Every finding on record at Corona Regional Medical Center D/P SNF

Based on observation, and interview, the facility failed to ensure timely maintenance of equipment when:1. Rust found on the rack in the kitchen.2. Five worn out cooking pans found in kitchen.These failures had the potential to cause cross contamination to a population 6 out of 60 sample residents who received food from the kitchen.1. According to the Federal Food Code 2022, the Food Code indicates, Food-contact surfaces and utensils are to be clean to sight and touch. Utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to pitting, chipping, crazing, scratching, scoring and decomposition.On June 2, 2026, at 10:20 a.m., a concurrent observation and interview were conducted with the Director of Food Services (DFS) and [NAME] (CK) 1 in the kitchen at cook area. The rack stored clean kitchenware, pots and pans was observed had brown grime. The DFS referred the brown grime as rust. The CK 1 stated rust could contaminate the clean kitchenware, pots and pans. The DFS stated the rack needed to be replaced. 2. According to the Federal Food Code 2022, the Food Code indicates, Food-contact surfaces and utensils are to be clean to sight and touch. Utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to pitting, chipping, crazing, scratching, scoring and decomposition.On June 2, 2026, at 10:32 a.m., a concurrent observation and interview were conducted with the DFS and in the kitchen at cook area. Five worn out cooking pans found in kitchen. The DFS stated one of the pans had disfigure on the edge; the other four pans with peeling nonstick coating. The DFS stated all of them needed to be replaced.

Based on dietary observations, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. Serving pans did not air dried before stacked and stored.2. Two Cooks with facial hair did not wear hair restraint while preparing meals.3. Dust found on the rack and above walk in freezer.4. Grime buildup found on several pieces of equipment.5. Several food items found in kitchen were not properly labeled.6. Expired beverages found in Annex Resident's refrigerator.These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that results from ingesting contaminated foods) for 6 out of 60 sampled residents who received foods from the kitchen.1. On June 2, 2026, at 10:20 a.m., a concurrent observation and interview were conducted with [NAME] (CK) 1 in the kitchen at cook area. There was a rack stored clean kitchenware, pots and pans. Several of the serving pans stacked and stored in wet condition. CK 1 stated kitchen equipment should air dried before stacked and stored otherwise the wet environment promoted bacteria growth.During a review of the facility's policy and procedure (P&P) titled, Policy: Cleaning and sanitizing Pots and Pans, Review dated 9/2022, the P&P indicated, PURPOSE: To ensure proper cleaning and sanitizing of equipment by providing the employees with specific, detailed information. SUMMARY: The following steps are to be performed in the washing of pots and pans to ensure proper cleaning and sanitation of cooking equipment. PROCEDURE: .6. Air Dry: After items have been sanitized, they should be thoroughly air dried on a clean drain board (at the end of the Power Soak machine).2. During a review of the FDA (Food and Drug Administration) Food Code 2022, the FDA Food Code indicated, Food employees shall wear hair restraints such as, hair coverings, nets, or bears restraints to cover body hair to keep hair from contacting exposed food, clean equipment, and utensils. On June 2, 2026, at 11:28 a.m., a concurrent observation and interview were conducted with the Director of Food Services (DFS), CK1 and CK 2 in the kitchen. CK 1 with facial hair did not cover while working in cook area. CK 2 with facial hair not fully covered with mask was observed preparing meal in front of stove. The DFS acknowledged both Cooks (CK 1 and CK 2) needed to wear beard restraints.3. On June 2, 2026, at 10:20 a.m., a concurrent observation and interview were conducted with the DFS in the kitchen. [NAME] debris was observed hanging on the rack used to store cleaned kitchenware, pots and pans. The DFS stated brown debris was dust which could cause cross contamination of the cleaned kitchenware, pots and pans.On June 2, 2026, at 10:48 a.m., a concurrent observation and interview were conducted with the DFS in the kitchen. Above walk-in freezer, there was brown/black debris accumulated on the wall. The DFS stated brown/black debris was dust and the kitchen should keep clean. During a review of the FDA (Food and Drug Administration) Food Code 2022, the FDA Food Code indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.4. On June 2, 2026, at 9:18 a.m., a concurrent observation and interview were conducted with the DFS in the kitchen. Black grime was observed accumulated on the coffee machine. The DFS stated the coffee machine should keep clean to prevent cross contaminate.On June 2, 2026, at 10:08 a.m., a concurrent observation and interview were conducted with CK 1 in the kitchen. Black sticky grime was observed accumulated on the can opener based. CK 1 stated bacteria and fungus could growth on the can opener based which could contaminate the foods when using the can opener.During a review of the facility's policy and procedure (P&P) titled, Policy: Departmental Infection Control, Review dated 10/2019, the P&P indicated, SCOPE: Nutritional Service Staff.POLICY Efforts are directed toward assuring that cross-contamination is minimized; .and employee conduct is such as to contain infection or minimize the exposure to recognized hazards.PROCEDURE .5. Food Preparation: .a) Equipment i) All kitchenware and food contact surfaces used in preparation and/or serving food and drink are cleaned .ii) .all food contact surfaces of equipment .are handled and stored so as to prevent contamination.5. On June 2, 2026, at 9:48 a.m., a concurrent observation and interview were conducted with CK 1 in the kitchen. A white plastic container used to store rice was observed did not have any label. CK 1 stated the procedure for food item not stored in original container should labeled with the food item name and opened dated. CK 1 stated without labeled opening date for the rice, he did not know how long the rice stored in the container, so he had to discard the rice.On June 2, 2026, at 10:02 a.m., a concurrent observation and interview were conducted with CK 1 in the kitchen. Three shakers stored with brown powder were observed only labeled with used by dated. CK 1 stated employees should label the three shakers with the food items name otherwise employees could mistake the cinnamon powder with [NAME] powder.On June 2, 2026, at 10:49 a.m., a concurrent observation and interview were conducted with DFS in the kitchen. Two food items (sausage and hot dog) stored in Ziploc bags only labeled with opened date found inside reach-in freezer number 2. The DFS stated food items not in original package should label the food items name.During a review of the facility's policy and procedure (P&P) titled, Policy: Departmental Infection Control, Review dated 10/2019, the P&P indicated, SCOPE: Nutritional Service Staff.POLICY Efforts are directed toward assuring that cross-contamination is minimized; .and employee conduct is such as to contain infection or minimize the exposure to recognized hazards.PROCEDURE .5. Food Preparation: .b) .l) All items not in their original package are .dated and labeled as to contents .6. On June 2, 2026, at 3:39 p.m., a concurrent observation and interview were conducted with the DFS and DON in Annex nourishment room. Three expired beverages (20 fluid (fl) ounce (oz -unit for measurement) Fruit punch with expired dated May 5, 2025; 20 fl oz Vitamin water with expired dated [DATE]; 12 fl oz zero sugar soda with expired dated March 30, 2026) belong to Resident 42 found inside Refrigerator. The DON stated those beverages were brought in by the Resident 42 family. The DFS stated those beverages were beyond manufacturers' used by/best by date and should throw away.During a review of the facility's policy and procedure (P&P) titled, Policy: Food Brought in From Outside, Review dated 5/2026, the P&P indicated, .The nursing staff is responsible for discarding .foods on or before the Use by date.During a review of the facility's policy and procedure (P&P) titled, Policy: Expired or Recalled Food and Beverage items, dated 6/2026, the P&P indicated, .PURPOSE: To provide criteria to develop a monitoring system designed to ensure the retrieval and safe handling and disposal of expired .beverage items to reduce the potential of adverse reactions and to ensure the safety of the patients . PROCEDURE .Discard outdated, expired .beverage products immediately .

