I. Based on observations, interviews, and policy and procedure reviews, the facility failed to maintain a clean and sanitary kitchen to prevent cross contamination and the likelihood of foodborne illnesses to the 110 residents who ate meals prepared from the facility's kitchen. This deficient practice resulted in an Immediate Jeopardy on 08/18/2024 at 9:15 a.m. when the following was observed during multiple visits in the facility's kitchen: 1. Equipment: a. Excessive food residue on the stove top. b. Black residue under the ice machine's filter. Water dripped down over the black residue. c. Collection receptacle of the oven's grill top with old food, thick black burnt residue, and uncooked pasta. d. Dry food particles and grease on the oven handle. e. Burnt food particles on the stove burners. f. Food splatter on the shelf of the stove. g. Grease on the backsplash of the fryer. h. Dried grease on the back surface of the stove and grill. i. Ice buildup on the floor located on the back wall in the walk-in refrigerator. 2. Dish and cookware storage and cleanliness: a. Four rack shelf for dirty dishes with dried food residue. b. Three small bowls stored on the clean dish shelf had food debris. 3. Food Storage a. One can of sliced apples in the pantry with a dent on the upper rim. b. Bag of cereal in the pantry unlabeled with no date of opening. c. Container of tuna fish unlabeled with no date of preparation. d. Residue on the top of the sugar, rice, and flour storage bins. 4. Surfaces a. Trash debris and dirt on the floor under the rolling rice container. b. Large spot of dirt on the floor outside of the pantry door. c. Counter to the left of the rinsing sink with food debris and thick black gritty substance noted on the top edges of the backsplash where it connected to the wall. d. Black residue buildup resembling mildew on top of base board on the back corner of the south wall in the dishwashing room. e. Front exterior panel of the three compartment sink in the dishwashing room covered with dried food debris. f. Large amount of dirt/dust on the pipes underneath the three compartment sink. g. Trash debris on the floor near the trash can next to the rinsing sink in the dishwashing room. h. Large area of black residue resembling mildew on the wall behind the steam exhaust of the automatic dishwasher. A portion of the residue stain was covered with a thick black, gritty substance. i. Large amounts of dried brown splatter noted on the wall to the right and left of the dishwasher. j. Multiple brown spots and food splatter on the dishwashing room door with a dirty towel hanging on the top of the door. k. Food splatter noted on the spice shelf. l. Food crumbs noted on the preparation table. m. Dried food particles and green rust noted on the baking table drawer. 5. Pests a. Swarm of gnats flying in the dishwashing room and a few randomly throughout the kitchen. b. Live small cockroach crawling behind the stove. c. Live small cockroach in dry storage room. d. Three dead roaches in a small red bucket under the food prep counter. 6. Dietary workers observed without proper hair and facial hair restraints. These failures placed residents at risk for food-borne illnesses. S1ADM (Administrator), S4HR (Human Resources), and S2DON (Director of Nursing) were notified of the Immediate Jeopardy on 08/18/2024 at 5:51 p.m. The Immediate Jeopardy was removed on 08/20/2024 at 10:40 a.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implementing an acceptable Plan of Removal (POR) prior to survey exit. The deficient practice had the likelihood to cause more than minimum harm to the 110 residents who ate out of the kitchen. Findings: Review of the facility's policy, Cleaning Schedule, with a last reviewed date of 02/14/2024, revealed the following in part: Policy: The dietary manager shall establish a cleaning schedule for the food service department to ensure that food is stored and prepared under sanitary conditions. 1. All equipment and work areas are cleaned after each use, or, on a routine basis. 9. The DM (Dietary Manager) checks routinely to see that the task is completed according to standards. Review of the facility's policy, Cleaning and Sanitizing Equipment, last reviewed on 02/14/2024, revealed the following in part: Policy: All equipment is kept clean and food contact surfaces are cleaned and sanitized. 2. Remove food and soil from under and around the equipment. 3. Remove detachable parts and manually wash, rinse and sanitize or run through dish machine. Review of the facility's policy, Cleaning Procedure, last reviewed on 02/14/2024, revealed, the following in part: Item: Stainless steel shelving, counter, and tables. When: As used, daily, weekly .Stainless steel/aluminum storage racks, When: Monthly or more if needed Item: Baseboards. When: Monthly/more frequent if needed. 