GRAND PAVILION AT THE PLAZA

Based on interview and record review, the facility failed to ensure residents were able to
organize and participate in the Resident Council meeting at a location that was large
enough to accommodate all the residents who wanted to attend the resident council meeting;
to communicate with the resident council on where they would like to have the resident
council meetings during the renovations and to have a coffee stand on the first floor for
the residents who arise early and during the day to enjoy during the renovations. Seven
residents attended the resident group meeting. The facility census was 68 residents.
Record review of the facility’s titled Resident Rights Policy Statement dated (MONTH) 2009
showed the employees shall treat all residents with kindness, respect and dignity.
Record review of facility’s policy titled Interpretation and Implementation dated (MONTH)
2009 showed:
-Federal and state laws guarantee certain basic rights to all residents of the facility,
and these rights include the resident’s right to:
-Be informed about what rights and responsibilities he or she has;
-Residents are entitled to exercise their rights and privileges to the fullest extent
possible and
-Our facility will make every effort to assist each resident in exercising his/her rights
to assure that the resident is always treated with respect, kindness, and dignity;
Resident Council Policy Statement dated (MONTH) (YEAR) showed the facility supports
resident’s rights to organize and participate in the Resident Council;
-.The purpose of the Resident Council is to provide a forum for;
– Residents, families and resident representative to have input in the operation of the
facility;
– Discussion of concerns and suggestions for improvement;
– Consensus building and communication between residents and facility staff;
-Disseminating information and gathering feedback from interested residents;
-All residents are eligible to participate in the Resident Council;
-The facility staff encourages residents who are willing to participate;
-A resident council response form will be utilized to track issues and their resolution
and
-The facility department related to any issues will be responsible for addressing the item
of concern.
1. During the group interview on 3/11/19 at 10:45 A.M., the residents shared they enjoyed
having their monthly Resident Council Meeting in the first floor dining room. The
residents said they were abruptly moved from the first floor dining room to a room on the
second floor. The room space on the second floor was not big enough to conduct their
monthly meetings;
-After the recent renovation efforts the residents wanted to continue to have there
monthly meetings in the first floor dining area;
-The residents expressed they would like to have the coffee stand back on the first floor
so that the residents who were early risers would have their coffee to drink prior to
their breakfast hour;
-The Activities Director had not been as attentive to their needs during the Resident
Council group due to the recent building renovations at the facility;
-The residents said the Activities Director gets pulled on the floor a great deal to help
with providing baths to the residents and other assigned duties;

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Based on observation and interview, the facility failed to maintain the second and third
floors free from persistent and strong urine odors; to maintain mattresses in rooms 331,
329, 330, 319, 305 free from damage; to maintain the floors in resident rooms 324, 309,
303, free from damage; to maintain the floors of the third floor dining room, shower room
[ROOM NUMBER] and in resident rooms 321, 309, 308, 305, 303, 234, and 220, free from a
buildup of debris and grime; to have a regular cleaning schedule for fans in resident
rooms [ROOM NUMBER], and the second floor nurse’s station; to maintain two lifts free of a
dust and debris buildup; and to prevent two slings (a flexible strap or belt used in the
form of a loop to support or raise a hanging weight) that were severely damaged, from
making it back to the second floor Central Supply room. This practice potentially affected
57 residents who resided on the second and third floors. The facility census was 68
residents.
1. Observations on 3/7/19, showed the following:
-At 9:09 A.M. there was a strong urine odor on the third floor that could be detected to
the elevator;

