Based on observation, interview and record review, the facility failed to ensure two out of 12 sampled residents' (Resident 11 and 22) dignity were protected when their urinary bags were clearly visible from the hallway and were not contained in urinary bags. This failure may cause feelings of embarrassment to both Residents 11 and 22. Findings: During initial observation on 04/25/2023 at 10:00 AM, Resident 11's urinary bag was hanging by the foot of his bed and was clearly visible from the hallway. During initial observation on 04/25/2023 at 11:25 AM, Resident 22's urinary bag was hanging by the foot of her bed and was clearly visible from the hallway. During an interview on 04/28/2023 at 8:49 AM, the Charge Nurse (CN) stated the facility has privacy bags to cover up a resident's urinary bag. However, staff only put the privacy bags on when a resident goes out. Review of the facility's policy titled Policy - Indwelling Urinary Catheter Insertion, Maintenance, and Removal (Adults and Pediatrics), revised on 06/06/2022, found no information about use of privacy bags.

Based on interview, and record review, the facility failed to send a copy of the written notice to a representative of the Office of the State Long-Term Care Ombudsman after the facility-initiated discharge for Resident 20. This failure had the potential not to provide added protection to residents from being inappropriately discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Ombudsman is aware of facility practices and activities related to transfers and discharges. Findings: Review of Resident 20's Discharge Summary, dated 4/24/23, indicated, he was admitted in the facility on 2/8/23, then discharged on 4/24/23 with discharge diagnoses including heart failure (a condition that develops when your heart does not pump enough blood for your body's needs), acute renal failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and diabetes mellitus (a disease of inadequate control of blood sugar). Review of Resident 20's Care Team Note, dated 4/24/23, indicated, . Left unit via wheelchair, escorted downstairs by hospital staff . During a concurrent interview and record review, on 4/28/23, at 9:34 AM, with Registered Nurse (RN) 1, Resident 20's clinical medical records were reviewed. RN 1 stated, Resident 20 was discharged on 4/24/23 to a shelter with home health and accommodation. RN 1 stated, his discharge was a planned, facility initiated, and safe discharge. But, when asked if staff sent the copy of the written notice to Ombudsman after his discharge, she stated, No. A search of Resident 20's medical record with RN 1 found no evidence of the notice to Ombudsman. During an interview on 4/28/23, at 10:43 AM, with Nursing Operations Manager (NOM), NOM stated, They did not send the notice to the Ombudsman when asked about the notice to Ombudsman. During an interview on 4/28/23, at 10:45 AM, with Interim Director of Care Coordination (IDoCC), IDoCC stated, We were not aware that we have to send the notice to the Ombudsman. During an interview on 4/28/23, at 11:05 AM, with IDoCC, IDoCC acknowledged, We didn't send when asked about the notice to the Ombudsman. During a concurrent interview and record review, on 4/28/23, at 1:20 PM, with NOM, the facility's policy and procedure (P&P) titled, Policy-Discharge of Patients, revised on 4/1/14, was reviewed. A search of the P&P with NOM found no mention of the notice to Ombudsman on it. NOM acknowledged, there was no mention of the Ombudsman notice on the P&P.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to measure pressure injuries for 1 of 12 sampled residents (Resident 8) upon admission and on a regular basis. This failure to measure Resident 8's pressure injuries on his left and right heels upon admission and on a regular basis did not ensure the facility was objectively monitoring these pressure injuries over time (102 days). Findings: Review of Resident 8's medical record titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 03/29/2023, indicated he was admitted to the facility on [DATE]. He was totally dependent on two staff for bed mobility, and he was totally dependent on one staff for: dressing, toilet use, and personal hygiene. His MDS indicated he was admitted with unhealed pressure injuries. During an interview and concurrent record review on 04/27/2023 at 10:45 AM, RN 2 (Registered Nurse) stated Resident 8 was originally admitted to the hospital's emergency room with two pressure injuries back in 01/02/2023. On 