Gardens At Tunkhannock, The

F-F679

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(e)(1)(3) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51726

Residents Affected - Few Based on a review of clinical records and staff interview, it was determined the facility failed to ensure coordination of care and services between the facility and the Hospice agency for one resident (66) out of 20 sampled.

Findings include:

A review of facility policy titled Coordination of Hospice Services, last reviewed by the facility on June 1, 2024, revealed it is the facility policy to coordinate a plan of care and implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible. The policy indicates the plan of care will identify the care and services that each entity will provide in order to meet the needs of the resident and his/her expressed desire for hospice care.

A review of Resident 66's clinical record revealed she was admitted to the facility on [DATE REDACTED], with diagnoses to include peripheral vascular disease (a condition that affects the blood vessels outside of the heart and brain) and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

A review of physician's order dated October 23, 2024, revealed the resident was admitted into hospice services for a diagnosis of peripheral vascular disease.

A review of the resident's care plan initially dated February 15, 2024, and last revised March 18, 2025, revealed that the resident's care plan failed to reflect coordination of services between the facility and the Hospice agency in meeting the resident's daily care needs and specific needs related to care and services provided for the resident's terminal diagnosis.

An interview conducted with the DON on March 20,2025 at approximately 8:35 AM, indicated the resident's care plan did not reflect coordination of services between the facility and the hospice agency. There was no documented evidence of interdisciplinary communication or coordination ensuring that hospice and facility staff were aligned in their provision of care for Resident 66.

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services

28 Pa. Code 201.21(c) Use of outside resources

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52053 potential for actual harm Based on a review of clinical records, select facility policy, observations, and resident and staff interviews, it Residents Affected - Few was determined the facility failed to implement enhanced barrier infection control procedures for one resident out of the 20 residents sampled (Resident 12).

Findings include:

A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on June 1, 2024, revealed it is the facility policy to expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug-resistant organisms (MDROs) to staff hands and clothing. The policy indicates nursing home residents with wounds are especially high risk for both the acquisition of and colonization with MDROs. The policy indicates that the facility will make gowns and gloves available immediately outside of the resident's room for those who require enhanced barrier precautions, and that clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment, and the high-contact resident care activities that require the use of gowns and gloves. The policy indicates high-contact resident care activities include wound care of any skin opening requiring a dressing.

A clinical record review revealed Resident 12 was admitted to the facility on [DATE REDACTED], with diagnoses that included atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal) and hypertension (blood pressure that is higher than normal).

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 25, 2025, revealed that Resident 12 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

A review of Resident 12's wound assessment report dated February 25, 2025, documented the presence of

a left heel wound with serous drainage (clear to yellow fluid leaking from a wound). Treatment orders included the application of medical-grade honey and a bordered gauze dressing. However, a review of the clinical record revealed no physician orders for Enhanced Barrier Precautions (EBP) at the time of assessment.

An observation of Resident 12's room on March 18, 2025, at 12:20 PM, revealed:

No signage or postings indicating that Resident 12 required enhanced barrier precautions.

No PPE (gowns or gloves) readily available outside the resident's room for staff use.

In an interview with the Director of Nursing (DON) on March 20, 2025, at 11:50 AM, it was confirmed that Resident 12's physician orders for Enhanced Barrier Precautions were initiated on March 20, 2025, at 12:07 PM-two days after the observation and after surveyor inquiry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a follow-up interview on March 20, 2025, at 1:15 PM, the DON confirmed that the facility is responsible for ensuring full implementation of infection control procedures, including enhanced barrier Level of Harm - Minimal harm or precautions, in accordance with facility policy and nationally recognized infection control guidelines. potential for actual harm 28 Pa. Code 211.10(d) Resident care policies. Residents Affected - Few 28 Pa code 211.12 (d)(1)(5) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0920 Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Level of Harm - Minimal harm or potential for actual harm 43944

Residents Affected - Some Based on observations, staff interviews, and review of facility practices, it was determined that the facility failed to provide adequate dining space to accommodate the number of dependent residents requiring staff assistance during meals in one of two occupied resident units (Blue Unit).

