Based on observation, record review, and interview, it was determined that the facility failed to ensure a call light was kept within a resident's reach to allow the resident to summon assistance, and to provide prompt assistance to address a resident ' s pain and discomfort once requested for one (Resident # 62) of one sampled resident dependent on staff for assistance. The findings are: A review of an admission Record indicated Resident #62 was admitted to the facility with diagnoses, which included heart attack and type 2 diabetes with diabetic neuropathy (a type of nerve damage that often affects feet and legs). The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2025, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #62 was cognitively intact. The MDS revealed the resident had impairment in both lower extremities and used a walker and wheelchair for mobility. A review of Resident #62's Care Plan, initiated 04/22/2025, revealed the resident had an Activities of Daily Living self-care performance deficit related to limited mobility and weakness and required dependent assistance by two staff, via mechanical lift, during transfers. Interventions included to encourage Resident #62 to use their call light to alert staff if assistance was needed. A review of Resident #62's Care Plan initiated 04/23/2025 revealed the resident was at risk for falls related to gait/balance problems and weakness. Interventions included encouraging the resident to use the call light, or ask for assistance as needed, and to keep personal items within reach. The care plan indicated the resident had limited physical mobility due to weakness, and indicated Resident #62 required dependent assistance from one staff member for locomotion using their wheelchair. On 05/14/2025 at 8:32 AM, Resident #62 was overheard from the hallway, moaning and crying. Resident #62 was observed seated in a wheelchair in the resident ' s room. The resident was approximately three feet from the bed, with the bedside table placed in front of the resident. The resident was saying, I want to lay down. I'm hurting. The call light was observed wrapped around the bedrail. The surveyor asked if the resident was able to reach their call light to call for assistance. Resident #62 said, I don ' t even know where it is. The surveyor indicated where the call light was located, and Resident #62 reported they were unable to reposition themselves in order to reach the call light. The surveyor observed Resident #62 attempt and fail to reach the call device. On 05/14/2025 at 8:35 AM, when asked about Resident #62 moaning and crying, Licensed Practical Nurse (LPN) #2 said that (Resident #62) moans and cries out a lot. On 05/14/2025 at 9:00 AM, the surveyor observed Resident #62 continuing to cry out and ask for help getting back in bed. The resident said, I've been sitting here since 6:30 or 7:00 this morning. I want to go back to bed. LPN #2, who was present during this observation, said that the resident was able to use the call light and took the call light from around the side rail and placed it in the resident's lap. Resident #62 pushed the call light for assistance. At 9:20 AM Certified Nursing Assistant (CNA) #3 came into the resident's room. CNA #3 said that the resident's call light should have been within reach, but she did not get Resident #62 up this morning. During an interview on 05/14/2025 at 3:08 PM, Physical Therapy Assistant (PTA) #4 said their main goal was working on transferring so Resident #62 could discharge home. The resident had a fear of falling and would not even try to stand. During an interview on 05/14/2025 at 3:23 PM, LPN #2 said that Resident #62 would not help by standing, and required total assistance. During an interview on 05/14/2025 at 3:24 PM, CNA # 3 said that Resident #62 required a lift and was dependent on two staff. Review of a facility policy titled Answering the Call Light revised March 2021 indicated The purpose of this procedure is to ensure timely responses to the resident ' s requests and needs .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation and interview, the facility failed to ensure after eating lunch, 1 (Resident #24) of 1 sampled resident's face was cleaned and clothing changed before going into the sitting area to promote dignity and respect. The findings are: 1. On 2/5/24 at 11:02 am, Resident #24 was sitting in a specialized chair in the sitting area with the neck bent over and drainage coming from the mouth and nose running down onto the shirt. 2. On 2/5/24 at 12:27 pm, observed staff taking Resident #24 into the Dining Room for lunch. 3. On 2/5/24 at 1:11 pm, observed staff giving Resident #24 a bowl of spaghetti to begin eating. Resident #24 proceeded to spill spaghetti on the front of the shirt until a Certified Nursing Assistant (CNA) went by and placed a clothing protector on the resident. 4. On 2/5/24 at 1:28 pm, observed a CNA come and sit by Resident #24 to help assist in feeding the remainder of lunch. 5. On 2/5/24 at 1:43 pm, Resident #24's face was dirty with spaghetti sauce and the shirt had been wiped but had spaghetti sauce on the front of it with a wet spot on the right front from the drainage from the mouth and nose when a CNA pushed Resident #24 into the sitting area. 6. On 2/5/24 at 2:03 pm, a staff came into the sitting area to get Resident #24. Staff took Resident #24 to the bathroom and then took the resident to their room to lay down to rest. Resident #24's clothing was not changed, or face cleaned. 7. On 2/8/24 at 9:13 am, the Surveyor asked Licensed Practical Nurse (LPN) #1, if you observe a resident with food and drool on their face and clothing, what should you do. LPN #1 confirmed, take them to their room, wash their face and change their clothing. The Surveyor asked should a resident be left in a sitting area with other residents and visitors with food and drool on them. LPN #1 confirmed, no, they should not. 8. On 2/8/24 at 9:33 am, the Surveyor asked the Director of Nursing (DON) if you observe a resident with food on their face and drool and food on their clothing what should you do. The DON confirmed, take them to their room and change their clothing and clean them up. The Surveyor asked should a resident be left in a sitting area with other residents and visitors while having food on their face and clothing and drool on their shirt. The DON confirmed, absolutely not, never should that happen. 9. On 2/9/24 at 8:46 am, the Administrator provided a policy titled, Dignity, which documented, Policy Statement Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 14. On 02/05/24, during initial rounds the following observations were made: a. On 02/05/24 at 11:41 am, Resident #29 expressed that she felt like the walls were caving in on her and that her room was not like a homelike environment. b. On 02/06/24 at 08:44 am, Resident #29 was talking to the Social Worker about her room not being homelike and that she felt like the walls were caving in on her. c. On 02/07/24 at 11:45 am, Resident #29 voiced in the Resident Council meeting to that she felt like her room was not homelike, there are no pictures on the walls and no clock in my room or personal items in my room and I feel like the walls are just caving in on me. d. On 02/08/24 at 09:14 am, the Surveyor asked LPN #1, what should be in a resident's room to make it feel like a homelike environment? LPN #1 confirmed, their personal belongings. The Surveyor asked, if a resident tells you that they don't feel like their room is homelike and the walls are caving in, what should you do? LPN #1 confirmed, talk with the resident, and ask what can be done to make you feel like it is more homelike for you. e. On 02/08/24 at 09:21 am, the Surveyor asked LPN #2, what should be in a resident's room to make it feel more homelike? LPN #2 confirmed, pictures, stuffed animals, their personal items, blankets. The Surveyor asked, if a resident tells you they don't feel like their room is homelike and the walls are caving in on them, what would you do? LPN #2 confirmed, first I would take them out of the room to talk to them. I would also get the Social Worker involved, to see what we as a facility could do to make them feel like their room was more homelike. f. On 02/08/24 at 09:30 am, the Surveyor asked the Director of Nursing (DON), what should be in a resident's room to make it feel more homelike? The DON confirmed their personal belonging, family pictures and anything they bring from their home. The Surveyor asked, what if they don't come from home, or don't have a home? The DON confirmed we would talk to them about what the facility could do to make it more homelike for them. 15. On 02/05/24 at 10:21 am, Residents #2 and #37's room had a strong urine odor in the room and in the bathroom. a. On 02/05/24 at 12:18 pm, Residents #2 and #37's room had a strong urine odor in the room and in the bathroom. b. On 2/6/24 at 10:34 am, Residents #2's and #37's room had a strong urine odor in the room and in the bathroom. c. On 2/8/24 at 09:14 am, the Surveyor asked LPN #1, how do you ensure that a resident's room is kept free of foul smelling odors? LPN #1 confirmed, by cleaning it daily and making sure trash is taken out. The Surveyor asked, how often is a resident's room cleaned? LPN #1 confirmed, daily. The Surveyor asked, how often is a resident's room deep cleaned? LPN #1 confirmed, they have a deep cleaning schedule they go by, and I think it is weekly. d. On 2/8/24 at 09:21 am, the Surveyor asked LPN #2, how do you ensure that a resident's room is kept free of foul smelling odors? LPN#2 confirmed, make sure the trash is taken out, no food is left open, and that they have clean linen in place. The Surveyor asked, how often does housekeeping clean the resident room? LPN#2 confirmed, daily. The Surveyor asked, how often are the resident rooms deep cleaned? LPN#2 confirmed, they have a schedule they go by. e. On 2/8/24 at 09:30 am, the Surveyor asked the DON, how do you ensure that a resident's room is kept free of foul smelling odors? The DON confirmed, we do angel rounds, and me, and the Administrator, make several rounds throughout the day to ensure there are no odors. The Surveyor asked, how often are the resident rooms cleaned? The DON confirmed, daily. The Surveyor asked, how often are the rooms deep cleaned? The DON confirmed, they go by a schedule. f. On 2/8/24 at 09:35 am, a policy titled, Homelike Environment, was provided by the Nurse Consultant. The policy documented, Policy Statement Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .c. inviting colors and décor; d. personalized furniture and room arrangements; .3.b. institutional odors . 