Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to follow the appropriate diet and serve the appropriate portions for (2) residents (#11, #18) who received pureed diets and failed to follow the menu diet for all residents who received gravy. The facility reported a census of 35 residents. Findings include: On 1/08/25 at 10:40 AM, Staff B, Cook, began making the pureed pork. He placed six (6) small pieces of pork into the blender and added 2 ounces (oz) of beef base. He blended the contents. He emptied the contents into a steam table bowl. Some of the contents was observed still in the blender when rinsed. The total volume was not measured and the Dishers Scoop Sizes, Colors and Yields chart was not used to determine the appropriate serving size prior to being served. At 11:37 AM, Staff C, Dietary Aide (DA), placed serving utensils in each menu item pan. She stated a #20 disher (1.6 fluid oz) was used for the pureed pork and pureed vegetable serving sizes, and a black handled scoop was used for gravy. She was not able to identify the black handled scoop size. A continuous meal service observation revealed every resident who received gravy got one (1) scoop of gravy with the black handled scoop. At 1:55 PM, Staff A, Cook, stated he did not puree egg rolls. He stated he just didn't think about it. He also stated he made the pureed vegetables and based the serving size on the combined individual amounts of vegetables and tomato juice used during the pureed process. He stated he did not measure the total volume and used the facility Disher Scoop Sizes, Colors and Yields (DSSCY) conversion chart to determine the disher size. At 2:15 PM, the Certified Dietary Manager (CDM) stated the facility used the facility specific conversion chart. A review of the menu indicated a #6 scoop (5.33 fluid oz) was the appropriate pureed pork serving size which resulted in a -3.73 oz serving. It also indicated a #12 scoop (2.67 fluid oz) was the appropriate pureed vegetable serving size which resulted in a -1.07 oz serving. and 2 oz was the appropriate gravy serving size. The menu also identified 2 oz of gravy was the appropriate serving size. The black handled serving scoop used was later identified as a one (1) oz serving size which resulted in a -1 oz serving. An Electronic Health Record review revealed both Resident #11 and Resident #18 were ordered pureed diets without portion restrictions. A policy titled Kitchen Weights and Measures revised 10/2018 indicated cooks and staff plating food for meal service will follow the portion sizes per menu and will use appropriate utensil. On 1/09/25 at 2:01 PM, the Administrator stated staff should follow the scoop diagram (pureed disher conversion chart) and menu items serving sizes.

Based on observation, staff interview, and policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature for one of one meal service observed. The facility reported a census of 35 residents. Findings include: On 1/08/23 at 11:37 AM, a continuous lunch service observation revealed Staff C, Dietary Aide (DA), obtained the temperature of one (1) food item, Salmon croquettes, prior to service and noted the temperature of 123.5° Fahrenheit (F). All other lunch menu items met acceptable temperatures. At 12:20 PM, Staff C obtained the temperatures of remaining lunch menu items after meal service ended. The results were: 1) Salmon croquettes - 117° F 2) Mashed potatoes - 124.8° F 3) Vegetable egg rolls - 122° F 4) Pureed pork - 124° F 5) Mechanical Soft egg rolls - 120° F A policy titled Food Preparation and Service revised 10/2018 indicated food held at temperatures between 41° F and 135° F promoted the rapid growth of pathogenic organisms that cause foodborne illness and must be maintained above 135° F. On 1/09/25 at 2:03 PM, the Administrator stated staff should bring menu items to appropriate temperatures before serving. She also stated staff should have reported the low temperatures to the CDM and implemented corrective procedures to ensure the food maintained correct temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to maintain sanitary practices by improperly storing and serving food. The facility reported a census of 35 residents. Findings include: On 1/06/25 at 10:20 AM, an initial kitchen observation identified the following findings: A [NAME] refrigerator contained: 1) Two (2) undated, unlabeled, sealed packs of long, round, hot-dog looking items. 2) Three (3) opened, undated bags of grapes in a single labeled box. 3) One (1) undated, previously opened 2-liter bottle of A&W root beer. 4) Three (3) undated, unlabeled, clear dispensers with a clear liquid and round, orange, disk shaped items. 5) Four (4) unlabeled, loaf shaped packages of a dark pink substance. A [NAME] freezer 1) One (1) undated, unlabeled, clear plastic bag with round, yellow items. 