**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident's sense of well-being was promoted due to enhanced barrier precautions (EBP). Specifically, a sign was posted on the door for one of 28 sampled residents (Resident (R) 30), which caused a negative effect on R30's sense of well-being. The facility census was 117. Findings include: Review of R30's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, showed she was admitted to the facility on [DATE] with a diagnosis of end stage renal disease (ESRD). Review of R30's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/24, located in the EMR under the MDS tab, revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. Observation on 08/20/24 at 8:32 AM revealed there was an enhanced barrier precautions (EBP) sign posted on the outside of R30's door. During an interview at this time, R30 stated she feels that the EBP sign posted on her door was an invasion of her privacy and does not like that residents and family members were asking if she had COVID [coronavirus disease] all the time. Continued interview with R30 on 08/20/24 at 9:42 AM, R30 told the Assistant Administrator that she did not want the EBP sign placed on the outside of her door and the Assistant Administrator replied, I do not like it either, but this is what we have to do. During an interview on 08/22/24 at 6:46 AM, the Director of Nursing (DON) stated she was not aware the EBP sign on the door was a concern for R30. The DON also stated she understood how the sign posted on the door was a dignity issue. During an interview on 08/22/24 at 7:31 AM, the Assistant Director of Nursing (ADON) stated R30 never mentioned the EBP signage on the door was a dignity issue and she was not aware that the signage did not have to be placed on the door. Review of the facility-provided policy titled Dignity, revised February 2021 revealed, Policy Statement Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times . Review of the facility-provided policy titled Enhanced Barrier Precautions, revised March 2024 revealed, Policy Statement Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents . Policy Interpretation and Implementation . 11. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE [personal protective equipment] required .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan that addressed activities for six of 28 sampled residents (Resident (R) 33, R59, R67, R85, R89, and R102). This failure had the potential to result in activities not provided for the residents. Facility census was 117. Findings include: 1. Review of R33's undated admission Record located in the electronic medical record (EMR) in the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease without dyskinesia. Review of R33's Annual Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/11/23, revealed a Brief Interview for Mental Status (BIMS), score of nine out of 15 indicating R33 was moderately cognitively impaired. Further review of the MDS revealed it was very important for R33 to keep up with the news, to listen to music he likes, to do favorite activities, to do things with groups of people, to go outside, and participate in religious activities. Review of R33's quarterly MDS with an ARD of 06/08/24 revealed a BIMS score of 12 out of 15 which indicated that R33 was moderately cognitively impaired. Review of R33's comprehensive Care Plan, dated 02/08/23, located in the EMR under the Care Plan tab, revealed a focus area, I have problems with my memory, but am able to answer most questions . with an intervention of encourage me to attend acts of my current or past interest . However, the care plan did not address activities for R33. 2. Review of R59's undated admission Record located in the EMR under the Profile tab, revealed he was admitted to the facility on [DATE] with a diagnosis of diffuse traumatic brain injury. R59 was readmitted on [DATE] with a diagnoses of noninfective gastroenteritis and colitis. Review of R59's Annual MDS under the MDS tab of the EMR, with an ARD of 11/28/23, revealed a BIMS, score of 15 out of 15 indicating R59 was cognitively intact. Further review of the MDS revealed it was very important for R59 to listen to music he likes, to keep up with the news, to do things with groups of people, and to go outside. Review of R59's quarterly MDS with an ARD of 05/24/24 revealed a BIMS score of 15 out of 15 which indicated R59 was cognitively intact. Review of R59's comprehensive Care Plan, dated 10/25/21, located in the EMR under the Care Plan tab, revealed there was no focus area for activities on the care plan. 3. Review of R67's undated admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of other schizophrenia. Review of R67's Annual MDS under the MDS tab of the EMR, with an ARD of 05/01/24, revealed a BIMS, score of 15 out of 15 indicating R67 was cognitively intact. Further review of the MDS revealed it was very important for R67 to keep up with the news, to do your favorite activities, to go outside, and participate in religious activities. Review of R67's comprehensive Care Plan, dated 06/09/23, located in the EMR under the Care Plan tab, revealed a focus area, I have problems with my memory but am able to make simple choices between items or tasks . with an intervention to encourage me to attend acts of my current or past interest . The care plan did not address activities for R67. 