Based on interview and record review, the facility failed to ensure criminal background
checks (CBC) were completed on newly hired staff and re-hired staff per facility policy
for seven out of 16 sampled employees. The facility census was 68 residents.
Record review of the facility’s undated Abuse, Neglect and Exploitation policy and
procedure showed it is the policy of the company to take appropriate steps to prevent the
occurrence of abuse, neglect, injuries of unknown origin, and misappropriation of resident
property, and to ensure that all alleged violations of federal or state laws which involve
mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of personal
property are reported immediately to the Administrator. Violations will also be reported
to state agencies in accordance with state law. The screening process showed all
applicants for employment in the company shall, at a minimum, have the following:
-Reference checks with the current and/or past employer;
-Appropriate licensing board or registry check;
-Criminal background check pursuant to company policy or state law;
-The Director of Nursing, or Human Resources is responsible for the initial licensing
and/or registry check, the Administrator of Human Resources must ensure that all screening
is completed and
-No applicant shall be considered for employment unless all screenings are completed, and
the applicant’s license is unrestricted.
1. Record review of the following Employee records showed:
-Certified Nursing Assistant (CNA) J was hired on 9/25/18 and there was no documentation a
criminal background check was requested or received;
-CNA L was hired on 2/5/19 and there was no documentation that a criminal background check
had been requested or received;
-Certified Medication Technician (CMT) C was hired on 11/28/18 and there was no
documentation that a recent criminal background check was requested or received (the
employee was re-hired);
-CMT D was hired on 8/15/18 and there was no documentation that a criminal background
check had been requested or received;
-Licensed Practical Nurse (LPN) E was hired on 7/25/18 and there was no documentation that
a criminal background check had been requested or received and
-There were no employee files for CNA H or CNA K to review.
During an interview on 3/13/19 at 9:03 A.M., the Staffing Coordinator said:
-He/she did not complete background checks for new employees;
-They should complete a background check when they hire or re-hire a potential employee
and
-They were unable to find any employee records for CNA H and CNA K (also chosen in the
sample are no longer employees at the facility).

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Based on observation, interview and record review, the facility failed follow physician’s
orders to administer one sampled resident’s (Resident #38) [MEDICATION NAME] (a medication
used to treat mental disorders, including [MEDICAL CONDITION] and [MEDICAL CONDITION]
disorder) at bedtime as ordered to help minimize his/her Dementia (a group of thinking and
social symptoms that interferes with daily functioning) with behavioral disturbance and to
stay and watch the residents take their medications to ensure that the medications are
swallowed for two sampled residents (Resident #11 and Resident #3) out of 17 sampled
residents. The facility census was 68 residents.
Record review of the facility’s policy titled Documentation of Medication Administration
dated (MONTH) 2007 showed:
-The facility shall maintain a Medication Administration Record [REDACTED]
– Nurse or Certified Medication Technician (CMT) (where applicable) shall document all
medication administered to each resident on the resident’s MAR;
– Administration of medication must be documented immediately after (never before it is
given).
-Documentation must include, as a minimum:
– Name and strength of the drug;
– Dosage;
– Method Administration e.g. oral, injection (and site);
– Date and time;
– Reason(s) why a medication was withheld, not administered, or refused (as applicable)
and
– Signature and title of the person administering the medication;
Record review of the facility’s policy for Medication Administration Procedure showed:
-The purpose was to administer all medications safely and appropriately to aid the
resident to overcome illness, relieve, and prevent symptoms, and help in [DIAGNOSES
REDACTED].>-The person administering the medications to the resident must remain with
the resident to ensure that the medication is swallowed.
1. Record review of Resident’s #38’s Face Sheet showed he/she was admitted to the facility
on [DATE] with the following Diagnoses: [REDACTED].
-Dementia with Behavioral Disturbance; and
-Major [MEDICAL CONDITION] – (A mental health disorder characterized by persistently
depressed mood or loss of interest in activities causing impairment of daily life).
Record review of the resident’s quarterly Minimum Data Set (MDS – a federally mandated
assessment tool to be completed by the facility staff for care planning) dated 8/23/18,
showed the resident:
-Was mild to moderately cognitively impaired which means the resident was not cognitive
alert and oriented;
-Was incapable of communication beyond answering either yes or no closed questions;
-Did not respond at all to the staff attempts to talk about his/her physical and spiritual
needs;
-Was unable to have meaningful conversations with others;
-Continued to walk the halls constantly with fidgeting behaviors and

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Based on observation, interview and record review, the facility failed to ensure an
activity plan of care and care plan goals and objectives were identified and documented to
ensure the resident’s activities were individualized and according to the resident’s
abilities and interests, and to ensure activity updates were documented at least quarterly
to show the resident’s activity progress for a resident who required total care and had
communication challenges for one sampled resident (Resident #27) out of 17 sampled
residents. The facility census was 68 residents.
1. Record review of Resident #27’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED].), [MEDICAL CONDITION] (difficulty speaking),
dysphagia (difficulty swallowing), cognitive communication deficit, [MEDICAL CONDITION] (a
surgical procedure to create an opening through the neck into the trachea (windpipe)-a
tube is most often placed through this opening to provide an airway and to remove
secretions from the lungs) and a gastrostomy tube ([DEVICE] – a tube inserted through the
abdomen that delivers nutrition directly to the stomach).
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 9/20/18, showed
he/she:
-Was severely cognitively impaired and had a communication deficit;
-Was totally dependent for bathing, dressing, toileting, transferring and mobilizing, and
eating;
-Was unable to answer questions regarding activity preferences and
-Staff assessment of the resident’s daily activity preferences showed the resident had
family involvement in care planning and he/she liked music.
Record review of the resident’s Medical Record showed he/she did not have any activity
notes documented to show the resident’s participation in activities and progress with
his/her activity plan/goals.
Record review of the resident’s comprehensive Care Plan dated 12/15/18 showed:
-The resident had a communication problem and would respond appropriately to yes/no
questions and

