**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to maintain a safe, comfortable and homelike environment when Resident 18's wall beside the right side of his bed had scattered areas of peeling paint. This failure had the potential to compromise the health and safety of the resident and could negatively impact the resident's psychological health. Findings: Review of Resident 18's Facesheet indicated, Resident 18 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 18 's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/24/25, indicated that the resident was able to understand others and was understood by others clearly without assistance. During an initial tour on 4/7/25 at 10:33 a.m., Resident 18 was lying in bed and was awake. Resident 18's wall was observed to have scattered areas of peeling paint. Resident 18 stated his wall was ugly. During a concurrent observation and interview on 4/8/25 at 3:31 p.m., with the Maintenance Technician (MT) in Resident 18's room, MT described Resident 18's wall's paint as chipping and acknowledged that Resident 18's wall needed to be repainted. During a concurrent observation and interview on 4/08/25 at 3:49 p.m., with the Director of Nursing (DON) in Resident 18's room, the DON stated the condition of Resident 18's wall was not providing a homelike environment to the resident. During a review of the facility's policy and procedure (P&P) titled, quality of life-Homelike Environment, revised May 2017, the P&P indicated, Residents are provided with a safe, clean, comfortable and home like environment .1. Staff shall provide person-centered care that emphasizes the residents comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible , the characteristics of the facility that reflect a personalized home like setting. These characteristics include: a. clean sanitary and orderly environment .c. inviting colors and décor .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices were followed when upon inspection of the medication refrigerator, medications for the following discharged residents were found: 1. Eight packets of Veltassa 8.4 grams powder which belonged to Resident 154 (Veltassa is a medication used to correct the high potassium in the body. Potassium is a mineral that your body needs to work properly). 2. One Arexvy 120 micrograms kit which belonged to Resident 37 (Arexvy 120 micrograms kit contains two containers to be mixed to form a vaccine which is given to residents for the prevention of a lung infection caused by a virus called respiratory syncytial virus; a vaccine is a shot that trains your body's immune system to fight off a specific disease. Micrograms or mcg. is a form of measurement). 3. One Arexvy 120 mcg. kit which belonged to Resident 39. 4. One Arexvy 120 mcg. kit which belonged to Resident 157. These failed practices could contribute to unsafe storage of medications and potential for medication error. Findings: 1. A record review for Resident 154 indicated, Resident 154 was admitted to the facility on [DATE] and was discharged from the facility on 5/27/23. During a concurrent observation and interview on 4/8/25, at 10:01 a.m., with the Infection Preventionist (IP), in medication room, eight packets of Veltassa 8.4 grams powder were found which belonged to Resident 154 in the medication refrigerator. The IP confirmed that Resident 154 was already discharged from the facility. During a review of Resident 154's physician order dated 5/11/23 , indicated an order dated 1/29/25 for Parotimer Sorbitex Calcium Oral Packet 8.4 grams, one packet by mouth every Tuesday ,Thursday, Saturday and Sunday. ( Veltassa 8.4 grams is the brand name for Parotimer Sorbitex Calcium Oral Packet 8.4 grams). 2.A record review for Resident 37 indicated, Resident 37 was admitted to the facility on [DATE] and was discharged from the facility on 3/17/25. During a concurrent observation and interview on 4/8/25, at 10:01 a.m., with the IP in the medication room, Arexvy 120 micrograms kit which belonged to Resident 37 was found in the medication refrigerator. The IP confirmed that Resident 37 was already discharged from the facility. During a review of Resident 37's physician order dated 2/19/25, indicated an order for RSVPreF3 Vac Recomb Adjuvanted intramuscular suspension reconstituted 120 mcg/0.5 ml, inject 0.5 ml for RSV vaccination . ( Arexvy is the brand name for RSVPreF3 Vac Recomb Adjuvanted intramuscular suspension reconstituted 120 mcg/0.5 ml). 3. A record review for Resident 39 indicated, Residented 39 was admitted to the facility on [DATE] and was discharged from the facility on 3/10/25. During a concurrent observation and interview on 4/8/25, at 10:01 a.m., with the IP in the medication room, Arexvy 120 mcg. kit which belonged to Resident 39 was found in the medication refrigerator. The IP confirmed that Resident 39 was already discharged from the facility. During a review of Resident 39's physician order dated 2/19/25, for RSVPreF3 Vac Recomb Adjuvanted intramuscular suspension reconstituted 120 mcg/0.5 ml, inject 0.5 ml for RSV vaccination . 4. A record review for Resident 157 indicated, Resident 15 was admitted to the facility on [DATE] and was discharged from the facility on 1/25/25. During a concurrent observation and interview on 4/8/25, at 10:01 a.m., with the IP in the medication room, Arexvy 120 mcg. kit which belonged to Resident 157 was found in the medication refrigerator. The IP confirmed that Resident 157 was already discharged from the facility. During a review of Resident 157's physician order dated 1/9/25, for RSVPreF3 Vac Recomb Adjuvanted intramuscular suspension reconstituted 120 mcg/0.5 ml, inject 0.5 ml for RSV vaccination . During an interview on 4/9/25 at 1:12 p.m., with the Director of Nursing (DON), DON stated, stated that the medications of discharged residents should had been disposed from the medication refrigerator because of the risk of medication error. Stated a medication nurse would have accidentally given the discharged resident's medication to another resident. During a telephone interview on 4/10/25 at 12:17 p.m., with the Consultant Pharmacist (CP), the CP stated that the medications should be disposed as soon as the residents were discharged . Further stated that the risk of keeping the medications belonging to the discharged residents in the medication refrigerator was medication error because the medications could have been accidentally given to another resident. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications undated, the P&P indicated, The facility shall store all biologicals in a safe, secure, and orderly manner . 4. The facility shall not use discontinued, outdated , or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that staff were following isolation precautions to prevent the spread of disease for two of 16 sampled residents when: 1. A Licensed Vocational Nurse (LVN) did not use the proper personal protective equipment (PPE) while giving medications via gastrostomy tube (a gastrostomy is a surgical procedure that creates an opening in the stomach through the abdominal wall. A tube, called a gastrostomy tube is then inserted through this opening to provide nutrition and medication directly into the stomach) to a resident who was on enhanced barrier precaution (Enhanced Barrier Precautions are an infection control strategy that focuses on using gowns and gloves during high-contact resident care activities to reduce the transmission of infection). 2. Two Certified Nursing Assistants (CNAs) did not use the proper personal protective equipment (PPE, equipment worn to minimize exposure to illnesses) when they were giving care and changing the bed linen of a resident on EBP. This failure had the potential for transmission of diseases and infection among residents. Findings: 1. Review of Resident 32's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 32 was admitted to the facility on [DATE] with diagnoses that included the presence of a gastrostomy. During a medication pass observation and interview with LVN 1 on 4/09/25 at 8:37 a.m., LVN 1 entered Resident 32's room (room [ROOM NUMBER]) without isolation gown and gave the resident's medications via gastrostomy tube with just wearing gloves and mask. Posted on the door outside of room [ROOM NUMBER] was a sign which indicated: STOP Enhanced Barrier Precaution and what to do before entering room and a small plastic cart with PPEs was outside Resident 32's room. On interview, LVN 1 stated she had training on isolation precautions and acknowledged that she should have worn the isolation gown to prevent the spread of infection. 2. Review of Resident 44's Facesheet indicated, Resident 44 was admitted to the facility on [DATE] with diagnoses that included the presence of a gastrostomy. During an observation on 4/09/25, at 10:39 a.m , in Resident 44's room (room [ROOM NUMBER]), Resident 44 was in his bed when CNA 1 and CNA 2 were not wearing isolation gowns while changing the resident's bed linen . Posted on the wall outside of room [ROOM NUMBER] was a sign which indicated; STOP Enhanced Barrier Precaution and what to do before entering room and a small plastic cart with PPEs was outside Resident 44's room. During a joint interview on 4/09/25, at 10:45 a.m., with CNA 1 and CNA 2, both of them stated they had trainings on isolation precautions, and both acknowledged they should have worn the isolation gown when they gave care to Resident 44 to prevent the spread of infection. During a review of the EBP signs posted outside Resident 32 and 44's rooms, the signs indicated .Providers and Staff must also: Wear gloves and gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy . During an interview on 4/10/25 , at 12:54 p.m., with the Director of Nursing (DON),the DON stated the staff should have worn the appropriate PPEs when giving care to Residents 32 and 44 to prevent the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, Revised 3/6/25, the P&P indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .11. Prevention of Infection a. Important facets of infection prevention include . (3) educating staff and ensuring that they adhere to proper techniques and procedures .(7) implementing appropriate isolation precautions when necessary .

Based on interview and record review , the facility failed to ensure the designated Infection Preventionist (IP is a professional who ensures healthcare workers and patients are doing all the things they should to prevent infections) had completed and received certification for specialized training in infection prevention and control program in accordance with the facility's policy and procedure and CMS (Centers for Medicare and Medicaid Services ) requirement. This failure resulted in the infection control and prevention program of the facility not having the benefit of a fully qualified and competent IP and possibly negatively affecting the quality of care provided to all residents. Findings: During an interview on 4/09/25 at 3:01 p.m., with the Director of Nursing (DON), the DON stated the IP had been working as designated IP for the facility since September of 2024. DON stated IP could not provide proof of IP certification. During an interview on 4/10/25 at 10:30 a.m., with IP, IP stated she had two roles in the facility since September of 2024: 1) IP and; 2) Nursing Supervisor. The IP stated she was aware of the requirement to complete Infection Prevention training. She stated she had completed taking the Centers for Disease Control and Prevention (CDC) Infection Control Preventionist Training for Infection Control but was unable to provide proof that she completed the IP certification. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, Revised 3/6/25, the P&P indicated, . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .5. Coordination and Oversight a. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist). b. The qualifications and job responsibilities of the Infection Preventionist are outlined in the Infection Preventionist Job Description . During a review of the facility's undated Job Description of Infection Preventionist/Nurse Supervisor, indicated that one of the qualifications for the infection preventionist was, .Certifications: Infection Preventionist (IP) certification . During a professional reference review from https://www.cms.gov titled specialized infection prevention and control training for nursing home staff dated 3/11/19 indicated specialized training for infection prevention and control. CMS and the CDC collaborated on the development of a free online training course in infection prevention and control for nursing home staff. The course includes information about the core activities of an infection prevention and control program, with a detailed explanation of recommended practices to prevent pathogen transmission and reduce healthcare associated infections and antibiotic resistance in nursing homes. Completion of this course will provide specialized training in infection prevention and control . A review of the AFL 21-51 indicated Effective January 1, 2022, AB 1585 expands existing eligibility and minimum qualifications for a SNF's IP. The IP must have primary professional training as a licensed nurse, medical technologist, microbiologist, epidemiologist, public health professional, or other health care related field. The IP must be qualified by education, training, clinical or health care experience, or certification, and must have completed specialized training in infection prevention and control ( Skilled Nursing Facility is a health facility and is also called a SNF; An All Facilities Letter or AFL is a letter that was sent from the California Department of Public Health to all health facilities that are licensed or certified).

Based on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: 1. Unlabeled and undated food was stored in the kitchen refrigerator. 2. Unlabeled and undated food was stored in the kitchen freezer. 3. Unlabeled, undated and beyond use by date for food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for 43 residents who received food from the kitchen and had access to use the resident refrigerator. Findings: During an observation 4/7/25, at 9:40 a.m., in the kitchen, the refrigerator, and freezer and was observed. The refrigerator had one unsealed plastic bag of carrots that was not labeled with date. The freezer had one unsealed plastic bag of tilapia. During an observation on 4/7/25, at 10:25 a.m., the resident refrigerator and freezer was observed with one plastic bag of unsealed carrots and two egg salad sandwiches that were not labeled with resident name and date. The resident refrigerator and freezer had one bulk box of strawberry yogurt with a use by date 3/28/25. During an interview on 04/10/25, at 1:30 p.m., with Certified Dietary Manager (CDM), CDM stated it was important to label all food stored in the kitchen refrigerator and freezer, and the resident refrigerator and freezer so they would have known when to throw the food out. CDM stated unlabeled and undated food could have been old and could have caused the residents to get sick if it was served to them. CDM stated it was important to label food with resident name in the resident refrigerator and freezer to make sure residents got the correct diet. CDM stated food that was beyond it's use by date could have caused the residents to get sick if it was served to them and should have been thrown out. During a review of the facility's P&P titled, Food Storage, revised 7/11/24, the P&P indicated, All products should be . dated upon receipt, when open and when prepared. During a review of the facility's P&P titled, Foods Brought in by Family/Visitors, revised October 2017, the P&P indicated, Perishable foods must be stored in re-sealable containers with tight-fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The P&P indicated, The nursing staff will discard perishable foods on or before the use by date.