4. Review of R85's undated admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of intestinal adhesions with complete obstruction. R85 was readmitted to the facility on [DATE] with a diagnosis of gastrointestinal hemorrhage. Review of R85's Annual MDS under the MDS tab of the EMR, with an ARD of 07/13/24, revealed a BIMS, score of 15 out of 15 indicating R85 was cognitively intact. Further review of the :MDS revealed it was very important for R85 to have things to read, to do things with groups of people, to go outside and participate in religious activities. Review of R85's comprehensive Care Plan, dated 10/10/23, located in the EMR under the Care Plan tab, revealed a focus area, I have problems with my memory from time to time . with an intervention to encourage me to attend acts of my current or past interest . The care plan did not address activities for R85. 5. Review of R89's undated admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnosis of paroxysmal atrial fibrillation. Review of R89's Annual MDS under the MDS tab of the EMR, with an ARD of 01/17/24, revealed a BIMS, score of 12 out of 15 indicating R89 was moderately cognitively impaired. Further review of the MDS revealed it was very important for R89 to have things to read, to listen to music she likes, to do favorite activities, to go outside, and participate in religious activities. Review of R89's quarterly MDS with an ARD of 07/16/24 revealed a BIMS score of 13 out of 15 which indicated R89 was cognitively intact. Review of R89's comprehensive Care Plan, dated 03/15/23, located in the EMR under the Care Plan tab, revealed there was no focus area for activities on the care plan. 6. Review of R102's undated admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE] with a diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of R102's admission MDS under the MDS tab of the EMR, with an ARD of 12/04/23, revealed a BIMS, score of 14 out of 15 indicating R102 was cognitively intact. Further review of the MDS revealed it was very important for R102 to have things to read, to listen to music she likes, to keep up with the news, to do favorite activities, to go outside, and participate in religious activities. Review of R102's quarterly MDS with an ARD of 06/02/24 indicated a BIMS score of 15 out of 15 which indicated that R102 was cognitively intact. Review of R102's comprehensive Care Plan, dated 12/27/23, located in the EMR under the Care Plan tab, revealed a focus area, I have problems with my memory from time to time . with an intervention to encourage me to attend acts of my current or past interest . The care plan did not address activities for R102. During an interview on 08/21/24 at 2:16 PM, the Minimum Data Set Coordinator (MDSC) confirmed she does not write care plans for activities, but the former Activities Director used to write them for the residents. The MDSC stated she did not know who was to review and complete the resident's activity care plan. During an interview on 08/22/24 at 10:04 AM, the Activity Coordinator acknowledged that she was not aware that a care plan had to be completed for activities. During an interview on 08/22/24 at 6:33 AM, the Director of Nursing (DON) stated she did not know that care plans for activities were not being completed for the residents. During an interview on 08/22/24 at 10:53 AM, the Administrator stated activities should be care planned and resident centered. Review of the facility-provided policy titled Care Plans, Comprehensive Person-Centered, revised March 2022 revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 7. The comprehensive, person-centered care plan: . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review and facility policy review, the facility failed to provide a program of activities to support residents in their choice of activities on the weekends for six of six residents (Resident (R) 33, R59, R67, R85, R89, and R102) that attended the group meeting. This failure had the potential to negatively impact the quality of life for the affected residents. The facility census was 117. Findings include: 1. Review of R33's undated admission Record located in the electronic medical record (EMR) in the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R33's Annual Minimum Data Set (MDS) under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 12/11/23, revealed a Brief Interview for Mental Status (BIMS), score of nine out of 15 indicating R33 was moderately cognitively impaired. Further review of the MDS revealed it was very important for R33 to keep up with the news, to listen to music he likes, to do favorite activities, to do things with groups of people, to go outside, and participate in religious activities. Review of R33's quarterly MDS with an ARD of 06/08/24 revealed a BIMS score of 12 out of 15 which indicated that R33 was moderately cognitively impaired. 