Based on observation, interview, and record review, the facility failed to ensure safe dietary services were provided to 88 of 93 residents who were served food from the kitchen, when:1. On 8/13/2025, from 5:30 am to 2:25 pm, liquid eggs (processed form of whole eggs, also known as cartoned eggs) were thawed (defrost) at room temperature (ambient temperature [actual temperature] measured by a thermometer around 73 degrees Fahrenheit ([ F]- a unit of temperature) without monitoring the time and temperatures. Liquid eggs were at 55 F which was within the danger zone [41-135 F] temperature range where bacteria grow quickly). 2. On 8/13/2025 from 12:10 p.m. to 1:30 p.m., ground beef was thawed at room temperature without time and temperature monitoring. At 12:10 p.m., the ground beef was at 64 F. At 1:30 p.m., [NAME] 3 placed the ground beef back into the refrigerator (fridge). 3. [NAME] 1 failed to check food temperatures (refers to the safe internal cooking temperatures for various types of food to prevent foodborne illnesses) of the regular, mechanical soft and pureed food preparations of beef steaks, mashed potatoes, and a carrot and green bean mix while cooking lunch on 8/12/2025 and the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage while cooking breakfast on 8/13/2025. 4. [NAME] 1 failed to check trayline (an assembly line to plate food for meals) food temperatures for lunch on 8/12/2025 and breakfast on 8/13/2025.5. On 8/12/2025, [NAME] 2 failed to check food cooking temperatures for lunch items.6. Dietary staff substituted green beans for carrots without the Registered Dietitian's ([RD] licensed healthcare professional who specializes in nutrition and dietetics) approval. 7. [NAME] 1 did not follow the recipe to thicken pureed food (a texture-modified food for residents who can't handle solid food due to things like chewing or swallowing difficulties, or gut issues) when preparing pureed food for lunch on 8/12/2025 and breakfast on 8/13/2025.8. [NAME] 1 did not follow a recipe to make the gravy (sauce) on 8/12/2025 for lunch.9. On 8/13/2025, [NAME] 1 used a broken metal whisk (a cooking utensil) to prepare breakfast items.10. The kitchen did not have any supervision from qualified personnel like a Dietary Supervisor, Dietary Services Manager (DSM), Certified Dietary Manager, or RD for food safety preparation.These deficient practices had the potential to cause foodborne illness (any illnesses caused by consuming foods or beverages contaminated with harmful bacteria, viruses and parasites or their toxins), food allergies, medical complications such as malnourishment (excesses or imbalances in a resident's intake of nutrients and or energy), choking (blockage of the upper airway by food or other objects that prevents breathing), aspiration pneumonia (a lung infection caused by inhaling oral contents into the lungs) to the 88 residents who received food from the kitchen, resulting in hospitalizations and death.On 8/13/2025 at 5:46 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of Registered Nurse (RN 2) with the Administrator (Admin) present via telephone due to the facility's failure to ensure safe and sanitary dietary services were provided. On 8/15/2025 at 2:45 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] interventions to immediately correct the deficient practices). After verification of IJRP implementation through observation, interview, and record review, the IJ was removed onsite on 8/15/2025 at 3:30 p.m. in the presence of the Admin, Regional [NAME] President of Operations (RVPO), and Licensed Vocational Nurse (LVN 2). The IJRP included the following immediate actions: 1. On 8/13/2025, the improperly thawed liquid eggs, ground beef and the broken whisk were discarded by the dietary staff. [NAME] 2 was removed from the dietary department schedule due to failure to respond to calls from the Admin to receive in-service for the improperly thawed meat and eggs, and temperature monitoring of food. [NAME] 2 remained off duty until the cook participated in individual in-service training sessions and competency assessed in areas including proper thawing and preparation of food, maintenance of sanitary equipment, notification and approval procedures with the RD for substitutions, verification of food temperatures, following recipes (including puree food and gravies) and menus. 