**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews conducted during the Recertification Survey from 9/26/2024 to 10/03/2024, the facility failed to ensure menus were followed. This was evident for 3 residents of 38 total sampled residents (Resident # 70, Resident # 193 and Resident # 247). Specifically, Residents # 70, #193 and #247 did not receive the key lime parfait in accordance with their menu. The findings include: The policy titled Food Preferences revised 09/2024 documented that resident's food and beverage preferences will be obtained upon admission and periodically as needed to assist the Food and Nutrition Services department in providing preferred food and beverages to enhance/maintain quality of life and nutritional status. In case a food item is not available, a substitute will be provided as an alternative. The resident will be made aware of the substitute using a peel and stick label which reads substitute. The sticker will be placed on the tray mat of the resident's meal tray. Resident #70 had diagnoses of hyperlipidemia unspecified, Disease of intestine unspecified, hypercalcemia, and vitamin D deficiency. The Quarterly Minimum Data Set 3.0 dated 6/21/2024 documented Resident #70 was cognitively intact. Resident #193 had diagnoses of Dysphagia oral phase, dysphagia following cerebral infarction and vitamin D deficiency, Vitamin B deficiency. The Quarterly Minimum Data Set 3.0 dated 09/06/2024 and The Annual Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #193 was moderately cognitively impaired. Resident # 247 had diagnoses of diabetes and hyperlipidemia and cerebral infarction. The Quarterly Minimum Data Set 3.0 dated 7/26/2024 documented Resident #247 was severely cognitively impaired. On 09/26/2024 at 11:44 AM - 12:24 PM dining was observed on the 5th floor. The dessert served for the residents included a key lime parfait dessert item. Three residents (resident #70, # 193 and #247 with pureed level 4 texture diets were served unsweetened applesauce on their lunch tray versus the ½ cup of key lime pie parfait on their tray ticket. The residents did not receive the Key Lime Parfait but was offered a 4-ounce cup of unsweetened applesauce instead. The menu substitution offered was not indicated on the resident's tray ticket and there was nothing on the resident tray to indicate a substitution was made for the item. On 09/26/2024 at 12:20 PM, Resident #106 was asked if they like their food preferences and they did not reply to the question and continued eating their food. Resident #106 tray contained an 8-ounce low fat milk, a can of ginger ale, unsweetened apple sauce, coffee, pureed pasta loaf, puree vegetable blend, puree chicken with gravy. Their tray ticket documented Regular Pureed 4 diet with thin liquids, Key lime Parfait ½ cup, 5-ounce coffee, 8-ounce carton of 1% milk, ginger ale, 3-ounce pureed chicken loaf, 1 ounce gravy. ½ cup pureed pasta loaf, 4-ounce pureed winter blend vegetable and 6-ounces of Carrot Ginger soup. Resident # 106 did not receive the key lime parfait but received unsweetened applesauce instead. On 09/26/2024 at 12:24 PM, Resident #247 was observed with their lunch tray which contained 4 ounce skim milk, 6 ounces of hot tea, applesauce cup, 3 ounces of pureed chicken loaf with 1 ounce gravy, 4 ounce pureed winter blend vegetables, 6 ounces of carrot ginger soup. The tray ticket menu delivered with the meal documented Resident #247 was to have ½ cup of key lime parfait on their meal tray and this item was not on the resident's tray. There were no observations of any corrections to the resident's tray ticket. On 09/26/2024 at 12:29 PM, Resident #193 was observed with their lunch tray which contained pureed thickened liquid tea, applesauce, 1 carton of thickened milk nectar consistency, pureed vegetables, puree pasta, puree chicken loaf, carrot ginger soup, 2 peanut butter and jelly sandwiches, salad, coffee, 4 oz fat free milk, and fruit cocktail. The tray ticket menu delivered with the meal documented Resident # 193 was to have ½ cup of key lime parfait on their meal tray and this item was not on the resident's tray. There were no observations of any corrections to the resident tray ticket. On 09/26/2024 at 12:39 PM, the Patient Care Technician #5 for Resident #106 stated that the resident was supposed to receive 8 ounces of milk on their tray but they milk they got is smaller and there was no substitute today. To make sure resident is eating the right food, resident could be allergic to a food item and to make sure the resident eats properly. On 09/26/2024 at 12:36PM, Patient Care Assistant #6 was interviewed and stated they check the Resident # 70 tray before feeding. The resident got applesauce they are missing key lime parfait and probably substitute it sometimes on menu board or ticket. In case a resident has a food allergy the tray ticket needs to be correct and since resident is on thickened liquids to make sure the consistency is correct. On 09/26/2024 at 12:48 PM, an interview was conducted with Licensed Practical Nurse # 1 who stated they monitor the dining room during lunch time for the residents in their rooms. They check the meal trays; nursing staff and dietary staff take the trays off the cart, and they check to make sure items on the tray match the tray ticket. They stated that they are not aware of any substitute of food for lunch. One goal is to prevent aspiration, allergic reaction and to make sure residents are eating what the dietitian set for their diet and consistency is correct to prevent aspirations. On 09/26/2024 at 12:51 PM, an interview was conducted with the Registered Dietitian who stated the key lime parfait and applesauce is for the puree texture diet. The key lime pie is todays special, and we introduce new food items to support residents' palates to be on the menu in the future. The residents should have received the food item that was on their tray ticket. On 10/02/2024 at 11:16 AM, an interview was conducted with Dietary Aide #2 who stated we had the key lime pie but the puree texture we got it late. It was replaced with applesauce for the puree. They stated they spoke to the manger to let them know there was not key lime pie for the puree, and we are supposed to put substitute tickets on the tray to show that we don't have the supply and the supervisors will have the diet ticket. On 10/02/2024 at 11:21 AM, an interview was conducted with the Assistant Coordinator Dietary Manager who stated the food item was a special item and they could not locate the dessert item for the puree soft