01/15/2023, Resident 8 was transferred to the hospital's skilled nursing facility (SNF) for care. A search of Resident 8's medical record with RN 2 found no evidence staff measured these pressure injuries upon admission to the SNF. Furthermore, RN 2 could find no documented evidence these pressure injuries were measured on a regular basis (from 01/15/2023 to 04/27/2023, a total of 102 days). RN 2 was asked to search hospital records (prior to the SNF admission) in order to provide a baseline of how large these pressure injuries were prior to his SNF admission. Review of Resident 8's medical record from the hospital titled Wound and Ostomy Care Team Note, dated 01/04/2023, indicated wound size measurements for .right heel 8 x 6 cm left heel 2.5 x 2.5 cm . During an interview on 04/27/2023 at 3:11 PM, RN 4 was asked to explain the facility's pressure injury monitoring process. RN 4 stated he worked as a wound care nurse. RN 4 stated in general, nurses in the SNF will assess and chart on a pressure injury. These nurses may put in a consult for the wound care team depending on the severity of the pressure injury. The assessments of these SNF nurses may or may not involve measuring the pressure injury. However, if the wound care team was consulted, RN 4 stated he would measure the pressure injury as part of his assessment. RN 4 was asked how frequently these pressure injuries should be measured? RN 4 answered, in general, these pressure injuries should be assessed once a week and sometimes longer depending on the clinical conditions of the resident. For example, frequency of assessments may be longer for residents on comfort care, use of a specialty wound dressing or if the resident was experiencing a lot of pain. During an interview on 04/28/2023 at 10:52 AM, RN 4 was asked to clarify his expectations on pressure injury assessments and how he was trained as a wound care nurse regarding pressure injury documentation. RN 4 stated he was trained to describe pressure injuries and measure pressure injuries as part of his assessments. RN 4 stated serial pressure injury measurements is one of the parameters clinicians look at to determine if a pressure injury was healing or deteriorating. Review of the facility's policy titled Procedure - Pressure Injury Intervention, revised on 03/18/2021, found no mention of pressure injury measurements or frequency of pressure injury measurements. Additionally, the facility did not have a pressure injury policy that clearly states when and how often pressure injuries should be measured. During an interview on 04/28/2023 at 1:00 PM, the DAL (Director of Accreditation and Licensing) was asked to clarify the facility's pressure injury assessment/monitoring policy. The DAL stated the facility does not currently have policies regarding pressure injury measurements nor how frequently these pressure injuries should be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage when nine expired nutrition supplements were found in the kitchen storage room. This failure had the potential to put residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 4/25/23, at 11:20 AM, with Registered Dietitian (RD), there were nine items of nutrition supplements labeled, Katefarms Peptide 1.5 cal/mL plain in the kitchen storage room, with marks indicating Best if used by: [DATE]. When asked if these nine items were expired, RD stated, Expired. Yes, correct. During an interview on 4/25/23, at 11:24 AM, with Food and Nutrition Manager (FNM) who was witnessing this incident stated, Yes, I agree . when asked if these nine items were expired. During an interview on 4/25/23, at 11:33 AM, with Nursing Operations Manager (NOM) who was also witnessing this incident acknowledged, these nine items were expired. Review of the facility's policy and procedure (P&P) titled, Receiving and Storage Standards, revised on 5/19/22 indicated, . Storage . 4. Discard out-of-date products . Review of the Guidance of Appendix PP, revised on 10/21/22, from Centers for Medicare and Medicaid Services (CMS) indicated, the facility should follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Appendix PP also indicated, unsafe food handling practices represent a potential source of pathogen exposure for residents. Review of U.S. Food and Drug Administration's 2022 Food Code indicated, . The Food Code states the person in charge of a food establishment is accountable for developing, carrying out, and enforcing procedures aimed at preventing food-borne illness .