2. On 8/13/2025, the Registered Dietitian (RD I) delivered initial in-service training to four of ten (10) dietary staff members, covering procedures for appropriate food thawing preparation (1. Under running water (submerging frozen food under running water at a temperature of 70 F), 2. refrigeration method (thawing food inside a refrigerator with temperature maintained at 41 F or lower to prevent the growth of dangerous microorganisms), and 3. microwave process (a quick and effective thawing method, requiring careful attention to ensure safety and even thawing), the new process for reviewing menus daily to pull frozen items and place in the refrigerator for thawing 3 days before use, equipment sanitation, notification protocols for substitutions, and monitoring food temperatures during cooking process and during trayline. Competency evaluations were conducted with verbal discussion and staff return demonstration to confirm comprehension of the material presented. 3. On 8/14/2025, the RD 1 conducted one-on-one in-service education (personalized, individualized training or professional development session designed to enhance an employee's skills, knowledge, or performance in their current role) to [NAME] 1 covering procedures for appropriate food thawing, the new process for reviewing menus daily to pull frozen items and place in the refrigerator for thawing 3 days before use, equipment sanitation, notification protocols for substitutions, and monitoring food temperatures during cooking process and during trayline, following recipes (including puree food and gravies) and menus. Competency evaluations were conducted with verbal discussion and staff return demonstration to confirm comprehension of the material presented. 4. On 8/14/2025, RD 1 conducted an initial in-service education to 1 more dietary personnel, for a total of 6 out of 10 dietary personnel. The in-service covered procedures for appropriate food thawing preparation, the new process for reviewing menus daily to pull frozen items and place in the refrigerator for thawing 3 days before use, equipment sanitation, notification protocols for substitutions, monitoring food temperatures during the cooking process and during trayline and following menus and recipes. Competency skills check was completed to verify understanding of topics discussed. In-service education will proceed until all dietary staff have received instruction and demonstrated competency. One of the remaining employees is currently on vacation and will receive training prior to their next scheduled shift upon returning to work. The RD 2 will provide ongoing monthly in-services for existing staff and onboard training for new employees. New dietary staff will complete a competency checklist during orientation and annually thereafter, facilitated by the Certified Dietary Manager or RD. 5. On 8/13/2025 and 8/14/2025, RD 1 verified competency with verbal discussions with staff return demonstration of the 6 dietary staff that were provided with in-service education, through skills check evaluation regarding appropriate food thawing (1. Under running water, 2. refrigeration method, and 3. microwave process; thawing food at room temperature will no longer be used), the new process for reviewing menus daily to pull frozen items and place in the refrigerator for thawing 3 days before use, food preparation, equipment sanitation, notification protocols for substitutions, monitoring food temperatures during food preparation and during trayline, location of recipes, and following menus and recipes. All cooks will check food temperatures while cooking and during trayline. The cook will log the temperatures in the temperature log binder. An audit was completed to verify the recipes are available for pureed diet and for gravy. The recipes were confirmed and available in a binder. 6. On 8/14/2025, the Admin provided one-on-one in-service to RD 2 regarding the oversight and approval of meal substitutions. RD I or RD 2 will review all substitutions for appropriate equivalent nutritional value and sign-off on the alternative food item as a substitute on the dietary substitution form. Additionally, the RD will review menus and recipes and conduct inventory of stock to place food orders to ensure recipes are followed and therefore minimize the need for substitutions. 7. On 8/14/2025, dietary staff, Admin, and RD 2 performed a comprehensive sanitation inspection of the kitchen using the Dietary Skills Checklist form, emphasizing correct food thawing procedures and equipment. 