Findings include:

An observation of the Blue Unit dining room on March 18, 2025, at 12:15 PM revealed that five dining tables were occupied by thirteen residents in wheelchairs, while two additional residents in Geri reclining chairs were seated with mobile bedside tables in front of them. The dining area was congested, making it difficult for staff to pass through, set up meal trays, and assist residents effectively. The limited space also restricted residents' ability to maneuver safely within the room.

A subsequent observation of the same dining area on March 19, 2025, at 12:35 PM revealed fifteen residents in wheelchairs seated among the five dining tables, along with two residents in Geri reclining chairs using mobile bedside tables. Due to the number of residents requiring assistance and the presence of staff providing feeding support, the space remained congested, further restricting movement for both residents and staff.

During an interview with the Director of Nursing (DON) and in the presence of the clinical nurse consultant on March 21, 2025, at 10:30 AM, the DON stated that due to staffing constraints, there was only one seating for each meal in the dependent resident dining rooms. The DON and the clinical nurse consultant acknowledged that the dining area was a tight fit during meals and confirmed that the current setup should be reassessed to ensure adequate space for residents, enhancing both safety and the overall dining experience.

The failure to provide adequate dining space compromised the ability of staff to efficiently assist residents with meals and restricted residents' movement, creating an environment that did not support a dignified and comfortable dining experience.

28 Pa Code 201.18 (e) (2.1) Management

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 395433

F-F801

28 Pa. Code 211.6 (a) Dietary services.

28 Pa. Code 201.18 (e)(2)(3) Management

28 Pa. Code 201.29(a) Resident rights.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm 51726 Residents Affected - Many Based on review of select facility policy, resident staff interviews and direct observations, it was determined that the facility failed to routinely offer snacks to six of six residents interviewed (Residents 15, 26, 30, 42, 59, and 65).

Findings include:

Review of the facility policy titled Snack Policy indicated that snacks will be provided between meals if ordered and in the evening for residents who desire them. Furthermore, the policy indicated HS snacks will be delivered to the nurse's station. Nursing staff will offer residents the snack and will be responsible for making sure the snack intakes are recorded.

Resident Council minutes dated December 30, 2024, indicated Residents were not receiving snacks. A grievance was filed December 30, 2024, by Resident 26 which stated, No snacks readily available, or if snacks are available the bowl of snacks are on top of the fridge - unreachable.

Resident Council minutes dated February 25, 2025, revealed that residents must ask for a snack or retrieve

it themselves. On February 25, 2025, Resident Council members filed a second grievance regarding the same issue. On March 1, 2025, the Assistant Director of Nursing (ADON) documented a response indicating that a memorandum was posted on the units directing staff to offer snacks and drinks regularly and that staff had been educated, with signed education forms on file.

On March 18, 2025, at 12:04 PM, observations of the blue and green unit resident pantry areas revealed small baskets of individually wrapped graham crackers placed on top of the unit refrigerators and pitchers of juice for medication pass inside the refrigerators.

During a group meeting with residents conducted on March 19, 2025, at 10:15 a.m. six out of six residents (Residents 15, 26, 30, 42, 59, and 65) in attendance, stated that they are not offered snacks as desired. All residents in attendance confirmed that despite two grievances being filed, residents are still not being offered snacks.

In an interview on March 20, 2025, at 1:00 PM, the Director of Nursing (DON) confirmed that the issue of snack distribution has been raised multiple times by residents. The DON acknowledged that each unit should have an ample supply of snacks to accommodate residents' preferences and dietary/texture requirements for bedtime snacks.

28 Pa. Code 211.12 (d)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 26142

Residents Affected - Many Based on a review of facility documentation, it was determined the facility failed to comprehensively review and update its facility-wide assessment to ensure it accurately reflected the specific needs of its resident population and the personnel resources necessary to meet those needs for 24 of 71 residents.