2) One (1) undated, unlabeled, clear plastic bag with a pink, meat-looking item on a cookie pan. The kitchen area contained: 1) A white bin labeled sugar had 1 sealed bag of sugar, 1 opened bag of sugar, and a plastic scoop lying on top of the sugar at the bottom of the bin. 2) An undated, unlabeled clear plastic container with a blue lid had a white flaky product. The dry goods storage contained: 1) Multiple unlabeled bags of brown, flaky items. 2) Multiple unlabeled bags of tan, donut-shaped items. On 1/08/25 at 7:06 AM, a follow-up kitchen visit revealed: 1) One (1) undated, previously accessed plastic container of strawberries. 2) Two (2) pans of unlabeled, red, gelatin-like substance with orange colored chunks. 3) Three (3) opened, undated bags of grapes in a single labeled box. 4) One (1) undated 2-liter bottle of A&W root beer. 5) Three (3) undated, unlabeled, clear dispensing containers with clear liquid and round, light green disk-shaped items. A [NAME] freezer contained: 1) One (1) undated and unlabeled clear plastic bag of rounded, rectangular shaped items. 2) Multiple bags of multicolored vegetable-like items. The kitchen contained one (1) white bin labeled sugar that had 1 sealed bag of sugar, 1 opened bag of sugar, and a plastic scoop lying on top of the sugar at the bottom of the bin. The dry goods storage contained: 1) One (1) bag of undated, unlabeled jug of white liquid beside a Frymax container. 2) One (1) bag of unlabeled tan grain-shaped items. On 1/08/24 at 10:35 AM, Staff A, Cook, grabbed a can of spray butter with his gloved hand and sprayed the inside of a steam table bowl. He then grabbed the egg rolls with the same gloves and placed them in 3 steam table bowls. No hand hygiene or glove change was performed between touching the spray can and eggs rolls. At 10:37 AM, Staff B, [NAME] opened the walk-in freezer door with gloved hands. He then grabbed a bread loaf with the same gloves and positioned it on the food preparation table. After cutting the bread, he grabbed several different utensils and a mustard container. He took two (2) slices of lunch meat from a package and placed them on the bread. No hand hygiene or glove change was performed throughout the process. At 10:55 AM, Staff B performed hand hygiene and donned gloves. He opened a large container of pickles, grabbed a knife, opened the stack of cheese, stuck his gloved hand inside the pickle container and grabbed and handful of pickles. On 1/09/25 at 2:10 PM, the Administrator stated staff should follow the facility's policies regarding food storage, hand hygiene, and prevention of cross-contamination. A policy titled Food Receiving and Storage revised 10/2018 indicated dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). It also indicated all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on staff interview, review of the facility's Provider History Profile reports, and facility policy review, the facility failed to ensure an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies. This resulted in multiple repeat deficiencies identified on the facility's current recertification and complaint survey. The facility reported a census of 35 residents. Findings include: Review of the facility's Provider History Report revealed the facility received the same deficiency for three (3) consecutive recertification surveys. The deficiency category was for failing to accurately follow resident menus. On 1/09/25 at 2:50 PM, the Certified Dietary Manager (CDM) stated she assigned all staff to watch a video on diet portion sizes as part of the QAPI Performance Improvement Plan (PIP). At 2:55 PM, the Administrator stated the CDM held monthly in-services and the administrative team held a skills fair twice yearly. She stated the video was provided to staff on 4/30/24 and 5/02/24. She stated all staff should be done as it was mandatory. She stated the facility's internal program contained the detailed information of the PIP. At 3:38 PM, the administrator stated there was no documentation of follow-up to the efficacy of the aforementioned PIP. The facility policy, titled Quality Assurance and Performance Improvement (QAPI) Manual revised 1/2024, indicated ongoing monitoring will be achieved by using tools specifically developed to monitor desired outcomes. It also indicated the Quality Assessment and Assurance (QAA) committee will monitor progress, provide input, and ensure the individuals involved in the project have the resources they need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and facility policy review, the facility failed to maintain a clean, comfortable and homelike environment for 2 out of 8 resident rooms. The facility reported a census of 39 residents. Findings include: 1. On 09/25/23 at 11:00 AM observation of the carpeted floor in room [ROOM NUMBER] revealed excessive stains of various sizes and colors. A urine odor noted in the room. A second observation on 09/26/23 at 09:00 AM of room [ROOM NUMBER] revealed no changes to the stained carpet and continued to have a strong urine odor. A third observation on 09/27/23 at 10:00 AM of room [ROOM NUMBER] showed stained carpet and urine odor remained unchanged. During an interview on 09/27/23 at 12:20 PM the Housekeeping Supervisor and the Maintenance Supervisor both confirmed the carpet was excessively stained and the urine odor noted but could not provide a date of the last time the carpet was shampooed. 