Health inspection·April 13, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain resident's dignity during dining for 4 of 15 residents assessed for dining of a total sample of 43 residents, (#37, #27, #52 & #54). Findings: 1. Resident # 37 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, dementia, and type 2 diabetes. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] indicated resident #37 had severe cognitive impairment and was totally dependent on staff for eating. Review of the resident kardex used by Certified Nursing Assistants (CNA) to guide the care of the resident, indicated the resident was totally dependent on one staff for eating. Review of the medical record revealed an Activity of Daily Living (ADL) care plan dated, 12/08/21 which indicated the resident required total assistance of one person for feeding. On 04/10/22 at 1:02 PM, CNA H was observed standing at the left side of resident #37's bed. The CNA was watching television that was on the wall to her left above the roommate's bed. She had her left arm on her hip, feeding resident with right hand while she watched television. The right side of her body was turned toward the resident. At this time, CNA H stated she had received education in the past about the proper way to assist residents with meals. CNA H remained standing and after a brief pause looked at the chair that was on the other side of the bed, but continued feeding the resident in a standing position. She explained she could not lift the chair over the footboard of the bed and demonstrated that she could not move the bed as it was too heavy to push. She said she was aware how to unlock the wheels on the bed but returned to the left side of resident's bed and continued to stand while assisting the resident with his meal. Her left hand remained on her hip and her face was turned towards the TV. The resident's mouth was at the level of her waist/lower chest. She stated, I have received education on being seated while feeding residents as she continued to stand. On 04/10/22 at 1:07 PM, the Minimum Data Set (MDS) Registered Nurse (RN) entered the room and informed CNA she should be sitting. The nurse had to repeat the direction twice to the CNA before he left the room. He commented the CNA was from an agency. Page 1 of 12 105332 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Resident #27 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, diabetes mellitus, quadriplegia, and muscular dystrophy. The MDS Quarterly Assessment with reference date 1/6/22, revealed resident #27 had a Brief Interview for Mental Status score of 15, which indicated he was cognitively intact. The assessment showed the resident needed extensive assistance from one staff for eating. Review of the medical record revealed resident #27 had a care plan for nutritional risk related to dependence on staff at meals and deficits in his activity of daily living (ADL) self-care performance. Planned interventions included staff to assist as needed with meals. On 4/10/22 at 12:31 PM, CNA B stood on the right side of resident #27's bed assisting the resident. with his meal. The resident's head was at the level of CNA B's abdomen while the CNA assisted with his meal. On 4/13/22 at 12:02 PM, CNA E stated resident #27 required total assistance from staff to eat. She explained, You have to sit down, position the resident to make sure they are comfortable, so they won't choke. She said, If you sit down, you can see them better, and continued to explain, It can be intimidating for the residents if you stand. 3. Resident #52 was re-admitted to the facility on [DATE] with diagnoses including advanced chronic kidney disease, muscle weakness, dysphagia, need for assistance with personal care and Alzheimer's disease. The Significant Change Assessment MDS dated [DATE] revealed resident #52 had memory problems and severely impaired cognitive skills for daily decision making. The assessment indicated resident #52 required extensive assistance from one staff member for eating. Review of the medical record revealed resident #52 had a care plan for ADL self-care deficit related to recent decline in participation in ADLs, weakness and health issues. Planned interventions included, Resident is totally dependent on staff for eating, and Provide and serve diet as ordered. On 4/10/22 at 12:20 PM, CNA G was observed standing between the privacy curtain and the right side of resident #52's bed. She was standing up looking toward resident #52's television while assisting the resident with eating lunch. On 4/10/22 at 12:37 PM, CNA G stated she worked for an agency but knew she was supposed to be seated while assisting residents to eat their meals. She was unable to provide a reason why she had been standing while she assisted resident #52 with lunch. On 4/13/22 at 2:53 PM, Registered Nurse (RN) C stated resident #52 had declined and was unable to feed herself any longer. She explained staff fed resident #52 her meals as she needed total care from the staff for her ADLs. 4. Resident #54 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, chronic lung disease, heart disease, dementia, blindness in the right eye and difficulty swallowing-oral phase. The MDS Annual assessment with reference date 2/23/22 revealed resident #54 had moderate cognitive 105332 Page 2 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0550 Level of Harm - Minimal harm or potential for actual harm impairment, had severely impaired vision and required extensive assistance from one staff member for eating. The