Waterfront Rehabilitation And Healthcare Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that low-air-loss mattresses were accurately set according to resident weight for two residents who were identified as at risk for skin breakdown and were using pressure-reducing bed surfaces. Resident #31, who had amyotrophic lateral sclerosis and intact cognition, was observed resting in bed on a low-air-loss mattress with the setting between 250 and 280 pounds, while the resident’s most recent documented weight was 191 pounds. The resident’s care plan included an intervention to provide an air mattress, and the order summary later showed a physician order to check the mattress placement and function every shift. Resident #76, who had weakness, low back pain, spinal stenosis, and moderately impaired cognition, was observed in bed on a low-air-loss mattress set to 485 pounds. The resident’s care plan included a pressure-reducing mattress and keeping the skin clean and dry, and the order summary included a physician order for a low-air-loss mattress with placement checks every shift. The resident’s most recent documented weight was 120 pounds, and the TAR showed nurses signed that the mattress was checked for placement on the day of the observation. During interview, an LPN stated she was unsure how to determine the correct mattress setting and had not been trained on how to determine it, while an LPN supervisor stated the mattress should be set according to the resident’s weight and confirmed the findings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store and maintain ice scoopers in a sanitary manner in 3 of 4 nursing wings that had ice coolers, specifically Wings #1, #3, and #4. On 9/29/2025 between 11:18 AM and 12:20 PM, the surveyor observed a blue ice cooler on Wing #1 with a white mesh bag attached and an ice scooper resting in the mesh bag; the bottom of the mesh bag contained a moderate amount of black residue. On Wing #3, the surveyor observed a blue ice cooler with a mesh bag attached, and inside the mesh bag was an ice scooper resting inside a foam cup containing yellow-tinged liquid with black residue. On Wing #4, the surveyor observed a blue ice cooler with a mesh bag attached, and when opened, the mesh bag revealed an ice scooper placed into a plastic bag that was not self-draining as required. At 12:21 PM, the surveyor toured the units with the Infection Preventionist, who confirmed the findings and stated that ice scoopers should not be stored in foam cups or plastic bags, only in the designated mesh bags. The IP also stated that the mesh bags used to store the scoopers should be cleaned daily by kitchen staff for infection control purposes. At 12:44 PM, the Food Service Director stated he was unaware that the mesh bags existed and that the kitchen staff never cleaned them, and he noted that bacteria and mold could build up. The facility was unable to provide a policy related to maintaining the ice scoopers and cleaning the mesh bags.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to consistently document care provided to a resident in accordance with the facility's Charting and Documentation policy and accepted professional standards. Specifically, review of the Documentation Survey Report (DSR) for one resident revealed blank entries for the type of assistance provided on multiple shifts, despite the expectation that all care should be documented without omissions. The resident in question had a history of neoplasm of the prostate, anxiety disorder, and acute kidney failure, and was assessed as moderately cognitively impaired. The care plan indicated an ADL Self Care Performance Deficit, yet documentation was incomplete for several shifts. Interviews with staff, including a CNA, the Unit Manager, the Administrator, and the Interim DON, confirmed that CNAs were responsible for documenting all care in the electronic system and that nursing management was expected to ensure documentation was complete. The facility's policy, reviewed in March 2025, required that all services provided to residents be fully and accurately documented. The presence of blank entries in the DSR indicated a failure to adhere to these requirements.

