**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 08/15/24, the facility provided an acceptable IJ Removal Plan which included the following: Inservice was completed on 08/13/24, to 100% of the dietary staff by the Staff Development Coordinator on CMS guidelines. Refrigerator temperatures are to be maintained at 41F. Freezer temperatures are to be maintained at 0F. Temperatures are to be recorded: first shift, midday, and end of second shift. If any temperatures do not fall within guidelines, the supervisor is to be notified and use emergency food supply. Do not use food from equipment that does not meet regulatory temperature. A new refrigerator and freezer temperature log were created, specific instructions were placed on the logs regarding required temperature and actions to take if temperature does not meet regulation. 100% present of staff were in-serviced under the new temperature log on 08/13/24. New logs were implemented on 08/13/24. Facility recognizes that all residents have the potential to be affected by this deficient practice. Measures put into place to ensure that this deficient practice does not occur again include the following: education to dietary staff on proper storage and maintenance of food will be provided upon hire and annually. Dietary staff will be required to complete an annual competency on these requirements. Education was provided to staff on taking food temperatures prior to servicing and recording with every meal. Unannounced observations of temperature logs will be conducted by the Administrator, Dietary Manager, and Registered Dietician. Dietary Manager was re-educated on 08/13/24 on the maintenance system which identifies maintenance needs in all departments. Monitors to be put in place to ensure the deficient practice does not reoccur include new temperature logs were created and implemented. Re-education on the maintenance system and unannounced observations. The Dietary Manager will be informed of any adverse findings, re-education will be provided. Results of these audits will be brought to the Quality Assurance and Performance Improvement (QAPI) committee monthly for the next months and quarterly thereafter until the issue is deemed to require no further review. Other actions taken include: A contracted refrigeration repair service was called to the facility and repairs were provided on 08/12/24 and 08/13/24. All refrigeration equipment in the facility was checked by contracted refrigeration technician. All food in the effected freezer and refrigerator was discarded. Emergency food supplies were utilized until the new refrigerator was installed and brought to proper temperature. Temporary refrigerator was purchased and installed on 08/13/24. The facility obtained new perishable food and placed them in the new refrigerator until food supplies are delivered from distributor on 08/14/24. Based on observation, interview, review of facility policy, and review of the Centers of Disease Control (CDC) recommendation for Food Safety, the facility failed to ensure that food items were properly stored and maintained below 41 Degrees Fahrenheit (F) to reduce the potential of foodborne illnesses. The facility further failed to ensure that monitoring of kitchen equipment (refrigerators and freezer) was completed accurately for 1 of 1 kitchen. On 08/13/24 at 1:30 PM, the Administrator was notified that the failure to ensure food items were properly stored and maintained below 41 Degrees Fahrenheit (F) and the failure to ensure the monitoring of kitchen equipment was completed accurately constituted Immediate Jeopardy (IJ) at F812. On 08/13/24 at 1:30 PM, the survey team provided the Administrator and Director of Nursing (DON) with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 08/09/24. The IJ was related to §483.60 - Food and Nutrition Services. On 08/15/24, the facility provided an acceptable IJ Removal Plan. On 08/15/24 at 11:50 AM, the survey team validated the facility's corrective actions and removed the IJ as of 08/15/24. The facility remained out of compliance at a scope and severity level of F. Findings include: Review of the facility policy titled, Food Storage revealed, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and by methods designed to prevent contamination. Procedures include, Temperature for refrigerators should be 41 degrees F and below. They must be recorded daily. Every refrigerator must be equipped with an internal thermometer. Cooked foods must be stored above raw foods to prevent contamination. Freezer temperatures: Temperatures for freezer be 0 degrees or below and must be recorded daily. Holding temperature for frozen foods is 0 degrees or below. Frozen meats must be defrosted in a refrigerator on tray on a lower shelf. Every freezer must be equipped with an internal thermometer, even if equipped with an external thermometer. Chemicals must be clearly labeled, kept in original containers when possible, and kept in a locked area away from food. Review of the facility policy titled Hair Restraints revealed, Hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table. Procedures include, Staff shall wear restraints in