. Based on interview, observation, and record review, the facility failed to ensure facility approved menus were followed for 2 residents (#'s 2 and 18), out of 2 residents who received pureed meals. This failed practice had the potential to compromise the nutritive adequacy of foods, decrease palative and overall quality of food, and affect the resident's nutritional well-being. Findings: Pureed Meal Guidelines During an interview on 10/24/24 at 4:30 PM, the Kitchen Manager stated the facility used the International Dysphagia Diet Standardisation Initiative (IDDSI) standards for therapeutic diet consistency guidelines and used recipes from the Menu2U website, at www.webmenuplus.com/docs/login.asp, to make pureed diet meals. Review of the facility's IDDSI guidelines, undated, revealed: - Nectar thick liquids were considered mildly thick and a level 2 liquid and defined as Flows at a slower rate, able to sip but may take some effort using a straw. - Honey thick liquids were considered moderately thick and a level 3 liquid and defined as Can drink from a cup or with a spoon, need a wide diameter straw. - Pudding thick liquids were considered extremely thick and a level 4 liquid (EX4) and defined as can be eaten with a spoon, does not drip through fork, smooth texture. - A pureed meal was considered a level 4 diet (PU4), and defined pureed as eaten with a spoon and does not require chewing, smooth texture. Random observations on 10/21-25/24 revealed the facility used Simply Thick EasyMix instant food thickener, bulk-sized bottles of 55 fluid ounces (fl oz), to thicken liquids and pureed foods for residents who required pureed meals. Review of the Simply Thick EasyMix website at https://www.simplythick.com/How-to-Use-Videos, undated, revealed 1 pump stroke from the bulk bottle made a nectar thick consistency, 2 pump strokes made a honey thick consistency; and 4 pump strokes made a pudding thick consistency in liquids and foods. Resident #2 Record review on 10/21-25/24 revealed Resident #2 was admitted to the facility with diagnoses that included Alzheimer's Disease, reduced mobility, and abnormal weight loss. Further review revealed Resident #2 had a diet order, dated 7/19/22, which stated, Puree (IDDSI PU4) texture, Extremely Thick (IDDSI EX4) consistency, Resident need very small portions four to five times a day as tolerated. Resident #18 Record review on 10/21-25/24 revealed Resident #18 was admitted to the facility with diagnoses that included dementia, dysphagia following cerebral infarction (difficulty swallowing after a stroke), and weakness. Further review revealed Resident #18 had a diet order, dated 5/3/24, which stated, Puree (IDDSI PU4) texture, thin (IDDSI TN0) consistency, meds [medications] in applesauce, post stroke dysphagia, double portions. Pureed Meal Preparation Observation An observation on 10/24/24 at 3:44 PM, revealed [NAME] #4 was preparing pureed meals for dinner and prepared the following food items: Steamed Cabbage Cook #4 prepared to puree steamed cabbage. [NAME] #4 was observed to place a couple of unmeasured handfuls of cooked cabbage into a blender, then poured an unmeasured amount of hot water into the blender from a spout from a coffee pot machine. [NAME] #4 blended the cabbage/water mix until it was thoroughly blended, creating a watery mix. [NAME] #4 then added 8 pump strokes of thickener and blended the mix again. After this, [NAME] #4 checked the consistency and then added another 5 pump strokes of thickener and blended again. [NAME] #4 checked the consistency, then placed the pureed steamed cabbage in bowls and placed a lid on the bowls. [NAME] #4 placed the bowls in the hot food holding cabinet ready to serve to the residents. Review the facility's Menu2U recipes, dated 2022-2024, for pureed steamed cabbage revealed it called for 1/2 cup (2 1/2 cups for 5 servings) of steamed cabbage per resident. The pureed method of the recipe stated, 1. Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. Add thickener and hot water. Process until smooth . Further review revealed the recipe called for only 3 tablespoons of thickener and there was no guidance on the amount of hot water to add to the recipe. Chicken Tenders Further observation revealed [NAME] #4 prepared to puree chicken tenders. [NAME] #4 placed 3 to 4 chicken tenders into a blender. [NAME] #4 added a small amount of unmeasured gravy and also placed an unmeasured amount of hot water from the coffee pot spout in the blender. [NAME] #4 blended the chicken/gravy/water mix until it was thoroughly blended. [NAME] #4 then added 5 pump strokes of thickener and blended again. [NAME] #4 checked the consistency, then placed the pureed chicken tenders in bowls and placed a lid on the bowls. [NAME] #4 placed the bowls in the hot food holding cabinet ready to serve to the residents. Review the facility's Menu2U recipes, dated 2022-2024, for pureed chicken tenders revealed it called for 2 chicken tenders per resident. The pureed method of the recipe stated, Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 2 [tablespoons] thickener and 1/2 [to] 2 tablespoons cup hot liquid; mix well with a wire whip. Add 1/2 of the slurry to the meat; process for 1 minute. If too dry, add more slurry until meat is pudding consistency . serve with a #6 scoop [2/3 cup] topped with . gravy or sauce. During an interview on 10/24/24 at 5:20 PM, the Dietary Manager stated the hot liquid identified in the chicken tenders pureed recipe was meaning hot water. During an interview on 10/25/24 at 8:23 AM, the Dietician stated that if the Menu2U recipe called for water, then water would be added to make pureed meals. When asked if water would decrease the nutritive value of the pureed meal, the Dietician stated water would decrease the nutritional value. The Dietician further stated that thickener added no nutritional value to the meals made. When asked for a policy or procedure for preparing therapeutic diets, the Kitchen Manager and Dietary Manager stated the facility relied on the Menu2U recipe directions to ensure these foods were prepared and served appropriately. .