Based on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the California Department of Public Health (CDPH) within 2 hours, for one of one sampled resident (Resident 1), when Resident 1 alleged they were raped. This failure had the potential to cause a delay in investigations and affect physical and psychological well-being of resident 1. A review of Resident 1's admission Record printed 4/11/24, indicated Resident 1 was admitted to the facility in 2024 with a diagnosis of Traumatic Subdural Hemorrhage without loss of consciousness (a type of bleeding near your brain that can happen after a head injury). During a review of Resident 1 ' s Nurses Note, dated 4/7/24, the note indicated, Resident 1 notified staff on 4/6/24 at 11:30 p.m., they were raped. During a review of Resident 1 ' s Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 4/7/24, the SOC 341 indicated Resident 1 had an allegation of rape on 4/6/24 at 11:30 p.m. The SOC 341 indicated the report was faxed to CDPH on 4/8/24. During an interview on 4/11/24, at 2:29 p.m., with Administrator (APC) and Director of Nursing (DON), APC stated Resident 1 ' s alleged rape was first reported to CDPH by phone on 4/8/24 at approximately 4 p.m. DON stated it was important to report abuse allegations immediately and within 2 hours to appropriate agencies for resident safety. During a review of the facility ' s policy and procedure (P&P) titled, Abuse Reporting and Investigation, dated 1/10/24, the P&P indicated, Policy . To promptly report all allegations of abuse as required by law and regulations to the appropriate agencies within the required time frames To ensure Resident ' s safety and well-being of the resident once admitted to the facility . All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, shall be reported by APC/ Designee to local CDPH, LTC (long term care) Ombudsman and Local Law Enforcement either by telephone, email or in writing (SOC 341) immediately . within 2 hours after the allegation is made or reported, if the alleged violation involves abuse with or without serious bodily injury.

Based on interview and record review, the facility failed to complete Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) annual comprehensive assessments for two of 14 sampled residents (Residents 41 and 58). This failure had the potential to result in inaccurate assessments and improper interventions for Residents 41 and 58. During a review of Resident 41's admission Record dated 11/3/23, the record indicated Resident 41's recent admission date was 4/2023 and initial admission date was 11/2019, with multiple diagnosis including an admission diagnosis of Osteomyelitis of vertebra, sacral and sacrococcygeal region (an infection in spinal bone and lower spine). During a review of Resident 58's admission Record dated 11/3/23, the record indicated Resident 58 was admitted 10/2022 with multiple diagnosis including an admission diagnosis of Hemiplegia and hemiparesis (Hemiplegia refers to complete paralysis while hemiparesis refers to partial weakness) following cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain) affecting left non-dominant side. During an interview on 11/02/23, at 10:49 a.m., with MDS Coordinator (MDSC), MDSC stated the MDSC was responsible for the completion and accuracy of the MDS annual comprehensive assessments. MDSC stated MDS annual comprehensive assessments were important because they were used to assess resident progress, and to see if the plan of care was effective and consistent. During an interview on 11/03/23, at 9:25 a.m., with Director of Nursing (DON). DON stated the importance of the MDS comprehensive assessment was for compliance purposes. DON also stated that when MDS comprehensive assessments were not completed on time, it was not a risk to the residents. During a concurrent interview and record review on 11/03/23 12:08 p.m., with MDSC, Residents 41 and 58's, MDS annual comprehensive assessments were reviewed. MDSC stated Resident 41's MDS, dated 10/18/23, was 1 day overdue. MDSC stated Resident 58's MDS, dated 8/11/23, was 68 days overdue. During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, revised 2017, the P&P indicated, Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. During a review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, the manual indicated, The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days).

2. During a review of Resident 40's admission Record, dated 11/3/23, the record indicated Resident 40 was admitted 1/2021 with multiple diagnosis that included anxiety disorder, muscle weakness, Polyneuropathy (a condition in which a person's peripheral nerves are damaged with symptoms that include problems with sensation, coordination, or other body functions) and functional quadriplegia (a condition characterized by complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord). During a review of Resident 40's MDS, dated 9/8/23, the MDS indicated Resident 40's BIMS score was 15. The MDS indicated Resident 40 needed physical help limited to transfer only with one person to physically assist them with bathing. During an interview on 10/31/23, at 10:54 a.m., with Resident 40, Resident 40 stated they haven't had a bed bath or shower for the last two weeks. Resident 40 stated they notified staff two weeks ago, that they preferred bed baths and wanted them in the morning because it was too cold on the night shift. Resident 40 stated staff never offered showers or bed baths in the morning or night in the last two weeks. Resident 40 stated she felt dirty and upset. During a concurrent interview and record review on 10/31/23, at 12:50 p.m., with CNA 2, the Shower Binder was reviewed. CNA 2 stated CNAs should have documented resident showers, bed baths and refusals on Shower Sheets and placed it in the Shower Binder. CNA 2 stated CNAs should have also documented resident showers, bed baths and refusals on POC. CNA 2 stated Resident 40 didn't have any showers, bed baths or refusals documented in October 2023, in the Shower Binder. CNA 2 stated residents had the right to choose between showers or bed baths and what time they wanted it. CNA 2 stated CNAs should have notified the nurse, found out why and tried to honor their choices, when residents refused. CNA 2 stated Resident 40 should have taken a shower or bed bath at least 2 times a week. CNA 2 stated showers were important for resident health. During a concurrent interview and record review on 10/31/23, at 1:02 p.m., with RN 2, Resident 40's POC was reviewed. RN 2 stated Resident 40 didn't have any showers, bed baths or refusals documented in POC for October 2023. RN 2 stated CNAs should have documented resident showers, bed baths and refusals in POC in addition to the Shower Sheets in the Shower Binder. RN 2 stated residents had the right to choose if they wanted a shower or bed bath and what time they wanted it. RN 2 stated resident showers and bed baths were important for their skin and health. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs - Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) Supporting, dated March 2018, the P&P indicated, Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: 1. Hygiene (bathing, dressing, grooming, and oral care). Based on observation, interview, and record review for two out of 26 sampled residents (Residents 20 and 40), the facility failed to ensure that services to maintain good hygiene was provided on a regular basis. Residents 20 and 40 were not given or offered shower or bed bath regularly. This failure had a potential to affect their health and feeling of well-being when basic and essential services were not provided. Findings: 1. During a record review of facility's admission Record indicated Resident 20 had an initial admission date of 6/2022 and the most recent readmission of 3/2023 with multiple diagnoses that included Fracture of unspecified part of the neck of left femur, subsequent encounter for close fracture with routine healing (break in the uppermost part of thighbone) and chronic obstructive pulmonary disease (COPD - condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Resident 20's most recent completed Minimum Data Set's (MDS - standardized comprehensive clinical assessment for residents) dated 5/19/23 indicated a Brief Interview for Mental Status score of 12, (BIMS - score range from 00-15, with 00-07 indicating severe impairment, 08 -12 indicating moderate impairment, and 13 -15 indicating cognitively intact). Functional assessment for activities of daily living indicated Resident 20 needed extensive assistance with one-person physical assist for personal hygiene. Resident 20 was fully dependent with one-person physical assist for bathing. During a concurrent observation and interview on 10/31/23 at 12:16 p.m., with Resident 20 was lying in bed. Resident 20 appeared to have dry flaky skin on their face and arms, cracked lips with dark debris around their mouth with heavy build up on their lower teeth, and with clumpy and sticky looking eyelashes. Resident 20's fingernails were long and had brown discoloration on the tips of their nails. Resident 20's hair appeared uncombed and rumpled. Resident 20 stated the staff had not had shower and they would only shower them when the staff When they think of it. Resident 20 stated they were supposed to receive shower or bed bath twice a week and it makes them feel dirty. Resident 20 stated they don't know when their shower or bed bath scheduled. During a concurrent interview and record review on 10/31/23 at 12:28 p.m., while at Resident 20's bedside, with Certified Nursing Assistance (CNA) 3, CNA 3 stated Resident 20's shower scheduled were on Monday and Thursday during the afternoon shift. CNA 3 stated Resident 20 should have had shower yesterday during the afternoon shift. CNA 3 stated the Shower Binder was kept in the nursing station, and CNA 3 looked for the log. CNA 3 showed the schedule for Resident 20, indicating Resident 20 was scheduled to shower every Monday and Thursday in the afternoon shift. CNA 3 was unable to locate a form indicating Resident 20 had a shower on Monday afternoon. CNA 3 stated if the resident receives either bed bath or shower, or refuse the form had to be completed. Another CNA, CNA 5 said they showered Resident 20 last week, CNA 4 but was unable to find the form indicating Resident 20 was given a shower. CNA 3 continued to review the shower binder and asked CNA 2 for assistance to locate the form for Resident 20's shower. CNA 2 looked for the month of October and was not able to find any form indication Resident 20 had a shower or refuse a shower for the month. CNA 2 looked for Resident 20's form for the month of September and could only locate one bed bath was provided on 9/25/23. During a concurrent interview and record review on 12:42 p.m., with Director of Staff Development (DSD), stated CNA inputs the shower/bed bath data in POC (Point of Care -electronic health record). DSD reviewed Resident 20's shower information and was not able to show that Resident 20 had a shower or bed bath on 10/20/23. DSD stated they could not show the whole month of October's data and would have someone print the information. During a concurrent interview and record review on 10/31/23 at 1:40 p.m, with CNA 5, CNA 5 stated they found Skin Check Sheet for Resident 20 had a shower on 10/23/23. CNA 4 stated the form was not filed properly in the shower binder. During a concurrent interview and record review on 10/31/23 at 1:58 p.m., with Minimum Data Set Coordinator (MDS) stated the facility was recently transitioning to log in the shower data to POC. MDS stated they could only print the data for the month of October. MDS stated since Resident 20 was scheduled for the PM shift shower, it would only show it during that shift. MDS provided the Documentation Survey Report v2, and reviewed the data, MDS stated on 10/5 and 10/9 Resident 20 had a bed bath, on 10/12 it showed Not Applicable, and the rest of the month there was no data indicating if Resident 20 had bed bath or shower.

