**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the vent-a-hood in the kitchen was kept free of a buildup of grease, grime and debris which could result in improper functioning and/or fire resulting in serious injury, serious harm, serious impairment, or death. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 05:02 PM. The facility also failed to ensure potentially hazardous items were stored in a secure location to prevent potential access by cognitively impaired, independently mobile residents for 1 (Resident #19/31) of 1 sampled resident; the mattress fit the bed for 1 (Resident #23) of 1 resident to prevent the potential for harm; and oxygen cylinders containing oxygen were stored and secured in an oxygen holder to prevent the potential for accidents/hazards. The findings are: 1. On 12/05/23 at 02:10 PM, the vent-a-hood was observed to be covered in grease and contained a film of dust and debris. The film of debris and dust was so thick that it looked fuzzy and was rough to the touch. The grease extended into the vent. The grease had dripped along the edges. The vent was also covered in grime and grease. The shelf above the range was sticky with grease and grime. a. On 12/05/23 at 2:12 PM, a sticker on the front of the vent-a-hood from [Company Name] Pressure Washing and Vent Hood Cleaning documented had been serviced in April 2022. The expiration date is 180 days from the last service. There was also a blackened area on October 2024. b. On 12/06/23 at 05:02 PM, an Immediate Jeopardy was called due to the facility's failure to ensure that the vent-a-hood was maintained in a manner to prevent the potential for improper functioning and or/fire. The Administrator was informed that a plan of removal including the cleaning of the vent-a-hood and a plan to maintain fire safety until the unit can be inspected by a reputable service was received. A Plan of Removal was presented at 6:21 PM. The vent hood was cleaned, and the nursing and maintenance staff-maintained fire watch every 30 minutes until the facility was able to have the vent hood inspected. c. On 12/06/23 at 06:31 PM, the Administrator provided an invoice for the inspection of the vent-a-hood dated 11/14/23. The service was for inspection of the vent hood but did not include cleaning. 2. A review of an admission Record indicated the facility admitted Resident #31 with a diagnosis that included major depressive disorder. a. The Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident was unable to complete the interview. The resident required extensive assistance with activities of daily living (ADLs). b. On 12/05/23 at 02:09 PM, a blue plastic container containing a used and opened bottle of electric shave solution, a bottle of aftershave and a tube of toothpaste was observed on the built in cabinet in Resident #31's room and was not contained. c. On 12/05/23 at 02:55 PM, a blue plastic container containing a used and opened bottle of electric shave solution, a bottle of lotion, a bottle of aftershave and a tube of toothpaste was observed on the built in cabinet in Resident #31's room and was not contained. d. On 12/05/23 at 04:58 PM, a blue plastic container containing a used and opened bottle of electric shave solution, a bottle of aftershave and a tube of toothpaste was observed on the bed in Resident #31's room. e. On 12/08/23 at 9:12 AM, the Director of Nursing (DON) was asked where personal care items such as lotions, aftershave, cologne, and toothpaste are supposed to be stored when not in use? The DON stated, Out of reach of the residents. The DON was asked why should personal care items be contained and free from residents access. The DON stated, For the safety of the residents. 3. A review of an admission Record indicated the facility admitted Resident #23 with a diagnosis of paranoid schizophrenia. a. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. b. On 12/05/23 at 02:08 PM, Resident #23 was lying in bed. The mattress did not fit the bed frame. There was a 12 inch gap between the foot board and the mattress and a 12 inch gap between the headboard and the mattress. Resident #23 was asked how long had he been here. Resident #23 replied about 5 years. Resident #23 was asked how long he had been in this room in this bed. Resident #23 stated not long I was in another room before this one. c. On 12/05/23 at 03:00 PM, Resident #23 was lying in bed. The mattress did not fit the bed frame. There was a 12 inch gap between the foot board and the mattress and a 12 inch gap between the headboard and the mattress. d. On 12/06/23 at 9:23 AM, Maintenance #1 was asked to measure the gap between the end of the mattress to the footboard and the gap between the end of the head of the mattress and the headboard of Resident #23's bed. Per Maintenance #1's measurements, the gap between the end of the mattress to the footboard measured 4.5 inches and the gap between the head of the mattress and the headboard measured 6 inches. 