Based upon observation, record review, and interviews conducted during the recertification survey on 7/31/2023 - 8/4/2023, the facility did not ensure that the garbage storage area was maintained in a sanitary condition. Specifically, the ground under the loading dock located near the door to the trash compactor was heavily littered with solid debris including two (2) treatment items labeled with personal health information. The findings are: An Environmental Services (ES) policy and procedure dated 12/2008 and titled Non-Hazardous Waste Removal documented the policy is To remove all trash from the facility in a safe and sanitary condition., and the purpose is To provide residents, staff, and visitors with a sanitary and comfortable environment and endeavor to prevent the development and transmission of infection. Procedures included that assigned housekeeping staff collect trash per schedule removing and sealing the clear plastic liners from each wastebasket, each sealed plastic liner is placed in a large trash bin on wheels, the trash is wheeled to/emptied into a dumpster at least twice each day and more frequently as indicated, and the dumpster is removed/replaced every 10-14 days. Observation on 8/02/2023 at 11:39 AM revealed that the ground area under the the loading dock located near the door to the trash compactor was heavily littered with solid debris inclusive of: a. 13 oral syringes in a variety of sizes ranging from 4 milliliters to 20 milliliters which had been used as evidenced by no substance observed in the oral syringes and the black stopper was at the top of the syringes. b. One approximately 12 inch length of clear tubing with a white connector attached. c. One approximately 24 inch length of red tubing with a green connector attached. d. An opened plastic bag labeled Piston enteral feeding syringe which was labeled with personal health information (residents' name) e. One empty 50 ml bottle of sodium bicarbonate injection without a stopper. f. One empty 2 oz. tube of desitin labeled with personal health information (residents' name) g. One capped 100 ml, half filled bottle of sterile saline. h. A variety of snack food wrappers and plastic utensils. During interviews on 8/02/2023 at 11:52 AM and 12:21 PM, the Director of Environmental Services (ES) stated that none of the debris should have been on the ground, the ES department was responsible for checking and cleaning up after themselves each time staff get rid of garbage, it is everyone's job, and there were no scheduled rounds or logs for monitoring the trash compactor area for cleanliness. During an interview on 8/02/23 at 11:59 AM the Lead Environmental Worker stated that they were responsible to check the compactor area daily by 9AM, and today when they checked they did not look at the the area under the loading dock. During an interview on 8/2/2023 at 1:25 PM the Director of Nursing (DON) stated that the red tubing and clear tubing are suctioning catheters which are used either orally, through the tracheostomy tube, or nasally, and the tubing should be discarded in the regular garbage. DON stated that housekeeping is responsible to tie the bags of garbage, and the tubing may have been on the ground if the bag was not closed properly. DON stated that any medication or treatment items labeled with identifying resident information should have a de-identifier label sticker, which will obliterate the personal information, before being discarded in the regular garbage. 415.14(h)

Based upon observation, interview, and record review conducted during the recertification survey on 7/31/2023 - 8/4/2023, the facility did not ensure that foods were stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1. unwrapped, uncooked ground beef was stored in a walk-in refrigerator, 2. an unsecured chest freezer located in a hallway near the kitchen contained foods intended for consumption by residents which were not labeled with expiration dates or use by dates, and 3. A dietary staff member was observed checking food temperatures prior to meal service and did not properly sanitize the thermometer. The findings are: During the initial and follow up tours of the kitchen on 7/31/2023 at 9:33 AM and on 8/2/2023 at 10:55 am the following were observed: 1. Observation on 7/31/23 at 9:57 AM revealed approximately one pound of ground beef stored in a walk in refrigerator. The ground beef was not adequately wrapped, and one side of the beef was open to the air and to contamination. In an interview conducted at that time the Food Service Supervisor (FSS) stated that the ground beef should have been fully covered so that it did not drip into other foods, so other foods do not fall into it, and to prevent cross contamination. 