8. On 02/05/24 at 10:23 am, when entering the Secured Unit a very strong urine odor was noted. When entering room [ROOM NUMBER], the odor was stronger. 9. On 02/06/24 at 09:17 am, when entering the Secured Unit a very strong urine odor was noted. 10. On 02/07/24 at 01:53 pm, the Secured Unit continues to have a very strong urine odor. 11. On 02/08/24 at 09:35 am, the Secured Unit continues to have a very strong urine odor. 12. On 02/08/24 at 09:42 am, the Surveyor asked Registered Nurse (RN) #1, how do you ensure a room is free of any foul odors for the residents? RN #1 stated, When finished changing the resident's briefs we take the brief out of the room and dispose of it, sanitize mattresses, and use odor eliminator. The Surveyor asked how often are the resident's rooms cleaned and deep cleaned? RN #1 stated, The resident's rooms are cleaned daily by the CNAs and nurses. The deep cleaning is done monthly or as needed by housekeeping. 13. On 02/08/24 at 10:08 am, the Surveyor asked Licensed Practical Nurse (LPN) #3 how do you ensure a room is free of any foul odors for the residents? LPN #3 stated, Go into the room, smell it, and clean it. The Surveyor asked how often are residents rooms cleaned and deep cleaned? LPN #3 said housekeeping cleans weekly. Surveyor: Young, [NAME] Based on observation and interview, the facility failed to provide a sanitary, uncluttered, odor free, and homelike physical environment to enhance quality of life for the residents in Rooms #102, #108, #109, #111 and #115 and 1 (Resident #417) of 1 sampled resident. The findings are: 1. On 02/05/24 at 11:05 am, room [ROOM NUMBER] had a television (TV) mounted on the wall. A white cable and 2 electrical wires were tangled together and hanging 2 feet down the wall to the electrical outlet above the counter where the sink is. 2. On 02/05/24 at 11:12 am, room [ROOM NUMBER] had a TV on the counter under the wall mounted soap dispenser. A white cable and an electrical wire ran under the mirror, over the paper towel dispenser into the cable outlet on the other side of the counter. A black metal box had various cords screwed into it. 3. On 02/05/24 at 11:15 am, room [ROOM NUMBER] had 3 black electrical cords hanging from the TV and down the wall 3 feet. A white cable was hanging from the ceiling and a white plastic hanger was hanging from the white cable. 4. On 02/08/24 at 08:36 am, room [ROOM NUMBER] had black electrical wires running from the back of the wall mounted TV to the electrical outlet 3 feet away. 5. On 02/08/24 at 08:47 am, room [ROOM NUMBER] had a black electrical wire running from the back of the TV down the wall 3 feet to the electrical outlet below the paper towel dispenser; a black cable running from the back of the TV down the wall and over the paper towel dispenser; and a white cable running over and to the other side of the mirror to a cable outlet on the wall. 6. On 02/08/24 at 02:17 pm, Certified Nursing Assistant (CNA) #1 was asked to come to Rooms #102, #108, #109, #111 and #115. CNA #1 was asked would you like cable and electrical wires running down the walls in your home? CNA #1 stated, No. The Surveyor asked would you consider these rooms to be homelike with cable and electrical wiring stretched across the wall? CNA #1 stated, I wouldn't think so. 7. On 02/08/24 at 02:25 pm, the Maintenance Supervisor was asked to come to Rooms #102, #108, #109, #111 and #115. The Maintenance Supervisor was asked, would you like cable and electrical wires running down the walls in your home? The Maintenance Supervisor stated, No. The Surveyor asked, would you consider these rooms to be homelike with cable and electrical wires running down the walls? The Maintenance Supervisor stated, I wouldn't consider them homelike, but it is something that we are working on. We are putting shelves up in the rooms. We just haven't gotten around to it yet.

Based on observation, interview and record review, the facility failed to provide a pressure relieving device to 1 (Resident #29) of 1 sampled resident who did not have a pressure relieving device in the wheelchair. The findings are: 1. On 2/5/24 at 11:41am, Resident #29 was sitting in a wheelchair in the resident's room. Resident #29 said that the resident had previously had a wound on their bottom. It was healed now however, when the resident sits in the wheelchair it hurts the residents bottom. Resident #29's wheelchair did not have a cushion in it. The Surveyor asked, have you told anyone that you wanted a cushion in your wheelchair, and that your bottom hurt when you sat in your wheelchair? Resident #29 confirmed, yes, I told a nurse and I told someone in therapy, but they haven't gotten me a cushion yet. 2. On 2/7/24 at 12:40 pm, the Surveyor asked the Wound Care Nurse, if a resident who had previously had a wound on their bottom that is now healed complains that when they sit in their wheelchair that it hurts their bottom, should they have a cushion in their wheelchair? The Wound Care Nurse confirmed, absolutely, especially if they had breakdown previously however, everyone should have a cushion in their wheelchair. 3. On 2/8/24 at 9:33 am, the Surveyor asked the Director of Nursing (DON), should a pressure relieving device be in a wheelchair for a resident who has history of skin breakdown on their bottom, or is at risk for skin breakdown? The DON confirmed, absolutely, everyone should have a cushion in their wheelchair. 4. On 2/9/24 at 8:46 am, the Administrator provided a policy titled, Prevention of Pressure Injuries, which documented, .Support Surfaces and Pressure Redistribution 1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Device-Related Pressure Injuries 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device .3. For prevention measures associated with specific devices, consult current clinical practice guidelines .

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from the medication carts and medication rooms on 2 (Rose Hall and [NAME] Hall) halls. The findings are: On 2/7/24 at 8:42 AM, the following observations were made in the [NAME] Hall Medication Room: i) One Foaming Hand Wash with an expiration date of 11/23. ii) One Hydrogen Peroxide 3% with an expiration date of 11/23. iii) One Peri Guard Ointment with an expiration date of 10/23. On 2/7/2024 at 8:50 AM, the Surveyor asked Licensed Practical Nurse (LPN) #4, what do you do with expired medications? LPN #4 stated, We enter them into the blue book with description, quantity, and expiration date. Then we put the expired medications in a locked container. Periodically, the Director of Nursing (DON) will come down and empty the container. On 2/7/2024 at 8:57 AM, the following observations were made in the [NAME] Hall Medication Cart: i) BindxNOW with an expiration date of 7/24/23, ii) Two Arginaid Powder with an expiration date of 1/21/24. iii) Deep Sea Saline with an expiration date of 8/23. On 2/7/2024 at 9:35 AM, the following observations were made in the [NAME] Hall Medication Room: i) Wound Cleanser with an expiration date of 1/24. ii) Hand Sanitizer with an expiration date of 10/29/23. On 2/7/2024 at 9:42 AM, the Surveyor asked Registered Nurse (RN) #1, how often do you go through the medication room? RN #1 stated, Thoroughly once a month, and spot check weekly. On 2/7/24 at 9:47 AM, the Surveyor asked LPN #3, how do you dispose of narcotics when they expire? LPN #3 said, we contact the DON, and she comes to get them from us. Until she does, we keep them locked in the narcotic medicine drawer. On 2/8/2024 at 9:35 AM, the Nurse Consultant provided a Policy titled, Storage of Medications, . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4.Discontinued, outdated, or deteriorated drugs or biological are returned to the dispensing pharmacy or destroyed .

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The findings are: On 2/5/23 at 10:30 AM, during initial rounds, 3 residents complained that the food they receive is cold. They reported that breakfast is usually ok, but the other meals were cold. On 2/7/24 at 10:45 AM, a Resident Council meeting was held. During the meeting all 6 residents in attendance expressed dissatisfaction with the food and described it as poorly prepared and consistently cold. That it didn't matter if you eat in your room or in the dining room the food is cold. On 2/7/23 at 12:55 PM, Dietary Aide #3 was breaking a dinner roll into small pieces and placing the pieces on a plate. When the Surveyor asked why the bread was being pinched into small pieces, Dietary Aide #3 stated, We do this for the mechanical softs. Sometimes when the bread isn't soft, we break it up into pieces for them. This bread is kind of hard. On 2/7/24 at 1:12 PM, a test tray was filled and taken by this Surveyor and the Dietary Manager directly to the Conference Room. Upon entrance, the Dietary Manager removed the insulated dome and took the temperature of the food. The temperature of the roasted red potatoes was 123 degrees Fahrenheit; the baked sweet potato was 106 degrees Fahrenheit; the baked pork loin was 115 degrees Fahrenheit; the green bean casserole was 144 degrees Fahrenheit; and the green beans were 106 degrees Fahrenheit. On 2/7/23 at 1:15 PM, the Dietary Manager and 2 members of the Survey Team sampled the test tray. The items were room temperature. The pork loin was thin, dry, and over cooked. The meat was difficult to cut with the butter knife provided and was difficult to chew. The sweet potato was undercooked with a hard spot in the middle. On 2/8/23 at 2:12 PM, the Dietary Manager (DM) was asked to address the resident complaints concerning the temperature of the food. The DM was uncertain as to why the food was cold when served. The DM described checking the temperature of the food just prior to serving and reheating any item that wasn't hot enough. The DM was asked if the dietary department delivers the trays in carts or if the nursing staff comes for them. The DM described a system that frequently changed, and she could not identify how long it took for the trays to be delivered once they arrived on the hall.