4. On 12/05/23 at 4:39 PM, Resident #24 was sitting in a wheelchair with cigarettes and vape on the bedside table. a. On 12/07/2023 at 1:33 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 if the residents are allowed to keep their cigarette's, lighter, and vapes in their room with them. LPN #1 said, No cigarettes, but the vapes are cared planned. b. On 12/08/2023 at 1:03 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2 how are the tobacco products, vapes, and lighters stored and who takes the residents out to smoke. LPN #2 said the cigarettes and lighters are kept under lock and key, at the nurse's station and the CNA's take the residents out to smoke. e. The Director of Nursing provided their Smoking Policy on 12/7/2023 at 10:32 AM which documented, .15. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision . 5. On 12/07/23 at 09:46 AM, observed an oxygen cylinder not contained in a metal oxygen cylinder holder in the oxygen storage room on hall 400. The door to the oxygen storage room was unlocked and there were residents rolling down the hallway in wheelchairs. a. On 12/07/23 at 10:28 AM, observed the 400 hall oxygen storage room remained unlocked. There was a coded lock on the door that was not working. There was an oxygen cylinder observed that contained oxygen and was not properly stored in an oxygen cylinder holder. The cylinder was standing up between an oxygen concentrator and multiple cylinders in cylinder holders that contained oxygen. There were residents observed in wheelchairs in the hallway passing by. b. On 12/07/23 at 02:45 PM, the Surveyor asked Registered Nurse (RN) #1 if the oxygen storage room on hall 400 should be locked. RN #1 answered, Yes, it should be locked. The Surveyor asked how oxygen cannisters should be stored safely. RN #1 answered, They should be upright in an eggcrate. The Surveyor asked what could happen if oxygen was not stored properly. RN #1 answered, It could catch on fire or cause an accident. The Surveyor asked who was responsible for checking to make sure oxygen is stored safely. RN #1 answered, The nurses. The Surveyor asked how often oxygen is checked. RN #1 answered, I don't know. I'm not sure who they have the contract with.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a clean condition to minimize the risk of food borne illness; food products were used or removed prior to their expiration dates/viability; hands were washed between clean and dirty tasks and prior to applying gloves; dishes and utensils were cleaned prior to being used for residents during meal service; and food was stored in a manner that was free of exposure/contamination due to the presence of insects or rodents. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 05:02 PM. The facility also failed to ensure orange was stored in the refrigerator and hand washing was practiced when feeding residents snacks. The findings are: On 12/05/23 at 02:05 PM Surveyors observed initial kitchen rounds with Dietary Aide #1. The Hand Washing sink was located directly next to the 3-compartment sink. A large stack of baking sheets and other cooking vessels were stacked on top of the basin preventing proper hand washing. On 12/05/23 at 2:08 PM, the floor of the kitchen was covered with a variety of debris. Despite being on wheels, the worktables had been moved as the layer of dirt and food particles was more dense in the corners and closer to the wheels. On the wall just above where the insulated domes were stored was a piece of wooden trim that extended down the wall. The ledge formed by the trim was covered in dirt, grime and a dead fly. On 12/05/23 at 2:16 PM, the deep fryer was uncovered. The inner shelf was covered in food particles and a layer of gummy grease. The fat was a dark brown color with food particles floating on top. The floor between the fryer and the range was covered in grease and grime as was the wall behind the range. On 12/5/23 at 2:17 PM, located in the two-door refrigerator was a 1/8 steam table pan that included 6 leftover fried eggs. There was no date on the eggs. A saucepan was identified as holding the leftover boiled eggs that were spilled before the eggs could be counted. The container was not dated. On 12/5/23 at 2:25 PM, the following was observed in the first two door refrigerator: 9 packages of flour tortillas opened 10/12/23 were expired as of 11/17/23. In the second two door refrigerator the following was observed: three 8-ounce servings of whole milk were not dated. Dietary Aide #2 was asked when the milk was portioned. She stated, This morning, because I poured them. The Surveyor asked how another worker would know the age of the milk. The [NAME] stated, I guess they wouldn't. I should have put a date on it. A one gallon pitcher of tea, with no date and the spout turned open to air and contaminants; 1 gallon of lime juice that was half full and expired 11/16/23; a 5 pound container which was ½ full of sour cream had a use by date of 12/1/23; a large plastic resealable bag of peaches containing about 3 cups with the date of 11/28/23 written on top. The [NAME] was asked how long leftovers are used, and she stated, I'm not sure. On 12/5/23 at 2:35 PM the following observations were made in the Dry Storage area: a 27 quart plastic container containing grits was labeled with a tag that recorded prepared 