Based on interview and record review, the facility failed to ensure care and treatment was provided, for one of 15 sampled residents (Resident 60) when midodrine (medication used to treat low blood pressure) was not administered according to the physician's order. This failure had the potential for a delay in care and treatment and could have caused a decline in the resident's overall health condition. Findings:A review of Resident 60's admission Record, dated June 3, 2026, indicated Resident 60 was admitted to the facility on [DATE], with diagnoses which included heart failure and hypertensive (high blood pressure) heart disease. A review of Resident 60's medical records indicated the following provider's orders: On February 12, 2026, midodrine (used to treat low blood pressure) tablet give 45 mg (milligram, unit of measurement) by mouth every 6 hours as needed for PRN (as needed) Blood Pressure SBP (systolic blood pressure, the top number in a blood pressure reading when the heart contracts [beats]) < (less than) 100 mmHg (millimeters of mercury, a unit of pressure); and On August 29, 2025, Monitor BP (Blood Pressure) every 6 hours. Give Midodrine PRN as ordered if SBP < 100 mmHg. A review of Resident 60's Medication Administration Record (MAR), dated January 2026 through May 2026, indicated nursing staff did not administer midodrine as ordered by the physician when Resident 60's SBP less than 100 mmHg on the following days (22 missed doses in total): On January 6, 2026, at 12:00 p.m., SBP 95 mmHg;On January 13, 2026, at 12:00 p.m., SBP 97 mmHg;On January 13, 2026, at 18:00 (6 p.m.), SBP 92 mmHg;On January 15, 2026, at 18:00 (6 p.m.), SBP 99 mmHg;On January 19, 2026, at 00:00 (12 a.m.), SBP 98 mmHg;On January 23, 2026, at 18:00 (6 p.m.), SBP 92 mmHg;On February 9, 2026, at 18:00 (6 p.m.), SBP 97 mmHg;On February 10, 2026, at 12:00 p.m., SBP 97 mmHg;On February 10, 2026,at 18:00 (6 p.m.), SBP 94 mmHg;On February 15, 2026, at 12:00 p.m., SBP 99 mmHg;On February 17, 2026, at 12:00 p.m., SBP 99 mmHg;On February 23, 2026,at 18:00 (6 p.m.), SBP 96 mmHg;On March 11, 2026, at 06:00 (6 a.m.), SBP 98 mmHg;On March 11, 2026, at 12:00 p.m., SBP 90 mmHg;On March 11, 2026, at 18:00 (6 p.m.), SBP 95 mmHg;On March 20, 2026, at 18:00 (6 p.m.), SBP 92 mmHg;On March 24, 2026, at 18:00 (6 p.m.), SBP 98 mmHg;On March 28, 2026, at 00:00 (12 a.m.), SBP 99 mmHg;On April 7, 2026, at 12:00 p.m., SBP 95 mmHg;On April 7, 2026, at 18:00 (6 p.m.), SBP 94 mmHg; On April 12, 2025, at 12:00 p.m., SBP 94 mmHg; [NAME] May 26, 2026, at 18:00 (6 p.m.), SBP 84 mmHg. On June 3, 2026 at 10:21 a.m., an interview and concurrent record review was conducted with Registered Nurse (RN) 2. RN 2 stated she had occasionally cared for Resident 60 since September 2025. RN 2 stated nursing staff measured Resident 60's blood pressure every 6 hours as ordered at the following times: 00:00 (12 a.m.), 06:00 (6 a.m.), 12 p.m., and 18:00 (6 p.m.). Regarding Resident 60's midodrine order, RN 2 stated nurses only administered the medication when SBP was less than 100 mmHg. RN 2 reviewed Resident 60's MAR dated May 26, 2026 at 18:00 (6 p.m.). RN 2 acknowledged midodrine was not administered on May 26, 2026 at 18:00 (6 p.m.) when Resident 60's SBP was less than 100 mmHg and stated midodrine should have been given. On June 3, 2026 at 10:57 a.m., a group interview and concurrent record review was conducted with Registered Nurse Manager (RNM) and the Director of Staff Development (DSD). The RNM and DSD reviewed Resident 60's provider order for midodrine, MAR, and blood pressure results as listed above. The RNM acknowledged midodrine was not administered on the above dates and times when Resident 60's SBP was less than 100 mmHg and stated midodrine should have been given. On June 3, 2026 at 4:20 p.m., a follow-up interview was conducted with RNM. RNM stated the expectation was for nursing staff to administer medications according to the provider's order, including following blood pressure parameters. On June 4, 2026 at 3:43 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated nursing staff should have followed the instructions on the doctor's order. A review of the policy and procedure titled Medication Administration - General Guidelines, dated June 2026, indicated Medications are administered in accordance with written orders of the physician .Medication order with parameters must be given according to specification.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a visitor was observed in the room of Resident 8, who was on isolation for contact precaution for Candida Auris (C. Auris - a highly contagious and multidrug resistant fungus), not wearing personal protective equipment (PPE- specialized clothing or equipment worn to create a barrier between healthcare workers and potential sources of infection, like blood, body fluids, or other potentially infectious materials).This failure had the potential to spread Candida Auris to the community.Findings:On June 2, 2026, at 9:48 a.m., during an observation of Resident 8's room, there was a sign posted at the door indicating .Contact Precautions.Gloves and gown are Required.Use disposable equipment or dedicated equipment and leave it in the room.wash hands with soap and water or alcohol-based hand sanitizer.Visitors Must check with nurse before entering room.On June 2, 2026, at 12:38 p.m., Resident 8's room was observed with a visitor at bedside, sitting in the chair, not wearing any PPE. On June 2, 2026, at 12:40 p.m., a concurrent observation and interview was conducted with Registered Nurse (RN 1). RN 1 stated she was assigned to Resident 8 and confirmed Resident 8 was on contact isolation for C. Auris. RN 1 stated that all staff and/or visitors should wear PPE when in Resident 8's room.On June 3, 2026, Resident 8's medical record was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure (loss of ability to exchange oxygen and carbon dioxide), tracheostomy (surgically created hole through the front of the neck into the trachea [windpipe]), ventilator dependency (mechanical breathing machine [ventilator] to deliver air into their lungs).The physician order dated February 17, 2026, indicated .Isolation .Contact Precaution.Candida Auris positive .The laboratory test result titled Candida Culture Auris Screening, dated February 20, 2026, indicated .Candida Auris isolated .On June 4, 2026, at 9:05 a.m., a concurrent interview and record review was conducted with the Director of Quality Control (DQC). The DQC stated Resident 8 was C. Auris positive upon admission to the facility. The DQC stated the facility expectations for nursing, staff, and visitors were to comply with the PPE and hand hygiene standards for contact precaution. The DQC further stated the facility staff are to gather the proper PPE and give it to the visitors if they see them not wearing PPE and educate the visitor on the spread of C. Auris to the community by not wearing PPE. The DQC stated visitors should wear PPE in contact precaution rooms.A review of the facility policy and procedure titled, Isolation Precautions in the Subacute Unit, dated June 2026, indicated .contact precautions .is an extension of standard precautions in that gloves and gowns are required for all patient/resident contact and contact with environmental surfaces in the patient/resident room .

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for one of four residents (Resident 34) when nursing staff did not administer pantoprazole (used to treat stomach acid) in accordance with the manufacturer's instructions. This failure had the potential to result in Resident 34 not receiving the full benefit of the medication, leading to further health complications. Findings: A review of Resident 34's admission Record, dated June 3, 2026, indicated Resident 34 was initially admitted on [DATE] and re-admitted to the facility on [DATE] with diagnoses including Gastro-esophageal reflux disease (GERD, or acid reflux), chronic respiratory failure, and gastrostomy (G-tube, a small flexible tube inserted through the belly directly into the stomach). A review of Resident 34's medical record indicated a physician's order for pantoprazole (used to treat acid reflux or prevent stomach bleed) oral packet 40 mg (milligram, unit of measurement), give 40 mg via G-tube one time a day for GI (digestive system) bleed prophylaxis (prevention) mix with applesauce/apple juice; do not use any other liquids or foods including water. Do not crush or chew granules, dated September 3, 2025. On June 3, 2026 at 8:48 a.m., a medication pass observation for Resident 34 was conducted with licensed vocational nurse (LVN) at nursing station 1 in the hallway in front of Resident 34's room. LVN was observed preparing six medications on top of the medication cart, including one packet of pantoprazole 40 mg for delayed release oral suspension. The manufacturer's instructions printed on the pantoprazole outer packet indicated, suspension in apple juice or applesauce only. Additionally, the pharmacy label on the plastic bag for Resident 34's pantoprazole packet indicated, Mix 1 packet with apple sauce/apple juice and give via G-Tube . During the same medication pass observation for Resident 34 on June 3, 2026 at 9:11 a.m., LVN went to Resident 34's bedside and was observed using water to mix the pantoprazole 40 mg packet. LVN stated she was using water to mix all the medications. LVN administered all six medications, including pantoprazole 40 mg for delayed release oral suspension, via Resident 34's G-tube and flushed the G-tube with water after each medication. On June 3, 2026 at 9:24 a.m., a concurrent interview and record review was conducted with LVN. LVN stated Resident 34 did not have any dietary restrictions. LVN reviewed the manufacturer's instructions printed on the pantoprazole outer packet and the pharmacy label on the plastic bag for Resident 34's pantoprazole packet and stated the instructions indicated the pantoprazole packet contents should have been mixed only apple juice or apple sauce. LVN stated she was not aware water should not have been used. On June 3, 2026 at 4:20 p.m., an interview was conducted with Registered Nurse Manager (RNM). RNM stated the expectation was for nursing staff to administer medications according to the provider's order. RNM stated when nursing staff administered Pantoprazole for Delayed-Release Oral Suspension, they should have used apple juice or apple sauce instead of water according to the manufacturer's instructions and physician's order. On June 4, 2026 at 3:43 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated nursing staff should have followed the instructions on the doctor's order and manufacturer's instructions. A review of the Prescribing Information (PI, manufacturer's instructions) for Pantoprazole for Delayed-Release Oral Suspension, dated March 2025 provided by the facility, indicated Because proper pH [a measurement of how acidic or alkaline (basic) a substance is] is necessary for stability, do not administer pantoprazole sodium for delayed-release oral suspension in liquids other than apple juice, or foods other than applesauce. A review of the manufacturer's document titled, Medication Guide Pantoprazole Sodium for Delayed-Release Oral Suspension, dated March 2025 provided by the facility, indicated Do not mix pantoprazole sodium for delayed-release oral suspension in liquids other than apple juice or foods other than applesauce. A review of the manufacturer's document titled, Instructions For Use Pantoprazole for Delayed-Release Oral Suspension, dated March 2025 provided by the facility, indicated Should only be taken with applesauce or apple juice .should not be mixed in water or other liquids, or other foods .Mix pantoprazole sodium for delayed-release oral suspension only in apple juice when given through NG tube [nasogastric tube, a flexible plastic tube that goes into nose, down throat, and directly into stomach] or gastrostomy tube. A review of the policy and procedure titled Medication Administration - General Guidelines, dated June 2026, indicated Medications are administered in accordance with written orders of the physician.

