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 31 of 36 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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46793

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident 67) received foods that accommodated the residents' preferences and allergies. This failure placed residents at risk for meal dissatisfaction, allergic reaction, and a diminished quality of life.

Findings included .

Resident 67 was admitted to the facility on [DATE REDACTED]. The Admission Minimum Data Set, dated dated [DATE REDACTED], documented Resident 67 was cognitively intact.

On 06/11/2024 at 9:07 AM, Resident 67 was observed with three unopened apple juice containers on the bedside table. Resident 67 said they were on a cardiac diet and had allergies to apples but still received apple juice every day with breakfast.

On 06/12/2024 at 3:09 PM, Resident 67 was observed with two unopened containers of apple juice sitting on

the bedside table.

On 06/14/2024 at 7:39 AM, Resident 67 was observed with one unopened container of apple juice on the breakfast tray.

A Life Enrichment Evaluation, dated 05/03/2024, showed Resident 67 had a known allergy to apples. No other documentation in the electronic health record documented the apple allergy.

On 06/17/2024 at 10:38 AM, in a joint interview with Staff D, Dietary Manager/Cook and Staff N, Regional Registered Dietitian, both staff said they are informed of resident preference/allergies when the resident is admitted to the facility either by evaluation or word of mouth from other staff members. Staff D said she had just been informed about Resident 67's apple allergy that morning.

Reference WAC 388-97-1120 (2)(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 36 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 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** 37044 potential for actual harm Based on observation, interview, and record review, the facility failed to establish and maintain effective Residents Affected - Some infection prevention and control practices to prevent the spread of infections and communicable diseases. Facility staff failed to follow accepted infection control practices during the provision of wound care for 3 of 3 residents (Residents 62, 40 & 69) reviewed for wound care, failed to perform hand hygiene after contact with residents and/or their environmental surfaces (Staff AA), and failed to wear required personal protective equipment (PPE) when providing care to residents on transmission based precautions for 3 of 3 residents (Residents 324, 53 & 10) reviewed for transmission based precautions. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Findings included .

Review of the facility's Handwashing/Hand Hygiene policy, revised 08/2019, showed all facility personnel would be trained, regularly in-serviced, and shall follow handwashing/hand hygiene procedures to prevent

the spread of infections. Hand hygiene should be performed when coming on duty, before preparing and handling medications, before and after direct contact with residents or resident environmental surfaces,

before and after entering an isolation room, before and after assisting residents with meals, before applying gloves and after glove removal. The use of gloves does not replace hand washing/hand hygiene.

Review of the facility's Enhanced Barrier Precautions (EBP) policy, revised 08/2022, showed EBP expanded

the use of personal protective equipment and referred to the use of gown and gloves during high-contact resident care activities that provide opportunities for multi-drug resistant organisms (MDRO) to staff hands and clothing. High-contact resident care activities included dressing; Bathing/showering; transferring; providing hygiene; changing briefs or toileting; changing linens; wound care; and device care like catheters intravenous access devices etc.

Transmission Based Precautions

<Resident 324>

Resident 324 had a Contact Precautions sign posted outside their door that directed staff to perform hand hygiene, gown , and glove prior to entering the room.

On 06/11/2024 at 12:46 PM, Staff JJ, Physical Therapy Assistant (PTA), was observed working with Resident 324 at bedside, without wearing gloves or a gown.

<Resident 53>

Resident 53 had an EBP sign outside of their door, which directed staff to wear a gown and gloves for high-contact resident activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 36 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 0880 On 06/10/2024 at 1:12 PM, Staff II, Nursing Assistant (NA), entered Resident 53's room and placed a meal tray on the overbed table. Staff II then placed their arms around the resident, lifting and boosting the resident Level of Harm - Minimal harm or up in bed. Staff II then utilized the bed control to elevate the head of the bed. potential for actual harm <Resident 10> Residents Affected - Some Resident 10 had an EBP sign outside of their door, which directed staff to wear a gown and gloves for high-contact resident activities.

On 06/11/2024 at 11:16 AM, Staff AA, CNA, was observed without a gown or gloves on, positioning Resident 10 in bed. After boosting Resident 10 up in bed, Staff AA tucked pillows under the resident's back and backside to assist with positioning.

On 06/17/2024 at 1:46 PM, when informed of the above observations Staff E, Infection Preventionist, said if Staff II and Staff AA provided care that required direct contact, they should have gowned and gloved. Staff E then said Staff JJ should have gowned and gloved prior to entering the room, just as the sign directed.

42960

<Meal Tray Delivery>

On 06/10/2024 at 1:33 PM, Staff AA, (NA), delivered a meal tray to room [ROOM NUMBER] and did not use hand sanitizer when coming out of the room.