2. Review of R59's undated admission Record located in the EMR under the Profile tab, revealed he was admitted to the facility on [DATE]. Review of R59's Annual MDS under the MDS tab of the EMR, with an ARD of 11/28/23, revealed a BIMS, score of 15 out of 15 indicating R59 was cognitively intact. Further review of the MDS revealed it was very important for R59 to listen to music he likes, to keep up with the news, to do things with groups of people, and to go outside. Review of R59's quarterly MDS with an ARD of 05/24/24 revealed a BIMS score of 15 out of 15 which indicated R59 was cognitively intact. 3. Review of R67's undated admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R67's Annual MDS under the MDS tab of the EMR, with an ARD of 05/01/24, revealed a BIMS, score of 15 out of 15 indicating R67 was cognitively intact. Further review of the MDS revealed it was very important for R67 to keep up with the news, to do your favorite activities, to go outside, and participate in religious activities. 4. Review of R85's undated admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R85's Annual MDS under the MDS tab of the EMR, with an ARD of 07/13/24, revealed a BIMS, score of 15 out of 15 indicating R85 was cognitively intact. Further review of the MDS revealed it was very important for R85 to have things to read, to do things with groups of people, to go outside and participate in religious activities. 5. Review of R89's undated admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R89's Annual MDS under the MDS tab of the EMR, with an ARD of 01/17/24, revealed a BIMS, score of 12 out of 15 indicating R89 was moderately cognitively impaired. Further review of the MDS revealed it was very important for R89 to have things to read, to listen to music she likes, to do favorite activities, to go outside, and participate in religious activities. Review of R89's quarterly MDS with an ARD of 07/16/24 revealed a BIMS score of 13 out of 15 which indicated R89 was cognitively intact. 6. Review of R102's undated admission Record located in the EMR under the Profile tab, revealed she was admitted to the facility on [DATE]. Review of R102's admission MDS under the MDS tab of the EMR, with an ARD of 12/04/23, revealed a BIMS, score of 14 out of 15 indicating R102 was cognitively intact. Further review of the MDS revealed it was very important for R102 to have things to read, to listen to music she likes, to keep up with the news, to do favorite activities, to go outside, and participate in religious activities. Review of R102's quarterly MDS with an ARD of 06/02/24 indicated a BIMS score of 15 out of 15 which indicated that R102 was cognitively intact. During an interview on 08/20/24 at 10:15 AM, the Activity Coordinator stated the Activity Director resigned and there were only two staff members in the department. The Activity Coordinator confirmed the activity coordinators no longer work on the weekends. The Activity Coordinator stated she left activity packets on the weekends for residents at the nurses' stations which included coloring sheets, puzzles and things to read. During the Group interview on 08/21/24 at 10:35 AM, six residents (R33, R59, R67, R85, R89, and R102) confirmed there were no activities provided on the weekends and they would like evening activities because the evenings were long. The residents stated they have never used the packets that are left for them on the weekends because coloring is not something that stimulated them. The residents also stated a church group came to provide services every other Sunday, but they were not allowed to receive communion because there was no staff at the church service to ensure residents did not choke on the bread, or any diabetics did not drink the juice. During an interview on 08/22/24 at 6:33 AM, the Director of Nursing (DON) stated she was not aware that the activity coordinators did not work on the weekends. The DON also stated she thought communion was being done. During an interview on 08/22/24 at 10:53 AM, the Administrator acknowledged she was aware that the activity coordinators did not work on the weekends, and they alternate schedules for weekends and evenings. Review of the facility-provided documents titled Activity Calendar, dated August 2024, revealed on the 100, 200, 300, 400, and 500 halls activity packets were listed as an activity on 08/03/24, 08/10/24, 08/17/24, 08/24/24, and 08/31/24; Color Away Sunday was listed as an activity on 08/04/24, 08/11/24, 08/18/24 and 08/25/24; and Chapel Service was listed as an activity on 08/11/24 and 08/25/24 at 10:00 AM. Review of the facility-provided policy titled Activity Programs, revised June 2018, revealed Policy statement Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation . 12. Individualized and group activities are provided that: . b. are offered at hours convenient to the residents, including evenings, holidays, and weekends; .