1. Heavily soiled deposits may require several applications of cleaning solution and scrubbing action to remove the soil. Review of the facility's policy, Storage of Refrigerated Food, last reviewed on 02/14/2024, revealed the following in part: Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage procedures. Procedure: 4. All non-hazardous, opened foods are labeled with name of food and date stored. 5. All hazardous foods are labeled with name of food and date to be discarded or the date stored. Cooked food should not be held longer that 48 hours. Review of the facility's policy, Employee Sanitation Practices, last reviewed on0 2/14/2024, revealed the following in part: Policy: Food service employees shall follow sanitary practices to prevent the spread of food borne illness and reduce those practices which result in food contamination and compromised food safety. 3. Proper Work Attire, b. Wears a clean hat or other hair restraint. Employees with facial hair wear a beard restraint. On 08/18/2024 at 9:15 a.m., an initial tour of the kitchen conducted with S15PM (Production Manager) revealed the following: 1. Three small bowls stored on the clean dish shelf had food debris 2. One can of sliced apples in the pantry with a dent on the upper rim 3. Bag of oat cereal in the pantry unlabeled with no date of opening 4. Container of tuna fish unlabeled with no date of preparation 5. Trash debris and dirt on the floor under the rolling rice container 6. Large area of black residue resembling mildew on the wall behind the steam exhaust of the automatic dishwasher. A portion of the residue stain was covered with a thick black gritty substance 7. Large amounts of dried brown splatter on the wall to the right of the dishwasher 8. Counter to the left of the rinsing sink with food debris and thick black gritty substance on the edges between the backsplash and the wall 9. Front exterior panel of the three compartment sink in the dishwashing room covered with dried food debris 10. Large amount of dirt/dust on the pipes underneath the three compartment sink 11. Large spot of dirt on the floor outside of the pantry door 12. Four rack shelf for dirty dishes with dried food residue. S15PM confirmed all observations listed above. She confirmed that the items should have been cleaned; the dented can of sliced apples should not be in the dry storage area and should have been discarded; the bag of oat cereal should have been dated with the date of opening; and that the container of tuna fish in the refrigerator should have been labeled and dated with the date of preparation. On 08/18/2024 at 11:40 a.m., S18DW (Dietary Worker) was observed wearing a hair net only covering half of his hair. S18DW's hair around his crown was exposed and he had no covering for his facial hair. S17DW (Dietary Worker) was observed with her hair up in a bun. S17DW's hair net only covered her bun with a portion of hair outside of the bun. The hair around her crown was exposed. On 08/18/2024 at 11:40 a.m., an interview was conducted with S16DM (Dietary Manager). She confirmed that S17DW was not wearing a hair net appropriately and her hair net should cover all of her hair. She also confirmed that S18DW should have a beard restraint for his facial hair and was not wearing a hair net appropriately by not covering all of his hair. On 08/18/2024 at 4:05 p.m., and interview and observation of the dishwashing room was conducted with S16DM, S1ADM, and S19MA (Maintenance Assistant). S16DM stated that the thick black gritty residue on the wall behind the dishwasher had to be scrubbed with bleach cleaning solution time and time again because the substance continued to return. S19MA observed the substance on the wall and stated he was not sure what it was. He could not confirm if the black residue stain was mold or mildew, but acknowledged that the residue appeared to not have been cleaned recently and was located where steam was released from the washer in an area that remains wet. S19MA stated due to the thickness and grittiness of the substance coving portions of the residue stain on the wall behind the dishwasher, he believed it was a build-up of dirt. S19MA was asked how an accumulation of dirt could form in the dishwashing area of which he did not give a clear answer. S19MA obtained a dry napkin and attempted to wipe the black residue off the wall. Very little of the black reside came off onto the napkin with much of the reside remaining on the wall which was not easily wiped off. S19MA stated that no one reported to him this issue to assess if there was a mold/mildew issue. S19MA stated it was the kitchen's staff responsibility to keep the kitchen clean. S16DM that this area of black residue behind the dishwasher required cleaning and scrubbing with bleach but it continued to return. S1ADM stated that she was not aware of this black substance on the wall behind the dishwasher. S1ADM and S16DM were was asked to observe the black substance lining the