ESTATES OF PERRYVILLE, THE

Based on observation and interview, the facility failed to notify residents of the
availability and location of the most recent survey results and did not post the most
recent survey results in an accessible location to the residents. This practice affected
three residents (Residents #4, #43, and #61) outside of the 18 sampled residents and had
the potential to affect all residents. The facility’s census was 77.
Observation of the facility’s survey results located in the front lobby on 3/18/19 at 2:00
P.M. showed the survey results of the years (YEAR), (YEAR) and (YEAR). The most recent
survey results of (YEAR) were not available.
During a Resident Council interview on 3/19/19 at 1:54 P.M., Residents #4, #43, and #61
collectively said they were not aware of the survey results availability.
During an interview on 3/22/19 at 1:41 P.M., the Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff), Coordinator said she would
expect the current survey results to be available to residents and to the public. The
(YEAR) results had not been in the binder, but that had been corrected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to send a copy of the notice of
transfer to a representative of the Office of the State Long-Term Care Ombudsman (an
advocate source for residents in the nursing home) for one resident (Resident #42) and
failed to provide written notification of a transfer to the hospital to the resident’s
representative for one resident (Resident #174) out of 18 sampled residents. The
facility’s census was 77.
1. Record review of Resident #42’s medical record showed the resident was transferred to
the hospital on [DATE] and readmitted on [DATE].
During an interview on 3/21/19 at 3:08 PM, the Ombudsman representative said they did not
receive any notifications of hospitalization s for the month of (MONTH) 2019.
During an interview on 3/22/19 at 1:41 P.M., the Administrator said she would expect a
list of transfers and discharges to be sent to the Ombudsman each month. She said the
admissions coordinator sends a list at the end of each month.
2. Record review of Resident #174’s medical record showed the resident transferred to the
hospital on [DATE]. The record did not contain documentation of written notification of
transfer to the resident or resident representative.
During an interview on 3/20/19 at 11:17 A.M., the Social Worker said the facility sends
the notice of transfer to the responsible party. The facility failed to send the notice
for this resident because the nurse that sent the resident out to the hospital only works
one time a month. The nurse didn’t know he/she was supposed to send it.
The facility did not provide a policy for notification of an unplanned transfer to a
hospital.

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Based on interview and record review, the facility failed to provide and document
sufficient preparation and orientation to residents to ensure safe and orderly transfer
from the facility in a manner that the resident can understand for two residents (Resident
#42 and #174) out of 18 sampled residents. The facility’s census was 77.
1. Record review of Resident #42’s medical record showed no documentation of preparation
or orientation of the resident for transfer to the hospital on [DATE].
2. Record review of Resident #174’s medical record showed no documentation of preparation
or orientation of the resident for transfer to the hospital on [DATE].
3. During an interview on 3/22/19 at 1:40 P.M., the Director of Nursing (DON) said they
would expect the resident to be oriented and prepared for a transfer, especially if they
were alert. They usually give a lot of reassurance before they are transferred but need to
document it.
4. The facility did not provide a policy for orientation for transfer.

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Based on interview and record review, the facility failed to inform the resident and/or
resident’s representative of their bed hold policy at the time of transfer to the hospital
for three residents (Resident #42, #57, and #174) out of 18 sampled residents. The
facility’s census was 77.
1. Record review of Resident #42’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– The medical record did not contain documentation of a letter which notified the resident
and/or the resident’s representative of the facility bed hold policy.
2. Record review of Resident #57’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– Resident transferred to the hospital on [DATE] and readmitted on [DATE];
– Resident transferred to the hospital on [DATE] and readmitted on [DATE];
– Resident transferred to the hospital on [DATE] and readmitted on [DATE];
– The medical record did not contain documentation of a letter which notified the resident
and/or the resident’s representative of the facility bed hold policy.
3. Record review of Resident #174’s medical record showed:
– The resident transferred to the hospital on [DATE] and readmitted to the facility on
[DATE];
– The medical record did not contain documentation of a letter which notified the resident
and/or the resident’s representative of the facility bed hold policy.
4. During an interview on 3/20/19 at 11:17 A.M., the Social Worker said the facility does
not send the bed hold policy with each transfer because it is provided when the resident
is admitted .
5. Record review of the facility’s undated policy, titled Bed Hold Policy, showed it is

