Based on observations of the kitchen and staff interviews, the facility failed to ensure that temperature logs for kitchen refrigerators were consistently completed and failed to ensure clean dishes were stored away from potential contaminants. The findings included: 1. An initial observation of the kitchen with the Food Service Manager on 3/24/2025 at 11:00 AM identified the temperature log for March 2025 for Produce Cooler #1 and Produce Cooler #2 were missing morning temperatures for 3/23/2025. A review of the February 2025 temperature logs identified the morning temperature for 2/28/2025 for Produce Cooler #1 and Produce Cooler #2 were missing. Although requested, the facility was unable to provide a temperature log for January 2025. An interview with the Food Service Manager identified when he started in mid-January 2025, he may have discarded old temperature logs when implementing new forms. After the surveyor inquiry, the Food Service Manager provided copies of the February and January 2025 temperature logs with the missing temperatures. The Food Service Manager indicated that he had called the cook working on 3/23/2025 and 2/28/2025 who indicated to the Food Service Manager that the temperatures were within normal range, but she/he had forgotten to complete the log. An interview with the Administrator on 3/25/2025 at 12:28 PM identified the facility did not have the missing refrigerator temperature logs secondary to the logs may have been discarded or misplaced with the change in management. The Administrator further indicated the older logs should have been maintained. 2. An observation of the dish room with the Food Service Manager on 3/24/2025 at 11:15 AM identified a large fan with a large amount of gray-colored debris and lint blowing over clean dishes, including pots, pans, and utensils. An interview with the Food Service Manager indicated the clean dishes were from breakfast service and the fan was used for keeping staff cool in the dish room. The Food Service Manager further indicated maintenance is responsible for cleaning fans. An interview with Food Service Aide #1 who was working in the dish room on 3/24/2025 at 11:20 AM identified she was told that fans were okay to be blowing on the dishes if far enough away from the dishes. Food Service Aid #1 was unable to recall when and from whom she had received the information. After surveyor inquiry, maintenance cleaned the fan in the dish room. The facility policy for Food Safety Requirements given during the survey notes, the facility must store, prepare, distribute, and serve food in accordance with professional standards for food safety.

Based on review of facility documentation, facility policy, and interviews the facility failed to have consistent monthly resident council meetings. The findings include: Review of the resident council meeting minutes between 1/1/22 through 3/31/23 (15 months) identified that meetings were held only 6 months out of the 15-month review period. Review of council meeting documentation dated 3/2022 identified the council meeting was canceled because Resident #6 could not attend. Review of council meeting documentation dated 7/2022 identified due to the hot summer months, there will be no resident council meeting for the months of July and August. Resident council will resume on 9/21/22. Review of council meeting documentation dated 9/21/22 identified the council meeting was canceled because Resident #6 could not attend. Review of council meeting documentation dated 12/2022, 1/25/23 and 2/2023 identified the council meeting was canceled because Resident #6 could not attend. Interviews with members of the resident council, Resident #6, 7, 15, 17, and 21 on 4/18/23 at 9:30 AM indicated the resident council has not consistently met monthly for various reasons. Resident #6 indicated there were many months he/she could not hold/attend the monthly council meetings, but it would have been okay for the other residents to still have the meetings. Resident #7, 15, and 17 indicated despite Resident #6 not being able to attend, they would have still wanted to have the monthly meeting, including during the summer months. Resident #7, 15, 17, and 21 indicated they were not informed by a staff person that the meetings were cancelled and were not offered to have the meetings without Resident #6. Resident #7, 15, 17, and 21 indicated they would have wanted to continue the meetings even if Resident #6 could not attend. Resident #7, 15, 17, and 21 indicated they would like to have the meetings every month to have concerns discussed and addressed and discuss the upcoming events. Interview with the Director of Recreation (DOR) on 4/18/23 at 11:10 AM indicated she was responsible to assist the residents to the meetings, record the minutes for the meetings, and mediate the meetings. The DOR indicated the resident council was to meet every month, but when, at the last minute, Resident #6 indicated he/she would not attend, she would cancel the meeting and announce the cancellation in the dining room. The DOR indicated the facility would normally cancel the resident council monthly meetings during the summer months (July and August). The DOR further indicated she did not ask the residents if they wanted to have a meeting in July and August of 2022 because they have just never had a council meeting during the summer. The DOR indicated she was not aware who directed that the council not meet in the summer. The DOR indicated it was her understanding that if a specific member of the resident council was not going to attend, the meeting would be cancelled. Review of Resident Council Manual identified the resident council is the forum for residents to verbalize any suggestions monthly.