8/10/23, with a plastic scoop protruding from the dry grits; two opened peanut butter containers with missing use by dates. The rim of the containers and the lid were covered with what appeared to be peanut butter which extended out the outside of each container; Strawberry syrup was noted in a plastic gallon container, the label date was unreadable except the 4, expired 4/14/2019; A large plastic tub containing approximately 1 pound of lasagna noodles was not dated. On 12/5/23 at 2:43 PM, a large plastic tub had a label that said, 8/20/20, low calorie. The rest of the label was unreadable. The tub held a white, powder like substance with black specks. Several packets of nondairy creamer had been dropped into the middle of the powder mixture. Located toward the back of the tub was what appeared to be two dead insects. The [NAME] stated, They look like bugs. The floor under the shelves of the dry storage area was observed to be caked with a black gummy substance which contained various pieces of food, debris, dead insects, and what appeared to be other evidence of pests. On 12/5/23 at 2:45 PM, located on a rack next to the freezer multiple packages of bread were observed. The first bag contained ¾ loaf of sliced bread which was not dated or sealed. A second loaf contained 1/8 loaf of sliced bread was not dated or sealed. No use by dates could be located on the bags. On 12/5/23 at 2:51 PM, the following was observations were made in the first two door freezer: a package of round lunch meat. Dietary Aide #2 could not identify the exact food product. The stack of sliced meat was observed to be covered in ice particles and was a variety of shades of pink and brown. No date could be found on the packaging; a 1-gallon plastic resealable bag contained what Dietary Aide #2 reported to be beef brisket. The date on the bag was unreadable. The food product was covered in ice crystals. When asked to describe the product the cook stated, It looks like its frost bit.; a 1-gallon plastic resealable bag of beef tips labeled 11/15/23. When Dietary Aide #2 was asked to describe the bag, she stated, Its' frost bit.; a quart bag of three hot dogs dated 9/19/23. When Dietary Aide #2 was asked to describe it, she again described the product as frost bit; two pounds of hash brown patties with no date, DA #2 described it as frost bit; 2 pounds of fish in a plastic resealable bag, dated 10/21/23; a 5-pound bag of curly fries was 1/3 full, labelled 11/23/23 and was sealed. When Dietary Aide #2 was asked to describe the food product, she stated it was frost bit. On 12/5/23 at 3:00 PM, the bottom of the one door freezer was observed be covered in food particles/pieces and spilled liquid. Located on top of the Dessert Refrigerator were 9 packages of 12 hot dog buns which were not dated. Dietary Aide #2 reported that the buns were removed from the freezer the previous evening tonight's meal. When asked how other workers would know when the bread was removed from the freezer, Dietary Aide #2 stated, They won't since it's not dated. The Surveyor then observed 2 frozen pizza crust labelled 10/22/2, the last numeral was unreadable. When asked to describe the product, Dietary Aide #2 stated it was frost bite. The bottom of the one door freezer contained 2/3 inches of ice. Held in the ice was various food, debris, and labels. The ice had a yellow area in the back left corner. On 12/5/23 at 4:43 PM, the Dietary Manager was observed to don gloves without washing her hands. She proceeded to obtain a plastic resealable bag out of the two-door refrigerator. With the contaminated gloves, the Dietary Manager reached into the bag and retrieved a head of iceberg lettuce. After placing the lettuce on the cutting board, the Dietary Manager obtained a canvas roll that contained several knives. She unrolled the holder, took out a knife, rolled the holder back up and returned it to an area above the 3-compartment sink. The Dietary Manager proceeded to chop the lettuce. She used both contaminated hands to scoop the lettuce into a bowl. Dietary Aide #2 was observed gathering items for dinner with gloved hands. Contaminated gloves were used to reach into the bag of hot dog buns, obtain a bun and place on the plate for every resident who had the polish sausage for dinner. Contaminated gloves were also used to place the insulated dome over the dinner plate. Fingers were placed inside the dome of each tray. On 12/6/23 at 10:54 AM, Dietary Aide #3 was observed to place trays along the tray line. The trays were visibly wet and many of them were littered with food particles. On 12/6/23 at 11:05 AM, Dietary Aide #2 took the temperature of each lunch item. She inserted the probe and when finished she wiped the probe on a paper towel. The same paper towel was used multiple times. Dietary Aide #2 was observed to place her ungloved hands on her chin and neck rubbing her chin multiple times. She then placed her gloves on her hands without washing them to serve the lunch meal. The menu called for 3 ounces of chicken. The Dietary Manager was asked to provide a scale so the chicken pieces could be weighed. The Dietary Manager said that they have