Based on observation, staff interview, and operational requirement review, the facility failed to ensure routine monitoring and record keeping of the wash and rinse cycle requirements for the dishwasher to ensure the dishes were properly sanitized and disinfected. This had the potential to affect the one resident residing in the facility at the time of the survey. The facility census was one. Findings include: Observation on 07/31/23 at 9:05 A.M. of the dishwasher operation revealed the wash cycle was 122 degrees Fahrenheit (F), the rinse cycle was 128 degrees F, and the test strip results were 100 parts per million. Observation on 07/31/23 at 9:09 A.M. of the temperature/sanitizer log revealed there was an area to document the wash temperature, rinse temperature and strip parts per million (PPM) and initials. There was no temperatures logged for the wash or rinse cycles for April, May, June or July 2023. This was verified with Kitchen Coordinator #10. Interview on 08/01/23 at 7:29 A.M. with Dietary Manager #14 revealed he was unaware the temperatures needed to be monitored and recorded for the dishwasher. He stated staff education would be provided to ensure temperatures were taken and recorded moving forward. Review of the dishwasher operational requirements revealed the wash and rinse cycle each required 120 degrees F temperature minimum.

Based on observation, resident and staff interview, and medical record review, the facility failed to follow up on recommendations from the physician. This affected one (#56) of four reviewed. The census was four. Findings include: Review of Resident #56's medical record revealed an admission date of 02/07/20. Diagnoses included depression, peripheral artery disease, vitamin D deficiency, chronic kidney disease, insomnia, and chronic diastolic heart failure. Review of a physician order dated 02/09/20 revealed Resident #56 was ordered a basic metabolic panel (BMP) blood test. Review of results of the BMP revealed Resident #56's blood glucose was elevated measuring 126 milligrams per deciliter (mg/dL). The facility laboratory set a normal range for blood glucose levels between 74 and 99 mg/dL. Review of a physician visit progress note dated 02/09/20 revealed the physician identified Resident #56 with a focused problem area of type two diabetes mellitus with peripheral neuropathy and documented Resident #56 would be placed on rapid blood glucose finger checks (Accu-Cheks) with insulin coverage. The progress note was signed by the physician on 02/09/20 at 11:54 A.M. Review of Resident #56's medical record between 02/10/20 and 02/12/20 revealed no further blood glucose laboratory values and no finger stick blood glucose levels were obtained, no physician orders were initiated for Accu-Cheks or insulin, and no additional progress notes were documented related to the physician's recommendation for Accu-Cheks with insulin coverage. Review of a progress note dated 02/12/20, written by Registered Nurse (RN) Clinical Coordinator #100, revealed the physician was contacted for clarification of his recommendation on 02/09/20 for Resident #56 to have Accu-Cheks and insulin, and the physician verified he wanted Resident #56 on a medium dose sliding scale insulin with Accu-Cheks before meals and at bedtime. Observations on 02/10/20 at 7:52 A.M., at 10:49 A.M., at 2:21 P.M.; on 02/11/20 at 1:03 P.M., 2:39 P.M., and at 3:52 P.M.; and on 02/12/20 at 8:24 A.M. revealed Resident #56 was calm and free from distress. Resident #56 did not display any lethargy or signs of an altered mental state, and her overall health condition remained unchanged. Interview on 02/11/20 at 4:02 P.M. with Resident #56 stated she had no concerns about the current status of her health and verified she had not experienced any significant changes with her health since she was admitted to the facility. Interview on 02/12/20 at 9:49 A.M. with RN Clinical Coordinator #100 verified the physician intended to start Resident #56 on Accu-Cheks with insulin coverage, but forgot to initiate an order for it. RN Clinical Coordinator #100 stated the physician wanted to monitor Resident #56's blood glucose levels to make sure they were not going too high.

Based on observations, staff interview, and review of the manufacturer's recommendations/facility policy, the facility failed to ensure food was properly labeled and stored, and dishes were sanitized in a manner to prevent contamination. This had the potential to affect two (#107 and #108) of two residents who reside in the facility. Findings include: Observations on 12/26/18 at 8:52 A.M. with Food Service Director (FSD) #300, revealed the walk-in freezer contained multiple food items that were expired. The food were as follows: diced chicken (two packs) opened and repackaged in gallon size zip lock bags dated 08/12/18; corn beef wrapped in aluminum foil dated 05/08/18; pastrami (two packs) wrapped in aluminum foil dated 06/07/18; one unidentified food item wrapped in aluminum foil, unlabeled and undated; apple corn bread stuffing opened and repackaged in gallon size zip lock bags dated 01/24/18, ham wrapped in aluminum foil and undated; and one bag of frozen peas, opened and undated. In the reach in freezer there was an opened and undated package of English muffins, and toast was repacked in a zip lock bag dated 12/10/18. In the walk-in refrigerator there were multiple opened and repackaged containers including: chili sauce dated 12/11/18; two opened and repackaged containers of tomato paste dated 12/16/18; pesto sauce opened, repackaged and undated; ketchup opened and repackaged dated 12/15/18; and oyster sauce opened and repackaged dated 12/11/18. In the service area reach-in refrigerators there were three opened and undated packages of cheese. Interview with FSD #300 during the time of the observations, verified all the items noted above were opened and expired or undated. FSD #300 stated he needs to work on dating food. FSD #300 stated the facility practice was to discard opened food after seven days in the refrigerator. Regarding foods in the freezer, FSD #300 stated he discards foods after three or four months but was unsure of the facility policy for the length of time things can be stored in the freezer. FSD #300 further verified the frozen foods noted above should have been discarded. FSD #300 stated the items in the walk-in refrigerator should have been labeled with the manufacturer's expiration date. He also verified both Resident #107 and Resident #108, were served meals from the kitchen. Continued observations revealed the kitchen three-sink dishwashing system was in use. FSD #300 obtained a test strip to check the sanitizer. He dipped the strip in the third sink and held it in the water for the manufacturer's recommended ten seconds. He removed the strip from the water and compared the strip to the package. The strip did not change color. The sanitizer was not at the recommended 200 parts per million (ppm) for effective sanitizing. Interview at the time of the observation revealed FSD #300 verified the dietary staff were currently washing dishes in the three sinks dish system. FSD #300 stated the three sink dish system used Quaternary solution for dish sanitizing. FSD #300 verified the Quaternary solution did not meet the minimum of 200 ppm for effective dish sanitation. Further interview with FSD #300 on 12/26/18 at 10:02 A.M., stated the facility policy does not address dating opened food. Review of the facility policy titled, Food Storage, revised 07/16, revealed foods must be protected from contamination, spoilage and other damage during storage. Foods stored in refrigerators should be covered, labeled and dated. All frozen foods should be labeled and dated. Review of the manufacturer's instructions revealed the Quaternary solution must be 200 ppm concentration for effective dish sanitizing. Review of the Quaternary test strip instructions, revealed the proper testing method was to dip a test strip in the water and hold it for ten seconds. Remove the strip from the water and immediately compare the color.