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Based on observation, interview and record review, the facility failed to follow
physician’s order for ongoing weekly skin assessment and to have detail documentation on
any skin issues reported or found; to follow physician’s orders to apply topical
medication to the resident’s skin issues, and to transcribe physician’s orders for a
topical medication to the resident’s Treatment Administration Record (TAR) which caused
the resident not to receive that medication in (MONTH) for one sampled resident (Resident
#58) out or 17 sampled residents. The facility census was 68 residents.
1. Record review of Resident #58 Admission Face Sheet showed he/she was admitted to the
facility on [DATE] with the following [DIAGNOSES REDACTED].>-Lumbosacral root disorder
(causes pain in the leg rather than in the lumbar spine) and
-Swelling of lymph nodes and [MEDICAL CONDITION].
Record review of the resident’s Quarterly Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 2/5/19 showed he/she:
-Was severely cognitively impaired and had short term and long term memory problem;
-He/she was usually able to understand others and make his/her needs known;
-Required limited assistance from staff for all cares and transfers and
-Had a treatment for [REDACTED].
Record review of the resident’s medical record showed there was no Weekly Skin Assessment
documentation found for (MONTH) (YEAR).
Record review of the resident’s Physician’s Order Sheet (POS) dated (MONTH) 2019 and
(MONTH) 2019 showed the resident had a physician’s order for the nursing staff to complete
a Weekly Skin Assessments every Wednesday during the evening shift.
Record review of the resident’s TAR dated 2/1/19 to 2/28/19 showed;
-Ammonium [MEDICATION NAME] Cream 12% was not documented as applied on 2/2/19,
2/3/19,2/7/19, 2/11/19, 2/13/19, 2/14/19 and 2/25/19 during the day shift;
-The staff put their initials in the box to show the Weekly Skin Assessments were
completed on every Wednesday during the evening shift on 2/6/19, 2/13/19, 2/20/19, and

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Based on observation, interview and record review, the facility failed to ensure physician
order included coordination of the resident’s bolus tube feeding (Bolus feeding is a type
of feeding method using a syringe to deliver formula through your feeding tube-a medical
device used to provide nutrition to patients who cannot obtain nutrition by swallowing)
and pleasure feeding meals to maintain adequate nutrition intake; and to ensure to have
detail care plan for the resident bolus tube feedings and pleasure feeding, for one sample
resident (Resident #35) out of 17 sampled residents. The facility census was 68 residents.
1. Record review of Resident #35’s Admission Record showed he/she was admitted to the
facility on [DATE] and had a [DIAGNOSES REDACTED].
Record review of the resident’s Admission Minimum Data Set (MDS-a federally mandated
assessment tool completed by facility staff for care planning) dated 12/31/18 showed
he/she:
-Was not cognitively impaired and no issue with short term and long term memory problems;
-Was able to understand others and make his/her needs known;
-Required limited assistant from staff for all cares and transfer and
-Had a feeding tube for all nutritional needs.
Record review of the resident’s Physician’s Order Sheet (POS) dated 2/1/19 to 2/28/19
showed physician’s orders for:
-Pleasure feedings for a regular mechanical soft diet with thin liquids consistency;
-[MEDICATION NAME] 1.5 calorically (Cal, is a calorically dense liquid food with a
patented fiber blend that provides complete, balanced nutrition) of 237 milliliter (ml) of
supplement, to be administered through the feeding tube, to be given by bolus tube
feedings (or gravity feeding, is a type of feeding method using a syringe to deliver
formula through a feeding tube) four times a day at 8:00 A.M., 12:00 P.M., 4:00 P.M., and
8:00 P.M.,
–For a total volume of 948 ml in a 24 hour period;
-Every shift to check and record the residual (the amount of fluid remaining in the
stomach at a point of time during enteral tube feedings) If residual is greater than 150
ml, hold tube feeding and call the resident’s physician;
-There were no physician’s orders guide the staff on what to do if the resident eats a
sufficient amount of food and does not need his/her bolus feeding and
-The resident bolus feedings are at the same time as the meals are being served at 8:00
A.M., 12:00 P.M., 4:00 P.M. there were no guidance for the staff if the resident wants to
eat.