Based on observation and interview, the facility failed to ensure residents with a physician's order for a pureed, or a mechanical soft diet, received food of the correct consistency to prevent choking. The findings are: On 2/7/24 at 11:35 AM, Dietary Aide #1 placed boneless pork loin in the bowl of the food processor, then placed the lid on the bowl and proceeded to chop the meat. After several minutes Dietary Aide #1 removed the lid and peered into the bowl. The meat in the bowl had been reduced to pieces, bite size or smaller. Dietary Aide #1 reached into the bowl and retrieved one large piece of pork that had failed to be chopped. Dietary Aide #1 placed the large piece in the bottom of the bowl and continued to blend the pork. When the food processor was stopped, the pork was in tiny, granular size pieces and looked like powder. On 2/7/24 at 12:55 PM, Dietary Aide #3 was breaking a dinner roll into small pieces and placing them on a plate. When the Surveyor asked why the bread was broken into small pieces, Dietary Aide #3 stated, We do this for the mechanical softs. Sometimes when the bread isn't real soft, we break it up into pieces for them. On 2/7/24 at 1:00 PM, Dietary Aide #3 filled bowls for a resident receiving a pureed diet. Dietary Aide #3 placed a scoop into the pan containing the pureed bread. Dietary Aide #3 brought the scoop out of the pan, careful to keep the scoop upright to prevent the pureed bread from pouring from the scoop prior to reaching the bowl. The pureed bread was poured from the scoop and into the bowl. The substance did not hold its shape. On 2/7/24 at 1:03 PM, Dietary Aide #3 placed a scoop into the pan containing pureed green beans. Dietary Aide #3 carefully brought the scoop up from the pan so that the serving of pureed green beans would remain in the scoop. As the scoop was held over the bowl the green bean mixture was poured into the bowl. The substance did not hold its shape. On 2/7/23 at 1:10 PM, Dietary Aide #3 placed a scoop of pork onto the plate which had been prepared for the residents who received a mechanical soft diet. The dry particles of meat scattered across the plate and required Dietary Aide #3 to use the scoop to scrape the meat particles back into a pile so that gravy could be put on top. On 2/7/23 at 1:20 PM, The Dietary Manager (DM) was asked to address the practice of pinching the dinner roll into small pieces for the residents who received a mechanical soft diet, and if it was the Registered Dietitian who instructed her to pinch/break the bread into small pieces for the residents who receive a mechanical soft diet. The DM reported that there was an email conversation concerning bread and that she believed the final instruction came from the Director of Nursing. The DM was asked what the correct consistency of pureed food was. She stated, Pudding. The DM was asked how large the pieces of meat should be for a resident receiving a mechanical soft diet. The DM described, Small, not ground but small. The DM was asked why it is important to provide residents who receive a pureed diet or a mechanical soft diet food that is the correct consistency. The DM stated, Because they could choke.

Based on observation and interview the facility failed to ensure kitchen employees washed their hands and changed gloves between clean and dirty tasks; utilized food items were used prior to their expiration date to prevent food borne illness; the kitchen was clean and free of excess trash, grease, grime, and dust. The findings are: On 02/05/24 at 10:11 AM, two trays of cookies for the lunch meal were on the counter uncovered. On 02/05/24 AM at 10:12 AM, a large hard plastic container containing 4 one-pound packets of sliced turkey was in the 3-door refrigerator. The use by date located on the package was 1/19/23. Located on the same shelf was a resealable plastic bag containing 3 chicken strips. The bag had no date on it. On 2/5/24 at 10:17 AM, the top of a rack over the main worktable, which had skillets and other items hanging down from it, had a film of grease and grime to which dust had adhered. On 2/5/24 at 10:27 AM, upon entering the walk in freezer, the motor was observed on the top and to the left of the door. A large cascade of ice, 2 to 3 inches thick, was stuck to a hose that runs from the motor out of the top of the freezer. Water was observed in the bottom of the freezer. The floor of the freezer and the bottom shelf of the middle rack were covered in rust. On 2/5/24 at 10:40 AM, Dietary Aide #1 used gloved hands to obtain large cooking trays. She then retrieved a box of bread sticks from the walk-in freezer. She opened the box and placed the bread sticks on the tray with the same contaminated gloves. On 2/6/24 at 11:13 AM, the trash can adjacent to the hand washing sink was overflowing onto the floor. The lids of the receptacle remained open due to excess trash. Paper towels and discarded gloves were on the floor. On 02/07/24 at 10:58 AM, a large rectangle pan containing cinnamon peaches was on the worktable. The pan was uncovered and opened to air and contaminants. On 2/7/23 at 11:02 AM, a large, uncooked pork loin was laying on a cutting board on the worktable. Dietary Aide #1 picked up the raw meat with her gloved hands. Wearing the same gloves, Dietary Aide #1 placed the meat into a resealable plastic bag and then determined the bag was too small. Dietary Aide #1 removed the pork from the bag with the same gloves and placed it in a larger resealable plastic bag. Dietary Aide #1, wearing the same gloves contaminated with raw pork, sealed the bag, and placed it in a pan. Dietary Aide #1 then opened the door to the walk-in refrigerator with the same gloves and placed the pork into the refrigerator. On 2/8/23 at 11:09 AM, the hood above the range was covered in a film of grease and grime. Dust had adhered to the grease, giving the hood a textured appearance. The shelf above the range was also covered in dust and grime. On 2/8/24 at 11:14 AM, the floor between the deep fryer and the oven was shiny and covered in a layer of oil. Dust and food particles were to be stuck in the oil. On 2/8/24 at 11:50 AM, Dietary Aide #1 used gloved hands to obtain a can of chicken base from the shelf above the worktable. Dietary Aide #1 then retrieved a pitcher, carried it to the sink and added water. Dietary Aide #1 opened the container of chicken base and added some to the water. A spatula was then used to mix the chicken broth. Dietary Aide #1 then obtained two 1/4 steam table pans which contained pork loin. Dietary Aide #1 picked up tongs and used them to pick up the pork loin and place in the food processor. The pitcher was picked up by the handle and broth was added through the top of the food processer. The gloves were changed after the meat was poured from the food processor into a pan for the steam table. On 2/8/24 at 12:00 PM, Dietary Aide #1 opened the door to the range and removed a large tray of sweet potatoes from the oven using her gloved hands. After placing the tray on the worktable Dietary Aide #1 obtained a 1/2 steam table pan to hold the potatoes. With the same gloves, Dietary Aide #1 picked up a sweet potato and removed the skin and was then cut into fourths and placed into the pan. On 2/8/24 at 12:05 PM, Dietary Aide #2 with gloved hands opened the right door of the 3-door refrigerator and retrieved a clear plastic container which contained packages of deli ham and a container of sliced cheese. After placing the ham and cheese on the worktable Dietary Aide #2 returned to the refrigerator, opened the flap of a box containing 16-ounce blocks of butter. Dietary Aide #2 then reached into the box and brought out a block of butter. Dietary Aide #2 closed the door, moved to the first door, opened it, reached in, and retrieved a bag of bread. After placing the bread on the worktable, Dietary Aide #2 opened the bread bag, reached in, and got two slices of bread with the contaminated gloves. Dietary Aide #2 continued to assemble the sandwich, placing butter and bread in a skillet. Upon completion of the cooking process the sandwich was wrapped in aluminum foil. The sandwich was completed using contaminated gloves. Two boxes of frozen beef patties were observed on the worktable. Dietary Aide #2 continued to use the contaminated gloved hands to open the top of the box and retrieve the frozen beef patties and place them on a tray. On 2/8/24 at 12:30 PM, the lid of the trash can adjacent to the hand washing sink was held open by an excess of trash. The trash was overflowing, and paper towels and discarded gloves littered the floor. The large trash can next to the 3-compartment sink had trash protruding from the top, preventing the top from closing. On 2/8/24 at 12:34 PM, Dietary Aide #1 with gloves on carried a pan containing sweet potatoes to the worktable for pureeing. With the same gloves Dietary Aide #1 opened the right door of the 3-door refrigerator, reached in, pushed aside the flaps of a cardboard box, and retrieved a 16 ounce block of butter. Dietary Aide #1 then unwrapped the butter and placed it in a clear plastic container, opened the door to the microwave and placed the butter inside. After the butter was melted in the microwave, Dietary Aide #1 placed large pieces of baked sweet potato into the bowl of the food processor. Without removing the contaminated gloves, Dietary Aide #1 used a finger to push the sweet potatoes down into the bowl, so that the lid would close. On 2/8/24 at 12:50 PM, Dietary Aide #3 was filling plates on the tray line, with gloved hands. Dietary Aide #3 obtained insulated plate bases and insulated domes. Dietary Aide #3 held the plate with the thumb on the surface of the plate adjacent to the food items. Contaminated fingers were placed in the top of each insulated dome prior to being placed over the plate. On 2/8/23 at 12:55 PM, Dietary Aide #3 used contaminated gloves to break a dinner roll into small pieces and place it on a plate. When the Surveyor asked why the bread was broken into small pieces, Dietary Aide #3 stated, We do this for the mechanical softs. Sometimes when the bread isn't real soft, we break it up into pieces for them. This bread isn't very soft. On 2/8/24 at 1:20 PM, the Dietary Manager (DM) was asked to address the issue of breaking the dinner roll into small pieces for the residents who received a mechanical soft diet. The DM reported that the practice began some time ago and the Director of Nursing (DON) was where the instruction originated. On 2/8/24 at 2:12 PM, the Dietary Manager was asked when hands should be washed in the kitchen. The DM replied, When you first come in, whenever you change your gloves or after going from one thing to another. When the Surveyor asked when gloves should be changed. The DM described the need to change gloves between tasks. When the Surveyor asked about the importance of keeping the kitchen clean. The DM described her attempts to implement a new cleaning schedule. When the Surveyor asked who was responsible for taking out the trash in the kitchen. The DM identified the cook or the cook's aide.

