Based on observation, interviews and record reviews, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. This could have a potentially negative outcome on its current census of 67 residents. At the time of the survey, none of the dietary staff had current dietary training. The findings include: A tour of the kitchen was conducted on 6/29/2025 at 11:23 a.m. [NAME] C was observed and Dietary Aide D was also present. On 6/29/2025 at 11:35 a.m. Dietary Aide D was observed in the sanitation area of the kitchen. She was asked if the dishwasher was a high-temperature or low-temperature machine. She stated she was not sure. She was asked how she would determine whether or not the dishes were clean and sanitized. She again stated she was not sure and added that she eyeballs it. Observed the dishwasher temperature log hanging on the wall. The temperature had not been recorded for five shifts. The Certified Dietary Manager (CDM) arrived on 6/29/2025 at 11:57 a.m. He was made aware of the incomplete temperature log. He confirmed that it should have been completed. During an interview on 6/29/2025 at 12:15 p.m. with the CDM, he was asked to provide any dietary education provided to the staff within the last six months. A follow-up tour of the kitchen was conducted on 6/30/2025 at 9:18 a.m. Observed that the dishwasher temperature log had not been completed for any shift on 6/29/2025. (Photographic Evidence Obtained) During an interview conducted on 7/01/2025 at 11:45 a.m. with the CDM, he stated he was unable to locate any of the recent training for the dietary staff. On 7/02/2025 at 11:05 a.m., the Human Resources Manager provided training rosters for all of the dietary staff. Observed multiple training topics were marked Not Attempted. She was asked what this meant. She stated it meant the training was assigned but the employer had not completed the training. (Photographic Evidence Obtained) During an interview conducted on 7/02/2025 at 11:40 a.m. with the CDM, he stated the dietary staff were required to complete annual training. He confirmed that none of the dietary staff had completed any of their required training. He stated this was not discovered until June 2025. He stated they started doing the basic facility required training and that all of the dietary-related training remained undone. A review of the facility's policy titled Storage of Foods Brought to Residents by Family/Visitors (revised 1/18/2018), revealed: Policy Statement: Staff must be aware of, and approve, food(s) brought to a resident by family/visitors to ensure safe and sanitary storage, handling and consumption of foods. Policy Interpretation and Implementation: * Family members / responsible parties should inform nursing staff of their desire to bring foods into the facility, The Dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. * If necessary, the nursing staff or Dietitian will discuss with the Physician whether a diet can be liberalized. * The Dietitian will counsel residents or families about requests that conflict with residents' dietary restrictions and whenever diets cannot be liberalized. *The Dietitian or a nurse will document any such discussions in the residents' medical records. * Non-perishable foods retained in the residents' rooms must be stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. Perishable foods must be stored in a manner which minimizes risk of cross contamination in the designated resident refrigerators. These foods will be labeled with the resident's name, and dated. * The nursing staff is responsible for discarding perishable foods within 3 days or before the use by/ expiration date, whichever comes first. * The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (or example, mold growth, foul odor, past due package expiration dates). 9. Home-prepared and home-preserved foods are permitted if brought by family or visitors for individual residents. Such foods may not be shared or distributed to other residents. 10. Facility staff only will assist with reheating food to ensure safe food handling practices. 11. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded. Reviewed the facility's policy: Food Receiving and Storage revised 1/30/2024 Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times, 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 3. Foods that are prepared off site will only be accepted from institutions that are subject to federal, state or local inspection. The Food Service Manager shall verify the latest approved inspection and also monitor the food quality of the supplier. 4. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 5. Food in designated dry storage areas shall be kept off the floor (at least 6 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated. 8. Refrigerated foods must be stored at 41°F or below. 9. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. 10. Freezer temperature maintained to keep frozen food solid. Frozen food wrapping must stay intact until thawing. 11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented on an approved log. 12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers with a date and below fruits, vegetables and other ready-to-eat foods. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: *Perishable food items will be covered/labeled and dated under refrigeration at 41°F or below. *Frozen food items will be covered/labeled and dated at a temperature maintained to keep frozen *All foods belonging to residents must be labeled with the resident's name, room number and food solid. *Refrigerators and freezers must have working thermometers and be monitored for temperature. date. *Other opened containers (food/beverage) must be dated and sealed or covered during storage and held no longer than 72hrs *Partially eaten food may not be kept in the refrigerator. *Medications, blood or blood products may not be stored in the same refrigerator with food 14. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in storerooms for food or food preparation equipment and utensils. 15. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage. .

