Health inspection·June 26, 2024

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Based on observations and interviews, the facility failed to honor the resident's right for food preference for portion sizes for 2 of 5 sampled residents (Resident #1 and #4). Residents Affected - Few The findings include: 1) An interview was conducted with Resident # 1 on 06/25/24 at approximately 10:45 AM. He expressed that the facility no longer provides him with large portions after the new company took over. He further stated that he was a big guy, and this little protein portion of meat is not good. The resident then became emotional and stated, they don't listen to me, I've tried to tell them; this little bit of food is not enough. I will sometime order something from somewhere that will deliver. An observation of the resident's lunch tray on 06/25/24 revealed that the resident was served a small portion of chicken thigh on his plate. The resident's vegetables were in a separate container. The resident again expressed that the serving was insufficient. An interview with the Certified Dietary Manager (CDM) and the resident was conducted on 06/25/24 at approximately 12:30 PM. The resident expressed that his tray was incorrect and that the serving was too small. The CDM informed the resident that the dietitian would have to assess the resident because they could only provide large or double portions when medically necessary. Another interview was conducted with the CDM on 06/26/24 at approximately 12:50 PM, who reported that since the change in ownership, they cannot provide large portions or double portions unless when medically necessary. She then contacted her District Manager, who confirmed this policy. The surveyor further questioned her regarding resident's preferences being honored. She again repeated that this is what she was informed. She further confirmed that the resident previously had large portions but that is no longer honored. An interview was conducted on 06/26/24 at 1:40 PM with the Dietitian. She stated she is new to the facility, but it was her understanding that she must complete a nutritional assessment and the resident has to meet the criteria of medically necessary, to be offered the option of double portions and/or large portions. Residents with wounds, increased BMI, or who have increased caloric needs then we can order but not based on the resident's preferences. We can then put it in as a therapeutic diet and get reimbursed for it. 2) An interview was conducted on 06/26/24 at approximately 2:00 PM with Resident #4. The resident said that he used to get large portions, but he doesn't receive that anymore. He said he was told that with the new owners, they can't get their preferred large portions. It must be a medical reason Page 1 of 3 105257 105257 06/26/2024 Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950

F 0806 for the resident to get this now. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105257 Page 2 of 3 105257 06/26/2024 Aviata at Saint Lucie 611 S 13th St Fort Pierce, FL 34950

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, administrative record review and interviews, the facility failed to store, distribute and serve food in accordance with professional standards for food service safety. This is evidence by the facility serving and storing milk beyond the manufacturer's expiration date. This failure affected 1 of 4 sampled residents who have a preference for chocolate milk for three or more days (Resident #5). The findings included: The surveyor also conducted an observation of the kitchen refrigerator on 06/26/24 at approximately 9:00 AM accompanied by the Certified Dietary Manager. Observed in the refrigerator was a red crate full of approximately 30 plus individual chocolate milk cartons dated 6/23/24. Also noted were 2 cartons of chocolate milk dated June 23 on another tray which contained lunch items such as salad. An interview was conducted with the CDM at the time of the observation, who confirmed that the milk was out of date. She further stated that the milk was delivered on Monday, June 24. The surveyor then stated so, your staff accepted out of date milk when delivered and failed to check expiration dates on items served to the residents to ensure food safety. An interview was conducted on 06/25/24 beginning at approximately 10:00 AM with Resident #5, who expressed that he has been served milk that is expired. The resident continued to tell the surveyor that he received outdated milk on multiple occasions and proceeded to show the surveyor pictures of dates the milk had expired. The resident had been served milk with an use by date of June 23, 2024, this morning, 06/25/24. The resident also showed the surveyor of picture of milk expiring on 06/23/24 with a tray ticket dated 06/24/25. The resident further showed the surveyor a picture of tray ticket dated May 13, 2024, with chocolate milk carton that had a date of May 9, 2024. An observation of the breakfast meal on 06/26/24 beginning at 8:15 AM on all units. An observation with Resident #5 breakfast meal delivery on 06/26/24 at approximately 8:50 AM confirmed another instance when Resident # 5 was again served milk dated June 23. Further review of the Resident Council Minutes revealed that during the 04/12/24 meeting, the issue of expired milk being served was brought up. Despite being made aware of the issue of expired milk, the facility failed to develop a plan to ensure this does not occur again. An interview was conducted on 06/26/24 at 11:30 AM with the Resident Council President, who stated she recalls a previous problem of the residents expressing that the milk was expired but the facility was able to get the company to deliver more milk. However, she wasn't aware that this continues to be a problem. She stated they have a meeting coming up later this week and she will follow up. 105257 Page 3 of 3