all food production, dishwashing and serving areas. Hair restraints, hats, and or bear guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged, any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. Review of the facility policy titled Refrigerator and Freezer Temperatures revealed, A food item is selected, and the temperature is taken. If this is the first check of the day, and the food item(s) are below 41 F and cannot be validated to have been below 41 F for less than four hours, the food is discarded. If this is a visual check during normal operating hours, and the food is below 41 F the staff member will validate if it has been in the danger zone for four or less the product is moved to another refrigerator/freezer and monitored to cool to proper temperature within four hours. If the food is below 41F the unit will be emptied and the food stuff transferred to another refrigerator/freezer and the unit locked out/tagged out per facility policy. Food stuff will be transferred back into the refrigerator/freezer until it is repaired and returned to service or until the temperature reaches and maintains the appropriate temperature. Review of the Centers of Disease Control (CDC) recommendation for Food Safety revealed, CDC Steps to Food Safety . Prevention Steps and Strategies dated April 29, 2024 revealed, Chill: refrigerate promptly. Bacteria can multiply rapidly if left at room temperature or in the Danger Zone between 40°F and 140°F. Never leave perishable food out for more than 2 hours (or 1 hour if exposed to temperatures above 90°F). Keep your refrigerator at 40°F or below and your freezer at 0°F or below and know when to throw food out before it spoils. If your refrigerator doesn't have a built-in thermometer, keep an appliance thermometer inside it to check the temperature. Package warm or hot food into several clean, shallow containers and then refrigerate. It is okay to put small portions of hot food in the refrigerator since they will chill faster. Refrigerate perishable food (meat, seafood, dairy, cut fruit, some vegetables, and cooked leftovers) within 2 hours. If the food is exposed to temperatures above 90°F, like a hot car or picnic, refrigerate it within 1 hour. Thaw frozen food safely in the refrigerator, in cold water, or in the microwave. Never thaw food on the counter because bacteria multiply quickly in the parts of the food that reach room temperature. During an initial tour of the kitchen on 08/12/24 at 10:43 AM, the dry food storage revealed the following: 1-108 oz (once) dented can of corn beef hash. 1-105 oz dented can of sliced carrots. 1-92 oz box of instant mashed potatoes on the floor. 14 boxes of [NAME] oatmeal with a best by date of 07/27/24. 1-25 lb (pound) box of premium parboiled rice opened, with no open date and not sealed. 2-10 lb boxes of lasagna noodles open, not sealed or labeled with an open date. 2-10 lb bags of penne pasta open and not labeled. 1-16 oz box of raisins opened and not sealed. 5-16 oz boxes of raisins with a best by date of 08/09/23. 2-10 lb packages of spaghetti noodles opened, not sealed, and not labeled. 1 package of 5 burrito wraps opened with no open date and not sealed. Sugar bin not labeled and no scoop. During an observation and interview with the Dietary Manager (DM) on 08/12/24 at 10:50 AM, the walk-in refrigerator revealed the internal thermometer temperature reading at 60 F. Further observation revealed the refrigerator ceiling fans motor cover has ice accumulated on its surface and was actively defrosting, with a black substance coating the pipes connected to the fan. The DM revealed that the veggie walk-in refrigerator had been down but came back up today. The DM states that they receive deliveries three times a week and staff check for outdated items in the refrigerator once a week. During an observation on 08/12/24 at 10:55 AM, of the walk-in refrigerator revealed the following food items that were expired/not properly labeled and or stored: 2-5 lb containers of cottage cheese with a best by date of 07/29/24. 1-5 lb container of cottage cheese with best by date of 07/01/24. 2-10 lb boxes of macaroni salad with a use by date of 08/11/24. 7 prepared bowls of salad not dated. During an observation on 08/12/24 at 11:37 AM, of the meat freezer, revealed a puddle of water on the floor and approximately 40 boxes of food items actively defrosting, with some boxes having water damage and dripping with water. Further observation revealed the following food items were not properly stored 3 bags of garlic bread opened with no open date. 4-4 lb bags of sweet peas not properly stored. 