Hospital Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form dated 3/21/19 indicated resident #54 had a regular diet and required assistance with eating. Residents Affected - Few Review of the medical record revealed a care plan for risk for impaired cognitive function related to dementia, memory problems and decision-making problem. The planned goal was for needs to be met and dignity maintained through the review date. Planned interventions included staff to face resident when speaking and maintain eye contact. A care plan for ADL self-care performance deficit related to blindness and other diagnoses. A planned intervention for eating included, Resident requires assistance by staff to eat related to blindness. On 4/10/22 at 12:20 PM, RN H stood on the left side of resident #54's bed as she assisted the resident to eat her lunch. Resident #54's head was approximately at the nurse's abdomen level while the RN looked down while she assisted the resident to eat. On 4/10/22 at 12:41 PM, RN H stated she usually helped with residents who needed assistance to eat. She explained in order to maintain eye level with the residents she was supposed to be seated when she assisted them to eat. She stated she was standing to feed resident #54 because there was no chair in the room. On 4/10/22 at 12:24 PM, the East Wing Unit Manager (UM) confirmed CNA G and RN H stood while they assisted with residents #52 and #54 with eating on either side of the curtain. The East Wing UM stated she was not sure of the facility's policy and was not sure if staff should stand or sit while they fed the residents. On 4/10/22 at 12:34 PM, the East Wing UM stated agency staff were provided education of the facility's policies and procedures on assisting residents to eat meals. She stated staff should sit at eye level with the resident and added it was a dignity issue for staff to sit and not stand over the resident while feeding them. On 4/13/22 at 12:13 PM, the Director of Nursing stated, My expectation is the staff will always have the dignity of the resident in mind when they are providing any kind of care. Review of the Job Description, Certified Nursing Assistant dated 4/20 revealed CNAs should, Assist with promoting a compassionate physical and psychosocial environment for the residents. Review of the Job Description, Registered Nurse dated 4/20 revealed essential duties included nurses ensured all nursing personnel assigned to them, comply with written policies and procedures established by the facility. 105332 Page 3 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide personal hygiene care for a resident dependent on staff for activities of daily living (ADLs) for 1 of 4 residents reviewed for ADL care in a total sample of 43 residents, (#93). Residents Affected - Few Findings: Resident #93 was admitted to the facility on [DATE]. Her diagnoses included dementia, cerebral vascular accident (CVA), dysphasia, hemiparesis of the left dominant side, and impaired visual function. She started hospice services on 11/2/21 post Coronavirus Disease 2019 diagnosis. Resident #93's quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 3/17/22 noted the resident had a Brief Interview for Mental Status (BIMS) Score of 3 out of 15 which indicated severe cognitive deficit. Review of Section G related to Functional Status revealed the resident required supervision of one staff person to eat, and was totally dependent on one staff person for personal hygiene and bath care needs. Resident #93's ADL Care Plan initiated 11/10/21 noted ADL self-care performance deficit related to cerebral vascular accident, dementia, and heart failure. The ADL care plan indicated the resident required supervision of one staff person to eat, was totally dependent on one staff for personal hygiene. Review of resident #93's Certified Nursing Assistant [NAME] revealed she was totally dependent on staff for personal hygiene and bathing needs. Interventions included Adjust ADLs to compensate for resident's changing abilities. On 4/10/22 at 12:14 PM, resident #93 was observed sitting in her bed with an empty plate of food in front of her on the overbed table. She had creamy colored food residue on the left side of her face from her lips to her upper left cheek and on the top front of her gown. At 12:35 PM, the creamy colored food residue remained on her face and gown. At about 4:15 PM, the resident was in bed with most of the food residue removed from her left cheek but her gown had not been changed. On 4/11/22 at 10:15 AM, resident #93 had dried whitish colored residue to the left side of her face and cheek. At 11:10 AM, Certified Nursing Assistant (CNA) A was observed walking out of the resident's room. The resident's face had not been cleaned and she had residue on her face. At 11:13 AM, CNA A acknowledged that resident #93 usually fed herself and had left sided weakness. CNA A acknowledged the dried residue on the resident's face and stated she was responsible to wash the resident's face following meals. She did not provide an answer as to why she had not done it. On 4/11/22 at 12:13 PM, Licensed Practical Nurse (LPN) D noted resident #93 required assistance to clean herself up after meals. She stated the resident had left sided weakness from a stroke, drooled and could not clean herself. On 4/11/22 at 3:45 PM with the Director of Nursing (DON) verbalized the CNA would be expected to provide personal hygiene care for a resident who was dependent on staff. She indicated that washing a resident's face when needed would be included in personal hygiene needs. 