Based on interview and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 64), that care and services provided while on dialysis (treatment that helps the body remove extra fluid and waste products from the blood when the kidneys were not working) meet the needs to maintain healthy and safe. Resident 64's medications were given before dialysis days and post dialysis assessment were not consistently completed. These failures had a potential to affect the resident's health and safety due to decrease its effectiveness of medications and inconsistent monitoring. Findings: 1. During a review of facility's admission Record indicated Resident 64 was admitted on 9/2023, with multiple diagnoses that included End Stage Renal Disease (ESRD -progressive loss of kidney function that reaches an advanced state when kidneys no longer work to meet your body's needs. Kidneys had many functions including filtering the blood, fluid balance, make enzymes that helps control blood pressure, produce hormones to make red blood cells, activate vitamin D to maintain healthy bones and adjust levels of minerals and other chemicals to keep the body working properly.), and Dependence on renal dialysis. Resident 64's Physician Order Summary for the month of 11/23 that included the following: Hemodialysis Schedule: MWF (Monday, Wednesday, and Friday), Folic Acid oral tablet 1 milligram (mg), give one tablet by mouth one time a day for supplement (water-soluble vitamin and is essential for maintaining cell functions. Dialysis removes folate resulting in folate deficiency), and Renal Multivitamins Formula oral tablet (B-Complex with C and Folic Acid), give one tablet by mouth one time a day, and Aspirin EC tablet Delayed Release 81 mg, give 1 tablet by mouth one time a day for prophylaxis. During an interview on 11/1/23 at 8:06 a.m., with Licensed Vocational Nurse (LVN) 2 stated Resident 64 receive all his medication before they leave the facility for dialysis treatment in the morning. During a review of the Resident 64's medication administration record (MAR) for the month of October indicated the following medications were scheduled to be administered at 9:00 a.m., Folic Acid oral tablet 1 mg., Renal Multivitamins (B-complex with C and Folic Acid) give 1 tablet, and Aspirin EC tablet Delayed Release 81 mg tablet, given 1 tablet. During an interview on 11/2/23 at 2:40 p.m., with Director of Nursing Services (DON), stated during dialysis days Resident 64's Renal Vitamins and Folic Acid had to be given at nighttime since they were water soluble, and it would be dialyzed if given before dialysis. During a review of the facility's policy and procedure titled End-Stage Renal Disease, Care of a Resident with indicated Resident with end-stage renal disease (ESRD) will be care for according to currently recognized standards of care. Policy Interpretation and Implementation indicated 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: . e. Timing and administration of medications, particularly those before and after dialysis. 2. Resident 64's Physician Order Summary for the month of 11/23 that included the following: Hemodialysis Schedule: MWF, monitor vital signs pre and post dialysis at the facility, and may remove dressing at least at least 4 hours post dialysis if no sign and symptoms of complication or bleeding. During a record review of Resident 64's dialysis binder (communication between the facility and dialysis treatment center), indicated Resident 64 had dialysis treatment on 10/27/23 and 10/30/23. The Post Dialysis Assessment part of the forms was not completed. The required assessment included the resident's arrival time, mode of transportation, checking the vital signs, dialysis access site location, condition of the access site, respiratory condition, skin condition, any other concern, and person completing the assessment. During a concurrent interview and record review on 11/1/23 at 8:48 a.m., with DON while reviewing Resident 64's dialysis binder, stated the nurses should be documenting in the communication binder the post dialysis assessment. DON confirmed that some of the post dialysis assessments were not completed. During a review of Resident 64's MAR for the month of October for the following: May remove dressing at least at least 4 hours post dialysis if no sign and symptoms of complication or bleeding, and to monitor vital signs pre and post dialysis at the facility, the MAR indicated there was no data charted. During a concurrent interview and record review on 11/1/23 at 9:02 a.m., with DON while reviewing Resident 64's MAR for the month of October for the post dialysis monitoring, DON stated the monitoring was written as an FYI only, so the nurses do not have to chart on those spots. DON stated if there was any changed with the resident's condition, then the nurse would write and Change of condition notes. During a review of facility's policy and procedure titled Hemodialysis Access Care indicated The general medical nurse should document in the resident's medical record the following as needed: 1. Condition of dressing (interventions if needed). 2. Any part of report from dialysis nurse post-dialysis being given. 3. Observation post-dialysis. 4. Any change of condition.

Based on observation, interview, and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 20), had routine dental services were provided to maintain good oral health. This failure had a potential to affect their health due to delay in obtaining necessary treatment due to lack of routine services provided. Findings: During a record review of facility's admission Record indicated Resident 20 had an initial admission date of 6/2022 and the most recent readmission of 3/2023 with multiple diagnoses that included Fracture of unspecified part of the neck of left femur, subsequent encounter for close fracture with routine healing (break in the uppermost part of thighbone) and chronic obstructive pulmonary disease (COPD - condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe). Resident 20's most recent completed Minimum Data Set's (MDS - standardized comprehensive clinical assessment for residents) dated 5/19/23 indicated a Brief Interview for Mental Status score of 12, (BIMS - score range from 00-15, with 00-07 indicating severe impairment, 08 -12 indicating moderate impairment, and 13 -15 indicating cognitively intact). Functional assessment for activities of daily living indicated Resident 20 needed extensive assistance with one-person physical assist for personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands. Resident 20's physician orders for the month of November indicated May have dental consultation and exam. During a concurrent observation and interview on 10/31/23 at 02:22 a.m., with Resident 20 lying in bed and Family Friend (FF) visiting at bedside, Resident 20 stated that the staff does not brush her teeth regularly. FF stated sometimes Resident 20 would ask them to brush their teeth since the staff does not brush Resident 20's teeth regularly. Resident 20 had their upper and lower set of teeth that appeared discolored and had thick build up around the gum line of the lower teeth. During an interview on 11/1/23 at 12:09 a.m., with Certified Nursing Assistant (CNA) 3, CNA 3 stated they brushed Resident 20's teeth, and they must do it every shift. CNA 3 stated they used her electric toothbrush that was kept at bedside. During a concurrent observation and interview on 11/1/23 at 2:38 a.m., in Resident 20's bedside, with CNA 3, they set up the supplies for Resident 20's oral care. CNA 3 had small bin with toothbrush and toothpaste --all looked brand new. CNA 3 brushed Resident 20's teeth, on the left upper teeth side, there was one tooth that appeared completely discolored. During an interview on 11/03/23 at 10:15 a.m., with Director of Staff Development (DSD), DSD stated the facility had a dentist that visits the facility routinely. DSD stated they would find Resident 20's dental record for their file. During an interview on 11/03/23 11:23 a.m. with Director of Nursing (DON), DON stated they were looking for Resident 20's dental record, DON stated the facility sent the request back in July 2023, and they were not sure if Resident 20 was seen by a dentist. During a concurrent interview and record review on 11/03/23 at 11:35 a.m., with DON while the Social Services Director (SSD) was on the phone, SSD stated that Resident 20 was on the list to be seen by the dentist for April and July. SSD stated Resident 20 had a share of cost of $1500, and Resident 20 needed to meet the share of cost first for the dentist to bill the insurance for their services. During an interview on 11/03/23 at 12:42 p.m., with SSD, SSD stated Resident 20 had met the share of cost for the during the months of April and July 2023. During an interview on 11/03/23 at 12:56 p.m., with Business Office Manager (BOM), BOM stated that Resident 20 did not have a share of cost until after August 2023. BOM stated Resident 20 should have been seen by the dental hygienist for April and July scheduled visit. During a review of the facility's policy and procedure titled Dental Services indicated Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care . 1. Routine and 24-hour emergency dental services are provided to our residents through: a. A contract agreement with licensed dentist that comes to the facility monthly . All dental services provided are recorded in the resident's medical record.

Based on observation, interview, and record review for one out 26 sampled resident (Resident 20), the facility failed ensure that assistance and adaptive device were available during mealtimes. Resident 20's meal was served at bedside without assistance and adaptive equipment not readily available. This failure had a potential for Resident 20 to regress on their skills with using the adaptive equipment due to lack of consistency with its use. Findings: During a record review of facility's admission Record indicated Resident 20 had an initial admission date of 6/2022 and the most recent readmission of 3/2023 with multiple diagnoses that included Post Polio Syndrome (PPS- usually occurs years after the infection and recovery, and believed to be the result of a deterioration of nerve cells called motor neurons over many years that leads to loss of muscle strength and dysfunction). Resident 20's most recent completed Minimum Data Set's (MDS - standardized comprehensive clinical assessment for residents) dated 5/19/23 indicated a Brief Interview for Mental Status score of 12, (BIMS - score range from 00-15, with 00-07 indicating severe impairment, 08 -12 indicating moderate impairment, and 13 -15 indicating cognitively intact). Functional assessment for activities of daily living indicated Resident 20 needed extensive assistance with one-person physical assist for eating. During a concurrent observation and interview on 11/01/23 at 12:52 P.M., with Resident 20, Resident 20 was sitting up on their bed with lunch tray set-up on top the bedside table in front them. Resident 20's lunch plate was uncovered, and Resident 20 stated they needed help to eat their lunch. Resident 20 stated no staff came to help them yet. Resident 20 stated they could not hold spoon/utensils they gave them. Resident 20 stated their build-up spoon (Adaptive eating utensils designed to assist a person with feeding difficulty to help improve feeding) was better. There was built-up spoon on table next to their tray with dried food on it. Resident 20 stated they kept the spoon in her room. Resident 20 attempted to pick up cup to drink and was not able. During a concurrent observation and interview on 11/03/23 at 1:05 P.M., with Resident 20 was sitting up on her bed with lunch tray on top of the bedside table. The plate was uncovered, and the fork was placed on top of the plate, and there were spoon and knife on the tray. On the bedside table next to the tray, were two foam (red/yellow) handle used as part of the adaptive equipment next to the tray. Resident 20 stated someone place the lunch tray for their bedside table. Resident 20 stated they wanted to eat. Resident 20 attempted to pick up the fork and stated it was hard for them to hold it. Resident 20 stated the staff didn't give them the spoon and fork with handle, Resident 20 stated it's easier to hold the built-up spoon and fork. Licensed Vocational Nurse (LVN) 2 walked in at Resident 20's bedside. Resident 20 asked LVN 2 for their built-up spoon and fork. LVN 2 stated they would clean the soft foam handle and attached it to the spoon and fork. LVN 2 stated soft foam handle should have been set up for Resident 20. LVN 2 stated said the tray lunch cart probably delivered around 12:30 p.m. During an interview on 11/3/23 at 9:09 A.M., with Director of Nursing (DON), DON stated Resident 20's the adaptive equipment was supposed to be on the tray and they could use it as they wishes based on Occupational Therapist's (OT) recommendation. During an interview on 11/3/23 at 9:26 A.M., with Rehabilitation Director (RD), RD stated the OT had been working with Resident 20 with using the adaptive equipment. RD stated Resident 20 just finished with the training and would be handing it off to nursing. RD stated Resident 20 use the adaptive device to help with eating, for independence, and improve quality of life. During a review of Resident 20 Occupational Therapy Discharge Summary with date of service from 8/2/23 - 10/30/23 indicated Interventions Provided: Patient received skilled interventions to decrease contracture risk. Pt and Caregiver Training: Instructed nursing caregivers in use of adaptive equipment and splinting/orthotic schedule in order to increase functional mobility skills with 100% carryover demonstrated by primary caregivers. Progress & Response to Tx: Patient's functional performance has improved as a result of instruction in compensations, modifications and adaptations. During an interview on 11/3/23 at 9:49 A.M., with Director of Staff Development (DSD), DSD stated the fork and spoon comes from the kitchen, but the adaptive handles stay with Resident 20, and had to be cleaned before using it again with meal. DSD stated Certified Nursing Assistant (CNA) needs to set-it up for the resident. DSD stated it's not okay to keep the dirty spoon on the bedside. During a record review of the facility's policy and procedure titled Assistance with Meals indicated Residents shall receive assistance with meals in a manner that meets the individual needs of each resident . Residents Who May Benefit from Assistive Devices 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. 2. Assistance will be provided to ensure that residents can use and benefits from the special eating equipment and utensils.