Based on observation, interview, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure one of one clean laundry cart was covered to prevent potential contamination of all residents' in the facility personal items. The facility census was 117. Findings include: Review of the CDC guidance titled Healthcare-Associated Infections (HAI) dated 03/19/24 https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html#:~:text=Each%20floor%2Fward%20should%20have,detergent%20and%20warm%20water%20solution indicated, . Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Observation on 08/19/24 at 10:52 AM, the uncovered clean laundry cart came through the dining room. The laundry cart contained personal items During an interview on 08/19/24 at 11:43 AM, the Housekeeping/Laundry Aide 1 stated she delivered resident laundry to all rooms and has never been told to cover the clean laundry on the cart. During this observation, the cart contained residents' personal items. During an interview on 08/21/24 at 10:25AM, the Director of Housekeeping/Laundry stated she was told not to cover personal laundry only linens. The Director of Housekeeping/Laundry stated the facility outsourced all linens and the facility was only responsible for washing personal laundry. During an interview on 08/22/24 at 11:03 AM, the Administrator stated it was his expectation that residents' personal laundry was covered during transportation from the laundry to the residents' rooms.

Based on observation and interview, the facility failed to provide one of five shower rooms (300 unit shower room) that was functional and had a sanitary environment for residents in the facility. Specifically, the facility failed to ensure that the 300 unit shower room was clean and free of mold and feces on the floor, the shower curtain was free of brown stains, the shower cord did not spray water and the toilet was clean and in good repair. These failures had the potential to affect all residents on the 300 hallway who used the 300 shower room. The facility census was 117. Findings include: Observation on 08/20/24 at 9:53 AM of the shower room at the end of the 300-hall revealed a strong unrecognizable odor. The toilet in the shower room was dirty with stains and was loose from the floor. The shower curtain was heavily soiled. The shower walls had a pinkish/orange and black substance on them. There was a dead bug on the shower room floor. Registered Nurse (RN) 2, Nurse Manager for the 300, 400, and 500 halls, was present during this observation and confirmed the observations. During the Group interview on 08/21/24 at 10:35 AM, six residents (R)33, R59, R67, R85, R89, and R102) stated the shower rooms were nasty especially the 300-hall shower room. The six residents stated there was a pinhole leak in the shower cord and that they would get sprayed in the face during a shower. The six residents stated the shower curtain was dirty with brown stains; the floors were dirty and there were times there was feces on the floor. The six residents stated the inside of the shower has mold and shower floor was not clean. During an interview on 08/22/24 at 6:26 AM, the Director of Nursing (DON) stated she was aware of the 300-hall shower room condition. The DON stated she was unaware of the hole in the shower line spraying the residents. During an interview on 08/21/24 at 2:03 PM, the Director of Housekeeping/Laundry confirmed the 300-hall shower room needed to be scrubbed. The Director of Housekeeping/Laundry stated that the housekeeping staff clean the showers daily. The Director of Housekeeping/Laundry stated she did see black mold. During an interview on 08/22/24 at 11:11 AM, the Administrator stated that the shower rooms should be cleaned prior to each resident use.

Based on observations, interviews and policy review, the facility failed to ensure food was served under sanitary conditions and failed to ensure kitchen equipment were cleaned and stored in a manner to prevent contamination from foreign substances and the potential for development of foodborne illness. Specifically, the facility did not ensure staff used and maintained proper hand hygiene during food service and distribution, as well as failing to clean and maintain ice/water machine and steam table. This deficient practice has the potential to affect 117 of 117 residents who receive meals and beverages prepared in and served from the facility's kitchen. Findings include: On 08/19/24 at 11:38 AM, [NAME] 1 was observed checking the temperature of the food on the steam table prior to lunch service. [NAME] 1 removed the thermometer from her scrubs top and removed the thermometer from its sleeve cover. Without cleaning the thermometer, Cook1 placed the thermometer in the pureed meatloaf. After confirming the meatloaf was at the appropriate temperature, Cook1 removed the thermometer and was provided alcohol wipes by the Dietary Manager (DM). Cook1 was having a difficult time getting an appropriate reading of the pureed bread and asked Dietary Aid (DA1) to assist. DA1 took the thermometer and with her fingers touched the under portion of the head