NORTH VILLAGE PARK

Based on observations and interviews the facility failed to respect the dignity of one
resident (Resident #132) when staff did not assure resident’s sides and abdomen remained
covered when in public areas. The facility census was 170.
1. Review of resident #132’s Minimum Data Set (MDS) a federally mandated assessment
instrument completed by facility staff, dated 9/11/18, showed:
– Impaired decision making skills;
– Required assistance with transfers, locomotion in hallways, dressing and personal
hygiene.
The MDS did not show the resident was a current tobacco user.
Review of the resident’s care plan, revised 9/20/18, showed:
– Requires one to two person assist with activities of daily living, grooming and eating;
– Resident needs supervision with eating;
– Resident will be well groomed at all times.
Observation on 10/18/18 from 7:42 A.M., until 8:27 A.M., showed the resident sat in the
assist dining room eating breakfast. The resident wore a white thermal-like shirt and a
pair of gray sweat pants. At least four inches of the resident’s bare skin on the right
side and across the front of his/her abdomen was visible to all residents and staff in the
dining room. Multiple staff spoke to the resident but did not pull down the resident’s
shirt to cover his/her abdomen and right side. At 8:27 A.M., the charge nurse adjusted the
resident’s shirt, which still left about two inches of his/her right side visible, and
pushed the resident to the doorway of the dining room. An office staff pushed the resident
on out into the hallway and to his/her room.
Observation and interview on 10/19/18 at 1:20 P.M., showed the resident sat in a line of
residents in a hallway close to the entrance of the facility. The resident sat in his/her
wheelchair with a dark coat on over a white shirt. The front of the shirt did not reach
the resident’s pants. The coat was open in the front, four to five inches of bare skin was
visible across the resident’s abdomen and on the resident’s side. The resident said he/she
was waiting to go outside and smoke. Another resident pushed the resident’s wheelchair in
the line of residents.
During an interview on 10/19/18 at 5:52 P.M., the Director of Nurses said staff should
make sure the resident’s skin was not showing when the residents were in public areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and record review, the facility failed discuss moving
the resident to another hall and failed to find a suitable room for one of 34 sampled
residents, (Resident #35), who required a bathroom large enough for his/her wheelchair.
The facility census was 170.
1. Review of the facility’s resident’s rights policy, reaffirmed, (MONTH) 22, (YEAR),
showed, in part:
– A room transfer of a resident within the facility, requires consultation with the

Based on observations, interviews and record reviews, the facility failed to create an
environment respectful of the rights of the each resident to make choices about
significant aspects of their lives. The facility census was 170.
1. Review of the facility policy for Resident’s Rights dated 3/22/17 showed:
-The resident has a right to a dignified existence, self-determination, and communication
with and access to persons and services inside and outside of the facility. The facility
must protect and promote rights of each resident;
-The resident has the right to be free of interference, coercion, discrimination and
reprisal from the facility in exercising his or her rights;
2. During a group interview on 10/17/18 at 10:30 A.M. the residents on the Rothwell,
Rothwell Senior, Parkwood and Parkwood Senior secured behavioral health unit said:
-All resident said there is not enough food. They are told that if they want seconds there
would have to be a physicians order obtained before a second portion could be given. Meals
are served late on the Parkwood and Parkwood Senior unit.
-The Parkwood and Parkwood Senior unit does not get served what is on the menu, dietary
runs out of the food and they are served what the kitchen has left.
– If there is a doctor’s order for large portions, the large portions not being served;
-If a resident does not show up for a meal, do not get served any food.
– If a want to sleep in of a morning, no breakfast is served. The resident may get a bowl
of cereal.
-There are not any snacks three times a day.
Observation on 10/18/18 at 7:56 A.M. showed eight trays were left on cart for the
residents for Rothwell Senior unit who did not come to the dining room. A staff member
took the remaining eight trays to the Rothwell Senior unit and placed them on a counter.
During an interview on 10/18/18 at 9:00 A.M. Certified Nurse Aide (CNA) A said:
-The seven breakfast trays were for the residents who did not get up for breakfast on the
Rothwell Senior unit. He/she has thrown away the food. No resident wanted to get out of
bed and eat the breakfast.
During an interview on 10/18/18 at 9:15 A.M. Resident #47 said:
-He/she just got up;
-He/she did not have any breakfast;
-The staff will not go to the kitchen to get any breakfast foods for those who want to
sleep in;
-He/she may get a bowl of cereal or a graham cracker when the staff pass snacks at 10:00
A.M.;
-But the staff does not always pass snacks at 10:00 A.M., if they don’t you have to wait
until lunch.
During an interview on 10/19/18 at 5:30 P.M., Licensed Practical Nurse (LPN) A, who was
the Rothwell and Rothwell Senior unit manager, said:
– Food trays should not be left in the snack room for residents who slept during meal
service. Staff were to get food from the kitchen for residents who wanted to eat when they
woke up.
– Staff does not tell residents that they are not allowed to fist bump or hug.
During an interview on 10/19/18 at 4:43 P.M. the Dietary Manager (DM) said in order for
staff to serve residents increased food portions an approval by registered dietician or
resident’s physician was required.

