California Nursing Home Failed to Provide Proper Modified Diets, Placing Residents at Risk
TORRANCE, CA - A state inspection at Driftwood Healthcare Center documented serious failures in dietary services and care coordination that placed vulnerable residents at risk of choking and aspiration, while delays in scheduling specialist appointments left residents without needed medical care for extended periods.
Improper Diet Preparation Created Serious Safety Risks
On August 14, 2024, surveyors observed dietary staff serving sandwiches made with regular, unmodified white bread to seven residents who required a specialized dysphagia minced and moist diet. The residents—identified in the report as Residents 10, 11, 50, 53, 62, 81, and 83—all had documented swallowing difficulties and were under physician orders to receive only foods that had been ground to a fine consistency and moistened to prevent choking.
During the lunch service observation, inspectors watched as kitchen staff plated pimento cheese sandwiches using two slices of regular soft white bread with crusts intact, with ground pimento cheese filling between them. According to facility protocols, bread for residents on minced and moist diets should be processed in a food processor for 4-6 seconds to create a bread crumb consistency, then moistened with vegetable spray, water, or broth before being formed into a sandwich shape with the ground filling.
When questioned about the error, the cook stated she had not been paying attention and had treated the dysphagia minced and moist diet the same as the mechanical soft diet—a less restrictive texture modification. The dietary aide working the tray line acknowledged that the bread "did not look correct" for the dysphagia diet but did not raise concerns because she assumed the cook had prepared it properly.
The dietary supervisor initially stated he was not concerned about the sandwiches until the registered dietician reviewed the facility's diet manual, which clearly listed soft bread and rolls as foods to avoid for residents on minced and moist diets unless modified to a fine, soft bread crumb texture and moistened.
Understanding Dysphagia and Aspiration Risk
Dysphagia refers to difficulty swallowing, a condition that affects the ability to safely move food and liquids from the mouth to the stomach. When someone has dysphagia, foods or liquids can enter the airway instead of the esophagus, leading to aspiration—a potentially life-threatening complication.
Regular bread poses multiple hazards for individuals with swallowing difficulties. The texture becomes sticky and can form a bolus (clump) in the mouth that is difficult to control and swallow. Bread can also absorb saliva, becoming dry and adhering to the throat. For residents with cognitive impairments who may not chew thoroughly, pieces of regular bread can break off and block the airway.
The International Dysphagia Diet Standardization Initiative (IDDSI) provides global standards for texture-modified foods. Level 5—Minced and Moist—requires foods to be ground to pieces no larger than 4mm (the size that would fit between fork tongs) and must be moist throughout. These specifications are designed to ensure residents can safely form and swallow each bite without the food breaking into unpredictable pieces or requiring excessive chewing.
When facilities fail to follow these standards, residents face immediate risk of choking events that can cause death within minutes. Aspiration can also lead to aspiration pneumonia, a serious lung infection that develops when food particles or liquids enter the lungs. For elderly residents with multiple health conditions, aspiration pneumonia frequently results in hospitalization and carries significant mortality risk.
Vulnerable Residents Affected
The inspection report revealed that all seven residents who received improper sandwiches had complex medical conditions that made them particularly vulnerable to the consequences of dietary errors.
Resident 10, who had been admitted with dysphagia and dementia, had previously experienced a choking event requiring oral suctioning. A speech therapist evaluation recommended strict adherence to swallowing precautions including small bites, slow eating, and alternating solids with liquids. The resident's care plan specifically stated the goal was to increase ability to safely swallow minced and moist consistency foods.
Resident 11 had a documented history of aspiration pneumonia and severe cognitive impairment. Speech therapy notes from November 2023 indicated the resident had been evaluated to assess readiness to upgrade from pureed foods, with the goal of safely tolerating minced and moist consistency. The resident's care plan included interventions to prevent aspiration episodes.
Resident 53's medical record showed complaints of pain and difficulty swallowing, with speech therapy notes from July 30, 2024—just two weeks before the inspection—recommending continuation of mechanical soft ground texture foods with mildly thick liquids.
Several residents required substantial assistance with eating and had severe cognitive impairments that would prevent them from recognizing or communicating if they were choking. Resident 81 had been evaluated just days before the inspection due to food residue remaining in the mouth while eating, prompting the speech therapist to downgrade the diet to minced and moist with specific swallowing precautions.
Systemic Failures in Dietary Management
The inspection uncovered concerning gaps in staff competency and supervision. When initially questioned, the registered dietician stated the sandwiches were appropriate based on the facility's dietary spreadsheet and said staff "must follow what corporate wanted." Only after reviewing the facility's own diet manual did the dietician acknowledge that soft bread was listed as a food to avoid for dysphagia diets.