of the thermometer. DA1 pushed the thermometer in the dish until the bottom of the head of the thermometer touched the food. DA1 removed the thermometer and cleaned the thermometer. DA1 approached the steam table, the thermometer slipped from her hand, and she caught it against her right side, with the thermometer resting between her hand and scrubs. DA1 did not clean the thermometer and placed the thermometer into the meatloaf. During the lunch meal service on 08/19/24 at 12:00 PM, DA2 was observed providing drinks to residents in the main dining room. DA2 was utilizing a beverage cart that contained multiple beverage types and an ice chest with a scoop. DA2 offered beverages to residents at 11 tables. During this observation DA2 did not sanitize her hands. DA was observed touching handles of wheelchairs, tables, the beverage cart, and her own scrubs, as she took residents' their drink orders. After touching those items, DA2 was observed grabbing either coffee cups or cold beverage cups from the bottom of the beverage cart, and if the resident requested ice, DA2 would grab the ice scoop that was located inside of the ice chest, place ice in the cold beverage cup and place the ice scoop back inside the ice chest. Residents that requested coffee with cream, DA2 opened each individual creamer and or sugar packet. Observation at 12:29 PM, DA2 without wearing gloves, was observed assisting a resident with a straw. DA2 removed the paper sleeve of the straw and placed the straw in the resident's beverage. During a second dining observation on 8/20/24 at 11:43 AM, [NAME] 2 was observed plating the meal service. [NAME] 2 placed the hamburger on the bun, then the top bun on the burger with her hands, without the use of gloves. The DM, who was present during the meal service, was asked what her expectation was regarding hand hygiene during meal service. The DM stated that staff should sanitize their hands in between residents and to not touch food directly without wearing gloves. Review of the facility policy titled Food Preparation and Service dated November 2022, revealed, Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness Distribution Service .Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. During an observation of the common areas on 08/21/24 of the 400/500 hallway at 8:43 AM and the 100/200 hallway dining at 8:59 AM, revealed ice/water machines that were used to provide residents ice and water on the unit. The ice/water machine on the 400/500 hallways had crystallized whitish-gray and brown debris located on the ice and waterspouts. The chute cover for the waterspout was missing and located on the top of the machine, which was covered in a layer of dust and other debris. The reservoir grate also contained crystallized whitish-gray and brown debris along with dust and other unknown particles. The ice/water machine in the 100/200 hallway dining room revealed the same crystallized whitish-gray and brown debris on the water and ice spouts and chute covers. On the reservoir grate was an uncovered ice scoop that was covered in a yellowish flaky substance. Interview on 08/21/24 at 9:00 AM with Housekeeper (HK)1, he confirmed that housekeeping was responsible for cleaning and maintaining the outside of the ice/water machine daily. He added that the maintenance department was responsible for deep cleaning and maintaining the internal portion of the machine. Interview with the Maintenance Director (MD) on 08/21/24 at 9:11 AM, was asked if he maintained and cleaned the ice/water machines and he stated that he was not sure. In a subsequent interview with the MD, on 08/22/24 at 9:33 AM, he provided a book labeled Ice Machine Maintenance Monthly Log Sheet. Inside the book was a single sheet of paper that contained columns, which were each headed with a hallway followed by a month and year. Besides each date was a staff's initial. During an interview with the Director of Housekeeping and Laundry Services (DHLA) on 08/21/24 at 10:13 AM, she confirmed housekeeping staff is responsible for wiping down the ice/ water machine each evening. She was asked if there was documentation to show that this is done daily, and she stated that she does not have any documentation. Observation on 08/22/24 at 5:49 AM of the ice/water machine in the 400/500 common area revealed crystallized whitish-gray and brown debris located on the ice and waterspouts. The water chute cover was missing and was located on the top of the machine. Interview on 08/22/24 at 6:15 AM, HK2 stated that she is only responsible for wiping the ice machine down and that it is done each morning. Interview on 08/22/24 at 6:22 AM, the Director of Nursing (DON) confirmed that the ice machine in the common area of the 400/500 did not appear as if it had been cleaned weekly. Review of the facility policy titled Ice Machines and Ice Storage Chests dated January 2012 provided by the DON revealed, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. The policy also revealed that the facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. During an observation on of the steam table area on 