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure an admission, a
quarterly, and an annual Minimum Data Set, (MDS, a federally mandated assessment to be
completed by the facility staff), had been completed in a timely manner, for two residents
(Resident #23 and #26) out of 18 sampled residents and five residents, (Resident #6, #18,
#19, #38, and #67) outside the sample. The facility’s census was 77.
1. Record review of Resident #6’s medical record showed:
– admitted on [DATE];
– No admission assessment;
– A quarterly assessment on 10/05/18;
– An annual assessment, in process, dated 1/03/19.
2. Record review of Resident #18’s medical records showed:
– admitted [DATE];
– No admission assessment;
– An annual assessment on 10/25/18;
– A quarterly, in process, on 1/23/19.
3. Record review of Resident #19’s medical record showed:
– admitted [DATE];
– A quarterly assessment on 10/31/18;
– An annual, in process, on 1/25/19.
4. Record review of Resident #38’s medical records showed:
– admitted [DATE];
– An admission assessment on 11/01/18;
– A quarterly, in process, on 1/30/19.
5. Record review of Resident #67’s medical record showed:
– admitted on [DATE];
– A discharge on 7/28/18;
– No re-entry assessment;
– A discharge assessment on 9/20/18;
– A re-entry on 9/22/18;
– A discharge on 9/25/18;
– An entry tracking on 9/26/18;
– A quarterly assessment on 10/10/18;
– A quarterly, in process, on 1/08/19.
6. Record review of Resident #23’s medical record showed:
– admitted on [DATE];
– An admission assessment on 10/23/18;
– A quarterly, in process, on 1/20/19.
7. Record review of Resident #26’s medical record showed:

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Based on interview and record review, the facility failed to complete a significant change
assessment for one resident (Resident #28) out of 18 sampled residents. The facility’s
census was 77.
Record review of Resident #28’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s care plan, updated 1/10/19, showed the resident admitted
to hospice care on 12/29/18 with a [DIAGNOSES REDACTED].
Record review showed an annual Minimum Data Set (MDS, a federally mandated assessment
instrument completed by facility staff), dated 11/20/18, completed for the resident.
The facility failed to complete a significant change MDS assessment within 14 days of the
resident’s election of the hospice benefit on 12/29/18.
During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said they fell a little
behind. There were concerns with missing assessments and knows there were some that were
not finished.
Record review of the facility’s policy titled, MDS Completion and Submission Timeframes,
revised,January 2011, showed the facility will conduct and submit resident assessments in
accordance with the current federal and state submission timeframes. The Assessment
Coordinator or designee shall be responsible for ensuring that the resident assessments
are submitted to The Centers for Medicare and Medicaid Services (CMS) Quality Improvement
and Evaluation System (QIES) Assessment Submission and Processing System (ASAP), in
accordance with the federal and state guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to complete and electronically
transmit, annual and quarterly Minimum Data Sets (MDS, a federally mandated assessment to
be completed by facility staff), in a timely manner and in accordance to guidelines for
two residents (Resident #23 and #26) out of 18 sampled residents and five residents
(Resident #6, #18, #19, #38 and #67) outside the sample. The facility’s census was 77.
1. During an interview on 3/22/19 at 1:41 P.M., the MDS Coordinator said they have fell
behind and there was some that had not been finished. The ones showing in process were not
transmitted. The MDS Coordinator said he/she called the Quality Improvement Program for
Missouri (QIPMO), about the previous Coordinator not doing any of the MDSs accurately.
He/she was instructed to start with annual assessments for each resident to start the
processes for the MDSs to get on a quarterly schedule.
2. Record review of Resident #6’s medical record showed:
– An admission date of [DATE];
– No admission assessment completed;
– An annual assessment, in process, dated 1/3/19 but not transmitted.
3. Record review of Resident #18’s medical record showed:
– An admission date of [DATE];
– No admission assessment completed;
– A quarterly assessment, in process, dated 1/23/19 but not transmitted.
4. Record review of Resident #19’s medical record showed:
– An admission date of [DATE];
– An annual assessment, in process, dated 1/25/19 but not transmitted.
5. Record review of Resident #38’s medical record showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to document a complete and
accurate Minimum Data Set (MDS, a federally mandated assessment to be completed by the
facility) for three residents (Residents #11, #35, and #45) out of 18 sampled residents
and one resident (Resident #28) outside of the sample. The facility’s census was 77.
1. Record review of Resident #11’s (MONTH) 2019 physician’s orders [REDACTED].
Record review of the resident’s significant change MDS, dated [DATE], showed section J1400
was checked ‘no’ for prognosis less than six months.
2. Observation on 3/18/19 at 12:30 P.M., of Resident #35 showed the resident to have
missing and broken front teeth.
Record review of the significant change MDS, dated [DATE], section L0200 showed ‘none’ for
missing or broken teeth.
Record review of the resident’s nurse progress notes, dated 1/1/19 through 2/25/19, showed
the resident fell on [DATE] with a laceration to left eye lid and abrasion to cheek bone.
On 1/3/19 the resident had a swollen left hand and an x-ray was obtained. The result of
x-ray showed displaced thumb.
Record review of the resident’s quarterly MDS, dated [DATE], section J1900 showed was
checked for ‘2 or more falls without injury’.
Record review of the resident’s medical chart showed the resident admitted to Hospice care
on 11/23/18.
Record review of the resident’s quarterly MDS, dated [DATE], section J1400 checked ‘no’
for prognosis less than six months.
3. Record review of Resident # 45’s admission MDS, dated [DATE], showed section M0210, the
resident did not have any pressure ulcers on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a
baseline care plan within 48 hours of admission that included the minimum healthcare
information necessary to properly care for the immediate needs for four residents
(Resident #23, #33, #41, and #173) and failed to provide a copy of the baseline care plan
to two resident’s representatives (Resident #57 and #174) out of 18 sampled residents. The
facility’s census was 77.
1. Record review of Resident #23’s (MONTH) 2019 Physician order [REDACTED].
– admission date of [DATE];
– [DIAGNOSES REDACTED].
Record review showed the resident’s medical record did not contain a baseline care plan.
During an interview on 3/21/19 at 3:40 P.M., the Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff) Coordinator said the resident
did not have a baseline care plan.
2. Record review of Resident #33’s POS, dated 2/21/19 through 3/21/19, showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
Record review showed the resident’s medical record did not contain a baseline care plan.
During an interview on 3/22/19 at 11:00 A.M., the Director of Nursing (DON) said the
resident did not have a baseline care plan.
3. Record review of Resident #41’s baseline care plan, dated 2/21/18, showed:
– admission date of [DATE];
– No code status (the level of medical interventions a patient wishes to have started if
their heart or breathing stops).
4. Record review of Resident #57’s POS, dated 2/18/19 through 3/18/19, showed:
– admission date of [DATE];
– [DIAGNOSES REDACTED].
– Resident not own responsible party.
Record review of resident’s baseline care plan showed a copy was given to the resident but
not the resident’s representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to implement an individualized
comprehensive care plan for five residents (Resident #11, #35, #42, #56, and #174) out of
18 sampled residents and one resident (Resident #9) outside the sample. The facility’s
census was 77.
1. Record review of Resident #9’s physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– [MEDICATION NAME] (an antipsychotic to treat certain types of mental disorders) 100
milligram/milliliter (mg/ml) 1 ml intramuscular once a day every 29 days;
– [MEDICATION NAME] 50 mg/ml, 1 ml intramuscular once a day every 29 days.
Record review of the resident’s care plan showed no care plan for antipsychotic drugs.
2. Record review of Resident #11’s (MONTH) 2019 POS, showed:
– [DIAGNOSES REDACTED].
– Do Not Resuscitate (DNR)-Hospice (a type of care focused on the terminally ill or
seriously ill patient’s pain and symptoms, with the prognosis of death/dying in less than
six months).
Record review on 3/20/19 at 2:25 P.M., of the resident’s care plan showed:
– Full code status (all resuscitative and aggressive curative treatment are provided);
– No care plan for hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to revise and update
comprehensive care plans with specific interventions to meet the individual needs of three
residents (Resident #11, #26, and #33) out of 18 sampled residents. The facility’s census
was 77.
1. Record review of Resident #11’s significant change Minimum Data Set (MDS, a federally
mandated assessment instrument completed by facility staff) dated 3/2/19 showed the
resident was placed on hospice (a type of care focused on the terminally ill or seriously
ill patient’s pain and symptoms, with the prognosis of death/dying in less than six
months).
Record review of the resident’s (MONTH) 2019 physician’s orders [REDACTED].
Record review of the resident’s care plan on 3/20/19 at 2:25 P.M. showed:
– Full code status (all resuscitative and aggressive curative treatment are provided);
– Hospice was not care planned.
Record review showed the facility provided a new copy of the resident’s updated care plan,
last revised 3/21/19 at 8:13 A.M., showed:
– DNR status;
– Crown Hospice is following the resident for hospice care.
2. Record review of Resident #26’s (MONTH) 2019 POS, showed:
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s nurse’s notes, dated 10/27/18 through 3/6/19, showed:
– On 10/27/18, the resident found on hands and knees at bed side. He/she was up in
wheelchair on fall mat. No apparent injuries noted;
– On 12/19/18 at 3:45 A.M., the resident up in wheelchair in dining room. He/she quickly
decided to stand up and attempted to walk. He/she fell to left knee, striking the chair.
Has small abrasion to left knee;
– On 12/19/18 at 8:45 P.M., Aide on hall reported the resident on floor. Aide informed
nurse when he/she returned from getting ice for hall, he/she found resident lying on right
side in lunch/television room. Upon nurse’s arrival to hall, resident was up in a sitting
position. No one witnessed the fall and no injury noted;
– On 2/11/19, the resident found sitting on bottom next to empty bed in room. Denied

