**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of facility policies, the facility failed to ensure that side were not used in a manner to physically restrain Resident #107. This affected one of one sampled residents reviewed for side rail use as a restraint. Findings included: A review of the facility's policy titled, Bedrail Use, effective 10/26/2022, revealed, PURPOSE: Bedrails are used to enable a resident/guest to become more functionally independent, and when the medical condition of the resident/guest requires the use of a bedrail. STANDARD: Bedrails could be considered a form of physical restraint; therefore, the need for bedrails should be identified in the resident/guest assessment, and the plan of care, per RAI [Resident Assessment Instrument] guidelines and regulatory requirements. This policy further indicated, Refer to Physical Restraint policy if deemed to meet restraint definition. A review of the facility's policy titled, Physical Restraints, effective 11/28/2016, revealed, PURPOSE: For each resident/guest to attain and maintain his/her highest practicable well being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident/guest has medical symptoms that warrant the use of restraints. STANDARD: Physical restraints are defined by federal regulations as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident/guest(s) body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: Using side rails to keep resident/guest from voluntarily getting out of bed. This policy further indicated, A physician's order should be obtained for the use of a restraint, however, the presence of a physician's order alone is not justification for restraint use in absence of documentation of a medical symptom indicating use. Physicians' orders should specify: When to use the restraint, How long to apply, Why it is to be used, Specific type of restraint to be used. A review of a Face Sheet revealed the facility admitted Resident #107 to the facility on [DATE]. A review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/2023, revealed Resident #107 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making and had short-term and long-term memory problems. The MDS indicated the resident required extensive assistance of two staff for transfers and limited assistance of one staff for bed mobility. Further review revealed Restraints used in bed: bed rail were not used during the assessment period. A review of Resident #107's Care Plan, with a start date of 01/13/2021, revealed Resident #107 exhibited behaviors, including likes to lay on the floor on the mat. Further review revealed a Care Plan for Potential for Falls, with a start date of 01/09/2021. This care plan directed staff to encourage the use of handrails/appropriate assistive devices (started on 01/10/2021), observe the need for additional assistive devices (started on 01/10/2021), and to place mats on the floor while in bed (started on 11/26/2021). A review of a Restorative Review revealed that on 06/01/2023 at 2:08 PM, Registered Nurse (RN) #7 assessed Resident #107 to have weakness/paresis (muscle weakness) and limited range of motion in the bilateral upper and lower extremities. RN #7 documented Resident #107 was not steady when moving from a seated position to a standing position as well as surface-to-surface transfers. The box labeled Care Plan Reviewed and updated was left blank. A review of a Side Rail Evaluation, completed on 06/01/2023 at 2:09 PM by RN #7, revealed the Reason for Side Rail Use included Altered cognition, Ambulation with assistance, Balance deficit, Weakness, Incontinent. The Side Rail Evaluation indicated the side rail would assist the resident with bed mobility, transfers, and safety. The evaluation also indicated Side of Bed Side Rails Recommended For was Bilateral. The evaluation further indicated, Use of side rails can be considered a restraint which and can only be used after less restrictive assistance has been attempted is prohibited by regulation unless they are necessary to treat a resident's medical condition and, Residents who attempt to exit a bed through, between, over or around a side rail are at risk for injury or death. The Side Rail Evaluation did not specify the number of side rails or the size of siderails Resident #107 required. A review of Resident #107's Physician Orders for the month of June 2023 revealed there was no order for side rails or any type of restraint. Further review of Resident #107's comprehensive care plans revealed no updates to the care plan after the Side Rail Evaluation was completed on 06/01/2023, to instruct staff on the proper usage of side rails, including instruction on the