Based on observation, interview, and record review, the facility failed to ensure the medications were administered within 60 minutes of their scheduled times for one resident, Resident 3.This failure had the potential to result in decreased effectiveness of Resident 3's medications.Findings:On March 11, 2026, at 11:18 a.m., during a medication pass (med pass) observation and interview with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared the following medications for Resident 3:-ascorbic acid (Vitamin C) 500 mg for supplement;-benztropine mesylate (Cogentin) 0.5 mg for muscle spasm;-cranberry 250 mg for urinary tract infection prophylaxis;-esomeprazole 40 mg for gastrointestinal prophylaxis;-lactobacillus for supplement;-multivitamin and mineral 15 ml for supplement; and-quetiapine (Seroquel) 100 mg for generalized anxiety. During the same observation, LVN 1 administered these medications at 12:08 p.m., to Resident 3 via gastric tube (a soft, flexible tube inserted directly through the skin of the abdomen into the stomach). LVN 1 stated Resident 3's medications were scheduled for 10:00 a.m.A review of Resident 3's face sheet indicated she was admitted to the facility on [DATE], with diagnoses which included respiratory failure.A review of Resident 3's Order Summary Report dated March 11, 2026, and Medication Administration Record for the month of March 2026, indicated Resident 3 had the following medications scheduled to be administered at 10:00 a.m.:-ascorbic acid 500 mg for supplement;-benztropine mesylate 0.5 mg for muscle spasm;-cranberry 250 mg for urinary tract infection prophylaxis;-esomeprazole 40 mg for gastrointestinal prophylaxis;-lactobacillus for supplement;-multivitamin and mineral 15 ml for supplement; and-quetiapine 100 mg for generalized anxiety.On March 11, 2026, at 1:09 p.m., during an interview, LVN 1 stated they have one hour before and one hour after the scheduled time to administer residents' medications. LVN 1 stated for the 10:00 a.m., med pass, they have between 9:00 a.m., to 11:00 a.m., to administer the residents' medications. LVN 1 stated he was behind on med pass because he attended to other residents who needed a dressing change and as needed medication. LVN 1 stated if he is getting behind with med pass, he would talk to the other licensed nurses to help him out, but they were all busy.On March 12 at 4:08 p.m., during an interview with the Director of Nursing (DON), the DON stated the licensed nurses were expected to administer medications one hour before and one hour after the scheduled time. A review of the facility's policy and procedure, titled, Medication Administration - General Guidance dated July 2025, indicated .Medications are administered within one hour before and one after the scheduled time, except for orders relating to before, after and during meal orders. Which are administered as ordered (sic) Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility .

Based on observation, interview and record review, the facility failed to ensure physician's orders were followed for two of three residents, Residents 1 and 2, when:Resident 1 did not have hand rolls in her left and right hands; andResident 2 did not have a left elbow splint.These failures had the potential to result in Residents 1 and 2 having skin impairments and further decline in range of motion.Findings:1.A review of Resident 1's electronic medical record indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included respiratory failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood).A review of Resident 1's Minimum Data Assessment (MDS - an assessment tool) dated July 3, 2025, indicated the resident has functional limitations in range of motion to her left and right, upper and lower extremities.A review of Resident 1's Order Summary Report dated March 11, 2026, indicated the following were ordered by the physician on March 13, 2025:-left towel roll in hand every day shift; and-right towel roll in hand every day shift.On March 11, 2026, at 10:23 a.m., during a concurrent observation and interview, Resident 1 was lying in bed with head of bed elevated at least 30 degrees, eyes were closed, non-verbal and she had a tracheostomy tube (an artificial airway to help a person breathe, remove mucus, or deliver oxygen directly to the lungs) connected to oxygen. Resident 1's upper extremities were flexed on her chest, and her left and right hands did not have hand rolls.On March 11, 2026, at 2:39 p.m., during a concurrent observation of Resident 1 and interview with the Restorative Nursing Assistant (RNA), Resident 1 did not have towel rolls in her left and right hands. The RNA stated Resident 1 was supposed to have towel rolls in each of her hands. The RNA stated she gave Resident 1 a shower that morning and forgot to place the towel rolls in each of her hands. The RNA stated she was responsible for placing the towel rolls in Resident 1's hands.2. A review of Resident 2's electronic medical record indicated Resident 2 was initially admitted to the facility on [DATE], with diagnoses which included respiratory failure. A review of Resident 2's MDS dated September 23, 2025, indicated the resident has functional limitation of range of motion to his left and right, upper and lower extremities. A review of Resident 2's Order Summary Report dated March 11, 2026, indicated the following was ordered on November 25, 2025: -RNA/ nursing manage left elbow extension splint (a medical device used to support, protect, and immobilize the elbow) up to four hours as tolerated daily every day shift. On March 11, 2026, at 10:54 a.m., during an observation, Resident 2 was in his room, lying in bed with head of bed elevated at least 30 degrees, alert, non-verbal, with tracheostomy tube connected to oxygen. Resident 2's left upper extremity was extended by his left side with no splint. On March 11, 2026, at 2:36 p.m., during a concurrent observation of Resident 1 and interview with the RNA, Resident 1 did not have a left elbow splint. The RNA stated she was not aware Resident 1 had a left elbow splint. The RNA stated they keep all splints for Resident 1 in the mesh bag and there was no elbow splint in there. On March 12, 2026, at 4:08 p.m., during a concurrent interview with the Director of Nursing (DON) and record review of Resident 2's medical record, the DON stated the RNA should follow the doctor's order and apply the left elbow splint for Resident 2. A review of the facility's policy and procedure titled, Restorative Nursing Assistant Program dated July 2025, indicated, The facility is responsible for providing maintenance and restorative programs .to achieve and maintain the highest practicable outcomes .The Restorative Nursing Assistant carries out the programs according to the written plan of care and documents it daily .Restorative Nursing Responsibility . splinting, application of orthotics and Braces (sic)

Based on interview and record review, the facility failed to ensure the Comprehensive Minimum Data Set (MDS - standardized assessment tool used to evaluate clinical, functional, and psychosocial status of all residents) Assessment accurately reflected the residents' current status for one of three residents reviewed (Resident 1), when discrepancies were found in Resident 1's Quarterly Comprehensive MDS Assessment.This failure had the potential to lead to inappropriate care planning for Resident 1.Findings:On February 11, 2026, Resident 1's medical record was reviewed.Resident 1 was initially admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (medical condition where the lungs cannot get enough oxygen into the blood) with hypoxia (low blood oxygen levels), tracheostomy (surgical opening in the neck to breath), dependence on respiratory ventilator (inability to breath independently requiring mechanical assistance to get air in and out of the lungs), hemiplegia (paralysis on one side of the body), hemiparesis (weakness or paralysis on one side of the body), and vascular dementia (decline in thinking skills related reduce blood flow to the brain).Resident 1 was discharged from the facility to a GACH (General Acute Care Hospital) on May 25, 2025.The history and physical, dated May 23, 2024, indicated Resident 1 did not have the capacity to make decisions. The responsible party (RP) for Resident 1 was her daughter.The wound care note dated May 19, 2025, indicated .sacral fragile skin scar tissue reopening measuring 3 cm (a unit of measurement) length, 1 cm width, and 0.1 cm depth. Notified (named physician) with new order given.cleanse with normal saline pat dry apply traid cream (a sterile, zinc-oxide-based, paste used to treat pressure ulcers) cover with DD (dry dressing) for 30 days.The Quarterly MDS dated [DATE], indicated Resident 1 had no unhealed pressure ulcer (PU) injuries and was not receiving PU care.On February 18, 2026, at 10:00 a.m., a concurrent interview and record review was conducted with the Nurse Manager (NM). The wound care note dated May 19, 2025, was reviewed. The NM stated the wound care note indicated Resident 1 had a PU that reopened measuring 3 cm in length, 1 cm in width, 0.1 cm in depth with a physician order to clean with normal saline, apply triad and cover with a dry dressing for 30 days. The Quarterly MDS assessment dated [DATE], was reviewed. The NM stated the MDS assessment indicated Resident 1 had no PU and was not receiving PU care. The NM stated the MDS assessment did not reflect Resident 1's PU status and should have accurately reflected Resident 1's PU status. The NM further stated the facility follows the federal mandate for MDS assessments.A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual MDS 3.0 RAI Manual, dated October 2018, indicated .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment.

