**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow safe food handling practices when: 1. A refrigerator used to store residents' food brought in by visitors, which included TCS foods (foods that require time/temperature control to prevent bacterial growth) had recorded temperatures above 41 degrees F that were unaddressed by staff. Formerly known as Potentially Hazardous foods); and the facility did not ensure staff followed directions to label food items with an open date, the name of the resident and room number. An Immediate Jeopardy (IJ, a situation in which recipient(s) of care has suffered or is likely to suffer serious injury, harm, impairment, or death as a result of a provider's noncompliance with one or more health safety requirements) was called on 2/14/22, at 5:07 p.m. On 2/14/22, the facility discarded the food in the resident food refrigerator. On 2/18/22 it was verified the facility replaced the refrigerator with a new refrigerator in nursing station 2/3 with a lock only accessible by nursing staff. The facility provided an in-service to staff on cold storage temperatures and labeling and dating food. A plan was put in place to provide oversight to ensure refrigerated foods would be stored at 41 degrees F or less for food safety. The IJ was removed on 2/18/22, at 1:14 p.m. with an acceptable corrective action plan; 2. An ice machine used for residents' beverages was not maintained clean; and the Maintenance Director (MD), who was in charge of cleaning the ice machine, was not knowledgeable about how to clean the equipment per manufacturer's manual. An IJ was called on 2/15/22 at 1:55 p.m. On 2/15/22, the facility discarded all ice from the facility, and cleaned and sanitized all containers used to hold ice. On 2/17/22, it was verified the facility had an outside vendor thoroughly clean the ice machine. A contract was put into place to have an outside vendor clean the ice machine every 6 months or as needed. The outside vendor trained MD on preventative maintenance cleaning, using the ice machine manufacturer's manual. A monitoring plan was put into place to ensure the ice machine would remain clean. The IJ was removed on 2/17/22 at 4:20 p.m. with an acceptable corrective action plan; 3. The facility served unpasteurized, runny (egg white firm and the yolk not firm with a liquid consistency) eggs to 15 residents who preferred undercooked eggs out of a facility census of 89. An IJ was called on 2/22/22 at 8:50 a.m. It was verified that all unpasteurized eggs were removed from the facility, cooks were in-serviced by the Registered Dietitian regarding egg safety, and the facility incorporated a plan and monitoring system to ensure unpasteurized eggs were not used at the facility. The IJ was removed on 2/22/22 at 12:27 p.m. with an acceptable corrective action plan; 4. The facility did not ensure proper procedures were followed for washing items in the kitchen 3-compartment sink; 5. The facility did not ensure proper procedures were followed for the surface sanitizer used in the kitchen; 6. The facility did not ensure the walls and shelving in the kitchen were maintained in good repair; 7. The facility did not ensure shelving and floors in the kitchen dry-food storage room were clean; 8. The facility did not ensure floor tiles in the kitchen were clean and maintained in good condition; 9. The facility did not ensure food was stored 6 inches off the ground inside the kitchen; 10. The facility did not ensure a storage rack for food containers was maintained in good condition; 11. The facility did not ensure a plastic strip curtain inside a walk-in refrigerator was maintained in good condition; 12. The facility did not ensure cooking utensils were stored in a clean and maintained area; 13. The facility did not ensure a freezer used to store food was maintained in good condition; 14. The facility did not ensure an industrial can opener was stored clean and maintained in good condition; 15. The facility did not ensure cooking knives were stored in a clean area; 16. The facility did not ensure proper procedures were followed for drying food pans; and 17. The facility did not ensure maintenance of air-gaps for the ice machine and food preparation sink drains. These failures had the potential to result in serious and potentially life-threatening foodborne illnesses to residents in this long-term care facility for 87 residents, who ate food by mouth, out of a facility census of 89. Findings: 1. Food and Drug Administration (FDA, responsible for protecting public health) Food Code 2017, section For Consumers on Storage Basics, indicated, keep the refrigerator temperature at or below 40 degrees Fahrenheit (F) [temperature measurement]. In Chapter 3 of FDA, Food, subpart 3-501, Time/Temperature Control for Safety Food, Slacking (food preparation), the Food