Forest Ridge Health & Rehab

F-F802.

Reference WAC 388-97-1100(1)

50488

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 505240

F-F803, Menus meet Resident Needs/Prep in Advance/Followed, related to the facility's failure to follow the menu for residents on pureed diets, and the residents were served and assisted with eating the wrong diet texture. The facility removed the immediacy on 06/17/2024 with onsite verification from surveyors by conducting interviews of staff and reviewing the updated puree recipes.

Findings included .

<Resident 35>

Resident 35 admitted to the facility on [DATE REDACTED]. Review of the 04/03/2024 Minimum Data Set (MDS, an assessment tool), showed the resident had severe cognitive impairment, was on a mechanically altered diet, and required substantial to maximal assistance with eating.

Review of a diet order, dated 04/04/2024, showed Resident 35 was on a pureed diet (food that has been blended, mixed, or processed into a smooth and uniform texture)

Review of a progress note, dated 05/13/2024, showed Resident 35 had an episode of choking at breakfast, requiring staff to intervene and perform the Heimlich maneuver to clear the airway.

Review of a swallowing problem care plan (CP), dated 05/21/2024, showed Resident 35 had intermittent episodes of coughing and choking with meals and staff were directed to alternate small bites and sips, check

the resident's mouth after meals for pocketed food and debris, keep the head of bed elevated 45 degrees

during meals and for at least thirty minutes afterwards, instruct the resident to eat slowly, and to chew each bite thoroughly and provide the diet as ordered.

Review of a progress note, dated 05/21/2024, showed the nurse was called to Resident 35's room due to the resident coughing and having difficulty swallowing during the lunch meal. The nurse alternated providing small bites of food followed by small sips of fluid, but the resident's coughing with attempts to swallow persisted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 505240 Department of Health & Human Services Printed: 09/23/2025 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 505240 B. Wing 06/18/2024

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

Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312

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 On 06/14/2024 at 8:19 AM, Staff V, Certified Nursing Assistant (CNA), delivered Resident 35's breakfast tray. Staff V elevated the resident's head of bed to approximately 60 degrees, sat down and began assisting Level of Harm - Immediate the resident with their meal. jeopardy to resident health or safety At 8:36 AM, Resident 35's breakfast tray was observed, and the tray card identified the resident's diet as dysphagia [difficulty swallowing] pureed. When asked to describe the foods and textures on the tray, Staff V, Residents Affected - Few who was assisting Resident 35 to eat, said there were regular textured scrambled eggs, chopped sausage, and pureed pancakes.

<Resident 125>

Resident 125 admitted to the facility on [DATE REDACTED]. Review of the 06/18/2024 admission MDS showed the resident had severe cognitive impairment, received hospice services, and required an altered texture diet.

Review of the physicians' orders, (date order was written unknown) but order was current on 06/14/2024, showed Resident 125 was on a regular, pureed diet, with thin liquids.

On 06/14/2024 at 8:34 AM, Staff Q, CNA, was observed delivering Resident 125's breakfast tray. Staff W, CNA, who was already in the resident's room began setting up the meal as Staff Q exited the room.

At 8:36 AM, Resident 125's breakfast tray was observed. The tray card identified the resident's diet as dysphagia pureed. When asked to describe the foods and textures on the tray, Staff W, who was assisting

the resident with the meal, identified regular texture scrambled eggs, chopped sausage and pureed pancakes. When asked what diet was on the resident's tray card, Staff W stated, pureed.

On 06/14/2024 at 8:50 AM, Staff Z, Regional Nurse Consultant (RNC), confirmed Resident 35's tray card showed the resident was on a dysphagia pureed diet. When asked to describe the food and associated texture Staff Z, RNC, said there was chopped sausage and pureed pancakes. No scrambled eggs remained

on the tray at that time. Resident 125's tray had already been removed from the floor.