8. All 82 residents who received meals from the kitchen were evaluated by the designated Licensed Nurses for any gastrointestinal symptoms of foodborne illness, food allergy, medical complications such as malnourishment, choking, aspiration pneumonia. No issues have been identified. Designated Licensed Nurses notified the attending physicians regarding the identified deficient practice. Nursing Staff will continue to monitor residents for seventy-two (72) hours for any potential symptoms of gastrointestinal symptoms or changes in condition. Should any concerns arise, attending physicians will be promptly informed for fm1her assessment and management as appropriate.Findings: 1. During an observation on 8/13/2025 at 6:15 a.m. in the kitchen, a (cardboard [heavyweight paper-based]) box (container used for packaging) labelled Liquid Egg Product and Keep Refrigerated 33 F - 40 F was on the countertop next to the stove. The cardboard box contained a bag filled with yellow liquid eggs that was cold and hard to touch. During a concurrent interview and record review on 8/13/2025 at 9:53 a.m. with Registered Nurse (RN 1), the facility's policy and procedure (P&P) titled, Food Preparation, dated 2023, was reviewed. RN 1 stated the P&P indicated food preparation should be supervised by the Director of Food and Nutrition Services and reviewed by the Registered Dietitian, employees should prepare food in a safe manner to protect residents from foodborne illnesses and the facility should use proper defrosting methods in defrosting frozen food. RN 1 stated the P&P indicated, prepared food should be stored at proper temperature until serving time and the temperature forms should be utilized. RN 1 stated the P&P also indicated, cold foods must be kept at or under 41 F, and hot foods at or more than 140 F. RN 1 stated food (unspecified) must be kept in safe temperature zones. RN 1 stated there were 88 of 93 residents in the facility who ate food served from the kitchen. RN 1 stated these residents had the potential to develop foodborne illness, dehydration (a state where the body loses more water than it takes in, resulting in a lack of fluid), and hospitalization, if cold food was kept over 41 degrees. During a concurrent observation and interview on 8/13/2025 at 12:10 p.m., with [NAME] 1 in the kitchen, the box labelled Liquid Egg Product and Keep Refrigerated 33 F - 40 F was in the same area on the countertop next to the stove, as previously observed on 8/13/2025 at 6:15 a.m. The box and bag (containing the liquid egg) were wet and felt soft and cold when touched. The temperature of the liquid egg was 55 F. [NAME] 1 stated he removed the box of liquid eggs from the freezer on 8/13/2025 at 5:30 a.m. [NAME] 1 stated the eggs were being thawed until completely defrosted (liquid in consistency). [NAME] 1 stated [NAME] 3 would place the box of liquid eggs in the refrigerator that evening to be cooked tomorrow morning. [NAME] 1 stated he was not trained in how to thaw frozen food. [NAME] 1 stated countertop thawing at room temperature was standard practice in the facility's kitchen. [NAME] 1 stated the facility did not have a temperature monitoring log when thawing food and there was no Pull Schedule (schedule of when to pull food from the freezer) to thaw. During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated food should never be thawed at room temperature. RD 1 stated thawing food at room temperature was not safe and placed residents at risk of foodborne illness. RD 1 stated the cooks should have thawed the frozen eggs in the refrigerator, or through one of three safe methods to prevent bacterial growth and potential illness in residents. RD 1 stated the cooks should have used one of the following safe thawing options: labelling and placing the liquid eggs in the fridge, fully submerging the bag of liquid eggs under running water or microwaving the bag of eggs. RD 1 stated temperatures of thawing food had to be monitored and recorded throughout the thawing process to limit the amount of time that the food temperature was held in the danger zone. During a concurrent observation and interview on 8/13/2025 at 2:25 p.m. with [NAME] 3 in the kitchen, the box labelled Liquid Egg Product and Keep Refrigerated 33 F - 40 F were observed on the countertop. [NAME] 3 stated the liquid eggs on the countertop were left to thaw at room temperature. [NAME] 3 stated she did not measure or record the temperatures and planned to put the liquid eggs in the fridge when fully defrosted to cook on 8/14/2025 for breakfast. [NAME] 3 stated eggs could be thawed at room temperature because eggs were not meat. [NAME] 3 stated thawing liquid eggs at room temperature was standard practice in the facility kitchen. During a concurrent interview and record review on 8/13/2025 at 2:35 p.m. with [NAME] 3, the facility's breakfast, lunch, and dinner menus and recipes dated 8/13/2025 through 8/16/2025 were reviewed. The menus and recipes indicated eggs on the menu for breakfast on 8/14/2025. [NAME] 3 stated eggs were on the menu on 8/14/2025 for breakfast. [NAME] 3 stated the liquid eggs in the box on the countertop had been thawing at room temperature for nine hours and were to be prepared for residents' breakfast on 8/14/2025. 