top edge of the stainless steel back splash and corner where it met the wall to the left of the dishwasher. She was also asked to observe the walls with brown, dry splatter to the right and left of the dishwasher as well as the black residue on the baseboards underneath the counter to the left of the dishwasher. S16DM referred to the thick gritty black build-up as dirt. She explained that she was not sure how long the build-up of dirt had been on the walls and floor. S16DM stated she was not sure if the residue on the wall was mold or mildew, and further stated that she had not contacted maintenance staff nor notified S1ADM of this issue. During continued interviews while inside the kitchen, a swarm of gnats were observed flying around the dishwashing room. S16DM stated that a bug light was out of order in the kitchen. S16DM and S1ADM confirmed the kitchen was unclean and not sanitary. Neither could state exactly when the kitchen was last thoroughly cleaned. S16DM stated she was responsible for supervising and assuring that kitchen staff cleaned and sanitized the kitchen daily. She further acknowledged the facility's kitchen cleaning practices were not effective. On 08/18/2024 at 4:45 p.m., an additional tour of the kitchen by the survey team was conducted with S15PM and S16DM and revealed the following: 1. Excessive food residue on the stove top 2. Black residue under the ice machine's filter; water dripped down over the black residue 3. Collection receptacle of the oven's grill top with old food, thick black burnt residue, and uncooked pasta 4. Dry food particles and grease on the oven handle 5. Burnt food particles on the stove burners 6. Food splatter on the shelf of the stove 7. Grease on the backsplash of the fryer 8. Dried grease on the back surface of the stove and grill 9. Ice buildup on the floor located on the back wall in the walk-in refrigerator 10. Four rack shelf for dirty dishes with dried food residue 11. Residue on the top of the sugar, rice, and flour storage bins 12. Large spot of dirt on the floor outside of the pantry door 13. Counter to the left of the rinsing sink with thick black gritty substance on the top edges of the backsplash where it connected to the wall 14. Black residue buildup resembling mildew on top of base board on the back corner of the south wall in the dishwashing room 15. Front exterior panel of the three compartment sink in the dishwashing room covered with dried food debris 16. Large amount of dirt/dust on the pipes underneath the three compartment sink 17. Trash debris on the floor near the trash can next to the rinsing sink in the dishwashing room 18. Large area of black residue resembling mildew was on the wall behind the steam exhaust of the automatic dishwasher. A portion of the residue stain was covered with a thick black gritty substance. 19. Large amounts of dried brown splatter on the wall to the right and left of the dishwasher 20. Multiple brown spots and food splatter on the dishwashing room door with a dirty towel hanging on the top of the door. 21. Food splatter on the spice shelf 22. Food crumbs on the preparation table 23. Dried food particles and green rust on the baking table drawer 24. Swarm of gnats flying in the dishwashing room and a few randomly throughout the kitchen 25. Live small cockroach crawling behind the stove 26. Live small cockroach in dry storage room 27. Three dead roaches in a small, red bucket under the food prep counter. The findings above were again reviewed with the S16DM. S16DM stated, I saw everything y'all saw. II. Based on observation and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety by leaving used soiled gloves in the residents drink service area. On 08/18/2024 at 11:45 a.m., an observation was made during lunch service in Dining Room A. There was a pair of used food gloves turned inside out on the counter where the residents' drinks were being poured and served. An interview was conducted with S21RN (Registered Nurse), who stood by the counter. She confirmed that she used the gloves for pouring and serving the residents' water and drinks, removed the gloves, then placed them on the counter afterward. She stated that she should have placed the used gloves in the garbage can when she took them off but did not. On 08/19/2024 at 2:37 p.m., an interview was conducted with S20IP (Infection Preventionist). She stated that S21RN should have placed the dirty gloves in the trash can and not left them on the counter that was used for serving the residents' drinks.