BREMERTON, WA - State health inspectors documented serious safety violations at Forest Ridge Health & Rehab after staff repeatedly served incorrect food textures to residents with swallowing difficulties, including two residents who received regular-textured foods despite being prescribed pureed diets due to documented choking hazards.
Critical Breakdown in Dietary Safety Systems
On June 14, 2024, state surveyors observed multiple instances where residents with documented swallowing difficulties received foods that posed immediate choking risks. The violations revealed systemic failures in the facility's food service protocols, with staff serving regular scrambled eggs and chopped sausage to residents whose medical orders specifically required all foods to be pureed to a smooth, uniform consistency.
The inspection found that kitchen staff were not following standardized recipes for pureed meals, and that a supposedly fail-safe "triple-check" system designed to prevent such errors had completely broken down. The facility's inability to properly prepare and verify meal textures for vulnerable residents prompted inspectors to issue an immediate jeopardy citation—the most serious level of violation indicating a substantial likelihood of death or serious injury.
Residents With Choking History Served Wrong Foods
One resident, identified as Resident 35, had an especially concerning medical history that made the dietary errors particularly dangerous. This individual had experienced a choking episode at breakfast on May 13, 2024, that was severe enough to require staff to perform the Heimlich maneuver to clear their airway. Following that incident, the resident's care plan specifically documented "intermittent episodes of coughing and choking with meals" and directed staff to provide small bites, check for pocketed food, keep the head of bed elevated, and crucially, "provide the diet as ordered."
Just one week after the choking incident, on May 21, 2024, nursing staff were called to Resident 35's room again when the resident experienced coughing and difficulty swallowing during lunch. Despite these documented safety concerns and clear medical orders for a pureed diet, surveyors observed on June 14 that Resident 35 was served and assisted with eating regular-textured scrambled eggs and chopped sausage—foods that posed significant aspiration risks.
Swallowing difficulties, medically known as dysphagia, represent a serious health concern in long-term care settings. When individuals with dysphagia consume foods of inappropriate textures, they face increased risks of choking, aspiration pneumonia (when food or liquid enters the lungs), and potentially fatal airway obstruction. Pureed diets are specifically prescribed to eliminate these risks by ensuring all foods have a smooth, uniform consistency that can be safely swallowed without adequate chewing ability.
The assessment documentation showed Resident 35 had severe cognitive impairment and required substantial to maximal assistance with eating, meaning they relied entirely on staff judgment and care to receive safe nutrition. The cognitive impairment would have prevented the resident from recognizing or communicating that they were being served the wrong food texture.
Multiple Residents Affected by Systematic Failures
A second resident, Resident 125, faced identical safety risks on the same morning. This individual, who had severe cognitive impairment and was receiving hospice services, also had clear medical orders for a pureed diet. Yet surveyors observed staff delivering and beginning to assist the resident with a breakfast tray containing regular scrambled eggs and chopped sausage alongside pureed pancakes—a dangerous mix of appropriate and inappropriate textures.
The facility's Head Cook and Dietary Manager in Training explained that the facility employed a "triple-check" process designed to prevent exactly these types of errors. The first check occurred when cooks read tray cards and plated meals according to prescribed diet types. The second check happened when dietary aides added cold items and beverages while verifying tray accuracy. The third check was supposed to occur when nursing assistants removed trays from carts and validated that the foods matched the tray card before delivering meals to residents.
Despite this multi-layered verification system, both residents received incorrect diet textures that went undetected through all three checkpoints. Staff explanations revealed that the system collapsed due to inadequate staffing and training. The Head Cook stated they had planned to train a new cook on reading tray cards that very day but could not provide proper oversight because a dietary aide had called in sick, forcing them to cover multiple roles simultaneously. Additionally, the Certified Dietary Manager from another facility who was training staff had not yet arrived when breakfast service began.
Kitchen Staff Operating Without Standardized Recipes
Further investigation revealed another fundamental gap in dietary operations: kitchen staff were not using recipes when preparing pureed foods. When asked directly whether dietary staff had access to and utilized recipes for pureed diets, the Head Cook stated simply, "no."
Standardized recipes serve critical functions in healthcare food service beyond simple meal preparation. They ensure consistency in texture modification, which is essential for patient safety when dealing with specialized diets. Without recipes, different kitchen staff may prepare foods to varying consistencies, creating unpredictable risks for residents with swallowing difficulties. Recipes also provide specific guidance on proper pureeing techniques, appropriate liquid additions, and texture testing methods.
The Regional Registered Dietitian later confirmed that kitchen staff were supposed to follow recipes when making pureed food and that recipes had been reviewed, updated, and used for staff education following the inspection findings. This admission indicated that proper procedures existed but were not being implemented in daily operations.