Based on interview and record review, the facility failed to complete Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) quarterly assessments for eight of 14 sampled residents (Residents 9, 11, 20, 23, 40, 47, 51, and 72). This failure had the potential to result in inaccurate assessments and improper interventions for Residents 9, 11, 20, 23, 40, 47, 51, and 72. During a review of Resident 9's admission Record dated 11/3/23, the record indicated Resident 9 was admitted 4/2022 with multiple diagnosis including an admission diagnosis of hypertensive chronic kidney disease (a persistent kidney disease that reduces the rate at which kidneys filter waste and fluids with narrowing of blood vessels that transport blood to the kidneys) with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. During a review of Resident 11's admission Record dated 11/3/23, the record indicated Resident 11 was admitted on 4/2023 with multiple diagnosis including an admission diagnosis of Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. During a review of Resident 20's admission Record dated 11/3/23, the record indicated Resident 20 was admitted 3/2023 with multiple diagnosis including an admission diagnosis of Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. During a review of Resident 23's admission Record dated 11/3/23, the record indicated Resident 23 was admitted 12/2022 with multiple diagnosis including an admission diagnosis of Lumbago with sciatica (low back pain that shoots down your legs), left side. During a review of Resident 40's admission Record dated 11/3/23, the record indicated Resident 40 was admitted 1/2021 with multiple diagnosis including an admission diagnosis of Diverticulosis of large intestine (a disease characterized by the presence of one or more balloon-like sacs in the large intestine causing abdominal pain and other symptoms) without perforation or abscess (a buildup of pus) without bleeding. During a review of Resident 47's admission Record dated 11/3/23, the record indicated Resident 47 was admitted on 3/2021 with multiple diagnosis including an admission diagnosis of Other Pulmonary Embolism (a sudden blockage in your blood vessels that send blood to your lungs) without acute cor pulmonale (a condition that causes the right side of the heart to fail). During a review of Resident 51's admission Record dated 11/3/23, the record indicated Resident 51 was admitted 2/2023 with multiple diagnosis including an admission diagnosis of Unspecified dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. During a review of Resident 72's admission Record dated 11/3/23, the record indicated Resident 72 was admitted 5/2023 with multiple diagnosis including an admission diagnosis of Sepsis, unspecified organism (a life-threatening condition that arises when the body's response to an infection injures its own tissues and organs). During an interview on 11/02/23, at 10:49 a.m., with MDS Coordinator (MDSC), MDSC stated the MDSC was responsible for the completion and accuracy of the MDS quarterly assessments. MDSC stated they should have been done every three months. MDSC stated MDS quarterly assessments were done to see how a patient was doing during the look back period of the last three months. MDSC stated the MDS quarterly assessments were important because they were used to assess resident progress, and to see if the plan of care was effective and consistent. During an interview on 11/03/23, at 9:25 a.m., with Director of Nursing (DON). DON stated the importance of the MDS quarterly assessment was for compliance purposes. DON also stated that when MDS quarterly assessments were not completed on time, it was not a risk to the residents. During a concurrent interview and record review on 11/03/23 12:08 p.m., with MDSC, Residents 9, 11, 20, 23, 40, 47, 51, and 72's MDS quarterly assessments were reviewed. MDSC stated Resident 9's MDS, dated 9/29/23, was 14 days overdue. MDSC stated Resident 11's MDS, dated 10/17/23, was 2 days overdue. MDSC stated Resident 20's MDS, dated 8/18/23, was 61 days overdue. MDSC stated Resident 23's MDS, dated 9/15/23, was 34 days overdue. MDSC stated Resident 40's MDS, dated 9/8/23, was 40 days overdue. MDSC stated Resident 47's MDS, dated 9/1/23, was 47 days overdue. MDSC stated Resident 51's MDS, dated 9/22/23, was 27 days overdue. MDSC stated Resident 72's MDS, dated 8/30/23, was 50 days overdue. During a review of the facility's policy and procedure (P&P) titled, MDS Completion and Submission Timeframes, revised 2017, the P&P indicated, Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. During a review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, the manual indicated, The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.

Based on observation, interview, and facility document review, the facility failed to ensure qualified staff carried out the functions of the food and nutrition services when the Registered Dietitian and the Certified Dietary Manager had minimal to no oversight of food received, stored, prepared, and served to residents. This failure had the potential to result in intake of an inadequate and/or a harmful amount of nutrients further compromising residents' medical status; and contamination of food leading to foodborne illness for 40 residents who received food from the kitchen. Findings: The document titled Department of Food and Nutrition Services Consultant (Consultant Dietitian) Job Description with an effective date of 11/1/22, showed The Registered Dietitian provides consultation to the facility for the purpose of providing nutrition care and oversight of the operations of the Department of Food and Nutrition Services, which will result in optimal health of the resident/patient. Responsibilities included: evaluates and participates in implementing in-service programs for Department of Food and Nutrition Services; evaluates and monitors the food service department to assure that the department is providing adequate, acceptable quality food; evaluates and monitors the meal delivery system; monitors and recommends food service standards for sanitation, safety, and infection control; coordinates, implements, and evaluates the facility menus for nutritional adequacy; evaluates, and advises and counsels the Director of Food and Nutrition Services in all areas of food service and nutritional care for all local, State and Federal Regulations. Review of the document titled Agreement to Provide Consultant Services signed on 12/3/19 by the RD showed responsibilities of the consultant included: provides consultation to administration regarding planning, policy development, and priority setting, based on initial and ongoing evaluations of the food service needs; reviews sanitation in accordance with current standards. In addition, the contract showed the RD shall make recommendations necessary to comply with all rules and regulations of the federal, state, or local government, bureau, or department applicable to said food service facility or to the service of meals therein. The facility is responsible for approving, implementing, and maintaining those recommendations made by the RD. Review of the undated document presented as the CDM's job description titled Dietary Manager Responsibilities showed the Dietary Manager or RD must complete monthly in-services with kitchen staff, covering required educational areas of sanitation and correct medical diet modification. Review of the document titled Shared Services Agreement with an effective date of June 30, 2014, showed the skilled nursing facility was leased from the owner of the building who also owned an assisted living at the same address. In an interview on 10/30/23 at 10 a.m., Outside Resource Director of Food Service (ORDFS) stated she ran the kitchen, and she was an employee of the Assisted Living. The Certified Dietary Manager also introduced himself and stated he worked at the skilled nursing facility for seven months. CDM and ORDFS explained the staff who worked in the kitchen were Assisted Living staff and the food for the Skilled Nursing Facility came from this kitchen. During observations and interviews starting on 10/30/23 at 10 a.m. through the end of the survey on 11/3/23, issues were identified with: following the planned menu (Cross-reference F803), serving food at a palatable temperature (Cross-reference F804), and safety and sanitation in the kitchen (Cross-reference F812). Multiple issues identified during the survey were also identified on the last two inspections conducted by the RD. These inspections included a full inspection just over one year ago on 10/12/22, as well abbreviated inspection conducted more recently on 10/25/23. On 11/1/23 at 1:30 p.m., RD provided documentation of the last two kitchen inspections. Review of the document titled Sanitation and Food Safety Checklist dated 10/12/22 and provided by the RD as the last full kitchen inspection document showed: for the ice machine there was excessive bacteria present and multiple strains of mold found in excess, unsafe; For labeling and dating refrigerated items many items missing labels; For menus spreadsheets not used and no substitution log noted. For ceilings and vents excessive potential contaminates on ceiling; For painted surfaces several chipped walls w/ [with] missing drywall present; For storage devices food residue inside drawers; For can opener blade need replacing, insert with excessive food residue; For pots and pans non-stick surface has worn and can contaminate food. These issues were similar, if not the same, as the issues identified by surveyors during the survey beginning on 10/30/23. Review of the e-mail document titled Kitchen Walkthrough 10/25 showed the email from the RD was sent to the Administrator (ADM) on 10/25/23, showed I focused primarily on the 'bigger ticket items' that could lead to the strictest deficiencies rather than go through every fine detail in the kitchen . The RD documented that the ice machine was not safe in its current state. He recommended a full cleaning and sanitizing with a chlorine-based solution. He documented it is important to follow the procedure the manufacturer states and not someone else's recommendation. I recommend having the procedure printed and attached to the side of the machine . you can pull this information direct from the manufacturer's website. The RD also documented there was the potential for contamination of food due to dust debris hanging from the ceiling throughout the kitchen. The RD also documented there were several ceiling lights missing covers and to replace them as soon as possible. These issues were similar, if not the same, as the issues identified by surveyors during the survey beginning on 10/30/23. In an interview on 11/1/23 at 2:12 p.m., the RD explained he worked at the facility four-five years and was on site at the facility once a week. He stated a couple of years ago the Assisted Living staff stated he was not allowed in the kitchen. He said this was why his last full kitchen inspection was just over a year ago on 10/12/22. He stated there was a scheduled kitchen walk-through last week with the Assisted Living upper management. The RD stated he felt he should do an inspection once a month, but he was tired of asking if he could do inspections and not being allowed into the kitchen. He also stated he did not do in-services for kitchen staff. In an interview on 11/1/23 at 2:50 p.m., Outside Resource Director of Food Service (ORDFS) stated she did the training for kitchen staff. She also stated she did not have any qualifications for supervising a Skilled Nursing kitchen such as a Certified Dietary Manager or Dietary Services Supervisor. She stated the Assisted Living kitchen did not require these qualifications. In an interview on 11/2/23 at 9:21 a.m., the Certified Dietary Manager (CDM) stated it's kind of hard to get in there when asked if he went into the kitchen to do observations or inspections. He stated ORDFS did not like him in the kitchen as well as some of the other Assisted Living kitchen staff. He said, if he did enter the kitchen ORDFS did not want him to go into the food preparation and food storage areas beyond the first room inside the kitchen where the Skilled Nursing trayline food service took place. The CDM also said he did not really observe trayline food service which is where he would ensure safety and sanitation practices were followed during food service as well as ensure the menu was followed. CDM also stated he did not assess food for palatability when it came out of the kitchen. CDM stated there was no framework to follow as far as his job duties when he started the job and he's been trying to figure it out. In an interview on 11/2/23 at 11:13 a.m., the RD stated he did not assess food that came of the kitchen for palatability. He stated he was fully aware food was not hot enough for residents and recipes were not followed. RD also stated he did not give in-services to the Assisted Living kitchen staff. In an interview on 11/2/23 at 1:51 p.m., when the Administrator (ADM) was asked how he ensured the RD and CDM carried out their job duties and ensured regulations and safety and sanitation procedures were followed in the kitchen, CDM stated the staff in the kitchen were Assisted Living staff. ADM stated CDM gave in-services to kitchen staff regarding the food and the RD did kitchen inspections. In an interview on 11/3/23 at 11:50 a.m., CDM stated he did not do any in-services for the Assisted Living kitchen staff. He stated he tried to schedule a time to do one, but he did not receive a response showing interest. CDM provided emails he sent to ORDFS dated 6/15/23, 6/21/23, 7/27/23, 8/30/23, 9/26/23, 10/6/23, 10/28/23 which showed he attempted schedule in-services for the assisted living kitchen staff regarding food texture. Examples of the emails included one sent to ORDFS on 10/6/22 which read We need to in-service staff about different therapeutic diets and textures. I have asked you when would be a good time to do that with the staff on 6/15, 6/21, 7/28, 8/30, and 9/26, but you never get back to me. This needs to get done on a priority basis. We should really be doing in services monthly about various foodservice topics in regards to safety/sanitation and the like .