08/22/24 at 5:51 AM revealed two meal trays on the bar above the steam table. The two meal trays contained soiled plates, cups, silverware, and uneaten food. The counter below the bar top includes cabinets and three sinks. The middle sink contained soiled silverware and the sink to the right contained a large pot. The countertop surrounding the sinks was stained with a whitish substance which could also be seen on and around the faucet. There were also food particles on the counter, on the floor, underneath the steam table and on the steam table. The lids of the steam table along with the compartments were soiled. The water in the five compartments steam table was cloudy and there were visible food particles floating within the water. The base and the side of the compartments were also stained with a whitish substance. During an interview on 08/22/24 at 6:02 AM, [NAME] 2 stated that the nursing staff leaves trays overnight on the bar top, adding that there are usually a lot more items left overnight, and this has led to an issue with pests, specifically ants. When asked what her responsibility was in that area, she stated she is only responsible for the steam table itself. Cook2 advised that she wipes it down daily and adds water to the steam compartments. She stated that the water is usually brown and the area around the steam table was not appropriate for food service. During an interview on 08/22/24 at 7:25 AM, the DM stated that the steam table was cleaned regularly. She added that some of the stains are persistent due to the hard water, but stated the compartments were de-limed weekly. The DM also provided a cleaning schedule that indicated which staff was responsible for a specific item and it indicated the cooks were responsible for the steam table, maintenance is responsible for the ice machines, and all dietary staff are responsible for cleaning sinks, counters, and mopping and sweeping floors.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 94. Record review of the facility's policy titled, Operational Manual, dated September 2013, showed: - It is policy that the dietary department participates in a strict environmental sanitation program; - Staff is trained to properly clean and sanitize all food service equipment in the food service department; - Steam tables, ovens, carts, racks, tables and all other equipment is cleaned and sanitized by Dietary daily; - Cracked China and glassware will be discarded; - Dishwashing procedures and techniques will be carried out as specified by State and local health codes; - Walls, pipes, sinks and fixtures are cleaned routinely with sanitizing compounds by Housekeeping; - Floors are swept by Dietary and mopped by Housekeeping nightly. Floors are also deep scrubbed with scrubber on Mondays and Thursdays; - Ceilings, vents, walk-in cooler and freezer fans, motors on top of fridges and freezers, electrical cords, electric boxes and hood filters are cleaned by Maintenance; - Garbage shall be removed from work stations by Housekeeping after each meal; clean up and more frequently as needed. Record review of the facility's policy titled, Operational Manual, dated October 2016, showed it is the policy of the facility that: - Any food brought into the facility must be in an airtight disposable container (zipper bags, plastic ware type sealed container); - Food must be marked with resident name, room number, labeled, and dated; - Food needing refrigeration must be stored in refrigeration units on hall; - Food that is in resident room is controlled by the resident; - Food must be reheated to 165 for 15 seconds by a Dietary staff member to assure proper temperature; - Food will only be reheated once then discarded; - Food not reheated and used within three (3) days will be discarded from the refrigerator by the dietary department; - Food found not to be in airtight disposable containers or labeled and dated will be disposed of immediately by food service personnel. Record review of an untitled facility policy showed: - Sundays clean all shelves and tables top and bottom; - Wipe down pot holder rack over counter; - Wipe down little table with toaster top, bottom and sides; - Wipe table that holds trays; - Wipe down rack that holds tops and bottoms; - Clean glass rack holders and coffee pot table; - Clean and wipe any food splatters you see on walls; - Mondays clean all fridges and freezers in the kitchen outside and on top edges; - Clean behind stove; - Clean ice machine on top and outside filter, raise lid and clean with bleach water; - Tuesday clean stove, take top off and clean really good; - Pull out shelves, clean and replace foil; - Clean knobs, front and sides of oven; - Pull down shelf over stove and clean; - Wednesdays clean both fast ovens in, out, top and sides; - Tilt skillet top legs and sides; - Thursdays clean cold bar in and out clean over by electric boxes, it likes to gather dust in that corner where the lines go up, make sure it is all dusted on top of electric boxes; - Clean trash cans and any other things you see that needs cleaning because I am sure I have missed things; - Also deep fryer will need pulled out once a month; - Sides and front cleaned but we will have to schedule that; - We will schedule steam tables, fridges etc.; - Clean under stoves, tables, fridges etc.; - If any extra time just clean what you feel needs cleaned and clean all your areas. 