Findings Include:

A review of the facility-wide assessment provided to the survey team on February 19, 2025, indicated that

the facility had last reviewed its assessment on January 14, 2025. The document was intended to evaluate

the specific and unique needs of the resident population, along with the available and accessible resources to meet those needs on a daily basis and during emergent situations.

At the time of the survey ending March 21, 2025, the facility census was 71 residents, including 24 residents with a documented diagnosis of dementia. The facility-wide assessment stated that the facility provided a more structured environment with additional diversional activity hours on the secured Memory Care Unit (MCU), along with food-related activities and snacks as a diversion for behaviors. Additionally, the assessment noted that annual dementia and Alzheimer's care training was provided to staff to enhance their ability to care for residents. It further described the MCU as a secured unit where residents could move freely and gather safely in a large multi-purpose room.

However, there was no locked Memory Care Unit in the facility at the time of the survey, and the assessment did not reflect the actual care environment for the 24 residents with dementia who resided throughout the facility. Furthermore, the assessment lacked specific details regarding the care needs, staffing requirements, and specialized activity programming necessary to meet the needs of residents with dementia or Alzheimer's disease.

Additionally, there was no evidence the facility had updated its facility-wide assessment to address how available resources were being used to support staffing and operational decisions in a manner that ensured compliance with regulatory requirements. The assessment lacked comprehensive data regarding the current resident population and necessary resources to deliver safe and appropriate care.

On March 18, 2025, at 10:30 AM, 10 residents were observed seated in wheelchairs and geri-chairs in the Blue Unit activity room. The television was on, playing a cartoon program; however, none of the residents appeared engaged or watching.

A review of the March 2025 activity calendar indicated that Trivia and Word Games was the scheduled activity during that time, but there was no evidence the activity was conducted.

At 1:00 PM on the same day, the same 10 residents remained in the activity room with the television still playing cartoons, despite a different activity being scheduled on the posted calendar as 1 to 1 visits. Again,

the scheduled activity did not take place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 The 10 residents observed in the activity room were noted to have advanced dementia and were unable to express their preferences or level of engagement due to cognitive impairment. Level of Harm - Minimal harm or potential for actual harm On March 19, 2025, at 10:00 AM, Employee 1 (LPN) stated that the residents in the small activity room all had dementia, and the television was turned on to keep them in one area for easier staff monitoring rather Residents Affected - Many than to provide meaningful engagement.

During an interview with the Activity Director on March 21, 2025, at approximately 11:00 AM, the Activity Director confirmed that the facility lacked adequate activity staff to provide specialized dementia care activities. The Activity Director further acknowledged that the facility's evening activity programming was minimal, with little to no structured activities offered during evening hours.

The facility-wide assessment presented during the survey ending March 21, 2025, did not include comprehensive, current data regarding the resident population or the necessary resources to provide competent and safe care.

Refer

F-F803

28 Pa Code 201.18(e)(1)(6) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 43944

Residents Affected - Many Based on observations, resident and staff interviews, a review of the facility's 4-week menu cycle, and Food Committee meeting minutes, it was determined that the facility failed to ensure the menu was periodically reviewed and updated to reflect reasonable consideration of resident food preferences, thereby failing to enhance meal variety for six out of 20 sampled residents (Residents 26, 42, 30, 59, 65, and 15).

Findings include:

During a group meeting conducted on March 19, 2025, at 10:15 AM, Residents 26, 42, 30, 59, 65, and 15 reported concerns regarding the repetitiveness of the facility's menu and snack options. They stated that meal variety was lacking, side dishes were often unfamiliar, and portion sizes, particularly for meat-based dishes such as casseroles and tacos, were insufficient. Additionally, they expressed frustration that condiments such as sour cream and salsa were inconsistently available due to the facility running out due to

the food order not arriving yet.