. Based on interview, observation, and record review, the facility failed to prepare pureed meals by methods that conserve nutritive value for 2 residents (#'s 2 and 18), out of 2 residents who received pureed meals. Specifically, the facility failed to ensure liquids of similar nutritive value were used to make pureed meals, and instead used water and thickener which had no nutritive value. This failed practice had the potential to compromise or diminish the nutritive value of foods and affect the resident's weight and overall health. Findings: Pureed Meal Guidelines During an interview on 10/24/24 at 4:30 PM, the Kitchen Manager stated the facility used the International Dysphagia Diet Standardisation Initiative (IDDSI) standards for therapeutic diet consistency guidelines and used recipes from the Menu2U website, at www.webmenuplus.com/docs/login.asp, to make pureed diet meals. Review of the facility's IDDSI guidelines, undated, revealed: - Nectar thick liquids were considered mildly thick and a level 2 liquid and defined as Flows at a slower rate, able to sip but may take some effort using a straw. - Honey thick liquids were considered moderately thick and a level 3 liquid and defined as Can drink from a cup or with a spoon, need a wide diameter straw. - Pudding thick liquids were considered extremely thick and a level 4 liquid (EX4) and defined as can be eaten with a spoon, does not drip through fork, smooth texture. - A pureed meal was considered a level 4 diet (PU4), and defined pureed as eaten with a spoon and does not require chewing, smooth texture. Random observations on 10/21-25/24 revealed the facility used Simply Thick EasyMix instant food thickener, bulk-sized bottles of 55 fluid ounces (fl oz), to thicken liquids and pureed foods for residents who required pureed meals. Review of the Simply Thick EasyMix website at https://www.simplythick.com/How-to-Use-Videos, undated, revealed 1 pump stroke from the bulk bottle made a nectar thick consistency, 2 pump strokes made a honey thick consistency; and 4 pump strokes made a pudding thick consistency in liquids and foods. Resident #2 Record review on 10/21-25/24 revealed Resident #2 was admitted to the facility with diagnoses that included Alzheimer's Disease, reduced mobility, and abnormal weight loss. Further review revealed Resident #2 had a diet order, dated 7/19/22, which stated, Puree (IDDSI PU4) texture, Extremely Thick (IDDSI EX4) consistency, Resident need very small portions four to five times a day as tolerated. Resident #18 Record review on 10/21-25/24 revealed Resident #18 was admitted to the facility with diagnoses that included dementia, dysphagia following cerebral infarction (difficulty swallowing after a stroke), and weakness. Further review revealed Resident #18 had a diet order, dated 5/3/24, which stated, Puree (IDDSI PU4) texture, thin (IDDSI TN0) consistency, meds [medications] in applesauce, post stroke dysphagia, double portions. Pureed Meal Preparation Observation An observation on 10/24/24 at 3:44 PM, revealed [NAME] #4 was preparing pureed meals for dinner and prepared the following food items: Steamed Cabbage Cook #4 prepared to puree steamed cabbage. [NAME] #4 was observed to place a couple of unmeasured handfuls of cooked cabbage into a blender, then poured an unmeasured amount of hot water into the blender from a spout from a coffee pot machine. [NAME] #4 blended the cabbage/water mix until it was thoroughly blended, creating a watery mix. [NAME] #4 then added 8 pump strokes of thickener and blended the mix again. After this, [NAME] #4 checked the consistency and then added another 5 pump strokes of thickener and blended again. [NAME] #4 checked the consistency, then placed the pureed steamed cabbage in bowls and placed a lid on the bowls. [NAME] #4 placed the bowls in the hot food holding cabinet ready to serve to the residents. Chicken Tenders Further observation revealed [NAME] #4 prepared to puree chicken tenders. [NAME] #4 placed 3 to 4 chicken tenders into a blender. [NAME] #4 added a small amount of unmeasured gravy and also placed an unmeasured amount of hot water from the coffee pot spout in the blender. [NAME] #4 blended the chicken/gravy/water mix until it was thoroughly blended. [NAME] #4 then added 5 pump strokes of thickener and blended again. [NAME] #4 checked the consistency, then placed the pureed chicken tenders in bowls and placed a lid on the bowls. [NAME] #4 placed the bowls in the hot food holding cabinet ready to serve to the residents. Recipe Review Review of the facility's Menu2U recipes, dated 2022-2024, for pureed preparation for steamed cabbage and chicken tenders revealed: Steamed Cabbage Review of the recipe for pureed steamed cabbage revealed it called for 1/2 cup (2 1/2 cups for 5 servings) of steamed cabbage per resident. The pureed method of the recipe stated, 1. Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. Add thickener and hot water. Process until smooth . Further review revealed the recipe called for only 3 tablespoons of thickener and there was no guidance on the amount of hot water to add to the recipe. Chicken Tenders Review of the recipe for pureed chicken tenders revealed it called for 2 chicken tenders per resident. The pureed method of the recipe stated, Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. For every 5 portions needed, prepare a slurry with 2 [tablespoons] thickener and 1/2 [to] 2 tablespoons cup hot liquid; mix well with a wire whip. Add 1/2 of the slurry to the meat; process for 1 minute. If too dry, add more slurry until meat is pudding consistency . serve with a #6 scoop [2/3 cup] topped with . gravy or sauce. During an interview on 10/24/24 at 5:20 PM, the Dietary Manager stated the hot liquid identified in the chicken tenders pureed recipe was meaning hot water. During an interview on 10/25/24 at 8:23 AM, the Dietician stated that if the Menu2U recipe called for water, then water would be added to make pureed meals. When asked if water would decrease the nutritive value of the pureed meal, the Dietician stated water would decrease the nutritional value. The Dietician further stated that thickener added no nutritional value to the meals made. When asked for a policy or procedure for preparing therapeutic diets, the Kitchen Manager and Dietary Manager stated the facility relied on the Menu2U recipe directions to ensure these foods were prepared and served appropriately. Review of the Simply Thick EasyMix nutrition facts at https://www.simplythick.com/Nutrition-Panels-English, dated 2022, revealed there was no fat or protein nutrition to the thickener. Further review revealed the following calories for each amount of thickener: - 4 g (grams), or 0.12 fl oz (fluid ounce), each = 0 calories; - 6 g, or 0.2 fl oz, each = 5 calories; - 12 g, or 0.4 fl oz, each = 10 calories; - 48 g, or 1.6 fl oz, each = 5 calories; - 96 g, or 3.2 fl oz, each = 10 calories; and - 1.6 L (liters), 1.7 quarts, each = 5 calories. .