Based on interview and record review, the facility failed to ensure that a resident with a non-pressure related skin impairment received appropriate treatment and services in accordance with professional standards of practice for one of three residents reviewed (Resident 1), when the CNA (certified nurse assistant) failed to identify and report a left abdominal fold skin tear to the wound care nurse, resulting in a delay in treatment and increased risk of infection.This failure had the potential to cause a negative outcome in Resident 1's physical health.Findings:On February 17, 2026, Resident 1's medical record was reviewed.Resident 1 was initially admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (medical condition where the lungs cannot get enough oxygen into the blood) with hypoxia (low blood oxygen levels), tracheostomy (surgical opening in the neck to breath), dependence on respiratory ventilator (inability to breath independently requiring mechanical assistance to get air in and out of the lungs), hemiplegia (paralysis on one side of the body), hemiparesis (weakness or paralysis on one side of the body), and vascular dementia (decline in thinking skills related reduce blood flow to the brain).Resident 1 was discharged from the facility to a GACH (General Acute Care Hospital) on May 25, 2025.The history and physical, dated May 23, 2024, indicated Resident 1 did not have the capacity to make decisions. The responsible party (RP) for Resident 1 was her daughter.The I View and O (a section of the Electronic Medical Record used for real time patient assessments and interventions) completed by the Certified Nurse Assistant (CNA) dated May 25, 2025, indicated Resident 1 had a complete linen change, face care, peri care (washing the genital and anal area), and a shower.The physician order dated May 25, 2025, at 6:02 p.m., indicated .transfer patient (Resident 1) to ER (emergency room) due to seizure (sudden burst of electrical activity in the brain), hypertension (high blood pressure), and tachycardia (fast heart rate).The (name of GACH ER) photograph dated May 25, 2025, at 8:14 p.m., indicated an unnamed skin tear covered with a white cream on an unnamed part of the body.On February 17, 2026, at 9:55 a.m., a concurrent interview and record review was conducted with the skilled nursing facility (SNF) CNA/RNA (restorative nurse assistant - a certified nurse assistant who provides rehabilitation care and services) assigned to Resident 1. The RNA stated the facility process is for CNAs to perform skin checks when performing incontinent care (care giving after experiencing involuntary loss of bladder or bowel), bed baths, showers, and report abnormal findings or significant changes in the skin to the wound care nurse or charge nurse. The RNA reviewed the I View and O dated May 25, 2025, at 10:00 a.m., and stated she assisted the (named CNA) with showering Resident 1 on May 25, 2025, at 10:00 a.m. The RNA stated she performed a skin check on Resident 1 during her shower. The RNA stated there were no abnormal findings from Resident 1's skin check to report to the wound care nurse. The RNA stated she applied triad barrier cream (sterile, zinc-oxide-based, paste used to protect skin from moisture) to Resident 1's abdominal folds. The RNA reviewed the photo taken at (named GACH ER). The RNA stated the photo dated May 25, 2025, at 8:14 p.m., indicated a skin tear of an unknown body part covered with barrier cream. The RNA stated the skin tear indicated in the (named GACH ER) photo would be considered an abnormal finding reportable to the wound care nurse. The RNA stated she did not identify the skin tear in the named hospital photo when giving Resident 1 a shower. On February 25, 2025, at 3:53 p.m., a telephone interview was conducted with the GACH Wound/Ostomy Nurse ([NAME]). The [NAME] stated the facility process upon admission the floor nurse will assess the residents' skin and photograph any abnormalities. The [NAME] stated Resident 1 was admitted into the (second named GACH) on May 26, 2026, at 2:40 a.m., and the floor nurse photograph Resident 1's left abdominal fold skin tear. A concurrent review was conducted of the photo dated May 26, 2026, at 2:40 a.m. The [NAME] stated the picture indicated a left abdominal fold skin tear. The [NAME] stated Resident 1 arrived to (second named GACH) with the left abdominal fold skin tear. The [NAME] stated after reviewing Resident 1's left abdominal fold skin tear picture she informed Resident 1's assigned nurse to apply a hydrofiber with silver (wound care product that transform into gel upon contact with wound fluid) to the left abdominal fold skin tear.On March 2, 2026, at 11:39 a.m., a concurrent interview, and record review was conducted with the SNF Nurse Manager (NM). The NM stated the CNAs are to perform skin checks during incontinent care, bed baths, showers, and report abnormal findings to the wound care nurse. The NM stated it is the facility's standard to apply traid barrier cream to areas of the resident that accumulate moisture. The NM reviewed the photo taken at the (named GACH ER). The NM stated the photo dated May 25, 2025, at 8:16 p.m., indicated a skin tear of the abdominal fold covered with barrier cream. The NM reviewed the (second named GACH) photo dated May 26, 2025, at 2:40 a.m. The NM stated the photo indicated a left abdominal skin tear. The NM stated the CNAs should have identified the left abdominal skin tear during the shower on May 25, 2025, at 10 a.m., and reported the abnormal finding to the wound care nurse.A review of the job description titled, Nursing Asst (CERT), revised March 4, 2026, indicated .Essential Job Duties and Responsibilities.Notifies the license nurse for any noticeable changes in the patients/resident's medical condition.Monitors patient/residents' safety and immediately reports concerns to the licensed nurse.A review of the facility policy and procedure titled, Skin Care and Prevention of Pressure Injury, dated July 2025, indicated .To provide guidelines for assessment, interventions, documentation, and management of patient's skin.Routinely assess.the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown.

Based on interview and record review, the facility failed to ensure that the Interdisciplinary Team (IDT - a collaborative group of diverse healthcare professionals who work together to create and implement a unified, comprehensive care plan for a resident) notes accurately reflected the residents' current status for one of three residents reviewed (Resident 1), when discrepancies were found in Resident 1's IDT Notes.This failure had the potential to lead to improper care planning and inaccurate communication between disciplines.Findings:On February 11, 2026, Resident 1's medical record was reviewed.Resident 1 was initially admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (medical condition where the lungs cannot get enough oxygen into the blood) with hypoxia (low blood oxygen levels), tracheostomy (surgical opening in the neck to breath), and dependence on respiratory ventilator (inability to breath independently requiring mechanical assistance to get air in and out of the lungs).Resident 1 was discharged from the facility to a GACH (General Acute Care Hospital) on May 25, 2025.The IDT Monthly Meeting Notes for the months of November 2023; December 2023; February 2024 - June 2024; August 2024 - December 2024; and January 2025 - May 2025, were reviewed and indicated .restraints.two bedrails raised and locked while in bed for seizure activity and whole body jerking while coughing or while being suctioned.There was no documented evidence that Resident 1 had a diagnoses of seizures.On February 18, 2026, at 10:00 a.m., a concurrent interview and record review was conducted with the Director of Subacute (DS) and the Nurse Manager (NM). The IDT Monthly Meeting Notes for the following months were reviewed: November 2023; December 2023; February 2024 - June 2024; August 2024 - December 2024; and January 2025 - May 2025. The NM stated there was no documented evidence of Resident 1's seizure diagnosis from admission [DATE]) to discharge (May 2025).The DS stated the IDT Monthly Meeting Notes inaccurately reflected Resident 1's restraint usage by citing a diagnosis of seizures, rather than noting two locked bed rails for ventilator-dependent whole body jerking while coughing or while being suctioned. The DS further stated the MDS nurse failed adequately customize the IDT Monthly Meeting Notes to reflect Resident 1's correct diagnosis resulting in documentation that did not accurately reflect the resident's specific clinical or functional status.A review of the facility policy and procedure titled, Medical Record Content & Documentation, revised June 20, 2025, indicated .Purpose.To ensure correct documentation for patient safety.Medical Records must be completed accurately.