number or size of siderails Resident #107 required. During an observation on 06/13/2023 at 10:35 AM, Resident #107 was lying in bed with their eyes closed and the head of the bed elevated approximately 45 degrees. All four side rails (a side rail on each side of the upper and lower portions of the bed) were in the raised position on the resident's bed. During an observation on 06/14/2023 at 11:01 AM, Resident #107 was lying in bed with their eyes closed and the head of the bed elevated approximately 45 degrees. All four side rails (a side rail on each side of the upper and lower portions of the bed) were in the raised position on the resident's bed. During an observation on 6/15/2023 at 1:12 PM, Resident #107 was lying in bed with their eyes closed and the head of the bed elevated approximately 30 degrees. All four side rails (a side rail on each side of the upper and lower portions of the bed) were in the raised position on the resident's bed. During an interview on 06/15/2023 at 1:18 PM, RN #8 stated Resident #107 used side rails for safety. RN #8 stated she was not aware that all four side rails were up and indicated that was considered a restraint. RN #8 stated the resident was bed-bound but could try to crawl over the bed rails, and the resident wiggled and turned sideways. RN #8 stated if a resident had side rails in use, the side rails should be included on the care plan. During an interview on 06/15/2023 at 1:23 PM, RN #20 (Unit Manager) stated Resident #107 should have half side rails to assist the resident in turning from side to side. RN #20 stated she was not aware the resident had all four side rails up and stated that would be considered a restraint. RN #20 stated she was responsible for updating the resident's care plan and indicated the use of side rails should be included on the care plan. At this time, RN #20 reviewed the resident's care plan in the Electronic Health Record (EHR) and stated the care plan did not address the use of side rails, but stated the resident had behaviors, and the use of the side rails was to prevent the resident from getting on the floor. During an interview on 06/15/2023 at 1:31 PM, RN #7 stated Resident #107 used side rails for safety and bed mobility. RN #7 stated she was unaware the resident had all four side rails up and indicated that would be considered a restraint. During an interview on 06/15/2023 at 1:41 PM, the Director of Nursing (DON) stated Resident #107 used side rails for bed mobility and to assist the resident with transferring out of bed. The DON stated she was not aware the resident had all four side rails in use and unless the resident had a specific diagnosis that required all four side rails, it would be considered a restraint. During an interview on 06/15/2023 at 1:53 PM, the Administrator stated Resident #107 used side rails for repositioning in bed and was not aware that the resident had all four side rails up. The Administrator stated using all four side rails was considered a restraint. The Administrator stated the nursing department was responsible for updating the resident's care plan and indicated the use of side rails should be included on the resident's care plan. The Administrator also stated the facility did not use all four side rails for residents.

Based on observations, interviews, record review, and facility policy review, the facility failed to revise a comprehensive person-centered care plan for (Resident #107). Specifically, the facility failed to revise a comprehensive care plan for Resident #107 to include the use of siderails as an enabler for bed mobility and transfers. This affected one of 26 sampled residents comprehensive care plans reviewed. Findings included: Review of a facility policy titled, Bedrail Use, effective on 01/01/2019, revealed: . PURPOSE of bedrails was to enable a resident/guest to become more functionally independent, and when the medical condition of the resident requires the use of a bedrail. The policy indicated . Bedrails could be considered a form of a physical restraint; therefore, the need for the bedrails should be documented in the resident's/guest's assessment, and plan of care . The policy also indicated a side rail evaluation should be completed upon implementation of the side rail and should be addressed in the resident's care plan. Review of a Face Sheet indicated the facility admitted Resident #107 on 01/08/2021. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/2023, revealed Resident #107 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had severely impaired cognitive skills for daily decision making and had short-term and long-term memory problems. The MDS indicated the resident required extensive assistance of two staff for transfers and limited assistance of one staff for bed mobility. Further review indicated the resident did not use bed rails for a restraint. Review of a Side Rail Evaluation, completed on 06/01/2023 at 2:09 PM by Registered Nurse (RN) #7, indicated the evaluation was completed for a MDS review. The evaluation revealed bilateral side rails were recommended for Resident #107. The reasons for side rail use for Resident #107 were for altered cognition, ambulation with assistance, balance deficit, weakness, and incontinence. The evaluation indicated side rails would assist the resident with bed mobility, transfers, and safety. Review of a Care Plan(s), with a start date of 01/09/2021, revealed Resident #107 was at risk for falls with an intervention that directed staff to encourage the use of handrails and/or appropriate assistive devices. The Care Plan, dated 01/13/2021, revealed Resident #107 exhibited behaviors of laying on the floor on a mat with a goal not to sustain any injuries from behaviors. The Care Plan did not address the use of side rails. Observations of Resident #107 on 06/13/2023 at 10:35 AM and on 06/14/2023 at 11:01 AM revealed the resident was lying in bed with their eyes closed and the head of the bed was elevated approximately 45 degrees. Also, an observation on 06/15/2023 at 1:12 PM, revealed that Resident #107 was lying in bed with their eyes closed and the head of the bed was elevated at approximately 30 degrees. During the observations, all four side rails (a side rail on each side of the upper and lower portions of the bed) were in the raised position on the resident's bed. During an interview on 06/15/2023 at 1:31 PM, Registered Nurse (RN) #7 stated Resident #107 used side rails for safety and bed mobility, but RN #7 stated she would have to look up the information regarding the use of side rails. RN #7 stated the Unit Manager (RN #20) was responsible for updating the resident's care plan if a resident had side rails in use, and the side rails should be care planned. During an interview on 06/15/2023 at 1:18 PM, Licensed Practical Nurse (LPN) #6 stated Resident #107 used side rails for safety, and stated the side rails were care planned. LPN #8 stated if a resident had side rails in use, the side rails should be care planned, and RN #20 was responsible for updating the resident's care plan. During an interview on 06/15/2023 at 1:23 PM, RN #20 stated Resident #107 used the side rails so the resident could turn from side to side, and the resident had half side rails in use. RN #20 stated she was responsible for updating the resident's care plan, and the side rails should be care planned. RN #20 reviewed the resident's care plan in the Electronic Health Record (EHR) and stated the care plan did not address the use of side rails, but the resident had behaviors, and the use of the side rails was to prevent the resident from getting on the floor. During an interview on 06/15/2023 at 1:41 PM, the Director of Nursing (DON) stated Resident #107 used side rails for bed mobility and to assist the resident with transferring out of bed. The DON stated if a resident used side rails, it should be care planned, and the care plan LPN and the Unit Managers were responsible for updating the resident's care plan. During an interview on 06/15/2023 at 1:53 PM, the Administrator stated Resident #107 used side rails for repositioning in bed. The Administrator stated the nursing department was responsible for updating the resident's care plan, and the side rails should be included in the resident's care plan.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure residents who required extensive to total assistance with personal hygiene were regularly offered trimming or shaving of facial hair and trimming of fingernails to maintain good grooming and hygiene. This affected two of five sampled residents reviewed for activities of daily living (ADLs) for (Resident #65 and Resident #107). Findings included: Review of a facility policy, titled, Nail Care, with an effective date of 10/01/2010, revealed, PURPOSE: Routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well being for the resident. Further review of the policy indicated, Nail care is a routine part of grooming each day. Review of a facility policy, titled, Shaving the Resident, with an effective date of 01/15/2010, revealed, PURPOSE: Shaving improves the resident's appearance and feeling of well-being. Further review of the policy indicated, Male and Female residents are shaved daily or as needed. 