. Based on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure food was stored under proper sanitation and food handling practices. This failed practice had the potential of causing or spreading foodborne illness to all residents, based on a census of 16. Findings: Initial Kitchen Tour Pantry Storage: An observation on 10/21/24 at 4:34 PM, of the pantry storage of the kitchen, revealed the following expired items: - 1 opened Sysco Classic Chocolate Instant Pudding and Pie Filling Mix, 24-ounce bag, 1/4 full. This was stored in a Ziploc plastic bag labeled, Use by 10/19/24; - 2 unopened Nabisco Entertainment Crackers boxes, each containing 8 packages of assorted cracker types, Net weight 2.51 lbs. (pounds), with a manufacturer expiration date of 8/29/24; - 1 Ziploc plastic bag of loose pecans. This Ziploc plastic bag was not labeled and had no open date and no expiration date; - 1 opened Sysco Classic Almond Slices, 32-ounce bag, 1/4 full with a manufacturer expiration date 6/2/24; - 1 plastic container labeled Polenta - with a use by date of 7/24/24; - 1 jar Organic Coconut Oil, 14-fluid-ounces - with a manufacturer use by date 7/24/24; - 1 container Sysco Classic Imitation Vanilla Flavor, 32-fluid-ounces - 3/4 full - with a manufacturer use by date of 2/27/24; and - 1 bottle S&B Wasabi Sauce, 5.3-fluid-ounces, full and unopened - with a manufacturer expiration date of 9/2/24. Further observation revealed the following dented cans of food items: - 1 can Sysco Sliced Apples, 6.5 lbs., can dented on rim seal of the can; - 1 can Sysco Imperial Pizza Sauce, 6.63 lbs., can dented on rim seal of the can; and - 1 can Diced Pears, 6.56.lbs., can dented on rim seal of the can. Walk-In Freezer: An observation on 10/21/24 at 5:00 PM, of the kitchen's walk-in freezer, revealed the following: - 1 bag Sysco Imperial Winter Vegetables, 4 lbs. bag, this bag was open and not sealed causing the vegetables to be exposed to the elements. - 1 opened box of Sysco Cut [NAME] Beans, 30-pound box, 1/2 full. The bag inside the box was open to air. [NAME] beans visible and were covered with small ice crystals. During an interview on 10/21/24 at 5:17 PM, the Kitchen Manager stated the Ziploc bag of pecans should have been labeled and dated. The Kitchen Manager acknowledged the expired crackers, pudding, and dented cans when discovered. When shown the expired wasabi sauce, the Kitchen Manager mentioned just having purchased it from the store. Review of the facility's policy Food Safety: Food Handling, dated 2023, revealed: . All foods that are received into Aramark [Food Service Provider] locations must be labeled . Discard foods that are not labeled in accordance with these standards . Discard foods that are not used by the manufacturer's Use By/Best Before date . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review and interview, the facility failed to maintain the central kitchen's Hot Food Holding Cabinet (a unit that holds cooked food at a safe temperature prior to serving) in safe operating conditions. Specifically, the facility failed to ensure the accuracy of the cabinet's internal and external thermometers was maintained to be of similar temperatures. This failed practice had the potential to not hold cooked foods at appropriate temperatures and placed all residents (based on a census of 16) at risk for foodborne illness. Findings: Random observations on 10/21-25/24 revealed the facility used an [NAME]-Shaam Hot Food Holding Cabinet, model 1000-UP, to store and hold cooked food prior to serving for meals. An observation on 10/24/24 at 3:45 PM, revealed an external thermostat reading on the Hot Food Holding Cabinet of 200 degrees Fahrenheit (F), and an internal thermometer reading of 180 degrees F. An observation on 10/25/24 at 8:19 AM, revealed an external thermostat reading on the Hot Food Holding Cabinet of 200 degrees F, and an internal thermometer reading of 180 degrees F. Record review of the facility-provided instruction manual for the [NAME] Shaam 1000-UP, dated 7/2018, revealed directions to verify thermostat accuracy by enacting a series of diagnostic tests to ensure temperature accuracy. During an interview on 10/24/24 at 3:31 PM, the Kitchen Manager stated that kitchen staff were previously told to keep the Hot Food Holding Cabinet at 165 degrees F, but as of 10/24/24 they have kept the Hot Food Holding Cabinet at 200 degrees F to keep food warmer. During an interview on 10/24/24 at 3:37 PM, when asked how often the accuracy of the temperatures for the Hot Food Holding Cabinet was checked, the Facilities Manager stated, the unit was purchased four years ago. At that time calibration was done. Review of the facility's policy Food Safey: Service [and] Delivery, dated 4/16/24, revealed: . Facilities, Equipment, [and] Utensils: Visually inspect all utensils and equipment before using them and during operating hours to make sure they are in proper working condition. Maintain all utensils and equipment in good condition . Hot Holding: Make sure that proper hot holding temperatures can be maintained by equipment in use . Follow the manufacturer's instructions for hot holding equipment . .

. Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set - A federally required assessment) accurately represented a resident's status for 1 resident (#3), out of 10 sampled residents. Without an accurate assessment, the resident was at risk for erroneous information that had the potential for inappropriate or no care and services. Findings: Record review from 6/7-9/22 revealed Resident #3 admitted to the facility with diagnoses that included heart failure, diabetes, chronic kidney disease and sensorineural hearing loss (results from loss of or damage to the tiny hair cells in the cochlear of the inner ear) in both ears. During an interview on 6/7/22 at 9:59 AM, Resident #3 stated he/she needed hearing aids, but became ill and had to cancel a scheduled appointment. The Resident further stated he/she hoped the facility rescheduled because he/she was sick of saying 'what' all the time. Review of Resident #3's most recent MDS, an admission assessment, dated 5/3/22, revealed under Hearing, the resident was coded as having adequate hearing. During an interview on 6/9/22 at 8:20 AM, Licensed Nurse (LN) #3 stated Resident #3 and his/her daughter talked about the Resident needing hearing aids. During a joint interview on 6/9/22 at 2:09 PM, with the MDS Coordinator and LN #2, when asked if she was aware of Resident #3's hard of hearing status, the MDS Coordinator stated she was, but when the Resident was interviewed, the television was off and the Resident heard her well. When asked if the Resident's diagnosis was reviewed for the MDS, the MDS Coordinator stated it was. It was further stated the facility was aware of the Resident's request for hearing aids prior to the Resident's admission to the facility, and the facility was working on how to honor this request with the Resident's poor health status. Review of CMS's RAI [Resident Assessment Instrument] Version 3.0 Manual, dated 10/2019, accessed at https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf, revealed the intent was to Document the resident's ability to hear, understand, and communicate with others and whether the resident experiences visual, hearing or speech limitation and /or difficulties. Further review revealed Problems with hearing can contribute to sensory deprivation, social isolation, and mood and behavior disorders. Unaddressed communication problems related to hearing impairment can be mistaken for confusion or cognitive impairment. Further review revealed Steps for Assessment .Interview the resident and ask about hearing function in different situations (e.g. hearing staff members, talking to visitors, using telephone, watching TV, attending activities) .Review the medical record . Further review revealed coding instructions for adequate, was No difficulty in normal conversation, social interaction, or listening to TV. The resident hears all normal conversational speech and telephone conversation and announcements in group activities. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and interview, the facility failed to ensure the care plan was individualized to meet medical needs for 1 resident (# 2), out of 10 sampled residents. This failed practice placed the resident at risk for not having necessary safety measures implemented to address his/her individual needs. Findings: Record review on 6/7-9/22 revealed Resident #2 was admitted to the facility with diagnoses that included vascular dementia (dementia resulting from impaired blood flow to the brain) and diabetes. An observation on 6/7/22 at 2:11 PM, revealed a fall mat on the floor by Resident #2's bed. Review of Resident #2's Minimum Data Set (MDS - a federally required assessment), a quarterly assessment dated [DATE], revealed the resident required 2+ persons physical assist for bed mobility, 1 person physical assist for transfer between surfaces, and 1 person physical assist for walking. Further review revealed Resident #2's balance when moving from seated to standing position and walking was not steady, and the resident was only able to stabilize with human assistance. During an interview on 6/7/22 at 4:07 PM, Licensed Nurse (LN) #2 stated Resident #2 had a history of falls and for this reason the fall mat was put into place as a fall precaution. LN #2 further stated the fall mats were at the nurse's discretion, not requiring a Physician's order, and would have been an intervention in the Resident's Care Plan. During an interview on 6/9/22 at 2:10 PM, when asked how Certified Nursing Assistants (CNAs) knew to use fall mats with a resident, LN #2 and the MDS Coordinator stated the CNAs used the Resident's Care Plan, that detailed the interventions used daily. Review of Resident #2's Care Plan, last revised on 3/22/22, revealed: Focus: The resident is High Risk for falls [related to] vascular dementia and ocular hypertension [when the pressure inside the eye is higher than normal]. Further review revealed no intervention for the use of a fall mat by his/her bed for safety. Review of the facility's policy Fall Assessment and Prevention, last reviewed 7/15/20, revealed: . Nursing staff (RNs, LPNs, CNAs) caring for residents assessed for fall risk must be familiar with the care plan and intervention(s) to prevent falls and work to support those interventions during each shift . Further review revealed no mention of fall mats, when they should have been initiated, how they would have been initiated, or who was responsible for initiating them when needed. .