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Based on observation, interview and record review, the facility failed to ensure
coordination of care between the facility and the [MEDICAL TREATMENT] (a process for
removing waste and excess water from the blood, and is primarily used to provide an
artificial replacement for lost kidney function in people with [MEDICAL CONDITION]) center
was maintained to ensure the continuum of care for one sampled resident (Resident #163);
to ensure monitoring and detail documentation of the resident’s [MEDICAL TREATMENT], and
to obtain physician’s order for the monitoring of the resident’s [MEDICAL TREATMENT] for
two sampled residents (Resident #35 and #163) out of 17 sampled residents. The facility
census was 68 residents.
Record review of the facility’s [MEDICAL TREATMENT] Access Care policy and procedure dated
10/2020, showed:
-Care involves the primary goals of preventing infection and maintaining patency of the
catheter (preventing clots);
-To prevent infection and/or clotting, keep the access site clean at all times, Check for
signs of infection at the access site when performing care and at regular intervals, do
not use the arm to check blood pressure, advise the resident not to sleep on, wear tight
jewelry or lift heavy objects with the access arm; check the color and temperature of the
fingers, and the radical pulse of the access arm when performing routine care and at
regular intervals; check the patency of the site at regular intervals. Palpitate (feel)
the site to check the thrill (vibration) or use a stethoscope to hear the bruit (swooshing
sound caused by blood moving through the access site);
-Care immediately following [MEDICAL TREATMENT] (the clinical purification of blood as a
substitution for the function of the kidneys) treatment: the dressing change is done in
the [MEDICAL TREATMENT] center post treatment. If the dressing becomes wet, dirty, or not
intact, the dressing should be changed by a licensed nurse trained in this procedure. Mild
bleeding from the site is expected. Apply pressure to the insertion site and notify the
[MEDICAL TREATMENT] center. If there is major bleeding, apply pressure to the insertion
site and contact emergency services and the [MEDICAL TREATMENT] center and
-The nurse should document in the resident’s medical record the location of the [MEDICAL
TREATMENT] site, condition of the dressing, if [MEDICAL TREATMENT] was done during the
shift, any part of report from the [MEDICAL TREATMENT] center post-[MEDICAL TREATMENT]
being given and observations post [MEDICAL TREATMENT].
1. Record review of Resident #163’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (increased pressure in the eye
causing a gradual loss of eyesight), amputation of bilateral legs below the knee, high
blood pressure, [MEDICAL CONDITION] (formation of blood clots in the veins, particularly
in the lower legs) and sleep disorders.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated 2/13/19, showed
he/she:
-Was alert and oriented;
-Needed moderate to extensive assistance with mobility and transfer, bathing and dressing;
-Needed supervision with eating;
-Was continent and
-Had [MEDICAL CONDITION] diagnosis ([MEDICAL TREATMENT]).
Record review of the resident’s Physician’s Order Sheet (POS) dated 3/2019, showed a
physician’s orders for:

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Based on observation, interview and record review, the facility failed to do a initiate a
follow up evaluation and treatment when the resident began exhibiting behaviors that were
identified by the facility and to care plan interventions in response to the resident’s
behaviors, once the behaviors were identified, timely for one sampled resident (Resident
#163) out of 17 sampled residents. The facility census was 68 residents.
1. Record review of Resident #163’s Face Sheet showed he/she was admitted to the facility
on [DATE], with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (increased pressure in the eye
causing a gradual loss of eyesight), amputation of bilateral legs below the knee, high
blood pressure, [MEDICAL CONDITION] (formation of blood clots in the veins, particularly
in the lower legs) and sleep disorders.
Record review of the resident’s Preadmission Screening and Resident Review (PASSAR) level
I screening dated [DATE], showed he/she had no history of a major mental disorder and no
signs of a mental disorder at the time of the screening. It showed the resident had no
serious problems in functioning and had no psychiatric treatment in the past two years. No
level II screening was warranted.
Record review of the resident’s admission Minimum Data Set (MDS-a federally mandated
assessment tool to be completed by facility staff for care planning) dated [DATE], showed
he/she:
-Was alert and oriented;
-Needed moderate to extensive assistance with mobility and transfer, bathing and dressing;
-Needed supervision with eating;
-Was continent;
-Had [MEDICAL CONDITION] diagnosis ([MEDICAL TREATMENT]) and
-Did not have any psychiatric [DIAGNOSES REDACTED].
Record review of the resident’s Physician’s Order Sheet (POS) dated ,[DATE] showed there
were no physician’s orders for any anti-psychotic, anti-hypnotic, anti-anxiety or
anti-depressant medications.
Record review of the resident’s Social Service Notes showed:
-On [DATE], the resident was wheeled to this writer’s office insisting on getting a cab to
run errands. (He/she) demanded this writer to call a cab to pick (him/her) up. This writer
stated that lunch is being served in less than 30 min. and (he/she) is diabetic, plus it
is raining outside and (there are) concerns with (his/her) vision problems. (The resident)
irritably said, I don’t care. This writer then asked if (he/she) wanted (his/her) sisters
to be called to pick (him/her) up. (He/she) stated no, a cab was called and the resident
left and
-On [DATE], Admit Note: The resident was admitted to the facility on [DATE], from home and
is in the facility for long term care. The resident wouldn’t participate in the interview
process. He/she said that he/she didn’t want to answer any questions. He/she doesn’t have
glasses, and has difficulty seeing. He/she doesn’t wear dentures or hearing aids. They
discussed advanced health care directives and the resident is a Full Code. The resident
was insisting to go to the bank today but he/she did not want to talk to anyone. He/she
was rude to staff. The Social Service Director explained that if the resident wanted to
leave, he/she would have to sign out of the building.
Record review of the resident’s Nursing Notes showed:
-On [DATE] the resident’s lab results were reported to the Nurse Practitioner and there

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Based on observation, interview and record review, the facility failed to ensure to
monitor for out dated medical supplies; to ensure the medication room door was kept closed
and locked when unattended by authorized licensed staff and to store, label and date

-The black E-Kit box was unlocked with the broken E-Kit tag # 934;

Based on observation, interview and record review, the facility failed to check the
temperature of a Potentially Hazardous Food (PHF- a term used by food safety organizations
to classify foods that require time-temperature control to keep them safe for human
consumption, typically these foods contain moisture, protein and neutral to slightly
acidic) chicken after it was cooked. This practice potentially affected at least 64
residents who ate food from the kitchen on 3/7/19. The facility census was 68 residents.
1. Observations on 3/7/19, showed the following:
– At 9:15 A.M., the Dietary Cook (DC) cooked battered chicken in the deep fryer;
– At 9:17 A.M., the DC took out the 1st batch of chicken and did not check the
temperature;
– At 9:18 A.M., the DC placed the 2nd batch of chicken in the deep fryer;
– At 9:21 A.M. the DC took out that batch of chicken and placed on a pan to place in the
oven to keep the chicken pieces warm;
– At 9:35 A.M., the DC placed the 3rd batch of chicken into the deep fryer, and
– At 9:38 A.M., the DC took out the third batch of chicken up without measuring the
temperature of the cooked batch.
During an interview on 3/7/19 at 12:06 P.M., the DC said he/she should have checked the
temperature of the chicken, after it was cooked.
During a phone interview on 3/11/19 at 8:27 A.M., the Registered Dietitian (RD) said
he/she had not done any training with the facility dietary staff in checking the
temperatures of PHFs after they are cooked.
Record review of the 2013 Food and Drug Administration (FDA)
Chapter 3-401.11 Raw Animal Foods, showed:
(A) Except as specified under paragraphs B, C, and D of this section, raw animal FOODS
such as EGGS, FISH, MEAT, POULTRY, and FOODS containing these raw animal FOODS, shall be
cooked to heat all parts of the FOOD to a temperature and for a time that complies with
one of the following methods based on the FOOD that is being cooked:
1) 145ºF (degrees Fahrenheit) or above for 15 seconds for
Raw EGGS that are broken and prepared in response to a CONSUMER’S order and for immediate