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow physician’s orders for
three residents (Resident #26, #33, and #42) out of 18 sampled residents. The facility’s
census was 77.
1. Record review of Resident #26’s (MONTH) and (MONTH) 2019 Physician’s Order Sheet (POS),
showed an order for [REDACTED].
Record review of the resident’s weights showed:
– On 2/1/19, 175.0 lbs;
– On 3/4/19, 164 lbs;
– On 3/13/19, 175.0 lbs.
During an interview on 3/22/19 at 1:41 P.M., the Director of Nursing (DON) said she would
expect a resident with an order for [REDACTED].
2. Record review of Resident #33’s Registered Dietitian’s (RD) progress notes, dated
2/26/19 through 3/21/19, showed:
– On 2/26/19, the resident now with open areas to buttocks per nurse. Nurse reports
initially with one area and now with two. Current diet order is mechanical soft (a diet
that involves only foods that are physically soft, with the goal of reducing or
eliminating the need to chew the food) with nectar thick liquids (liquids which coats a
spoon and easier to swallow when the person has swallowing difficulty or chokes on regular
liquids) and is with 2/21/19 order for yogurt three times daily (TID) with meals while on
antibiotics. Has B complex vitamin in place and [MEDICATION NAME]. Will recommend addition
of multivitamin. Will also recommend start of house supplement (a weight loss supplement
with added calories to aid in nutrition) 90 milliliters (ml) TID to better assist with
meeting increased nutritional needs for wound healing. Goal is for adequate intake to
promote wound healing and weight stability. RD will continue to monitor weight, report of
wound healing, and follow up as needed;
– On 3/21/19, the resident continues with increased nutritional needs related to wound
healing, with multiple wounds noted to buttocks, and per nurse this date, wound progress
without change. Continues with B complex vitamin place and [MEDICATION NAME]. Will
recommend follow up with previous RD recommendation to add multivitamin and start of house
supplement of 90 ml TID to better assist with meeting increased nutritional needs for
wound healing.
Record review of the resident’s POS, dated 2/21/19 through 3/21/19, showed no order for
multivitamin or house supplement.
During an interview on 3/22/19 on 1:41 P.M., the DON said the dietitian puts
recommendations on a spread sheet and the DON prints them out. The nurse sends them to the
physician and we wait on the response to come back.
Record review of the facility’s policy, titled Registered Dietitian Protocol, dated
10/1/17, showed once the facility receives recommendations from the RD, nursing will
contact physician and follow associated physician orders.
3. During an interview on 3/18/19 at 3:01 P.M., Resident #42 said he/she has had diarrhea

