Kitchen staff were interviewed, which revealed that something was identified to be wrong with the blender when the food was being blended, an audible noise was heard during the puree. The food portions were checked upon plating with nothing abnormal being observed. Staff informed that after R1 began eating their meal, a piece of metal was observed in R1's mouth; staff inspected R1's food and additional metal pieces were found. Although the source of the metal was not found, staff interviews further revealed that precautionary steps were taken, such as discarding the metal fryer basket and switching out the blender blade.

During an unannounced facility visit LPA directly observed the kitchen equipment and utensils that would have been used to prepare the meal in question. LPA observed that the fryer basket metal was similar to the metal found in R1's food, however the investigation interviews revealed that none of the food prepared for R1 was fried. The metal grill brush and scouring pad did not match the metal found in R1's food according to photos taken. LPA observed the bags of frozen chicken used by the facility- no staples were used to secure the bags and no staples were seen on the box that the chicken was shipped in.

Review of facility and outside source records showed narrative charting notes regarding wire fragment being found in R1's pureed food. The notes showed that R1's primary care physician was contacted and R1 was placed on alert charting for 72 hours. The continued notes showed that R1 remained at baseline after the incident and showed no signs of discomfort. The photos taken by an outside source of the metal pieces in R1's food were consistent with the photos taken by staff.

An outside source involved in the incident confirmed observing the piece of metal in R1's mouth and in the puree in question.

An interview with R1 was attempted but unsuccessful due to R1's cognition and ability to participate as a valid historian.

While the source of the metal remains unknown, kitchen staff observed abnormalities while preparing the puree which was fed to R1. While staff attempted to visually observe if something was in the food, a thorough check was not conducted until after R1 began ingesting the food, when a piece of metal was found in R1's mouth and additional pieces were located in R1's puree upon thorough search.

(Continued on LIC9099 p.3)

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the Licensee. An exit interview was conducted with Memory Care Director Justine Hernandez, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.