2. During a concurrent observation and interview on 8/13/2025 at 12:10 p.m. with [NAME] 1 in the kitchen, a large tube of red, pink, and white substance was on the countertop. The outside of the plastic tube felt wet, soft and cold. [NAME] 1 stated the red, pink, and white substance in the cylinder-shape ([cylinder], tumbler shape) was ground beef. [NAME] 1 stated the temperature of the ground beef was 64 F. [NAME] 1 stated the large cylinder of raw, ground beef was removed from the freezer on 8/13/2025 around 9:45 a.m. [NAME] 1 stated he thawed the raw ground beef at room temperature to cook and serve as a meat option in case he ran out of the planned meat for dinner that evening of 8/13/2025. [NAME] 1 stated countertop thawing at room temperature was standard practice in the facility's kitchen. During an interview on 8/13/2025 at 2:25 p.m. with [NAME] 3 in the kitchen. [NAME] 3 stated the ground beef was placed in the fridge on 8/13/2025 around 1:30 p.m. (3.75 hours) after it was held at room temperature. [NAME] 3 stated the temperature of the beef was checked and was 39 F. [NAME] 3 stated the beef was safe in the fridge and could be cooked for the residents' future meals.During a concurrent interview and record review on 8/13/2025 at 2:35 p.m. with [NAME] 3, the facility's menu and recipes for 8/13/2025 through 8/18/2025 were reviewed. [NAME] 3 stated, there was no ground beef on the menu for any meals from 8/13/2025 through 8/16/2025. [NAME] 3 stated the thawed ground beef could safely be returned in the fridge and stored, cooked, and served to residents within the next week. 3. During an observation on 8/12/2025 from 11:35 a.m. to 12:45 p.m., in the kitchen, [NAME] 1 did not measure or record food temperatures of the regular, mechanical soft, and pureed food preparations of the beef steaks, mashed potatoes, and the carrot and green bean mix while cooking lunch. During an interview on 8/12/2025 at 12:00 p.m., with [NAME] 1, [NAME] 1 stated, he did not have time to monitor or record any food temperatures during cooking.During an observation on 8/13/2025 from 6:15 a.m. to 8:05 a.m. in the kitchen, [NAME] 1 did not measure or record food temperature when preparing the regular, mechanical soft, and pureed food preparations of grits (corn dish), scrambled eggs, ground turkey, and turkey sausage for breakfast.During an interview on 8/13/2025 at 8:05 a.m., [NAME] 1 stated breakfast was served one hour late and he had no time to monitor or record any food temperatures during cooking. During an interview on 8/13/2025 at 9:53 a.m. with RN 1, RN 1 stated food temperatures must be monitored while cooking and serving meals to decrease the risk of foodborne illness and to improve residents' satisfaction. RN 1 stated foodborne illness had the potential to cause residents to be dehydrated and hospitalized .During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated, cooks should follow the facility's P&P when cooking protein items such as beef and chicken. RD 1 stated the P&P indicated Cooks must monitor and record the food cooking temperature in the temperature log. RD 1 stated not monitoring food temperatures may cause undercooked food, food temperatures in the danger zone, bacterial growth and place residents at risk of foodborne illnesses. 4. During an observation on 8/12/2025 at 12:10 p.m., of the lunch trayline, in the kitchen, [NAME] 1 did not measure or record food temperatures of the regular, mechanical soft, and pureed food preparations of the beef steaks, mashed potatoes, and the carrot and green bean mix for lunch service prior to starting the trayline and serving lunch. During an observation on 8/13/2025 from 6:20 a.m. to 8:05 a.m., of the breakfast trayline in the kitchen, [NAME] 1 did not measure or record food temperatures prior to starting trayline and serving the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage for breakfast. During an interview on 8/13/2025 at 8:05 a.m. with [NAME] 1, [NAME] 1 stated he did not have time to measure trayline temperatures prior to serving the regular, mechanical soft, and pureed food preparations of grits, scrambled eggs, ground turkey, and turkey sausage for breakfast on 8/12/2025 and lunch on 8/13/2025. [NAME] 1 stated he did not know where the Food Temperature Log was and placed. During a concurrent interview and record review on 8/14/2025 at 12:33 p.m. with [NAME] 2, the facility's Food Temperature Log for 8/2025 was reviewed. [NAME] 2 stated the Food Temperature Log indicated food temperatures were not measured or recorded for meal items on the following dates and were blank: 1. 