2-5 lb bags of white diced chicken meat not properly stored. Further observation of the meat freezer revealed the internal thermometer was unreadable, the outside digital thermometer displayed an error code (APn6). The temperature log for the meat freezer for 08/12/24 documented, -3 F. During an interview with the DM and Maintenance Manager on 08/12/24 at 11:55 AM, revealed the first shift cook checked the meat freezer temperature when she arrived this morning. There were no issues with the temperature. The DM further explained that there is more food in the meat freezer due to the veggie freezer being down and that there is never usually any water on the floor. During the interview the Maintenance Manager stated, I think they had the door open for a long period of time. During an observation and interview on 08/12/24, during the lunch meal prep, revealed Kitchen Staff (KS)1 prepping food without a beard restraint. KS1 stated that male staff are expected to wear beard restraints when prepping food. KS1 put on a beard guard after the interview. During a follow up interview with the DM on 08/12/24, revealed that staff members are expected to cover all hair, including facial hair. During an observation on 08/12/24 at 1:00 PM, the stand-up freezer revealed an internal thermometer temperature of 52 F and the external thermometer gauge reading at 43 F. During an observation on 08/12/24 at 1:01 PM, the ice cream freezer revealed an internal thermometer temperature of 52 F and the external thermometer gauge reading at 43 F. During an observation on 08/12/24 at 1:10 PM, the walk-in cooler revealed the internal thermometer reading at 50 F and the external thermometer gauge reading at 43 F. Review of the temperature log for the meat walk-in freezer for August 2024, revealed the following: 08/12/24 the morning/AM temperature was documented at -3 F. 08/01/24 - 08/12/24 the afternoon/PM logs were incomplete. Review of the temperature log of the stand-up freezer for August 2024, revealed missing initials for morning/AM temperature checks on 08/07/24 - 08/12/24. Review of the temperature log for the ice cream freezer for August 2024, revealed the following: 08/09/24 - 08/12/24 missing morning/AM documentation. Review of the temperature log for the veggie freezer for August 2024, revealed the following: 08/01/24 no morning documentation; afternoon/PM (DOWN). 08/02/24 no documentation. 08/03/24 no morning documentation; afternoon/PM (DOWN) 08/04/24 no afternoon/PM documentation. 08/07/24 no morning/AM documentation. 08/08/24 no documentation. 08/09/24 no morning documentation; afternoon (DOWN). During an interview on 08/12/24 at 1:51 PM, the DM revealed there were no issues with neither the refrigerator nor freezers this morning. The DM continued to explain that when there is an issue, kitchen staff notifies them immediately and they call maintenance. During an interview on 08/12/24 at 1:55 PM, the 2nd Shift [NAME] revealed today's dinner will be a cold plate with deli sandwiches, macaroni salad and cucumber salad with an alternative of patty melts, scallop potatoes, and carrots. The 2nd Shift [NAME] stated they only had to prepare the sandwiches, patty melts and scallop potatoes. The 2nd Shift [NAME] further stated the macaroni salad and cucumber salad were prepared yesterday, we usually prepare those items a day in advance. The 2nd Shift [NAME] concluded temperatures for the refrigerators and freezers were already completed when they arrived to work today and they check them and document them daily at night before the they leave. During an interview on 08/12/24 at 1:59 PM, the Maintenance Director revealed they were unaware of any issues with the refrigerator/freezer, and there were no issues earlier this morning. During an observation on 08/12/24 at 2:11 PM, revealed the walk-in cooler internal thermometer reading at 55 F. During this observation, a green sanitizing bucket was observed next to a container of sliced cucumbers and boiled eggs. Additionally, there was a moist towel above the container storing boiled eggs. During an observation on 08/12/24 at 2:22 PM, revealed the stand-up freezer internal thermometer temperature at 30 F. The vegetable freezer revealed an internal thermometer temperature of 30 F. During a phone interview on 08/12/24 at 2:32 PM, the 1st Shift [NAME] stated, I check freezer and refrigerator temperatures when I use them. The 1st Shift [NAME] further stated the freezer on the porch wasn ' t' freezing well and staff noticed the issue on Friday [08/09/24], they had to throw away a few wet boxes because they were defrosting in the freezer. The 1st shift [NAME] recalled throwing away food yesterday [08/11/24], due to the defrosting food items. The 1st Shift [NAME] concluded they notified the DM about the freezers and was told that it was reported to Maintenance Staff. During a phone interview with the Registered Dietician (RD) on 08/12/24 at 2:56 PM, revealed the RD was made aware of the kitchen equipment (cooler/freezer) not reaching an adequate temperature of 41 F or below. The RD stated that she recommended the facility use the emergency food supply for the dinner meal to ensure foods will be stored/served at the appropriate temperature. During an observation and interview with the DM on 08/12/24 at 3:22 PM, revealed the kitchen staff plan to serve cold items as planned since cold items were prepared prior to the refrigerator/freezers malfunction. Additionally, the DM revealed the cold food items have been placed into the veggie cooler to cool down. The DM stated that the menu for the dinner meal is deli sandwiches, macaroni salad, cucumber salad, scallop potatoes, carrots, and bean salad. The DM stated the macaroni