TORRANCE, CA - State health inspectors identified serious food safety violations at Driftwood Healthcare Center after seven residents with diagnosed swallowing difficulties received meals that did not comply with their medically prescribed diets, creating immediate risk of choking and aspiration.
Improper Food Preparation for Residents with Swallowing Disorders
During an unannounced inspection on August 14, 2024, health surveyors observed that residents prescribed a specialized "dysphagia minced and moist" diet received sandwiches prepared with regular soft white bread instead of the required finely ground, moistened bread crumbs. The violation affected Residents 10, 11, 50, 53, 62, 81, and 83—all individuals with documented swallowing difficulties requiring texture-modified foods.
The prescribed diet specifically requires all bread products to be processed into fine crumbs using a food processor, then moistened with cooking spray or broth before assembly. Instead, kitchen staff served ground pimento cheese salad between two regular slices of soft white bread with crusts intact, cut in half like a standard sandwich.
According to the facility's own diet manual, soft bread and rolls are explicitly listed as foods to avoid for residents on minced and moist diets unless modified to a fine, soft breadcrumb texture and properly moistened. When questioned, the facility's registered dietician confirmed that serving this type of sandwich "placed the residents at the risk for choking, aspiration, and respiratory distress."
Understanding Dysphagia and Texture-Modified Diets
Dysphagia, or difficulty swallowing, affects millions of older adults and individuals with neurological conditions. When swallowing function becomes impaired, ordinary foods can become dangerous. Texture-modified diets represent a critical medical intervention designed to match food consistency with a person's specific swallowing capabilities.
The International Dysphagia Diet Standardization Initiative (IDDSI) established global standards for these diets. Level 5—Minced and Moist—is designed for individuals with mild to moderate oral dysphagia. Foods at this level must be ground, moist, and small enough to fit between the tongs of a fork. This specific texture reduces the oral effort required to prepare food for swallowing while maintaining adequate moisture to help the food move safely through the throat.
When someone with dysphagia consumes food that is too dry, too tough, or requires excessive chewing, the risk of aspiration increases dramatically. Aspiration occurs when food or liquid enters the airway and lungs instead of traveling to the stomach. This can trigger immediate choking or lead to aspiration pneumonia, a serious and potentially fatal lung infection.
Soft bread poses particular dangers for individuals with swallowing difficulties. Despite feeling soft to the touch, bread becomes sticky and cohesive when mixed with saliva, forming a mass that can be difficult to control in the mouth and challenging to swallow safely. The crust adds additional texture that requires more chewing force and coordination. For residents with dementia—several of the affected residents had this diagnosis—food pocketing (holding food in the cheeks rather than swallowing) compounds these risks.
Multiple System Failures in Kitchen Operations
The inspection revealed that the cook preparing meals on August 14 did not have access to the proper recipe for minced and moist sandwiches. During interviews, the cook acknowledged looking at the dietary spreadsheet and incorrectly preparing the dysphagia minced and moist diet the same way as the standard mechanical soft diet, which does not require bread to be ground into crumbs.
"I do not know what happened," the cook told inspectors, admitting that all residents on dysphagia minced and moist diets received the improperly prepared sandwich that day.
The dietary supervisor, who was present and overseeing meal preparation, stated he had not realized the cook lacked the necessary recipe. He reported assuming sandwiches were being prepared according to the mechanical soft diet specifications rather than the more restrictive minced and moist requirements. The supervisor acknowledged he was not concerned about the sandwiches being served to dysphagia residents until the registered dietician reviewed the diet manual's list of foods to avoid.
A dietary aide working the tray line that day recognized something was wrong. "The usual presentation for a minced and moist diet looked like finely ground pieces and bread was usually soaked in a liquid," the aide reported. However, despite knowing "the bread did not look correct for the dysphagia diet," the aide did not question the preparation because the cook had prepared it.
Nursing Staff Failed to Identify Unsafe Meals
The facility's system includes multiple checkpoints designed to catch dietary errors before meals reach residents. Licensed nurses are responsible for validating meal trays against physician diet orders before delivery. Dietary staff check tray cards against served meals at the tray line. Certified nursing assistants verify diet cards match the meals when delivering trays to resident rooms.
On August 14, these safety systems failed completely. A licensed vocational nurse checked lunch meal carts and observed the pimento cheese sandwiches on regular bread but "did not see anything wrong" with them being served to residents on minced and moist diets.
A certified nursing assistant delivering a tray to Resident 81 immediately recognized the problem. The aide stated "the bread served was not safe for Resident 81 to consume because the resident tends to pocket her food and she could choke." However, by this point, meal carts had already been distributed throughout the facility.
The facility's Director of Nursing acknowledged that licensed nurses checking meal trays "should have returned the trays to the kitchen due to incorrect food texture posing a choking hazard" and that nursing assistants should recognize proper diet consistencies and alert nurses when discrepancies occur.