Plan Of Correction

1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility met with resident #4 to ensure all ADL care was provided as scheduled on ADL record. The nurses and nursing assistants of resident #4 were educated on the performance and documentation of Activities of Daily Living on the electronic ADL record 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. The facility recognizes that all residents have the potential to be affected by this deficient practice 3) What measures will be put into place or systematic changes to ensure that the deficient practice would not recur The facility Director of Nursing or designee will provide education to all Nurses and Nursing Assistants on completion and documenting of all resident Activities of Daily Living completed in the electronic ADL record 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what program will be put into place to monitor the continued effectiveness of the systemic change The facility Director of Nursing or designee will audit resident electronic ADL records weekly for three months and then monthly for three months on different shifts to ensure ADLs are being completed and documented as appropriate on the ADL electronic record The Director of Nursing or designee will present the findings of the audits and review trends and needed follow up in the two facility Quarterly Quality Assurance Performance Improvement Meetings

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food and beverages stored in the kitchen were properly dated and free from expired manufacturer's use by dates, potentially affecting 114 of 116 residents who consumed food prepared in the facility's kitchen. During an inspection, it was observed that an opened one-gallon container of Russian dressing and multiple containers of cottage cheese in the walk-in refrigerator had expired use by dates. Additionally, 10 cartons of nutritional shakes were found undated and thawed. The Dietary Manager (DM) confirmed these findings and acknowledged that the staff, including herself, were responsible for checking expiration dates and discarding expired items. The supplier of the nutritional shakes informed the DM that the shakes should be dated when removed from freezer storage and used within 14 days after thawing. Further observations in the kitchen's dry storage room revealed several bread products with expired use by dates and many undated packages of bread. The DM confirmed the expired and undated bread products and stated that staff were expected to date bread products upon receipt and discard those with expired dates. The facility's policy on date marking for food safety was reviewed, indicating that food should be clearly marked with the date of opening and the date by which it should be consumed or discarded, not exceeding the manufacturer's use-by date or four days, whichever is earliest. The policy also outlined responsibilities for the Head Cook and DM to check and document compliance with these requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a dignified dining experience for several residents, as observed during a survey. One resident, with moderately impaired cognition, was left waiting for his meal while his tablemate had already finished eating. This resident expressed his preference to eat with his tablemates and to have his food and beverages served in non-disposable dishware, which was not honored. Another resident, who was cognitively intact, also received his meal in disposable dishware, which he did not prefer. During a resident group interview, multiple residents expressed dissatisfaction with the use of disposable silverware and cups, which were often small and inadequate for drinking. The dietary manager acknowledged the issue, citing a lack of sufficient non-disposable dishware as the reason for using disposable items. Additionally, a resident was left waiting for over 40 minutes for his meal, and his table was removed without explanation to accommodate a scheduled activity, which he found upsetting. Furthermore, the facility failed to respect a resident's right to self-determination by requiring her to wear an identification wristband against her wishes. Despite her moderate cognitive impairment, the resident was able to express her dislike for the wristband, which she felt compromised her dignity. The facility's policy required wristbands for identification purposes, but the resident's preference was not considered, even though alternative identification methods were available.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that menus were prepared in advance with specific vegetables, as required to meet the nutritional needs of residents. Instead, the menus frequently listed 'Vegetable of the Day' without specifying which vegetable would be served. This practice was observed in 39 out of 56 lunch and supper meals on the facility's four-week menu cycle, potentially affecting 114 of 116 residents. A resident, identified as R77, who was cognitively intact, expressed concerns about the repetitive serving of the same vegetables, such as peas and carrots, multiple times a week. Observations confirmed that the resident was served carrots as the vegetable for a meal, consistent with the 'Vegetable of the Day' listing on the menu. Interviews with dietary staff revealed that the decision on which vegetable to serve was made by the cook based on availability, rather than a pre-planned menu. The facility's Registered Dietitian acknowledged that the menus were signed and approved for nutritional adequacy, but admitted that without specific vegetables planned, it was not possible to ensure nutritional adequacy. The 'Vegetable of the Day' practice was implemented by a previous Dietary Manager, and the current system allowed for the possibility of serving the same vegetable too frequently. The facility's policies required menus to be planned in advance and reviewed for nutritional adequacy, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve food that was palatable and at an appetizing temperature for 13 of 13 residents reviewed for food palatability. This issue was identified through various methods including