Based on observation, interview, and record review, the facility failed to ensure privacy was provided during enteral bolus tube feedings to promote dignity for 1 (Resident #1) of 3 (#1, #2, and #3) sampled residents who received enteral tube feedings as documented on the Resident Matrix provided by the Administrator on 06/05/23 at 11:07 AM. The findings are: 1. Resident #1 had diagnoses of Anxiety Disorder and Bipolar Disorder. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/23 documented Section B0700 .rarely/never understood . and Section K0510 .Feeding tube .while a resident . a. On 06/05/23 at 2:05 PM, Licensed Practical Nurse (LPN) #1 administered medication and a bolus tube feeding to Resident #1 in his room with Registered Nurse (RN) #1 and Hospice RN/CM (RN/Case Manager) present. Staff/LPN/RN did not close the door or pull the privacy curtain during medication/nutrition administration, leaving Resident #1 exposed to the hallway. b. On 06/05/23 at 2:11 PM, the Surveyor asked RN #1, Why should the door be closed, or the privacy curtain be drawn when administering medications/liquid nutrition through a residents peg tube? RN #1 replied, It's their right and for dignity. The Surveyor asked, How are residents provided privacy during Activities of Daily Living (ADL's)/medication/nutrition administration through a peg tube? RN #1 replied, Door closed, and the privacy curtain drawn. The Surveyor asked, Did you close the door or pull the privacy curtain during the medication/nutrition administration for Resident #1? RN #1 replied, No, we did not. c. On 06/05/23 at 2:16 PM, the Surveyor asked the Hospice RN/CM why the door should be closed, or curtain drawn when administering medications and liquid nutrition. The Hospice RN/CM stated, For Privacy. The Surveyor asked if there was a reason the door remained open during Resident #1's administration of liquid nutrition. The Hospice RN/CM stated, No, one of us should have shut it. The Surveyor asked why a resident should be provided privacy during the administration of liquid nutrition. The Hospice RN/CM stated, Common respect. d. On 06/05/23 at 2:36 PM, the Surveyor asked the Director of Nursing (DON) why the door should be closed, or curtain drawn, when administering medications and liquid nutrition. The DON stated, To provide privacy. The Surveyor asked why residents should be provided privacy during the administration of liquid nutrition. The DON stated, It's a dignity issue. e. On 06/05/23 at 2:43 PM, the Surveyor asked the Administrator why doors should be closed, or curtains drawn, when administering medications and liquid nutrition. The Administrator stated, For privacy. The Surveyor asked what the expectations were for the staff regarding the following policies and procedures. The Administrator stated, I am pretty black and white. I want them to follow it to a T. f. The facility policy titled, Enteral Tube Feeding via Syringe (Bolus) provided by the ADON on 06/05/23 at 11:05 AM documented, .The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally .if the resident desires, return the door and curtains to the open position .

Based on observation, interview, and record review, the facility failed to ensure enteral feeding bags and containers were dated, and timed, when feeding was initiated for 2 (Resident #2 and #3) of 3 (Resident #1, #2, and #3) sampled residents who received nutrition via enteral tube feedings as documented on the Resident Matrix provided by the Administrator on 06/05/23 at 11:07 AM. The findings are: 1. Resident #2 had a diagnosis of Gastrostomy Status, Dysphagia, and Pneumonitis. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/02/23 documented Section K0510 Feeding Tube .while a resident . a. The Care Plan with a revision date of 03/05/23 documented, .ADL [activities of daily living] self-care performance deficit r/t [related to] CVA [Cerebral Vascular Accident] with left sided weakness .totally dependent on staff for eating .require tube feedings r/t Dysphagia .the resident depends on percutaneous endoscopic gastrostomy (peg tube) feeds and water flushes . b. The Physician Order with a start date of 05/04/23 documented, .enteral feed order every shift [named supplement] 1.5 @ [at] 65 ML/HR [milliliters per hour] continuous with 45 ML H20 [water] flushes Q Hour [every hour] . and .enteral feed order in the morning for weight loss 90 ml per peg . c. On 06/05/23 at 10:07 AM, Resident #2 was lying in bed, with a peg tube connected to a feeding pump and was running. A container labeled [named supplement] 1.5 containing 650 cc [cubic centimeters] of liquid was hanging with no name, rate, or date displayed on the bottle label. A clear bag containing 100 cc of clear fluid was hanging and running and was not labeled with Resident #2's name, rate, or date when the bottles were hung. d. On 06/05/23 at 11:45 AM, Resident #2 was lying in his bed, with a peg tube connected to a feeding pump and running. A container of [named supplement] 1.5 was hung and not labeled with a date, time, or rate. A clear bag with less than 100 cc's of clear fluid was hung and not labeled with a date, time, or rate. e. On 06/05/23 at 11:53 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1, Is Resident #2's container of liquid nutrition/bag labeled and dated? LPN #1 replied, No, I've got to get new bags. 3. Resident #3 had diagnoses of Gastrostomy Status and Dysphagia. The Quarterly MDS with an ARD of 04/27/23 documented Section K0510 Feeding Tube .while a resident . a. The Care Plan with a revision date of 02/26/23 documented, . ADL self-care performance deficit r/t Cerebral Infarction and right sided hemiplegia and hemiparesis .NPO [nothing by mouth], totally dependent on staff for nutrition/hydration via (peg tube) . [named nutrition supplement] @ 60 ml/hr continuous .is dependent with tube feeding and water flushes .see md orders for current feeding orders . b. The Physician Order with a start date of 04/20/23 documented, .enteral feed order every shift for [named nutrition supplement] 1.5 .if [named nutrition supplement] unavailable . @ [at] 60 ML/HR with H20 [water] @ 75 ML Q2H [every 2 hours] continuous via dual flow pump . NPO diet NPO texture, for swallowing difficulties . c. On 06/05/23 at 10:06 AM, Resident #3 was lying in his bed with a peg tube connected to feeding pump and running. A container labeled [named nutrition supplement] containing 900 cc of liquid was hanging with no name, rate, or date displayed. The feeding pump was beeping and read .Feeding Complete. A clear bag containing 800 cc of clear fluid was hanging and running. The clear bag with clear fluid was not labeled with Resident #3's name, rate, or the date the containers were hung. d. On 06/05/23 at 11:43 AM, Resident #3 was lying in his bed, with a peg tube connected to a feeding pump and running. The feeding pump display read pump on hold-error and was beeping. A container of [named nutrition supplement] 1.5 with 900 ccs of liquid was hung and was not labeled with a date, time, or rate. A clear bag with 600 ccs of clear fluid was hung and was not labeled with a date, time, or rate. e. On 06/05/23 at 11:50 AM, the Surveyor asked LPN #1, Why was Resident #3's feeding pump beeping/on hold? LPN #1 replied, The pump wasn't cleared, it was on hold. The Surveyor asked, Was Resident #3 receiving nutrition while the pump was on hold? LPN #1 replied, No. The Surveyor asked, Are the containers of liquid nutrition and bags supposed to be labeled? LPN #1 replied, Yes. The Surveyor asked, What information are the containers of nutrition/bags supposed to be labeled with? LPN #1 replied, The time I hang it, the patient's name, the rate and room number. The Surveyor asked, Why should containers of formula/nutrition/bags be labeled and dated? LPN #1 replied, So we know when they are hung up. The Surveyor asked, Who is responsible for ensuring containers of liquid nutrition/bags are labeled and dated? LPN #1 replied, Nurses. The Surveyor asked, Is Resident #3's container of liquid nutrition/bag labeled? LPN #1 replied, No, it's not labeled. f. On 06/05/23 at 2:36 PM, the Surveyor asked the Director of Nursing (DON) what the peg tube container, bags and liquid nutrition be labeled with. The DON stated, The feeding, date, time and initials or signature. The Surveyor asked why they are to be labeled. The DON stated, So we know how long it has been hanging and when we need to change it. The Surveyor asked who was responsible for ensuring they were dated and labeled. The DON stated, The charge nurses on the hall. The Surveyor asked if staff had been trained in labeling feeding tube containers, bags, and liquid nutrition. The DON stated, We learn this in nursing school. The Surveyor asked what the expectation was of staff regarding following CMS guidelines and the facility policies and procedures. The DON stated, All staff are to abide by all policies and procedures at all times. g. On 06/05/23 at 2:43 PM, the Surveyor asked the Administrator what the expectations were for the staff regarding following the facility's policies and procedures. The Administrator stated, I am pretty black and white. I want them to follow it to a T. h. The facility policy titled, Enteral Tube Feeding via Continuous Pump provided by ADON on 06/05/23 at 11:05 AM documented, .5. On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . i. The facility policy titled, Enteral Feedings - Safety Precautions, provided by the ADON on 06/05/23 at 11:05 AM documented, .5. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order .