Code indicated to maintain the food temperature at 5 C [Celsius - temperature measurement] (41F) or less . According to the FDA Food Code 2017, prepared, refrigerated, ready-to-eat, Time/Temperature Control for Safety (TCS) Food . is to be clearly marked to indicate the date or day by which the food is to be consumed on the premises or discarded when the food is held at a temperature of 41 degrees F or less for a maximum of 7 days. The preparation or open date is counted as day 1. According to the FDA Food Code 2017, A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised (people with low resistance to illness) . older adults; and (2) Obtaining food at a facility that provides services such as custodial, health care . hospital or nursing home . According to California Department of Education website, potentially hazardous foods include, but are not limited to meat, eggs, milk and dairy products, and heat-treated plant foods (rice, beans, and vegetables). Review of the facility's Procedure for Refrigerator Storage, dated 2018, indicated the refrigerator temperature should be 41 degrees F or lower. The policy also indicated in order to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2 degrees Fahrenheit (F) lower. On 2/14/22 at 12:45 p.m., a full-sized refrigerator/freezer used to store food for the residents was observed in the staff breakroom. The refrigerator color was white, and the majority of the outside surface of the refrigerator was covered with an orange residue. A sign taped to the outside of the refrigerator read for patients use only. Another paper taped to the outside of the refrigerator read Attention Staff: All food needs to be label with open date, room # [number] and residents name please. Food can only be store in fridge for 72 hr [hour] MAX [maximum]. All Food that is not labeled with residents Name, Room #, and Date will be thrown away, lets avoid this please. Please remain [remind] residents about our 72Hr/3day Rule before storing food in fridge. Thank you for all you do, it is truly appreciated - [First name of Infection Preventionist (IP) and the Director of Staff Development (DSD)]. Food stored inside the refrigerator included: a. Leftover pasta with red sauce and cheese in a foil to-go container; there were two white and grey fuzzy spots the size of peas on the pasta that resembled mold. The container was labeled with a resident name, room number, but no date. b. A paper bag labeled with a room number and name. Inside the bag was a reuseable, clear plastic container of rice soup. There was no date on the paper bag or the plastic container. c. A large pizza carton had 3 slices of left-over pizza inside. A room number was written on the box. The label lacked a name and date. d. A reuseable plastic container had what appeared to be a partially eaten, bean and cheese quesadilla (tortillas with refried beans and melted cheese in between the tortillas). The container was labeled with a name and room number, but no date. e. A reuseable plastic container with pasta salad (pasta mixed with other ingredients). There was no label to indicate the date, name, or room number. f. A plastic container contained a boiled egg in sauce and carrots. The container lacked a label with a date, name, or room number. g. A large plastic bag had various items. The bag was labeled with a room number but no name. Two single serve yogurts inside the bag had a manufacturer's use-by date of November 2021. h. A 32-ounce yogurt container contained a brown matter. A note handwritten on the lid indicated, Please give her a scoop for [NAME] [breakfast]. The container was labeled with a resident name but no date. i. A yellow gel substance in a small Styrofoam container with a lid. The yellow substance had a foul, sour smell. The container was labeled with a room number, but no name or date. j. Two cheese and lunch meat sandwiches in plastic bags with no dates, names, or room numbers. k. Four peanut butter and jelly sandwiches in plastic bags with no dates, names, or room numbers. l. an open carton of creamer, with a manufacturer's use-by date of February 9, was labeled with a name, but lacked a room number. m. A large cardboard container of sausages and cheeses was labeled with a resident name. One sausage was partially eaten and not re-wrapped in the plastic wrapper. There was no date on the container to indicate when it was opened. n. A plastic container had pickle and carrot slices in fluid. The container lacked labeling with a date, name, or room number. o. Three travel mugs with liquid inside, two of the mugs were not labeled with a date, name, or room number. One mug was labeled with a room number, but no date or name. p. A sponge cake in a plastic wrapper with a manufacturer's best-by date of 2/6/22 was not labeled with a name or room number. During an interview