Based on interview, record review and review of the facility policy, the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care for 1 of 6 sampled residents, (Resident (R)3). Review of the Baseline Care Plan dated 04/01/2025, revealed the facility failed to develop a care plan for R3 related to nutritional risk until 04/16/2025, 15 days following admission to the facility. The findings include: Review of the facility policy, Care Plans, reviewed on 11/29/2023, revealed, to ensure that a resident's immediate care needs were met and maintained, a baseline care plan would be developed within forty-eight (48) hours of admission. Continued review revealed the interdisciplinary team (IDT) was to review orders, dietary needs, social needs, therapy orders, and treatments to ensure the care plan met the residents' baseline needs. Review of the medical record for R3 revealed the facility admitted the resident on 04/01/2025, with diagnoses to include postmenopausal vaginal bleeding, morbid obesity, and physical deconditioning. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 04/04/2025, revealed the facility assessed R3 to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. Continued review of the Care Area Assessments (CAA) revealed a nutrition care plan was to be developed. Review of the Baseline Care Plan dated 04/01/2025, revealed no documented evidence the facility developed a care plan for R3 related to nutritional risk until 04/16/2025, 15 days following admission to the facility. Review of the Comprehensive Care Plan dated 04/16/2025, revealed the facility developed a nutritional risk care plan for R3 due to being the resident being a new admission to the facility and having an elevated body mass index (BMI) with interventions. Review of the Nutrition/Dietary Note dated 04/15/2025 at 3:08 PM, and signed by the Registered Dietician (RD) revealed the patient had experienced a 17.7 pound, 7% weight loss since admission. Continued review revealed R3 was not on a diuretic and was to continue on a regular diet. Further review revealed the RD noted adding Ensure Clear TID (Nutritional supplement three times a day). In addition, review revealed R3 had very poor intakes due to nausea, might benefit from an appetite stimulant, and staff were to encourage intakes of meals and supplements. In interview with the RD on 04/24/2025 at 2:00 PM, she stated the Director of Nursing (DON) was responsible for developing the residents' baseline care plans. She reported care plans should be developed within 72 hours of admission. The RD said residents' weights and intakes were checked twice weekly by herself, the Administrator, and the DON. In interview with the DON on 04/24/2025 at 2:25 PM, she stated she was responsible for the residents' baseline care plans. She stated the baseline care plans were based on a resident's diagnoses and medications and was typically completed within two hours of admission. In interview with the Administrator on 04/24/2025 at 3:45 PM, he stated his expectation was that the DON complete the baseline care plan, if applicable, when a resident was admitted and within forty-eight hours.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation revealed opened food items which were not dated or labeled; no thermometer in the walk in cooler; a meat thermometer in the freezer; and an employees lunch bag in the walk in cooler. The findings include: Review of the facility policy, Culinary Service Group, Label and Date Standards, undated, revealed, a mandatory label and date system was to be used for all food items that were opened, cooked, processed, or changed in any manner. Per policy review, a food label must be attached to all food items intended to be used at a later date, and if being stored in a refrigerator, freezer, or in dry storage area. Continued review revealed refrigerator temperatures should be at 40 degrees Fahrenheit (F) or below. Further review revealed every refrigerator must be equipped with an inside thermometer and was not to exceed 40°F, and freezer temperature should be at 0°F or below. In addition, policy review revealed Do not refreeze frozen food which has been thawed, and the holding temperature for frozen foods was from 0°F or below. Observation of the facility's kitchen area on 04/23/2025 at 10:50 AM, revealed the walk-in cooler did not have a thermometer inside and an employees lunch bag was stored inside the cooler. Observation of the freezer revealed it contained two bags of frozen green beans which were opened, unlabeled and undated. Continued observation of the freezer revealed a bag of diced onions wrapped with plastic wrap, not labeled or dated, with black marker writing that read, refrozen 04/11/2025. Further observation of the freezer revealed it had a meat thermometer inside it. In interview with the Food Service Director on 04/23/2025 at 11:15 AM, he stated the cooler and freezer should have had the appropriate thermometers in them, and the freezer should not have had a meat thermometer. He stated the temperature readings were also located on the outside. The Food Services Director said the employee lunch bag should not have been stored in the walk in cooler as employees had their own refrigerator to store their items. He reported thawed items were not to be placed back in the freezer once thawed, and the frozen beans should have been labeled and dated. The Food Services Director further stated there was not a policy on employees storing meals in the coolers; however, he expected the kitchen staff to follow the guidelines. In interview with the Administrator on 04/24/2025 at 3:34 PM, he stated he expected the food services staff to follow their guidelines. He stated items should be labeled and dated before being stored. The Administrator reported the correct thermometers should be used in the coolers and freezers and employees could not store their personal lunch bags in the coolers. He said there was a designated area for employees to store their personal items. The Administrator further stated outcomes for patients could be nausea and vomiting if served food that was not stored properly.

Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation revealed opened food items which were not dated, and/or expired. The findings include: 1. Review of the facility policy titled, Food and Supply Storage, revised 01/2022 revealed all food, non-food items and supplies used in food preparation were to be stored in such a manner as to prevent contamination and maintain the safety and wholesomeness of the food for human consumption. Continued review revealed unused portions and open packages of food items were to be covered, labeled and dated. Further review revealed food items which were past the use by, sell by, best by or enjoy by dates should be discarded. Observation of the facility's kitchen area on 03/29/2022 at 9:45 AM, revealed the walk-in cooler had an opened container of strawberries with approximately a quarter of berries left in it, and an opened container of blueberries with approximately half the berries left in it. Continued observation revealed both containers of berries were unlabeled and not dated with an opened date. Observation of the walk-in freezer area revealed an opened bag of frozen turkey sausage links which were not labeled and dated with the opened dated. In addition, observation of the reach in refrigerator revealed an expired half gallon of milk which was dated 03/28/2022. Interview on 03/30/2022 at 2:11 PM, with the Director of Food and Nutrition Services revealed all opened food items located in the refrigerator or freezer areas should always be labeled and dated. She revealed items not dated or labeled should have been removed and discarded as there was a potential for food borne illness if such items were used. 2. Review of the facility policy titled, Uniform Dress Code revised 01/2022 revealed personal cleanliness and a neat appearance were essential components for the food service worker. Further review revealed associates working with food were to wear the approved hair restraint when on duty regardless of the length or presence of hair. Observation on 03/29/2022 at 10:45 AM, revealed a kitchen staff member entered the kitchen area without applying a hair covering to her head. Continued observation revealed the staff member walked all the way through the kitchen area to a coat rack area located at the side of the kitchen. Interview on 03/29/2022 at 10:45 AM, with the kitchen staff member, a Dietary Aide revealed she had not applied a hair covering upon entering the kitchen area. Further interview revealed she typically did not apply a hair covering at the doorway of the kitchen (as required by policy). Interview on 03/30/2022 at 2:11 PM, with the Director of Food and Nutrition Services revealed anyone entering the kitchen area were to apply a hair covering upon entering through the door. She revealed hair coverings were located at each entrance into the kitchen for that reason and should be utilized as required.