2. Observation on 8/02/23 at 10:55 AM revealed a large chest freezer was found located in the hallway near the kitchen. Signage on the chest freezer documented: Emergency Kitchen Supply: Please do not touch/open. The chest freezer was unsecured and easily accessible. In an interview on 8/02/23 12:29 PM the Food Service Director stated that the food service supervisor was responsible for: a. the use of the chest freezer, and b. for managing the contents of the chest freezer. At that time the contents of the chest freezer which were intended for use by residents were checked and revealed the following: a. Thirty-six (36) 4-6 oz. containers of kosher puree chicken with a received date of 7/13/2023 were not labeled with a use by or expiration date. b. Thirty-six (36) 4-6 oz. containers of kosher puree chicken with a received date of 7/26/2023 were not labeled with a use by or expiration date. In an interview on 8/2/2023 at 12:32 PM the FSS stated that the chest freezer is currently being used for freezer overflow and contained some kosher foods used for the residents in that building. The FSS stated that the unit is not locked and should be locked to prevent anyone from tampering with the food. The FSS stated they did not have any documented monitoring of the freezer to ensure it is secured against tampering. The FSS stated that they are responsible to ensure all foods in the freezer are labeled with the date the food item was received, name of the food item, and the expiration date/discard date of the item. In an interview on 8/2/2023 at 1:12 PM the FSD stated that they need to do a better job of determining expiration dates, and discard the items on that date. 3. A facility policy and procedure dated 12/2022 and titled Food temperature documented Method for measuring temperatures: a clean, rinsed, sanitized and air-dried thermometer .is needed. Observation on 8/04/23 at 11:57 AM revealed the Dietary Aide checking food temperatures prior to meal service for the six (6) residents receiving meals. The Dietary Aide was observed dipping the probe tip of the thermometer into a cup of water and wiping the probe dry with a paper napkin. Surveyor stopped the Dietary Aide before they could proceed to insert the probe into the food. In an interview at that time the Dietary Aide stated that they dip the thermometer into the warm water to kill the bacteria, and then wipe with a paper napkin to wipe the water or excess food from the thermometer. 415,14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure that food brought in from the outside was handled according to professional standards of practice. Specifically, food items found in the refrigerators on resident units were either outdated or not labeled and dated. This was evident on 2 of 8 resident units ([NAME] Park and [NAME] Park). The findings are: Leftovers and Food Safety Often when we cook at home or eat in a restaurant, we have leftovers. To ensure that leftovers are safe to eat, make sure the food is cooked to a safe temperature and refrigerate the leftovers promptly. Not cooking food to a safe temperature and leaving food out at an unsafe temperature are the two main causes of foodborne illness. Safe handling of leftovers is very important in reducing foodborne illness. Follow the USDA Food Safety and Inspection Service's recommendations for handling leftovers safely. Store Leftovers Safely Leftovers can be kept in the refrigerator for 3 to 4 days or frozen for 3 to 4 months. Although safe indefinitely, frozen leftovers can lose moisture and flavor when stored for longer times in the freezer. https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/leftovers-and-food-safety/ct_index Refrigerators on resident units were checked on 9/23/19 between 1:30 and 2:00PM. On the [NAME] Park unit a container of homemade soup was dated 9/16/19 (7 days old). The RN unit manager was interviewed at that time. He stated food from the outside can be kept for about a week. When asked about the policy for keeping food from the outside he produced a Policy and Procedure - Food from Outside that indicated the following; All food/homemade tube feeds in refrigerator will be discarded after 5 days by Environmental Services. In an interview with the Director of Environmental services at that time he stated his staff are aware of how long food can be kept but they do not discard any of the food. He stated they are instructed to bring it to the attention of the nursing staff. The refrigerator on the [NAME] Park unit was checked on 9/23/19 at 2:00PM. Two containers of food brought in from home for a resident were not dated. The resident's father was present at the time and stated he thought the food had been brought in over the previous weekend. In an interview with the Food Service Supervisor on 9/23/19 at 2:15PM she stated that food should be labeled and dated and discarded after 3 days. In an interview with the Director of Nutrition Services on 9/23/19 at 2:30PM she stated there have been a lot of issues related to food brought in by families that was discarded by nursing staff when outdated. The policy was updated to have Environmental Services discard the food to avoid conflict with the families. She was unaware that this was not being done. 415.14(h)