8/6/2025, 8/7/2025, 8/8/2025, 8/10/2025, 8/11/2025, 8/12/2025, and 8/13/2025 for hot food served for breakfast.2. 8/6/2025, 8/7/2025, 8/8/2025, 8/10/2025, 8/11/2025, and 8/12/2025 for hot food served for lunch.3. 8/6/2025, 8/9/2025, 8/11/2025, and 8/12/2025 for all food served for dinner.Cook 2 stated the Food Temperature Log was only used to record trayline temperatures prior to starting trayline. [NAME] 2 stated food temperatures were supposed to be measured and recorded prior to starting trayline for every meal. 5. During a concurrent interview and observation on 8/12/2025 at 12:15 p.m., with [NAME] 2 in the kitchen, [NAME] 2 did not measure the temperature of ground turkey while cooking. [NAME] 2 plated (placed on a plate) and served the ground turkey to 16 residents without measuring or recording the temperature. [NAME] 2 stated he did not check the temperature of the ground turkey. [NAME] 2 stated the ground turkey was safe for residents' consumption based on the meat's color. [NAME] 2 stated he had decades of cooking experience and did not need a thermometer (equipment to measure temperature) to check food temperatures. During an observation on 8/12/2025 at 12:45 p.m., CNA 4 served the ground turkey to three residents that was prepared by [NAME] 2 on 8/12/2025 at 12:15 p.m. with the temperature not measured or recorded. During an interview on 8/13/2025 at 1:00 p.m., with RD 1, RD 1 stated cooked food must reach certain temperatures while cooking and prior to serving to limit bacteria growth and decrease the potential for food-borne illnesses. RD 1 stated meat temperatures must be measured and recorded in the food temperature log while cooking and prior to serving. 6. During a review of the facility's menu, dated 8/12/2025, the menu indicated roasted carrots for lunch. During a concurrent observation and interview on 8/12/2025 at 9:55 a.m. with [NAME] 1 in the kitchen, a small bag of carrots was in the fridge. [NAME] 1 stated the facility did not have enough carrots to serve full portions to over 80 residents. [NAME] 1 stated he did not ask RD 1 what to substitute for the carrots. [NAME] 1 stated he will substitute missing carrots with green beans for the vegetable serving. During an observation on 8/12/2025 at 12:00 p.m., in the kitchen, three trays of mixed steamed carrots and green beans, chopped green beans, and pureed green beans instead of carrots were served to 71 residents, for lunch.During an observation 8/12/2025 at 12:33 p.m. in the kitchen, [NAME] 1 ran out of the regular textured steamed carrots and green beans for 9 residents. [NAME] 1 substituted the missing steamed carrots, and green beans mixed with two scoops of mashed potatoes for 4 residents who were on regular textured diets. [NAME] 1 substituted a reheated fried vegetable roll for carrots and green beans and served to 5 residents on regular texture diets.During an interview on 8/12/2025 at 12:37 p.m. with [NAME] 1, [NAME] 1 stated he did not inform RD 1 about the carrots substitutions because he did not have time. [NAME] 1 stated he ran out of regular texture vegetable servings for 9 regular texture trays. [NAME] 1 stated he replaced the missing vegetable serving with an extra scoop of mashed potatoes or a reheated fried vegetable roll. [NAME] 1 stated he knew the nutritional value was not the same but had used all the vegetables he had.During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated she was not notified about any food shortages and was not asked about any dietary substitutions over the past week. RD 1 stated the facility had a list of approved food substitutions in case of shortages. RD 1 stated carrots and green beans were not of similar nutritive value. RD 1 stated deviating (changing or not following) recipes could introduce allergens and cause allergic reactions for residents. RD 1 stated not following the menu and recipes had the potential for residents to lose weight, develop vitamin or mineral deficiencies, and skin issues. 