Based on interview and record review, the facility failed to ensure that the patients' rights were protected, specifically the right to have their designated representative informed of significant events or changes, for one of three residents reviewed (Resident 1), when the facility did not notify Resident 1's representative of the change in the prescription medication Tylenol #3 (acetaminophen-codeine, pain medication) to the prescription medication tramadol (pain medication).This failure prevented the residents' representative from participating in decisions related to the residents' care and well-being as authorized.Findings:On February 11, 2026, Resident 1's record was reviewed.Resident 1 was initially admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (medical condition where the lungs cannot get enough oxygen into the blood) with hypoxia (low blood oxygen levels), tracheostomy (surgical opening in the neck to breath), gastrostomy (surgical opening into the stomach to insert a feeding tube), dependence on respiratory ventilator (inability to breath independently requiring mechanical assistance to get air in and out of the lungs), hemiplegia (paralysis on one side of the body), hemiparesis (weakness or paralysis on one side of the body), and vascular dementia (decline in thinking skills related reduce blood flow to the brain).Resident 1 was discharged from the facility to a GACH (General Acute Care Hospital) on May 25, 2025.The history and physical, dated May 23, 2024, indicated Resident 1 did not have the capacity to make decisions. The responsible party (RP) for Resident 1 was her daughter.The nursing note dated May 7, 2025, at 3:49 p.m., indicated MD (medical doctor) made rounds and ordered Tylenol #3 staff made aware.The physician order dated May 7, 2025, indicated the following: .Tramadol HCl Oral Tablet 50 MG (milligram - unit of measurement) (Tramadol HCl) Give 50 mg via G-Tube (gastrostomy tube) every 12 hours as needed for Moderate to severe pain (Pain scale 4-10 .) .Acetaminophen-Codeine Oral Tablet 300-30 MG (Tylenol #3) Give 1 tablet via G-Tube every 8 hours as needed for pain .The facility admission record indicated Resident 1 had allergies to hydrocodone (pain medication).On February 24, 2026, at 3:17 p.m., a concurrent interview and record review was conducted with the Registered Nurse (RN). The RN stated on the day the tramadol was ordered, Resident 1's RP was at her bedside when the physician was making rounds. The RN stated Resident 1's RP was the one who asked for her mother to be prescribed something for pain. The RN stated Resident 1's RP was informed by the physician of the order for the Tylenol #3. The RN stated the Tylenol #3 order was faxed to (named pharmacy) and the (named pharmacy) notified the RN that Resident 1 had an allergy to hydrocodone and Tylenol #3 was not recommended. The RN stated he contacted Resident 1's physician of her allergy to hydrocodone and the physician changed the order to tramadol 50mg. The RN stated Resident 1's RP was not notified of the change in medication from Tylenol #3 to tramadol and stated the RP should have been notified of the medication change.On February 24, 2026, at 3:23 p.m., a concurrent interview and record review was conducted with the Nurse Manager (NM). The NM stated the facility process is to inform the resident RP's of resident changes in condition, care, services, and transfers out of the facility. The NM stated the nursing staff should have informed Resident 1's RP of the change in medication from Tylenol #3 to tramadol 50 mg.The facility's policy and procedure titled, Patient's Rights and Responsibilities 1501, dated August 2024, was reviewed. The policy indicated .Informed participation in decisions regarding his/her care.The designation of a representative decision-maker in the event that a patient is unable to understand a proposed treatment or procedure or is unable to communicate his/her wishes regarding care.The hospital involves the patient in making decisions about his or her care, treatment, and services.the patient has the right to actively participate in decisions regarding his/her healthcare.The patient has the right to the information necessary to assist him/her to give informed consent or refuse the course of treatment.

Based on observation, interview and record review, the facility failed to ensure services provided meet professional standards of practice, for one of one resident reviewed (Resident 39), when the Licensed Vocational Nurse (LVN) did not check the NGT (nasogastric tube - a flexible tube inserted through the nose and down the throat into the stomach) placement prior to medication administration. This failure had the potential for Resident 39 to develop aspiration pneumonia (a lung infection that occurs when food, liquid, or objects are inhaled into the lungs causing inflammation and fluid build-up). Findings: On May 21, 2025, at 11:23 a.m., a concurrent medication administration observation and interview was conducted with the LVN. The LVN was observed to prepare Resident 39's medications and checked the arm band to verify her identity. The LVN stopped the feeding, attached a 60 ml (milliliter - a unit of measurement) syringe into the NGT and tried to aspirate for gastric residual (stomach contents). There was no gastric residual observed after the LVN aspirated from the NGT. The LVN was observed to pour the medications into the 60 ml syringe. The LVN was asked prior to administering the medication if she checked the NGT placement. The LVN stated there was no need to check the tube placement since Resident 39 had NGT and not a G-tube (gastrostomy tube - a medical device inserted through the abdominal wall directly into the stomach, used to provide enteral nutrition or medications). The LVN was instructed to check NGT placement prior to medication administration. Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with diagnoses which included post partum cardiac arrest (a sudden, unexpected loss of heart function, breathing and consciousness after giving birth). Resident 39's care plan, dated January 9, 2025, indicated, .Resident has NGT .The resident will be free of aspiration .Check for tube placement and gastric contents/residual volume per facility protocol . On May 21, 2025, at 3:18 p.m., the Director of Nursing (DON) was interviewed. The DON stated all licensed nurses (LVN or Registered Nurse) were expected to check tube placement, NGT or G-tube prior to administering tube feedings and/or medications. The DON stated placement verification of the tube could be done by aspirating for gastric residual. He stated if there was gastric residual, the tube was in place. He stated if there was no gastric residual, the licensed nurse should slowly inject a small amount of air using a 60 ml syringe into the tube and listen with the use of a stethoscope for the swooshing sound to verify placement. The DON stated the LVN should have checked the NGT placement by slowly injecting a small amount of air into the tube and listened to the swooshing sound before administering medications. A review of the facility's policy and procedure titled, Medication Administration Through an Enteral Tube, reviewed April 2024, indicated, .Verify placement of the Nasogastric tube or Gastrostomy tube by either one or both procedure .Attach the syringe to the feeding tube and try to aspirate stomach contents .Place the stethoscope just below the xiphoid process (pointed end at the bottom of the breastbone) and instill 10-25 ml of air on (sic) the feeding tube. Listen for gurgling or whooshing sound, which indicates proper placement .

Based on observation, interview, and record review, the facility failed to ensure one of 15 vials of Ativan (medication used to treat anxiety disorders) two (2) mg (milligram - a unit of measurement) was not stored beyond the manufacturer's recommended discard date during an inspection of the medication refrigerator in the medication storage room located in the main building. This failure had the potential for a resident to receive an expired and ineffective medication. Findings: On [DATE], at 2:12 p.m., a medication storage room inspection was conducted with the Nurse Manager (NM). One vial of Ativan 2 mg with an expiration date of [DATE], was found stored in the medication refrigerator in the medication storage room located in the main building. In a concurrent interview with the NM, she stated any expired medication should be removed from use to prevent a licensed nurse from administering to a resident. On [DATE], at 3:18 p.m., the Director of Nursing (DON) was interviewed. The DON stated the staff checked the medications for expiration date and failed to see the expired Ativan 2 mg vial. The DON stated the expired medication should have been removed from use and returned to the pharmacy. A review of the facility's policy and procedure titled, Medication Storage, reviewed [DATE], indicated, .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to a vulnerable facility population. Findings: On May 19, 2025, at 7:15 a.m., an initial tour of the kitchen was conducted with the Director of Nutritional Services (DNS). Two fruit cups labeled with a use-by date of May 18, 2025, were observed in the refrigerator, readily available for use. One fruit cup with no label or date was also observed in the refrigerator, readily available for use. On May 19, 2025, at 7:15 a.m., a concurrent interview and record review was conducted with the DNS. The DNS stated all items stored in the refrigerator should have a use-by date. The DNS stated the one fruit cup with no label or date should not have been stored in the refrigerator, readily available for use. The DNS stated the two fruit cups should have been discarded on or before the expiration date (use-by date), and not stored in the refrigerator, readily available for use. A list of residents on an oral diet (food and drink consumed by mouth) indicated two residents out of the 60 residents in the facility were on an oral diet. A review of the facility policy and procedure, titled, Food Storage, revised January 2020, was reviewed. The policy and procedure indicated, .The Nutritional Service Department assures that safe, sanitary food storage .for a variety of food forms occurs in a strictly defined manner .All .prepared salads are covered, labeled, and dated with use by date and placed in refrigerator until further use .