Based on interview and record review, the facility failed to complete a comprehensive
discharge summary for one resident (Resident #58) out of one closed record review. The
facility’s census was 77.
Record review of Resident #58’s medical record showed:
– No recapitulation of the resident’s stay including diagnoses, course of
illness/treatment or therapy, and pertinent lab, radiology, and consultation reports;
– No reconciliation of all pre-discharge medications with the resident’s post-discharge
medications;
– No post-discharge plan of care developed to assist the resident to adjust to his/her
living environment.
During an interview on 3/22/19 at 1:40 P.M., the Regional Director of Clinical Operations
said the recapitulation is on our discharge summary and each discipline would offer input
for a planned discharge. If there is an unplanned discharge, that may not happen because
we don’t have enough time.
Record review of the facility’s undated policy, titled Discharge Summary and Plan Policy,
showed:
– When the facility anticipates a resident’s discharge to a private residence or another
nursing care facility (I.e., skilled, intermediate care, residential care facility (RCF),
etc.), a discharge summary and post-discharge plan will be developed which will assist the
resident to adjust to his or her new living environment;
– The discharge summary will include a recapitulation of the resident’s stay at this
facility and a final summary of the resident’s status at the time of the discharge in
accordance with established regulations governing release of resident information and as
permitted by the resident;
– The discharge summary will include a description of the resident’s;
– Medically defined condition and prior medical history;
– Medical status;
– Physical and mental functional status;

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Based on record review and interview, the facility failed to ensure physician orders
[REDACTED]. This affected 10 out of 18 sampled residents (Residents #8, #10, #11, #35,
#41, #42, #57, #71, #123, and #174) and one resident (Resident #9) outside the sample. The
facility’s census was 77.
1. Record review showed Resident #8’s primary care physician (Physician D) failed to sign
and date:
– The Physician order [REDACTED].
– POS signed 3/13/19.
2. Record review showed Resident #9’s primary care physician (Physician D) failed to sign
and date:
– POS dated 2/1/19 – 2/28/19 within one month;
– POS signed 3/13/19.
3. Record review showed Resident #10’s primary care physician (Physician C) failed to sign
and date:
– POS dated 2/01/19-2/28/19 within one month;
– POS signed 3/04/19.
4. Record review showed Resident #11’s primary care physician (Physician D) failed to sign
and date:
– POS dated 2/1/19 – 2/28/19 within one month;
– POS signed 3/12/19.
5. Record review showed Resident #35’s primary care physician (Physician D) failed to sign
and date:
– Telephone orders dated 12/10/18, 12/24/18, 12/28/18, 1/3/19, 1/7/19, 1/14/19 and
2/25/19;

Based on observation and interview, the facility failed to post the nurse staffing data in
a clear and readable format in a prominent place readily accessible to residents and
visitors on a daily basis at the beginning of each shift. The facility’s census was 77.
Observations on 3/19/19, 3/20/19, and 3/21/19 showed the facility did not post the nurse
staffing data in a prominent place.
During an interview on 3/22/19 at 1:40 P.M., the Administrator said the nurse staffing is