On 06/14/2024 at 9:59 AM, Staff D, Head Cook/ Dietary Manager in Training, indicated residents' meal trays were triple checked for accuracy prior to being delivered to ensure the diet type and texture were correct. Staff D explained the triple check process as follows: First check- the cook read the tray card, identify the diet type and texture, and plated the meal; Second check- the tray then went to the dietary aide to add the cold dishes and beverages. The dietary aide would review the tray card, validate that what was on the tray was correct, and then place the tray in the tray cart for delivery; Third check- when direct care staff removed

a meal tray from the tray cart, they would check the tray card against the diet type and texture present on the tray and validate accuracy prior to delivering it to the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 505240 Department of Health & Human Services Printed: 09/23/2025 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 505240 B. Wing 06/18/2024

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

Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312

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 At 10:03 AM, when asked how regular scrambled eggs and chopped sausage made it through the triple check and were served to Resident 35 and 125 without staff identifying the wrong texture diet was provided, Level of Harm - Immediate Staff D said they were scheduled to train the new cook on how to read tray cards that day, 06/14/2024, but jeopardy to resident health or the dietary aide had called off, so they could not provide the level of oversight of the new cook that they safety normally did because they had to work as the dietary aide, preparing the cold dishes and beverages for the meal. Staff D said Staff X, Certified Dietary Manager (CDM), a CDM from another facility who was training Residents Affected - Few Staff D for the Dietary Manager position, hadn't yet arrived for the day. Staff D confirmed staffing and their inability to provide oversight of the new cook contributed to the diet texture errors.

At 11:41 AM, when asked if dietary staff had access to and utilized a recipe when preparing pureed diets, Staff D stated, no.

On 06/17/2024 at 1:53 PM, Staff N, Regional Registered Dietitian, said that kitchen staff were to follow recipes when making pureed food. Staff N said recipes for pureed meals were reviewed and updated and dietary staff had been educated in their use.

<Resident 61>

Resident 61 admitted to the facility on [DATE REDACTED]. Review of the 01/25/2024 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of stroke and malnutrition and had significant weight loss of greater than 5% in a month or 10% in six months.

On 06/11/2024 at 2:23 PM, Resident 61 said they ate well at breakfast but had not had lunch and dinner because the facility primarily served vegetables and some form of pasta for those meals. Resident 61 said

they had informed Staff H, Social Services Director (SSD), and multiple other staff members on multiple occasions about his dislike of pasta and vegetables and had completed a food preference form where they listed their likes and dislikes. The resident indicated despite the above, the kitchen continued to frequently serve pasta and vegetables for lunch and dinner.

Review of the electronic health record (EHR) showed a Nursing to Nutrition Referral Communication form was completed on 02/12/2024 for food preferences.

Review of Resident 61's progress notes showed the following documentation:

01/29/2024- social services note Resident not eating due to food dislikes.

02/05/2024- social services note Resident not eating due to food dislikes.

02/12/2024- social services note documented, a dietary referral is required for the following reasons: Food preferences.

02/19/2024- social services note documented Resident 61was not eating due to food dislikes.

02/26/2024- social services note documented Resident 61was not eating due to food dislikes.

03/28/2024- nurse's note documented Resident 61 said they believed their appetite was fine. They were not eating because they didn't care for the food the facility was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 505240 Department of Health & Human Services Printed: 09/23/2025 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 505240 B. Wing 06/18/2024

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

Port Washington Post Acute 140 South Marion Avenue Bremerton, WA 98312

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 04/14/2024- nurse's note documented Resident 61 was on alert for weight loss and indicated it was due to not liking the food the facility provided. Level of Harm - Immediate jeopardy to resident health or Review of the EHR showed Staff H, SSD, completed a Food Preference Record on 06/07/2024, which safety identified Resident 61 did not want pasta for lunch or dinner, did not want applesauce or broccoli and little rice. Residents Affected - Few

On 06/17/2024 at 11:59 AM, Staff H, SSD, said they spoke directly to Staff Y, former Dietary Service Manager, about Resident 61's food preferences at the end of May 2024, and Staff Y was supposed to have input them into the dietary computer. Staff H indicated when they followed up one to two weeks later, the resident's preferences still had not been input into the dietary system. Staff H said they completed a second Food Preference Record on 06/07/2024, again delivering it directly to Staff Y, the former DSM. Staff H reported a CNA, whose name they did not recall, had also informed Staff Y of Resident 61's food preferences, but Staff Y failed to enter them into the dietary computer.

Review of the tray card on 06/14/2024 and 06/17/2024, showed Resident 61's likes/dislikes still had not been input into the dietary computer, thus were not reflected on the tray card.

On 06/17/2024 at 2:27 PM, when asked if Resident 61's food preferences had been input into the dietary computer Staff N, Regional RD, stated, No.

Refer to