Health inspection·June 3, 2024

F 0800 Level of Harm - Potential for minimal harm Residents Affected - Some On 5/13/24 at 1248 hours a concurrent observation, interview, facility document review, and medical record review was conducted with LVN 1. LVN 1 was asked to describe the facility's process to ensure the residents received their prescribed diets. LVN 1 stated before a staff passed out the resident meal trays, she would verify to ensure the resident meal trays were consistent with theirphysician's orders. LVN 1 stated the process for verifying the resident meals included conducting a review of the physician's diet order, a review of the residents' food cart log (log attached to the food cart which showed residents' name and prescribed diet type), a review of the residents' dietary card (card attached to the residents' meal tray showing information specific to the residents' name and prescribed diet), and observing the food on the resident's meal tray to ensure the food served to the residents was consistent with the physician's orders, cart logs, and dietary cards. After LVN 1 explained the facility's process for resident meal distribution, an observation was conducted of Resident 1 who was eating lunch in his room. LVN 1 verified Resident 1's lunch tray contained a packet of salt. LVN 1 verified Resident 1's lunch tray also did not contain a dietary card. LVN 1 was then able to locate Resident 1's dietary card which was found inside of the food cart. Resident 1's dietary card showed Resident 1 was to receive a regular diet. LVN 1 then reviewed the food cart log which showed Resident 1 was to receive a regular diet. LVN 1 was asked if she reviewed Resident 1's physician's order for his diet. LVN 1 stated she had already returned (to the kitchen) the list of physician's orders specific to the resident diets and had already verified Resident 1's lunch was consistent with the physician's order. LVN 1 was asked if she could retrieve the list of physician's orders for the resident diets to verify Resident 1 received his prescribed diet. LVN 1 then retrieved the list which showed Resident 1's physician had ordered a regular diet with no added salt on 5/9/24. LVN 1 verified Resident 1 had not received his lunch with no added salt in accordance with Resident 1's physician's order. LVN 1 also verified the food cart log and dietary card failed to show the correct diet (no added salt) for Resident 1. LVN 1 stated there was an oversite on her part and Resident 1 had not received his prescribed diet. LVN 1 was asked who was responsible for the oversite of resident meal preparation and who wrote the dietary information on the resident dietary cards, to which LVN 1 replied, the DSS. On 5/13/24 at 1318 hours an interview, and concurrent medical record review, and facility document review was conducted with the DSS. The DSS was asked her process when preparing meals for the residents. The DSS stated the facility nurses would submit a diet order form to the kitchen, which showed the physician's order for the resident diets. The DSS stated she would then transcribe the residents' dietary order onto a [NAME]. The DSS stated she would also write the residents' dietary order onto the residents' dietary card. The DSS stated when preparing the resident meals, the cook would review the residents' dietary card which showed the physician's prescribed diet. The DSS reviewed Resident 1's Diet Order Form dated 5/9/24, the [NAME], food cart log, and Resident 1's dietary lunch card. The DSS verified Resident 1's Diet Order Form dated 5/9/24, the [NAME], food cart log, and Resident 1's dietary lunch card all showed Resident 1 had an order for a regular diet. The DSS then reviewed Resident 1's physician's orders. The DSS verified Resident 1 had a physician's order dated 5/9/24, for a regular textured diet with no added salt. The DSS verified Resident 1's diet order form dated 5/9/24, the [NAME], the food cart log, and Resident 1's dietary lunch card contained the incorrect diet order for Resident 1 (failing to show no added salt). The DSS was asked how often she reviewed the physicians' orders for all resident diets. The DSS stated there was no set interval for which she reviewed the physician's orders for the resident diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 2 of 2