals identified as pureed food provided to R1. The photographs were consistent with the reported food-consistency concerns and were considered with the facility documentation and witness interviews.

On January 31, 2025, an SLP performed a swallowing evaluation and meal/medication analysis. The SLP documented puree texture, thickened liquids, crushed medications, upright positioning, small portions, slow feeding, and supervision due to R1's high aspiration/choking risk. The meal observed during that specific clinical assessment was documented as appropriately prepared. This was considered as contrary evidence demonstrating that the facility was capable of providing an appropriate puree consistency.

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On February 3, 2025, an OMP issued additional aspiration-prevention instructions that specifically directed that R1's food contain no chunks, among other precautions. The order reinforced the medical importance of providing R1 food at the prescribed texture.

During staff interviews, staff confirmed two food-consistency incidents on or about January 15 and February 2, 2025, in which food provided to R1 contained pieces or chunks inconsistent with the required puree texture. Staff acknowledged that food intended to be pureed should not contain the pieces or chunks described and confirmed that staff spoke with and apologized to an outside source after the first incident.

Additional direct-care evidence was obtained from staff who remembered R1 and regularly worked in Memory Care. Staff recalled that R1's pureed food was at times too thick or sticky and required additional water and mixing before R1 could safely eat the food. Staff described one occasion when R1's food was taken back, additional water was added, and the food was mixed to create a softer consistency. Staff also stated that an outside source requested further mixing because R1 had difficulty swallowing food that was not adequately prepared.

During an interview, facility management denied that staff failed to follow R1's dietary requirements. Facility management stated that the facility followed physician orders, used specific puree preparation methods and molds, and did not believe corrective action or additional training was necessary. LPA also reviewed later feeding and progress documentation that generally reflected appropriate pureed food, thickened liquids, upright positioning, and feeding assistance.

The Department considered this contrary evidence. The allegation is not that every meal provided to R1 was improperly prepared. Evidence that compliant meals were provided on other dates and that the facility had procedures for preparing puree meals did not negate the specific failures established by facility documentation, photographs, staff admissions and firsthand observations, and R1's medical orders.

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Based on records reviewed, photographs, interviews with facility staff and outside sources, and all information obtained during the investigation, the preponderance-of-evidence standard was met. Therefore, the allegation that staff did not prepare a resident's food to meet their needs while in care is SUBSTANTIATED.

A deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations and is detailed on the LIC 9099-D. A Plan of Correction (POC) was jointly developed with Executive Director Jessica Zepeda.

An exit interview was conducted with Executive Director Jessica Zepeda. A copy of this report, the LIC 9099-D, the Licensee Appeal Rights (LIC 9058), and LIC 811 were provided at the conclusion of the visit.

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