Based on observations, record reviews and interviews, the facility failed to store food kept in the nourishment room refrigerator in accordance with professional standards for food service safety. Food stored in the nourishment room refrigerator was observed to be unlabeled and undated, which could result in residents receiving other residents' food items, or food items that were potentially unsafe due to extended storage in the refrigerator. The findings include: A tour of the facility's nourishment room was conducted on 6/30/2025 at 10:18 a.m. Signage attached to the door of the refrigerator revealed Resident Food Only. Any resident food stored here must be labeled with: Resident name and date. Any food items stored here that are open/already prepared must be thrown away if > 3 days old. Food items may be kept until expiration date only if prepackaged and sealed/unopened. No staff food. Several undated and unlabeled items were observed in the refrigerator and freezer. (Photographic Evidence Obtained) A follow-up tour of the nourishment room was conducted on 7/1/2025 at 2:32 p.m. Undated and unlabeled items remained in the refrigerator and freezer. Additional items had been added since 6/30/2025 at 10:18 a.m. which were not dated or labeled. (Photographic Evidence Obtained) On 7/2/2025 at 11:28 a.m., undated and unlabeled items remained in the refrigerator and freezer of the nourishment room. (Photographic Evidence Obtained) An interview was conducted on 7/2/2025 at 11:36 a.m. with Licensed Practical Nurse (LPN)/Unit Manager E. She stated all staff were responsible for the upkeep of the nourishment room. She stated it was usually checked in the morning by herself, the Assistant Director of Nursing (ADON), or a Dietary Staff member. She stated all items had to be labeled with the residents' names and room numbers. She also stated that open items had to be discarded within three days. A review of the facility's policy titled Storage of Foods Brought to Residents by Family/Visitors (revised 1/18/2018), revealed: Policy Statement: Staff must be aware of, and approve, food(s) brought to a resident by family/visitors to ensure safe and sanitary storage, handling and consumption of foods. Policy Interpretation and Implementation: - Family members/responsible parties should inform nursing staff of their desire to bring foods into the facility, The Dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. - If necessary, the nursing staff or Dietitian will discuss with the Physician whether a diet can be liberalized. - The Dietitian will counsel residents or families about requests that conflict with residents' dietary restrictions and whenever diets cannot be liberalized. - The Dietitian or a nurse will document any such discussions in the residents' medical records. - Non-perishable foods retained in the residents' rooms must be stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. Perishable foods must be stored in a manner which minimizes risk of cross contamination in the designated resident refrigerators. These foods will be labeled with the resident's name, and dated. - The nursing staff is responsible for discarding perishable foods within 3 days or before the use by/ expiration date, whichever comes first. - The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (or example, mold growth, foul odor, past due package expiration dates). 9. Home-prepared and home-preserved foods are permitted if brought by family or visitors for individual residents. Such foods may not be shared or distributed to other residents. 10. Facility staff only will assist with reheating food to ensure safe food handling practices. 11. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded. A reviewed the facility's policy titled Food Receiving and Storage (revised 1/30/2024), revealed: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times, 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 3. Foods that are prepared off site will only be accepted from institutions that are subject to federal, state or local inspection. The Food Service Manager shall verify the latest approved inspection and also monitor the food quality of the supplier. 4. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 5. Food in designated dry storage areas shall be kept off the floor (at least 6 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated. 8. Refrigerated foods must be stored at 41°F or below. 9. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. 10. Freezer temperature maintained to keep frozen food solid. Frozen food wrapping must stay intact until thawing. 11. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented on an approved log. 12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers with a date and below fruits, vegetables and other ready-to-eat foods. 13. Food items and snacks kept on the nursing units must be maintained as indicated below: *Perishable food items will be covered/labeled and dated under refrigeration at 41°F or below. *Frozen food items will be covered/labeled and dated at a temperature maintained to keep frozen *All foods belonging to residents must be labeled with the resident's name, room number and food solid. *Refrigerators and freezers must have working thermometers and be monitored for temperature. date. *Other opened containers (food/beverage) must be dated and sealed or covered during storage and held no longer than 72hrs *Partially eaten food may not be kept in the refrigerator. *Medications, blood or blood products may not be stored in the same refrigerator with food 14. Pesticides and other toxic substances and drugs will not be stored in the kitchen area or in storerooms for food or food preparation equipment and utensils. 15. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and interviews, the facility failed to ensure that one (Resident #25) of ten residents receiving oxygen, from a total sample of 27 residents, received oxygen at the correct settings as ordered by the physician. The findings include: An observation was made of Resident #25 on 8/22/23 at 9:00 a.m. in her room. She was lying in bed with oxygen infusing at 3 liters per minute via an oxygen concentrator. (Photographic evidence obtained) On 8/22/23 at 3:01 p.m., Resident # 25 was observed sitting in a wheelchair at bedside with oxygen flowing at a rate of 3 liters per minute via nasal cannula via the oxygen concentrator. Resident #25 did not know what the flow rate setting should have been. (Photographic evidence obtained) An observation was made of Resident #25 on 8/23/23 at 12:25 p.m. receiving a.m. care. Oxygen was observed infusing at 3 Liters per minute via nasal cannula. (Photographic evidence obtained) An observation was made of Resident #25 on 8/23/23 at 1:26 p.m. sitting up in a wheelchair at bedside. She had just finished her lunch. Oxygen was infusing at 3 Liters per minute via nasal cannula. (Photographic evidence obtained) A review of Resident #25's electronic medical record revealed that she was admitted on [DATE] with diagnoses including congestive heart failure, atrial fibrillation and neoplasm of the uterus. A physician's order dated 7/27/23, noted oxygen continuous at 2 liters per minute via nasal cannula in the medical record. A review of the Medication Administration Record (MAR) for August 2023, revealed that the physician's order dated 7/27/23 for oxygen continuous at 2 Liters per minute via nasal cannula, was signed off daily as having been administered per the order. The care plan, updated on 7/28/23, noted the resident was at risk for complications related to respiratory disease, shortness of breath, and congestive heart failure. The intervention was to administer oxygen as ordered by the resident's physician. An interview was conducted with Registered Nurse (RN) A at 1:28 p.m. on 8/23/23. The RN was asked how many Liters of oxygen Resident #25 was receiving, and she stated she needed to review the resident's physician's orders. She reviewed the orders and reported that oxygen should be infusing at 2 Liters per minute. RN A was accompanied to Resident #25's room to check the resident's oxygen flow rate. RN A confirmed that the resident's oxygen was set at 3 Liters per minute and she changed the setting to 2 Liters per minute. An interview was conducted with the Director of Nursing (DON) on 8/23/23 at 1:45 p.m. The DON reported continuous oxygen settings should be checked every shift by the assigned nurse. A review of the facility's policy for Oxygen (revised on 1/25/23) revealed the following: Steps in setting up the oxygen: Number 2: Turn on oxygen. Start flow at ordered rate. Under step #4: Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. .