7. During a concurrent observation and interview on 8/12/2025 at 11:35 a.m., [NAME] 1 used an unmarked, white, Styrofoam (made of a lightweight, disposable plastic) cup to transfer white powdered thickener from a plastic storage bin to pureed food items. [NAME] 1 stated the Styrofoam cup was a drinking cup with no measurement indicators. [NAME] 1 stated he eyeballed (looked) to measure the thickener and did not use a system or method to evaluate the thickness of the pureed foods.During an interview on 8/13/2025 at 9:53 a.m. with RN 1, RN 1 stated residents on pureed texture diets had issues with swallowing. RN 1 stated if pureed texture diets were not provided, residents had the potential to choke, aspirate and develop pneumonia, requiring hospitalization and could cause death.During an interview on 8/13/2025 at 1:00 p.m., with RD 1, RD 1 stated, the cooks should follow the manufacturer's instructions and P&P to thicken pureed food items. RD 1 stated, not following instructions to prepare a thickener could cause pureed items to be too runny, potentially causing choking, aspiration, and pneumonia. RD 1 stated not following recipes could alter the calories, vitamins, and minerals of each meal, potentially causing residents' weight loss and skin breakdown. 8. During a concurrent observation and interview on 8/12/2025 at 11:35 a.m. with [NAME] 1 in the kitchen, gravy was observed boiling on the stove. [NAME] 1 stated there was no pre-made gravy available for lunch. [NAME] 1 stated he prepared the gravy by mixing milk, garlic powder, and powdered beef broth. [NAME] 1 stated he did not have a recipe on how to make gravy. [NAME] 1 stated the lunch menu indicated to use pre-made gravy. [NAME] 1 stated he did not have any concerns about exposing residents to allergens, such as milk, or salt content in the gravy. During an interview on 8/13/2025 at 9:53 a.m., with RN 1, RN 1 stated menus, recipes, and diet orders must be followed for residents with electrolyte-restricted therapeutic diets (diets that limit the intake of electrolytes, such as potassium or sodium) orders. RN 1 stated 59 residents were on sodium-restricted diets and were at risk of high blood pressure, stroke, worsening cardiac issues, worsening kidney function, unintended weight gain, fluid retention, hospitalization, and organ failure. During an interview on 8/13/2025 at 1:00 p.m., with RD 1, RD 1 stated the Cooks did not notify her about any need for menu item substitutions or any food shortages over the past week. RD 1 stated any food served to residents must be standardized and cooked according to a recipe. RD 1 stated staff must follow a recipe for every menu item and should not have made and served the gravy without a standardized recipe. RD 1 stated deviating from recipes could introduce allergens and cause allergic reactions. 9. During a concurrent observation and interview on 8/13/2025 at 6:20 a.m. with [NAME] 1 in the kitchen, [NAME] 1 used a broken large metal whisk to combine the powdered-thickened grits in a small metal tray. [NAME] 1 stated the two metal whisk wires had been broken for several days. [NAME] 1 stated he informed RD 1 about the broken whisk on 8/12/2025. [NAME] 1 stated he had to continue using the broken whisk to prepare menu items because there was no other large whisk in the facility. During an interview on 8/13/2025 at 9:53 a.m. with RN 1, RN 1 stated if the Cooks continue to use the broken metal whisk to prepare food in the kitchen, it placed all residents receiving kitchen-prepared diets at risk for broken metal pieces left in the food. RN 1 stated broken metal pieces in food placed residents at risk of infection, choking, and gastrointestinal (relating to the stomach and the intestines) perforation (poke a hole).During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated she was not made aware of broken equipment in the kitchen and was not notified about a broken metal whisk on 8/12/2025. RD 1 stated using a metal whisk was extremely dangerous for residents and placed residents at risk of consuming metal pieces from the whisk. 