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff wore hairnets to keep hair from contacting exposed food, clean and sanitized equipment, utensils and linens, or unwrapped single-service articles in 1 of 1 kitchen. This failed practice had the potential to affect 77 residents who received meals from the kitchen as documented in the Resident Matrix provided by the Administrator on 06/05/23 at 11:07 AM. The findings are: a. On 06/05/23 at 9:17 AM., Dietary Assistant #1 was at the stainless preparation table in the kitchen wearing a ball cap and no hair net. The Surveyor asked, Do you have a hair net on? Dietary Assistant #1 replied, No. The Surveyor asked, Are you supposed to wear hair nets in the kitchen? Dietary Assistant #1 replied, Yes, I'm new. b. On 06/05/23 at 9:23 AM, Dietary Assistant #1 was cutting tomatoes without a hair net. c. On 06/05/23 at 9:24 AM, the Surveyor asked the Dietary Manager (DM), Are you supposed to wear hair nets while in the kitchen? The DM replied, I do not know. d. On 06/05/23 at 1:14 PM, the Surveyor asked the Infection Preventionist (IP) via a phone call when hair nets are to be utilized in the kitchen. The IP stated, At all times while in the kitchen. The Surveyor asked why hair nets were to be utilized. The IP stated, So you don't get hair and stuff in the residents' food. The Surveyor asked if kitchen staff had been trained or in-serviced on wearing hair nets. The IP stated, I personally have not done one. I did one on proper PPE [Personal Protective Equipment] and having it there, but it's been a while. e. On 06/06/23 at 2:43 PM, the Surveyor asked the Administrator when hair nets were to be worn in the kitchen. The Administrator stated, During preparation, but I want them on when they come in the door whether they are prepping or not. The Surveyor asked if the kitchen staff had been trained on wearing hair nets. The Administrator stated, Yes they have. The Surveyor asked what the expectations were for the staff regarding to following policy and procedures. The Administrator stated, I am pretty black and white. I want them to follow it to a T. f. The facility policy titled Cleaning and Sanitizing and Proper Hair Restraints, provided by the Administrator on 06/05/23 at 11:18 AM documented, .6. Employees must wear hair restraint when in food preparation areas.

Based on observation, interview, and record review, the facility failed to ensure meals were prepared and served according to the planned written recipes and menu to meet the nutritional needs of 5 residents who required pureed diets per the Diet List provided by the Administrator on 11/7/22 for 1 of 1 meal observed. The findings are: 1. On 11/09/22, the facility's menu for lunch listed Spaghetti Noodles, Meat Sauce, Italian Vegetable Blend, Garlic breadstick, Lemon cheesecake bar, and Beverage of choice. 2. On 11/09/22 at 11:29 AM, Dietary Employee (DE) #2 pureed the spaghetti, meat sauce, and breadstick all combined and at 12:23 PM, DE#2 failed to add milk to the cheesecake bars in the food processor per the recipe. 3. On 11/09/22 at 02:23 PM, The Surveyor asked the Dietary Manager (DM) to provide the recipes for lunch. The Surveyor asked the DM, How do you know residents are receiving adequate nutrients? The DM stated, I follow the guidelines on the spreadsheets. That tells us how much to serve. The Surveyor pointed to the recipe binder, Should those recipes be followed? The DM stated, Yes. The Surveyor asked, If the recipes are not followed, could that negatively affect the residents? The DM stated, Yes, very much. Ok, say they are diabetic and can only have a certain amount of carbs and you don't follow the recipe you could be doubling the carb intake. The Surveyor referred to the puree recipes and asked the DM, Should all ingredients listed be included when following the recipes? The DM stated, Yes, if it calls for ingredients, they all should be in there. The Surveyor informed DM that milk was not added to lemon cheesecake bars. DE#2 had put only cheesecake bars in the food processor which was not realized that milk needed to be added until I saw the recipes. I added the observation above. The Surveyor asked if pureed items should be pureed together. The DM stated No, they should be individual foods, as they would be if they were not pureed. The Surveyor asked, How often do dietary staff receive training for proper preparation of foods? The DM stated, I just took over. I am really not sure. I was trained in the beginning. I ran everything past him [previous DM]. I think DE #2 was just nervous. 4. On 11/08/22 at 03:28 PM, the weekly menu and spreadsheets were provided by the Administrator which documented, .Wednesday .Regular/Puree .1/2 (cup) P. Spaghetti noodles .1/2 C P Meat sauce .3/8 C P Italian vegetables .1/4 C P Garlic breadstick 3/8 C P Lemon Cheesecake bar .PUREED Diets should be pudding consistency . 5. On 11/09/22 at 02:59 PM, the recipes for Wednesday .Week: 3 .Lunch were provided by the Dietary Manager (DM) which documented the following: a. .P Spaghetti Noodles .Cook method: Puree .Ingredients Spaghetti Noodles and Milk, Homo Gal .To get the actual serving size, puree the number of portions needed, adding adequate liquid if needed to achieve desired consistency .then divide the total amount equally by the number of portions pureed .Blend until smooth, adding additional liquid/thickener as needed to obtain a pudding-like consistency .CCP (Critical Control Point)Reheat to an internal temperature of >165F [Fahrenheit] held for 15 seconds . b. .P Meat Sauce .Cook method: Puree .Ingredients Meat Sauce and Sauce tomato .To get the actual serving size, puree the number of portions needed, adding adequate liquid if needed to achieve desired consistency .then divide the total amount equally by the number of portions pureed .Blend until smooth, adding additional liquid/thickener as needed to obtain a pudding-like consistency .CCP - Reheat to an internal temperature of >165F held for 15 seconds .Maintain at an internal temperature of >140F for only 4 hours . c. .P Italian Vegetable .Cook method: Puree .Ingredients Italian vegetable blend . To get the actual serving size, puree the number of portions needed, adding adequate liquid if needed to achieve desired consistency .then divide the total amount equally by the number of portions pureed . Blend until smooth, adding additional liquid/thickener as needed to obtain a pudding-like consistency .CCP - Reheat to an internal temperature of >165F held for 15 seconds .Hold at 140F throughout service . d. No recipe for puree breadsticks was provided. e. .P Lemon Cheesecake Bar .Cook Method: Puree .Ingredients Lemon Cheesecake bar and Milk, Homo Gal .To get the actual serving size, puree the number of portions needed, adding adequate liquid if needed to achieve desired consistency .then divide the total amount equally by the number of portions pureed .Blend until smooth, adding additional liquid/thickener as needed to obtain a pudding-like consistency .CCP - Chill to an internal temperature of <41F .Maintain at an internal temperature of <41F . 6. On 11/10/22 at 01:00 PM, the Menu policy provided by the Administrator documented, .1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board .

Based on observation, interview, and record review, the facility failed to ensure pureed food items were blended to a smooth and pudding-like texture to promote good nutritional intake and prevent potential choking for residents who required pureed diets during 1 of 1 meal observed. The failed practice had the potential to affect 5 residents who required pureed diets, according to a Diet List provided by the Administrator on 11/7/22. The findings are: 1. On 11/09/22 at lunch the residents on pureed diets received pureed spaghetti, meat sauce and breadstick mixture, Italian vegetables, and lemon cheesecake. 2. On 11/09/22 at 11:17 AM, The Surveyor asked Dietary Employee (DE) #2, How many items did you have to puree? DE #2 stated, Three. The spaghetti, vegetables, and lemon cheesecake. 3. On 11/09/22 at 11:29 AM, DE #2 poured the contents of a stainless container into the food processor. The Surveyor asked what those items were? The DE #2 stated, spaghetti noodles, meat, and sauce. The Surveyor asked, How many residents are you pureeing for? DE #2 stated, seven. DE #2 tore breadsticks into pieces and added them into the food processor with the spaghetti noodles and meat sauce. The Surveyor asked, When do you measure appropriate servings of items for puree? DE #2 stated she measured servings before putting them into the pans and then again when serving from the steam table. a. At 11:46 AM, DE #2 checked the puree and stated, This is not smooth yet. It still has pieces. b. At 11:48 AM, DE #2 tore 2 more breadsticks into pieces and added them into the processor. c. At 11:53 AM, DE #2 put the puree mixture into a stainless-steel pan. The surveyor used a white plastic spoon and obtained a tablespoon of puree. The surveyor rubbed the puree between thumb and forefinger and found 4 pieces of hard food not pureed smooth. The Surveyor showed them to DE #2 and asked her to describe the puree. DE #2 stated, hard tiny pieces of meat or hard noodles that were not cooked. The Surveyor asked, What texture should puree be like? DE #2 stated, It should be like pudding. d. At 11:56 AM, DE #2 put the puree back into the food processor. e. At 12:10 PM, DE #2 stopped the food processor and checked the puree. DE #2 stated, It won't puree the meat smooth. DE #2 started the food processor again. f. At 12:15 PM, DE #2 checked the puree. DE #2 stated, Somewhat better. Some things just won't puree. We just got this food processor not long ago. DE #1 overheard and stated, About 3-4 months ago. DE #2 spooned the puree into the stainless pan and the surveyor scooped out a teaspoon of puree which contained 2 pieces of hard matter. DE #2 took the pan to the stream table. 4. At 12:23 PM, DE #2 picked up bowls that contained slices of lemon cheesecake and poured 7 of them into the food processor. DE#2 failed to add milk to the cheesecake bars in the food processor per the recipe. DE #2 poured the pureed cheesecake into bowls, she did not measure the pureed cheesecake. 5. At 12:27 PM, DE #2 picked up a stainless pan of mixed vegetables and poured it into the food processor. a. At 12:40 PM, DE #2 checked the mixed vegetables and poured them into a stainless pan. The puree dripped off spoon and was a thin consistency. After the Surveyor checked the texture of the mixed vegetables, the Surveyor asked DE #2 about the consistency of the puree. DE #2 asked, Is it too runny? The surveyor stated, Do you think it is too runny for puree? DE #2 stated, I think it's ok. b. At 12:44 PM, DE #2 placed the mixed vegetables puree on the steam table. 