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Based on observation, interview, and record review, the facility failed to ensure the
Registered Dietician (RD) was scheduled for monthly visits to the facility between the
dates of 6/11/18 and 8/6/18 and between 10/3/18 and 12/17/18. The facility also failed to
provide training to the dietary staff and have a qualified Dietary Manager (DM) in the
kitchen to provide training and leadership to dietary employees in the areas of processing
and tasting of the pureed food and checking temperatures of chicken a Potentially
Hazardous Food (PHF- a term used by food safety organizations to classify foods that
require time-temperature control to keep them safe for human consumption, typically these
foods contain moisture, protein and neutral to slightly acidic). This practice potentially
affected all residents in the facility. The facility census was 68 residents.
1. Record review of the RD Reports dated 4/18 through 2/19, showed the RD did not visit
the facility for a period of 55 days from 6/11/18 through 8/6/18, and for a period of 66
days from 10/3/8 through 12/7/18.
On 3/12/19 at 7:09 P.M., during a written response to a question about the length of time
when the visits did not occur, the RD wrote:
-The company he/she consulted for notified him/her that he/she could not go into a
facility since they had not received payment;
-The RD placed the facility on hold until he/she was told that he/she could go into the
facility, and
-If he/she did not go into a building for a whole month and nonpayment was the reason.
During a phone interview on 3/18/19 from 8:45 A.M. through 8:57 A.M., The owner of the
Registered/Consultant Dietitian’s group, said:
-There were problems with payment to his/her company, because the facility was behind on
payment;
-The times the RD did not go into the facility for nonpayment, training was delayed, and
-Once payment was made, his/her company would work to try and catch up with regular
visits.
During a phone interview on 3/20/19 at 8:39 A.M., the Administrator said:
-The previous dietary services company left the faciity on [DATE];
-When the RD did not visit the facility between 6/11/18 and 8/6/18, it was due to a
payment issue;
-He/she was not sure what the issue was during the RD’s absence between 10/3/18 and
12/7/18 and
-The previous dietary services company left the faciity on [DATE].

Based on observation, interview and record review, the facility failed to follow the menu
for two sampled residents (Residents #17 and #20) with pureed diets, by not serving those
residents pureed (cooked food, usually vegetables or legumes, that has been ground,
pressed, blended or sieved to the consistency of a creamy paste or liquid) side dishes of
garlic bread and vegetables. This practice affected 2 residents with pureed diets. The
facility census was 68 residents.
1. Record review of Resident #17’s care plan dated 10/7/14, showed he/she had Dementia and
was on a pureed diet.
2. Record review of Resident #20’s care plan dated 12/6/18, showed he/she received a
pureed diet and received honey thickened liquids.
3. Record review of the menu for the lunch meal on 3/7/19, showed chicken breast filet,
buttered pasta, tossed salad, bread sticks, Mandarin oranges, and coffee.
During an interview on 3/7/19 at 12:06 P.M., the Dietary Cook (DC) said he/she did not
pureed the garlic bread or the tossed salad or add any equivalent food for the residents
with pureed diets.
Observation on 3/7/19 at 12:09 P.M., showed Resident #17 and #20 did not receive their
sides of garlic bread and tossed salad or the equivalent.
During an interview on 3/7/19 at 12:10 P.M., the Staffing Coordinator who helped out in
the dining room that date, said Residents #17 and #20 did not receive their sides of
garlic bread and vegetables, during that lunch meal.

Based on observation, interview and record review, the facility failed to process pureed
(cooked food that has been ground pressed, blended or sieved to the consistency of a
creamy paste or liquid ) pasta to the same taste as the regular pasta and to have a recipe
for the pureed pasta. This practice potentially affected three residents with pureed diets
in the facility. The facility census was 68 residents.
1. Record review of the facility’s recipe book showed the absence of a recipe for pureed
pasta.
2. Observation on 3/7/19 from 10:53 A.M. through 10:55 A.M., showed:
-The Dietary Cook (DC) pureed the buttered pasta in the same unwashed container that the
chicken was pureed in just a few minutes earlier;
-The DC pureed the buttered pasta and he/she added water and pureed it;
-The DC placed the pureed mixture in a metal container without tasting it, and
-The DC placed a metal cover on the metal container and placed it on steam table and did
not check the temperature.
3. On 3/7/19 at 11:40 A.M., during a taste test with the Interim Dietary Manager (DM), the
pureed pasta was very bland compared to the non pureed buttered pasta.
During an interview on 3/7/19 at 11:49 A.M., the Interim DM said:
-He/she knew the recipe was not in the book, and
-The pureed pasta did not have as much flavor as the regular.
During a phone interview on 3/11/19 from 8:25 A.M. through 8:41 A.M., the Registered
Dietician (RD) said:
-He/she had not done training in the kitchen;
-He/she did not know who to speak with when he/she went into the kitchen;
-He/she has not done any training with employees in the processing of pureed foods, and
-He/she did not advise the dietary employees to taste the foods after the foods were
pureed.
During a phone interview on 3/11/19 at 11:52 A.M., the Regional Director of Dietary
Services agreed that the pureed food should be tasted after it was processed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to puree (make
cooked food into a texture that is ground, pressed, blended or sieved to the consistency
of a creamy paste or liquid) the battered chicken breasts to have a smooth pudding like
consistency. This practice affected 2 residents (Residents #17 and #20) with pureed diets.
The facility census was 68 residents.
1. Record review of the undated recipe for 16 servings of pureed meat, showed:
-Two pounds of meat;
-3/4 quarts of whole warm milk, and
-14 3/8 slices of bread.
The directions for the pureed meat recipe showed to place hot meat and warmed milk into
the blender and mix until meat is pureed and seasoned appropriately, add bread to meat
mixture and blend at medium speed until a semi liquid consistency is reached and there are
no visible pieces of bread in the mixture. Test seasoning and adjust if necessary.