Based on observations and interviews, the facility failed to post all required
information. The facility census was 170.
1. Observations on the Homestead unit during the survey on 10/16, 10/17.10/18, and 10/19
showed:
– No contact information for the Ombudsman.
– The state elder abuse hot line number was posted on the wall behind the nurse’s station
at a height of about six feet.
During a group interview with the Homestead and Meadow brook units, on 10/17/18 at 10:05
A.M. the residents said:
– They did not know who the Ombudsman was or what they did.
– They did not have a sign on their units with contact information for the Ombudsman.
– They had not seen the contact information for the elder abuse hot line.
During an interview on 10/19/18 at 4:55 P.M. the Administrator said:
– The facility posted the numbers for the Ombudsman and the elder abuse hot line.
– Residents frequently tore the contact information down.
– Staff did not make rounds to see if the notices were visible.
2. Observation on 10/16/18, 10/17/18 and 10/18/18 on the Rothwell and Rothwell Senior wall
showed:
-No resident rights posted, no addresses or phone numbers for the Missouri Division of
Aging, Missouri Department of Social Services, Missouri Ombudsman Program, Missouri

Based on observations, on interviews, and record reviews, the facility failed to provide
residents with reasonable access to a telephone and privacy for phone conversations. The
facility census was 170.
1. Observations on 10/16, 10/17, 10/18, and 10/19 showed a pay phone for resident use on
the Homestead unit and a cordless phone locked inside the kitchen.
During a group interview, on 10/17/18 at 10:05 A.M., with residents from the Homestead and
Meadowbrook units the residents said:
– They had to use a pay phone to make phone calls.
– They had to call collect to the number and either hope the person accepted the call or
call them back.
– Most of their friends and family had cell phones and cell phones would not accept a
collect call.
– They could call someone from the pay phone if they purchased a phone card.
– After they got someone on the phone, sometimes staff would provide them with a portable
phone.
– Usually they just had to talk on the pay phone.
– They would like to be able to make and receive phone calls in private.
– They cannot afford phone cards.
During an interview on 10/19/18 at 5:24 P.M. the Administrator said:
– Residents could call collect or use a phone card on the pay phone.
– The units all had a cordless phone that residents could receive phone calls.
– Residents needed to ask staff for the cordless phone.
2. Observation on 10/16/18, at 12:25 P.M., showed a pay phone in the commons area on the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interviews, the facility failed to assure staff indicated in
the resident’s medical record their wishes for CPR (Cardo [MEDICAL CONDITION]
Resuscitation) and documented the residents choice of code status in such a way to be
readily accessible to staff in the event of an emergency. This affected three residents
(Resident #64, #147 and #153) out of 34 sampled residents. The facility census was 170.
Review of the facility for Advance Directives dated [DATE] showed:
-It is the policy of this facility to follow the directions given by each resident with
regard to accepting or refusing medical or surgical treatment to the extent permitted by
law;
-At the time of admission as a resident of the facility, the resident will be provided
with written information concerning the resident’s rights under state law, both statutory
and case law, to make decisions concerning medical care, including the right to accept or
refuse medical or surgical treatment, and the right to formulate advance directives;
-There shall be documented in the resident’s medical record whether the resident has
executed any advance directives, and copies shall be made a permanent part of the
resident’s medical record;
-Advanced directive includes a living will, durable power of attorney for health care or
any other written document executed by the resident, signed, and dated that expresses the
individuals health care treatment decisions;
-The Administrator, Social Services Director, Consumer Service Consultant and all nursing
staff shall be educated about advance directives and this policy.
1. Review of Resident #64’s quarterly Minimum Data Set (MDS), a federally mandated

