Based on observation, interviews, record review, and facility policy review, the facility failed to label and date prepared foods in the refrigerator and freezer and failed to prevent the possible spread of infection when a kitchen staff member failed to wear a beard guard while preparing plates for the dining hall for one (1) of four (4) days of kitchen observation. Findings include: A review of the facility's Food Storage Labeling policy, revised 8/24, revealed, .Procedure .2. All food items that are not in their original container must be labeled with the common name of the food and the use by date. 3. Foods that are prepared and stored for later service must be labeled and dated . A review of the facility's Employee Work Practices policy, revised 10/17, revealed, .Procedure .2. Proper Work Attire .c. The food service employee observes the following dress standards .iii. Food handlers with facial hair wear a beard restraint . On 02/10/2025 at 10:24 AM, during an initial tour with the Dietary Manager (DM), an observation was made of the refrigerator of one (1) pot of peas and carrots, one (1) pan of uncooked beef burger patties, one (1) pan of yeast rolls, mashed potatoes, beef fingers, cooked rice, and corn-all covered in aluminum foil without a preparation date, description, or use-by date. The DM confirmed that the food items were not labeled with the date, description, or use-by date as required by facility policy. On 02/10/2025 at 11:25 AM, during an observation, a male kitchen worker was observed preparing meal trays for residents without wearing a beard guard. On 02/11/2025 at 9:57 AM, during an interview, a kitchen staff worker stated that staff had recently been in-serviced regarding food dating and labeling. On 02/12/2025 at 10:00 AM, during an interview, the Registered Dietitian (RD) stated that the facility's policy for food preparation required all stored food to be labeled with a date and description on the outside of the container. The RD confirmed that staff were required to wear hair restraints while in the kitchen and stated that the male kitchen worker had forgotten to put on a beard restraint. The RD further stated that the expectation for staff was to follow policy and prepare food according to proper food safety guidelines. On 02/13/2025 at 11:56 AM, during an interview, the Administrator stated that the expectation for kitchen staff was to follow facility policies to safely prepare food and prevent the spread of infection among residents. The Administrator stated that food safety measures were essential to ensuring that residents received meals that met their preferences and nutritional needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to provide a safe, functional, sanitary, and comfortable environment as evidenced by resident rooms with excessive rust on the ceiling grids for two (2) of nine (9) resident rooms observed on the North Hall. rooms [ROOM NUMBERS] Findings Included: A review of the facility's policy, revised 9/2022, revealed, It is the policy of this facility to provide services based on the following regulation .Safe/Functional/Sanitary/Comfortable Environment .The facility will provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public . On 9/12/24 at 11:15 AM, in an observation of room [ROOM NUMBER] and room [ROOM NUMBER] on the North Hall, the metal ceiling grids were excessively discolored with rust. The rusted areas were more excessive over the beds that were near the windows in the room. On 9/12/24 at 12:10 PM, in an interview and observation of room [ROOM NUMBER] with Housekeeper #1, she confirmed the ceiling grids were excessively rusted. She explained she had worked on the North Hall for approximately one (1) month and had not noticed the rusted ceiling grids. On 9/12/24 at 2:15 PM, in an interview and observation of rooms [ROOM NUMBERS] with the Maintenance Director, he confirmed the ceiling grids were rusted and was unsure why the grids were more rusted in the two rooms above the beds than other places throughout the facility. He stated he felt like the rust was caused by using aerosol disinfecting products during the COVID-19 pandemic. He explained he would repair the grids and that he had not gotten to it yet. On 9/12/24 at 4:15 PM, in an interview with the Administrator, she explained she was not aware of the rusted ceiling grids in the rooms but acknowledged the facility utilized aerosol disinfectant during COVID-19.