Based on observation, interview and record review, the facility failed to maintain the fan
vent cover in the walk-in refrigerator free of grime; to ensure the food preparation area
at the toaster area was adequately illuminated; maintain utensils free of handles that
were not easily cleanable; to refrigerate a bottle of jelly according to the label;
maintain the ceiling vent above the food preparation table free of a black mildew like
substance; to maintain the mittens in good repair; to maintain the stove free of burnt on
grease and food deposits; to maintain two cutting boards in an easily cleanable condition;
to maintain the ice machine and an ice cooler on the 3rd floor free from damage; to store
condiment packets in an organized and a spill free manner and to ensure the nursing staff
used proper hand hygiene practices during the lunch meal and snack services for the
residents who were eating their meals in the dining room on the second floor. This
practice potentially affected at least 64 residents who ate food from the kitchen. The
facility census was 68 residents.
1. Observations and interviews on 3/7/19 from 8:49 A.M. through 12:59 P.M., during the
lunch preparation, showed:
-At 8:49 A.M. , grime on the fan vent cover of the walk-in refrigerator;
-At 8:49 A.M., the Interim DM said in 3 months no one has notified the maintenance
department about the grime on the fan vent cover;

Based on observation, interview and record review, the facility failed to ensure the
dumpster’s on the north Side of the facility were closed on 3/7/19. This practice affected
the outdoor area on the north side of the facility. The facility census was 68 residents.
1. Observations on 3/7/19 at 8:08 A.M. 9:29 A.M., 10:05 A.M., 11:13 A.M., 2:35 P.M.,
showed two dumpster’s open on the north side of facility. One dumpster did not have a
cover and the other dumpster had lids and the lids were not closed.
During an interview on 3/7/19 at 2:36 P.M. the Maintenance Director said one of the
dumpster’s needed a lid.
Review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri
Food Codes, showed:
5-501.113 Covering Receptacles.
Receptacles and waste handling units for refuse, recyclables, and returnables shall be
kept covered:
(A) Inside the Food establishment if the receptacles and units contain food residue and
are not in continuous use; or
(2) After they are filled; and
B) With tight-fitting lids or doors if kept outside the Food Establishment
– In Chapter 5-501.15, receptacles and waste handling units for refuse, recyclable’s, and
returnables used with materials containing food residue and used outside the food
establishment shall be designed and constructed to have tight-fitting lids, doors, or
covers; and receptacles and waste handling units for refuse and recyclable’s such as an

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure the corporate
leadership coordinated with the facility to use resources effectively to pay the
Registered/Consultant Dietician’s group in a timely manner. This practice created a gap in
the Registered Dietician (RD) scheduled for monthly visits to the facility between the
dates of 6/11/18 and 8/6/18 and between 10/3/18 and 12/17/18 and the residents that needed
to be seen by the RD was not seen. This practice potentially affected the residents who
were scheduled to be seen by the RD during those months the RD was not at the facility.
The facility census was 68 residents.
1. Record review of the RD Reports dated 4/18 through 2/19, showed the RD did not visit
the facility for a period of 55 days from 6/11/18 through 8/6/18, and for a period of 66
days from 10/3/8 through 12/7/18.
Record review on 3/12/19 at 7:09 P.M., during a written response to a question about the
length of time when the visits did not occur, the RD wrote:
-The company he/she consulted for notified him/her that he/she could not go into a
facility since they had not received payment;
-The RD placed the facility on hold until he/she was told that he/she could go into the
facility, and
-If he/she did not go into a building for a whole month and nonpayment was the reason.
During a phone interview on 3/18/19 from 8:45 A.M. through 8:57 A.M., The owner of the
Registered/Consultant Dietician’s group, said:
-There were problems with payment to his/her company, because the facility was behind on
payment;
-The times the RD did not go into the facility for nonpayment, training was delayed, and
-Once payment was made, his/her company would work to try and catch up with regular
visits.
During a phone interview on 3/20/19 at 8:39 A.M., the Administrator said:
-The previous dietary services company left the faciity on [DATE];
-When the RD did not visit the facility between 6/11/18 and 8/6/18, it was due to a
payment issue;
-He/she was not sure what the issue was during the RD’s absence between 10/3/18 and
12/7/18 and
-The previous dietary services company left the faciity on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure infection