Based on interview and record reviews the facility failed to inform two residents
(Residents #48 and #103) when changes were made in his/her Medicare coverage prior to the
end of service date. The facility census was 170.
1. Review of Resident #103’s NMNC showed:

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Based on observation and interview, the facility failed to maintain resident use areas in
a clean homelike manner when resident rooms and common areas were not kept clean and
maintained. The facility census was 170.
1. Observations throughout all days of survey from 10/16/18 through 10/19/18 showed:
– Dead bugs in ceiling lights located in resident room restrooms for rooms 102, 105 and
304.
– Privacy curtains either not in the room for each resident in a shared room and/or not
secured in room [ROOM NUMBER],101, 102, 107, 201, 204 and 206.
– No light covers in resident rooms 111, 302, 311 and 315 restrooms
– Resident rooms including room [ROOM NUMBER], 303, 306, 308, 309, 311, 315, 316 had room
ceiling vents covered with dirt and dust and /or a loud sounding motor.
– Wall paint chipped and/or dented, spotted and damaged in rooms 303, 309, 408, 605, 701,
707 and 101.
– Floor tile up to 100 percent of the area either stained and/or dirty, marked, sticky,
dusty, streaked, wax build up and separation between tiles in rooms 303, 308, 311,400,
402, 406, 408, 409, 411, 500, 501, 502, 504, 507, 508, 509, 601, 603, 604, 605, 702, 707,
701, 704, 707, 202, 101, 103, 107, the 200 hall corridor and 400/500 hall dining room.

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Based on observations, interviews, and record review, the facility failed to ensure staff
followed professional standards of care when staff failed to follow the recommended
guidelines when administering nasal spray and did not administer food with Vitamin D 3 for
one of 34 sampled residents, (Resident #32). Additionally, staff failed to clarify
specific times for medications scheduled every 12 hours; failed to monitor food allergies
[REDACTED]. Staff failed to date when opened oxygen tubing and oxygen humidifier and
failed to clean an oxygen concentrator filter which affected one resident (Resident #105).
The facility census was 170.
1. Review of the facility’s medication administration and monitoring policy, reaffirmed,
(MONTH) 6, (YEAR), showed, in part:
– The nurse or Certified Medication Technician (CMT) will check each medication to the
Medication Administration Record [REDACTED]
– It is imperative that all medications are given using he seven rights to medication
administration and that the professional caregiver ensures that medications are swallowed:
right resident, right medication, right dose, right route, right time, right documentation
and right dosage form;
– If time is specified, give medication as ordered on time (specified medications should
be scheduled to best reflect the physician’s orders [REDACTED].>- Medications that are
to be given with food, will be given within 30 minutes before or 30 minutes after the meal
consumption;
– If the medications must be given with food, and it is out of the 30 minute window, then
a small snack will be provided to the resident to prevent GI upset, according to their
diet.
Review of the website, www.[MEDICATION NAME].com.dosage and administration, showed:
– Blow your nose gently to clear nostrils;
– Put the tip of the spray nozzle into a nostril and tilt head forward while keeping
bottle upright.
2. Review of Resident #32’s consumption sheet, dated, October, (YEAR), showed:
– The staff documented the resident refused breakfast (MONTH) 1st through (MONTH) 16th;
– Staff did not document a percentage for breakfast on (MONTH) 17th.
Review of the resident’s physician order [REDACTED].
– an order for [REDACTED].M. to 11:00 A.M.;
– an order for [REDACTED]. to 11:00 A.M.