Persistent Failure to Accommodate Food Preferences
Beyond the immediate safety violations, inspectors documented a separate but equally concerning pattern of neglect regarding a resident's documented food preferences. Resident 61, who was cognitively intact and had diagnoses including stroke and malnutrition, experienced significant weight loss exceeding clinical thresholds—more than 5% in one month or 10% over six months.
The resident reported to inspectors that while they ate well at breakfast, they regularly skipped lunch and dinner because the facility "primarily served vegetables and some form of pasta" for those meals—foods they had repeatedly stated they disliked. Despite informing multiple staff members on numerous occasions and completing a formal food preference form, the kitchen continued serving these foods regularly.
Progress notes documented a troubling timeline of inaction spanning nearly five months. Beginning January 29, 2024, and continuing through April 14, 2024, social services and nursing staff repeatedly documented that Resident 61 was "not eating due to food dislikes." On February 12, a dietary referral was specifically submitted for food preferences, yet the resident's situation remained unchanged.
"I spoke directly to [the former Dietary Service Manager] about Resident 61's food preferences at the end of May 2024," the Social Services Director told inspectors, explaining that the information was supposed to be entered into the dietary computer system. When following up one to two weeks later, the preferences still had not been entered. A second Food Preference Record was completed on June 7, 2024, again delivered directly to dietary management, yet the information remained absent from the system.
The documented food preferences were specific and reasonable: no pasta for lunch or dinner, no applesauce or broccoli, and minimal rice. These preferences were never incorporated into the resident's meal planning. Even after surveyors brought attention to the issue, tray cards reviewed on June 14 and June 17, 2024, showed the resident's likes and dislikes still had not been entered into the dietary computer.
Weight loss in long-term care residents often creates a downward health spiral. Inadequate nutrition compromises immune function, delays wound healing, reduces muscle mass and strength, and increases fall risks. For a resident already diagnosed with malnutrition, the continued failure to provide acceptable food options represented a significant threat to health and recovery.
Medical Context and Industry Standards
The violations documented at Forest Ridge Health & Rehab represent failures in fundamental aspects of long-term care. Dietary services in skilled nursing facilities must operate with the same precision and safety consciousness as medication administration. Just as giving the wrong medication can cause serious harm, serving inappropriate food textures to residents with dysphagia creates immediate risks of choking, aspiration, and potentially fatal complications.
Federal regulations require nursing facilities to ensure that residents' nutritional needs are met through proper meal planning, preparation, and service. This includes following prescribed diet orders, accommodating individual preferences to the extent possible, and maintaining adequate quality control systems. The regulations recognize that nutrition directly impacts residents' health outcomes, recovery trajectories, and quality of life.
Speech-language pathologists typically conduct swallowing evaluations to determine appropriate diet textures for residents with dysphagia. These assessments consider factors including cognitive status, physical ability to self-feed, presence of teeth, muscle strength, and swallowing coordination. Based on these evaluations, physicians order specific diet modifications using standardized terminology such as "pureed," "mechanical soft," or "chopped" to ensure consistent preparation across all meals.
Facilities should maintain detailed recipes and preparation guidelines for texture-modified diets, train all kitchen and nursing staff on the importance of diet texture compliance, implement effective verification systems before meals reach residents, and regularly audit dietary operations to identify and correct gaps. The absence of these basic safeguards at Forest Ridge Health & Rehab created an environment where preventable errors could and did occur.
Additional Issues Identified
Beyond the major violations detailed above, the inspection narrative revealed several contributing factors to the facility's dietary service failures. The breakdown in the triple-check verification process highlighted inadequate backup staffing plans when key dietary personnel were absent. The new cook who plated the incorrect meal textures was operating without sufficient supervision or completed training on reading tray cards and identifying appropriate diet textures.
The facility's failure to utilize standardized recipes for pureed foods demonstrated a lack of basic quality control measures in food preparation. The months-long delay in entering a resident's documented food preferences into the dietary computer system showed systemic communication failures between departments, with social services staff providing information that dietary management failed to implement despite multiple attempts and follow-ups.
The inspection findings indicated that management oversight of dietary operations was insufficient to ensure compliance with basic safety protocols and individualized care requirements. Staff reported relying on personnel from other facilities to provide training and supervision, suggesting potential gaps in on-site leadership and accountability structures.
Facility Response and Corrective Actions
The facility was able to remove the immediate jeopardy designation on June 17, 2024, after taking corrective actions verified by surveyors. These actions included conducting staff interviews to verify understanding of proper procedures and reviewing updated puree recipes that kitchen staff would be required to follow.
The Regional Registered Dietitian confirmed that recipes for pureed meals had been reviewed and updated, and that dietary staff received education on their proper use. However, the inspection report focused on the documented violations and immediate corrections rather than long-term systemic changes to prevent recurrence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Forest Ridge Health & Rehab from 2024-06-18 including all violations, facility responses, and corrective action plans.
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