no scale for use in the kitchen. On 12/6/23 at 11:06 AM, observation of additional dry food products that were in the large plastic tubs in the dry storage area revealed the following: Upon lifting the lid of the tub containing granulated sugar, a dead fly was observed to be laying on top. Dietary Aide #2 stated, I don't know when anyone has used this sugar. On 12/6/23 at 11:15 AM, the attention of the Dietary Manager was called to the bag of approximately 3 cups of peaches in the refrigerator with the date of 11/28/23 and was asked what the facility's policy was concerning the use of leftovers. She stated, I'm going to say two days, so this needs to be thrown out. On 12/6/23 at 11:20 AM, the Dietary Manager was asked to about the pan under the steam table. She described that the steam pans were known to leak and that the pan was placed there to catch the water. Water was observed to be dripping from two spots and splashing on the shelf below. When asked how long the pans had been dripping, the Dietary Manager stated, I think, pretty much since I've been here. On 12/6/23 at 11:33 AM, observed a resident sitting in the area just outside of the dish room. To the left was the window into the dish room through which the dirty trays are passed. To the right was an open rack which contained two trays from the morning meal which had been served. The resident was holding a glass of milk and a bowl which contained cooked cereal. When asked what he was eating the resident replied, I'm just having some milk and some grits. The Director of Nursing (DON) approached the area and was asked what the possible harm was to a resident who consumed food off a dirty tray. She stated, Bacteria. The resident asked, Did I do something wrong? I was just hungry. On 12/6/23 at 5:02 PM, Immediate Jeopardy was called concerning maintaining a clean environment to minimize the risk of food borne illness, that food is used prior to their expiration date and that hands were washed prior to and between clean and dirty tasks, that dishes and utensils were cleaned prior to use and that food is stored in a manner that is free from exposure/contamination due to insects or rodents. On 12/6/23 at 5:10 PM, the Administrator was asked how often he enters the kitchen area of the facility. He stated, Three or four times per day. We have all new kitchen staff that we hired from scratch. The issue with the steam table is new. I'm not necessarily in the freezers. On 12/7/23 at 10: 40 AM, a Policy titled, Food Receiving and Storage documented, .Policy Interpretation and Implementation 1. Food Services, or other designated staff, will maintain clean food storage areas at all times.4. Non-refrigerated foods .will be stored ., free of insects and rodents and kept clean.7. All foods stored in the refrigerator or freezer will be covered, labeled and dated, (use by date) . The Immediate Jeopardy was removed on 12/08/23 at 10:18 AM when the following Plan of Removal was implemented: Step #1 Upon notification of failure to ensure that kitchen was maintained in a clean condition to minimize the risk of food borne illness, that food products were used or removed prior to expiration dates, that hands were washed between clean and dirty task, that hands were washed prior to applying gloves, that dishes and utensils were cleaned prior to being used for resident meal service, that food is stored in a manner that is free of exposure/contamination due to insects or rodents. On 12-6-2022 Dietary Manager discarded all food that was expired, or freezer burned. On 12-5-2023 the Maintenance director fixed all freezers and refrigerators that had ice built up to ensure that food could be stored safely with no risks of exposure or contamination. On 12-6-2023 the Dietary Staff cleaned all freezers and refrigerators removing all ice and debris that could have led to contamination of food stored. On 12-6-2023 the dietary staff cleaned all equipment that is used in food storage and preparation to ensure a clean sanitary environment for food preparation. On 12-7-2023 the Administrator in serviced the Dietary Manager to the proper hand washing and proper use of gloves to ensure a sanitary environment for food preparation and service. On 12-7-2023 the Dietary Manager in serviced staff to the proper hand washing and use of gloves to ensure a sanitary environment for food preparation and service, that dishes and utensils would be cleaned prior to being used for resident meal service, that food is stored in a manner that is free of exposure/contamination due to insects or rodents. On 12-7-2023 Maintenance supervisor inspected kitchen to ensure the kitchen was free of rodents with no negative findings noted. Step #2 on 12-7-2023 the Administrator in serviced the Dietary Manager to the proper hand washing and use of gloves to ensure a sanitary environment for food preparation and service. On 12-7-2O23 the Dietary Manager in serviced staff to the proper hand washing and use of gloves to ensure a sanitary environment for food preparation and service, that dishes and utensils would be cleaned prior to being used for resident meal service, that food is stored in