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Based on record reviews and interviews, the facility failed to develop a discharge plan
according to the resident’s wishes for two sampled residents (Resident #93 and Resident #
130) out of 39 sampled residents. The facility census was 170.
1. Review of Resident # 93’s MDS, dated [DATE], showed:
– Capable of making decisions;
– Needed only supervision/cueing with personal hygiene, eating and bathing;
– Independent in other activities of daily living;
– No mood disorders noted;
– No behaviors noted;
– [DIAGNOSES REDACTED].
– No discharge plan.
Review of the resident’s social service note, dated 8/9/18, showed:
– The resident able to communicate wants and needs effectively.
– The resident continues to request to move to independent living near his/her sisters
though the guardian has explained that moving back to the St. Louis area is not an option
at this time.
– Current plan is continued placement at the facility and for Social Services to meet with
the resident as needed or requested.
Review of the care plan last updated 9/18 showed:
– Discharge plans per guardian is for continued long term placement;
– Resident has expressed desire to move closer to family in to a residential care
facility. Guardian stated unable to move at this time.
-Goal: Maintain current physical and mental health;
-Approaches: interdisciplinary team to meet with resident and guardian via phone at
facility to discuss current placement; hospital evaluation and treatment as needed or
ordered. Undated handwritten note: Will follow guardian directives/wishes at this time.
Will communicate resident’s needs/desires to guardian as requested/needed.
Following a group meeting at 10/17/18 at 10:05 A.M., which the resident attended and again

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Based on observations, interviews, and record review, the facility failed to assure staff
transferred residents with a mechanical lift in a safe manner to prevent the possibility
of injury. This affected two of 34 sampled residents (Resident #125 and # 37). The
facility census was 170.
1. Review of the manufacturer’s Operating Manual for the Invacare Electric Portable
Patient mechanical lift shows:
– Warning: Do not lock the rear casters of the patient lift when lifting an individual;
– Locking the rear casters could cause the patient lift to tip and endanger the patient
and assistants.
Review of the manufacturer’s User Manual for the Invacare Stand Up Patient Lift, showed:
– Warning: Invacare does not recommend locking the rear casters of the Stand Up Lift when
lifting and transferring an individual the patient and assistants;
– Invacare recommends that the rear casters be left unlocked during lifting and
transferring procedure to allow the stand up lift to stabilize itself when the patient is
initially lifted from and transferred to a chair, bed, or any stationary object.
2. Review of Resident #125’s Minimum Data Set, (MDS) a federally mandated assessment
instrument completed by facility staff, dated 6/10/18, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews the facility failed to provide care
to prevent urinary tract infections [MEDICAL CONDITION] for two residents (Residents #152
and #167). The facility census was 170.
1. Review of the facility policy, dated 4/6/17. on perineal (peri) care showed:
– Staff must clean the resident’s genital and rectal area.
– If a resident had retractable perineal folds, staff must retract the resident’s perineal
folds, clean underneath them, dry the folds, and replace the folds.
– Staff must clean the anal area as well.
2. Review of Resident #152’s care plan showed:
– 7/2/18 the resident had incontinence with occasional [MEDICAL CONDITION] and staff must
provide pericare after each incidence of incontinence.
– 8/18/18 Bactrim DS (an antibiotic) two times a day for 10 days to treat a UTI.
– 9/11/18 Staff to [MEDICATION NAME](an antibiotic) and start [MEDICATION NAME] (an
antibiotic) and Azo (used to treat urinary pain).
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 9/22/18, showed:
– Cognitively intact;
– Required extensive staff assistance for transfers, toileting, and hygiene;
– Frequently incontinent of bladder;
– Occasionally incontinent of bowel.
Observation on 10/17/18 at 1:48 P.M. of Certified Nurse Assistant (CNA) K and CNA L
providing peri care for the resident showed:
– The resident had retractable perineal folds.
– CNA K retracted the resident’s perineal folds and cleaned between them.
– He/she did not dry the perineal folds.
– He/she did not replace the perineal folds.
– He/she did not clean the resident’s anal area.
During an interview on 10/17/18 at 1:50 P.M. both CNAs said:
– They did not know how to provide peri care for a resident with retractable perineal
folds.
– They should have cleaned the resident’s anal area.
During an interview on 10/17/18 at 1:50 P.M. the Director of Nursing (DON) said:
– If a resident had retractable perineal folds, staff must retract the folds, clean under
the folds, dry the area, and then replace the folds.
– Staff must clean the resident’s anal area.
3. Review of Resident #167’s annual MDS, dated [DATE], showed:
– Cognitively intact;
– Independent for toileting;
– Continent of bowel and bladder;
– [DIAGNOSES REDACTED].
Review of the resident’s care plan showed on 10/1/18 staff should assist the resident with
drinking at least 60 ounces of water a day.
Review of the resident’s physician order sheet (POS) dated (MONTH) (YEAR), showed:
– His/her physician recommended the resident drink 60 ounces of water a day.
– An order on 10/8/18 an order for [REDACTED].>- AN order on 10/9/18 [MEDICATION