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to ensure the well-being of residents by failing to provide oversight in the kitchen. This lack of oversight resulted in an Immediate Jeopardy on 08/18/2024 at 9:15 a.m., when the kitchen was observed to have equipment, environment, food storage, preparation practices; and dinnerware storage practices that were unsanitary and unsafe for meal distribution to residents with the high likelihood to cause foodborne illness. S1ADM (Administrator) was notified of the Immediate Jeopardy on 08/18/2024 at 5:51 p.m. The Immediate Jeopardy was removed on 08/20/2024 at 10:40 a.m., after it was verified through observations, interviews, and record reviews that the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice had the potential to cause foodborne illness in 110 residents who consumed meals from the kitchen. Findings: Cross Reference F812 On 08/19/24 3:36 p.m., an interview was conducted with S22RD (Registered Dietician). S22RD stated that she performed a walkthrough of the entire kitchen quarterly with the last walkthrough conducted on 06/19/2024. Reviewed S22RD's quarterly report dated 6/19/2024 that stated no cleanliness issues noted with S22RD. S22RD reported that she observed the kitchen randomly when she visited the facility but it was not a full detailed inspection. S22RD stated she had not done a walkthrough of the entire kitchen since 06/19/2024 and has had no reports of any cleanliness issues nor has she observed any since then. She stated that she had been aware of the ongoing presence of gnats in the kitchen for a few months. She further stated that administration was aware of the presence of gnats in the kitchen. Review of the facility's State of Louisiana Department of Health, Office of Public Health, Retail Food Notice of Violations dated 06/11/2024 at 9:30 a.m. read in part: Non-Critical Items: Code Reference: Non-food contact surfaces are not cleaned at a frequency necessary to preclude accumulation of soil residues. On 08/19/2024 at 3:50 p.m., an interview and review of the Food Notice of Violations referenced above was conducted with S1ADM. S1ADM stated that the State Sanitarian reported to her the results of his inspection before he left the faciity on the day of inspection. She stated that no intervention was needed after the inspection because the Sanitarian had informed her that all deficiencies had already been corrected. S1ADM stated S16DM (Dietary Manager) was responsible for the cleanliness of the kitchen. S1ADM stated that S16DM had not reported any issues with cleanliness in the kitchen. S1ADM stated that S22RD (Registered Dietician) came three times a month. If S22RD identified any issues in the kitchen, she would have notified S1ADM, but she had not. She stated that S3RA (Regional Administrator) was at the facility twice a week and conducted full facility rounds, but he had not reported any kitchen concerns. S1ADM stated she was aware of issues with gnats in the kitchen that was reported to her on 08/09/2024. S1ADM stated she observed gnats in the kitchen on 08/09/2024 and called pest control. She reported that pest control came on 08/12/2024 for the gnat problem and that this was the last date she recalled being in the kitchen. On 08/20/2024 at 8:50 a.m., an interview was conducted with S3RA (Regional Administrator). He stated that he was not aware of the cleanliness issue in the kitchen. He stated that he conducted rounds in the facility and observed the kitchen on 08/12/2024. He stated there were no pest or cleanliness issues in the kitchen on 08/12/2024 that he observed. S3RA stated he may have documentation of these rounds of which was requested. On 08/20/2024 at 10:17 a.m., an interview and email review was conducted with S1ADM. The email dated 06/5/2024 at 1:37 p.m. was from S1ADM to S16DM. The email read: I realized I skipped over dietary. Staff are not wearing beard covers. Ice build-up on the floor of the fridge. Garlic bread without date. Food items in bag on floor under the shelf. S1ADM stated that she sent this email to S16DM after a third party consultant mock survey had been conducted. She stated she had forgotten to address these issues in a meeting, and sent the email to notify S16DM of the findings. On 08/20/2024 at 1:51 p.m., an interview was conducted with S3RA, S1ADM, and S16DM. Both S3RA and S1ADM stated they were unaware of the cleanliness issues in the kitchen and were attempting to manage the pest issues. S1ADM stated that she was last near the kitchen on 08/12/2024 when the pest control was present, but was in the hallway behind the kitchen and did not enter the kitchen. S1ADM stated she did not remember entering the kitchen after this date. S3RA stated there were no cleanliness issues that he observed on 08/12/2024. S16DM stated that she was responsible for doing visual checks to ensure daily, weekly, and monthly cleaning/sanitation tasks were completed by kitchen staff and that she was responsible for ensuring they did so effectively. S16DM stated she was last present in the kitchen on 08/16/2024, just prior to survey entrance (08/18/2024). S1ADM stated she was ultimately responsible for the kitchen as she was S16DM's direct supervisor. No documentation of S3RA or S1ADM kitchen rounds were provided before exit.