on 2/14/22 at 1:30 p.m. with the director of nursing (DON), he stated resident food items stored in the refrigerator had to be labeled with a date, room number, and resident's initials. He stated nurses and certified nursing assistants were responsible for labeling the items, but did not know how long items could be stored. The DON stated he did not know the proper temperature for refrigerated food and was not sure if the refrigerator temperature was monitored. He stated the IP nurse was in charge of the refrigerator, and she kept it clean and organized and was responsible for discarding items. During an interview on 2/14/22 at 1:56 p.m., the IP stated the temperature of the residents' food refrigerator located in the staff break room was documented on a log twice a day by herself and the DSD. She showed the refrigerator documentation sheet for the month of February and there were two temperatures by each date and a signature by each temperature. She said the signatures belonged to herself and the DSD. She stated she thought refrigerated food had to be stored at 42 degrees maximum, but the documentation form said up to 46 degrees so she said the refrigerated food could be stored up to 46 degrees. She stated she was not trained on food storage refrigerator temperatures. She stated whoever put the food in the refrigerator was responsible for labeling and dating, and it was usually a CNA or a nurse. She stated in addition to the date the label needed to include the resident name and room number. The IP said the resident name was more important than the room number because residents could change rooms. She said anyone was responsible for discarding the food including housekeeping, CNAs, and nurses. The items stored in the resident food refrigerator located in the staff breakroom were observed with the IP. She stated the fluid in the travel mugs was coffee for a resident. She confirmed it was not dated and 2 of the mugs were not labeled with the resident's name. She confirmed the 6 sandwiches in plastic bags were not dated and they should be. The IP stated the ½ and ½ creamer probably belonged to a staff and should not be stored in the resident refrigerator. She stated the sponge cake was expired and should not be in the refrigerator. She confirmed the pasta salad was not labeled with a date and resident name. She said maybe it belonged to a staff. She confirmed the leftover pizza in the large pizza carton belonged to a resident and was not dated. She stated the leftover pasta with red sauce and cheese was moldy, and confirmed it belonged to a resident and was not dated. She confirmed the reuseable plastic container with the egg and carrot in fluid was not dated and labeled to identify a resident. She also confirmed the left-over quesadilla was not dated. The IP said the 2 single-serve yogurts were expired. She confirmed the soup with rice in the reuseable plastic container belonged to a resident and was not dated. She confirmed the yellow substance in the plastic Styrofoam container was not dated and did not know what the yellow substance was. She confirmed there was no date showing how long the brown substance in the yogurt container was in the refrigerator and she did not know what the brown substance was. Review of the resident refrigerator documentation log provided by the IP, titled AM & PM Shifts Resident Refrigerator Temperature Log (36 degrees F - 46 degrees F) dated February 2022 documented a.m. and p.m. refrigerator temperatures from 2/1/22 - 2/13/22. The temperatures had a signature next to them. On 2/6/22 the documentation showed the p.m. refrigerator temperature was 45 degrees F. On 2/7/22 the p.m. temperature was 42 degrees F. On 2/11/22, the a.m. temperature was 45 degrees F. On 2/13/22 the a.m. temperature was 42 degrees F, and the p.m. temperature was 42 degrees F. During an interview on 2/14/22 at 4:01 p.m., the Registered Dietitian C (RD C) and the Dietary Supervisor (DS) stated there was no training they knew of that was provided to nursing staff, including the IP, regarding proper food storage in the refrigerator and that kitchen staff did not monitor the resident food refrigerator. Review of the job description checklist for the IP, titled Infection Control Nurse dated 9/16/20, showed a checklist of duties and responsibilities. There were no duties and/or responsibilities listed to show the IP was responsible for anything having to do with refrigerators that stored food. On 02/14/22 at 5:07 p.m., an Immediate Jeopardy was called in the presence of the Administrator for not ensuring the safe storage of resident food in the resident food refrigerator. In an interview on 2/17/22 at 2:40 p.m., the DSD stated she was aware that refrigerator temperatures were supposed to be 41 degrees or below, but she did not report temperatures above 41 degrees