2. Review of the facility's undated policy and procedure (P&P) titled Menus showed, menus must be followed as written. Also, when changes to the menu are made, menu changes are to be reviewed and approved in advance by the dietitian. When emergency substitutions in the menu are necessary, substitutions and reasons for substitutions are made in writing on the posted menu. a. Review of the document titled Menu Advantage- [Facility Name] dated 23-24 F/W Day: Tuesday, for the puree therapeutic diet showed, four ounces (oz, a unit of measure) of pureed cheesecake was being served for dessert. During a concurrent observation and interview with the Outside Resource Director of Food Service (ORDFS), the Registered Dietitian (RD) and the Certified Dietary Manager (CDM) on 10/31/23 at 11:35 a.m. in the tray line area of the kitchen, ORDFS plated lunch for residents. For dessert, sugar free pudding was placed on trays for residents on a pureed diet instead of pureed cheesecake. ORDFS stated residents on the puree texture diet received sugar free pudding for dessert instead of pureed cheesecake even though cheesecake was on the menu. In addition, residents on a mechanical soft diet (diet for residents who have trouble chewing and swallowing) received a 4-oz cup of mixed fruit on their tray for dessert instead of cheesecake. ORDFS stated residents on a mechanical soft diet could have cheesecake. ORDFS did not provide a reason why mechanically altered diets did not receive cheesecake. The RD and CDM stated they were not made aware of any menu changes for lunch that day. During an interview on 10/31/23 at 12:42 p.m., the RD stated all substitutions on menu should get his approval first or should be discussed with CDM before any changes were made to the menu. The RD stated residents should receive what is on the menu and/or written on the tray ticket. In an interview on 11/1/23 at 2:50 p.m., ORDFS stated she did not discuss menu changes with the RD or CDM and she did not document menu changes. b. Review of the document titled Menu Advantage- [Facility Name] dated 23-24 F/W Day: Tuesday, for the CCHO therapeutic diet showed, ½ serving of chef's choice cake was being served for dessert. During a concurrent observation and interview with the ORDFS, RD, and CDM on 10/31/23 at 11:35 a.m. in the tray line area of the kitchen, ORDFS plated lunch for residents. On the tray for the residents who received a CCHO therapeutic diet was one 3.25-oz cup of sugar free pudding. ORDFS said residents on the CCHO diet received sugar free pudding or sugar free jello for dessert. ORDFS confirmed CCHO diets were to receive cake according to the menu. The RD and CDM stated they were not made aware of any menu changes for lunch that day. During an interview with the CDM and the RD on 10/31/23 at 12:34 p.m., both the CDM and RD stated they were not aware all CCHO diets did not want a regular dessert. RD also stated residents should receive what was on the menu. The RD stated all substitutions on menu should get his approval first or should be discussed with CDM before any changes were made to the menu. During an interview with the CDM on 11/2/23 at 9:18 a.m., CDM stated the residents who are on the CCHO were supposed to receive cheesecake for lunch on 10/31/23 not sugar free pudding. CDM stated some residents asked for sugar free desserts as a preference, but this was not for all residents on a CCHO diet, and it would be listed as a preference on the tray ticket if a resident specified sugar free desserts. In an interview on 11/1/23 at 2:50 p.m., ORDFS stated she did not discuss menu changes with the RD or CDM and she did not document menu changes. c. Review of the document titled Menu Advantage- [Facility Name] dated 23-24 F/W Day: Tuesday, for the renal therapeutic diet showed, 8-oz of Penne Pasta and Chicken was being served for lunch. During a concurrent observation and interview with the ORDFS, the RD, and CDM on 10/31/23 at 11:35 a.m. in the tray line area of the kitchen, ORDFS plated lunch for residents. On the plates for the residents who received a renal therapeutic diet was 8-oz of spaghetti pasta with turkey meatballs. ORDFS stated she did not follow the menu for residents on a renal diet because she liked to keep the renal diet menu as close to the regular menu as possible. The RD and CDM stated they were not made aware of any menu changes for lunch that day. In an interview on 10/31/23 at 12:42 p.m., the RD stated all substitutions on menu should get his approval first or should be discussed with CDM before any changes were made to the menu. The RD stated residents should receive what is on the menu and/or written on the tray ticket. In an interview on 11/1/23 at 2:50 p.m., ORDFS stated she did not discuss menu changes with the RD or CDM and she did not document menu changes. d. Review of the document titled Menu Advantage- [Facility Name] dated 23-24 F/W Day: Tuesday, showed all diets received mixed baby green salad except for pureed and dysphagia (difficulty swallowing foods or liquids) diets which were supposed to receive tomato juice instead of salad for lunch. During a concurrent observation and interview with the ORDFS, the RD, and CDM on 10/31/23 at 11:35 a.m. in the tray line area of the kitchen, ORDFS plated lunch for residents. A bowl of soup was placed on most trays with no salad. ORDFS stated soup was always served for lunch and salad was no longer served for lunch unless it was requested. ORDFS stated all diets received chicken soup except for mechanical soft, puree, and renal diets. The RD and CDM stated they were not made aware of any menu changes for lunch that day. A record review for Resident 41 showed his original admission date was 9/10/2018 and diagnoses included but were not limited to unspecified protein-calorie malnutrition. The MDS Comprehensive Assessment (MDS- an assessment tool to guide care) dated 10/18/23 showed Resident 41 had a Brief Interview for Mental Status (BIMS, a mental status exam) score of 14 out of 15, indicating intact mental status. Resident 41's diet order from 9/10/18 to current was Regular diet and Regular textured. During an interview with Resident 41, on 11/1/23 at 1:00 p.m. in Resident 41's room, Resident 41 stated he used to get a salad with his lunch, but he did not anymore. Resident 41 stated he does not get nearly enough fresh fruit and vegetables with his meals. Resident 41 also stated that he does not like it when he does not receive a salad with his lunch. In an interview on 11/1/23 at 2:50 p.m., ORDFS stated she did not discuss menu changes with the RD or CDM and she did not document menu changes and she did not discuss her decision to always provide soup for the meals instead of salad the RD or CDM. e. Review of the document titled Menu Advantage- [Facility Name] dated 23-24 F/W Day: Tuesday, for the puree therapeutic diet showed, 8-oz of pureed pasta with meatballs was being served for lunch. During a concurrent observation and interview with the ORDFS, RD and the CDM on 10/31/23 at 11:35 a.m. in the tray line area of the kitchen, ORDFS plated lunch for residents. On the tray for the residents who received pureed texture food was a plate that contained one 4-oz scoop of pureed pasta and one 4-oz scoop of pureed meatballs. Review of the recipe titled Spaghetti with Meatballs dated March 29, 2017, showed directions for preparing spaghetti and meatballs. For the pureed preparation, the recipe showed to remove the desired number of servings of spaghetti and meatballs and blend together until desired consistency. f. Review of the document titled Menu Advantage- [Facility Name] dated 23-24 F/W Day: Tuesday, for all diet types showed, 8-oz of pasta with meatballs was being served for lunch. An observation of trayline lunch service on 10/31/23 at 11:35 a.m., showed ORDFS plated 4-oz of pasta and 4-oz of meatballs on plates. The pasta was covered with a brown sauce. During an interview with ORDFS on 11/3/23 at 10:19 a.m., ORDFS stated for pasta served on 10/31/23, tomato sauce was not used, but instead, a brown sauce intended for the chicken marsala was used. ORDFS stated she changed the sauce because she felt like there was a lot of tomato being served on the following week's menu. In an interview on 10/31/23 at 12:42 p.m., the RD stated all substitutions on menu should get his approval first or should be discussed with CDM before any changes were made to the menu. In an interview on 11/1/23 at 2:50 p.m., ORDFS stated she did not discuss menu changes with the RD or CDM and she did not document menu changes. Based on observation, interview and record review, the facility failed to ensure the menu: 1. Met the nutritional needs of residents in accordance with established national guidelines; and; 2. Was followed when: a. Cheesecake was not served to residents on a modified textured diet. b. Cheesecake was not served to residents who were on a controlled carbohydrate (CCHO, a diet which has consistent amount of carbohydrate for each meal. This diet is typically prescribed for individuals who have difficulty with controlling blood sugars) diet. c. Penne pasta and chicken was not served for residents who were on a renal diet (diet that helps promote kidney health). d. Mixed baby green salad was not served to residents on a regular textured, and mechanical soft diet. e. Pureed pasta and pureed meatballs were served on a plate separately, rather than mixed together. f. Pasta with meatballs was not served with tomato sauce. These failures had the potential to result providing residents with an inadequate and/or a harmful amount of nutrients further compromising residents' medical status for 40 residents who received food from the kitchen. FINDINGS: 1. Per the National Institute of Health, Nutrient Recommendations: Dietary Reference Intake (DRI) are documents issued by the Food and Nutrition Board of the National Academies of Sciences Engineering, and Medicine. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and sex, include Recommended Dietary Allowance (RDA): the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals and often used to plan nutritionally adequate diets for individuals; and Adequate Intake (AI): Intake at this level is assumed to ensure nutritional adequacy and is established when evidence is insufficient to develop an RDA. In an interview on 10/31/23 at 12:42 p.m., the RD stated the outside resource company who owned the building and staffed the kitchen, was responsible for the menu and the nutrient analysis of the menu. He stated just last week he received the first nutrient analysis to review since he worked for the facility. The RD confirmed it was the nutrient analysis for fall/winter quarter menu. Review of the documents titled Menu Template Nutrition Summary dated 9/30/22, and 4/27/23 showed nutrient analyses for 2022-2023 Fall Winter Menus and 2023 Spring Summer Menu respectively. The analyses showed they were each an average of daily nutrient values for 28 days and the goal percentages of nutrients reflected Adult/Child. The nutrient analysis did not indicate the diet analyzed. There was one nutrient analysis provided for a menu quarter, which indicated nutrient analyses were not provided for all of the therapeutic diets provided at the facility. In addition, it could not be identified if resident nutrient needs were being met on a daily or even weekly basis. In an interview on 11/1/23 at 9:45 a.m., the RD stated the nutrient analysis was not complete. He confirmed the nutrient analysis reflected the average nutrients for 28 days, it did not identify age or gender to show it reflected the facility demographics, and it only reflected the Regular diet and not the therapeutic diets served at the facility. In an interview on 11/3/23 at 11:03 a.m., the ADM confirmed the RD was provided a nutrient analysis for the menu a couple of weeks ago. He stated he was aware the RD did not want to sign off on the menus because the RD did not think the nutrient analysis showed the nutrient analysis met the needs of the residents.

Based on observation, interview, and record review, the facility failed to provide food at a palatable temperature. This failure had the potential to result in a decreased intake of food by residents leading to nutrition related medical complications for 40 residents who received food from the kitchen. Findings: Record review for Resident 62 showed her original admission date was 9/14/2023 and diagnoses include but were not limited to adult failure to thrive (a syndrome including weight loss, decreased appetite, poor nutrition, and inactivity) and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). The MDS (Minimum Data Set) Comprehensive dated 9/20/23 showed Resident 62 had a BIMS (Brief Interview for Mental Status; a score of 8-12 suggests moderate cognitive impairment, and a score of 13-15 suggests cognitive intactness) score of 15. In an interview on 10/30/23 at 11:45 a.m., Resident 62 stated the food was always cold. An observation of trayline food service in the kitchen on 10/31/23 at 11:35 a.m. to 12:30 p.m., showed resident food was plated by the Outside Resource Director of Food Service (ORDFS) for lunch. Three tray carts were loaded with resident lunch trays. Plates of food were covered with plastic domes and bases (devices that help keep food warm). On the last cart loaded, 15 plates of hot food were covered with foil instead of domes and bases. Also, on the last cart loaded, two test trays including regular textured food and pureed textured food served for lunch that day, were placed on the cart. The test trays were the last trays plated on trayline. The plates of hot food for the test trays were covered with foil instead of domes and bases. An observation on 10/31/23 at 12:30 p.m., showed all three carts were wheeled out of the kitchen and nursing staff began passing trays to residents. On 10/31/23 at 12:42 p.m., in the presence of the facility Registered Dietitian (RD) and the Certified Dietary Manager (CDM) two test trays were sampled after the last resident lunch tray was passed. Temperatures of the food were measured by CDM with a facility thermometer and the surveyor with the surveyor's calibrated thermometer. Food was also tasted by the two surveyors, the RD, and CDM. Some of the food felt lukewarm in the mouth. The foods that the RD and CDM agreed were lukewarm were: regular textured meatballs 109.4 degrees Fahrenheit (F), regular textured ratatouille (mixed vegetable stew) 116.1 degrees F, regular textured pasta 107.4 degrees F, and pureed pasta 117.9 degrees F. CDM stated the food could be warmer. A record review for Resident 13 showed his original admission date was 9/26/2023 and diagnosis included but not limited to type 2 diabetes mellitus with foot ulcer. The MDS Comprehensive dated 9/20/23 showed Resident 13 had a BIMS score of 15. On observation and concurrent interview with Resident 13 on 10/31/23 at 12:48 p.m., showed Resident 13 was in his room with his lunch tray on his bedside table. The plate of food on the tray consisted of pasta and meatballs and vegetables. Resident 13 stated his lunch was cold and he would eat more if his lunch was hot. On 11/1/23 at 11:45 a.m., an observation of trayline food service and concurrent interview with ORDFS, showed Outside Resource Dietary Aide 2 (ORDA2) plated food for resident lunches. Test trays were placed on the first cart at the beginning of trayline when the first lunch trays were plated. The test trays consisted of regular and pureed textured food, as well as ground chicken and were covered with domes and bases. ORDFS stated some of the hot food plates for residents were covered with foil instead of domes and bases because there were not enough domes and bases available. On 11/1/23 at 12 p.m., an observation showed the first tray cart holding lunch trays was wheeled out of the kitchen. On 11/1/23 at 12:35 p.m., in the presence of the facility Registered Dietitian (RD) and the Certified Dietary Manager (CDM) the test trays were sampled after the last resident lunch tray was passed from the first tray holding cart. Temperatures of the food were measured by the CDM with a facility thermometer and by the surveyor with the surveyor's calibrated thermometer. Food was also tasted by the two surveyors, the RD, and CDM. Some of the food felt lukewarm in the mouth. The foods that the RD and CDM agreed were lukewarm were: regular textured chicken 113.2 degrees F, regular textured rice 114.4 degrees F, regular textured carrots 100.8 degrees F, mechanical soft chicken 107.4 degrees F, pureed chicken 110 degrees F, pureed rice 112 degrees F, and pureed carrots 110 degrees F. RD 1 stated the temperatures were low and said they were even lower than yesterday test tray temperatures. A record review for Resident 394 showed his original admission date was 10/18/2023. The MDS Comprehensive dated 10/24/23 showed Resident 394 had a BIMS score of 10. Resident 41's diet order showed he received a mechanical soft textured diet ordered on 10/19/23. In an interview with Resident 394 on 11/1/23 at 12:45 p.m., Resident 394 stated he was at the facility for about 2.5 weeks and the food was always cold. A record review for Resident 41 showed his original admission date was 9/10/2018 and diagnoses included but were not limited to unspecified protein-calorie malnutrition. The MDS Comprehensive dated 10/18/23 showed Resident 41 had a BIMS score of 14. Resident 41's diet order from 9/10/18 to current was Regular diet and Regular textured. In an interview with Resident 41 on 11/1/23 at 1 p.m., Resident 41 stated he was at the facility 3-4 years and the temperature of the food was not consistent. He stated sometimes the food was nearly if not cold as if it was sitting around a while. In an interview on 11/2/23 at 9:21 a.m., CDM stated he was aware of complaints of cold food and cold food was a reoccurring theme and was an issue since he started the job. In an interview on 11/2/23 at 11:13 a.m., RD stated in all honesty, I know what's being provided [to residents]. RD stated he was fully aware that food served was not hot enough. In an interview on 11/2/23 at 1:51 p.m., ADM stated he was aware of residents receiving cold food. Review of the Resident Council Meeting minutes dated 1/31/23, showed Council members reported that sometimes the food on their tray is cold. Review of the Resident Council Meeting minutes dated 6/10/23, showed Sometimes food comes cold when delivered. Review of the undated Policy and Procedure titled Food Temperatures, showed the point of service [food] temperatures to residents will be within the range of 120-140 degrees based on the resident's preference.