At 1:34 PM, Staff AA delivered a meal tray to room [ROOM NUMBER] and did not use hand sanitizer when coming out of the room.

At 1:36 PM, Staff AA, delivered a meal tray to room [ROOM NUMBER] and brought the tray back out to the cart and did not use hand sanitizer.

At 1:36 PM, Staff AA, delivered a meal tray to room [ROOM NUMBER] and did not use hand sanitizer when coming out of the room.

On 06/17/2024 at 2:19 PM, Staff AA said when they deliver meal trays they should have used hand sanitizer

after every tray when before going into the room and then when they came out of a resident's room.

<Wound Care>

<Resident 62>

Resident 62 was admitted to the facility on [DATE REDACTED] and had a diagnosis of Venous Stasis Ulceration (caused by damaged valves inside the leg veins). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 04/17/2024 documented the resident was cognitively intact and needed maximum to partial assistance with activities of daily living (ADLs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 36 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 0880 On 06/13/2024 at 1:31 PM, Staff P, Lincensed Practical Nurse (LPN), was observerd completing a dressing change and wound care for Resident 62 and changed her gloves multiple times but did not use hand Level of Harm - Minimal harm or sanitizer or wash her hands between changing her gloves. potential for actual harm <Resident 40> Residents Affected - Some Resident 40 was admitted to the facility on [DATE REDACTED] and had a diagnosis of stage 4 pressure ulcer (bed sore).

The MDS, dated [DATE REDACTED], documented the resident was cognitively intact and was dependent to substantial maximum assist with ADLs.

On 06/13/2024 at 2:03 PM, Staff P was observed completing a dressing change and wound care for Resident 40 and Staff P entered Resident 40's room with the same box of medium gloves that were in the previous room with Resident 62. Staff P changed gloves multiple times and did not use hand sanitizer or wash her hands between changing gloves when performing the dressing change.

At 2:31 PM, Staff P stated when I was in school we were told to use hand sanitizer when changing gloves but I don't know if you noticed there is no hand sanitizer in the rooms and there are not medium gloves in the room, I typically put them in my pocket and did not today.

At 2:51 PM, Staff B, Director of Nursing (DNS), said her expectation would be for staff to wash their hands when changing gloves during a dressing change and to not take a box of gloves from one resident's room to another resident's room.

50945

<Resident 69>

Resident 69 was admitted to the facility on [DATE REDACTED]. The Admission MDS, dated [DATE REDACTED], showed the resident was cognitively intact and had a stage 2 pressure ulcer (bedsore).

On 06/12/2024 at 11:51 AM, Staff P was observed performing wound care. Outside of Resident 69's room, Staff P put on a gown for Enhanced Barrier Precautions, put down supplies on a tray in the room, then came back outside of the room to put on gloves without using any hand sanitizer or washing her hands. Staff P touched Resident 69's tray, then went and grabbed more gloves, placed extra gloves on the resident's bed, touched the trash can, put on additional gloves (double gloved), and then helped the resident turn to left side. Staff P removed her gloves and put on new gloves from the pile on the resident's bed, without using any hand sanitizer. Wound cleanser was sprayed on a gauze stack, gauze was then used to wipe the resident's skin, was then thrown away, and additional gauze was used for cleaning. Staff P removed sticky residue from Resident 69's skin from a previous dressing. Staff P removed their gloves and then put on new gloves from pile of gloves on Resident 69's bed, no hand sanitizer was used, then patted the wound area dry with gauze, and an oil emulsion dressing was cut to size and placed on wound. Staff P, LPN, tucked the resident's brief further under them, did not change gloves or use hand sanitizer, then applied skin barrier film

on the skin around the wound, an abdominal (ABD) pad was applied with paper tape along the edges, gloves were changed without any hand santizer, and then the resident's brief was changed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 36 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 0880 On 06/17/2024 at 10:27 AM, Staff P was interviewed on wound care. When asked what should be done when entering a room with enhanced barrier precautions, Staff P said you should wash your hands when you Level of Harm - Minimal harm or enter and exit, and that you should wear gloves and a gown with patient care. When asked when hand potential for actual harm sanitizer should be used, Staff P said before gloves, before entering room, between glove changes, after any task, going from patient to patient, and for many instances. When asked if it was appropriate to add a glove Residents Affected - Some after you have been using another glove (without changing prior gloves), Staff P said no. When asked if you can take your gloves off and put new gloves on, without using hand sanitizer, Staff P responded, you should not. Staff P stated, this facility does not have hand sanitizer inside the room.

Reference WAC 388-97-1320 (1)(c), -1320 (2)(b)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 36 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 28 of 36 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 29 of 36 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 30 of 36 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