105332 Page 4 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0677 The facility's ADL Policy and Procedure read, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105332 Page 5 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and provide wound care services for 1 of 1 resident reviewed with a reoccurring left heel wound in a total sample of 43 residents, (#53). Residents Affected - Few Findings: Resident #53 was admitted to the facility on [DATE] with diagnoses that included history of sacral pressure ulcers and a reoccurring left heel wound. She had multiple co-morbidities that included heart failure, obesity, bilateral artificial knee joints, rheumatoid arthritis, fibromyalgia, limited mobility, muscle spasms, seizures, and chronic pain syndrome. Review of the resident's quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 2/22/22 showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. The assessment indicated she did not have any wounds at that time. On 4/10/22 at 12:17 PM, resident #53 was observed sitting up in bed. She had a low-loss air mattress and a large positioning bolster on the bed. The resident stated her left foot hurt. She said nursing staff were supposed to put her feet up on a pillow, but had not. Her lower body was covered with bed linen and not visible at this time. On 4/10/22 at 12:45 PM, observation of resident #53's left foot was conducted with the resident's nurse, Registered Nurse (RN) A. The nurse removed the bed covers from her feet which were hanging off the left side of the bed. The resident said it made her left heel feel better because it hurt. The resident's left heel was dry, scaly and had a dark purplish brown area, the size of a dime. The resident told the nurse that a pillow was supposed to be under her legs to keep her heels off the mattress. RN A reported she was not aware of the left heel wound until now and did not know of any order for pillows underneath the resident's legs. RN A said the the resident had a left heel wound in the past that looked similar to this, but it had healed. RN A could not recall when the previous heel wound occurred or if the wound was classified as a pressure ulcer or other type of wound. She stated the Wound Care Physician determined the classification of the wounds. Review of the Wound Care Physician's notes dated 2/9/22 revealed the previous left heel wound was an intact, flat clear blister that measured 1 centimeter (cm) in length by 1 cm in width. The left heel wound was noted as friction wound. Treatment orders included to cleanse the wound with normal saline, apply skin prep, and apply a foam dressing every other day. A follow-up note dated 2/16/22 revealed the left heel blister was resolved. On 2/16/22, orders included to discontinue wound care. On 2/24/22, an order for Waffle Boots to be worn in bed every shift were resumed. There were no orders for the resident's feet to be offloaded with pillows as indicated by the resident. During the above observations of resident #53, Waffle Boots were not observed on the resident while she was in bed. A review of the resident's weekly skin assessments from 2/22/22 to date showed they were done on 2/22/22, 3/1/22, 3/9/22, 3/15/22, 3/30/22, and 4/10/22. There were two weekly skin assessments not done on 3/22/22 and 4/5/22. On 4/13/22 at 11:10 AM, the Unit Manager (UM) acknowledged two weekly skin assessments were not done on 3/22/22 and 4/5/22. She was not aware they had not been completed and did not know the reason why. She indicated it was the expectation for nurses to do them on a weekly 105332 Page 6 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0684 basis. Level of Harm - Minimal harm or potential for actual harm On 4/13/22 at 1:15 PM, observation of resident #53's left heel was conducted with the facility's Wound Care Nurse (WCN) and Unit Manager (UM). The resident's feet were observed off-loaded with a pillow. The WCN provided skin prep to the resident's left heel which was an order obtained after surveyor brought it to the facility's attention on 4/10/22. The WCN measured the left heel wound which was 1 cm by 1 cm. The area was dark purple in color, flat, not open and without any drainage. The WCN reported the Wound Care Physician had conducted a telehealth visit by phone on 4/10/22 and indicated it was a blood blister. She said he wanted to assess it more closely in person and will visit on 4/14/22. At this time, the resident said, They gave me pillows for my feet again. The WCN and UM stated the resident refused the Waffle Boots, so the order was discontinued and an order for pillows to offload both feet was obtained on 4/10/22. The WCN recalled the resident had a left heel wound in the same place in the past, but it had healed after treatment. The resident said the left heel blister appeared when her feet slip on the bed as she pushes with them to position herself up in bed. Residents Affected - Few Review of resident #53's care plan for skin issues and the Certified Nursing Assistant's (CNAs) electronic [NAME] care plan initiated on 8/29/21 identified the resident was at risk for skin breakdown related to decreased mobility, fibromyalgia, muscle spasms, seizures, obesity, anxiety and depression. Interventions by nursing staff included to complete weekly skin assessments, monitor and inspect skin during bathing and daily, especially over bony prominences and report abnormalities to the nurse. Review of a facility Wound Prevention and Management Policy and Procedure included that care and services were to be provided to residents to prevent and promote healing of existing injuries. It included that weekly skin assessments were to be conducted, interventions were to be put into place, and orders were to be obtained to prevent and promote wound healing. 