Based on observation, staff interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for safety when: 1. The inside of two ice machines were not maintained clean. 2. Fish was not thawed safely. 3. Fish was not stored safely. 4. Chicken held on trayline was not maintained at a safe temperature. 5. A food service staff was unable to properly calibrate thermometers. 6. Food was stored and available for use in the walk-in refrigerator past the use-by-dates and without identified use-by-dates. 7. Food stored in a reach-in freezer was not covered and had freezer burn. 8. Dry food stored in the dry storeroom was not protected from contamination. 9. Bulk, dry food storage bins containing bulk foods, were not maintained clean. 10. An industrial can opener was not maintained clean. 11. Four frying pans stored and ready for use were in poor condition and were not clean. 12. Nine cutting boards were in poor condition. 13. A meat slicer was not clean and stored uncovered. 14. The inside of a drawer used to store clean utensils, shelving, and the inside of retired refrigerators were not maintained clean. 15. The inside of two microwave ovens was not maintained clean. 16. Food service staff were unable to properly test the sanitizer solution concentration. 17. Non-food service staff entered the kitchen and handled items without following kitchen safety and sanitation standards. 18. The kitchen ceiling was not maintained clean and was in poor condition. 19. Two vents over the food prep areas were not maintained clean. 20. 5 ceiling light fixtures in the kitchen were missing covers with the bulbs exposed. 21. A floor drain and a grease trap were not maintained to adequately drain contents. 22. A wall in the kitchen had exposed drywall and was in poor condition. These failures put the facility at increased risk for food contamination and food borne illness for 40 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview in the trayline food service area of the kitchen with the Outside Resource Maintenance Director (ORMD) on 10/31/23 at 9:50 a.m., showed an ice machine with a full bin of ice. ORMD opened the ice machine so the inside could be viewed. The plastic surface surrounding the evaporator plate (where what flows over and ice is formed) had a brown and black residue on the surface and when it was wiped with a paper towel, there was black, pinky, slimy residue on the paper towel. ORMD stated the ice machine was not really clean. ORMD stated the ice machine was just cleaned four days prior by Outside Resource Maintenance Technician (ORMT). ORMD stated when the ice machine was cleaned, it was shut down, taken apart and the internal parts were cleaned with a solution called Nickel Safe. He stated this was the only chemical used for the ice machine. During a concurrent observation and interview with the ORMT in the trayline area in the kitchen on 11/1/23 at 10:31 a.m., ORMT was cleaning the inside of the ice machine. ORMT stated he was responsible for cleaning the inside of the ice machine. ORMT stated the last time he cleaned the ice machine was about five months ago. ORMT stated he only used hot water to clean the inside of the ice machine because the chemicals previously used burned his eyes. ORMT stated he did not follow the manufactures instructions when cleaning the ice machine because he cleaned the ice machine at his previous place of employment and already knew how to clean ice machines. An observation on 11/1/23 at 10:31 a.m., showed manufacturer's instructions for maintaining the ice machine were located on the inside surface of the ice machine cover. The instructions showed the appliance must be maintained in accordance with the instruction manual and the labels provided. The cleaning instructions showed detailed steps to follow and to use the chemical [Ice Machine Brand] Scale Away. The sanitizing instructions showed detailed steps for sanitizing the ice machine and to use an 8.25 percent sodium hypochlorite solution (chlorine bleach). A concurrent interview and observation on 11/02/23 at 12:45 p.m. in the nursing station area with the Certified Dietary Manager (CDM) and the Maintenance Assistant (MA), showed an ice machine located underneath the counter opposite from a reach-in refrigerator. The ice machine had a full bin of ice. MA stated he was responsible for cleaning this ice machine and removed the cover of the evaporator plate. There was an orange, black, and yellow residue on the inside surface of the evaporator plate cover. In addition, on the plastic surrounding the evaporator plate was brown, yellow, dark orange, pink, black residue. When the plastic around the evaporator plate was wiped with a paper towel, slimy and chunky clear, yellow, black, and pink residue came of onto the paper towel. MA stated he never cleaned the evaporator plate cover. MA stated when he cleaned the ice machine, he removed all of the ice from the bin, flushed out and sanitized the water filter with a chemical per manufacturer's instructions. He stated he used one chemical when he cleaned the machine. MA stated he did not consider the ice machine to be clean. An invoice was provided for the chemical used to clean the ice machine titled [Ice Machine Company Name] Scaleaway Cleaner dated July 5, 2023. In an interview and document review on 11/2/23 at 3:11 p.m., showed the facility's P&P titled Ice Machine Cleaning Procedures dated 2018 was a general policy and procedure for maintaining ice machines and stated to clean the inside of the ice machine with a sanitizing agent per the manufacturer's instructions. MA stated he used the facility Ice Machine Cleaning Procedures for cleaning the ice machine and did not have the manufacturer's manual to follow the manufacturer's instructions. Review of the ice machine manufacturer's manual for the ice machine titled [Ice Machine Company Name] Self-Contained Crescent Cuber dated 1/15/14, showed cleaning is recommended once a year but cleaning more often may be needed in some existing water conditions. The manual contained specific step-by-step instructions for cleaning and sanitizing the ice machine. The cleaning and sanitizing instructions included removing parts to clean and sanitize. The cleaning and sanitizing instructions showed to use the [Ice Machine Company Name] Scaleaway in addition to a 5.25 percent hypochlorite solution (chlorine bleach). Review of the facility's undated P&P titled Cleaning and Sanitizing Dietary Areas and Equipment showed, .all kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil . Review of the facility's P&P titled Sanitation dated 2018 showed, .all equipment shall be kept clean . According to the 2022 Federal Food Code food-contact equipment and utensil surfaces are to be clean to sight and touch, and nonfood-contact surfaces of equipment are to be free of an accumulation of dust, dirt, food residue, and other debris. 2. An observation on 10/30/23 at 11:21 a.m., showed six raw fish fillets thawing in a food preparation sink. The fish fillets were in a shallow pan and water from the faucet above the pan was dripping onto the fish. One of six of the fillets was not submerged in the water. In an interview on 10/30/23 at 12:02 p.m., the Outside Resource Director of Food Services (ORDFS) stated thawing fish in the food preparation sink should be in a deep pan so all the fish can be submerged with water and the water should be running over the fish at a rate to remove any debris from the fish, not just dripping onto the fish. According to the 2022 Federal Food Code, when thawing Time/Temperature Control for Safety (TCS) Food is to be using water, completely submerged under running water at a temperature of 70 degrees or below with sufficient water velocity to agitate and float off loose particles in an overflow. 3. An observation on 10/30/23 at 11:25 a.m., showed a plastic bin with more than 20 frozen fillets of fish stored on a food preparation table. In an observation and interview on 10/30/23 at 11:49 a.m., the surveyors calibrated thermometer indicated the kitchen air temperature was 86 degrees F. The CDM agreed it was warm inside the kitchen. An observation and interview on 10/30/23 at 12:02 p.m., showed the same container of frozen fish remained on the preparation table. Outside Resource [NAME] 1 (ORC1) stated she had the fish out to prepare it during trayline. ORDFS stated the fish should not be stored on the countertop and should be stored in the refrigerator. Review of the undated Policy and Procedure titled Sanitation showed steps in the sanitary preparation of food included food that is removed from the refrigerator for preparation is processed immediately upon removal and is not allowed to deteriorate. 4. During a concurrent observation and interview with the ORDFS and the Outside Resource Dietary Aide 2 (ORDA2) in the trayline area of the kitchen on 11/1/23 at 11:20 a.m., ORDA2 measured temperatures of food being served for a lunch meal. ORDA2 inserted a thermometer into three different pieces of chicken within a pan of many pieces of chicken. The thermometer read 123.4 degrees Fahrenheit (F, a unit of measure), 144 F and 143.6 F. When ORDA2 documented the temperature of the chicken, she wrote the chicken was 165 and 179 degrees F. The surveyor also measured the temperature of three pieces of chicken with a calibrated thermometer and the temperatures were 132.6 degrees F, 140.4 degrees F, and 124.3 degrees F. After taking temperatures, ORDA2 proceeded to place food on resident lunch trays. She plated five residents' lunch trays with the chicken and placed the plates on trays in a food cart for lunch service. The chicken temperatures were reviewed with ORDFS, and she stated she expected all food to be at least 165F on trayline, so food was hot when it was served. ORDFS stated the temperature of the chicken was too low and had to be heated more. In addition, 2 pieces of chicken were in a separate pan on the trayline. ORDFS stated the two pieces of chicken did not have a glaze and were for residents on a gluten-free diet. The temperature of one piece of unglazed chicken was measured with the surveyor's calibrated thermometer and was 120 degrees F. ORDFS stated the temperature of the unglazed chicken was too low. Review of the facility's undated P&P titled Food Temperatures showed, Foods will be maintained at proper temperature to ensure food safety .6. The following range of temperatures is recommended for food at point of tray assembly. B. Meat, portioned for service 160 degrees F . According to the 2022 Federal Food Code, time/temperature Control for Safety (TCS) Food (Food that is more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) is to be maintained at 135 degrees F or above when hot holding without using time as a public health control. 5. During a concurrent observation, interview, and record review with the ORDFS and the ORDA2 in the trayline area of the kitchen on 11/1/23 at 11:20 a.m., ORDA2 measured temperatures of food being served for a lunch meal. ORDA2 inserted a thermometer into a container of pureed rice. The thermometer showed 75.5 degrees Celsius (C, a unit of measure; 75.5 degrees Celsius equals 167.9 degrees F). ORDA2 then wrote 179F on a temperature log next to rice. ORDA2 then measured the temperature of pureed chicken. The thermometer showed 80 C (which is 176 degrees F). ORDA2 wrote 179 on the temperature log. ORDFS then told ORDA2 to change the thermometer from Celsius to Fahrenheit. During a concurrent observation, interview with the ORDFS and the ORDA2 in the trayline area of the kitchen on 11/3/23 at 11:32 a.m., ORDA2 was calibrating (process to ensure the thermometer is accurate) a thermometer before measuring the temperature of food on trayline. ORDA2 inserted a thermometer into a container of ice and water. The thermometer showed 27.5 F. ORDA2 stated 27.5 was okay and also stated the thermometer should be 25 or under. ORDFS then stated the thermometer ORDA2 was using was not working correctly. ORDFS then gave ORDA2 a new thermometer to calibrate. ORDA2 inserted the thermometer into a container of ice water. The thermometer showed -6 degrees C. She did it again and the thermometer read -4 degrees C. ORDA2 stated the temperatures were ok. ORDFS confirmed the thermometer was on Celsius and then instructed ORDA2 to change the thermometer to Fahrenheit. ORDFS then stated ORDA2 needed more training on calibrating thermometers. Review of the facility's undated P&P titled Thermometer Calibration showed, .To assure accuracy of food temperatures .Calibration in Ice Water: 3. If the thermometer does not read between 30 degrees F and 34 degrees F adjust to 32 degrees F. Non-adjustable thermometers should be removed from use until they have been professionally serviced . Review of the facility's P&P titled Sanitation dated 2018 showed, .2 .Each employee shall know how to operate . all equipment in his specific work area . 6. During a concurrent observation and interview with the ORDFS and the CDM during the initial kitchen tour on 10/30/23 at 10:00 a.m., located in the walk-in refrigerator and available for use were the following food items stored beyond the facility identified use-by dates: -one thawed 10 pound (lb., a unit of measure) raw pork roast labeled with a use-by-date of 10/25/23, three raw fish fillets labeled with a use-by-date of 10/27/23; -one re-useable container filled with kidney beans with a label showing a use-by-date of 10/28/23; and -one opened container filled with sauerkraut with a label showing a use-by-date of 10/22/23. ORDFS confirmed the items the food items were stored beyond the use-by date. CDM stated staff should be discarding items by the use-by-date daily. In addition, the following opened food items were stored without facility identified use-by dates: -one re-useable container labeled strawberry jam and labeled with an open date of 10/25/23; -one re-useable container labeled tomato sauce and dated 10/24/23; -one opened container of sauerkraut labeled with an open date of 10/24/23; -one re-useable container filled with garlic butter with an open date of 10/26/23; -one opened container of ketchup with an open date of 10/22/23; -one re-useable container of cut-up pieces of raw squash showing a prepared date of 10/26/23; -one opened 3-liter (L, a unit of measure) bottle of strawberry kiwi juice concentrate with an open date of 10/5/23; -one opened 3-L bottle of cranberry juice concentrate with an open date of 10/22/23; -one opened 3-L bottle of tropical mango juice concentrate with an open date of 10/10/23; -one opened 3-L bottle of passion fruit orange guava juice concentrate with an open date of 10/10/23; -one opened 3-L bottle of pineapple juice concentrate with an open date of 10/22/23; and -six opened 3-L bottles of various flavors of juice concentrates without open dates. ORDFS stated staff were supposed to label the items with use-by-dates and she confirmed staff were not doing so. ORDFS stated staff did not put open dates on some of the bottles of juice concentrates instead, staff went by the manufacturers use-by-date. ORDFS confirmed the manufactures use-by-date on the bottles of juice concentrate was 7/19/25. ORDFS then stated, it was not okay to keep open bottles of juice concentrate until 2025. Review of the facility's undated P&P titled Guidelines for Storage showed, a ten page list of food items use-by time frames for the foods. The policy stated to .Date your products with Use By Dates. 7. During a concurrent observation and interview with the ORDFS during the initial kitchen tour on 10/30/23 at 11:43 a.m., showed food greens in the plastic bag stored in a reach-in refrigerator. The plastic bag was not sealed, and the greens were exposed to the open air. The greens were covered with a layer of ice. ORDFS stated the bag contained spinach and confirmed there was ice covering the spinach. ORDFS stated the spinach should be completely covered and should not have ice on the surface. ORDFS stated the spinach had to be discarded. Review of the undated policy and procedure titled Food Ordering and receiving showed to rewrap packages of frozen food which have been opened to prevent freezer burn and spoilage. 8. A concurrent observation and interview with the ORDFS during the initial kitchen tour on 10/30/23 at 11:01 a.m., showed an opened 25-pound bag of powdered sugar stored in the dry food storeroom. The powdered sugar was in the original bag stored in a plastic container. The sugar inside the bag had a brown residue on the surface and what appeared to be an insect in the sugar. ORDFS confirmed there was a brown residue in the sugar but what appeared to be an insect was buried in the sugar before she saw it. ORDFS stated the sugar should be thrown out. Review of the undated policy and procedure titled Food Storage showed metal or plastic containers with tight fitting covers must be used for storing sugar and lots of bulk food. According to the 2022 Federal Food Code, food is to be protected from contamination. In addition, food shall be safe and unadulterated (a food rendered poorer quality by adding another substance). A food that is adulterated shall be discarded. 9. A concurrent observation and interview with the ORDFS during the initial kitchen tour on 10/30/23 at 11:26 a.m., showed six, bulk dry food storage bins stored under a food preparation table. The bins were labeled and contained oatmeal, rice, thickener, panko breadcrumbs, flour, and sugar. All six bins had brown residue on the inside surface. ORDFS stated the bins were not clean and they should be clean. Review of the facility's P&P titled Ingredient Bins dated 2018 showed, .ingredient bins must be kept clean to prevent food contamination . Review of the facility's undated P&P titled Cleaning and Sanitizing Dietary Areas and Equipment showed, .all kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil . Review of the facility's P&P titled Sanitation dated 2018 showed, .all equipment shall be kept clean . 10. A concurrent observation and interview with the ORDFS and the CDM during the initial kitchen tour on 10/30/23 at 11:30 a.m., showed an industrial can opener in a holder mounted to a preparation table. There was thick, black residue build-up on the blade of the can opener and on the cogwheel (the round wheel that helps move the can around while being opened), and there was thick, white, residue on the surface of the can opener shaft (the handle part of the can opener). ORDFS stated the can opener was not clean. Review of the facility's P&P titled Can Opener and Base dated 2018 showed, Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation .1. The can opener must be thoroughly cleaned each work shift and when necessary, more frequently . Review of the facility's undated P&P titled Cleaning and Sanitizing Dietary Areas and Equipment showed, .all kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil . Review of the facility's P&P titled Sanitation dated 2018 showed, .all equipment shall be kept clean . 11. During a concurrent interview and observation with Outside Resource [NAME] 2 (ORC2) on 11/2/23 at 10:56 a.m. in the kitchen, four frying pans were stored on a rack used to store clean cooking utensils. On the cooking surface of the pans was greasy residue. The cooking surface of two of the pans had a dry, black residue build-up. The cooking surface of one pan had a non-stick surface that was significantly scratched. ORC2 stated the pans were not clean and they were scratched. ORC2 stated the pans on the clean storage rack should be clean. Review of the facility's P&P titled Sanitation dated 2018 showed, .9. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas . According to the 2022 Federal Food Code, food-contact surfaces of utensils are to be clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulation. 12. During a concurrent observation and interview with the ORDFS and CDM during the initial kitchen tour on 10/30/23 at 10:00 a.m., nine of nine randomly selected cutting boards from those stored on a clean storage rack under a food preparation table, had a black residue imbedded in the cutting surface and also had visual signs of wear on the cutting surface. Three of the cutting boards also had a sticky residue on them. ORDFS and CDM both confirmed the black and sticky residue. CDM stated the boards were a little worn. CDM also stated, when there are visual signs of wear, the cutting boards should be replaced. Review of the facility's undated policy and procedure (P&P) titled Cleaning and Sanitizing Dietary Areas and Equipment showed, .all kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil . Review of the facility's P&P titled Sanitation dated 2018, showed all utensils and equipment shall be kept clean and maintained in good repair. According to the 2022 Federal Food Code, multiuse food-contact surfaces are to be smooth and food-contact equipment and utensil surfaces are to be clean to sight and touch. 13. A concurrent observation and interview with the ORDFS during the initial kitchen tour on 10/30/23 at 10:54 a.m., showed a meat slicer stored in the dry food storeroom. The meat slicer had dried residue resembling dried food on the blade surface and on the metal areas surrounding the blade. ORDFS stated, the meat slicer should be clean and covered. Review of the facility's P&P titled Electrical Food Machines dated 2018 showed, .Food Slicer: 1. Clean the slicer after each use .4. When not in use, food slicer should be covered . Review of the facility's P&P titled Sanitation dated 2018 showed, .all equipment shall be kept clean . 14. A concurrent observation and interview with the ORDFS and the CDM during the initial kitchen tour on 10/30/23 at 11:13 a.m., the shelf in a cabinet above the microwave had a residue on the surface that felt gritty to the touch. ORDFS stated the shelf was not clean and thought the gritty residue might be sugar. As the initial kitchen tour continued on 10/30/23 at 11:16 a.m., a three-door refrigerator located under the preparation table where the microwave was stored, had a dark brown and black residue on the inside surface and the rubber gaskets (rubber surrounding the perimeter of the door intended to seal the door to keep cold air inside) surrounding the refrigerator doors were filled with brown particles resembling food crumbs. ORDFS stated the refrigerators were not working and not used and confirmed they were dirty. An observation and interview on 10/31/23 at 11:18 a.m., showed a three-door refrigerator located under a trayline food service area had brown residue on the inside surface. ORDFS stated the refrigerator was broken and not in use and confirmed there was residue build-up inside and it was not clean. ORDFS stated the kitchen was short staffed. ORDFS stated there was a cleaning schedule, but it was for the cook area only. ORDFS stated cabinets and shelving outside of the cook area were not on a cleaning schedule. She stated areas not on the cleaning scheduled were cleaned on downtime. An observation and interview on 11/3/23 at 10:19 a.m., showed a drawer attached to a preparation table on the back wall that also housed the 3-compartment sink, contained clean cooking utensils, and had particles resembling food crumbs on the inside surface of the drawer. ORDFS stated the drawer holding the utensils was not clean and cooks were supposed to clean drawers if they saw them dirty. Review of the facility's undated P&P titled Cleaning and Sanitizing Dietary Areas and Equipment showed, .all kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil . Review of the facility's P&P titled Sanitation dated 2018 showed, .all equipment shall be kept clean . 15. During a concurrent observation and interview with the ORDFS and the CDM during the initial kitchen tour on 10/30/23 at 11:11 a.m., a microwave oven, located on a countertop across from a trayline food service area, had a significant amount of dried, orange residue resembling food residue, on the inside walls, inside ceiling, and on the rotating glass plate. ORDFS confirmed the microwave oven was not clean because the food particles were dried. An observation and interview on 10/31/23 at 10:23 a.m., the microwave across from the trayline food service area still had dried orange residue on the throughout the inside of the microwave. The amount of residue appeared to be more than observed on 10/30/23 at 11:11 a.m. ORDFS stated the microwave should be cleaned at the end of the day and as needed if something is spilled inside the microwave. ORDFS observed the ceiling inside the microwave and stated she did not think it was cleaned at the end of the day because the residue was dry. A concurrent interview and observation with the CDM on 11/02/23 at 12:45 p.m., showed in the nursing station area there was a counter with a microwave oven installed above the counter. The CDM stated the microwave oven was used to reheat resident food items. The CDM stated he was not sure, but thought housekeeping was responsible for cleaning and sanitizing the nursing station kitchen area. During a concurrent interview and observation with the Housekeeping Supervisor (HS) on 11/3/23 at 9:30 a.m., HS stated housekeeping was responsible for cleaning the countertop and microwave oven located in the nursing station area. HS stated the nursing station kitchen area was cleaned once daily and as needed. HS opened the microwave oven and stated the inside was very clean. HS then wiped the inside walls of the microwave oven with a paper towel. On the paper towel was a brown residue and confirmed it was not clean. HS stated the microwave oven was cleaned with a disinfectant that was kept in the housekeeping cart. On the housekeeping cart were bottles of various cleaning chemicals stored next to each other. HS confirmed that chemicals used for cleaning toilets in the facility, cleaning the microwave and the countertops in the nursing area kitchen were next to each other on the housekeeping cart. During a follow up interview with the CDM on 11/3/23 at 11:08 a.m., the CDM stated housekeeping should be using a food safe sanitizing solution to clean the nursing station kitchen area and not a disinfectant. The CDM stated disinfectant chemicals are too strong. CDM then stated housekeeping should not store toilet bowl cleaner and chemicals used to clean the microwave together. Review of the facility's undated P&P titled Cleaning and Sanitizing Dietary Areas and Equipment showed, .all kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease or other soil . Review of the facility's P&P titled Sanitation dated 2018 showed, .all equipment shall be kept clean .23. Do not use cleaning products or sanitizer in the food preparation or food storage areas in any way that could result in contamination . 16. During a concurrent observation and interview with the Outside Resource Server 1 (ORS1) on 10/31/23 at 10:45 a.m., ORS1 entered the kitchen with a cart of pitchers. ORS1 placed a red bucket on the ground underneath the three-compartment sink where a container of quaternary ammonia sanitizer (quat) was stored. ORS1 filled the red bucket up with the sanitizer and added water to the bucket. ORDFS instructed ORS1 to use the sanitizer distributed from the hose over the 3-compartent sink. Then ORS1 added some sanitizer solution to the red bucket from the hose. ORS1 used the sanitizer solution to wipe the surface of a cart. ORS1 did not test the strength of the sanitizer before she used it and stated the sanitizer solution was usually tested by a staff member who was not working that day. ORS1 stated she did not usually fill the red bucket with sanitizer, but she was trained on how to do it. The surveyor asked ORS1 to test the sanitizer solution. ORS1 dipped and held a quaternary ammonia test strip (strip of paper specifically designed for testing sanitizer solution concentration) in the bucket of sanitizer solution for 17 seconds. ORS1 then stated the concentration of the sanitizer solution was 500 parts per million (ppm, a unit of measure) when she compared the strip to the manufacturer's color chart. ORS1 stated she did not know how long the test strip was to be held in the sanitizer solution. During a concurrent observation and interview with the Outside Resource Dietary Aide 1 (ORDA1) on 10/31/23 at 10:49 a.m. in the three-compartment sink area of the kitchen, ORDA1 demonstrated how she tested the sanitizer used to clean surface areas in the kitchen. ORDA1 filled a red bucket up sanitizer solution from the hose above the 3-comaprtment sink. ORDA1 then tested the concentration of the sanitizer solution inside of the red bucket. ORDA1 dipped a test strip into the bucket of sanitizer solution for approximately one second (sec., a unit of measure). ORDA1 stated it was okay to dip the test strip in the bucket of sanitizer solution for one sec. In an interview on 11/1/23 at 10:35 a.m., ORDFS stated the sanitizer test strip for the red bucket sanitizer had to be held in the solution for 10 seconds and had to show the strength of the sanitizer was 150 to 400 ppm. Review of the instructions for the Quaternary Ammonia sanitizer solution test strips titled [Brand Name] Multi-Quat Sanitizer dated 2015, showed to dip the test paper in the solution for 10 seconds and the solution strength should be between 150 - 400 ppm. Review of the P&P titled Food Carts dated 2018, showed to sanitize the cart by preparing a quat sanitizing solution following manufacturer's instructions. Review of the P&P titled Quaternary Ammonium Log Policy dated 2018, showed quaternary solution is used for sanitizing clean work surfaces in the kitchen. The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution. The food and nutrition worker will place the sanitizer solution in the appropriate bucket and will test the concentration. The solution will be replaced when the reading is under 200 ppm. The procedures also showed to read the instructions on the quaternary container and the test strips for proper concentration, length of time the strip needs to be in contact with the solution, and if the temperature of the solution is to be conside[TRUNCATED]