6. On 11/09/22 at 02:23 PM, The Surveyor requested the recipe for lunch from the Dietary Manager (DM). The Surveyor asked the DM, How do you know residents are receiving adequate nutrients? The DM stated, I follow the guidelines on the spreadsheets. That tells us how much to serve. The Surveyor pointed to the recipe binder and asked, Should those recipes be followed? The DM stated, Yes. The Surveyor asked, If the recipes are not followed, could that negatively affect the residents? The DM stated, Yes, very much. Ok, say they are diabetic and can only have a certain amount of carbs [carbohydrates] and you don't follow the recipe you could be doubling the carb intake. The Surveyor referred to the puree recipes and asked the DM, Should all ingredients listed be included when following the recipes? The DM stated, Yes, if it calls for ingredients, they all should be in there. The Surveyor informed DM that milk was not added to lemon cheesecake bars. The Surveyor asked if pureed items should be pureed together. The DM stated No, they should be individual foods, as they would be if they were not pureed. The Surveyor informed the DM that the spaghetti noodles, meat sauce, and breadsticks were all pureed together. The Surveyor asked the DM, What should the consistency of puree be like? The DM stated, Like a pudding that does not fall off a spoon. The Surveyor informed the DM of the vegetable puree that ran off spoon and pieces of food not smooth in spaghetti mix puree. The Surveyor asked, How often do dietary staff receive training for proper preparation of foods? The DM stated, I just took over. I am not sure. I was trained in the beginning. I ran everything past him [previous DM]. I think DE #1 was just nervous. 7. On 11/08/22 at 03:28 PM, the weekly menu and spreadsheets provided by the Administrator documented, .Wednesday .Regular/Puree .1/2 C (cup) Spaghetti noodles .1/2 C P Meat sauce .3/8 C P Italian vegetables .1/4 C P Garlic breadstick 3/8 C P Lemon Cheesecake bar .PUREED Diets should be pudding consistency . 8. On 11/09/22 at 02:59 PM, the recipes for Wednesday .Week: 3 .Lunch were provided by the DM which documented the following: a.P Spaghetti Noodles .Cook method: Puree .Ingredients Spaghetti Noodles and Milk, Homo Gal .To get the actual serving size, puree the number of portions needed, adding adequate liquid if needed to achieve desired consistency .then divide the total amount equally by the number of portions pureed .Blend until smooth, adding additional liquid/thickener as needed to obtain a pudding-like consistency .CCP (Critical Control Point) Reheat to an internal temperature of >165F held for 15 seconds . b.P Meat Sauce .Cook method: Puree .Ingredients Meat Sauce and Sauce tomato .To get the actual serving size, puree the number of portions needed, adding adequate liquid if needed to achieve desired consistency .then divide the total amount equally by the number of portions pureed .Blend until smooth, adding additional liquid/thickener as needed to obtain a pudding-like consistency .CCP - Reheat to an internal temperature of >165F held for 15 seconds .Maintain at an internal temperature of >140F for only 4 hours . c.P Italian Vegetable .Cook method: Puree .Ingredients Italian vegetable blend . To get the actual serving size, puree the number of portions needed, adding adequate liquid if needed to achieve desired consistency .then divide the total amount equally by the number of portions pureed . Blend until smooth, adding additional liquid/thickener as needed to obtain a pudding-like consistency .CCP - Reheat to an internal temperature of >165F held for 15 seconds .Hold at 140F throughout service . d. No recipe for puree breadsticks was provided. e.P Lemon Cheesecake Bar .Cook Method: Puree .Ingredients Lemon Cheesecake bar and Milk, Homo Gal .To get the actual serving size, puree the number of portions needed, adding adequate liquid if needed to achieve desired consistency .then divide the total amount equally by the number of portions pureed .Blend until smooth, adding additional liquid/thickener as needed to obtain a pudding-like consistency .CCP - Chill to an internal temperature of <41F .Maintain at an internal temperature of <41F . 9. On 11/10/22 at 01:00 PM, the Menu policy was provided by the Administrator which documented .1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board .

Based on interview and record review, the facility failed to ensure pneumococcal immunizations were administered to eligible residents and immunization records were tracked and documented completely for 4 (Resident #5, R #10, R #63, and R #133) of 5 (Resident #5, R #10, R #59, R #63, and R #133) sample selected residents who had signed consents for the pneumococcal vaccine to help protect against pneumococcal bacteria which can cause serious infections and was potentially fatal. The findings are: 1. On 11/07/22 at 04:09 PM, the Infection Control and Preventionist (ICP) provided the resident immunization lists. 2. On 11/08/22 at 08:20 PM, The Surveyor reviewed the resident immunization records and found the following: a. Resident #5 had diagnoses of Type 2 Diabetes Mellitus and Malignant neoplasm of head, face and neck and had a signed Pneumococcal consent dated 4/20/22. b. Resident #10 had diagnoses of Type 2 Diabetes Mellitus and Idiopathic Epilepsy and had a signed Pneumococcal consent dated 6/28/18. c. Resident #63 had diagnoses of Type 2 Diabetes Mellitus and Acute kidney failure and had a signed Pneumococcal consent dated 4/29/22. d. Resident #133 had diagnoses of Type 2 Diabetes Mellitus and chronic kidney disease and had a signed Pneumococcal consent dated 4/19/22 which documented Pneumococcal was received at [Named Medical Facility] 4/3/22. 3. On 11/09/22 at 10:07 AM, The Surveyor asked the ICP to access R #63's immunization electronic record. The ICP stated, Her consent was signed when they completed new admission packets. The Surveyor asked, How long after consent is received should a resident receive their immunization? The ICP stated, I should make sure they receive them swiftly to be honest. I've been working the halls. I know technically it should have already been done. The Surveyor asked the ICP to access R #10's immunization electronic record. The ICP stated, Hers is the same situation regarding the consent but I called her POA [Power of Attorney], and she has cancer, so I reached out to her surgeon [in another city]. I am waiting to see if he feels the immunization is ok to receive. The Surveyor asked, Have you documented that you reached out to the surgeon? The ICP stated, No, I have not. I should have. The Surveyor asked the ICP to access R #133's Immunization Electronic Record. The ICP stated, I thought I had updated this one. R #133 refused the Flu vaccine when we did them last month and told me that she would do it later. I did not document that either. The Surveyor asked about the Pneumococcal discrepancy in the records. The ICP stated, I thought I had updated that and put in her vaccine from [Medical Facility]. The Surveyor asked the ICP to access R #5's Immunization Electronic Record. The ICP stated, His is the same as R #63's and R #10's. He gave consent with the new admission packets, but he refuses when we go to give them. Surveyor asked, Where do you note the residents that need and have consented to vaccinations or have refused? The ICP stated, I do not make notes. I just write them down. 4. On 11/07/22 at 04:00 PM, The Administrator provided the Pneumococcal Vaccine Policy which documented, .1. Each resident will be assessed for pneumococcal immunization upon admission .2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated .7. the resident's medical record shall include documentation that indicates at a minimum, the following: .b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal .

Based on observation and interview the facility failed to ensure the Dietary Manager (DM) had the necessary education and qualifications to meet the Centers for Medicare and Medicaid Services (CMS) minimum requirements to ensure nutritional needs and food safety needs were met for the 74 residents who resided in the facility and received trays from the kitchen. The findings are: a. On 11/07/22 at 09:03 AM, Dietary Employee (DE) #2 walked into the kitchen and the Surveyor introduced herself and asked if the Dietary Manager (DM) would be in later. DE #2 stated the facility did not have a DM and the Administrator was currently filling in as the DM until they found one. b. On 11/08/22 at 03:18 PM, The Surveyor asked the Administrator, When the DM would be available? The Administrator stated, We do not have a certified Dietary Manager. (Named) is the DM, but she is in training through [named] university. The Surveyor asked when the DM worked. The Administrator stated, She has been filling in in the evenings. The Surveyor asked the Administrator if they had a full time Dietician. The Administrator stated they have one that they could call if the Surveyor needed to ask her any questions. c. On 11/09/22 at 02:23 PM, the Surveyor asked the DM How often do dietary staff receive training for proper preparation of foods? The DM stated, I just took over. I am not sure. I was trained in the beginning. I ran everything past him [previous DM]. The DM explained that she is currently in training and has been covering the evening shift and has not had time to train the kitchen staff or oversee what they are doing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a sufficient number of competent staff were employed to carry out the functions safely and effectively for 1 of 1 kitchen in the facility which fed 74 residents according to the Diet List provided by the Administrator on 11/7/22. The findings are: 1. On 11/07/22 at 08:58 AM, the Surveyor asked Dietary Employee (DE) #1 if the Dietary Manager (DM) was available. DE #1 stated DE #2 (the Cook), was available once she returned from taking out the trash. 2. On 11/07/22 at 09:03 AM, there was a sandwich in an open plastic bag with no date on the prep table. 3. On 11/07/22 at 09:03 AM, DE #2 walked into the kitchen, the Surveyor asked if the DM would be in later. DE #2 stated the facility did not have a DM and the Administrator was currently filling in as the DM until they found one. The Surveyor asked DE #2 to complete the kitchen tour with the Surveyor. DE #2 stated she was available if the Surveyor needed, but there was only two of us and one dish washer in the kitchen. 