Based on record reviews and interviews the facility failed to maintain, store, prepare, distribute, and serve food under sanitary conditions. The facility failed to accurately monitor the refrigerator and freezer temperatures and failed to accurately maintain the dishwasher machine temperature. This had the potential to affect 18 residents who were served trays out of the kitchen according to the Dietary Manager. Findings: Review of the facility's refrigerator and freezer temperature logs revealed temperatures were documented with no variations from 11/01/2024 to 03/11/2025. The refrigerator temperature logs were listed as follows: the internal manual thermometer temperature was 36 degrees F (Fahrenheit), the internal electric thermometer temperature was 40 degrees F, and the external thermometer temperature was 41 degrees F. The freezer temperature logs were listed as follows: the internal manual thermometer temperature was 10 degrees F, the internal electric thermometer temperature was 10 degrees F, and external thermometer temperature was 10 degrees F. Review of the facility's dish machine temperature strip logs from 11/01/2024 to 03/11/2025 revealed the test strip reading as 100 degrees F daily with no deviations. Observation on 03/11/2025 at 8:00 a.m. with S2 Dietary Supervisor revealed S2 Dietary Supervisor was unable to find the manual internal thermometer for the refrigerator and the internal digital thermometer was in Celsius for the refrigerator and freezer. During an interview on 03/11/2025 at 8:00 a.m. S2 Dietary Supervisor reported I'm not gonna lie, the refrigerator and freezer temperatures were fine yesterday so I just used the same temps from yesterday and wrote them down. S2 Dietary Supervisor further reported she wasn't sure exactly where the temperatures recorded on the log came from and reported she could not work the digital thermometers and did not know how to read Celsius. During an interview on 03/11/2025 at 8:20 a.m. S3 Assistant Dietary Manager reported The dishwasher company turned the dish machine temperature down to 100 degrees F because we couldn't get an accurate reading about a year ago. During an interview on 03/11/2025 at 4:30 p.m. S1 Administrator reported are going to have to add a temperature booster to get the water up to where it should be at least 120 degrees Fahrenheit.

Based on record review and interviews, the facility failed to implement the care plan for 1 (#1) out of 3 (#1, #2, #3) residents reviewed for falls. The facility failed to use a gait belt for Resident #1 during ambulation. Findings: Review of Facility's Clinical Protocol for Falls (undated) revealed: Purpose: It is the policy of ___Care that the facility shall identify patients at risk for falling and take steps to prevent future fall occurrences. Review of Resident #1's medical records revealed an admit date of 12/18/2024 with the following diagnoses, in part but not limited to: femoral neck fracture, neuropathy, recurrent falls, and left knee DJD (degenerative joint disease). Review of Resident #1's Baseline Care Plan revealed summary concerns of a fall risk and gait belt use. Review of Resident #1's ___Fall Risk Assessment Scale dated 12/18/2024 revealed a total score of 23 indicating a high fall risk (15 or >). Further review of ___Rehab Fall Risk Care Plan revealed: mobility, in part: . gait belt when assisting patient to ambulate. During a telephone interview on 02/06/2025 at 8:05 a.m. S1 CNA (Certified Nurse Assistant) confirmed Resident #1 required a gait belt with ambulation. S1 CNA acknowledged on 01/17/2025 she ambulated Resident #1 without using a gait belt. During an interview on 02/06/2025 at 10:48 a.m. S1 ADON (Assistant Director of Nursing) reported the staff are to use a gait belt when assisting residents to ambulate. S1 ADON acknowledged Resident #1 was ambulated without a gait belt and should not have been.