observation, interviews, test tray reviews, and record reviews. Residents consistently reported that meals, particularly breakfast, were not served hot, and some described the food as barely edible. Specific complaints included cold scrambled eggs, weak and warm coffee, and a lack of variety in vegetables served. Several residents, including those with intact cognition and those with moderate cognitive impairments, expressed dissatisfaction with the temperature and quality of the food. For instance, one resident reported that the facility had run out of coffee and fresh fruit, requiring his wife to bring in fruit for him. Another resident mentioned that the facility frequently ran out of items like hotdog buns and coffee, leading her to purchase her own food and coffee-making equipment. Additionally, residents noted that the menu often listed "Vegetable of the Day" without specifying the actual vegetable, which was usually limited to carrots or green beans. A test tray was used to verify the residents' complaints, revealing that the food temperatures were below acceptable levels by the time they reached the residents. The scrambled eggs, oatmeal, toast, and bacon were all served at temperatures significantly lower than the acceptable standard of 135 degrees Fahrenheit. The coffee was also found to be warm and weak. The facility's Dietary Manager acknowledged awareness of these issues from previous Resident Council meetings, where residents had voiced concerns about food not being served hot. The facility's policy on food preparation emphasized the importance of serving food at safe and appetizing temperatures, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have deficiencies in meal service times, as meals were served later than scheduled to residents on four of the five facility hallways. This issue was observed to potentially affect 114 of 116 residents who consumed meals prepared in the kitchen. The Dietary Manager provided a meal service schedule, but observations revealed that meals were consistently served late, particularly on the 400 Hallway, where residents reported waiting long periods for their meals. Specific instances included a resident on the 400 Hallway who was observed waiting for lunch well past the scheduled time, expressing hunger and frustration. Other residents on the same hallway also experienced delays, with meal carts arriving significantly later than the posted times. Interviews with residents confirmed that late meal service was a frequent issue, with some residents reporting that breakfast and lunch were often served an hour or more after the scheduled times. The Dietary Manager and staff acknowledged the delays, attributing them to a late start in the kitchen's breakfast tray line and incomplete tasks from the previous evening's staff. Staffing issues were also cited as a contributing factor. Residents expressed dissatisfaction with the meal service during interviews and a Resident Group meeting, and the Director of Nursing confirmed receiving complaints about the timeliness of meal delivery.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an adequate supply of linens, specifically towels, for its residents, leading to a deficiency in providing a safe, clean, comfortable, and homelike environment. During a Resident Council Group interview, several residents reported issues with towel availability, with some residents resorting to using personal items like bathrobes as towels. Observations confirmed the lack of towels on linen carts across multiple halls, with some carts having no towels at all, despite the presence of numerous residents on each hall. Interviews with staff, including a CNA and the Maintenance/Housekeeping Director, revealed that towels were distributed twice daily on clean linen carts, but residents' rooms were not stocked with towels. The Director of Nursing, who was new to the position, was unsure about the policy regarding towels in residents' rooms. The facility's Administrator was unaware of the towel shortage issue until it was brought to attention during the survey. The deficiency was further highlighted by observations and resident interviews conducted by the surveyor and the Maintenance/Housekeeping Director. Many residents reported not having towels in their rooms, with some reusing towels due to the shortage. The linen carts on various halls were found to be inadequately stocked, with some having no towels at all, confirming the residents' complaints and the facility's failure to maintain an adequate supply of linens.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that guardianship documentation was in place for a resident who was not capable of making healthcare decisions. The resident, who had diagnoses including dementia, Down syndrome, and aphasia, was documented as having a legal guardian. However, the facility did not have the necessary guardianship documentation in the resident's electronic medical record (EMR). This deficiency was identified during a review of the resident's records, which included a Pennsylvania Orders for Life-Sustaining Treatment (POLST) form indicating a Do Not Resuscitate (DNR) status without a guardian's signature, and a physician's order for DNR and Do Not Intubate (DNI). Interviews with facility staff, including the Social Service Director, Admissions Coordinator, and Administrator, revealed that the guardianship papers were not uploaded into the EMR as required by the facility's policy. The Social Service Director, who had been employed for two months, confirmed the absence of the documentation. The Admissions Coordinator, who had been employed for three weeks, stated that the guardian claimed to have provided the papers to a previous social worker, but they were not found in the medical chart. The facility's policy on advance directives mandates that such documents be obtained and maintained in the resident's medical record, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from verbal abuse by a staff member, which was identified during a review of records and interviews. The resident, who had intact cognition and was experiencing frequent pain due to multiple health