a manner that is free of exposure/contamination due to insects or rodents. Starting on 12-7-2023 the Dietary Manager will monitor daily 5 x per week on an ongoing basis to ensure proper use of gloves and hand washing for food preparation and service, proper storing and discarding of food before expiration date and that all dishes and utensils are cleaned properly before being used for meal service. Starting on 12-7-2023 the Maintenance supervisor will inspect the kitchen 5 x per week for 6 weeks to ensure that the kitchen is free of rodents and will continue to monitor on a on going basis. Step #3 On 72-6.2023 at 5:45pm, Medical Director notified of confirmation of Immediate Jeopardy. Updated on findings, reviewed plan of removal and education provided Dietary Manager and Maintenance Supervisor. On 12/8/23 at 10:30 AM, the Dietary Manager was asked to describe the proper way to store food. She stated, It should always be put in a sealed container and dated. When asked to identify when hands should be washed, the Dietary Manager stated, When you come into the kitchen, when you change what you are doing, when you go to the rest room, all the time. The Dietary Manager was asked if she had completed a Saniserve class as she was charged with educating her staff. She stated, I have asked the Administrator to enroll me in that class. He said he would, and he told me they would help me get my certification. The Surveyor asked when she had accepted the position. She stated, I was hired as a cook in July and was offered this position. I was told I could get certified, but he [Administrator] still hasn't told me anything about a date to start my classes. The Dietary Manager was asked if there was a cleaning schedule that was used in the kitchen. She stated, I just started making a schedule last night. Review of a facility policy titled, Handwashing/Hand Hygiene, revised August 2015 specified, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled; and b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: .b. Before and after direct contact with residents; .h. Before moving from contaminated body site to a clean body site during resident care; i. After contact with resident's intact skin; j. After contact with blood or bodily fluids; .m. After removing gloves; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals.8. Hand hygiene is the final step after removing and disposing of personal protective equipment . 2. On 12/05/23 at 03:01 PM, a one gallon plastic picture filled with orange liquid and a one gallon picture with 1 quart of orange liquid were sitting on the cabinet on the secure unit. The gallon pictures were not labeled or dated. The gallon pictures were not refrigerated and not on ice. 3. A review of an admission Record indicated the facility admitted Resident #37 with a diagnosis that included neurocognitive disorder with Lewy bodies. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident had severe cognitive impairment. Review of Resident #37's Care Plan, initiated 3/8/2023 revealed the resident was at risk for decline in nutrition/hydration status related to cognitive deficit. Interventions included assist resident as needed with eating. On 12/05/23 at 05:09 PM, Certified Nursing Assistant (CNA) #6 was observed putting a used meal tray on the meal cart. CNA #6 did not perform hand hygiene. CNA #6 sat down next to Resident # 37 and picked up the silverware and assisted Resident #37 with her meal. CNA #6 did not perform hand hygiene. On 12/06/23 at 1:33 PM, observed CNA #7 exit from a Resident's Room with her left bare hand filled with goldfish cracker snacks. CNA #7 was picking one goldfish cracker snack from the left bare hand using the right bare hand and feeding it to Resident #37. CNA #7 sat down in a chair next to Resident #37 and using her right bare hand, removed a goldfish cracker snack from the left bare hand and fed it to Resident #37. CNA #7 was also observed eating the goldfish cracker snacks. On 12/06/23 at 1:37 PM, CNA #7 was asked why should staff not touch residents' food with their bare hands? CNA #7 stated, Because of germs. CNA #7 was asked why did you give Resident #37 goldfish cracker snacks with your bare hands? CNA #7 stated, I gave them to [Resident #37], and I gave them with my bare hands, that's not what [Resident #37] supposed to eat. I know I'm not supposed to do that. On 12/06/23 at 2:42 PM, Licensed Practical Nurse (LPN) #3 was asked why staff should not give residents food from their bare hands? LPN #3 stated, Germs and infection control. LPN #3 was asked why should staff sit at eye level while assisting residents with eating? LPN #3 stated, Most elders vision is impaired, and it helps residents eat. LPN #3 was asked how is orange juice supposed to be stored when not in use? LPN #3 stated, In the refrigerator. LPN #3 was asked why should orange juice be refrigerated or on ice? LPN #3 stated, To prevent bacteria. On 12/27/23 at 12:22 PM, the Infection Control Preventionist (ICP) was asked why staff should not feed residents food from their own bare hands and why should staff perform hand hygiene before assisting residents with meals. The ICP stated, For infection control and to keep infection rates down.

