Health inspection·October 22, 2024

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 observations, interviews and record review, the facility failed to ensure residents were served food in a manner that was appealing in appearance and that was palatable for consumption for six (#1, #2, #3, #4, #5, and #6) of six sampled residents. Residents Affected - Few Findings included: 1. On 10/22/2024 a review of photographic evidence provided by Resident #1's family member revealed Resident #1 had received a blue plate on her over the bed table with what appeared to be two diagonal cut sections of black toast. Further observation revealed the resident had received two grilled cheese sandwiches, both of which were totally black in color, burned, charred and not consumable. Four photographs of the burned and charred grilled cheese sandwiches were kept as evidence. It was determined the photos taken were taken in a manner showing Resident #1's personal belongings on the bed in the background, and it was evident she had received these burned and charred grilled cheese sandwiches. On 10/22/2024 at 1:45 p.m. Resident #1 confirmed the photos with the burned and charred grilled cheese sandwiches. Resident #1 explained one of her favorite foods was grilled cheese sandwiches and she usually looked forward to ordering and eating them. She revealed she had been a resident at the facility for a couple of months and at first the grilled cheese sandwiches were ok, but the last month or so, when she ordered grilled cheese sandwiches for dinner, they came to her burnt, as shown in the photographic evidence. She confirmed the sandwiches came out totally blackened and she did not like grilled cheese sandwiches or any food charred. Resident #1 also confirmed she, as well as her family, have spoken to various aides who served the burnt food and they would either return it and bring out something else, or Resident #1 would no longer be hungry and would just not eat Resident #1 revealed she would indeed like to eat grilled cheese sandwiches, which were one of her favorite foods, if they were served to her in a manner that was cooked correctly. Resident #1 revealed she received the burnt and charred grilled cheese sandwiches mainly during the evening meals, and that the photo of the burned and charred grilled cheese sandwich was taken during the evening meal about two weeks ago. She also confirmed it was during the week day. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE]. A review of the current Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #1 was cognitively intact. 2. On 10/22/2024 at 9:20 a.m., Resident #2, who was interviewable, said the food was generally ok and he ate most of what was served to him. At that time his roommate voiced aloud, except those grilled cheese sandwiches. Both resident #2 and his roommate #3 explained they both had been routinely Page 1 of 4 105343 105343 10/22/2024 Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few served grilled cheese sandwiches that were over cooked and burnt. Resident #2 and #3 revealed they loved grilled cheese sandwiches but had to send them back and just did not order them anymore. Resident #2 revealed he had complained about it to care aides but could not remember who he spoke to. Review of Resident #2's medical record revealed he was admitted to the facility on [DATE]. Review of the current Quarterly MDS assessment, dated 9/18/2024 revealed a BIMS score of 12, which indicated Resident #2 was cognitively intact. 3. On 10/22/2024 at 9:20 a.m., Resident #3, who was interviewable, said his grilled cheese sandwiches, which were usually his favorite, always came to him burnt and he had to send it back. He revealed staff would bring him another sandwich and that would be burnt as well. He revealed he just did not order them anymore. He had not complained about it to management but would definitely eat grilled cheese sandwiches if the cook did not burn them. Review of Resident #3's medical record revealed he was admitted to the facility on [DATE]. Review of the current Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS score of 13 which indicated Resident #3 was cognitively intact. 4. On 10/22/2024 at 9:34 a.m., Resident #4, who was interviewable, he said he ordered choice items to include grilled cheese sandwiches and they almost always came to his room burnt. He would at times just not eat it and other times would try to send it back. Resident #4 revealed there were times after he sent the burned food back, it took a long time to receive another, and there were times the replacement grilled cheese was also burnt. He had not spoken to management related to the burned food, but it happened often. Resident #4 revealed he would routinely eat grilled cheese sandwiches if they did not come to him burnt. Review of Resident #4's medical record revealed he was admitted to the facility on [DATE]. Review of the 5 Day Medicare MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #4 was cognitively intact. 5. On 10/22/2024 at 9:40 a.m., Resident #5, who was interviewable, revealed he had generally good things to say about the food and felt he received sufficient amount of food for the breakfast, lunch and dinner meals. He added that there were times he ordered grilled cheese sandwiches and they came to him burnt. He said he sent them back and most of the time the sandwich replacement was fine. Resident #5 said burnt items happened at times but he had not mentioned it to management. He revealed he would like for his grilled cheese sandwiches to not be burnt. Review of Resident #5's medical record revealed he was admitted to the facility on [DATE]. Review of the Medicare 5 day MDS assessment dated [DATE] revealed a BIMS score of 8 which indicated Resident #8 had cognition deficits, but was able to speak about his day and routines. 