conditions, reported that a registered nurse (RN) referred to her as a 'Drug Addict' while administering her medication. This incident was corroborated by a licensed practical nurse (LPN) who was present and heard the RN make the derogatory comment. The LPN later apologized to the resident for the RN's statement. The facility's investigation confirmed the incident, and the RN involved was suspended and subsequently quit. The facility's policy on abuse, neglect, and exploitation clearly prohibits verbal abuse, which includes the use of disparaging and derogatory terms. The incident was reported timely, and an investigation was initiated, but the deficiency highlights a failure to ensure the resident was free from verbal abuse, as required by the facility's policy and regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a Level One PASARR (Pre-Admission Screening and Resident Review) was revised for a resident who was newly diagnosed with a major mental illness. The resident, identified as R16, was admitted with diagnoses including congestive heart failure and anxiety. Approximately five months after admission, a diagnosis of bipolar disorder was added to the resident's medical record. Despite this significant change in the resident's mental health status, the Level One PASARR document, dated November 1, 2021, incorrectly indicated that the resident did not suffer from any major mental illness diagnoses. During an interview, the Nurse Consultant confirmed that the Level One PASARR assessment was incorrect and stated that it was expected to be updated timely with any change in a resident's health status. The facility's policy requires coordination with the PASARR program to ensure that individuals with a mental disorder receive appropriate care and services. The policy also mandates that any resident exhibiting a newly evident or possible serious mental disorder be referred promptly for a Level 2 resident review. This oversight created the potential for the resident to receive inadequate mental health services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the care plans for two residents, R9 and R100, to reflect their current care needs. R9, who was admitted with end-stage renal disease and required dialysis, had a physician's order for emergency dialysis dressing supplies to be maintained at the bedside. However, the care plan was not updated to include these supplies, despite the order being in place since March 2024. Interviews with facility staff, including an LPN and the MDS Coordinator, revealed that care plans are typically revised during care plan meetings, but any floor nurse could make necessary updates. The oversight was acknowledged by the staff, indicating a lapse in the care plan revision process. R100, admitted with acute respiratory failure and other conditions, had not participated in any care planning meetings since her initial care plan was implemented in December 2023. Despite having intact cognition, as indicated by a BIMS score of 15, R100 expressed a desire to be involved in care planning meetings to discuss her medications and treatments. The Social Services Director confirmed that quarterly care planning meetings were not being held as required, due to her limited availability. The facility's policy mandates quarterly reviews and revisions of care plans, which were not adhered to in this case, as confirmed by the Administrator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a meaningful activity program for a resident, identified as R74, who was reviewed for activities among 26 sampled residents. R74, who was cognitively intact with a BIMS score of 15 out of 15, expressed a preference for intellectual activities such as chess and dominoes. However, the facility did not assess R74's activity preferences adequately, and the care plan did not reflect R74's interests. As a result, R74 was not provided with sufficient activities to prevent boredom and reported spending most of the time in his room watching TV. Observations during the survey revealed that R74 remained in his room with the TV on during multiple checks over several days. Interviews with staff, including the Activity Aide and the Activity Director, indicated that R74 did not participate in group activities and was not on a one-to-one program. The Activity Director was unaware of R74's interest in chess or dominoes and confirmed that the care plan and recreation assessment failed to identify specific activity preferences for R74. The facility's policy on activities, which mandates providing an ongoing program based on residents' comprehensive assessments and preferences, was not followed in R74's case. The policy requires that each resident's interests and needs be assessed routinely, but this was not done for R74, leading to a lack of meaningful engagement and activity options tailored to his interests.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to a physician's order to change a resident's indwelling urinary catheter every month, which was identified during a review of the resident's medical records and interviews with staff. The resident, who was cognitively intact and had a diagnosis of obstructive uropathy, had a physician's order dated March 5, 2024, specifying that the catheter should be changed monthly. However, documentation revealed that the catheter was last changed on February 5, 2024, and there was no record of it being changed again until May 28, 2024. This lapse in care was confirmed by the resident, who expressed concern about the risk of developing a urinary tract infection due to the delay in catheter changes. Interviews with nursing staff and a nurse consultant revealed that the order to change the catheter monthly was incorrectly entered into the system as an order type that did not require documentation, resulting in the omission of the order from the resident's monthly treatment administration records for March, April, and May 2024. The facility's policy on catheter care, which emphasizes appropriate care and maintaining dignity and privacy for residents with indwelling catheters, was not followed in this instance, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide emergency dressing supplies at the bedside for a resident requiring dialysis, as per physician orders. The resident, who was admitted with end-stage renal disease and diabetes mellitus type II, was scheduled to receive hemodialysis three times a week. Physician orders specified that hemostats, gauze, and tape should be kept at the resident's bedside to address potential bleeding from the dialysis port. However, an observation revealed that these supplies were not present at the bedside. Interviews conducted with the resident and staff members indicated a lack of awareness regarding the physician's orders for maintaining emergency dressing supplies at the bedside. The resident mentioned that dressing supplies were brought by the nurse during dressing changes, but none were kept at the bedside. Both the LPN and the Unit Manager confirmed their unawareness of the requirement to maintain these supplies at the resident's bedside, highlighting a communication gap in adhering to the physician's orders.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, identified as R105, had appropriate physician's orders, informed consent, and a proper assessment for the use of side rails. The resident was admitted with multiple diagnoses, including bilateral primary osteoarthritis of the hip, cognitive communication deficit, dementia, and a history of repeated falls. Despite these conditions, the resident's admission records and Minimum Data Set (MDS) indicated that side rails were not in use, and there were no orders for their use. However, the resident's care plan included the use of bilateral 1/4 side rails to assist with transfers and positioning in bed, without any documented assessment or informed consent. Observations confirmed the use of side rails on multiple occasions, and interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that no assessment, physician's orders, or informed consent had been obtained for the use of the side rails. The facility's policy required a comprehensive assessment and informed consent before the use of bed rails, which was not followed in this case. This oversight had the potential to affect the safety of the resident, as the necessary procedures and documentation were not in place.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a documented response to the Pharmacist's recommendations for a resident who was prescribed Lexapro, an antidepressant medication. The Pharmacist recommended a dose reduction from 20 mg to 10 mg due to the resident's age, as the maximum recommended dose for individuals over a certain age is 10 mg. Despite these recommendations being made multiple times over several months, there was no documented response from the Physician indicating whether the recommendations were reviewed or acted upon. The resident continued to receive the higher dose of Lexapro without documented justification from the Physician. Interviews with facility staff revealed that the Physician claimed to have reviewed the Pharmacist's recommendations and decided against a dose reduction because the resident was stable on the current medication. However, this decision was not documented in the resident's medical record as required by the facility's policy. The Director of Nursing and the Nurse Consultant confirmed the absence of the Physician's documented response and were unaware of the location of the forms where such documentation should have been recorded. The facility's policy mandates that the attending physician must document any action taken or rationale for no change in the resident's medical record, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper infection control for a resident receiving respiratory services. The resident, who was admitted with diagnoses including pulmonary fibrosis and acute respiratory failure with hypoxia, was ordered to receive oxygen via nasal cannula at three liters per minute. The facility's policy required that the resident's oxygen tubing, cannula, and humidifier be changed weekly on Sunday nights. However, a review of the Treatment Administration Record indicated that the resident's oxygen tubing and humidification bottle had not been changed since admission, despite the policy requirements. Observations confirmed that the resident's oxygen tubing and humidification bottle were last changed on a date that was not in compliance with the weekly change requirement. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the expectation was for the nursing staff to change the oxygen equipment weekly, which had not been adhered to in this case. The facility's Oxygen Administration Policy also emphasized the importance of changing oxygen equipment regularly to maintain sanitary conditions, which was not followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate the food allergies and preferences of three residents, leading to repeated instances where residents were served foods they were allergic to or disliked. Resident 102, who has a documented allergy to melon, was served melon on multiple occasions despite the allergy being noted on her meal tray slip. The resident had informed the facility's Registered Dietitian (RD) about this issue, yet the problem persisted, with the most recent occurrence being on 05/29/24. Resident 77, who has gastro-esophageal reflux disease, expressed that his food preferences were not honored, as he was served pancakes and mashed potatoes despite indicating his dislike for these foods on his meal tray slip. The Dietary Manager (DM) confirmed that these foods should not have been served to Resident 77, acknowledging the oversight in honoring the resident's food preferences. Similarly, Resident 81, who has type two diabetes mellitus with hyperglycemia and hemiplegia, was served pancakes and toast, which were listed as disliked foods on his meal tray slip. Despite informing staff of his preferences, Resident 81 continued to receive these foods. The DM confirmed that the resident's dislikes were noted on the meal tray slip and should have been respected. The facility's policy mandates accommodating resident allergies and preferences, which was not adhered to in these cases.