Based on observation, interview, and facility policy review, the facility failed to ensure a resident's privacy as evidenced by posting of clinical care signage on the resident's wall for one two (2) of 20 sampled residents. Resident #32 and Resident #10. Findings Include: Review of the facility's policy, Personal Privacy/Confidentiality of Record, undated, revealed the document did not address clinical care signage in resident rooms. Resident #32 On 08/01/23 at 10:40 AM, an observation revealed there were signs posted on the resident's wall over the bed as follows: 1. When resident is in the bed ensure bed is in its lowest position with fall mat beside bed before exiting. 2. Nectar thickened liquids. 3. 201B Meal Instructions 1. Assist with all meals, 2. Slow rate, 3. Give one sip then swallow, 4. Give small bites/small sips, 5. Keep upright during meals and 30 min after meals. In an interview on 08/01/23 at 01:35 PM, Licensed Practical Nurse (LPN) #1 revealed that she acknowledged the signage was posted in resident's room but was unsure of who had placed it. She stated she believed it was possibly the hospice company. Resident #10 On 08/01/23 at 01:35 PM, an observation revealed there were signs posted on the resident's wall over the bed as follows: 1. When resident is in the bed ensure bed is in its lowest position with fall mat beside bed before exiting. 2. Keep head of bed elevated at all times On 08/01/23 at 02:02 PM, an interview with Registered Nurse (RN) #1 Charge Nurse, revealed the signage had been posted due to the removal of bed rails and the staff placed the signs as a reminder to place the beds in the lowest position. The charge nurse removed the signage during the interview and stated that reminders could be placed on the kiosks used by the Certified Nursing Aides (CNAs). On 08/01/23 at 02:41 PM, in an interview with the Director of Nurses (DON), she acknowledged the posted signage and stated the facility would remove the signs or place them so that only staff could view the information.

Based on observation, interview, and facility policy review it was determined the facility failed to serve food in a safe and sanitary condition to prevent the possible spread of infection and contamination, during one (1) of two (2) kitchen observation. The identified concerns placed all residents receiving food/nourishment from the kitchen at risk for foodborne illnesses. Findings include: A review of the facility's Food Service Operational Standards For Purchasing, Cooking and Storage policy, undated, revealed: This facility stores, prepares, distributes, and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. Avoid overloading cooking surfaces. Wash, rinse, and sanitize all equipment and utensils before and after each use. Review of the facility's Hand Washing Policy, undated, revealed, handwashing would be done by all staff throughout their shift, and to reduce the transmission of organisms from resident to resident, and from the staff to the resident. A review of the facility's Cleaning and Sanitizing Equipment policy, undated, revealed: All equipment is kept clean and food contact surfaces are cleaned and sanitized. Remove food and soil from under and around the equipment. Remove detachable parts and manually wash, rinse, and sanitize or run through dish machine. Allow to air dry. Wash and rinse fixed food contact surfaces, then wipe or spray with a chemical sanitizing solution. Review of the facility's training record, titled Safety and Dietary Procedures, dated 02/26/2020, revealed the dietary staff was in-serviced on Food Storage, Food Preparation, Food Service/Sanitation, Safety, Food Temperature and other Safety Measures, which included cross contamination, handwashing, cleaning surfaces and proper refrigeration of leftovers. A review of the facility's Employee Sanitation Practices policy, undated, revealed, gloves are worn to protect food by creating a barrier between the hands and food. Gloves should be changed as soon as they become soiled or torn and before beginning a different task. An observation, during the initial tour of the kitchen, on 03/03/2020 at 9:15 AM, revealed the conventional oven was dirty with build-up of food on the inside walls of the oven. The aluminum foil, in the bottom of the oven, was dirty with food build up. The two (2) small ovens had food build up on the inside walls and on the aluminum foil in the bottom of the ovens. The door of the oven had food build up on it as well. During an interview, on 03/03/2020 at 9:35 AM, the Dietary Manager (DM) stated that all the ovens were dirty. The DM stated she had a schedule for when the ovens are supposed to be cleaned, and they were apparently not cleaned according to the schedule. The DM stated