. Based on record review and interview, the facility failed to ensure 2 residents' (#4 and #11), out of 10 sampled residents, drug regimen was free from unnecessary drugs. Specifically, the facility failed to: 1) write pain parameters for multiple PRN (as needed) pain medications; and 2) identify potential errors in administration with 2 separate PRN orders for the same medication. These failed practices had the potential to improperly medicate the residents. Findings : Resident # 4: Record review from 6/7-9/22 revealed Resident #4 was admitted to the facility with diagnoses that included Alzheimer's disease and osteoarthritis (the most common form of arthritis occurring mostly in the hands, hips, and knees). Review of Resident #4's most recent Physician's Orders revealed an order for: 1. Ibuprofen Tablet 400 MG [Milligrams] Give 1 tablet by mouth every 6 hours as needed for fever ., and 2. Ibuprofen Tablet 400 MG Give 1 tablet by mouth every 6 hours as needed for pain or inflammation . Further review revealed no documentation regarding the maximum dosage of ibuprofen the Resident should not exceed. During an interview on 6/8/22 at 4:24 PM, when asked how he/she would have ensured the ibuprofen medication was not given more frequently than every 6 hours with 2 separate orders, Licensed Nurse (LN) #1 stated the Resident had not been taking the medication, so he/she did not know. LN #1 further stated the electronic health record would not have notified the nurses if they attempted to administer both ibuprofen orders within a 6-hour window. The LN stated there was a potential for the Resident to receive the medication more frequently than every 6 hours with 2 separate orders. During an interview on 6/9/22 at 10:02 AM, the Pharmacist confirmed that it was possible for Resident #4 to receive the ibuprofen medication greater than every 6 hours with 2 separate orders. Review of Ibuprofen Dosage, dated 5/5/22, accessed at https://www.drugs.com/dosage/ibuprofen.html, revealed Usual Adult Dose for Osteoarthritis For minor pains of arthritis: Initial dose: 200 mg orally every 4 to 6 hours; may increase to 400 mg orally every 4 to 6 hours as needed Maximum dose: 1200mg/day (over the counter) Further review revealed Usual Adult Dose for Pain Oral 200 to 400 mg orally every 4 to 6 hours as needed Maximum dose: 3200 mg/day (prescription strength); 1200mg/day (over-the counter). Further review revealed Usual Adult Dose for Fever . Maximum dose: 1200 mg/day. Resident #11 Record review from 6/7-9/22 revealed Resident #11 was admitted to the facility with diagnoses that included major depressive disorder, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), and age-related physical debility (inability to walk, limited mobility, less dexterity, and/or low stamina). Review of Resident #11's Medication Administration Record, dated April 2022 to June 2022, revealed the resident started the following medications in April: 1) On 4/17/22, started Acetaminophen [Tylenol - a medication to treat minor aches and pains] 650mg [milligrams] by mouth every 6 hours as needed for breakthrough pain; and 2) On 4/25/22, started Hydrocodone-Acetaminophen [Norco - an opioid, narcotic medication for pain] 5-325mg by mouth every 6 hours as needed for pain control . Further review revealed no parameters to indicate which pain medication to give based on a nursing assessment for pain. Additional review revealed that, from April 2022 to June 2022, Resident #11 received Tylenol 20 times, used for pain that ranged from 2 to 10 (based on a pain scale of 0, no pain, to 10, worst pain), and was effective to treat that pain 19 out of the 20 times administered. Resident #11 also received Norco 20 times, used for pain that ranged from 3 to 9, and was effective 19 out of 20 times. Review of Resident #11's Medication Regimen Review (MRR- a monthly medication review from the pharmacist), dated 4/28/22, revealed: . PRN Norco added 4/25/22, PRN acetaminophen added 4/17/22 . If continues on both PRN pain medications, recommend adding pain scale parameters and acetaminophen limitations . Further review revealed the Director of Nursing signed the Medication Regimen Review on 5/17/22 with the comment, Reviewed and agree. Additional review revealed Physician #1 signed the MMR on 5/11/22 with the comment, . As needed Norco added by another provider. We will see what [his/her] need is for this medication over the next month . Asking for pain medication may be more of a habit then a need at this point . Further review revealed no comment from Physician #1 to add pain parameters to the PRN Tylenol and PRN Norco. Review of Resident #11's Medication Regimen Review, dated 5/28/22, revealed: . continues PRN Norco[.] need parameters on both PRN acetaminophen (used x9 for pain scale 3-7 since last review with effective results documented) and PRN Norco (used x 14 for pain scale also 3-9 with effective results). Increased c/o [complaints of] on tasks . Further review revealed the MRR was signed by Licensed Nurse (LN) # 2 with the comment, Agree with recommendations. [Tylenol] trial ineffective for pain. Norco effective for pain in conjunction with Butrans patch [a topical medication patch for pain]. Further review revealed Physician #1 signed on 6/8/22 with the comment, At this month's appointment, I will evaluate [his/her] use of as needed Norco over the last 4 weeks. If [he/she] requests it with any significant frequency, we will increase [his/her] Butrans patch dose. If [he/she] has not been using it with any significant frequency, we will discontinue the as needed Norco and leave the Butrans patch at the current dose . Additional review revealed no comment from Physician #1 to add pain parameters to the PRN Tylenol and PRN Norco. During an interview on 6/9/22 at 2:43 PM, LN #2 stated he/she would have used what the resident was saying and describing during a pain assessment to determine which pain medication to use, however he/she could not identify the pain parameters for Resident #11's Tylenol and Norco orders. During an interview on 6/9/22 at 2:59 PM, Physician #1 stated multiple PRN medications for pain ordered for a resident should have absolutely had pain parameters set for each medication. Physician # 1 further stated that the parameters for Resident #11's PRN medications were missed. Surveyors requested a facility policy or procedure for parameters of pain medication; however, the facility representative stated the facility did not have a policy. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to obtain proper and timely informed consent for psychotropic medications (a psychoactive drug to include antipsychotics, antianxiety, or antidepressant medications, that affects behavior, mood, thoughts, or perception) prior to that medication's use for 4 residents (#'s 1; 3; 4; and 11), out of 10 sampled residents. Failing to obtain appropriate informed consent for psychotropic medications violated the residents right to make an informed decision, based on medication education of the risk and benefits, to include side effects. Findings: Psychotropic Medication Consent Process During an interview on 6/9/22 at 10:00 AM, the Pharmacist stated all psychotropic medications required a medication consent prior to the administration of that medication. The Pharmacist further stated that she completed a monthly psychotropic medication review and indicated if a medication consent still needed to be obtained and submitted review findings to nursing leadership each month. The Pharmacist further stated failure to obtain consents had been an ongoing issue. During an interview on 6/9/22 at 2:59 PM, Physician #1 stated the process to obtain medication consent for a psychotropic medication would have been to first talk to the resident and/or guardian about the risk and benefits of using the medication. The physician would have then ordered the medication and the nurse would have filled out a medication consent form, to be signed by the physician and the resident and/or guardian. The Physician further stated that a psychotropic medication should not have been initiated prior to the medication consent form being completed. The Physician stated the medication should have been held (not given) until the consent was obtained. Review of the facility's medication consent form, on 6/7/22, revealed the form itself had gone through different revisions: - Review of the Wrangell Medical Center and Long Term Care Consent for Drug Use consent form, dated 10/21/20, revealed . This form will be updated yearly while a resident is prescribed this medication . Further review revealed that there was a section discussing risks and benefits and a signature line for the physician and resident or legal guardian. In addition, there was a line for a witness. - The consent form was updated in 01/2021, which revealed 2 different medication consent forms with different titles: 1) SEARCH Southeast Alaska Regional Health Consortium: Long Term Care Consent for Psychotropic Medication and 2) Wrangell Medical Center SEARHC Care Network: SEARCH Long Term Care Consent for Psychotropic Medication. Review of these forms revealed there was a section discussing risks and benefits and a signature line for the physician and resident or legal guardian. Further review revealed there was a line for a witness (if verbal consent) and a section that indicated, If unable to obtain Patient/Guardian signature - Document Reason. During an interview on 6/7/22 at 3:53 PM, Licensed Nurse (LN) #2 stated nurses could have obtained verbal consents over the phone for psychotropic medication from guardians with the verification/signature of two nurses on the consent form. LN #2 further stated resident/guardian signatures would have been obtained later when the guardians were available to sign the consent forms. Resident #1 Record review from 6/7-9/22 revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease and delirium due to known physiological condition. Review of Resident #1's Medication Administration Record revealed the resident had the following psychotropic medications added: 1. On admission, 6/3/20, Resident #1 started: Clonazepam [Klonopin - A benzodiazepine, used to treat panic disorders or anxiety] 0.5mg [milligrams] by mouth PRN [as needed] for anxiety. 2. On 9/23/20, Resident #1 started: Citalopram [Celexa - An antidepressant] 10mg by mouth daily for 7 days, then increased to 20mg daily. Clonazepam Review of Resident #1's medical record, on 6/7/22, revealed the following psychotropic medication consent history for Clonazepam: Clonazepam Consent: 6/3/20 Review of Resident #1's original Clonazepam medication consent form, dated 6/3/20, revealed it was signed by the physician on 6/3/20 and not signed by the Power of Attorney (POA) until 6/5/20 (2 days later). Further review revealed a nurse witnessed the signature on 6/5/20. Clonazepam Consent: 8/25/21 Review of Resident #1's renewed Clonazepam medication consent form, dated 8/25/21, revealed the form was signed by the physician on 8/25/21 and not signed by the POA until 9/8/21 (14 days later). Further review revealed the witness (if verbal consent) and the If unable to obtain Patient/Guardian signature - Document Reason lines were blank. Clonazepam Consent: 12/9/21 Review of Resident #1's renewed medication consent form, dated 12/9/21, revealed two different consents with two different Clonazepam doses, to be administered the same day: 1) Clonazepam 0.25mg every afternoon and 2) Clonazepam 0.5mg twice a day (meaning each day Clonazepam 0.5mg was given in the morning, Clonazepam 0.25mg was given in the afternoon, and Clonazepam 0.5mg was given at night). Further review of these medication consents revealed they were signed by the physician on 12/9/21 and not signed by the POA until 3/15/22 (96 days later). Further review revealed the witness (if verbal consent) and the If unable to obtain Patient/Guardian signature - Document Reason lines on both forms were blank. Psychotropic Medication Reviews Review of Resident #1's Psychotropic Medication Review FY [fiscal year] 2021 Q1 [quarter 1] + Sept [September], dated 9/2020; 10/2020; 11/2020; and 12/2020, revealed the Pharmacist documented under Clonazepam Consent due to scheduled order for 10/2020, 11/2020, and 12/2020. Review of the Resident #1's Psychotropic Medication Review FY 2021 Q2, dated 01/2021, 02/2021, and 03/2021, revealed the Pharmacist documented under Clonazepam Consent due to scheduled order for all 3 months. Review of the Resident #1's Psychotropic Medication Review FY 2021 Q3, dated 04/2021, 05/2021, and 06/2021, revealed the Pharmacist documented for Clonazepam Consent due to scheduled order for 04/2021 and 05/2021; and Consent due for 06/2021. Review of the Resident #1's Psychotropic Medication Review FY 2021 Q4, dated 07/2021, 08/2021, and 09/2021, revealed the Pharmacist documented under Clonazepam Consent due for all 3 months. Further review revealed Informed consents in out-going mail week of 9/6/21. Review of the Resident #1's Psychotropic Medication Review FY 2022 Q1, dated 10/2021, 11/2021, and 12/2021, revealed the Pharmacist documented Consent due under Clonazepam 0.5mg PO BID for all 3 months and noted Told consent in out-going mail week of 9/6/21. Further review revealed the Pharmacist documented Need consent under Clonazepam 0.25mg for 12/2021. Review of the Resident #1's Psychotropic Medication Review FY 2022 Q2, dated 01/2022, 02/2022, and 03/2022, revealed the Pharmacist documented under Clonazepam Consent due for all 3 months. Review of the Resident #1's Psychotropic Medication Review FY 2022 Q3, dated 04/2022, 05/2022, and 06/2022, revealed the Pharmacist documented under Clonazepam Consent 12/9/21. Signed by POA 3/15/22, MD 12/9/21. Citalopram Review of Resident #1's medical record, on 6/7/22, revealed the following psychotropic medication consent history for Citalopram: Citalopram Consent for the 9/23/20 start date: Review of Resident #1's original medication consent form, dated 10/26/20, revealed it was signed by the physician on 10/26/20, (33 days after the start of the medication). Further review revealed the witness line of the consent form documented verbal consent