Based on observation, interview, and facility document review, the facility failed to ensure the lid of an outside garbage dumpster holding food containers was closed. This failure had the potential to attract insects and rodents to the facility that housed 41 residents. Findings: An observation and concurrent interview with the Outside Resource Director of Operations (ORDO) on 10/31/23 at 9:09 a.m., showed the lid of the outside garbage dumpster was open. The garbage dumpster was located in the outside garbage storage area outside of the facility. The dumpster was half full and contained plastic garbage bags filled with garbage including food containers. ORDO stated the dumpster lids were supposed to remain closed, so germs did not come out and for infection control. In an interview on 11/1/23 at 2:12 p.m., the Registered Dietitian (RD) stated a couple of years ago the Outside Resource who managed the kitchen said he was not allowed in the kitchen unless he scheduled and accompanied visit so the last full inspection of Food and Nutrition Services he completed was on October 12, 2022. Review of the Sanitation and Food Safety Checklist dated 10/12/22 and provided by the RD as the most recent checklist he completed, showed the outside trash bins were not closed. According to the 2022 Federal Food Code, refuse receptacles kept outside the food establishment are to be covered with tight-fitting lids or doors. In addition, receptacles that are not rodent-resistant, unprotected plastic bags and paper bags with food residue may not be stored outside.