4. On 11/07/22 at 09:05 AM, there were 6 open plastic containers of spices on a shelf above a stainless-steel prep table with no designated received or opened date on the container. 5. On 11/07/22 at 09:09 AM, the Surveyor observed a plastic jug of vanilla dated 11/5, with no designation of a received date or open date, a plastic container of [NAME] Enchilada sauce with no lid and no date, a plastic container of tartar sauce dated 10/7, with no designation of a received date or open date, two plastic containers of [NAME] sauce marked opened 3/22, with no received date, and five cottage cheese plastic containers that did not contain cottage cheese and were not labeled or dated with the ingredients. 6. On 11/7/22 at 09:17 AM, there were open box of peas dated 8/30 with the bag not tied/sealed and whiteish grey ice crystals on the peas 7. - open box of pie dough dated 8/28 with the bag not tied/sealed and whiteish grey ice crystals on the dough 8. - open box of strawberries dated 9/27 with the bag not tied and whiteish grey ice crystals on the strawberries 9. - open box of cauliflower pieces dated 10/31 with the bag not tied and whiteish grey ice crystals on the cauliflower 10. - open box of cinnamon rolls dated 11/1 with the bag not tied and whiteish grey ice crystals on the rolls 11. - open box of roll dough dated 11/3 with the bag not tied 12. - plastic bag of tator tots with a black clip holding bag closed and not dated open boxes of food in the walk-in freezer with the enclosed bags not tied/sealed and whiteish grey ice crystals on the food. 13. On 11/7/22 at 09:23 AM, there was a plastic package of sliced ham and two bags of hotdog buns not dated, and a Ziploc bag of French toast dated 11/6 with no received date in the walk-in refrigerator. 14. On 11/7/22 at 09:28 AM, there was food in five plastic bins, in the original bags, with the tops cut off, not dated. 15. On 11/7/22 at 09:31 AM, there were two plastic containers of macaroni and rice with no date in the dry storage room. 16. On 11/7/22 at 09:36 AM, there were 3 open boxes of meat with the enclosed bags not tied/sealed and whiteish grey ice crystals on the foods, 1 Ziploc bag of undiscernible meat labeled chicken dated 10/19 covered in whiteish grey ice crystals, and five Ziploc bags of undiscernible meats dated 10/18 that were covered in whiteish grey ice crystals in the meat freezer of the dry storage room. 17. On 11/7/22 at 09:39 AM, The Surveyor used a white napkin to wipe a brown substance from the inside of the ice machine and showed DE #2. The Surveyor asked the DE #2 to describe the substance on the napkin and on the plastic divider in the ice machine. The DE #2 stated, It looks like brown mold. 18. On 11/7/22 at 09:45 AM, The Surveyor wiped the inside of the ice machine in the Blue Hall Dining Room with a white napkin, there was a thick, pink substance on it. No staff witnessed or commented. 19. On 11/08/22 at 03:18 PM, the Surveyor asked the Administrator, When would the DM be available? The Administrator stated, We do not have a certified Dietary Manager. (Named) is the DM, but she is in training through the [named University] of (named state). The Surveyor asked when the DM worked. The Administrator stated, She has been filling in in the evenings. 20. On 11/09/22 at 11:25 AM, DE #1 placed a wet sheet pan against other sheet pans under the prep counter and a wet pot turned upside down on top of another pot under the prep counter. 21. On 11/09/22 at 11:27 AM, DE #1 placed a wet stainless colander upside down on top of another colander under the prep counter. 22. On 11/09/22 at 11:29 AM, the Surveyor observed DE#2 puree the spaghetti, the meat sauce, and the breadstick all combined and not as separate foods, per the recipes. 23. On 11/09/22 at 11:41 AM, DE #1 removed a white plastic container with a lid, not sealed or closed, from the stainless standing refrigerator and removed the lid the remainder of the way and scooped chocolate pudding into cups. 24. On 11/09/22 at 12:23 PM, DE #2 poured the pureed cheesecake into bowls, she did not measure the pureed cheesecake. 25. On 11/09/22 at 12:40 PM, the Surveyor asked if the consistency of the mixed vegetable puree was too runny, DE #2 responded with I think it's ok. 26. On 11/09/22 at 12:44 PM, DE #2 placed the mixed vegetables puree in a steam table and checked the temperature. The puree was 106 degrees Fahrenheit (F). The Surveyor asked DE #2 What is the appropriate temperature for food to be held in the steam table? DE #2 stated, 140 degrees. The Surveyor asked, Were all foods the appropriate temperatures? DE #2 stated, Yes. The Surveyor asked the appropriate temperature for cold foods. DE #2 stated, 41 degrees. DE #2 took the temperature of a carton of milk which was 45.1 degrees F and left the milk cartons in the stainless pan on the line. 27. On 11/09/22 at 02:23 PM, the Surveyor asked the Dietary Manager (DM), How often do dietary staff receive training for proper preparation of foods? The DM stated, I just took over. I am not sure. I was trained in the beginning. I ran everything past him [named previous DM]. I think DE #1 was just nervous. The DM explained that she was currently in training and had been covering the evening shift and had not had time to train the kitchen staff or oversee what they were doing. 28. The Surveyor asked the DM, How should dishes, pots and pans be dried? The DM stated, Maybe with a certain chemical that dries them after they are clean. 29. On 11/7/22 at 03:20 PM, the two-week Dietary schedule for November, provided by the Infection Control Preventionist, designated which staff would perform the following tasks and functions of a kitchen which served 74 residents: a. the DM was scheduled as the DW [Dishwasher] on 11/10/22, 11/12/22, 11/17/22, and 11/22/22. b. a cook was assigned as the DW on 11/11/22, 11/15/22, 11/18/22, and 11/21/22. c. 3 staff (1 cook, 1 aide, and 1 DW) were scheduled 6a to 1p and 3 staff were scheduled 1p to 8p on 11/10/22,11/15/22, 11/18/22, 11/21/22, and 11/22/22. d. 3 staff (1 cook, 1 aide, and 1 DW) were scheduled 6a to 1p and 2 staff (1 cook and 1 aide) were scheduled 1p to 8p on 11/14/22, 11/16/22, and 11/23/22. e. 2 staff (1 aide and 1 DW) were scheduled 6a to 1p and 2 staff (1 cook and 1 DW) were scheduled 1p to 8p 11/12/22 and 11/17/22. f. 2 staff (1 cook and 1 DW) were scheduled 5a/7a to 1p and 4 staff (1 cook, 1 aide, and 2 DW) were scheduled 1p to 8p/7p on 11/13/22. g. No staff was scheduled prior to 1p, and 3 staff (1 cook, 1 aide, and 1 DW) were scheduled 1p to 8p on 11/11/22. h. 1 cook was scheduled 5a to 1p and 3 staff (1 cook, 1 aide and 1 DW) were scheduled 1p to 8p on 11/19/22. i. 1 DW was scheduled 7a to 1p and 3 staff (1 cook, 1 aide, and 1 DW) were scheduled 1p to 8p/7p on 11/20/22. j. A statement at the bottom of the schedule documented Employees get 2/15-minute breaks and 1/30 break which left no or 1 staff in the kitchen, for 1 or 2 hours, on 9 of the 14 days of the schedule provided (11/11/22, 11/12/22, 11/13/22, 11/14/22, 11/16/22, 11/17/22, 11/19/22, 11/20/22, and 11/23/22).

Based on observation, interview, and record review, the facility failed to ensure meals were not prepared and held on the steam table losing nutritive value, flavor, and appearance; meals were held and served at acceptable temperatures, hot foods were maintained at or above a temperature of 135 degrees Fahrenheit (F.), and cold foods were maintained at or below 41 degrees (F.) while awaiting service to prevent potential food borne illness and to improve palatability and encourage good nutritional intake during 1 of 1 meal observed for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 74 residents who received a tray from the kitchen, as documented on a list provided by the Administrator on 11/7/22. The findings are: 1. On 11/09/22 at 11:33 AM, Dietary Employee DE #2 placed the mechanical soft spaghetti mixture and mixed vegetables on the steam table. The Dietary Manager (DM) entered the kitchen. 2. On 11/09/22 at 11:43 AM, the DE #2 made a grilled cheese sandwich on the stove, (wrapped the grilled cheese sandwich) in foil and placed it on the steam table. 3. On 11/09/22 at 12:28 PM, DE #2 checked the steam table line temperatures. The pureed spaghetti, meat and bread mixture was 136.3 degrees F. DE #2 left it on the steam table. 4. On 11/09/22 at 12:30 PM, The lemon cheesecake was 48.3 degrees (F) and DE #2 threw it away and left the rest of the servings on the trays to be served. 5. On 11/09/22 at 12:44 PM, DE #2 placed the mixed pureed vegetables on the steam table and checked the temperature. They were 106 degrees (F). The Surveyor asked DE #2 What is the appropriate temperature for food to be held in the steam table? DE #2 stated, 140 degrees. The Surveyor asked, Were all foods at the appropriate temperatures? DE #2 stated, Yes. The Surveyor asked the appropriate temperature for cold foods. DE #2 stated, 41 degrees. DE #2 took the temperature of a carton of milk which was 45.1 degrees (F) and left the milk cartons in the stainless pan on the line to be served. 6. On 11/09/22 at 12:46 PM, DE #2 and DE #1 prepared food trays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure foods stored in the kitchen freezer, refrigerators, and dry storage area were labeled and dated when received and/or opened; foods in unit refrigerators were labeled and dated; clean dishes were properly stored; 2 of 2 ice machines were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages; hot foods were maintained at or above a temperature of 135 degrees Fahrenheit (F), and cold foods were maintained at or below 41 degrees F. while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 74 residents who received meal trays and beverages from the kitchen, as documented on a list provided by the Administrator on 11/7/22. The findings are: 1. On 11/07/22 at 09:03 AM, there was a sandwich in an open plastic bag with no date on the prep table. The Surveyor asked Dietary Employee (DE) #2, What is this sandwich from? DE #2 stated, It must be a left over or something a resident requested. The Surveyor asked if it should be dated. DE #2 stated, Yes, it should be dated. 