in the resident refrigerator because the documentation form showed the temperature range for the refrigerator was up to 46 degrees F. The Corrective Action Plan (CAP) included the following: a. Food from the resident refrigerator was discarded b. The resident food refrigerator was replaced with a new refrigerator c. The RD provided an in-service to the IP and DSD on food safety basics d. Licensed nurses were in-serviced on labeling, dating resident food placed in the refrigerator and monitoring temperature below 41 degrees F. In-services will be completed when staff is scheduled by 3/4/22. The in-service will also be provided to new hires. e. CNAs were in-serviced to give food brought by visitors for residents, directly to a licensed nurse and only the licensed nurse may place the food in the refrigerator. In-services will be completed when staff is scheduled by 3/4/22. The in-service will also be provided to new hires. f. The IP or Manager of the Day (when the IP is not in the building) will monitor the refrigerator daily for labeling with resident name, room number and date. g. The IP or Manager of the Day (when IP is not in the building) will monitor twice a day (AM and PM) for refrigerator temperature below 41 degrees . h. The IP or Manager of the Day will monitor for food being discarded within 72 hours of date on the label or by the manufacture's expiration date if this date is less than 72 hours after being placed in the refrigerator. i. If monitored refrigerator temperatures are above 41 degrees F, the food will be discarded, and maintenance and the administrator will be notified. Also, residents known to have consumed food during this time period will be placed on monitoring for signs and symptoms of food borne illness. The Maintenance Supervisor will adjust the refrigerator temperature settings or service the refrigerator until the temperature is below 41 degrees F for 24 hours. j. The RD with the Interdisciplinary Team (IDT) will perform visual spot checks twice a week for 1 month for refrigerator temperatures below 41 degrees F, labeling with resident name and room number and date, until 100 percent compliance. Once 100 percent compliance is reached for 2 weeks, the RD will perform monthly spot checks. k. RD will report the visual spot-check audit findings to QAPI monthly until 100 percent compliance. In an interview with the Administrator on 2/18/22 at 9:17 a.m., he stated the patient food refrigerator was replaced with a new refrigerator and it was now located in station 2/3. On 2/18/22 at 12:44 p.m., an observation and interview with the DSD, showed the new patient food refrigerator located in nursing station 2/3. The temperature of the refrigerator was 33 degrees F. The DSD stated the refrigerator was to remain locked and only nurses had a key for the lock and were responsible for placing food that was labeled and dated in the refrigerator. She stated the refrigerator was monitored twice a day to ensure it was 41 degrees or below and if the refrigerator was above 41 degrees F the food was discarded. On 2/18/22 at 12:50 p.m., CNAs and licensed nursed were interviewed and it was determined the staff were knowledgeable about labeling and dating food as well as monitoring for safe refrigerator food storage. During a meeting on 2/18/22 at 1:14 p.m., with the Administrator, the IJ was lifted. 2. During a review of the FDA Federal Food Code 2017, it indicates that (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch and food-contact surfaces shall be smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free from sharp internal angles, corners, and crevices, finished to have smooth welds and joints . The Food Code states that the purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. The 2017 Food Code also states that freezing does not always kill microorganisms, and freezing may preserve microorganisms, so ice that comes into contact with other foods or is used directly for consumption must be as safe as drinking water. Also, the surface of equipment contacting food that is not time/temperature control for safety food such as ice makers, must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to the accumulation of microorganisms. According to the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guideline 12-2020, Legionnaires' disease is a severe form of pneumonia, which frequently requires hospitalization. Legionnaires' disease can be fatal, with approximately a 9% over-all fatality rate. Within the subgroup of health-care associated Legionnaires' fatality cases are higher at 25%. People at highest risk for this disease are smokers, those receiving chemotherapy (chemical) treatment for cancer, those with underlying diseases, such as cancer, renal (kidney) disease, diabetes, and chronic lung disease, those taking drugs that weaken the