Based on observation, interview, and record review, the facility failed to ensure infection control practice was implemented when the Licensed Vocational Nurse (LVN) did not properly clean and disinfect shared glucometer (measures the amount of glucose [sugar] in the body) in accordance with the disposable wipe manufacturer's specified contact time (contact time/wet time - amount of time a disinfectant needs to stay visibly wet on a surface to effectively kill germs). This failure had the potential to expose the resident to cross-contamination and development of infection. Findings: On May 21, 2025, at 12:08 p.m., during a medication administration observation with the LVN, the LVN was observed using a shared glucometer. The LVN was observed to wipe the glucometer with a Sani cloth disposable wipe (used to clean, sanitize and disinfect hard, non-porous surfaces [does not allow liquid or air to pass through it])) then proceeded to check Resident 18's blood sugar. The LVN was observed to wipe the glucometer with a Sani cloth disposable wipe but did not follow the manufacturer's specified contact time of two (2) minutes. On May 21, 2025, at 12:28 p.m., during an interview with the LVN, she stated she used the Sani cloth disposable wipe to sanitize the glucometer before and after each use and allowed to air dry. She stated the glucometer was wet but not for 2 minutes. The LVN stated she did not follow the contact time of 2 minutes as per manufacturer's instructions. On May 21, 2025, at 12:41 p.m., the Director for Staff Development (DSD) and the Director of Nursing (DON) were interviewed. The DSD and the DON stated the licensed nurse should sanitize the glucometer before and after use with the Sani cloth wipes. The DSD and DON stated the manufacturer's instructions for 2 minutes contact time should be followed by the staff. A review of the facility's policy and procedure titled, Disinfecting Patient Equipment, reviewed June 2024, indicated, .All patient care equipment is cleaned and disinfected .All patient care items are disinfected between patient use by point of care staff (Nursing, Transporters, Ancillary, etc.) .Manufacturer's instructions for use of each product are followed . A review of the manufacturer's instructions for Sani wipes indicated, .Contact time .thoroughly wet surface. Allow surface to remain wet for two (2) minutes, let air dry .

Based on interview and record review, the facility failed to implement interventions of turning and repositioning of dependent residents, for one of four residents (Resident 1), who had the potential for the development of a pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This failure placed the resident at an increased risk for developing and/or worsening of pressure injuries. Findings: On April 2, 2024, at 10:17 a.m., an unannounced visit was conducted at the facility for a quality-of-care complaint. On April 2, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included acute and chronic respiratory failure (unable to breath without difficulty) post tracheostomy (an artificial opening in the trachea to allow oxygen to the lungs), quadriplegia (inability to move all four extremities), and intracranial hemorrhage (bleeding in the brain). The physician History and Physical indicated Resident 1 was nonverbal and noncommunicative. The records indicated Resident 1 was transferred to the general acute care hospital on January 21, 2024. Review of Resident 1's Care Plan dated February 23, 2023, indicated, .Focus .High risk for alteration in skin integrity .Resident's mother wants resident to be turned at 9pm, 12mn (midnight), 3am, and 6am .Interventions .During night shift turn resident at 9pm, 12mn, 3am, and 6am per family request .Turn and reposition at least every 2 hours and as needed for comfort and pressure relief . Review of the facility document untitled which included resident function and activity (turning and repositioning) for January 17-21, 2024, indicated: -January 17, at 2:17 p.m., .Assistance Needs .Total .Patient Position .Lying . -January 17, at 6:18 p.m., .Assistance Needs .Total .Patient Position .Supine . -January 18, at 1:06 p.m., .Assistance Needs .Total .Patient Position .Lying . There was no other documentation indicating Resident 1 was turned or repositioned. On April 2, 2024, at 10:44 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated residents needed to be turned and repositioned every two hours and documented in the resident's record. CNA 1 stated if it was not documented, it was not done. On April 2, 2024, at 1:09 p.m., an interview was conducted with CNA 2. CNA 2 stated residents needed to be turned and repositioned every two hours and documented in the resident's record. CNA 2 stated some families requested the residents to be turned more frequently or at specific times, but they should be repositioned at least every two hours to prevent pressure injuries. On April 2, 2024, at 1:20 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated residents needed to be turned or repositioned every two hours with documentation in the resident's record. The DON stated Resident 1's record did not have any documentation that Resident 1 was turned or repositioned every two hours between January 17-21, 2024. The DON stated there should be documentation to indicate Resident 1 was turned and repositioned, and there was not. The DON stated if it was not documented then it was not done. On April 2, 2024, at 1:55 p.m., an interview was conducted with the Treatment Nurses (TXN) 1 and 2. TXN 1 stated Resident 1 had a pressure injury to his buttocks, but the wound was improving. TXN 1 stated it was important for Resident 1 to be turned and repositioned to promote healing and prevent further pressure injuries from developing. TXN 2 stated turning and repositioning were important for skin integrity and wound healing. Review of the facility document titled Skin Care and Prevention of Pressure Injury revised May 2023, indicated, .Pressure injury are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue .For a person in bed .Change position at least every time ADL (activities of daily living- example would be brief change or peri-care) care is provided or more frequently if needed .in a chair .Change position regularly at least every 1-2 hours .Bed/Chair Fast .Change position as frequent as possible .

Based on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. The Director of Nutritional Services and the Nutritional Service Manager did not instruct food service workers to follow manufacturer guideline for monitor temperature on dish machine. 2. The cook used wrong scoop plated lunch meal on February 13, 2024, for four residents (Residents 2, 19, 30, and 54). (Cross reference 803) These failures had the potential for unsafe food practices which may lead to foodborne illness (stomach illness acquired from ingesting contaminated food), and the potential to not meet the nutritional needs of the residents in a medically vulnerable population of seven out of 58 sample residents who received food prepared in the kitchen. 1. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Annex 3: Section 4-204.115 Warewashing Machines, Temperature Measuring Devices, the FDA Food Code indicated, The requirement for the presence of a temperature measuring device in each tank of the warewashing machine is based on the importance of temperature in the sanitization step. In hot water machines, it is critical that minimum temperatures be met at the various cycles so that the cumulative effect of successively rising temperatures causes the surface of the item being washed to reach the required temperature for sanitization. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Annex 3: Section 4-204.113 Warewashing Machine, Data Plate Operating Specifications, the FDA Food Code indicated, The data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The warewashing machine has been tested , and the information on the data plate represents the parameters that ensure effective operation and sanitization and that need to be monitored. On February 13, 2024, at 10:47 a.m., a concurrent observation, and record review of the high temperature dish machine was conducted. Observed the high temperature dish machine power wash temperature from gauge was 140 degrees Fahrenheit ( F - a unit of measurement) while doing dishes. Reviewed the manufacturer's guideline data plate for First tank power scrapper temperature on dish machine indicated Important keep temperature (temp) between 110 F to 140 F ; Second tank data plate for power wash temperature on dish machine indicated Important keep temp between 150 F to 165 F and third tank date plate for Final rinse temp on dish machine indicated, Important keep temp between 180 F to 195 F. Reviewed February 1-14, 2024, Dish machine temp log, there was no monitoring for power scrapper temperature. On February 14, 2024, at 10:05 a.m., an interview was conducted with the Dish machine Service Vendor (SCV). The SCV stated the dish machine need to stay in the manufacture recommended guideline temperature for properly sanitize the dishes. On February 14, 2024, at 4:00 p.m., an interview was conducted with the Director of Nutritional Services (DRD) and the Nutritional Services Manager (DSS). The DRD and the DSS stated they only focused on the dish machine final rinse temperature need to be over 180 F and the dish machine test strip turned orange color for properly sanitizing the dishes. The DRD and the DSS stated they did not concern about First tank power scrapper temperature and Second tank power wash temperature. Reviewed the manufacturer's guideline data plate for power wash temperature on dish machine indicated Important keep temp between 150 F to 165 F. Review of the facility's Dish Machine Temperature log, Eleven out of 14 days power wash temperature were out of range during February 2024. The facility's Dish Machine temperature log during February, 2024 indicated, Power wash temperature: 2/1/24: Breakfast (B): 189 F, Dinner (D):138 F; 2/3/24: B: 169 F, Dinner (D):173 F, 2/4/24: D:175 F, 2/5/24: D: 167 F, 2/6/24: B:181 F, D: 138 F, 2/7/24: B:172 F, 2/8/24: B: 189 F, L: 139 F, D:140 F, 2/10/24: B: 187 F, L:172 F, D: 189 F , 2/11/24: B: 187 F, L: 146 F, D: 138 F, 2/12/24: B:190 F, 2/14: D: 174 F 2. On February 13, 2024, at 11:53 a.m., a concurrent observation, interview, and menu review was conducted during lunch meal plating with the Cook (CK). The CK used a green scoop, 2.5 ounce (oz.- a unit of measure), for broccoli and rice instead of a grey scoop, four oz. per the menu for regular diet, No Concentrated Sweets diet and Low Sodium diet. Confirmed green scoop size with the CK, the CK stated green scoop was 2.5 oz. On February 13, 2024, at 2:30 p.m., an interview was conducted with the Director of Nutritional Services (DRD) and the Clinical Nutritional Manager (RD 1). The DRD and the RD1 were asked to explain the scoop colors and the size. They explained the green scoop was 2.5 oz. and the grey scoop was four oz. or equal to 1/2 cup. RD1 and DRD explained that if the wrong scoop size was used to plate the food for the residents, the residents would not get enough nutrition which could result in weight loss. During a review of the facility's Policy and Procedure titled, Portion Control Guidelines, revision date: 2/2024, indicated . Food Service Employees refers to production sheets for the proper portion size for all food service . When the patient/resident's menu has measured portions designated, food items may be measured by weight as appropriate . During a review of the facility's policy and Procedure titled, Menu Policy, review dated September 2022, indicated, .Standard recipes and standard serving guide are tools used by the food service staff to ensure nutritional adequacy is met for the patients/residents prescribed diet order . During a review of the job decription titled, COOK-DIETARY, undated, indicated, .POSITION SPECIFIC STANDARDS .1. Prepares all food items specified on daily production records in quantities indicated.