bite size, puree and mince moist diet textures. They communicated with the Operations Dietary Manager, and applesauce was used as an alternative. They were informed that a substitution was needed for the item and staff were to implement a substitution card. The substitution card should have been placed on the cold side of the tray. The substitution card is the only source we use to notify the units of a change on the resident's tray. They did not put the substitution card on the units that day. Residents are paying for a service, and they are entitled to everything they are paying for. On 01/02/2024 at 11:31 AM, an interview was conducted with the Operations Dietary Manager who stated the dessert items was a special item and they were notified that the puree texture for the key lime pie was not available, and another food item had to be used. They were notified that applesauce would be the substitute and the Assistant Coordinator Dietary Manager notified Dietary Service Aide #2. At home we are allowed to make choices of what we want to receive and if residents are given the option for a food substitution. We want to be accurate for resident's dietary needs. On 10/02/2024 at 11:40 AM, an interview was conducted with the Food Service Director who stated they order food items 2 weeks in advance for the menus. They were informed by staff that the dessert item was missing for the puree texture and they triple checked to locate it. They instructed their staff to make the item and sent it upstairs. When dietary staff use a substitute food item on a meal they are suppose to place a substitute ticket on the resident's tray. The checker on the tray line and the loader, dessert person and Dietary Manager double check items on resident trays as part of the monitoring process. 415.11(c)(1-3)

Based on observations, record review, and interview conducted during the Recertification Survey from 9/26/2024 to 10/03/2024, the facility did not ensure that infection control practices were maintained. This was evident in 1 of 4 floors (5th Floor) observed for the Dining Task and Infection Control. Specifically, Patient Care Technician #5 did not perform hand hygiene while assisting multiple residents in the 5th Floor dining room. The facility policy titled Dining Room Policy reviewed 03/2020 documented residents must have hand hygiene before meals using hand wipes. Staff must perform hand hygiene between each resident during meal preparation (cleansing hands, setting up meal trays). The charge nurse or designee checks to see all residents have received their trays. The facility policy titled Hand Hygiene reviewed 03/06/2023 documented the facility considered hand hygiene the primary means to prevent the spread of infections and will comply with current Centers for Disease Control and Prevention hand hygiene guidelines. Hand hygiene is the most effective measure in the prevention and control of transmission of infection. Effective hand hygiene reduces the incidence of healthcare associated infections. Indications for hand hygiene using alcohol-based hand rub in the following clinical situations before having direct contact with patients and after contact with residents intact skin. During a dining observation on 09/26/2024 from 11:43 AM to 12:38 PM, Patient Care Technician #5 was observed assisting residents in performing hand hygiene with bare hands during dining. Patient Care Technician #5 was observed picking up the used hand wipe from Resident #45. Then Patient Care Technician #5 assisting Resident #247 to perform hand hygiene with their bare hands. No hand hygiene was observed by Patient Care Technician #5 after assisting Resident #247. On 10/01/2024 at 03:08 PM, an interview was conducted with Patient Care Technician # 5 who stated that when they sat down to feed Resident #247 they realized that they did not do hand hygiene between the residents. Hand hygiene is to be done to prevent contamination between residents. They have had a hand hygiene inservice this year. On 10/02/2024 at 03:28 PM, an interview was conducted with Assistant Director of Nursing who stated that they monitor the patient care technicians. They look to see if residents want an extra food item or want a change in their menu and they intervene if they see anything abnormal. They stated that when staff walk into the dining room/day room they should use the hand sanitizer. The main thing is hand washing to prevent cross contamination and it should be done before and after each resident. Inservice was done after the survey began and every 1 month or every 3 months and in-service is done when anything triggers on the unit. We do an in-service for all staff (nurses and patient care technicians). On 10/02/2024 at 3:33 PM, an interview was conducted with the Infection Preventionist who stated they do rounds on unit Monday to Friday when they look for infection control, hand hygiene during resident care, personal protective equipment use, properly changing of gloves. They do periodic rounds for dining mostly during lunch and during dinner rounds they observe hand hygiene. There have been no recent concerns and for the past day or two they have noticed that staff are not properly carrying out hand hygiene and staff were in-serviced. It was observed during meal pass that staff were not practicing hand hygiene and they were re-inserviced. Staff should be doing hand hygiene when in the dining room prior to preparing residents and between serving residents trays. If they touch a residents wheelchair staff should sanitize their hands before touching meal trays to prevent dirt from getting on their hands that may have germs. On 10/03/2024 at 12:50 PM, an interview was conducted with the Director of Nursing who stated that they do rounds daily when they get a chance and if they cannot make it to the unit they can observe virtually while in the office or from home. They observe if staff are cleaning resident's hands. During dining it is recommended that staff use hand sanitizer between residents. Staff should do hand hygiene to protect themselves and the residents and there is constant education. When they use sanitizer, they should use the same friction as hand hygiene and get the sanitizer between their fingers. The Infection Preventionist is involved in hand hygiene education and we stress it to staff. We also do spot checks where there are secret shoppers who observe hand hygiene from patient rooms and in the dining rooms. There are new staff coming from the hospital to the nursing home and hand hygiene education is ongoing. 415.19 (b)(4)