Based on observation, interview, and record review, the facility failed to ensure a refuse (solid waste not carried by water through the sewage system) container had a lid and refuse were disposed in a proper manner. This failure had the potential to promote development and spread of communicable diseases and infections that could jeopardize the health of the residents in the facility. Findings: During a concurrent observation and interview on 4/26/23, at 8:53 AM, with food service supervisor (FSS), outside of the facility building far enough from the kitchen, there was a green plastic garbage container full of trash. There was no lid attached to the garbage container. There were also several very tiny flies flying around the garbage container. FSS stated, It should be shut when asked about the policy of the garbage container. When asked if he could see the tiny flies around the garbage container, FSS stated, Yes. Observation of another metal garbage container nearby indicated, it was closed but a garbage bag with dark brownish wet material inside was protruding outside the closed lid. FSS also acknowledged, refuse was not disposed in a proper manner when asked about the garbage bag hanging outside the garbage container. During an interview on 4/26/23, at 8:55 AM, with Nursing Operations Manager (NOM) who witnessed this incident, NOM acknowledged, Yes . I did when asked if she saw the green plastic garbage container without the lid, tiny flies around it and the garbage bag hanging outside the closed lid of another metal garbage container. During an interview on 4/26/23, at 8:59 AM, with Food and Nutrition Manager (FNM) who also witnessed this incident together, FNM also acknowledged, there was no lid with the green plastic garbage container and refuse was not disposed in a proper manner. During an interview on 4/26/23, at 9:12 AM, with EVS (environmental services) Lead Manager (EVSLM), EVSLM acknowledged, the garbage container should have been closed with a lid when this surveyor showed the garbage containers. EVSLM stated, . Always (covered) . when asked the policy of the garbage container. He also acknowledged, refuse was not disposed in a proper manner with the metal garbage container. During an interview on 4/26/23, at 9:19 AM, with EVS Senior Manager (EVSSM), EVSSM stated, That should be covered when asked about the policy regarding the garbage containers. He also acknowledged, refuse was not disposed in a proper manner. Review of the facility's policy and procedure (P&P) titled, Policy-Infection Control: Solid Waste Disposal in Food & Nutrition Services, revised on 6/23/21 indicated, . Garbage containers are kept covered . Review of U.S. Food and Drug Administration's 2022 Food Code indicated, . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . and used outside the FOOD ESTABLISHMENT (any operations, including without limitation schools, farmers markets and other public venues that store, prepare, package, serve, vend or otherwise provide food for human consumption) shall be designed and constructed to have tight-fitting lids, doors, or covers . 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents . 5-501.113 Covering Receptacles . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT . Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents . Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils . All containers must be maintained in good repair . in order to store garbage and refuse under sanitary conditions as well as to prevent the breeding of flies . Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents .

Based on observation, interview and record review, a nurse failed to follow facility policy regarding disinfecting a shared device after medication administration. Failure to disinfect a shared device did not ensure other residents were protected from infection. Findings: Review of Resident 12's medical records titled INFECTIOUS DISEASES FOLLOW UP PROGRESS NOTE, dated 04/17/2023, indicated he has a history of infections with MDRO (multi drug resistant organism) and was currently on three antibiotics to treat a bacterial infection. Review of the front page of Resident 12's electronic medical record with RN 2 on 04/28/2023 at 11:49 AM indicated Resident 12 was on contact precaution. Review of the facility's policy titled Policy - Infection Control Strategies- Guidelines for Use of Transmission Based Precautions: Airborne, Droplet, Contact Precautions, and Enhanced Contact Precautions, revised on 01/20/2022, indicated .Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Contact transmission can occur by directly touching the patient, through contact with the patient's environment, and by contaminated gloves or equipment. During medication administration observation on 04/26/2023 at 9:31 AM, RN 3 was administering a medication to Resident 12 and brought a (shared) ID bar code scanner into Resident 12's room. These ID bar code scanners are used to scan a resident ID band and to scan in the resident's medications prior to medication administration. Each scanner is electronically tethered to a specific mobile workstation. After medication administration, RN 3 did not disinfect the scanner and placed the scanner on her mobile workstation and later on she placed the scanner back onto the charging port behind her mobile workstation. The Director of Nursing (DON) was present during the medication administration observation. The DON was asked to comment on the observation. The DON stated RN 3 should have disinfected the scanner prior to placing the scanner on her mobile workstation. Review of the facility's policy titled Policy - Infection Control Strategies- Guidelines for Use of Transmission Based Precautions: Airborne, Droplet, Contact Precautions, and Enhanced Contact Precautions, revised on 01/20/2022, indicated .If shared equipment is used, it must be cleaned with hospital disinfectant after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure use of PRN (pro re nata as needed) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) was limited to 14 days for one of 12 sampled residents (Resident 3) when there was no end date and documented rationale for continued use of Ativan (a drug used to treat anxiety). This failure had the potential to result in unnecessary use of psychotropic medications. Finding: Resident 3 was admitted on [DATE] with diagnoses that included spinal cord injury (damage to the spinal cord resulting in loss of muscle function and loss of sensation), quadriplegia (paralysis of both the arms and legs), anoxic brain injury (occurs when the brain is deprived of oxygen causing cognitive problems and disabilities), and respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During an observation on 9/9/19 at 10:30 AM, Resident 3 was lying in bed, eyes closed with contractures on both hands and feet. Resident 3 was with a tracheostomy (a surgical opening through the neck into the trachea [windpipe] and ventilator (a machine that supports breathing) in use. Review of physician progress notes under neurological and psychiatric examination dated 9/11/19, indicated Resident 3 was non-verbal and unresponsive to voice. Review of Resident 3's physician order dated 9/12/19, indicated, Lorazepam (Ativan) . 1 mg [milligram] . Intravenous . Q4H [every 4 hours] PRN for Agitation .Scheduled Start Date . 08/21/19 . Behavior: persistent movement/grimacing despite addressing any obvious physiologic issues . End Date/Time: Blank . PRN Ativan was prescribed beyond the 14-day limit. Review of Resident 3's Medication Administration Record dated 9/12/19, indicated, Lorazepam (Ativan) Inj .1 mg .Intravenous .Q4H PRN: Agitation was last administered on 8/23/19. During a record review of Resident 3's physician order and concurrent interview with the Pharmacist (Pharm) 2, and Director of Pharmacy (DOP) on 9/12/19 at 10:20 AM, when asked about duration of use on PRN psychotropic drug such Ativan, Pharm 2 said, we give three months .quarterly, we recommend tapering .if not used within 2 weeks, if not needed, recommend to discontinue . Pharm 2 confirmed there was no end date on Resident 3's physician order for PRN Ativan. The DOP and Pharm 2 acknowledged they were not aware of the regulation pertinent to the limitation on PRN use of psychotropic drugs. The DOP stated that he will take a look at the regulation and revise their policy. Review of the facility policy and procedure titled, Policy - Patient Care Service Standards, last revision dated 1/18/19, indicated, Policy: The Department of Pharmacy Services shall endeavor to provide highest quality patient care in compliance with State and Federal regulations and The Joint Commission guidelines. Procedure: . 33. All skilled nursing unit patients will have their medical charts reviewed every thirty days by a pharmacist in accordance with State and Federal regulations . If there is an irregularity in drug regimen, pharmacist will document into electronic health record and contact the prescriber as needed upon the urgency of the matter. Irregularity includes (but not limited to) wrong dose, indication, frequency, route, duration, duplication of therapy, and inappropriate use of psychotropic drugs . 