Based on observation, interview, and record review, the facility failed to ensure the nutritional needs for four of five residents (Residents 2, 19, 30, and 54), was met for lunch, when the meal was not plated in accordance with menu guidance for lunch. This failure had the potential to result in under or over nutrition. When a resident receives foods that are not consistent with their physician ordered diet, it may result in further compromising the resident's medical status. Findings: During an observation of the lunch meal plating on February 13, 2024, at 11:53 a.m., the Cook (CK) used a green scoop, 2.5 ounce (oz.- a unit of measure), for broccoli and rice instead of a grey scoop, 4 oz. per the menu and diet orders. During an interview on February 13, 2024, at 2:30 p.m., with Nutritional Service Supervisor (DSS) and Director of Nutritional Services (DRD), were asked to explain the scoop colors and the size. They explained the green scoop is 2.5 oz. and the grey scoop is four oz. or equal to 1/2 cup. DSS and DRD explained that if the wrong scoop size was used to plate the food the residents would not get enough nutrition, which could result in weight loss. A review of the facility's document titled, Order Sheet-Diet, dated January 1, 2024, for Resident 2 indicated, No concentrated sweets . A review of the facility's document titled, Order Sheet-Diet, dated January 1, 2024, for Resident 19 indicated, Sodium Restriction 2.4 GM (gram- a unit of measurement) . A review of the facility's document titled, Order Sheet-Diet, dated January 1, 2024, for Resident 30 indicated, Regular . A review of the facility's document titled, Order Sheet-Diet, dated January 22, 2024, for Resident 54 indicated, .No concentrated sweets . A review of the facility Policy and Procedure titled, Portion Control Guidelines, indicated . Food Service Employees refers to production sheets for the proper portion size for all food service . When the patient/resident's menu has measured portions designated, food items may be measured by weight as appropriate . A review of the facility's menus for Regular, Low Sodium, and No Concentrated Sweets diets, indicated .portion size for these diets was half cup of rice and half cup of broccoli . During a review of the facility's policy titled, Menu Policy, dated September 2022, indicated, .Standard recipes and standard serving guide are tools used by the food service staff to ensure nutritional adequacy is met for the patients/residents prescribed diet order .