1. Review of a Face Sheet indicated the facility admitted Resident #65 on 01/30/2017 with diagnoses that included Schizoaffective Disorder, Schizophrenia, and a history of Transient Ischemic Attack (TIA) and Cerebral Infarction. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2023, revealed Resident #65 had short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident was totally dependent on the assistance of one staff for personal hygiene. According to the MDS, Resident #65 had unclear speech with slurred or mumbled words, was sometimes understood, and sometimes understood others. Review of a Care Plan, with a start date of 01/31/2017, revealed Resident #65 required assistance to complete daily activities of care safely. Interventions instructed staff to assist the resident with shaving, bathing, brushing their teeth/oral care, and grooming the resident's hair. There were no interventions in the care plan related to nail care. Review of Resident #65's ADL [activities of daily living] Assistance and Support sheet, for 06/01/2023 through 06/14/2023, indicated Resident #65 had not been provided with personal hygiene care. During an observation on 06/13/2023 at 10:43 AM, Resident #65 was lying in bed with the head of the bed elevated approximately 30 degrees. The resident had facial hair that was approximately 1/4-inch long. The resident's fingernails were approximately 1/2-inch long with brown debris underneath the nails. An attempt was made to interview the resident; however, the resident only stated their name. During an observation on 06/14/2023 at 10:29 AM, Resident #65 was lying in bed and had the same appearance as the previous observation on 06/13/2023 at 10:43 AM related to facial hair and long nails. During an interview on 06/14/2023 at 10:31 AM, Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #2 stated that CNAs were responsible for shaving Resident #65 and providing nail care. Both CNA #1 and LPN #2 stated the resident was shaved on their assigned shower days. CNA #1 stated the resident's showers were provided on Mondays, Wednesdays, and Fridays during the day shift. Both CNA #1 and LPN #2 stated that the resident's nails were trimmed every Sunday. LPN #1 stated the care provided was documented on the resident's care board (the ADL Assistance and Support Sheet), which was in the resident's Electronic Health ecord. CNA #1 stated the resident was fully dependent for all care. During a concurrent interview and observation on 06/14/2023 at 10:39 AM, CNA #3 stated that CNAs were responsible for shaving Resident #65 and providing nail care. CNA #3 stated the resident was shaved every three days or when facial hair was noticeable and nail care was also provided every three days. CNA #3 stated the care provided was documented on the resident's care board (the ADL Assistance and Support Sheet), which was in the resident's Electronic Health Record. CNA #3 stated the resident was dependent for all care. At this time, the surveyor and CNA #3 entered Resident #65's room. CNA #3 observed Resident #65 and stated the resident had facial hair and needed to be shaved. CNA #3 observed the resident's fingernails and stated they needed to be trimmed and filed and stated they were approximately 1/2-inch long with debris underneath. CNA #3 also pointed to the resident's right middle finger, left middle finger, and left ring finger and stated the fingernails were all jagged. CNA #3 then asked Resident #65 if the resident would let her trim their nails and shave them and the resident said, Yes. During an interview on 06/15/2023 at 1:44 PM, the Director of Nursing (DON) stated CNAs were responsible for shaving Resident #65. The DON stated CNAs provided nail care for residents unless a resident was diabetic. The DON stated Resident #65 was to be shaved as needed and the resident's nails were to be trimmed and cleaned as needed or when the nails got too long. The DON stated that staff did not document specifically when nail care or shaving was completed; however, staff were responsible for documenting on the ADL Assistance and Support sheet, whether personal hygiene care, which included shaving and nail care, was provided. The DON stated if staff were to observe a resident with facial hair and long, jagged fingernails with debris underneath, she expected them to shave the resident and trim their nails. During an interview on 06/15/2023 at 1:56 PM, the Administrator stated that if staff observed a resident with facial hair and long, jagged fingernails with debris underneath, she expected the staff to trim and file the jagged nails and shave the resident as the resident allowed. 2. Review of a Face Sheet indicated the facility admitted Resident #107 on 01/08/2021 with diagnoses that included Mood Disorder. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/31/2023, revealed Resident #107 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident required extensive assistance from one staff for personal hygiene. According to the MDS, Resident #107 did not speak, was rarely/never understood, and rarely/never understood others. Review of a Care Plan, with a start date of 01/11/2021, revealed Resident #107 required assistance to complete daily activities of care safely. Interventions directed staff to assist the resident with shaving and provide nail care as needed. Review of ADL [activities of daily living] Assistance and Support sheets, for 06/01/2023 through 06/14/2023, indicated Resident #107 had not been provided with personal hygiene care. During an observation on 06/13/2023 at 10:35 AM, Resident #107 was lying in bed with the head of the bed elevated approximately 45 degrees. The resident had facial hair that was approximately 1/4-inch to 1/2-inch long. The resident's fingernails were approximately 1/2-inch long. During an observation on 06/14/2023 at 11:01 AM, Resident #107 was lying in bed and had the same appearance as the previous observation on 06/13/2023 at 10:35 AM related to facial hair and long fingernails. During an interview on 06/14/2023 at 11:02 AM, Certified Nursing Assistant (CNA) #4 stated CNA #5 was responsible for shaving Resident #107 and providing nail care. CNA #4 stated Resident #107 was shaved and had nail care provided on the resident's shower days and the care was documented in the resident's Electronic Health Record (EHR). During a concurrent interview and observation on 06/14/2023 at 11:05 AM, CNA #5 stated the CNA assigned to the resident was responsible for shaving and trimming the resident's fingernails on the resident's shower days, which were scheduled on Mondays, Wednesdays, and Fridays during the second shift. CNA #5 stated that she provided the resident with a bed bath during the day shift and she shaved the resident when she saw facial hair or anytime the resident needed to be shaved. CNA #5 stated the resident's fingernails were trimmed about twice a week. CNA #5 stated that when the resident was shaved or had their nails trimmed, it was documented in the resident's EHR. At this time, the surveyor and CNA #5 entered the resident's room. CNA #5 observed the resident and stated the resident needed to be shaved but she had been busy answering call lights so shaving was not provided. CNA #5 stated the resident's facial hair was approximately 1/4-inch long and the resident's fingernails were approximately 1/2-inch long and needed to be trimmed. During an interview on 06/14/2023 at 11:42 AM, Licensed Practical Nurse (LPN) #6 stated the CNA assigned to provide the resident's care was responsible for trimming Resident #107's fingernails. LPN #6 said the resident's fingernails were to be trimmed and cleaned at least twice a week, sometimes three times a week, and staff were to trim and clean the resident's fingernails on their shower days. LPN #6 stated the resident was to be shaved every day or every other day. LPN #6 stated trimming of the nails and facial hair was documented in the resident's EHR. At this time, the surveyor and LPN #6 entered the resident's room. LPN #6 stated the resident's facial hair was 1/2-inch long and the resident's fingernails were also approximately 1/2-inch long. The resident's left hand, pinky and ring fingers had brown debris underneath the nails. During an interview on 06/15/2023 at 1:44 PM, the Director of Nursing (DON) stated CNAs were responsible for shaving Resident #107. The DON stated CNAs provided nail care for residents unless a resident was diabetic. The DON stated Resident #107 was to be shaved as needed and the resident's nails were to be trimmed and cleaned as needed or when the nails got too long. The DON stated that staff did not document specifically when nail care or shaving was completed; however, staff were responsible for documenting on the ADL Assistance and Support sheet, whether personal hygiene care, which included shaving and nail care, was provided. The DON stated if staff were to observe a resident with facial hair and long, jagged fingernails with debris underneath, she expected them to shave the resident and trim their nails. During an interview on 06/15/2023 at 1:56 PM, the Administrator stated that if staff observed a resident with facial hair and long, jagged fingernails with debris underneath, she expected the staff to trim and file the jagged nails and shave the resident as the resident allowed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,interview, medical record review and review of a facility document titled Peri-Care the facility failed to ensure a Certified Nursing Assistant (CNA) did not clean bowel movement from Resident Identifier (RI) #128, a resident with history of a Urinary Tract Infection (UTI), then with the same gloves, place a clean brief on the resident. This was observed on 6/11/19 and affected one of two residents observed for incontinent care. Findings Include: A review of an undated facility document titled: PERI-CARE revealed: . 