2. On 09/26/23 at 10:10 AM observation of the carpeted floor in room [ROOM NUMBER] revealed 2 red color stains of approximately 4 inches in diameter in front of a recliner. The room noted to be excessively warm. The thermostat on the wall was not functioning and the temperature was not displayed. The maintenance department confirmed the room temperature measured using an infrared thermometer was 86 degrees fahrenheit. During an interview on 09/26/23 at 12:20 PM the Maintenance Supervisor stated the expectation for the room temperature ranged between 70-80 degrees fahrenheit. He further stated he wasn't aware the room temperature was outside the expected range and that the thermostat on the wall wasn't functioning. The facility policy review on 09/28/23 at 2:30 PM titled Quality of Life-Home Environment undated, documented residents are provided with safe, clean, comfortable homelike environment, comfortable and safe temperatures (71 degrees fahrenheit - 81 degrees fahrenheit).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview and staff interviews, the facility failed to provide restorative activities for 1 of 1 sampled resident in order to maintain a functional range of motion and prevent a decline in activities of daily living (Residents #3). The facility reported a census of 39 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #3 had diagnoses that included anemia (low blood count), arthritis, Alzheimer's Disease, muscle weakness, and abnormal gait and mobility. The MDS revealed the resident required limited assistance of one for bed mobility, transfers, dressing, personal hygiene, and toileting. The MDS indicated no range of motion (ROM) impairment to the upper and lower extremities. The MDS revealed the resident had Occupational Therapy (OT) services from 4/10/23 - 5/31/23 and was actively receiving Physical Therapy (PT) services that began 7/2/23. The Electronic Health Record (EHR) for the resident recommended for Restorative Aide (RA) program services by OT on 5/31/23 focused on bilateral upper extremity (BUE) exercises two to three (2-3) times per week. The MDS assessment dated [DATE] included significant changes to Resident #3's functional status which required extensive assistance of one for bed mobility, transfers, dressing, personal hygiene, and toileting. The MDS indicated no ROM impairment to the upper and lower extremities. It also indicated the resident received one (1) day of restorative nursing program training and skill practice in transfer and walking in the seven (7) day look-back period. The EHR for the resident recommended restorative program services by PT on 8/18/23 focused on lower body exercises 2-3 times per week. The Progress Notes included RA documentation dated 8/31/23 indicating the resident received restorative program BUE exercise. The resident's Care Plan included Restorative Nursing exercises and directed staff to have the resident perform Upper Body tasks 2-3 times per week. The Lower Body restorative exercises 2-3 times per week were marked as resolved on 7/28/23. During an interview on 9/25/23 at 2:50 PM, Resident #3 stated that she was not getting around as easily as she used to. On 9/26/23 at 1:10 PM, the Rehabilitation Director stated the resident should be on RA program services for BLE & BUE through PT and OT respectively. On 9/26/23 at 3:30 PM, a therapy assistant stated the facility did not have a routine Restorative Aide. On 9/26/23 at 3:43 PM, the Assistant Director of Nursing (ADON) stated the resident had not received restorative program services 2-3 times per week due to staffing shortages. She stated a Performance Improvement Plan was being done as the facility was aware of the problem. The EHR included the restorative program BUE and BLE tasks. The subsequent Point-of-Care (POC) response history documentation revealed the resident had not received scheduled restorative program exercises. On 9/26/23 at 3:58 PM, Staff D, Certified Nurse Aide (CNA) stated the resident had not received dedicated restorative services within the previous three to four weeks. A policy titled Restorative Nursing Services revised 7/2017 indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence.