the food build-up on the ovens looked to be from several days of cooking. A review of the Cleaning Schedule #1, dated February 2020-March 01, 2020, revealed the small ovens were initialed as being last cleaned on February 27, 2020. The large oven was initialed as being last cleaned on February 29, 2020. During an observation, on 03/04/2020 at 10:56 AM, Dietary Worker #2 knocked a piece of white sandwich bread, that was in a paper sleeve, off of a serving cart onto the floor. Dietary Worker #2 picked the sleeve with the piece of bread in it, up off the floor, and placed it back on top of the cart with the other pieces of sandwich bread in sleeves. The sleeve with the piece of bread that had fallen to the floor, was taken off of the cart; however, the other sleeves of bread were served to the residents. Dietary Worker #2 did not remove her gloves or wash her hands after picking the sleeve of bread off the floor and placing it back onto the cart. Dietary Worker #2 went back to the food serving line, wearing the same gloves that she used to pick the bread up off the floor. During an observation, on 03/04/2020 at 11:02 AM, the Dietary Manager (DM) was assisting Dietary Worker #3 in calibrating the thermometer to check food temperatures. The DM, without wearing gloves, picked up the foam cup that was being used for calibration, went to the ice maker and dipped the foam cup into the ice machine to obtain more ice. During an interview on, 03/04/2020 at 11:04 AM, the DM stated that she used the foam cup to obtain ice from the ice machine, instead of using the scoop. The DM stated she shouldn't have done it, and that it was contamination. The DM revealed they did not discard the ice from the ice machine, nor did they clean the ice machine. During an interview, on 03/04/2020 at 11:06 AM, Dietary Worker #2 confirmed she picked up the paper sleeve containing the piece of sandwich bread, from the floor and placed it back on top of the cart with the other sleeves of bread. Dietary Worker #2 stated she was not supposed to do that. Dietary Worker #2 stated she should have thrown it away. Dietary Worker #2 revealed she threw the sleeve of bread away, but it was after she had sat it on the other sleeves of bread, on the cart. Dietary Worker #2 stated they still served the other sleeves of bread to the residents for lunch, and they should have thrown it away. On 03/04/2020 at 11:29 AM, during an interview, the Dietary Manager (DM) stated that she saw Dietary Worker #2 drop the sleeve, with the piece of bread in it, pick it up, and put it on top of the cart with the other sleeves containing the bread. The DM confirmed she saw Dietary Worker #2 throw away the sleeve of bread that had fallen on the floor, but it was after she had placed the contaminated bread back on the cart. The DM stated she told Dietary Worker #2 not to put it back on the cart, but she did it anyway. The DM stated what Dietary Worker #2 had done was contamination. She stated that Dietary Worker #2 should have discarded the whole cart of bread, after she laid the contaminated bread back onto the cart. During an interview, on 03/04/2020 at 1:25 PM, the DM stated that it was ultimately her responsibility to make sure the equipment was cleaned as scheduled. The DM stated that it was also her responsibility to make sure that the contaminated food was not served. On 03/06/2020 at 9:14 AM, during an interview, with the DM, revealed she saw Dietary Worker #2 go back to the serving line, without washing her hands and changing gloves, after picking the bread up off of the floor. During an interview, on 03/06/2020 at 11:47 AM, the Administrator stated that she considered it an infection control issue, with the staff not following the cleaning schedule for cleaning the oven and back splash on the oven. The Administrator stated the Dietary Manager getting the ice from the ice machine without gloves on, and without using the scoop, was an infection control issue. She stated that the Dietary Manager not washing her hands and changing gloves, after picking the bread up off the floor, and before returning to the serving line, was an infection control issue. The Administrator stated Dietary Worker #2 should not have placed the bread back on the cart. She stated the tray of bread, on the cart, should have been discarded since it was contaminated, and fresh bread should have been brought out to be served. The Administrator stated Dietary Worker #2 contaminated the other bread on the serving cart, when she placed the bread that was picked up off of the floor, back onto the serving cart. A review of the facility's training record, dated 02/26/2020, revealed the Dietary Manager and Dietary Worker #2 were in-serviced on Food Safety and Dietary Procedures.