34. Use of Psychotropic Drugs on the Skilled Nursing Unit - A. Refer to Post Acute Services policy on Behavior Monitoring and Psychotherapeutic Drug Use Protocol for further details on gradual dose reduction . Review of the facility policy and procedure titled, Procedure - Post Acute Services - Behavior Monitoring and Pyschotherapeutic Drug Use, Protocol last revision dated 6/1/10, indicated .Protocol . 3. Anxiolytics/Psychopharmacological medications other than antipsychotics and sedative/hypnotics - During the first year in which a resident is admitted on an anxiolytic ., or after the facility has initiated one, a gradual dose reduction should be attempted during at least 2 separate quarters with at least 1 month between attempts . Medications: . 2. PRN Psychotherapeutic Drug - Physician's prescribing as needed psychotherapeutic medications will clearly specify the behavioral indications for administering the drug in the medication order . There was no reference in the policy on limitations for PRN psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and medical supplies were properly labeled and stored when: 1. Expired supplies were found in the supplies pyxis (an automated storage device) and crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) 2. Unlabeled medications were found in the medication room 3. Expired medications were found in the medication pyxis (an automated medication dispensing system) 4. Expired medications were found in the medication refrigerator These failures had the potential to cause unsafe and inappropriate storage and administration of medications to residents. Findings: 1. During an observation of the supplies pyxis and crash cart on 9/10/19 at 7:53 AM, accompanied by Registered Nurse (RN) 3 and Director of Nursing (DON), the following were found: 1.1 seven vacutainer blood collection sets (a device used to draw blood) in the pyxis had expiration dates of 7/31/19. 1.2 two 18 gauge intravenous catheters (a small, flexible tube inserted into the vein used for medication or fluid administration, or blood sampling) in the crash cart had expiration dates of 8/31/19. During an interview with RN 3 and DON on 9/10/19 at 7:55 AM, they both confirmed the vacutainer sets were expired. RN 3 stated the Central Supplies Department was responsible for checking and stocking the supplies pyxis. During an interview with RN 3 on 9/10/19 at 8:16 AM, she confirmed the intravenous catheters were expired, and stated the crash cart was stocked by the Central Supplies Department. 2. During an observation of the medication room and concurrent interviews on 9/10/19 at 8:35 AM, with RN 3, DON, and Pharmacist (Pharm) 1 present, the following medications were found: 2.1 one unlabeled tablet of Senna Lax (used to treat constipation) 8.6 mg (milligram) was stored in a cassette [holding bin] marked for room [ROOM NUMBER]-B 2.2 one unlabeled unit dose container of Chlorehexidine Gluconate Oral Rinse (germicidal mouth wash) 0.12% 15 ml (milliliter) and one unlabeled packet of Healthylax Polythylene Glycol 3350 Powder for Oral Laxative Solution (used to treat constipation) 0.6 oz. were stored in a cassette marked for room [ROOM NUMBER]-C Pharm 1 stated medications not stocked in the pyxis would be filled by pharmacy and placed in cassettes. Pharm 1 stated all medications in cassettes should be labeled with the patient's name, medical record number, date filled [by pharmacy], room number and packaged in a small, plastic re-sealable bag. RN 3 acknowledged the above medications should be labeled or should be placed in the bin marked Pharmacy Returns. 3. During an observation of the medication pyxis and concurrent interview on 9/10/19 at 8:47 AM, with Pharm 1, RN 3 and DON present, the following were found: 3.1 one tablet Simvastatin (used to treat high cholesterol levels) 20 mg had an expiration date of 5/2019 3.2 two tablets of Spirinolactone (used to treat high blood pressure) 50 mg had expiration dates of 4/2019 Pharm 1 confirmed the above medications were expired, and that Pharmacy was responsible for checking outdated medications in the pyxis weekly. 