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve the appropriate portions for the last five (5) residents who received green beans or mashed potatoes. The facility reported a census of 39 residents. Findings include: On 9/27/23 at 12:53 PM, observed Staff C, Dietary Aide (DA) partially fill a #8 (4-oz) scoop for a serving of potatoes and a 4-oz ladle for a serving of green beans for the last 5 resident servings. At 12:59 PM, the Registered Dietician stated the serving size of vegetables is 4 oz. but less dense starches required larger portion servings. A review of the Week 5 Wednesday menu indicated a serving size of mashed potatoes was a #8 scoop and a serving size of green beans was four (4) ounces. A document titled Diet Type Report provided by the Dietary Manager revealed no resident was ordered half-portion sizes for meals. On 9/28/23 at 10:25 AM, the Dietary Manager stated staff should provide serving sizes according to the guidelines. A policy titled Kitchen Weights and Measures revised 10/2018 directed staff to follow the portion sizes per the menu and to use appropriate utensils.

Based on observations, staff interview, and facility policy review, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 39. Findings include: During a continuous observation on 9/27/23 beginning at 11:33 AM, Staff C, Dietary Aide (DA), obtained the temperatures of two (2) foods that were noted to be below the acceptable holding temperature. The mechanical soft turkey had a temperature of 131.4° Fahrenheit (F) and the pureed turkey had a temperature of 93° F. At 12:32 PM, Staff C prepared a resident plate containing the mechanical soft turkey but was asked to recheck the temperature of the mechanical soft turkey before serving it. The temperature observed to be 129° F and it was subsequently reheated to 190° F before being served to a resident. The pureed turkey was served to the resident without rechecking the temperature or being reheated. A policy titled Food Preparation and Service revised 10/2018 indicated food held at temperatures between 41° F and 135° F promoted the rapid growth of pathogenic organisms that cause foodborne illness and must be maintained above 135° F. On 9/28/23 at 10:25 AM, the Dietary Manager confirmed the temperatures were below acceptable limits for serving meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing, preparing, and serving food. The facility reported a census of 39 residents. Findings include: During an initial kitchen observation on 9/25/23 at 9:35 AM, the following findings were identified: -Observed all of the Heating, Ventilation, and Air-Conditioning diffusers (HVAC vents) missing and two (2) ducts blowing air directly on a pan of barbeque (BBQ) chicken located on the food preparation table. Another exposed duct blowing air directly on the area designated for newly washed dishware. -Observed a serving scoop stored inside a bin of flour in direct contact with the contents. -Observed Staff A, Cook, did not have his facial hair covered while preparing food and Staff B, Dietary Aide (DA), did not cover the back of her hair while handling food. -The [NAME] refrigerator contained an undated bag of previously opened dinner rolls, a partially covered tray of vegetable lasagna, and a partially covered block of butter. -The [NAME] freezer contained an undated, unlabeled, open brown bag of food, an undated bag of mixed vegetables, and a partially covered carton of Blue Bunny sorbet. A sealed bag and round package of meat were stored on the floor between two (2) storage racks and a stack of boxes were stored on the floor in the middle of the freezer. A dining observation on 9/25/23 at 11:33 AM revealed, Staff C's, (DA), hairnet did not cover the lower back of his hair. While serving food, Staff C picked up a plate with no gloves and his thumb touched a part of the inside of the rim of the plate then he put a piece of BBQ chicken on the plate where his finger touched. While Staff C was putting chips on another plate, the sandwich came in direct contact with the outside of the potato chip bag that Staff C opened with his bare hands. At 11:59 AM, Staff C put on gloves, served a plate of food, then opened a drawer to get another serving scoop, placed the scoop in the mashed potatoes then grabbed a slice of bread with same gloves. On 9/28/23 at 9:10 AM, the Dietary Manager stated the expectation was food should be labeled and dated when stored; staff should wear a hairnet properly; and staff should wash hands after touching nonfood items while serving food. A policy titled Food Receiving and Storage revised 10/2018 indicated all foods stored in the refrigerator or freezer will be covered, labeled and dated and opened containers must be dated and sealed or covered during storage. A policy titled Food Preparation and Service revised 10/2018 directed staff to wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. It further directed staff to wear gloves when food is handled directly and to change gloves between tasks.