3. WASH HANDS AND APPLY GLOVES 4. WASH PUBIC AREA . 8. REMOVE GLOVES AND WASH HANDS--APPLY CLEAN GLOVES 9. TURN RESIDENT ON SIDE 10. WASH ANAL AREA . 12. REMOVE GLOVES AND WASH HANDS-APPLY CLEAN GLOVES . 14. PLACE CLEAN BRIEF . RI #128 was admitted to the facility on [DATE] with a diagnosis to include Parkinson's Disease. A review of a Physician Order List dated 5/23/19 revealed: .BACTRIM DS TABLET ONE TAB (tablet) PO (by mouth) BID X 7 D (two times a day for 7 days) DX: (diagnosis) UTI (Urinary Tract Infection/ecoli) . A review of a facility laboratory form dated 5/21/19, revealed: .Procedure CULTURE URINE .Antimicrobial Susceptibility and Organism Identification Report Isolate Escherichia coli . On 6/11/19 at 4:09 PM, the surveyor observed Certified Nursing Assistants (CNAs) EI #3 and EI #4 performing peri-care for RI #128. The Staff Development nurse (EI #2) asked to observe. EI #3 performed the peri-care after EI #4 loosened the brief. EI #3 wiped the resident's front area, removed her gloves and washed her hands, then put on new gloves. Both CNAs turned RI #128 over to the left side. EI #3 wiped RI #128's buttock area until it was free of bowel movement, using a clean wipe each time. EI #3 picked up the clean brief with the same soiled gloves, and placed it under RI #128. EI #3 removed her gloves, washed her hands and put on clean gloves and continued placing and securing the brief. On 6/11/19 at 4:26 PM, an interview was conducted with EI #3. EI #3 was asked what was the policy for cleaning a resident during peri-care. EI #3 replied, wash hands, put on gloves and wipe the front, using a clean wipe each time; then remove your gloves and wash hands and put on new gloves. EI #3 explained they would then turn the resident, clean the back side and buttocks, remove the soiled brief, change gloves, wash hands and put on clean gloves then place the clean brief. EI #3 was asked if that was how she did the peri-care. EI #3 replied, no, she should have changed gloves before she placed the clean brief. EI #3 was asked why did she not wash hands and change gloves before placing the clean brief. EI #3 replied she was nervous. EI #3 was asked when should she change gloves and wash hands during peri-care. EI #3 replied, before starting, after cleaning the front, after cleaning the back, before placing the clean brief, then when finished. EI #3 was asked if RI #128 had a bowel movement. EI #3 replied, yes. EI #3 was asked what was the harm in her not changing gloves and washing hands before placing the clean brief. EI #3 replied, could transfer of germs or bowel movement On 6/13/19 at 10:45 AM, the surveyor asked EI #2 (Staff Development Nurse) what was the policy for hand washing during pericare. EI #2 replied, the staff was to wash hands, put on gloves before starting; after cleaning the front, remove gloves and wash hands, put on new gloves, then after cleaning the buttock area before they place the clean brief, and when finished. EI #2 was asked should staff clean bowel movement from a resident, then with the same gloves, place the clean brief. EI #2 replied, they should not. EI #2 was asked what would the harm be in the CNA placing a clean brief with the same gloves she cleaned bowel movement from the resident. EI #2 replied, the gloves were dirty and the CNA was touching a clean brief with a dirty glove; she cleaned well, so she did not think the CNA could spread germs. EI #2 was asked how could the CNA have been sure there was not bowel movement on her gloves after she cleaned the resident, that may have been transferred to the clean brief. EI #2 replied, it would not matter; the CNA should have changed her gloves after cleaning the buttock area and before placing the clean brief.