Based on observation, staff interviews, and record review, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time Registered Dietitian and/or a full-time Director of Food Services in accordance with California Code, Health and Safety Code - HSC S 1265.4 The lack of a full-time, qualified supervision over Food and Nutrition services had the potential to result in inadequate supervision leading to food borne illness for seven residents who received food from the kitchen out of a facility census of 58. Findings: During the Federal re-certification survey from February 12, 2024 - February 15, 2024, it was noted that Food and Nutrition services provided meals not only to skilled nursing residents but also to a separately licensed, Behavioral unit. The skilled nursing facility's Director of Nutritional Services (DRD) and the Nutritional Services Manager (DSS) were working in 3 different facilities, Acute Hospital, Skilled Nursing facility (SNF) and Behavioral unit. Review of the organizational structure of the facility identified that the Skilled Nursing Facility was part of a continuing care of the Acute Hospital care. According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. On February 12, 2024, at 9:56 a.m., an interview was conducted with the DRD and the DSS. The DRD and the DSS stated both of them were in charge as Food service/dietetic services supervisors with the Acute Hospital, Skilled Nursing Facility and Behavioral unit. On February 14, 2024, at 10:17 a.m., a phone interview was conducted with the Registered Dietician (RD) 3 and RD 4. RD 3 and RD 4 stated both of them worked as part time clinical dietitian two days per week at the SNF. RD 3 and RD 4 claimed they never involved any Food service/dietetic services work at the SNF. On February 14, 2024, at 10:36 a.m., an interview was conducted with RD 2. RD 2 stated she worked as a full time clinical dietitian at the SNF. RD 2 explained her main focus work loads were providing residents' nutrition assessment, evaluating Residents' with weight issue and developing residents' nutritional care plans. RD 2 stated she did not have experience of food service management work. RD 2 stated the Food service/dietetic services work at the SNF she perform were less than an hour test tray one time per month and less than an hour sanitation kitchen audit one time per month. On February 15, 2024, at 12:55 p.m., an interview was conducted with the Chief Operating Officer (COO). The COO confirmed the DRD and the DSS were the supervisors of Food and Nutrition Services which included the Acute Hospital, Skilled Nursing Facility and behavioral unit. During a review of the facility provided organizational chart, undated, indicated, Acute hospital and SNF organizational chart which showed the organization of Food and Nutrition Staff, reported to Chief Operating Officer and all Food and Nutrition staff were under the Director of Nutritional Services.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when : 1. The Prep sink did not have an air gap; 2. Nine cutting boards surface were heavily marred; 3. Three storage silver shelves in trayline area had rust; 4. Two microwaves in the kitchen were dirty; 5. Lacked temperature monitor for Prep table refrigerator; 6. Multiple areas in the kitchen were covered with dust; 7. The walk in refrigerator's gasket was wore out; 8. Unsanitary storage condition in walk in refrigerator; 9. Multiple areas in the kitchen's floor did not have smooth surface; 10. Trash were found in the multiple areas in the kitchen; 11. Build up grease and black/brown debris found on fire suppression unit above stove and fryer; 12. Cobweb found in dry storage room; and 13. Under the grill/stove range there was burn buildup material and black particles. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of seven out of 58 residents who received food prepared in the kitchen. Findings: 1. On February 12, 2024, at 10:45 a.m., an observation with the Cook (CK) in front of the Prep sink (sink used for washed produce). The CK used the prep sink to wash produce. On February 12, 2024, at 11:45 a.m., a concurrent observation and interview with the Director of Nutritional Services (DRD) and the Nutritional Services Manager (DSS) in front of the Prep sink was conducted. The DRD and the DSS stated they used this sink as the Prep sink. The DSS confirmed the Prep sink did not have an air gap (An air gap refers to a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevent drain water from backing up into the sink and possibly contaminating the area used for washing food). The DRD was not aware the Prep sink need to have an air gap. On February 14, 2024, at 4:00 p.m., an interview was conducted with the DRD, the DRD stated there was no policy and procedure for an air gap. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Section 5-203.14 Backflow Prevention Device, the FDA Food Code indicated, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap . 2. On February 12, 2024, at 11:57 a.m., a concurrent observation and interview was conducted with the DRD and the DSS in the kitchen. There was four 24 inch length x 18 inch width cutting boards and another five 12 inch length x 18 inch width cutting boards were observed heavily marred (impaired surface). Some of the cutting boards had black and brown stain on surface. The DRD and the DSS confirmed the nine cutting boards were heavily marred. The DRD explained heavily marred cutting boards were unable to clean properly due to food particles stuck on scratched surface which could cause cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated .13. Equipment/Environment: .iv. For cutting boards: .(d) Replace cutting board when deep grooves or gouges are visible on the board. 3. On February 12, 2024, at 9:59 a.m., a concurrent observation and interview was conducted with the DRD and the DSS in the kitchen trayline area. Three silver storage shelves were observed with brown grime. The DRD stated brown grime was rust on the silver storage shelves. The DRD stated storage shelves were not supposed to have rust because rust could get into foods stored on the shelves. On February 14, 2024, at 4:00 p.m., an interview was conducted with the DRD. The DRD stated there was no policy and procedure for rusting shelves. During a review of the Federal FDA (Food and Drug Administration) Food Code 2022, Section 4-101.11 Equipment Characteristics, the FDA Food Code indicated, .FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: (A) Safe; (B) Durable, CORROSION-RESISTANT, and nonabsorbent; . (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. 4. On February 12, 2024, at 9:53 a.m., a concurrent observation and interview was conducted with the DRD in the kitchen trayline area. Brownish particles were found inside the microwave and the microwave's door. The DRD stated the brownish particles inside the microwave and the microwave's door were splashed of the foods. On February 12, 2024, at 10:54 a.m., a concurrent observation and interview was conducted with the DRD and the DSS in the main cook area. The brownish particles were found inside the microwave. The DSS confirmed the brownish particles inside microwave were splashed of the foods. The DRD stated both microwaves needed to be clean after each used to prevent cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated .13. Equipment/Environment: .equipment and contact surfaces are cleaned and sanitized between uses. 5. On February 13, 2024, at 10:01 a.m., a concurrent observation, interview and record review was conducted with the DRD, and the Cook in the kitchen main cook area. There was no temperature monitoring for the Prep table refrigerator in front of walk-in refrigerator which had foods stored inside. The Cook stated she did not monitor the Prep table refrigerator in front of the walk in refrigerator because the other side of the Prep table refrigerator in front of oven was broken. The DRD stated the Cook should monitor the Prep table refrigerator in front of the walk in refrigerator. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated .10. Storage: .vi. Temperature records are maintained daily on refrigerators . During a review of the facility provided documentation, titled, Daily Record of Refrigerator/Freezer Temperature, indicated Prep table refrigerator was not monitored since September 8, 2023. 6. On February 12, 2024, at 10:30 a.m., a concurrent observation and interview was conducted with the DRD in kitchen trayline area. There was black debris hanging on the vent near the enter door. Opened boxes of food were observed stored under the vent. The DRD stated the black debris was dust, which could potentially fall into the foods stored under the vent. On February 12, 2024, at 3:13 p.m., a concurrent observation and interview was conducted with the DRD and the DSS in kitchen. There was black/brown debris hanging on the wall above hand washing sink, the vent in cook area, all light fixtures, fire sprinklers, the wall behind ice machine. The DRD confirmed black/brown debris was dust. The DRD stated the dust could potentially fall into foods and cause cross contamination. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I.SCOPE: Nutritional Service Staff.III. POLICY: Efforts are directed toward assuring that cross-contamination is minimized; . During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Section: 4-602.13 Nonfood-Contact Surfaces , the FDA Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 7. On February 12, 2024, at 4:28 p.m., a concurrent observation and interview was conducted with the DRD in the walk-in refrigerator. The gasket (rubber piece that lined around refrigerator door to prevent moist coming in refrigerator and cool air sip out refrigerator) on the walk-in refrigerator was observed to be worn out. The DRD explained worn out gasket was unable to prevent moist air from going into the walk-in refrigerator which could cause mold. On February 14, 2024, at 4:00 p.m., an interview was conducted with the DRD. The DRD stated there was no policy and procedure for Nutritional Services Department regarding Equipment maintenance. During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Annex 3 Section: 4-501.11 Good Repair and Proper Adjustment, the Food code indicated, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. 8. On February 12, 2024, at 10:39 a.m., an observation was conducted in the walk-in refrigerator. There was five food storage shelves inside the walk-in refrigerator. All five storage shelves were used to store produce, milk, eggs, and meats. The five storage shelves were observed covered with black/brown grime. Grayish/black, whitish fuzzy particles were found underneath of storage shelves. The wall was observed chipped and missing white paint. The white wall was observed with the black grime. The white pipe on ceiling behind the vent was covered with black debris. The floor under storage shelves had black grime. One orange, one yellow bell pepper, and one plastic bag were observed on the floor under the storage shelves. On February 12, 2024, at 4:28 p.m., an interview was conducted with the DRD and the DSS in the walk-in refrigerator. The DRD stated the grayish/black, whitish fuzzy particles underneath the storage shelves were mold. The DSS stated the food service workers were supposed to clean the storage shelves twice per week when they bring in new produce. The DRD stated the food service workers only wiped the top of the storage shelves and not underneath the shelves. The DRD also stated food service workers did not swept the floor under the storage shelves. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I. SCOPE: Nutritional Service Staff.III. POLICY; Efforts are directed toward assuring that cross-contamination is minimized; .and employee conduct is such as to contain infection or minimize the exposure to recognized hazards.12. Cleaning: a. The objective is to maintain the greatest degree of sanitation possible in all food areas and to prevent growth of bacteria in all areas.13. Equipment/Environment: .equipment and contact surfaces are cleaned and sanitized . 9. On February 12, 2024, at 4:49 p.m., a concurrent observation and interview was conducted with the DRD in the walk-in refrigerator. Multiple indentations on the floor was observed in the walk-in refrigerator where milks were stored. Whitish color liquid was observed sitting on the indentations of the floor. The DRD acknowledged the walk-refrigerator floor had multiple indentations. On February 13, 2024, at 10:41 a.m., a concurrent observation and interview was conducted with the DRD in front of the ice machine. The floor on the ice machine area was observed with rough surface with black grime. The DRD stated the floor did not have smooth surface and could not be cleaned properly. On February 14, 2024, at 4:00 p.m., an interview was conducted with the DRD. The DRD stated there was no policy and procedure related to the floor surface. During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Section: 6-101.11 Surface Characteristics, the Food Code indicated, (A) .materials for indoor floor, under conditions of normal use shall be: (1) SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted; . 10. On February 12, 2024, at 10:26 a.m., a concurrent observation and interview was conducted with the DSS in trayline area. Trash [one 4 ounces (oz- a unit of measurement) disposable cup, an opened butter condiment, plastic wraps, one container of 4 oz unopened orange juice], dirt, black grime were observed under the number four reach-in refrigerator. The DSS confirmed there was trash under the number four reach-in refrigerator. The DSS stated the potential risk of having trash in kitchen could attract pests. On February 12, 2024, at 10:49 a.m., a concurrent observation and interview was conducted with the DSS and the DRD in the utility room. An empty opened can soda and a bottle cap and black grime were observed on the floor. The DSS stated an empty opened can soda and cap were not supposed to be on the floor. The DRD confirmed the floor had black grime. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I. SCOPE: Nutritional Service Staff.12. Cleaning: a. The objective is to maintain the greatest degree of sanitation possible in all food areas . During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Section: 4-602.13 Nonfood-Contact Surfaces , the Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 11. On February 13, 2024, at 10:23 a.m., a concurrent observation and interview was conducted with the DRD and the DSS. The brown/black debris, build up grease was observed hanging on the fire suppression unit above the stove. The DRD and the DSS confirmed the brown/black debris was dust and the build up grease accumulated on fire suppression unit above the stove. The DRD stated there was a potential risk dust and grease could fall into foods when cooks preparing foods on the stove. On February 13, 2024, at 10:23 a.m., a concurrent observation and interview was conducted with the DRD and the DSS. The brown/black debris, build up grease was observed hanging on fire suppression unit above the fryer. The DRD and the DSS confirmed the brown/black debris was dust and the build up grease accumulated on fire suppression unit above the fryer. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I.SCOPE: Nutritional Service Staff.III. POLICY: Efforts are directed toward assuring that cross-contamination is minimized.12. Cleaning: a. The objective is to maintain the greatest degree of sanitation possible in all food areas . 12. On February 13, 2024, at 9:53 a.m., a concurrent observation and interview was conducted with the DRD in the dry storage room. Cobweb was observed under the storage shelves. The DRD confirmed there was cobweb under the storage shelves. During a review of the facility Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated .11. Pest Control: a. The objective is to maintain a sanitary environment, preventing contamination and transmission of disease by insects or rodents.f. Daily, Managers and supervisors inspect all areas where food is stored, prepared, and served. 13. On February 13, 2024, at 10:29 a.m., an interview was conducted with the DRD and the DSS in front of grill/stove range. There was burn buildup material and black particles under the grill. The DRD and the DSS confirmed there was burn buildup material and black particles under the grill. The DRD stated the burn buildup material and black particles was not supposed to be accumulated under the grill because it could cause cross contamination and could also attracted insects or pests. During a review of the facility's Policy and Procedure (P&P) titled, Departmental Infection Control; Section: Nutritional Services Department, Revision 2/2024, the P&P indicated I. SCOPE: Nutritional Service Staff.III. POLICY: Efforts are directed toward assuring that cross-contamination is minimized.and employee conduct is such as to contain infection or minimize the exposure to recognized hazards. 12. Cleaning: a. The objective is to maintain the greatest degree of sanitation possible in all food areas and to prevent growth of bacteria in all areas.13. Equipment/Environment: .equipment . are cleaned . During a review of the Federal Food and Drug Administration (FDA) Food Code 2022, Section: 4-602.13 Nonfood-Contact Surfaces , the Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.