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Based on observation, interview, and record review, the facility failed to store all drugs
and biologicals in a safe and effective manner by monitoring refrigerator temperatures and
keeping with accepted professional standards for infection control in the medication
refrigerator. The facility’s census was 77.
Observation on 3/21/19 at 2:30 P.M., of the 300 hall medication refrigerator showed:
– The refrigerator contained the emergency medication locked box located in unlocked,
vacant nurses’ office;
– The padlock on refrigerator unlocked;
– No temperature logs.
Observation on 3/21/19 at 2:40 P.M., of the 200 hall medication refrigerator showed:
– The refrigerator located in unlocked, vacant nurses’ office;
– The padlock on refrigerator unlocked;
– The refrigerator contained:
– One brown bag which contained yogurt, cottage cheese, and almonds;
– One bottle of Magnesium [MEDICATION NAME] (for constipation);
– 30 [MEDICATION NAME] suppositories (to treat/prevent flare-ups of ulcerative [MEDICAL
CONDITION]);
– 14 Biscolax suppositories (for constipation);
– 12 Promethegan suppositories (anti-nausea/vomiting medication);
– One bottle of [MEDICATION NAME] (antibiotic);
– One locked emergency medication kit.
– The temperature log showed:
– No temperatures recorded for January, 2019 or February, 2019;
– No temperatures recorded for (MONTH) 1, 2, 3, 4, 5, 6, 7, 8, 10, 14, 15, 19, 20, or 21,
2019.
During an interview on 3/21/19 at 2:50 P.M., Certified Medication Technician (CMT) F said
there used to be a temperature log on the front of the refrigerator on the 300 hall but
he/she could not find it in the office. He/she thinks it is the nurse’s responsibility to
check the temperatures.
During an interview on 3/21/19 at 2:55 P.M., Registered Nurse (RN) A said he/she didn’t
see the temperature log today.
During an interview on 3/22/19 at 1:40 P.M., the Director of Nursing (DON) said the night
nurse, or anyone, is responsible for checking the medication refrigerator temperatures and
it should be checked every night. There should not be food in the medication refrigerator.
The refrigerators have locks on them and should be kept locked.
Record review of the facility’s policy, titled Medication Storage, dated copyright 2014,

Based on observation, interview, and record review,the facility failed to maintain the
palatability of food by preparing and serving foods at the appropriate temperature for
four residents ( Resident #10, #23, #57 and #174) out of 18 sampled residents and one
resident (Resident #52) outside the sample. This practice potentially affected all
residents in the facility. The facility’s census was 77.
During an interview on 3/18/19 at 11:49 AM, the Administrator said they currently do not
have a dietary manager.
During an interview on 3/18/19 at 11:55 A.M., the Social Services Worker I said they
haven’t had a dietary manager for almost a month. Social Services Worker I said he/she
tries to help out wherever he/she can.
During an interview in the main dining room on 3/18/19 at 12:40 P.M., Resident #23, #57,
and #173 said the food was cold and not done.
An observation in the main dining room on 3/18/19 at 12:41 P.M. showed seven plates left
with more than 50% of uneaten food left on them.
Observation of a test tray on 3/18/19 at 12:54 P.M. showed:
– Unseasoned ground beef for a mechanical diet (easy to chew) due to no hamburger patties
left to be served/cooked, with a temperature of 127.3 degrees Fahrenheit (°F);
– The meat portion, hamburger patty, was substituted with the mechanical ground beef;
– Runny baked beans with a temperature of 118.7 °F;
– Unseasoned potato wedges not fully cooked, pale and firm in texture, with a temperature
of 99.5 °F.
During an interview on 3/18/19 at 1:04 P.M., Resident #10 said the fries (potato wedges)
need to be deep fried or cooked longer.
Observation on 3/18/19 at 1:05 P.M., of Resident #10’s meal tray showed the potato wedges
looked pale in color and firm in texture.
Record review on 3/19/19 at 11:36 A.M. of the facility’s Food Temperature Log, dated
3/17/19 through 3/23/19, showed no temperatures for breakfast or lunch meals on Monday
3/19/19.
During an interview on 3/19/19 at 10:00 A.M., Resident #52 said when he/she received
his/her lunch tray yesterday, it contained unseasoned ground meat for a mechanical diet
because they had run out of hamburger patties. The resident did not require a mechanical
diet.
During an interview on 3/19/19 at 11:36 A.M., Cook G said he/she takes and records the
temperatures in the kitchen before putting on the steam table and pointed out the food