4. During an observation of the medication refrigerator closest to the medication pyxis and concurrent interview on 9/10/19 at 10:45 AM, accompanied by Pharm 2 and DON, the following were found: 4.1 four single dose 2 ml vials of Cerebyx (used to prevent or control seizures) 100 mg PE/2 ml had expiration dates of 8/2019 4.2 two single dose 5 ml vials of Infuvite Adult Multiple Vitamins (used to prevent vitamin deficiency) Injection Vial 1 and two single dose 5 ml vials of Infuvite Adult Multiple Vitamins Injection Vial 2 had expiration dates of 7/2019 Pharm 2 confirmed the medications were expired. The DON stated the Pharmacy was responsible for checking expirations of the above medication refrigerator. The facility policy and procedure titled, Procedure - Drug Storage and Inspections, last revision dated 7/12/18, indicated, . Procedure: 1. Medications (drugs, chemicals, and biologicals) shall be stored within the Pharmacy Department and in other appropriate areas of the Medical Center in accordance with State and Federal regulations, TJC and USP guidelines and manufacturer's recommendations and in a secure fashion. 2. The Pharmacy Department shall have full access to all hospital storage areas of medication . The inspection shall be conducted by a licensed pharmacist every 30 days documenting the following: .Outdated, recalled, and discontinued medications, discharged patient medications, illegibly labeled medications or otherwise unusable products are removed and returned to Pharmacy for destruction in a timely fashion .3. Labeling: . Pharmacy will label all medications with proper storage, use and safety information as appropriate. Products for external use only must be clearly labeled as such and where possible, segregated from internal and parenteral medications . The facility policy and procedure titled, Policy - Crash Cart Maintenance and Module Exchange, last revision dated 4/17/19, indicated, Policy: All crash carts will be inspected routinely for intact locks, . and for outdated or unusable drugs and/or supplies . Procedure: I. Cart checks: Performed by designated Department/Unit staff . B. Daily checks include: .3. The supply list posted in the sheet protector attached on the side of the cart is checked for expirations . Notify Supply Chain to replace items that are within one week of expiration . II. Every 30 days . B. Performed by a Supply Chain employee: 1. All supplies stocked on the cart, including the Respiratory Module . will be inspected every 30 days by Supply Chain . 4. Any supplies due to expire prior to the next scheduled inspection will be replaced .

Based on observation, interview and record review the facility failed to ensure safe and sanitary conditions were met for food storage and service, and in and out of the Food and Nutrition Services department when: 1) Expired Potentially Hazardous Food (PHF)/Time and Temperature Control for Safety (TCS) food items were stored in the refrigerators 2) Food items in the refrigerators and dry storage area were not properly labeled and dated 3) Potentially hazardous foods (eggs) procured from vendor was not pasteurized 4) Food preparation equipment (grills, deep fryer, refrigerators) were not clean 5) Serving trays were stacked wet 6) Nutrition refrigerator of DP/SNF was dirty and contained expired food This deficient practice had the potential to put residents at risk for foodborne illness. Findings: 1) During the initial kitchen tour, observation and interview with the Director of Food and Nutrition Services 1 (DFNS 1), Food and Nutrition Service Director Davies Campus 2 (FNSD 2), Registered Dietician (RD) and Food and Nutrition Service Manager (FNSM) on 9/9/19 at 9:30 AM the following items were found inside the reach-in and walk in refrigerators: a.Reach in refrigerator #1 green bell peppers and red bell peppers dated 9/5/19, no Use By Date (UBD), broccoli dated 9/3/19 no UBD, a metal container, covered with plastic wrap, containing diced white onion, no label or UBD. During an interview on 9/9/19 at 9:35 AM with the FNSD 2, she stated that these items are expired. b. The small chefs reach in refrigerator contained alfredo sauce expired on 9/8/19, clam base expired on 5/30/19 and diced jalapeno expired on 9/5/19. During a concurrent interview on 9/9/19 at 9:50 AM, the DFNS 1 stated, These are all expired, and threw them out. c.Reach in refrigerator #8 zucchini dated 9/5/19 and broccoli dated 9/3/19. During an interview on 9/9/19 at 10 AM with FNSD 2, DFNS 1 stated, these are expired. d. Walk in refrigerator A, uncooked chicken with UBD of 9/5/19, biscuits with no label or UBD, open bag of cooked sausage no label, date opened or UBD, 3 large pieces of beef, with no label or UBD, 4 large white unlabled bakery boxes one contained chibata rolls with blue and black spots on the rolls, three boxes contained partial amounts of dry cornbread with no UBD. The DFNS 1 on 9/9/19 at 10:15 AM acknowledged, these are all expired. e. Walk in refrigerator D, 40 yoplait peach yogurt with UBD of 8/30/19, several packages of sliced cheese opened with no UBD, 8 tubs of ricotta cheese with expiration date of 8/8/19. During interview on 9/9/19 at 10:30 AM, FNSD 2 stated that these items were all expired. 