immune system, and the elderly. Infection is possible in any building environment where people can be exposed to water contaminated with Legionella. Outbreaks of Legionnaires' disease is most often associated with water systems in areas including hospitals and long-term care facilities. In the case of aerosols (a substance than can be released in a fine spray when under pressure), infection may result from inhaling Legionella carried in a fine spray of microscopic water droplets that may not be visible. Infection is also possible by aspiration (taking in foreign matter into the lungs when breathing in), where water contaminated with Legionella can unintentionally enter the lungs while drinking, eating, or vomiting. Ice machines have been implicated as the source of transmission by aspiration. Legionellae spend much of their aquatic life-cycle in association with other microorganisms, including bacteria, fungi, and protozoa in biofilm. ASHRAE defines biofilm as a group of microorganisms, imbedded in slime, that adhere to a moist surface. In biofilms, Legionella bacteria are protected from environmental stressors, such as extreme temperatures and disinfectants. Biofilms may be found on any continually moist substrate (the surface or material on or from which an organism lives, grows, or obtains nourishment). Established biofilms are extremely difficult to remove and may serve for decades as reservoirs for Legionella contamination. Characteristics of both hot and cold potable water systems influence the colonization and subsequent growth of Legionella. Aspiration of contaminated water from components such as ice machines can occur. In addition, sediment can provide a home for biofilm and can insulate Legionella from disinfectants. According to the Centers for Disease Control and infection (CDC) website, many buildings need a water management program to reduce the risk for Legionella growing and spreading within the water system and devices. The CDC refers ASHRAE Guidelines as reference. On 6/2/2017 the S&C (Survey and Certification) 17-30 was released and revised on 6.9.2017 to include the facility types. This S&C letter required all Skilled Nursing Facilities, as well as other provider types, to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. At a minimum, the plans and documentation were to include a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system; a water management program that considered the ASHRAE industry standards and the CDC toolkit; specified testing protocols and acceptable ranges for control measures and documented results of testing and corrective actions when the control limits were not maintained. The S&C letter explained that Legionella could grow in parts of building water systems that were continually wet, and certain devices could spread contaminated water droplets via aerosolization (the act of converting a physical substance into small and light particles which can be carried on air). The S&C letter provided examples of these system components and devices which included ice machines. The S&C letter included the following CMS (Centers for Medicare and Medicaid Services) Regulatory Authority: 42 CFR (Code of Federal Regulations) §483.80 for skilled nursing facilities and nursing facilities: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. On 2/15/22 at 9:05 a.m., an observation and interview with the Maintenance Director (MD) led to an ice machine located in the staff breakroom. MD stated it was the only ice machine in the facility. He said he worked at the facility for 6 months and cleaned the ice machine 1 time per month. He described how he cleaned the ice machine each month and said he checked the filter located on the back of the outside of machine, to make sure it was working. He said he also checked to ensure the ice machine did not leak and that the outside surface was not dusty. He also said he cleaned the inside of the machine by wiping all of the surfaces he could reach on the inside with soap and water. He said he wiped the surfaces with a soapy rag and rinsed with water. He opened the front metal cover of the top of the machine to show where he cleaned with soap and water. He said he washed the outside of the plastic water curtain (a piece of plastic that covers the evaporator which is a metal grid and the area where water runs and ice is formed), around the plastic that framed the water curtain and evaporator plate, and the outer surface of the water trough (holds water before it is frozen in the ice making process). These parts, which were all located in what is referred to as the evaporator compartment, were easily accessible when the front metal cover for the upper part of the ice machine was removed, and that he stated he only used soap and water to clean. Directly below the evaporator compartment was the