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide a safe
environment for facility staff by not maintaining two faucets in the kitchen, one faucet
in resident room [ROOM NUMBER], and one faucet in the 2nd floor soiled utility room in
good repair; to maintain the floor of the 2nd floor medication room free of grime, and to
maintain the elevator pump operating mechanism in good repair to prevent hydraulic fluid
from splattering across the floor in the elevator machine room. The facility census was 68
residents.
1. Observations during the lunch meal preparation on 3/7/19 from 9:10 A.M. through 12:30
P.M., showed:
– A 2.5 inch (in.) crack in the stainless steel frame of the hand washing faucet which
contributed to that faucet being out of alignment;
– A glove that was wrapped around the faucet spout (the part where the water came out of)
to prevent a leak within the spout from dispersing water in multiple directions and
– At 10:34 A.M. the Maintenance Director said the hand washing sink fixture needed to be
replaced due to a 2.5 in. crack in the stainless steel part of the fixture.
2. Observations with the Maintenance Director on 3/7/19 at 3:01 P.M., showed hydraulic
fluid across the floor of the elevator machine room which made that floor very slick for
walking.
During an interview at the time of the observation, the Maintenance Director said the
leakage of the hydraulic fluid came from the pump every time the elevator operated and
he/she had to clean up the fluid every 2-3 days.
3. Observations with the Maintenance Director on 3/8/19, showed:
– At 10:54 A.M., there was a buildup of grime on the floor of the 3rd floor medication
room;
– At 10:55 A.M., the Housekeeping Director said neither he/she nor his/her staff has been
in that medication room to clean the floors;
– At 12:51 P.M., a heavy buildup of lime on the faucet at the handwashing sink in resident
room [ROOM NUMBER];
– At 12:52 P.M, the Maintenance Director said that faucet definitely needed to be
replaced;
– At 1:21 P.M., there was not a knob on the hot water side of the faucet in the 2nd floor
soiled utility room, and
– At 1:22 P.M., the Maintenance Director said the cabinet around that faucet also needed
to be replaced and he/she had tried to get that accomplished in the past.
4. During interviews on 3/11/19, the following was said:
– At 11:27 A.M., the Maintenance Director said the corporate entity sometimes take a long

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, observation, and interviews, the facility failed to prevent the
influx of roaches in the kitchen and adjoining dining room, the 2nd floor shower room
[ROOM NUMBER], and the 2nd floor dining room and in the 3rd floor dining room. This
practice potentially affected all the residents that utilize these areas. The facility
census was 68 residents.
1. Record review of the work order from the local pest control company dated:
-2/22/19, showed no findings of live roaches;
-2/28/19, showed roaches were found in the kitchen and findings which included grease
deposits on the floor, which provided food for roaches grease and organic deposits on
equipment, missing or damaged tiles, which permitted the accumulation of water, food
deposits, standing water or irrigation soaking walls, and the application of various
pesticides and
-3/6/19, showed live roaches found, the same conditions in the kitchen as on the 2/28/19
application, and the application of pesticides.
2. Observation and interview on 3/7/19 from 9:49 A.M. through 12:57 P.M, during the lunch
meal preparation, showed the presence of live roaches at the following areas:
-Under the dishwasher, on the wall next to the cart with silverware on it, the wall next
to the door from the kitchen into the dining room, a roach crawled across the food prep
table during the food prep observation, there was food debris present above steam table
here food was being served, around the cutting boards and crawling along the wall in the
1st floor dining room and
– At 1:00 P.M., the Interim Dietary Manager (DM) said he/she thought when they sprayed
last night, the roaches started running around.
3. Observations with the Maintenance Director and the Housekeeping Director on 3/8/19,
showed:
– At 12:56 P.M., the presence of roaches in Shower #5 under two foot rest on the floor of
that shower room;