2. On 11/07/22 at 09:05 AM, the following were on a shelf above a stainless prep table in the middle of the kitchen: a. An open plastic container of Chili powder dated 12/14, 1/3 of the container remained, there was no designation of a received date or an opened date. b. An open plastic container of Italian Seasoning dated 9/5 was covered in a greasy clear substance, ½ of the container remained, there was no designation of a received date or an opened date. c. An open plastic container of Nutmeg dated 9/6, 3/4 of the container remained, there was no designation of a received date or an opened date. d. An open plastic container of Paprika with the lid open, had no date, and was covered in a greasy clear substance e. An open plastic container of Pepper with the lid open, dated 9/10, ¼ of the container remained, there was no designation of a received date or an opened date. f. An open plastic container of Cinnamon dated 10/22, ½ of the container remained, there was no designation of a received date or an opened date. g. An open plastic container of chicken base dated 9/27, 1/4 of the container remained, covered in a greasy clear substance, there was no designation of a received date or an opened date. h. An open plastic bottle of lemon juice, 1/3 of the container remained with no date 3. On 11/07/22 at 09:09 AM, the following were in the stainless 3-door refrigerator: a. A plastic jug of vanilla dated 11/5, 1/3 of the jug remained, there was no designation of a received date or an opened date b. A plastic container of Enchilada sauce with no lid and no date c. A plastic container of tartar sauce dated 10/7, 1/2 of the container remained, with no designation of a received date or an opened date d. Two plastic containers of sauce marked opened 3/22, with no received date e. five cottage cheese plastic containers that did not contain cottage cheese and were not labeled or dated with ingredients 4. The Surveyor asked the DE #2 to come over to the refrigerator. The Surveyor asked what was in the cottage cheese containers. The DE #2 stated, It could be cottage cheese or leftovers. They should be labeled and dated. The dates on the containers are not right. They might have been written on and just come off. I don't have enough clear containers. Is it ok to reuse plastic containers of other food? The Surveyor observed six more cottage cheese containers labeled Raw HB 11/6, Baked pot 11/6, applesauce 11/5, salad 11/6, ham 11/6, and cottage cheese 11/6. 5. On 11/7/22 at 09:17 AM, the following were in the walk-in freezer: a. An open box of peas dated 8/30 with the bag not tied/sealed, had whiteish grey ice crystals on the peas. b. An open box of pie dough dated 8/28 with the bag not tied/sealed, had whiteish grey ice crystals on the dough. c. An open box of strawberries dated 9/27 with the bag not tied, had whiteish grey ice crystals on the strawberries. d. An open box of cauliflower pieces dated 10/31 with the bag not tied, had whiteish grey ice crystals on the cauliflower. e. An open box of cinnamon rolls dated 11/1 with the bag not tied, had whiteish grey ice crystals on the rolls f. An open box of roll dough dated 11/3, the bag was not tied. g. A plastic bag of tator tots with a black clip holding the bag closed, was not dated. 6. On 11/7/22 at 09:23 AM, the following were in the walk-in refrigerator: a. A plastic package of sliced ham was not dated. b. Two bags of hotdog buns were not dated. c. A Ziploc bag of French toast dated 11/6 had no received date. d. The Surveyor handed DE #2 the box of open peas and asked, How should open boxes of foods be stored in the freezer? DE #2 stated, The bag inside should be tied. Some of the other cooks don't do what they are supposed to. I try to train them all. The Surveyor asked DE #2, When are these tots from? DE #2 stated, I am not sure when they are from. The Surveyor asked, When was the sliced ham received? DE #2 stated, I am not sure. It was the last one in the box. I would have to check the box in the trash to see the date. 7. On 11/7/22 at 09:28 AM, the following were in containers behind the oven: a. A blue plastic bin of flour, in the original bag, top cut off, no date b. A white plastic bin of rice, in the original bag, top cut off, no date c. A yellow plastic bin of sugar, in the original bag, top cut off, no date d. A white round plastic tub of biscuit mix, in the original bag, top cut off, no date e. A light blue plastic bin of brown sugar with no date 8. On 11/7/22 at 09:31 AM, the following were in the dry storage room: a. A plastic container of Macaroni noodles was not dated. b. A plastic container of Long Grain [NAME] was not dated. 9. On 11/7/22 at 09:36 AM, the following were in the meat freezer in the dry storage room: a. An open box of corn dogs dated 11/1 with the bag not tied and whiteish grey ice crystals on the corn dogs b. An open box of chicken nuggets dated 10/30 with the bag not tied and whiteish grey ice crystals on the nuggets c. Five Ziploc bags of undiscernible meats dated 10/18 that were covered in whiteish grey ice crystals d. A Ziploc bag of undiscernible meat labeled chicken dated 10/19 covered in whiteish grey ice crystals. e. An open box of breaded chicken fillets not dated, the bag not tied and whiteish grey ice crystals on the fillets f. The Surveyor asked DE #, how should meats be stored in the freezer? DE #1 stated, They need to be sealed closed, so they don't get freezer burn. 10. On 11/7/22 at 09:39 AM, The Surveyor used a white napkin to wipe a brown substance from the inside of the ice machine and showed DE #2. The Surveyor asked DE #2 to describe the substance on the napkin and on the plastic divider in the ice machine. DE #2 stated, It looks like brown mold. The Surveyor asked, What could happen if the residents ingested ice with the substance on it? DE #2 stated, They could get sick. The Surveyor asked, How often is the ice machine cleaned? DE #2 stated, Once a month. 11. On 11/7/22 at 09:45 AM, The Surveyor wiped the inside of the ice machine in the Blue Hall Dining Room with a white napkin. The white napkin returned with a thick, pink substance on it. 12. On 11/7/22 at 09:48 AM, The Surveyor asked (Registered Nurse) RN #1, Where the resident refrigerator was on the Blue Hall. RN #1 opened a door next to the nurses' station. The Surveyor observed a can of [vegetable juice], a can of [soda], 5 containers of [energy drinks], two TV dinners, and a plastic container with a [name] written on it. The Surveyor asked, How do staff know whose items these are and how long they have been in here? The RN #1 stated, Well, I know [name] was not in here on Friday. I don't know about the rest. 13. On 11/09/22 at 11:25 AM, DE #1 placed a wet sheet pan against other sheet pans under the prep counter and a wet pot turned upside down on top of another pot under the prep counter. The Surveyor asked DE #1 How should pots and pans be dried? DE #1 stated, By air I guess. The Surveyor asked, Should pots and pans be put away when they are still wet? DE #1 stated, No, they should be dry. The Surveyor asked, What could happen if pots and pans are put away wet? The DE#1 stated, I don't know. a. At 11:27 AM, DE #1 placed a wet stainless colander upside down on top of another colander under the prep counter. 14. On 11/09/22 at 11:41 AM, DE #1 removed a white plastic container with a lid, not sealed closed, from the stainless standing refrigerator and removed the lid the remainder of the way and scooped chocolate pudding into cups. 15. On 11/09/22 at 12:44 PM, DE #2 placed the mixed vegetables puree in a steam table and checked the temperature. The puree was 106 degrees Fahrenheit (F). The Surveyor asked DE #2 What is the appropriate temperature for food to be held in the steam table? DE #2 stated, 140 degrees. The Surveyor asked, Were all foods the appropriate temperatures? DE #2 stated, Yes. The Surveyor asked the appropriate temperature for cold foods. The DE #2 stated, 41 degrees. DE #2 took the temperature of a carton of milk which was 45.1 degrees F and left the milk cartons in the stainless pan on the line. 16. On 11/09/22 at 02:23 PM, The Surveyor asked the DM, How should foods be dated? The DM stated, The date they were delivered. The Surveyor asked, What does the date staff write on food items represent? The DM stated, The date we made it or packaged it. The Surveyor asked, If a container of a previously used item is used for storage, how should the item be marked? The DM stated, Oh, you are referring to the cottage cheese containers. We must use them because we do not have enough clear storage containers. They should be dated the date made and labeled with the product in them. The surveyor asked, How should open boxes of food be stored in the freezer? The DM stated, The bag inside should be tied, and the box closed completely. The Surveyor asked, How should meat not in its original packaging be marked? The DM stated, It should be in a clear container and labeled raw product with the opened such and such date. The Surveyor asked, How should items in the dry storage room, not in original packaging, be stored? The DM stated, If it is not in its original packaging, it should be labeled and dated. The Surveyor asked the DM, How should dishes, pots and pans be dried? The DM stated, Maybe with a certain chemical that dries them after they are clean. The Surveyor asked the DM, Should dishes, pots, and pans be put away wet? The DM stated, No, not at all. The Surveyor asked the DM, What are possible outcomes if put away wet? The DM stated, Mold, mildew, bacteria, and things like that, that could make people sick. The Surveyor asked the DM, How often are ice machines cleaned? The DM stated, I think it is monthly. 17. On 11/10/22 at 01:00 PM, The Food Receiving and Storage policy was provided by the Administrator which documented, .7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date) .8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . 18. On 11/10/22 at 01:00 PM, the Ice Machine policy was provided by the Administrator which documented, .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .1. Ice-making machines, ice storage chests/containers, and ice can all become contaminated by: .b. waterborne microorganisms naturally occurring in the water source; c. colonization by microorganisms; and or d. improper storage or handling of ice .3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions . 8. On 11/10/22 at 01:00 PM, the Foods Brought by Family/Visitors policy was received from the Administrator which documented, .3. Foods brought by family/visitors for individual residents may not be shared with or distributed to other residents .7. Food brought by family/visitors that is left with the resident to consume later will labeled and stored in a manner that it is clearly distinguishable from facility prepared food .b. Containers will be labeled with the resident's name, the item and the use by date .8. The nursing staff will discard perishable foods on or before the use by date .