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Based on observations, interviews and record reviews, the facility failed to provide
documentation that the consultant pharmacist (PharmD) performed monthly drug regimen
reviews (DRR). The facility failed to provide documentation that the PharmD identified any
attempts requesting a gradual dose reduction (GDR) in an effort to reduce or discontinue a
resident’s psychoactive (medications that alter brain function) and also failed to provide
documentation that the resident’s physicians were provided with this information in a
timely manner. Staff did not document on-going monitoring of adverse drug reactions. This
affected four of 39 residents (Residents #3, #20, #55 and #146). The facility census was
170.
1. Review of the facility policy, dated 4/7/17, on medication administration showed:
– The PharmD will review each resident’s drug regimen on a monthly basis.
– All PharmD recommendations will be given to the Director of Nursing (DON) and the
resident’s physician.
– All PharmD recommendations will be addressed and followed up by nursing and/or the
resident’s physician.
– Each resident’s psychoactive medications will be reviewed by the resident’s physician
and nursing on a quarterly basis.
2. The facility did not provide Resident #3’s abnormal involuntary movement scale (AIMS) (
a scale to help staff monitor adverse reactions to psychoactive medications).
Review of the resident’s care plan, dated 9/7/18, showed:
– The resident was at risk for adverse effects from psychoactive medications taken for
substance abuse, dementia, [MEDICAL CONDITION], impulse disorder, anxiety, and depression.
– PharmD to routinely review medications and ensure all recommendations sent to the
resident’s physician.
– Nursing to assist the resident’s physician.
– A handwritten unsigned note dated 9/7/18 on the care plan stating the resident’s Nurse
Practitioner (NP) said Gradual dose recommendation no recommended due to the potential
risk of returning [MEDICAL CONDITION]-at baseline.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/5/18, showed:
– Mild cognitive impairment;
– No behaviors noted;
– No mood disorders noted;

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Based on observations, interviews, and record reviews the facility failed to ensure staff
labeled when opened multi-use vials, which affected two residents (Residents #114, #167).
Additionally, staff failed to discard expired medications, and failed to discard opened
single use medications. The facility failed to ensure staff followed their policy for
staff checking medication rooms and carts. The facility census was 170.
1. Review of the facility policy, dated 4/6/17, on medication cart monthly inspections
showed:
– The charge nurse on the night shift would complete a monthly review of all medication
and treatment carts the last Saturday of each month.
– The night charge nurse must check medications for outdates and destroy any outdated
medications.
Review of the package insert, dated (MONTH) 2007, for [MEDICATION NAME] showed:
– The medication was used to treat elevated blood sugar.
– Staff must date all vials when opened.
– Staff must discard all opened vials 28 days after opening.
Review of the package insert, dated (MONTH) 2012, for Novalog insulin showed:
– The medication was used to treat elevated blood sugar.
– Staff must date all vials when opening.
– Staff must discard all opened vials 28 days after opening.
2. Observation 10/18/18 at 7:12 A.M. of the medication storage room on the Homestead Unit
showed:
– Resident #167’s opened, dated 9/1/18, vial of Novalog insulin;
– Resident #114’s opened, undated, vial of [MEDICATION NAME];
– Two vials of injectable hydrozyxine (used to treat anxiety and allergies [REDACTED].
– An opened vial of sterile water for injection (used to mix medications), dated 9/22/18,
with a label stating for single time use only;
– An opened, undated 10 milliliters (ml) vial of [MEDICATION NAME] (a numbing medication)
with a label stated for single use only;
– An opened, undated vial of [MEDICATION NAME] (used to treat [MEDICAL CONDITION]), with a
label stating single use only.
Observation on 10/18/18 at 2:30 P.M. of the crash cart on the Homestead emergency crash