salad and cucumber salad were prepared in advance, and the carrots and bean salad were from the canned goods/emergency supply. The concluded tomorrow's meal (08/13/24) would be changed due to the lack of working equipment and that the food items would come from the facilities emergency supply. During an observation of the walk-in cooler, where the macaroni salad and cucumber salad were stored, revealed the internal thermometer temperature of 55 F. During an interview on 08/12/24 at 4:08 PM, the Administrator revealed they were made aware of the issues in the kitchen related to the refrigerators and freezer today. The Administrator stated that the cold items that were prepared yesterday such as the macaroni salad and cucumber salad would be served tonight since they were prepared before the appliances malfunctioned and that the facility would serve food from their emergency supply tomorrow, until the temporary portable freezers were delivered to the facility by their food vendor. During an observation on 08/12/24 at 4:32 PM, of the 2nd Shift [NAME] conducting holding temperature checks of the dinner meal, revealed the following: Pasta Salad Puree - 46 F. Deli Meat Puree - 45 F. Macaroni Salad - 68 F. Deli Sandwiches - 58 F. Cucumber Salad - 62 F. All items were discarded after observation. During an interview with the 2nd Shift [NAME] on 08/12/24 at 4:35 PM, the 2nd Shift [NAME] revealed the cold items were prepared the day before and had been sitting in the walk-in cooler all day and was moved into the stand-up refrigerator about an hour ago. During an observation on 08/12/24 at 4:39 PM, revealed the stand-up refrigerator had an internal thermometer temperature of 50 F. During an observation on 08/12/24 at 4:50 PM, revealed the meat freezer had an internal thermometer temperature of 30 F. During an observation on 08/12/24 at 4:51 PM, revealed the stand-up refrigerator had an internal thermometer temperature of 50 F, and the external thermometer gauge reading was 45 F. During an observation on 08/12/24 at 4:53 PM, revealed the walk-in refrigerator had an internal temperature of 52 F. And the veggie freezer revealed an internal thermometer temperature of 20 F. During an observation and interview on 08/12/24 at 5:00 PM, the Administrator was informing them (kitchen staff) the food that was planned for the dinner meal no longer meet the requirements of being served safely according to the CDC standards and federal regulation. The Administrator stated the kitchen staff will not serve that meal and will prepare a different meal using their emergency food supply. During an interview on 08/12/24 at an unspecified time, Resident (R)220 stated, The food is awful, for example the toast is rubbery and scrambled eggs are nasty. I was recently (within the last week but unsure of which day) given spoiled milk and it wasn't expired but the taste and smell was disgusting. R220 further stated that they spoke with someone from the kitchen related to the food and substitutions, and for a few days the food improved. Now, they are serving foods that don't match his preferences. Review of R220's Face Sheet revealed R220 was admitted to the facility on [DATE], with diagnoses including but not limited to: muscle weakness, pain, and lack of coordination. Review of R220's admission Minimum Data Set (MDS) with an Assessment Reference Date of 08/09/24, revealed R220 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicates R220 is cognitively intact. During an interview on 08/12/24 at an unspecified time, R37 revealed their lunch and dinner meal is always served cold. R37 further stated at times they are not able to identify what they are being served and calls it mystery meat. Review of R37's Face Sheet revealed R37 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia without behaviors, muscle weakness, and type 2 diabetes. Review of R37's Quarterly MDS with an ARD of 07/17/24, revealed R37 has a BIMS score of 14 out of 15, which indicates she is cognitively intact. During an observation and record review on 08/13/24 at 9:30 AM, revealed the meat freezer external thermometer was malfunctioning, displaying an error code APn6, the internal thermometer reading was 10 F. Review of the August 2024 Meat Freezer Temperature Log for 08/13/24, revealed a documented temperature of -3 F with no initials for who documented the log. During an observation and record review on 08/13/24 at 9:53 AM, revealed the walk-in refrigerator's internal thermometer temperature reading at 50 F and the external thermometer gauge reading at -40 F. Review of the Walk-In Refrigerator August 2024 Temperature Log, revealed no documentation for the morning log on 08/13/24. During an observation and record review on 08/13/24 at 9:54 AM, revealed the stand-up refrigerator had no food items at this time, the internal thermometer temperature read at 70 F. Review of the August 2024 Stand-Up Refrigerator Temperature Log revealed the log for 08/14/24 was 42 F. During an interview on 08/13/24 at 9:55 AM, the DM revealed the temperature for the stand-up refrigerator was reading 50 F this morning. The DM states she was notified by the first shift