Based on observation, interviews, review of a facility policy (Budget Guidelines) and the 2017 Food Code United States Public Health, the facility failed to: 1) routinely date and discard food items within a timely manner; 2) prevent the cross-contamination of food prior to service on the 6/11/19 and during the 6/12/19 lunch tray lines via contact with an unsanitized thermometer handle, and flies; 3) ensure all foods were checked for safe and sanitary temperatures prior to service on the 6/12/19 lunch tray line; and 4) re-heat food found to be below 135 degrees on the 6/12/19 lunch tray line. This had the potential to affect all 137 residents for whom meals were prepared and served at the time of this survey. Findings Included: 1) FOOD LABELING/TIMELY DISCARD The facility policy titled, Budget Guidelines (policy number DS. VI-6, with an effective date of 08/10/18) specifies: h. Label and date leftovers and use leftovers before the 'use by' date . The 2017 Food and Drug Administration Food Code mandates under regulation 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) .refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded. During the initial Kitchen tour on 06/11/19 at 10:30 AM, the reach-in refrigerator included: a) a container of expired soft cheese (nacho type) with a labeled open date of 06/06/19 and a use by date (UBD) of 06/08/19; and b) a five pound container of Potato Salad with an open date of 06/06/19 and a UBD of 06/09/19; as well as a c) container of pears with a date of 06/9/19 and no UBD. On 06/11/19 at 10:40 AM, the Surveyor questioned the (Certified Dietary Manager) CDM (Employee Identifier) EI #6 about the dating of opened foods. EI #6 stated the facility company wanted them to use a three-day use by date, which was what she had always told staff to use. 2) CROSS CONTAMINATION Regulation 3-304.11 Food Contact with Equipment and Utensils. of the 2017 Food Code states: FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned . and SANITIZED . On 06/11/19 at 11:00 AM, staff had partially filled the steam table with food for lunch line. The steam table included a full-size pan of cooked English Peas. A thermometer with its detachable plastic handle was laying directly on top of the peas. The Surveyor asked the CDM, EI #6, what problem the thermometer handle would pose. EI #6 immediately responded, Cross Contamination. On 06/12/19 at 10:45 AM, the [NAME] (EI #12) dropped the handle of her thermometer into the pan of whole boiled okra as she checked food temperatures prior to the start of the tray line. EI #12 then let the handle of the thermometer dip into the pureed noodles. On 06/12/19 at 11:53 AM, the Surveyor asked the [NAME] (EI #12) what problem would the direct contact of the thermometer handle with the whole boiled okra and pureed noodles pose. EI #12 responded, Cross contamination. The 2017 Food Code regulation, 6-501.111 Controlling Pests. specifies: The PREMISES shall be maintained free of insects, rodents, and other pests. During the 06/12/19 lunch tray line (10:45 AM), flies landed in the cooked noodles as well as the beef tips, and on an oven mit. Throughout the tray line service, staff swatted flies out of their way, with as many as four flies seen at one time. On 06/12/19 at 11:45 AM, a fly landed on a filled hot pot containing a liquid sitting on the line. The lid was not on. The fly crawled inside the mouth of the pot, which the Surveyor pointed out to the CDM. 3) FOOD TEMPERATURES Food Code regulation, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. mandates the following: (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 degrees F or above . Food Code regulation, 3-401.13 Plant Food Cooking for Hot Holding. Plant FOODS that are cooked for hot holding shall be cooked to a temperature of 135 degrees F. On 06/12/19 pureed Okra was placed on the steam table at 11:05 AM (after the line had started). A pan of cooked Squash was placed on the line at 11:12 AM. Neither pan of food was checked for temperature adequacy. On 06/12/19 at 11:21 AM, a pan of ground Chicken was removed from the steamer, and placed in the oven behind the steam table. Staff did not check the temperature prior to service (to at least one resident). The float staff person (EI #8) was asked if she had checked the temperature of the chicken. EI said no, explaining the tray line staff was responsible. The CDM (EI #6) was interviewed on 06/12/19 at 11:36 AM and asked why the food added late to the steam table (the ground chicken, squash and pureed okra) was not checked for temperatures. EI #6 stated the staff were supposed to check the temperatures before adding the food to the line. 4) REHEATING OF FOOD Food Code regulation, 3-403.11 Reheating for Hot Holding. (A) .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 165 degrees F for 15 seconds. On 06/12/19 at 11:36 AM, the CDM asked the [NAME] to check the temperature of the pureed okra (not previously checked). EI #6 checked the pureed okra (only) and discovered it was 120 degrees F. This item was not reheated. Neither the ground Chicken, nor the cooked Squash were checked for temperature adequacy.