Based on observation, record review, and staff interviews, the facility failed to ensure staff served the proper serving size for 2 of 2 residents with a pureed texture diet (Resident # 26 and Resident # 32). The facility reported a census of 40 residents at the time of the survey. Findings include: The facility's document titled, Pivotal SS 2022 for Week 4 lunch Tuesday listed the food items planned for lunch on 6/21/22: apple butter pecan crusted pork loin chops, rice pilaf, buttered zucchini, dinner roll/margarine , bread pudding, milk. The document titled, Diet Spreadsheet directed staff to serve 1 serving of each of the apple butter pecan crusted pork loin chops, rice pilaf, buttered zucchini, dinner roll/margarine, bread pudding, and 8 oz of milk to residents on a pureed diet for lunch on 16/21/22 . During preparation of the pureed food on 6/21/22 at 10:40 AM, Staff A (dietary cook) said the facility had 2 residents on a pureed diet, but he planned to prepare 3 serving sizes for each kind of food. Staff A used 4 1/2 scoops to measure and prepare the vegetables (veggies), which resulted in a total of 15 ounces (oz). Staff A said the 15 ounces of veggies would make up for 3 servings of 5 oz portions. Staff A labeled the container for the prepared veggies as veggies 3 5 oz and then set aside. Staff A took 3 pieces of porkchops and added chicken broth to make 12 oz of pureed meat. Staff A said that to make 3 serving sizes, it would be 4 oz each serving, so he labeled the container to indicate 3 serving sizes of pork at 4 oz. However, on 6/21/22 at 12:45 PM, when Staff B (dietary aide) who worked at the kitchen/dining area measured the pureed food, he used a smaller scoop of 3 1/4 oz for the porkchop instead of 4 oz and also used a smaller scoop of 4 oz for the veggies instead of 5 oz. The pureed food were then served to Resident # 26 and Resident # 32. Staff B verified the size of the scoops used and the amount of food served to the 2 residents. Staff B verbalized that those were the correct scoops for each serving size, saying that 1 serving of meat equals 3 oz. On 6/21/22 at 12:50 PM the Dietary Director (DD) also identified the sizes of the scoops sitting on the countertops as 3 1/4 oz and 4 oz, which were used for the pureed meat and veggies served to the residents on pureed diet. The clinical records of the 2 residents on pureed diet showed the following: 1. Resident # 26's medical diagnoses include esophageal reflux disease, dementia, deficiency of other specified B group vitamins, esophageal obstruction, and anemia. Resident # 26's diet orders indicated regular diet, and pureed texture. Resident # 26's care plan showed potential for nutritional problem related to history of dysphagia (difficulty or discomfort in swallowing) and needed mechanically altered diet. The care plan also indicated a goal for Resident # 26's weight to remain stable. 2. Resident # 32's medical diagnoses include Alzheimer's disease, irritable bowel syndrome, protein-calorie malnutrition, and type 2 diabetes mellitus. The orders for Resident # 32 identified a regular diet with pureed texture. Resident # 32's care plan showed a potential for nutritional problem. The care plan indicated that Resident # 32's nose runs a lot while eating which can be a sign of aspiration. The care plan also indicated an occasional weak cough while eating and drinking. The care plan documented ed Resident # 32's risk for malnutrition. The care plan directed staff to provide general/pureed diet, to offer and encourage snacks and juice between meals, to offer and select a balanced meal, and to provide feeding assistance. During an interview on 6/22/22 at 11:32 AM, the Administrator was talking on the phone with the DD who reportedly verified that Staff B was correct in using the smaller-sized scoops to measure the serving amount of food given to the residents. The Administrator acknowledged that there was a need to educate dietary staff members to ensure knowledge and consistency on measurements and correct serving size of food being provided to residents with mechanically altered diet. The facility's policy titled, Kitchen Weights and Measures with revision date of October 2018, provides, Cooks and staff plating food for meal service will follow the portion sizes per menu and will use appropriate utensil. The policy also indicates that staff will be trained in the appropriate measurement and type of serving utensil to use for each food. The policy further noted, The Culinary Director will ensure cooks prepare the amount of food for the number of servings required.