10. During an interview on 8/12/2025 at 9:45 a.m., the Admin stated the facility did not have a dietary supervisor or Dietary Services Manager (DSM) for two weeks. During an observation on 8/12/2025 from 11:35 a.m. to 12:45 p.m., there was no Dietary Supervisor, DSM, or RD observed overseeing food preparation and trayline for lunch. During an observation on 8/13/2025 from 6:15 a.m. to 8:05 a.m., there was no Dietary Supervisor, DSM, or RD observed overseeing food preparation and trayline for breakfast.During an interview on 8/13/2025 at 1:00 p.m. with RD 1, RD 1 stated the Admin asked her to increase her hours at the facility as much as possible due to lack of dietary supervision in the kitchen. RD 1 stated she could not oversee the facility's kitchen operations daily because she worked at two other facilities. RD 1 stated she performed a monthly sanitation check and in-service for kitchen staff. RD 1 stated she was not involved in ordering food for the facility. RD 1 stated she primarily provided clinical services and visited the facility and kitchen twice per week, for two hours each visit. During an interview on 8/18/2025 at 2:06 p.m. with the Admin, the Admin stated she ordered food for the kitchen but was not certified to work in the kitchen. The Admin stated RD 1 was unable to provide additional hours and Cooks were not trained to oversee the operations of the kitchen. The Admin stated there was no certified supervisory dietary staff overseeing food preparation, equipment function, and menu coordination in the kitchen from 7/29/2025 until 8/15/2025. The Admin stated the presence of a Dietary Supervisor, DSM, or RD in the kitchen could have avoided the deficient practices. During a review of the facility's P&P titled, Food Preparation, dated 2023, the P&P indicated food preparation should be supervised by the Director of Food and Nutrition Services and reviewed by the Registered Dietitian, employees should prepare food in a safe manner to protect residents from foodborne illnesses and the facility should use proper defrosting methods in defrosting frozen food. The P&P indicated, prepared food should be stored at proper temperature until serving time and the temperature forms should be utilized. The P&P also indicated, cold foods must be kept at or under 41 F, hot foods at or more than 140 F, hot beverages at or more than 140 F, ice cream or sherbet at or less than 32 F. The P&P indicated all menus should have standardized recipes used to ensure meals provide necessary nutritive value. The P&P indicated frozen food must be defrosted using proper defrosting methods. The P&P indicated recipes should be used which are quantified for the facility needs. During a review of the facility's P&P titled, Menus, dated 2023, the P&P indicated menu substitutions must be made from the same food group as the omitted item and should be approved and signed off by the RD. The P&P indicated facilities must keep a menu substitution record on file for 30 days. The P&P indicated staff must refer to the List of Menu Substitutes to replace unavailable menu items. The P&P indicated List of Menu Substitutes, carrots- a vitamin A source; potatoes- a starch substitute, and mixed vegetables were a vitamin A source. The List of Menu Substitutes did not list green beans or fried vegetable as acceptable substitutes. The P&P indicated menus for the therapeutic and texture modified diets were written by the consultant dietitian for all diets served by the facility. During a review of the facility's undated Thick-It Usage Chart, the Usage Chart indicated pureed food should be mixed with the correct amount of Thick-It Original Food and Beverage Thickener using the enclosed measuring scoop. The Usage Chart indicated 1.5 tablespoons of Thick-It to be level measured prior to stirring into food. During a review of the facility's undated [NAME] job description, the job description indicated cooks handle, store, and dispose of raw food items in accordance with company and facility procedures, in compliance with state and federal regulations. The [NAME] job description indicated cooks should follow standardized recipes that correspond to the menu cycles developed by Registered Dietitians. The job description indicated that cooks maintained food service equipment in a clean and safe condition at all times. During a review of the facility's undated Registered Dietician - Salaried job description, the job description indicated RDs plan menus that meet resident's nutritional needs and confirms quality assurance processes are followed in preparation of food. The job description indicated that RDs may supervise food preparation using techniques that conserved nutritional values and may assist in the supervision of the Food Services staff and others for whom they were administratively and professionally responsible. During a review of the facility's undated Dietary Services Manager - Hourly, the job description indicated the position may be filled by a RD. The job description indicated the DSM coordinates the total operation of the dietary department, supervises preparation and service of planned menus, ensured food is stored, held, prepared, and served per company's P&P, state and federal guidelines.