obtained and signed by Licensed Nurse (LN) #2 and the MDS (Minimum Data Set - a federally required assessment) Coordinator on 10/26/20. Citalopram Consent: 8/19/21 Review of Resident #1's renewed medication consent form, dated 8/19/21, revealed it was signed by the Physician on 8/19/21 and not signed by the POA until 9/8/21 (20 days later). Further review revealed the witness (if verbal consent) and the If unable to obtain Patient/Guardian signature - Document Reason lines were blank. Citalopram Consent: 12/9/21 Review of Resident #1's renewed medication consent, dated 12/9/21, revealed they were signed by the Physician on 12/9/21 and not signed by the POA until 3/15/22 (96 days later). Further review revealed the witness (if verbal consent) and the If unable to obtain Patient/Guardian signature - Document Reason lines were blank. Psychotropic Medication Reviews Review of Resident #1's Psychotropic Medication Review FY 2021 Q1 + Sept, dated 9/2020; 10/2020; 11/2020; and 12/2020, revealed the Pharmacist documented under Citalopram Consent due for 09/2020; Consent done 10/26/20 for 10/2020; and Consent done 10/26/20 but need witness signature date for 11/2020, and 12/2020. Review of the Resident #1's Psychotropic Medication Review FY 2021 Q2, dated 01/2021, 02/2021, and 03/2021, revealed the Pharmacist documented under Citalopram Consent 10/26/20 (verbal) need signatures [and] dates. Review of the Resident #1's Psychotropic Medication Review FY 2021 Q3, dated 04/2021, 05/2021, and 06/2021, revealed the Pharmacist documented under Citalopram Consents 10/26/20 (verbal) need signatures [and] dates - see March MRR [Medication Regimen Review] [and] scanned into PCC [pointclickcare - electronic medical record]. Review of the Resident #1's Psychotropic Medication Review FY 2021 Q4, dated 07/2021, 08/2021, and 09/2021, revealed the Pharmacist documented under Citalopram Consents 10/26/20 (verbal) need signatures [and] dates - see March MRR [and] scanned into PCC. Review of the Resident #1's Psychotropic Medication Review FY 2022 Q1, dated 10/2021, 11/2021, and 12/2021, revealed the Pharmacist documented under Citalopram Consent due for all 3 months. Further review revealed Consents 10/26/20 (verbal) need signatures [and] dates. Review of the Resident #1's Psychotropic Medication Review FY 2022 Q2, dated 01/2022, 02/2022, and 03/2022, revealed the Pharmacist documented under Citalopram Consent due for all 3 months. Review of the Resident #1's Psychotropic Medication Review FY 2022 Q3, dated 04/2022, 05/2022, and 06/2022, revealed the Pharmacist documented under Citalopram Consent 12/9/21. Signed by POA 3/15/22, MD 12/9/21. During this survey, the surveyor requested all medication consents, verbal and written, for Resident #1's Clonazepam and Citalopram medications. The facility only provided the written consents previously discussed. Resident #3 Record review from 6/7-9/22 revealed Resident #3 was admitted to the facility with diagnoses that included anxiety disorder and depression. Review of Resident #3's Medication Administration Record, dated 04/2022, revealed a physician's order for Sertraline HCl [antidepressant medication] Tablet 50 MG Give 1 tablet by mouth one time a day for Depression .-Start Date- 4/27/2022 [9:00 AM]. Review of SEARHC LONG TERM CARE CONSENT FOR PSYCHOTROPIC MEDICATION, dated 1/2021, revealed the consent for the Sertraline medication with an original start date of 4/26/22 was signed by the physician and the Resident on 6/9/22, 44 days after the medication was first administered. Review of the Resident #3's Psychotropic Medication Review FY 2022 Q3, dated 5/2022, revealed the Pharmacist documented the consent for Sertraline was due. Resident #4 Record review from 6/7-9/22 revealed Resident #4 was admitted to the facility with diagnoses that included Alzheimer's disease, restlessness, and agitation. Review of Resident #4's Medication Administration Record, dated 05/2022, revealed a physician's order for: 1. Olanzapine [antipsychotic medication] tablet 2.5 MG Give 1 tablet by mouth for psychotic disorder related to WANDERING IN DISEASES CLASSIFIED ELSEWHERE .for 14 days -Start Date- 5/6/2022 [8:00PM] -[Discontinue] Date- 5/13/2022 [1:29 PM]. 2. Memantine HCl [Alzheimer's type dementia medication] Tablet 10 MG, Give 1 tablet by mouth two times a day related to ALZHEIMER'S DESEASE, UNSPECIFIED .-Start Date- 5/2/2022. A dosage change took place on 5/26/2022 and the medication was continued at a lower dosage. 3. Quetiapine Fumarate [antipsychotic medication] Tablet 25 MG Give 1 tablet by mouth two times a day related to ALZHEIMER'S DISEASE, UNSPECIFIED .; ANXIETY DISORDER, UNSPECIFIED .; RESTLESSNESS AND AGITATION .-Start Date- 05/17/2022 [6:00PM [Discontinuation] Date- 06/02/2022 [10:45 AM]. Review of Resident #4's Medication Administration Record, dated 06/2022, revealed the Quetiapine medication was continued at a lower dosage. Review of SEARHC LONG TERM CARE CONSENT FOR PSYCHOTROPIC MEDICATION, dated 1/2021, revealed the consent for Olanzapine, with an original start date of 5/6/22, was signed by the physician on 5/18/22, but was never signed by the Resident's POA. Review of SEARHC LONG TERM CARE CONSENT FOR PSYCHOTROPIC MEDICATION, dated 1/2021, revealed the consent for Memantine, with an original start date of 5/2/22, was signed by the physician on 5/12/22, but not signed by the Resident's POA until 5/18/22, 16 days after the medication was initiated. Review of SEARHC LONG TERM CARE CONSENT FOR PSYCHOTROPIC MEDICATION, dated 1/2021, revealed the consent for Quetiapine. The form listed the original start date of 6/2/22, the date in which the medication dosage was changed. The date the medication was initiated, on 5/17/22, was not listed on the form. The form was signed by the physician on 6/7/22, but not consented by the Resident's POA until 6/9/22, 24 days after the medication was initiated. Further review revealed If unable to obtain Patient/Guardian signature- Document Reason: out of town fishing. This section had no date to indicate the initial attempt to contact the POA. Review of Resident #4's Wrangell Medical Center Progress Notes, a COMMUNICATION-with Family/[next of kin]/POA, dated 6/8/22 revealed Phone call made to [family member]/POA .regarding need to sign psychotropic drug consent forms. Message left on identified voicemail to have [him/her] call [Long Term Care] back. Review of the Resident #4's Psychotropic Medication Review FY 2022 Q3, dated 5/2022, revealed the Pharmacist documented the consents for Memantine, Olanzapine and Quetiapine were all due. Resident #11 Record review from 6/7-9/22 revealed Resident #11 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), and age-related physical debility (inability to walk, limited mobility, less dexterity, and/or low stamina). Review of Resident #11's Medication Administration Record, dated 05/2022, revealed the resident started Mirtazapine [Remeron - An antidepressant] 15 mg by mouth at bedtimes for depression, poor appetite on 5/12/22. Further review revealed from 5/12/22 to 6/8/22, Resident #11 has received 28 