Resident 26, the elected Resident Council President, stated, You get a teaspoon of meat when casseroles and tacos are served. He further reported that resident concerns about the menu had been raised in multiple Food Committee meetings with the facility's Certified Dietary Manager (CDM), but no changes had been made. Resident 26 explained that the menu was developed by a corporate Registered Dietitian (RD), and

the CDM lacked the authority to adjust it to better accommodate resident preferences.

Resident 42 commented that poultry was served for multiple consecutive meals and often prepared the same way, despite being given different names. She also noted that fluffy rice was frequently on the menu but was too dry to eat. Residents 26, 30, 59, and 65 agreed with this assessment, stating they would prefer alternative side dishes that were not overly dry or sticky.

A review of the minutes from Food Committee meetings held on October 21, 2024, November 25, 2024, January 9, 2025, and February 25, 2025, confirmed that the residents in attendance had consistently reported issues regarding the repetitiveness of the menu and the lack of meal variety.

A review of the facility's adopted Diet Manual indicated that the menu was planned based on the Dietary Guidelines for American's (DGA's), 2020-2025 for Older Adulthood The Dietary Guidelines for Americans, 2020-2025 provides advice on what to eat and drink to meet nutrient needs, promote health, and help prevent chronic disease and this edition of the Dietary Guidelines provides guidance for healthy dietary patterns by life stage, from birth through older adulthood and indicated that older adults can improve their dietary patterns and better meet nutrient needs by choosing from a wider variety of protein sources.

A review of the facility's 4-week Fall/Winter 2024-2025 menu cycle revealed that the last documented review and approval by the regional RD occurred on October 4, 2024. An analysis of the menu cycle confirmed a repetitive pattern in meal planning, with the same protein sources served consecutively over multiple meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 395433 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395433 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 A review of Monday week one, the planned entree for dinner was a beef burrito (consists of a flour tortilla wrapped around a filling of meat, often beef, and combined with beans, rice, and salsa), lunch on Tuesday, Level of Harm - Minimal harm or the planned lunch was barbeque beef roast with beef served for consecutive meals. potential for actual harm Week one Thursday the planned entree for lunch was chicken Hawaiian thighs. The planned entree for Residents Affected - Many dinner was roasted turkey with pasta (poultry).

Additionally, week one Friday the planned entree for dinner was a chicken sandwich. The planned entree for lunch on Saturday was chicken breast with rosemary. The planned entree for lunch on Sunday was turkey breast with apple cider sauce (poultry). Poultry was served for three consecutive meals.

A review of Monday week two, the planned entree for Monday dinner was a turkey pot pie. The planned dinner on Tuesday was a chicken sandwich with cheese sauce. The planned lunch on Wednesday was chicken honey thigh. Poultry was served for three consecutive meals.

Thursday week two, the planned entree for lunch was spaghetti with meatballs. The planned entree for dinner was chili with beans. Beef was served for two consecutive meals.

Saturday week two, the planned entree for dinner was a beef sloppy joe. The planned entree for Sunday lunch was beef pot roast. Beef was served for two consecutive meals.

A review of Saturday week three, the planned entree dinner was turkey tetrazzini. The planned entree for lunch on Sunday was a chicken garlic oregano thigh. Poultry was served for two consecutive meals.

The planned dinner for Sunday week three was stuffed cabbage rolls (beef). The planned dinner for Monday week four was a meatball sandwich. The planned lunch for Tuesday week four was beef with broccoli. The planned dinner for Tuesday was a beef burger with cheese. The planned lunch for Wednesday was a beef hot dog on a bun. Beef was served for four consecutive meals.

Additionally, a review of week four, Saturday the planned lunch entree was a steak sandwich. The planned entree for Sunday dinner was beef lasagna. Beef was served for two consecutive meals.

An interview with the facility's nurse consultant and Director of Nursing (DON) on March 20, 2025, at 1:00 PM, confirmed that meal options were frequently repetitive and failed to provide adequate variety to mitigate menu fatigue. They acknowledged that resident concerns about limited variety had not been addressed and that adjustments to the menu had not been made despite repeated feedback from the Food Committee.

Refer