6. On 10/22/2024 at 10:00 a.m., an interview with Resident #6, who was interviewable, revealed and confirmed she received burnt grilled cheese sandwiches at times. She just sent it back and did not reorder. She would eat grilled cheese sandwiches if they were cooked correctly and not burned. She revealed she had spoken to care staff and various members of management about the burnt food in the past, but things generally do not turn out for the better. On 10/22/2024 at 10:20 a.m., the kitchen was toured with Staff A, Certified Dietary Manager (CDM). Also, Staff B, Assistant Kitchen Manager was interviewed. Staff A and B both revealed they usually 105343 Page 2 of 4 105343 10/22/2024 Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few worked Mondays - Fridays during the early hours in preparation for breakfast, through the breakfast meal service, and through to just before the dinner meal. Staff A and B confirmed they worked some weekends and some night dinner meal services, but not often. Staff A revealed at times, she monitored and supervised dinner to audit for best practices in the kitchen. Staff B confirmed she also had the role of a cook and she mainly cooked during breakfast and lunch, but rarely for dinner. Staff B also confirmed she worked at times during the weekends, but not often. Staff A revealed Staff C, who was the main cook, was not in the building at the time and that he came in just before lunch and stayed until after dinner was completed mostly weekdays, but also during some weekends. She revealed Staff C had been an employee at the facility and as a cook for several years. Staff A revealed she monitored and audited food items after they were prepared and prior to leaving the kitchen for service. She would observe food items to ensure they were cooked in a presentable and palatable manner, for resident consumption. Staff A said she, along with Staff B, would work the kitchen floor by either assisting with cooking, or monitoring the cooking process of all food items. Staff A said she did receive some but not a lot of complaints from residents and she felt that she handled them and worked to resolve those concerns with the residents quickly. Staff A was asked more specifically if she had received any complaints related to burnt food items being served. She said maybe about two weeks to a month ago but could not remember exactly when. She remembered a complaint from Resident #1, who complained about a burnt grilled cheese sandwich served during the evening meal. She revealed she heard from the family member as well and saw photos of the burnt grilled cheese sandwich. Staff A and B revealed that they believed cook, Staff C, had cooked that evening and he must have sent out the burnt sandwich to the resident. Staff A revealed she saw the photo of the grilled cheese and she agreed that it should not have been sent out that way and it appeared to have been very burnt. Staff B also confirmed the grilled cheese was overly cooked and burned but did not know about it at the time it was made and served. Staff A revealed after she was made aware of the burnt sandwich, she provided the cook with education on how to cook the sandwich and how not to send out burnt food to residents. However, she did not have any documentation to support Staff C or any other kitchen staff to include other cooks had ever been re inserviced on the proper way to prepare and cook food . Staff A and B also confirmed the burnt sandwich should have been caught by one of them and or tray line staff, as well as the nursing aides who served the plate to Resident #1. On 10/22/2024 at 12:00 p.m. the kitchen was entered for a second time for demonstration on how grilled cheese sandwiches were made. An interview with Staff B revealed Staff C, [NAME] came in today, 10/22/2024. She pointed him out in the kitchen as he was moving many boxes of food items. Staff A was not in the kitchen at the time. At 12:10 p.m., an attempt was made to interview Staff C but he kept walking away to do other tasks. Staff did not stop moving boxes around to be interviewed. Staff A came back to the kitchen and she was asked if Staff C would demonstrate on how to prepare and cook a grilled cheese sandwich. She revealed that either she or the assistant CDM could do that demonstration. On 10/22/2024 at 12:33 p.m., an interview was again attempted with Staff C. He kept walking away and would not stop to be interviewed. Staff C would not answer questions related to his cooking process. On 10/22/2024 at 1:20 p.m., an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) both confirmed they had not received any food complaints from any residents, family members, or staff within the past couple of months. The NHA and DON also confirmed they had no idea burnt and charred grilled cheese sandwiches were going out from the kitchen to the residents. The NHA and DON were provided with photographic evidence showing a heavily burned and charred grilled cheese sandwich that Resident #1 received. The NHA revealed she did not know that happened and 105343 Page 3 of 4 105343 10/22/2024 Heather Hill Healthcare Center 6630 Kentucky Ave New Port Richey, FL 34653

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few certainly the sandwich should have never left the kitchen. She said there were always supervisory staff in the kitchen to ensure food was prepared and cooked appropriately. There were also staff who compared the food to the meal ticket and there were other staff who served and set up meal trays for the residents. She said there were several lines of quality assurance and they all failed Resident #1. The NHA further added that if the kitchen management knew about this, it should have been brought to her attention so she could do the complete grievance process. However, it was not brought to her attention so she was not able to correct the situation as the Nursing Home Administrator. On 10/22/2024 at 1:00 p.m. the Director of Nursing provided the Resident Rights policy and procedure with a last revision date 6/2024. The policy stated; The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the day in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal Laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. Under Resident Rights section of the policy, stated; The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. #4 of the Resident Rights section (c ) revealed; The right to reside and receive services in the eh facility with reasonable accommodations of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. On 10/22/2024 at 1:00 p.m. the Director of Nursing provided the Food Safety Requirement policy and procedure with a last review date of 6/2024, for review. The policy stated; It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. The Definitions section of the policy revealed the following but not limited to: Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness; Foodborne illness refers to an illness caused by the ingestion of contaminated food or beverages. The policy Explanation and Compliance Guidelines section of the policy stated; 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: (c.) Preparation of food, including thawing, cooking, holding, and reheating. 4. When preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards: (b.) Cooking - foods shall be prepared as directed until recommended temperatures for the specific foods are reached. Staff shall refer to the current FDA Food Code and facility policy for food temperatures as needed. 105343 Page 4 of 4