105332 Page 7 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate suprapubic catheter care and services to reduce the risk of potential bladder infections for 1 of 2 residents (#53) reviewed in a total of 6 residents with indwelling or external urinary catheters. Findings: Resident #53 was admitted to the facility on [DATE]. Her diagnoses included heart failure, obesity, obstructive and reflux uropathy, and use of a suprapubic urinary catheter. On 4/10/22 at 12:17 PM, resident #53 in bed and her suprapubic urinary catheter bag was secured to the bedframe. The catheter tubing was noted with cloudy, amber urine with multiple thick clumps and strands of milky colored sediment. The resident indicated the Certified Nursing Assistants (CNAs) emptied her catheter bag every day but the nurses had not flushed the catheter in a while. A review of resident #53's most recent Quarterly Minimum Data Set Assessment with an assessment reference date (ARD) of 2/22/22 noted she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. On 4/10/22 at 12:45 PM, Registered Nurse (RN) C acknowledged the cloudy amber urine with the thick sediment. She could not remember whether or not the resident was currently being treated for a urinary tract infection (UTI). RN C said she could not recall the last time the catheter tubing was flushed or the catheter bag changed. A review of resident #53's medical record revealed she was transferred to the emergency room (ER) on 2/23/22 for a cough. The resident returned to the facility on the following day, 2/2422. A review of the January 2022 and February 2022 Treatment Administration Record (TARs) orders revealed that prior to the resident going to the ER, there were multiple orders for care and services of the catheter that included, monitor the suprapubic catheter for signs and symptoms of infection, irrigate the catheter as needed for blockage or sluggishness, change the catheter bag as needed, and clean the suprapubic site every shift. After the resident's return from the ER on [DATE] through 4/10/22, for a total of 45 days, there was no documented evidence she received the above catheter care. There was only one order on the monthly TARs to check the catheter tubing for patency every shift. On 4/10/22 at 2:45 PM, the Director of Nursing (DON) observed the resident's catheter tubing and stated it needed to be flushed and the catheter bag changed. She indicated the doctor should be notified of the cloudy urine and sediment which could potentially indicate an infection. The suprapubic insertion site was inspected with the DON. It was not covered with a dressing. The skin surrounding the suprapubic catheter was reddened and a slight musty odor was noted. The resident said the nurses had not recently cleaned it, but that she did. The DON verbalized the suprapubic site needed to be cleaned with normal saline. On 4/10/2022 at 4:15 PM, the resident's physician orders were reviewed with the DON and Unit Manager (UM). They acknowledged the resident's medical records did not include treatment and care orders for the suprapubic catheter other than monitoring for patency since 2/24/22, 45 days earlier. The DON explained the suprapubic care and treatment orders must have been deleted from the electronic 105332 Page 8 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical record after the resident went to the ER and were not reinstated when she returned. The DON indicated the nurses and the nursing management team should have identified the omission and re-obtained the orders. She added, We missed it. Review of resident #53's written care plan for suprapubic catheter initiated on 8/29/21 included catheter care would be provided every shift and as needed. The care plan noted urine would be monitored for sediment, cloud, odor, blood and amount, and that it would be monitored for signs and symptoms of infection and report to physician. The facility's Suprapubic Care Policy included: It is the policy of this facility to ensure that residents with suprapubic catheters receive appropriate catheter care catheter care will be performed every shift and as needed by licensed nursing personnel wash around the suprapubic site with soap and water empty drainage bags when bag is half-full or every 3-6 hours empty observe for redness, swelling, and signs and symptoms of infection 105332 Page 9 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review, the facility failed to post their licensed and unlicensed nursing staff data on a daily basis and/or in a timely manner for three consecutive days (4/8/22, 4/9/22, and 4/10/22). Residents Affected - Many Findings: On Sunday 4/10/22 at 10:05 AM, the nursing staff data form was observed posted in the front lobby by the receptionist's window. The form was dated three days earlier, 4/7/22. The nursing staff form did not include the resident census. On 4/10/22 at 10:10 AM, the weekend Receptionist F explained she was responsible to complete and post the daily nursing staff data forms on Saturdays and Sundays. She said that from Monday through Friday, the Staffing Coordinator completed and posted the form. She reported her shift started at 8 AM and that she had been busy and had not yet completed the 4/10/22 nursing staff form. She acknowledged nursing staff started their day shift at 7 AM, three hours earlier. The Receptionist conveyed she was unsure why the daily nursing staff