Every finding on record at Meadowbrook Village Christian Retirement Community

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standard of practice when: 1.Food stored in the refrigerators and freezer were expired and did not have a label, 2.Food stored in the dry storage room were expired or mislabeled, 3.Drying rack had scoopers stored in a container with debris and a green cutting board with discolored center had deep knife marks. 4.A stand electric fan with black debris on the blades was in the kitchen facing the food prep area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness.Findings: During the initial kitchen tour, a joint observation and interview was conducted on 2/10/26 at 7:55 A.M. with the facility chef. 1.Kitchen refrigerators: -Refrigerator 1 next to door entrance was observed with two unlabeled bottles of balsamic vinegar. -Refrigerator 2 next to steam table was observed with a bag of sliced carrots, bag of sprouts, bag of diced onions with celery, a container of red, sliced potatoes in water, a container with mushrooms. All were unlabeled. -Refrigerator 2 was observed with sliced cherry tomatoes with use by date of 2/1/26 and sauerkraut with use by date of 2/6/26. The freezer next across the ice machine was observed with sausages in a plastic bag with use by date of 2/5/26. 2.Dry storage room: -A large wooden rolling pin was observed on top shelf of food rack. -Dried blueberries in a plastic bag and poppy seed in plastic bag had a sticker with use by date 12/6, but no year. -Vanilla extract was observed with use by date 1/14, but no year. -A box of graffiti sprinkles with use by date 12/15, no year. -Sliced almonds in plastic bag was labeled 5/3/25, no use by date. -A bottle of food coloring dated 7/9/25 without expiration date. -A bottle of honey was observed with use by date 2/4/26. -White beans was observed with use by date 2/7/26. 3. A drying rack next to dishwasher was observed with food scoops in a container with debris. A large green cutting board with white discoloration in the center had deep knife marks. 4. A stand electric fan facing the food preparation area was observed with black debris on the blades. An interview on 2/12/26 at 1 P.M. was conducted with the Registered Dietician (RD). The RD stated she expected the kitchen to be cleaner, organized and food labeled for food safety, to prevent contamination and expiration of food. A review of the facility's policy and procedure (P&P) titled Food Storage, dated 1/1/18 was conducted. The P&P indicated, Food storage areas shall be clean at all times.Store, prepare, distribute and serve food in accordance with professional standards for food service safety.All open food items will have an open date and use-by-date per manufacturer's guidelines. According to the 2022 Federal FDA Food Code, section 3-501.17 (A) (B) (C) (D) indicate .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises .

Based on observation, interview, and record review, the facility failed to implement infection control standards of practice when: 1.Facility staff were unaware of the required Enhanced Barrier Precaution (EBP-an infection control strategy that mandate the use of gowns and gloves during high-contact resident care) for a resident (Resident 6) with an indwelling urinary catheter (soft, plastic or rubber tube that is inserted into the bladder to drain the urine), 2. A stand electric fan with black debris on the blades was inside the kitchen food prep area. Cross reference F812 This failure had the potential to spread infection throughout the facility.Findings: 1.Resident 6 was readmitted to the facility on [DATE] with diagnoses including urinary tract infection and retention of urine according to the facility's Resident Face Sheet. During an observation and interview on 2/10/26 at 9:43 A.M., Resident 6 was sitting up in a wheelchair in his room. Resident 6 showed a urine bag attached to his left thigh. Resident 6 stated he had a urinary catheter because he could not urinate. Resident 6 stated he has had two bladder infections and completed taking an antibiotic. There was no sign outside Resident 6's room to indicate EBP. An interview and joint record review on 2/11/26 at 11:23 A.M was conducted with Licensed Nurse (LN) 2. LN 2 reviewed physician's orders in Resident 6's electronic medical record (EMR) at the nursing station. Resident 6's physician's order indicated, Indwelling catheter connected to drainage bag. DX [diagnosis]: urinary retention. LN 2 stated she was not aware of EBP. LN 2 stated residents required isolation only in the presence of a contagious disease. During an observation and interview on 2/12/26 at 10:20 A.M., Resident 6 was sitting up in a wheelchair in his room. Resident 6 stated the Certified Nurse Assistants (CNA) changed his catheter bag to a leg bag. Resident 6 stated the CNAs wore gloves during the change of bags but did not wear gowns. An interview on 2/12/26 at 12:55 P.M. was conducted with CNA 2. CNA 2 stated EBP was for residents with contagious diseases. CNA 2 stated Resident 6 had a urinary catheter and did not need to have EBP because he had