Based on observation, interview, and facility document review, the facility failed to ensure a reach-in freezer was working in an efficient and safe manner in the way it was intended. This failure did not ensure food was stored in a way to promote food quality and food safety for 40 residents who received food from the kitchen. Findings: Review of the policy and procedure titled Sanitization dated 2018, showed the Food and Nutrition Services Department shall have equipment of the type and in the amount necessary for proper storing of food. All equipment shall be maintained as necessary and kept in working order. On 10/30/23 at 11:43 a.m., during an observation and concurrent interview with the Outside Resource Director of Food Service (ORDFS), a reach-in freezer located in the kitchen and holding food items had a layer of ice covering the bottom inside surface of the freezer. ORDFS stated she was aware of the ice build-up and notified maintenance of the issue. She stated she made maintenance aware the freezer was not fixed yet after a refrigeration vendor serviced the freezer last week. In an interview on 10/31/23 at 9:36 a.m., the Outside Resource Maintenance Director (ORMD) stated he basically fixed whatever was broken, such as broken equipment and he hired an outside vendor when the maintenance staff could not fix equipment themselves. He stated he was aware the there was something wrong with the freezer and it needed to be serviced. He stated a couple of days after the refrigeration vendor serviced the freezer last week, ORDFS notified him the freezer was still not working properly. Review of the refrigeration vendor invoice dated 10/23/23, showed the reach-in freezer was serviced on 10/23/23 at 4 p.m. In an interview on 11/2/23 at 10:40 a.m. ORMD stated the reach-in freezer was still not fixed and he called yesterday for the company who worked on the freezer last week to come back out. In an interview and observation on 11/3/23 at 12:08 p.m., ORMD showed on his phone, the work order for the reach-in freezer was placed by ORDFS on 10/2/23 which was over month ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to manage the nutritional needs for one (Resident 2) of 4 sampled residents with kidney failure receiving dialysis treatment (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) and transferred from the hospital for a leg fracture and management of wounds. This failure had the potential for Resident 21 to not receive the right amount of nutrients to help build muscle, repair wounds and fight infection. Findings: During an observation and concurrent interview on 11/3/, at 2:20 p.m., Resident 21 stated he had a broken left leg and did not get out of bed unless it was for his dialysis treatments scheduled three days a week. At the bedside, Resident 21 was drinking orange juice from a cup. During a review of the meal card for Resident 21, dated 11/3/21, indicated a diet order of Regular. Review of the hospital Discharge summary dated [DATE], indicated Resident 21 had a left tibia-fibula fracture, was cleared for a regular diet with 2 gram potassium by his kidney doctor. During a review of the medical record note, Nutritional Screen and Assessment, dated 9/29/21, indicated the Registered Dietician (RD 1) noted Resident 21 ate well with preferences honored, awaiting return call from hemodialysis to coordinate care, and the resident prefers a potassium restricted regular diet at this time. During an interview on 11/4/2,1 at 1:55 p.m., the Registered Dietician (RD 1) stated he had not heard from the dialysis clinic dietician to coordinate nutritional care for Resident 21. RD 1 further stated he did not follow-up with the dialysis facility because laboratory results were within the normal range and Resident 21 was okay to be on a Regular diet. RD 1 reviewed the medical record and verified that the physician order was for a Regular diet with 2 gram potassium. RD 1 stated oh, he is on a 2 gram potassium. Review of the facility's Diet Order, dated 9/24/21, indicated Regular diet. Potassium 2 gram for dietary. Review of the care plan dated 9/24/21, for impaired nutritional and hydration status related to End Stage Renal Disease with hemodialysis indicated Diet as ordered: Regular. Review of the Renal [kidney] Progress Note, dated 9/24/21 indicated to change diet to cardiac low salt low potassium with 1 liter per day fluids. During an interview on 11/4/21, at 2:35 p.m., the dialysis RD 2, stated Resident 21 was on a regular diet with 2 gram potassium limit. RD 2 further stated orange juice is not ideal for Resident 21 because it has high potassium content.

Based on observation, interview and record review, the facility failed to label and store food under sanitary conditions when: 1. Refrigerated food without month, date, and year available for use: a. Mayonnaise and salad dressing. b. Green and white substance on a lemon found in a box of lemons. 2. Open container of soy sauce 3. Spices were not labeled with date received, opened or expiration date. This failure had the potential to place the residents at risk for developing foodborne illness. Findings: 1. During an observation on 11/1/21 at 9:18, of the walk-in refrigerator a gallon size jar of mayonnaise, a gallon size container of salad dressing both which was two thirds full, had no date to show when it was opened or when the contents expired. The salad dressing had visible residue on the outside of the container. In addition, a box of lemons contained a lemon with a green and white substance on it. 2. During an initial observation on 11/1/21 at 9:45, of the dry storage room, one gallon plastic jug of soy sauce was open. One quarter of the container had dark liquid with black dried residue drippings on the outside of the container and it did not have an open date. 3. During an observation on 11/3/21, at 12:52, six 32-ounce dry spice containers of meat tenderizer, white sesame seeds, ground cayenne pepper, ground cumin, powdered onion and ground coriander were opened, partially used, and did not have a received date. During an interview on 11/4/21, at 11:50 a.m., the Diet Services Manager (DSM) stated the staff should put received dates on spices, not the use by dates. The DSM also stated staff were expected to check the facility's food storage guidance to ensure the food items were not expired before using.

Based on observation, interview and document review, Registered Nurse (RN 1) did not disinfect the blood pressure cuff, thermometer, and pulse oximeter between resident use for four ( Resident 1, 22, 41 and 91) of 7 sampled residents. This failure had the potential for the transmission of communicable diseases and infection. Findings: . During medication pass observations on 11/3/21, at 10:57 a.m. to 11:39 a.m., RN 1 checked each resident's blood pressure, oxygen saturations, and temperatures prior to administering their prescribed medications. RN 1 used a blood pressure cuff, pulse oximeter and temporal thermometer that RN 1 placed on each of the resident's side tables and beddings. After using these equipment on the residents, RN 1 stored them on the nursing cart without disinfection and no disinfection before using them for the next residents. During an interview on 11/3/21, at 11:56 a.m., RN 1 stated the blood pressure cuff, pulse oximeter and temporal thermometer needed cleaning and disinfection prior to returning items to the medication cart due to the risk of spread of infection. RN 1 stated she thought she disinfected the supplies before and after each use on the residents. During an interview on 11/4/21, at 10:30 a.m., the Director of Staff Development (DSD) stated equipment should be disinfected between patient use to avoid the spread of infection.