Based on observation, interview, and record review the facility failed to ensure essential equipment in the kitchen was maintained in safe, operational order to ensure food was kept at a safe temperature to minimize the risk of food borne illness. This failed practice resulted in Immediate Jeopardy which caused or could have caused serious harm, injury, or death to all 51 residents who resided in the facility due to the potential risk for food borne illness The Administrator was notified on 12/6/23 at 5:02 PM. The findings are: On 12/5/23 at 2:51 PM, in the first two door freezer there was a thick layer of ice observed in the bottom underneath multiple boxes of food items. The ice was covered in a variety of debris including food stuff. The ledge and bottom of the freezer contained dust and debris which extended to the vent and grate in the front of the freezer. The right side of the freezer contained a layer of ice 2 to 3 inches thick. Adhered to the bottom of the freezer was a bag containing a bright red food product that had been liquid at one time. The Dietary Aide was unable to dislodge the bag from the bottom of the freezer and was also unable to identify what was in the bag. There was no visible date on the bag. The bottom of the one door freezer contained 2 to 3 inches of ice. In the ice was various food, debris, and labels. The ice had a yellow area in the back left corner. On 12/5/23 at 4:25 PM, a large steam table pan was sitting on a shelf under the steam table. The pan contained a variety of food particles in various sizes. The shelf contained multiple areas where water had been present and then dried. The glass partition along the back of the steam table was covered in a thick layer of grime, grease, and dried food. The partition was held together on the right corner extending approximately 1/3 of the way down with black duct tape. The duct tape was also being used to hold the top of the glass in the frame. On 12/6/23 at 11:10 AM, in the first two door refrigerator, a layer of water 1 to 1½ inches deep covered the bottom of the appliance. A large cookie sheet which had previously contained chicken thawing for today's lunch, remained in the bottom of the refrigerator on top of the water and contained multiple food particles. The top of the refrigerator contained a black substance which covered the grate over the fan and extended to the top of the refrigerator. When asked how long the water had been a problem, the Dietary Manager stated that the water accumulating had been an issue since she began working at the facility in July. When asked if she had reported the issue, she stated, Yes, to maintenance, and I think the Administrator knows. On 12/6/23 at 5:02 PM, an Immediate Jeopardy was called due to the facility failing to ensure all essential equipment was maintained in good working order. The Immediate Jeopardy was removed on 12/08/23 at 10:37 AM when the following Plan of Removal was implemented: Step #1: Upon notification of failure to ensure essential equipment was maintained in safe, operational order. On 12-6-2023 the maintenance supervisor repaired a hose that drains the water from the three of the freezers that had frozen water standing in the bottom. On 12-6-2023 Dietary staff removed all frozen water and debris from all three freezers. On 12-6-2023 the Maintenance Supervisor cleaned the drain tube on both refrigerators that were not allowing proper draining of water that attributed to standing water in the bottom of both fridges. On 12-6-2023 the Dietary staff removed all water and debris from both fridges. All fridges and freezers did previously and currently have internal thermometer located inside of each fridge and freezer. On 12-6-2023 the Administrator purchased 4 new steam table pans to replace the old pans that contributed to the two small leaks that were noticed under the steam table. One of the old pans appeared to have small pin holes that was causing the leak. All leaks in all equipment have been fixed with no negative outcomes noted. Step #2: Dietary Staff and Maintenance supervisor were in-serviced by Administrator on 12/7/2O23 as to the requirement to maintain all equipment in safe and operational order. Starting on 12-7-2023 the Maintenance Supervisor will monitor all equipment located in the Dietary Department 5 x per week for 6 weeks to ensure that all equipment is working properly in safe, operational manner. Starting on 12-7-2023 the Dietary Manager will monitor daily 5 x per week on an ongoing basis to ensure proper functioning of all equipment located in the Dietary Department. Step #3: On 12-6-2023 at 5:45 pm, Medical Director notified of confirmation of Immediate Jeopardy. Updated on findings, reviewed plan of removal and education provided Dietary Manager and Maintenance Supervisor. On 12/8/23 at 10:45 AM the Dietary Manager reported that the issues with the refrigerator/freezer involved a small tube that had become dislodged, allowing the water to drain back into the unit vs. out. She stated, I don't think it was really hard to fix once someone looked at it.