2) a. During an observation of the walk in refrigerator C on 9/9/19 at 10:45 AM, the shelves contained plastic crates of vegetables with no labels or UBD's. One of the shelves contained half of a watermelon that was covered with plastic wrap with no label or UBD. b. Reach in refrigerator #2 contained an unlabeled and undated plastic bag with 3 large green melons with black spots on them. During an interview with the FNSD 2 on 9/9/19 at 9:40 AM, she stated that this must belong to staff . When the FNSD 2 was asked if it was the facility practice to store staff food in the kitchen refrigerators she stated, No, it is not our policy to store staff food in the kitchen refrigerator. c. During an observation in the kitchen, there was a shelve with many containers of unlabeled and undated items: almonds, chia seeds, flax seeds and raisins and a 12 quart tub of unlabeled and undated bulgur wheat. During an interview with FSND 2, she acknowledged, these items should be labeled and dated. d. During an observation of the onion bin in the kitchen, there were 6 onions with black spots. The FSND 2 acknowledged the items were rotten. Review of the Hospital policy, Infection Control-Food Handling and Monitoring in FNS, dated 1/18/18, indicated, .All foods that are received into Aramark locations must be labeled .Follow the shelp-life guidelines in Section 8.2 Aramark Use by Dates to determine the Use By date to apply when using the refrigerated/frozen food label .Discard foods that are not labeled in accordance with these standards. 3) During an observation in the kitchen, the reach in refrigerator #2 contained 15 dozen eggs with no evidence of pasteurization. Eggs were not stamped with a letter P to indicate if the eggs were pasteurized. A pasteurized egg is an egg that has been heated to eliminate bacteria. During an interview on 9/9/19 at 9:45 AM with the DFNS 1, she stated, I will have to check to see if the eggs are pasteurized. During an interview on 9/11/19 at 2 PM with FNSD 2, she stated, the eggs were not pasteurized and DFNS 1 is checking to see how they were delivered here. According to the Federal Food Code 2017, although foodborne illnesses can be severe or even fatal, milder cases are often not detected through routine surveillance. According to the Food Code, eggs are still a major source of Salmonella infections, causing large outbreaks when they are combined and undercooked so special added precautions need to be in place with those most susceptible to foodborne illness. The Food Code defines a highly susceptible population as persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney dialysis center, hospital or nursing home, or nutritional or socialization services such as a senior center. 4) During an observation in the kitchen 9/9/19 at 9:50 AM, the two large grills were greasy, many food particles were on the grills. Black grease was splattered and caked on to the back of the grills. During concurrent interview with FNSD 2 when asked who is responsible for cleaning the grills, she stated, the cooks clean the grills. The deep fryer had dark colored oil and many food crumbs along the side of the trays. During an interview with FNSD 2, she stated, the oil is changed every 2 days. The chefs refrigerator contained food spillage on the inside door and the shelves appeared grimy with food drops. DFNS 1 acknowledged that, It was dirty and will have someone come and clean it. According to the 2017 Federal Food Code all food-contact surfaces of cooking equipment and pans shall be kept free of soil accumulations and nonfood-contact surfaces of equipment shall be kept free of and accumulation of dust, dirt, food residue, and other debris. 