Residents' Medical Vulnerabilities
The seven affected residents had significant medical complexities that made proper diet adherence particularly critical. Medical records reviewed during the inspection documented multiple risk factors:
Resident 10 had been admitted with dysphagia, dementia, and depression. A June 2024 speech therapy evaluation followed a choking incident requiring oral suctioning. The resident had demonstrated "low tolerance of regular texture solid food" with coughing episodes, prompting the recommendation for texture modification.
Resident 11 carried a history of aspiration pneumonia and had been receiving speech therapy to work toward safely tolerating minced and moist consistency foods after requiring a pureed diet.
Resident 50 had experienced a cerebral infarction (stroke) along with dementia and diabetes, conditions that frequently affect swallowing coordination.
Resident 53 was receiving speech therapy for swallowing dysfunction and exhibited coughing or choking during meals, with documented complaints of pain while swallowing.
Resident 62 presented with mild oral dysphagia and required staff assistance with feeding, indicating dependence on others to monitor safe eating.
Resident 81 had been evaluated just two weeks before the incident due to residue remaining in the mouth while eating, prompting the recent diet downgrade to minced and moist consistency.
Resident 83, admitted in July 2024 with dysphagia and autism, was completely dependent on staff for feeding and had documented difficulty and pain with swallowing.
Each of these residents had individualized care plans specifically addressing aspiration risk. The plans documented goals to prevent aspiration episodes and interventions requiring staff to provide diets as ordered by physicians and monitor for swallowing difficulties. Speech therapists had evaluated swallowing function and made specific recommendations to reduce choking and aspiration risk.
Medical Response and Immediate Jeopardy Declaration
On August 15, 2024, state surveyors declared an Immediate Jeopardy situation—the most serious finding in nursing home oversight, reserved for circumstances where noncompliance has caused or is likely to cause serious injury, harm, or death.
All seven affected residents were assessed by licensed nurses on August 14 and 15 for adverse effects from receiving food inconsistent with their prescribed diet texture. Each resident remained in stable condition, and attending physicians were notified of the incidents.
The facility submitted an acceptable removal plan on August 16, which included immediate corrective actions. The registered dietician provided education to dietary supervisors, cooks, and licensed nurses regarding proper validation of residents' diet textures before meals are served. The facility's web-based menu system was updated to provide the missing recipes for mechanical soft minced and moist diets. One-on-one training was conducted with the dietary supervisor on food preparation according to menu recipes for prescribed diets.
After onsite verification of the plan's implementation through observation, interviews, and record review, the Immediate Jeopardy was removed on August 16, 2024.
Additional Issues Identified
The inspection documented systematic failures beyond the immediate diet preparation errors. The facility's recipe monitoring system had broken down—the dietary supervisor had not verified that cooks had access to all necessary recipes for therapeutic diet modifications. Communication failures existed between corporate recipe providers and facility kitchen staff, with the registered dietician noting that "corporate wanted" certain menu items followed, even when local staff lacked proper preparation instructions.
Staff training gaps were evident across multiple departments. Dietary aides recognized improper food preparation but did not feel empowered to question decisions. Licensed nurses responsible for final tray checks lacked sufficient knowledge to identify incorrect diet textures. Even the dietary supervisor, directly overseeing meal preparation, did not recognize the safety violation occurring under his supervision.
The facility's policies and procedures, while comprehensive on paper, were not effectively implemented. Written protocols required nutritionally adequate meals consistent with physician orders, proper recipe usage, and multiple verification checkpoints. Yet on August 14, every safety system failed simultaneously, allowing dangerous meals to reach vulnerable residents.
Industry Standards and Medical Protocols
Healthcare facilities are required to translate physician diet orders into actual meals that meet established nutritional and safety standards. This responsibility extends beyond simply cooking food—it encompasses understanding the medical rationale behind diet modifications, maintaining current recipes and preparation techniques, training staff competently, and implementing effective verification systems.
Speech-language pathologists play a central role in dysphagia management, conducting clinical swallowing evaluations to assess aspiration risk and recommending appropriate diet textures. These recommendations are based on observed swallowing physiology and are individualized to each person's capabilities. Physicians review these recommendations and issue diet orders that become part of the medical treatment plan.
The facility's Director of Rehabilitation emphasized that "it was important to follow closely the speech therapist's recommendations because [the speech therapist] was the one evaluating the safety of the resident's swallowing." The rehabilitation director noted that diet recommendations are "based on the speech therapist's clinical evaluation which was then reviewed by the physician following with a diet order. If the diet was not followed, there was a high risk for aspiration."
This inspection occurred at Driftwood Healthcare Center, located at 4109 Emerald Street in Torrance, California, on August 19, 2024.
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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