no infection. An interview on 2/13/26 at 8:13 A.M. was conducted with the Director of Nursing (DON). The DON stated EBP should be followed for residents with pressure ulcers [bedsores], intravenous lines [thin catheter into a vein], indwelling urinary catheters or other devices to prevent the spread of Multidrug-Resistant Organism (MDRO-bacteria or other germs that have developed resistance to three or more types of antibiotics, making them very difficult to treat) and to protect staff and residents. A review of the facility's undated policy and procedure (P&P) titled, INFECTION CONTROL PROGRAM, was conducted. The P&P indicated the facility shall establish an infection control program designed to provide a safe, sanitary and comfortable environment for residents and staff to help prevent the development and transmission (spread) of disease and infection. The P&P did not provide guidance regarding EBP. A review of the facility's P&P titled, Enhanced Standard [Barrier] Precautions, was conducted. The P&P was dated 2/12/26 during the facility's recertification survey. The P&P indicated, Enhanced Standard Precautions are used in addition to Standard Precautions for residents at increased risk of pathogen transmission (spread of germs). Enhanced Standard Precautions shall be implemented for residents who.have indwelling medical devices [.urinary catheter, central line, feeding tube, tracheostomy (trach-surgical opening in the neck)].Gowns and gloves are required during high-contact resident care activities, including but not limited to: Dressing, bathing, hygiene care, Transferring and repositioning, Toileting assistance, Wound care, Device care [catheters, trachs, feeding tubes], Changing linens, Handling soiled items. During a review of the Centers for Disease Control and Prevention (CDC- the national public health agency that protects the public's health in the United States) website at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, the CDC indicated, Even if the resident colonized with a MDRO is placed on Contact Precautions (e.g. (for example), for uncontained secretions or excretions, acute diarrhea, draining wounds, or ongoing transmission within the unit or facility is suspected), Enhanced Barrier Precautions are still recommended for other at-risk residents [i.e. (specifically), those with indwelling medical devices or wounds] in the facility. 2. The initial kitchen tour was conducted on 2/10/26 at 7:55 A.M. with the facility chef. A stand electric fan with black debris on the blades was observed in the kitchen facing food prep area. An interview on 2/12/26 at 1 P.M. was conducted with the Registered Dietician (RD). The RD stated she expected the kitchen to be cleaner for safety and infection control. During a review of the facility's policy and procedure (P&P) titled Food Storage, dated 1/1/18 the P&P indicated, Food storage areas shall be clean at all times. Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Based on observation, interview and record review, the facility failed to ensure a baseline care plan (the minimum healthcare information necessary to properly care for each resident immediately upon their admission) meeting was conducted within 48 hours for one of two residents (Resident 21) reviewed for baseline care planning. This failure had the potential for incomplete and lack of care interventions for residents in the event of a serious change of condition to potentially occur to residents after admission. In addition, the lack of communication among facility staff and resident or responsible party had the potential to affect the quality of care to the resident. Findings: Resident 21 was admitted to the facility on [DATE] with diagnoses including hydrops of gallbladder (severely distended gallbladder [an abdominal organ that releases bile into the small intestine] filled with clear, water mucus) and unspecified nausea and vomiting according to the facility's Resident Face Sheet. During an observation on 2/10/26 at 10:21 A.M., Resident 21 was lying in bed frowning. Resident 21 stated she was having pain on her left leg and abdomen and would like to speak with her attending physician. Resident 21 stated there has not been a meeting about her care and have not received a list of her medications. An interview on 2/11/26 at 9:47 A.M. was conducted with Licensed Nurse (LN) 2. LN 2 stated she did not complete baseline care plans. An interview on 2/11/26 at 10:13 A.M. was conducted with the Director of Staff Development (DSD- a licensed nurse certified for staff training). The DSD stated the nursing staff initiated care plans for newly admitted residents and other problems were added as needed during the residents' stay in the facility. The DSD stated residents or resident representatives did not receive a copy of their plan of care or medication list. During an interview on 2/13/26 at 8:13 A.M. with the Director of Nursing (DON), the DON stated she did not know about completing a baseline care plan for newly admitted residents. The DON further stated the facility did not have a policy and procedure regarding baseline care plans.