cook, who came in at 5:00 AM, of the temperature of the refrigerator when she (DM) came in at 7:00 AM. The DM revealed the food that was in the stand-up refrigerator was moved to a refrigerator on one of the halls and what couldn't fit was discarded. The DM explained the residents were served bacon, sausage and eggs which were pulled from the stand-up refrigerator, along with oatmeal and grits that came from the dry storage for breakfast. During an interview on 08/13/24 at 10:00 AM, the 1st Shift [NAME] revealed for breakfast the residents were served bacon, sausage, eggs, grits, and oatmeal. The 1st Shift [NAME] stated the bacon, and sausage were pulled from the stand-up refrigerator and the eggs came from the walk-in refrigerator. The 1st Shift [NAME] stated the temperatures for the freezers should be -3 F and the refrigerators should be 40 F, I think. The 1st Shift [NAME] further explained, I write down the temperatures that are shown on the outside of the freezers and refrigerators. The 1st Shift [NAME] confirmed that they documented the temperature for the meat freezer this morning was -3 F and the temperature for the stand- up refrigerator was 42 F. When asked if the stand-up refrigerator's temperature was reading 42 F, was that temperature too high to use the food from that refrigerator, the 1st Shift [NAME] responded, No, I don't think it was too high. During an interview with the DM on 08/13/24 at 10:07 AM, revealed the temperatures for the freezers should be below zero and the refrigerator temperatures should be below 40 F or 41 F. The DM further stated that the food from the stand- up refrigerator was moved as fast as possible to a refrigerator on the unit and the rest was thrown away if it couldn't fit. The DM stated for lunch today they will be using the emergency supply and they used liquid eggs and that the food needed for today's breakfast was pulled from the walk-in refrigerator the night before to make it more convenient for the cook to start their prep when they come in. When asked if the food from the stand-up refrigerator, which had a temperature of 42 F, should have been used to serve the residents, the DM replied, probably not. During an observation on 08/13/24 at 11:27 AM, the 1st Shift [NAME] and DM, during the lunch meal temperature observation, revealed the following items not at the appropriate temperature and were discarded: Milk - 44 F. Cranberry Juice - 47 F. Mighty Shake (nourishment drink) - 46 F. Further observation and interview with the DM revealed that those drinks were pulled from the walk-in cooler. During observation of the walk-in cooler, the internal thermometer temperature had a reading of 55 F. The DM confirmed that the temperature in the refrigerator was higher than recommended. During an observation and interview on 08/13/24 at 12:00 PM, of the refrigerator in the Therapy Room on the Peach Unit revealed the food that was moved earlier from the stand-up refrigerator in the kitchen. Further observation revealed a pan of scrambled eggs, 1 pan of sausage, 1 pan labeled pureed bacon, 1 pan labeled pureed meat, and a bag of salad mix. The DM revealed that deliveries are received on Monday, Wednesday, and Friday. An order was placed on Monday and a delivery will come on Wednesday, they will place an order on Wednesday to replenish the emergency supply. The internal temperature of the Therapy Room Refrigerator was at 41 F, there was no documentation related to daily logs of the temperature for this refrigerator. During an interview on 08/13/24 at 1:25 PM, the 1st Shift [NAME] revealed they documented the temperatures for the refrigerators and freezers by reading the external thermometer. During the interview the survey team asked how they were able document the temperature of the meat freezer due to the error code and they stated that they were unsure. During an observation on 08/14/24 at 11:20 AM, of the lunch meal temperature check revealed the temperature of the toss salad was 71 F, and was discarded after observation. During an observation and interview on 08/14/24 at 5:50 PM, revealed the walk-in cooler had an internal thermometer temperature of 47.5 F. The DM confirmed the current temperature of the walk-in cooler was out of compliance. The DM further stated the food in the walk-in cooler was delivered earlier in the morning and the food would have to be discarded. During an observation on 08/14/24 at 6:00 PM, the Administrator was informing the kitchen staff that the Immediate Jeopardy is still on-going due to the non-compliance in the kitchen because of improper temperatures in the walk-in cooler. The Administrator further informed the kitchen staff the shipment that arrived earlier would have to be discard. During an observation and interview on 08/15/24 at 11:46 AM, the Walk-In Cooler, Meat Freezer, and Stand- Up Refrigerator (all malfunctioning) were empty. The Veggie Freezer read 0 F. Observation of the Temporary Refrigerator revealed an internal temperature of 40 F (observation during lunch time and staff using this fridge to prep). The DM revealed that all food being prepped is coming from the Temporary Refrigerator and Veggie Freezer.