1. Observations of the walk in refrigerator on 1/24/23 at 11:08 A.M. showed: - A brown liquid on the floor under the right side food rack. 2. Observations of the dry food storage area on 1/24/23 at 11:10 A.M. showed: - One dented 6 lb. (pound) 10 oz. (ounce) can of pumpkin; - One dented 6 lb. 9 oz. can of sliced beets. 3. Observations of the kitchen on 1/24/23 at 11:15 A.M. showed: - Suspended ceiling (a type of ceiling paneling that hangs below the main structural ceiling) with eleven 2 ft. (foot) x 4 ft. plastic light fixture covers with dust and bug debris inside; - One in. (inch) PVC (Polyvinyl chloride) drain pipe covered with brown and black grime below ice machine; - Floor area beneath commercial gas range covered with food debris and brown grime; - Two, 18 in. frying pans with black grime build-up inside and outside, hung from a rack over a food prep area; - Fourteen assorted spice bottles with gray dust and oily film covered tops sat on shelves above food prep area; - Twenty-six 16 in. x 24 in. x 1 in. deep baking pans with black grime build-up inside the corners, on the cooking surface and outer surfaces; - Commercial dishwasher with white flake build-up outside of door and below dish removal area. 4. Observations of the dining room serving area on 1/25/23 at 3:23 P.M. showed: - The suspended ceiling over dining room steam table with one 2 ft. x 4 ft. panel with a thin layer of gray dust build-up hanging loosely from the edge; - The suspended ceiling over dining room steam table with two 2 ft. x 4 ft. non intact panels. 5. Observations of the kitchen on 1/25/23 at 3:33 P.M. showed: - Floor area beneath commercial gas range was covered with food debris, brown grime, and a chicken strip. During an interview on 1/25/23 at 3:31 P.M., the Dietary Manager (DM) said he/she had attempted to clean under the commercial gas range, but was unable to remove most of the food debris. 6. Observations of the walk in refrigerator on 1/25/23 at 3:36 P.M. showed: - One non intact 1 ft. x 1 ft. CVT (Composite vinyl tile) floor section in front of the door, outside of refrigerator; - Four non intact 1 ft. x 1 ft. CVT floor sections in front of the door, outside of the walk in freezer; - Floor covered in brown grime in front of the door, outside the refrigerator; - Two 1 ft. x 1 ft. plastic ventilation louvers inside the refrigerator with dust between the grids; - Two yogurt cups, one chocolate shake, a large onion peeling and food debris on the floor below food shelving. 7. Observations of the 200 hallway refrigerator on 1/25/23 at 3:55 P.M. showed: - The lower shelf with pink grime build-up; - One cardboard one half pt. (pint) milk container dated 1/23/23; - Three cheese sandwiches dated 1/21/23 on a plate with an opened clear plastic wrapper; - Two bologna sandwiches wrapped in clear plastic dated 1/20/23. 8. Observations of the 200 hallway ice and water dispenser on 1/25/23 at 3:57 P.M. showed: - The machine's outer surfaces with a white grime build-up; - The floor below the ice and water dispenser with white grime build-up. 9. Observations of the 300 hallway refrigerator on 1/26/23 at 9:22 A.M. showed: - A lower shelf with brown grime build-up; - An enclosed butter storage area with three bologna and cheese sandwiches wrapped in clear plastic dated 1/20/23. 10. Observations of the 300 hallway ice and water dispenser on 1/26/23 at 9:24 A.M. showed: - Dispenser cup holder with white and brown grime build-up in the drain area; - The machine's outer surfaces with a white grime build-up. 11. Observations of the kitchen on 1/26/23 at 4:03 P.M. showed: - Conveyor toaster with black grime build-up along the edge of bread rack; - Thirteen, twelve cup muffin baking pans with brown grime build on the cooking surface; - One 8 ft. x 30 in. section of wooden butcher block food prep counter with deep knife scrapes filled with black grime; - Eight small stainless steel drawers with greasy film on outer surface above butcher block food prep counter. 12. Observations of the dry food storage area on 1/27/23 at 9:40 A.M. showed: - Five individual jelly packs, one raw onion and one snack sized container of cheese puffs on the floor below food racks. 