Based on observations, interviews, and reviews, the facility failed to honor resident
preferences for meals. The facility census was 170.
1. Record review on 10/17/18 at 7:50 A.M. of the posted menu for the Homestead Unit
10/17/18 for breakfast showed:
– Scrambled eggs;
– Toast with butter;
– Oatmeal or cold cereal of choice.
Observation on 10/17/18 at 7:50 A.M. of the dining room on the Homestead unit showed:
– Without asking residents what they wanted to eat, staff served residents plates from
kitchen containing a small scoop of scrambled eggs, one piece of toast and jelly, and a
bowl of oatmeal.
– Dietary did not send any cold cereal or butter.
During a group interview with residents from the Homestead unit and the Meadowbrook unit
on 10/17/18 at 10:05 A.M. the group said:
– They could not request an alternative after the food arrived.
– Often, dietary did not send the items listed on the menu.
– They discuss dietary issues at council meetings but their issues were never resolved.
missed a meal, staff did not ask if they wanted anything to eat.
– Often dietary staff made menu substitutes.
– Staff always served cold toast and often did not serve butter or jelly with the toast.
– They have complained about often no butter for the toast.
Record review on 10/18/18 at 7:50 A.M. of the breakfast menu for the Homestead Unit
showed:
– Scrambled eggs;
– Cinnamon toast;
– Hot cereal or cold cereal of choice.
Observation on 10/18/18 at 7:50 A.M. of the dining room on the Homestead unit showed:
– Without asking residents what they wanted to eat, staff served residents plates prepared
in the kitchen containing a small scoop of scrambled eggs, one piece of plain toast and
jelly, and a bowl of oatmeal.
– Dietary did not send any cold cereal.
During an interview on 10/18/18 at 7:50 A.M. Certified Nurse Assistant (CNA) C said:
– He/she usually worked on the Homestead unit.
– Staff offered beverage choices with every meal.
– Dietary staff did not send any breakfast alternatives.
– Staff just served what dietary sent.
During an interview on 10/18/18 at 7:53 A.M. Resident #135 said:
– He did not like the facility served breakfast.
– He would like cold cereal and omelets.
During an interview on 10/18 at 7:53 A.M. Resident #145 said:
– The facility always served the same thing for breakfast.
– He/she would like to have some choices for breakfast.
– He/she did not like cereal but received cereal every morning.
– He/she would like pancakes and biscuits and gravy.
During an interview on 11/19/18 at 6:00 P.M. the Director of Nursing (DON) and Assistant
Director of Nursing (ADON) said:
– They did not know that the residents were not being offered substitutes.
– All the units should have cold cereal and milk.

Based on observation, interview and record review the facility failed to follow menus, or
offer substitutes of equal nutritional value and failed to obtain the Registered
Dietitian’s (RD) menu approval. The facility census was 170.
1. Review of the facility Menu and Diet Guidelines policy showed the facility dietitian
(RD) should review and sign the menu and menu components prior to implementation in order
to ensure state regulations as well as facility policies and procedures are met.
Review of the facility Cycle Menus Policy showed:
– Menus are implemented by the Dietary Manager (DM) in conjunction with the RD.
– The menus are three-meal plus a snack.
– When changes in the menu are necessary, the changes must provide equal nutritive value.
Menu changes are made on the menu (posted in Dietary) for regular and therapeutic diets
before the meal is served, or on the Substitution List. Menu changes are reviewed and
approved in advance by the DM.
– Menus must be followed as written.
Review of the facility Making Menu Substitutions policy showed that when substitutions are
made, the replacement item must be compatible with the rest of the meal, comparable in
nutritive value and reviewed by the DM for appropriateness.
2. During observation, interview and record review on 10/16/18 at 1:59 P.M., Cook A showed
a food alternates menu posted on the side of the kitchen refrigerator. Cook A said the
list of alternates were standard for all meals. Review of the POS [REDACTED].
During observation, interview and record review on 10/18/18 at 9:33 A.M.,
– Cook A, Cook C and DA A said they did not think the limited choices of the facility food
alternates equaled the comparative value of scheduled menu foods.
3. Record review on 10/18/18 at 6:03 A.M., showed the breakfast menu included choice of
hot or cold cereal and cinnamon toast.
Observation, interview and record review on 10/18/18 at 9:33 A.M., showed kitchen staff
did not prepare cinnamon toast as scheduled on the planned menu. DA A said he/she did not
make cinnamon toast as they probably did not have cinnamon. DA A then hunted for cinnamon
and found a small amount in a container. DA A said this would not have been enough
cinnamon for the number of residents they serve. Cook C confirmed that the amount of
cinnamon DA A found would not have been enough. Review of the scheduled menu showed it was
not updated to show a change from cinnamon toast to buttered toast. DA A said he/she did
not update the menu showing the change.
During an interview and record review on 10/18/18 at 10:05 A.M., DA A showed and said the
planned scheduled menu was for a choice of hot or cold cereal to be served every day for
breakfast. Review of the menu confirmed staff were to serve both hot and cold cereal
daily. DA A said that instead of preparing both hot and cold cereal daily, they alternated
by sending cold cereal one day and hot the next.
4. Observation on 10/18/18 at 7:07 P.M., showed:
– Six residents still in the dining room.
– Some residents had noodle soup, some had vegetable.
-Some residents had cake some had fruit cups.