data forms had not been posted on Friday 4/8/22 and Saturday 4/9/22. On 4/13/22 at 1:15 PM, the Staffing Coordinator acknowledged she was responsible to complete and post the daily nurse staffing information form on Mondays through Fridays. She acknowledged the resident census was required to be added to the form. The Staffing Coordinator indicated that on Friday 4/8/22, she had arrived early to the facility, then had to leave quickly due to family responsibilities, and forgot to complete it. At 1:20 PM, the Administrator said the nursing staff information form was to be completed and posted on a daily basis. She was not aware the daily staffing form had not been posted on 4/8/22 and 4/9/22. The Administrator indicated the the front desk receptionist would typically be the person responsible to back up the Staffing Coordinator on weekdays. 105332 Page 10 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide palatable meals for 1 of 4 residents reviewed for food of a total sample of 43 residents, (#51). Residents Affected - Few Findings: Resident #51 was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes mellitus, hypertension, hyperlipidemia, and depression. Review of the physician orders reflected the resident's diet was consistent carbohydrates, no added salt and mechanical soft consistency. The Minimum Data Set (MDS) 5-day Medicare assessment, dated, 3/22/21 revealed the resident was alert and oriented, had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact, and he required supervision with his meals. On 4/10/22 at 11:48 AM, resident #51 complained his food was usually cold by the time it was delivered to his room. On 4/11/22 at 9:49 AM, the resident stated he was not able to eat his breakfast that morning as his toast was cold. On 4/11/22 at 12:37 PM, resident #51's lunch tray included a tortilla folded in half with finely grated cheese on the plate around it. The resident opened the folded tortilla and showed the grated cheese inside was not heated or melted. The tortilla was cold to touch and resident #51 emphasized he would never eat that meal. On 4/11/22 at 12:44 PM, the Certified Dietary Manager (CDM) checked the resident's lunch tray and confirmed the meal ticket read, Cheese Quesadilla. She verified the item on his plate was not a quesadilla, instead it was an uncooked tortilla with cheese. She stated she would not eat that meal. On 4/11/22 at 4:34 PM, the CDM stated she returned resident #51's lunch to the kitchen and interviewed the cook regarding the cold tortilla and cheese. She reported, The cook did not know she was supposed to cook the quesadilla. 105332 Page 11 of 12 105332 04/13/2022 Winter Park Care and Rehabilitation 2970 Scarlett Rd Winter Park, FL 32792

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update and honor food preferences for 1 of 4 residents reviewed for food of a total sample of 43 residents, (#51). Findings: Resident #51 was admitted to the facility on [DATE] with diagnoses to include heart disease, diabetes mellitus, hypertension, hyperlipidemia, and depression. Review of the physician orders reflected the resident's diet was consistent carbohydrates, no added salt and mechanical soft consistency. The Minimum Data Set (MDS) 5-day assessment, dated, 3/22/21 revealed the resident had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact, and noted he required supervision with eating. On 04/10/22 at 11:48 AM, resident #51 stated he rarely received a food tray that reflected the items listed on his meal ticket. He said, They always lie. I never get what's written there. On 04/10/22 at 12:58 PM, the resident's lunch tray revealed apple juice, green peas, carrots, mashed potatoes, apple pie, and a roll. Review of the resident's meal ticket read his lunch meal should have included hot chocolate and broccoli instead of green peas. Resident #51's carrots were untouched, and he explained he disliked this vegetable. He stated he informed dietary staff many times that he did not like carrots, but he continued to receive them. The resident said he preferred not to eat much meat and had often informed dietary and nursing staff but still could not say what they planned to provide as a meat substitute. On 04/11/22 at 12:37 PM, resident #51's lunch meal ticket read, Lettuce salad with ranch dressing, Mandarin oranges, mashed potatoes and apple juice. Observation of the resident's tray indicated he received lettuce salad and Mandarin oranges, but not the mashed potatoes nor apple juice as listed on the meal ticket. On 04/11/22 at 12:44 PM, the Certified Dietary Manager (CDM) was informed of the resident's concerns about repeated inaccuracies of his meal tickets and frequent provision of items he disliked. She observed the resident's lunch tray and confirmed he did not receive the items he should have. She stated she frequently spoke with residents regarding their meals and did weekly random tray checks at different mealtimes to ensure accuracy but was not aware of the resident's concerns. On 04/11/22 at 4:34 PM, the CDM explained she spoke to residents regarding their likes and dislikes at least every quarter and spoke to resident #51 one to two times every week. She verified the resident communicated his preferences to her including his dislike of carrots and some meats. The CDM acknowledged although she was aware the resident disliked some meat products, she had not identified an acceptable substitute for him. The CDM, I am supposed to go into the system and change his likes and dislikes. I did not update the dislike for carrots. 105332 Page 12 of 12