13. Observations of the 300 hallway refrigerator on 1/27/23 at 9:25 A.M. showed: - An enclosed butter storage area with two bologna and cheese sandwiches wrapped in clear plastic dated 1/20/23. During an interview on 1/27/23 at 9:42 A.M., the (DM) said the facility has a three day limit on leftover food items placed in refrigerators. He/she said all dietary staff should follow facility policies. He/she said that other staff should be throwing away food that is left in the snack refrigerators. He/she said that ceiling areas should be clean and intact above any food service areas including the dining room. He/she said that kitchen appliances and machines should be clean. He/she said that gas range has a grease trap that should have been emptied. He/she said the grease trap overfilled and spilled into the floor below the gas range, creating a grease problem that is difficult to clean. He/she said there should be no food debris on the floor below food storage racks in the dry food storage area or walk in refrigerator. He/she said that light fixture covers should be clean. He/she said that all cookware should look clean and not have dark colored build up. He/she said baking pans will be thrown out if they can't be cleaned. During an interview on 1/27/23 at 9:51 A.M., Dietary Aide A said that some leftover foods are kept for seven days except egg salad or anything with mayonnaise. He/she said there should be no dented cans in the dry food storage area and all floors should be clean. He/she said refrigerators should be clean and no expired foods should be inside. He/she said the dry food storage area should be cleaned weekly and trash should be picked up if there are spills in between scheduled cleanings. He/she said ceilings should be clean in the kitchen and food service areas. He/she said that appliances should be clean on all surfaces and the floor should be clean below the gas range and under shelves. He/she said that pans and cookware should be clean. During an interview on 1/27/23 at 11:38 A.M., the Administrator said he/she expects staff to follow policy and keep the kitchen clean. He/she said the dry food storage area should be clean and no dented cans should be on the shelf. He/she said that all refrigerators should be clean and no expired foods should be left inside. He/she said the ice and water dispensers should be clean. He/she said the facility has a hard water problem. He/she would expect left over food to be thrown out after three days. He/she said light fixture covers and ceiling tiles should be clean and intact over food service areas. He/she said that baking sheets and other cookware should be clean with no build up. He/she said that the kitchen counter tops should be clean and intact.

Based on observation and interview, the facility failed to ensure the garbage dumpster and trash receptacles were covered for four of four days of observation. The facility census was 94. 1. Observation of the kitchen on 1/24/23 at 12:50 P.M. showed one uncovered trash receptacle partially full of refuse near the hand washing facility. 2. Observation of the dumpster area on 1/25/23 at 2:31 P.M. showed one 40 yd. (yard) compactor dumpster (a machine or mechanism used to reduce the size of material or bio mass through compaction) partially filled with trash bags that were full of refuse in the opened collection area of the dumpster. 3. Observation of the dining room serving area on 1/25/23 at 3:22 P.M. showed one uncovered, brown, 13 gal. (gallon) trash receptacle partially full of refuse beside the steam table. 4. Observation of the dumpster area on 1/26/23 at 9:34 A.M. and 1:05 P.M. showed the following: - One 40 yd. compactor dumpster with trash bags full of refuse in the opened collection area of the dumpster; - One 40 yd. compactor dumpster with trash bags full of refuse and a couch in the opened collection area of the dumpster. 5. Observation of the kitchen and dining room serving area on 1/27/23 at 9:29 A.M. showed the following: - One uncovered, brown, 13 gal. trash receptacle partially filled beside the steam table; - Three uncovered 32 gal. trash receptacles partially filled; - Two uncovered trash receptacles partially filled near the hand washing facility. 6. Observation of the dumpster area on 1/27/23 at 11:33 P.M. showed one 40 yd. compactor dumpster filled half way with trash bags that were full of refuse in the opened collection area of the dumpster. During an interview on 1/25/23 at 3:15 P.M., the Dietary Manager said facility staff are supposed to compact the trash every time it is placed in the opened area of the dumpster. He/she said trash receptacles should be covered in the kitchen and dining area near the steam table. During an interview on 1/26/23 at 1:10 P.M., the Building Operations Manager said the opened area of the trash dumpster is normally left open all day and night. He/she said this is due to most facility staff not being trained to engage the compactor ram so it may be left in a closed position to seal facility trash inside the dumpster. He/she said he/she was not aware it was a requirement to close the dumpster. During an interview on 1/27/23 at 11:38 P.M., the Administrator said that trash bags left in the opened receiving area of the dumpster hasn't caused a problem in the past. He/she said that OSHA (Occupational Safety and Health Administration) inspectors required the facility to place warning signs on the chain link fence and gate that surrounds the front entrance to the dumpster. He/she was not aware that trash cans in the kitchen near the staff hand washing stations should be covered. He/she said that trash cans in other areas of the kitchen and near food service areas should be covered. The facility failed to provide a policy.