doses of Mirtazapine. Review of Resident #11's medical record revealed no medication consent form for Mirtazapine. During an interview on 6/7/22 at 2:39 PM, the MDS Coordinator stated verbal consent was obtained for Resident #11's Mirtazapine with the Resident's daughter in a meeting. During this interview, the surveyor requested written documentation of this verbal consent, by close of survey the facility did not provide this documentation. Review of Resident #11's Psychotropic Medication Review, dated 04/2022, 05/2022, and 06/2022, revealed the Pharmacist documented under Mirtazapine Need consent for 05/2022 and the Pharmacist documented under Mirtazapine Consent due for 06/2022. During this survey, the surveyor requested all medication consents, verbal and written, for Resident #11's Mirtazapine, by close of survey the facility did not provide this documentation. Review of the facility's policy Psychotropic Medications, last reviewed 1/21/21, revealed: . The facility shall comply with state and federal regulations to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risk and/or benefits . Any resident who is prescribed a psychotropic medication shall be given an informed consent for signature .The resident, representative, and family, as appropriate, shall be involved in the decisions-making process to place the resident on psychotropic medications . Procedures . Informed consent for psychotropic medications is completed and signed by the resident or representative and the attending and/or consulting provider or designee . Discussion is documented with the resident and/or responsible party regarding the risk versus benefit of the use of these medications . Informed consent must be obtained and signed by the resident, their personal representative or guardian and the provider or designee . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and interview, the facility failed to obtain informed consent for or conduct necessary safety assessments for risks and benefits for the use of upper bed rails, used for mobility aids, for 4 residents (#'s 1; 2; 6; and 12), out of 10 sampled residents, and 1 unsampled resident (#14). Failure to obtain consent placed the residents at risk for not having necessary risk and benefit information; failure to conduct a safety assessment prior to use of bed rails had the potential to introduce hazards into the environment that could have lead to preventable accidents. Findings: Resident #1 An observation on 6/7/22 at 1:20 PM, revealed Resident #1's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #1's MDS (Minimum Data Set - A Federally required assessment), a significant change assessment dated [DATE], revealed the Resident required extensive assistance, 2+ persons physical assist with bed mobility and transfers (how the resident moves between surfaces). Review of Resident #1's medical record revealed a Safety Assessment: Bed Rails, dated 5/13/21, was completed. Further review revealed no Resident Bed Rail Consent Form for Resident #1. During this survey, the facility obtained a Resident Bed Rail Consent Form, dated 6/9/22, for Resident #1. Resident #2 An observation on 6/7/22 at 2:10 PM revealed Resident #2's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #2's MDS, a quarterly assessment dated [DATE], revealed the resident required extensive assistance, 2+ persons physical assist for bed mobility, and 1 person physical assist for transfers. Review of Resident #2's medical record revealed a Safety Assessment: Bed Rails, dated 12/22/21, was completed. Further review revealed no Resident Bed Rail Consent Form for Resident #2. During this survey, the facility obtained a Resident Bed Rail Consent Form, dated 6/9/22, for Resident #2. Resident #6 An observation on 6/7/22 at 3:19 PM, revealed Resident #6's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #2's MDS, an annual assessment dated [DATE], revealed the resident required extensive assistance, 1 person physical assist for bed mobility and transfers. Review of Resident #6's medical record revealed a Safety Assessment: Bed Rails, dated 4/27/21, was completed. Further review revealed no Resident Bed Rail Consent Form for Resident #6. During this survey, the facility obtained a Resident Bed Rail Consent Form, dated 6/9/22, for Resident #6. Resident #12 An observation on 6/7/22 at 10:31 AM, revealed Resident #12's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #12's MDS, a quarterly assessment dated [DATE], revealed the resident required supervised assistance, 1 person physical assist for bed mobility, and limited assistance, 1 person physical assist for transfers. Review of Resident #12's medical record revealed a completed Resident Bed Rail Consent Form, dated 7/30/21. Further review revealed no Safety Assessment: Bed Rails for Resident #12. During this survey, the facility obtained a Safety Assessment: Bed Rails, dated 6/8/22, for Resident #12. Resident #14 An observation on 6/7/22 at 1:10 PM, revealed Resident #14's bed had the upper bed rails, on both sides, in the raised position. Review of Resident #14's MDS, a quarterly assessment dated [DATE], revealed the resident required extensive assistance, 2+ persons physical assist for bed mobility and transfers. Review of Resident #14's medical record revealed a Resident Bed Rail Consent Form, had been completed. Further review revealed no Safety Assessment: Bed Rails for Resident #14. During this survey, the facility obtained a Safety Assessment: Bed Rails, dated 6/9/22, for Resident #14. Review of the facility's policy Bed Rails, last reviewed 1/14/21, revealed: . All residents will have a Bed safety Assessment completed and documented by an RN/LPN [Registered Nurse/Licensed Practical Nurse] within 24 hours of admission to the facility. This assessment must be re-evaluated with any change in the resident condition (e.g. fall, change in mentation), as this may require addition or removal of bed rails . Consent forms will be signed by resident/resident representative anytime beds rails are used and when a resident declines bed rails after they have been recommended . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to ensure: 1) food was stored under proper sanitary conditions; and 2) concentrations of sanitizing solutions were maintained within acceptable parameters. This failed practice placed all residents (based on a census of 14) at risk for foodborne illness and communicable disease. Findings: Food Storage An observation of the central kitchen on 6/7/22 at 8:00 AM, revealed: Dry Storage (Pantry) - One bag of Baker's all-purpose enriched flour bleached, 1/4 full, opened on the shelf with no open date, exposed to the elements. The flour had visibly dusted the shelf it was sitting on. - One bag of Baker's Source basic muffin mix, 1/4 full, open on shelf with open date of 3/16/22, exposed to elements. - One box of Barilla oven-ready lasagna noodles, less than 1/4 full, was torn and opened, exposed to elements, with no open date - Two large dry storage bins, 1 containing a large bag of [NAME] rice and 1 containing a large bag of sugar, with lids not covering the top of the bins, exposing the contents to the elements. - One opened box of Super Moist white cake mix, with no open date. - Two small Rubber Maid dry storage bins, stacked on top of one another, with the bottom container labeled AP Flour, dated 5/27/22 and use by 11/30/22, with a scoop stored inside the container. The top container was unlabeled as to the contents or dates. - One open box Gold Medal variety muffin mix, with no open date, exposed to the elements. Walk-In Freezer - Two bags of Brussel sprouts, one bag open, and exposed to the elements. The Brussel sprouts in the opened bag were discolored, some had brown spots, and ice crystals were visibly seen throughout the bag. - One opened box of Fully cooked beef steak burger patties, 3/4 full, open with plastic inner packaging open. The patties were exposed to the elements and ice crystals were visibly seen on all exposed surfaces. - One opened box of Bacon single slices, 3/4 full, opened with plastic inner packaging open. The bacon was exposed to the elements. Canned Goods - 4 6lb. 6oz. cans of Las [NAME] Enchilada Sauce, dented on sides and rims in multiple places. During an interview on 6/7/22 at 8:52 AM, the Food Service Manager stated the open flour and muffin mix bags should have been sealed closed, the lasagna box should have had an open date and should have been sealed closed, the dry storage bins should have been closed, and the cake and muffin mix boxes should have had open dates. The Food Service Manager further stated that the dented cans of enchilada sauce should have been returned to the vendor or thrown away. The Food Service Manager stated she was unaware the scoops could not be stored in dry bins. During an interview on 6/9/22 at 8:02 AM, the Food Service Manager stated the Sodexo Food Safety Management System: PQA [Product Quality Assurance] Food Product Shelf Life Guidelines (the facility's food storage guide) was not descriptive to each food item used in the facility's kitchen, and that they had called Sodexo with a lot of questions to often get clarification. Review of the facility's policy Food Storage, not dated, revealed: . Foods are regularly inspected for signs of damage due to spoilage or to detect unacceptable items, i.e. dented, swollen or rusted cans, thawed or refrozen items, crushed cases, etc. and are discarded or returned to the vendor for credit . Products are labeled and dated per NMS [[NAME] Management Systems - Food service offices in Alaska] and regulatory standards . Dry Bulk Foods: Store in non-reactive metal or plastic containers with tight fitting lids. Do not store scoops in the bulk goods . Concentration of Sanitizing Solutions An observation on 6/8/22 at 7:20 AM, revealed [NAME] #1 wiping down the counters in the unit kitchen during breakfast, using solution from a sanitation bucket placed the sink. During an interview on 6/8/22 at 8:05 AM, when asked what chemicals were used for the sanitation buckets, [NAME] #1 stated the facility used Ecolab SmartPower Sink [and] Surface Cleaner Sanitizer. When asked how the kitchen staff tested the concentration of the sanitation bucket solution, [NAME] #1 stated the facility used quat strips [test strips designed to test quaternary, or disinfectant, sanitizers], which [NAME] #1 pulled down from on top of the sanitation solution dispenser in the main kitchen sink area. [NAME] #1 further stated the sanitation bucket solutions were only tested when the chemical block was changed in the dispenser and not tested when each bucket was made. An observation on 6/8/22 at 8:05 AM, revealed the quat strips used by the facility were HR QAC QR Test Strips, Code SP - 2951HR strips. When asked if the facility documented on a sanitation solution log, [NAME] #1 stated the facility did, but only documented when staff changed the sanitation solution at every meal. An observation on 6/8/22 at 8:05 AM, through surveyor testing of the sanitation bucket in the unit kitchen and the sanitation bucket in the main kitchen (at the dishwashing station), using the quat strip HR QAC QR Test Strips, Code SP - 2951HR, revealed both bucket's had concentration levels that were less than 200 ppm (parts per million). Review of the facility's Sanitizer Solution Log - U.S., dated 07/2013, revealed: The Sanitizer Solution Log must be completed once a day for sample testing. Further review revealed 2 chemicals, and the required concentration levels for those chemicals not in use at the facility: - Required concentration for Mikroklene . stationary equipment, spray bottles, solutions for storing wiping cloths - must be maintained at 25 ppm and - Required concentration for Oasis 146: must be set at 150 - 400 ppm for all dispensing equipment, use on stationary equipment, spray bottles, solutions for storing wiping cloths. Further review of the sanitation log revealed no required concentration level for the facility's chemical Ecolab SmartPower Sink [and] Surface Cleaner Sanitizer. Review of the facility's Sanitizer Solution Log - U.S., dated 6/2022, revealed a check mark under a column labeled AM. Under that column, staff checked the S column (having a choice of marking under an S column or a U column) and the staff's initials for each date documented, 6/1-8/22. Further review of the log revealed S = Satisfactory, U = Unsatisfactory. If rating is Unsatisfactory, solution must be corrected. An observation on 6/8/22 at 8:34 AM, of the chemical storage closet in the main kitchen, revealed a poster on the wall for Ecolab SmartPower Sink [and] Surface Cleaner Sanitizer. Further review revealed concentration level testing required Ecolab Sink & Surface Cleaner Sanitizer test strips. Review of Ecolab's SmartPower Sink [and] Surface Cleaner Sanitizer: Frequently Asked Questions manufacturer's sheet, dated 2020, revealed: - Can I use quat test strips? No, quat strips . should not be used and will not work. During an interview on 6/8/22 at 8:35 AM, the Food Service Manager stated the kitchen staff had not been testing the concentration levels of sanitation buckets. When asked what education the kitchen staff received in regard to cleaning/sanitizing of the kitchen, the Food Service Manager stated all kitchen staff completed new hire training, which included cleaning/sanitizing. Review of the facility's New Hire: Two Step Food Safety Training Program Training Record, dated 9/2021, revealed during the first 10 days of employment, kitchen staff completed Cleaning and Sanitizing training. Review of the facility's Sodexo Technical Training: Food Safety - Cleaning [and] Sanitizing training curriculum, copywrite 2018, revealed no training for the use of Ecolab SmartPower Sink and Surface Cleaner Sanitizer. Review of the facility's policy Kitchen Sanitation, not dated, revealed: . To promote a clean, safety and effective environment and to prevent the transmission of disease-carrying organisms . The General Manager/Food Services Director monitors sanitation schedules and procedures . Local and State sanitation requirements are reflected in schedules, procedures, and sanitizing compounds in use . .