ice bin where ice was stored. There was no barrier between the water trough and the ice in the ice bin below. The MD stated he did not remove the ice from the ice bin when he cleaned the area above with the soap and water. MD stated he never removed the plastic water curtain that covered the evaporator plate. He said he was still learning how to clean the ice machine and did not know how to clean the inside yet. The front surface of the water trough and the front lower surface of the water curtain had yellow, brown, black, and pink residue along the length of these parts. Yellow and black residue was also on the inside surface of the water trough. Without removing the water trough, a portion of the inside bottom surface was visible, and majority of the visible area was covered in a layer of black residue. There was thick black residue on the underside corners of the water trough. MD removed the water curtain and more yellow, pink, and black residue was observed around the frame of the evaporator plate. There were a seam and crevices surrounding the plastic frame of the evaporator plate and black and yellow residue was imbedded in the seam. The frame of the evaporator plate was wiped with a white napkin and pinkish, brown, slimy residue easily wiped off onto the napkin. The underside of the water trough was wiped with a white napkin and thick, slimy, chunky, gel-like, black, white, and clear residue easily wiped off onto the napkin. The evaporator compartment was also moist with water on the surface of the water curtain, the plastic around the evaporator plate and the water trough. MD confirmed there was a significant amount of residue inside the ice machine and said it was not clean. During an observation and interview with MD on 2/15/22 at 12 p.m., he was in the staff breakroom working on the ice machine with its top opened. He stated he was cleaning the inside of the machine, including the evaporator compartment, and found the instructions on how to clean the ice machine stamped on the inner surface of the ice bin door. The instructions showed how to clean the ice bin but did not show how to clean the internal components of the upper part of the ice machine, including the evaporator compartment, where ice was made. He stated he just cleaned the top part of the machine by sanitizing it with the contents from a bottle of [Brand name] ice machine cleaner. He said he made a solution according to the instructions on the bottle and wiped down the inside surfaces. MD stated he did not use the manufacturer's manual for instruction on how to clean the internal components of the ice machine and stated he needed to find the manufacturer's manual/instructions. During an observation and interview on 2/15/22 at 12:21 p.m. with certified nursing assistant N (CNA N), she showed an ice water dispenser filled with ice and water at nursing station 4. CNA N stated the kitchen staff brought the ice dispensers to the nursing stations everyday around 8:30 a.m. to 9 a.m. There was a date stamp on the ice dispenser that showed Feb (February) 15 2022 AM. There was also an ice chest filled with ice at the nursing station. CNA N stated when the ice in the chest started to get low, it was refilled with ice from the ice machine by any staff. She stated the ice was used for medications and to put into resident drinks. She stated at meals, drinks were delivered from the kitchen without ice and some residents preferred ice in their drinks; so, staff used the ice from the ice chests for the resident drinks. During an observation on 2/15/22 at 12:25 p.m., a dispenser filled with ice water with a stamp date Feb [February 15 Tues [Tuesday] 2022 AM was observed at nursing station 2/3. During an interview on 2/15/22 at 12:30 p.m., Dietary Aide H and the Dietary Supervisor (DS) stated they were responsible for filling the nursing stations' ice dispensers with ice from the ice machine about 8 a.m. to 8:30 a.m. each morning. The DS stated kitchen staff had no oversite of the ice machine. During an observation on 2/15/22 at 12:35 p.m., a dispenser filled with ice water was at nursing station 1 (non-covid side). On 2/15/22 at 1:55 p.m., and Immediate Jeopardy was called in the presence of the administrator for having ice available to residents from the ice machine that was not clean and for not having a system to provide safe and sanitary ice to residents. In an interview with the Administrator on 2/15/22 at 2 p.m., he stated the last time the inside of the ice machine was cleaned was in April 2021 by a maintenance staff who no longer worked at the facility. He also stated their procedure for keeping the ice machine clean included having an outside vendor clean the machine on an annual basis, but the last annual visit did not happen due to Covid. He stated the last cleaning done by an outs[TRUNCATED]