This response revealed a fundamental misunderstanding of diet standards among the professional staff responsible for ensuring residents receive appropriate nutrition. A registered dietician should immediately recognize that regular bread does not meet the texture requirements for a minced and moist diet, regardless of what appears on a menu spreadsheet.
The dietary supervisor acknowledged he was not concerned about the sandwiches until after the dietician read the contraindicated foods list. This suggests a lack of baseline knowledge about the diets being prepared in the facility's kitchen. The cook's statement that she "overlooked" the requirements and "was not paying attention" points to inadequate training or supervision of food preparation.
The dietary aide's observation that the bread did not look correct, combined with her failure to raise concerns, indicates a workplace culture where staff may not feel empowered to question potential errors or may lack confidence in their own knowledge.
Additional Issues Identified
Beyond the dietary violations, inspectors documented failures in the facility's social services department to coordinate and schedule specialist appointments for residents.
Resident 51, who had been seen by the facility dentist on July 9, 2024, reported pain in three teeth. The dentist's notes indicated the resident had "been waiting for the endo and oral surgery for a while" and documented the need for follow-up appointments "as soon as possible" for endodontic referral for two teeth and oral surgery consultation for another tooth. When inspectors reviewed the case on August 16—more than five weeks later—the Social Service Director acknowledged the referral "should have been completed but it was overlooked." The director stated she had recently implemented a tracking book for referrals but had forgotten to enter this resident's appointments.
Resident 56 was evaluated by a podiatrist on July 16, 2024, who documented thickened, elongated toenails with fungal debris and pain on touch. The podiatrist's plan specified that the resident should come to the office for further nail debridement. During an inspection interview on August 13, the resident stated her toenails "looked terrible" and that she had requested nail trimming from nurses multiple times, but "no one ever came back."
An observation on August 15 confirmed the resident's toenails on both feet were thick and long. The licensed vocational nurse acknowledged the resident had a physician order for podiatry services "as clinically indicated" but stated she had only done "a quick glance" during medication pass rather than a thorough foot assessment. The nurse admitted she should have examined the toenails for infection and fungal conditions so the physician could be notified.
Proper foot care is particularly important for elderly residents, as thickened nails can cause pain when wearing shoes or socks, lead to skin breakdown from pressure, and create entry points for infection. For residents with diabetes or circulatory problems, minor foot issues can rapidly progress to serious complications.
The Social Service Director acknowledged that Resident 56's appointment was "overlooked," indicating a pattern of missed follow-through on specialist referrals rather than isolated incidents.
Regulatory Standards and Facility Obligations
Federal nursing home regulations require facilities to provide medically-related social services to help each resident achieve the highest possible quality of life. This includes coordinating medical appointments and ensuring residents receive necessary specialty care in a timely manner.
Dietary services regulations mandate that facilities employ sufficient support personnel who are competent to safely and effectively carry out food and nutrition service functions. Staff must be able to prepare and serve physician-prescribed therapeutic diets according to established standards. The facility's own policies stated that the primary objective of the dietary department included "preparation and provision of nutritionally adequate, well-balanced meals that are consistent with physician orders."
The facility's policy on dysphagia diets specifically stated the purpose was "to provide appropriate food and fluid consistencies to residents with dysphagia or swallowing problems, to ensure adequate hydration and diminish the risk for asphyxiation." Another policy required dietary staff to check tray cards against meals served at the tray line and correct any discrepancies—a step that clearly failed to occur.
According to the inspection report, the facility uses the DiningRD.com Long Term Care Diet Manual, which provides detailed specifications for each diet level based on IDDSI standards. The manual explicitly lists foods to avoid for minced and moist diets, including soft bread, rolls, cake, and crackers unless modified to fine, soft bread crumb texture and moistened. Despite having access to these professional guidelines, dietary staff failed to follow them.
The inspection classified these violations as causing "minimal harm or potential for actual harm," though the potential consequences—choking, aspiration, and aspiration pneumonia—can be severe or fatal. The classification likely reflects that no resident actually choked or aspirated during the observed meal service, but the risk created by the improper diet was substantial.
These findings at Driftwood Healthcare Center highlight the critical importance of staff training, competency verification, and supervision systems in nursing homes. When facilities fail to ensure that professional and support staff understand and can properly implement specialized diets and care coordination protocols, residents with complex medical needs face preventable risks to their health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Driftwood Healthcare Center from 2024-08-19 including all violations, facility responses, and corrective action plans.
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