Based on observations, interviews and record review the facility failed to preserve food
quality when staff did not check food temperatures at the time of meal service or store
food in a method to maintain food quality. The facility censes was 170.
1. Review of the facility Food Temperatures policy showed:
– Foods will be served at proper temperature to insure food safety.
– Record reading on Food Temperature Chart form at beginning of tray line and during the
tray line. If temperatures do not meet acceptable serving temperatures, reheat the product
or chill the product to the proper temperature. Take the temperature of each pan of
product before serving.
2. During an interview on 10/17/18, at 9:45 A.M.,in the main dining room Resident #35 said
the oatmeal is cold.
Observation on 10/18/18 at 7:44 A.M., showed breakfast service in the Homestead dining
room. Residents complained breakfast was cold.
Observation and record review on 10/18/18 at 8:37 A.M., showed:
– No staff took temperature of the breakfast foods prior to meal service.
– Review of the log to record food temperatures showed no temperatures were recorded.
– Dietary Aide A said he/she did not have time to take food temperatures. He/she was
supposed to check the food temperatures when the food was placed on the steam table and
again after three food trays were served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews, and record reviews, the facility failed to ensure

Based on observations, interview and record review the facility failed to properly store
foods and provide a sanitary environment in the kitchen. The facility census was 170.
1. Review of the kitchen polices showed:
– Cleaning Schedules policy showed no process for cleaning the standing refrigerator or
standing fans.
– The facility showed no policy for proper food storage.
– The facility showed no policy showing staff were required to cover hair in the kitchen.

2. Observation and interview during the initial kitchen tour on 10/16/18 at 10:55 A.M.,
showed:
– The center kitchen refrigerator had cake, pudding and fruit with no date. Salad in the
refrigerator was not uncovered and exposed.
– Dietary aide (DA) A looked but could not locate a thermometer for the refrigerator. DA A
said the refrigerator should have a thermometer in order to monitor the temperature. The
undated food was from the previous night and should have been dated prior to storage.
Observation and interview on 10/18/18 at 6:03 A.M., showed:
– The center kitchen refrigerator had uncovered broth dated 10/9/18. A second container of
broth was dated 10/14/18. DA A said the broth should be covered and should have been
discarded three days after it was opened.
– Two standing fans next to the food preparation area covered with think dust that could
be removed with touch of finger.
3. Observations on 10/18/18 at 7:00 A.M. and on 10/19/18 at 4:43 P.M. of the kitchen,

Based on observation and interview the facility failed to clean and maintain smoke room
ventilation. The facility census was 170.
1. Observation and interview on 10/18/18 at 2:15 P.M., showed no one smoking in the 800
hall smoke room. A black thick substance covered the smoke room vent. The room air smelled
heavy of smoke. The maintenance supervisor (MS) said he was scheduled to clean smoke vents
weekly but had not cleaned the 100, 500 and 800 hall smoke room vents in the past three
months. Other facility task occupied his time and prevented him from cleaning the vents.