Based on observation, review of facility policy and interviews the facility failed to ensure food items were labeled and dated, and that dietary staff in the kitchen wore hairnets and beard guard. The findings include: 1. Observation with the Director of Dietary on 4/17/23 at 9:25 AM in the salad bar refrigerator identified sliced mushrooms were not labeled or dated, and 3 pies had sell by dates of 3/31/23 and use by date 4/2/23. 2. Observation in the produce refrigerator identified 2 bunches of lettuce and 1 bunch of celery in saran wrap not labeled or dated, 1 metal container with a bunch of wilted celery not labeled or dated, and a large metal tray of cooked potato wedges not labeled or dated. 3. Observation of the production refrigerator identified a metal container with 10 cooked turkey thighs not labeled or dated and a tray of potato wedges in saran wrap not dated. Interview with the Director of Dietary, (DOD) indicated all food stored in the refrigerator must be labeled and dated, and it was his/her responsibility to do so. The DOD indicated the 3 pies were frozen prior to being put in the refrigerator and should have been dated when removed from the freezer. The DOD indicated the weekend cook or any dietary staff should have labeled and dated the food items prior to placing the items in the refrigerators. 4. Observation on 4/17/23 at 10:00 AM identified Dietary Aide #1 with a full mustache and beard at least 2 inches in length and was not wearing a beard guard while in the kitchen touching clean and dirty dishes in the dish room. Interview with Dietary Aide #1 on 4/17/23 at 10:02 AM indicated he/she did not have a beard guard to wear as there were no beard guards available. Interview with the DOD on 4/17/23 at 10:05 AM indicated Dietary Aide #1 works 3 days a week and the beard guards were on back order and there were none available in the kitchen. The DOD indicated he/she works with 1 distributor and had not tried to get beard guards anywhere else. Observation of Dietary Aide #2 on 4/18/23 at 1:51 PM in the kitchen failed to reflect he/she was wearing a hairnet or baseball cap. Interview with Dietary Aide #2 indicated he/she started a month and a half ago and was oriented that only the cooks needed to wear hairnets in the kitchen. 5. Observation on 4/18/23 at 2:36 PM identified [NAME] #1 with facial hair on the checks, neck and part of the chin area not covered by the surgical mask he/she was wearing. Interview with [NAME] #1 on 4/18/23 at 2:37 PM indicated he/she has worked at the facility on the evening shift full time as the cook for the last 8 months, and indicated everyone in the kitchen must wear a hairnet and a beard guard if they have facial hair. [NAME] #1 indicated he/she has never worn a beard guard because they are not available. Interview with the DOD on 4/19/23 at 6:42 AM indicated that all dietary employees and anyone entering the kitchen must put on a hair net or hat prior to entering. The DOD indicated it has been months since he was able to get beard guards because the distributor had informed him/her the beard guards were back ordered. The DOD indicated any employee with facial hair is required to wear a beard guard, but they were not available. Review of refrigerated food storage policy directed labeling, dating, and monitoring refrigerator foods, including, but not limited to leftovers so it is used by its use-by date, or frozen (where a applicable) or discarded. Review of food purchase and storage policy identified all refrigerator food is kept covered and labeled with a date. Review of general kitchen sanitation rules policy identified cover all food after chilled and label and date. Review of food and nutrition services dress policy identified hair restraints in the form of hair nets, bandanas, hats or caps or other appropriate coverings are worn while on duty. [NAME] restraints included.