5) During an observation and concurrent interview on 9/9/19 at 10 AM, serving trays small and long were stacked wet along the back wall of the kitchen. The DFNS 1 stated, these should not be stacked wet, they should be dry before stacking and pulled them all and had them rewashed and dried. According to the 2017 Federal Food Code, section 4-901.11 titled Equipment and Utensils, Air-Drying Required; .After cleaning and sanitizing, equipment and utensils shall be air-dried 6) During an observation and concurrent interview with DON on 9/12/19 at 11:30 AM, the nutrition refrigerator in the medication room of the Skilled Nursing Unit contained expired items: pineapple with use by date of 9/9/19, lettuce salad with use by date of 9/8/19. The refrigerator was dirty with food spillage on the shelves. The DON stated, it should be wiped down.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 7 was admitted on [DATE] with diagnoses that included muscular dystrophy (genetic disease that cause muscle weakness and muscle loss) and respiratory failure (condition in which not enough oxygen passes from the lungs into the blood). During an observation on 9/9/19 at 9:55 AM, Resident 7 was in bed, awake, and able to respond to questions. The T/Pump (warming and cooling machine) on the floor was turned on, and connected to a pad placed underneath the resident's lower legs. The pad was warm to touch. The sticker affixed on the machine indicated, PM [Preventive Maintenance] DUE May 15, 2019. During an interview with Registered Nurse (RN) 2 on 9/9/19 at 10:01 AM, she confirmed the preventive maintenance on the heating pad machine was past due and stated, we have to get a new one. When asked who checked preventive maintenance on the machine, RN 2 stated Biomed and Nursing should have checked on it. Review of Resident 7's care plan notes dated 12/10/18 indicated, .Electric heating pad also provided to patient for pain management . During an interview with Resident 7 on 9/10/19 at 12:16 PM, she stated the heating pad was used to keep her legs warm. Resident 7 stated that she would call the staff if she wanted the machine turned off or turned back on. The facility's undated, policy and procedure titled, Sutter Health Medical Equipment Management Program - Section 3. Inspection and Maintenance Strategies, indicated, I. Policy - To ensure that all medical equipment included in the inventory is appropriately inspected, tested and maintained for achieving safe, effective and reliable operation. II. Purpose - To provide a consistent set of inspection procedures to ensure a safe operation of all medical equipment used to treat Sutter Health patients regardless of ownership. III. Procedures - .B . The following maintenance strategies are used: 1 . interval-based maintenance are inspections in which the activities and frequencies are scheduled and performed in accordance with the manufacturer's recommendations . 2. AEM [Alternative Equipment Management] inspections based on interval-based maintenance are inspections in which the activities and/or frequencies are scheduled and performed in accordance with the AEM program . Based on observation, interview and record review, the facility failed to ensure essential equipment, including a walk -in freezer and T-pump, was maintained in a safe operating condition. This failure had the potential to cause contamination in food storage equipment, which could affect overall food service operations and injury to residents and staff. Findings: 1. During the initial kitchen tour on 9/9/19 at 10 AM, there were three large racks with large boxes of frozen food stacked on the shelves of the walk-in freezer. Condensation was noted on the racks and boxes and there was ice build-up on the ceiling and around the fans at the back of the freezer. The floor was made of red brick and it also had ice build-up on the floor. During an interview with the FSND 2 she acknowledged the condensation. During an observation on 9/11/19 at 2 PM, moisture was noted on the outer door of the walk-in freezer close to the electrical switch. Condensation remains on the walls and ceiling and floor of the freezer. A review of the facility maintenance request on 11/2/18 indicated condensation build-up on outer wall of freezer, insulation had degraded and recommended new walls be installed, once the insulation has been compromised it will no longer have the R factor needed to prevent this from happening. According to Refrigeration and Freezer Mechanics, the build-up of ice on the interior freezer components may be the result of issues within the condenser, evaporator or issues with the defrost cycle (Humitec Corporation , 2013).