Based on interview and record review the facility failed to ensure employee performance evaluations were completed annually for four of five Certified Nurse Assistants (CNA) reviewed for performance reviews. This deficient practice had the potential for CNAs to provide inadequate care to the residents.Findings: A concurrent employee personnel record review and interview was conducted on 2/12/26 at 10:07 A.M. with the Director of Staff Development (DSD- a licensed nurse responsible for staff training). The DSD stated she had not completed CNA performance evaluations for the year 2025. CNA records were reviewed: CNA 5 was hired by the facility on 11/11/22 and no performance evaluation was completed for 2025. CNA 6 was hired by the facility on 5/10/21 and no performance evaluation was completed for 2025. CNA 7 was hired by the facility on 2/6/24 and no performance evaluation was completed for 2025. CNA 7 was hired by the facility on 12/13/23 and no performance evaluation was completed for 2025. During an interview on 2/13/26 at 8:13 A.M. with the Director of Nursing (DON), the DON stated it was important to complete employee performance reviews to provide staff education for better patient outcome. A review of the facility's policy and procedure (P&P) provided by the DON titled, Job Descriptions and Performance Evaluations, dated August 2010 was reviewed. The P&P indicated, The primary purpose of our facility's job descriptions and performance evaluations is to provide uniform guidelines for the implementation of our job requirements and the evaluation of the standards of job performance.The objectives.are to.Assist employees in understanding the essential functions, responsibilities, working conditions, and specific and physical requirements of their positions.

Based on observation, interview, and record review the facility failed to ensure one of two residents reviewed for unnecessary medications were free from unnecessary use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: Resident 3 did not have an acceptable indication for use of seroquel (an antipsychotic medication that work to alter brain chemistry to reduce psychotic symptoms such as hallucinations [seeing things not there], delusions [irrational beliefs], paranoia [thoughts of others trying to harm of deceive] and disordered thinking), A gradual dose reduction (GDR- tapering of a medication's dosage to determine if the resident's symptoms can be managed on a lower dose or if the drug can be discontinued) for the use of seroquel was not completed (Resident 3). These failures resulted in unnecessary medications for Resident 3 which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: Resident 3 was admitted to the facility on [DATE] with diagnoses including right femur (thigh bone) fracture and Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out simple tasks) according to the facility's Resident Face Sheet. During an observation on 2/10/26 at 3:17 P.M., Resident 3 was sitting on a wheelchair in the activity room coloring a book. Resident 3 was smiling and stated she did not remember how long she had been at the facility. During a review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 12/30/25, section C0500 indicated Resident 3's Brief Interview for Mental Status (BIMS- evaluates cognition, the ability to remember and think clearly) score was 07, severe impairment. An interview and joint record review was conducted with Licensed Nurse (LN) 2 on 2/11/26 at 9:21 A.M. LN 2 stated Resident 3 often yelled out, Help me because Resident 3 preferred to have someone by her. LN 2 stated Resident 3 was easily re-directed when re-assured. LN 2 reviewed Resident 3's physician's orders in the electronic medical record (EMR) at the nurse's station. LN 2 stated Resident 3 had orders since admission for seroquel to be given at night for Resident 3's constant worrying asking, Where am I? LN 2 stated on 12/20/25 Resident 3 was yelling and requested for pain medication. LN 2 stated Resident 3's physician had ordered to increase the Seroquel but Resident 3's daughter declined to have the medication increased. During an interview on 2/11/26 at 9:58 A.M. with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 3 stayed in activities and called for staff to use the bathroom. CNA 3 stated Resident 3 had no behaviors. During an interview on 2/11/26 at 3:24 P.M. with afternoon shift CNA 4, CNA 4 stated Resident 3 was often anxious and called out, Help, help frequently. CNA 4 stated Resident 3 calmed down when staff sat with Resident 3. CNA 4 stated Resident 3 did not hallucinate but mumbled to herself stating, I'm lonely. An interview and joint record review was conducted with Licensed Nurse (LN) 2 on 2/11/26 at 9:21 A.M. LN 2 stated there was no GDR for the use of seroquel in Resident 3's EMR. LN 2 stated the Director of Nursing (DON) and the Director of Staff Development (DSD- a licensed nurse certified for staff training) completed GDRs for residents. A review of Resident 3's physician's progress notes (PN) was conducted. Resident 3's physician's PN indicated: 12/30/26 - Alzheimer's dementia. She will continue on the Seroquel for now. We will try to wean her off of this. She was oriented times 0 [zero] this morning. She is hard of hearing but attempts answering most questions. 1/9/26- Alzheimer's dementia. The patient is to continue with her current dosage of Seroquel. If she continues to have issues with behaviors and the daughter refuses to allow further increase in the Seroquel, I may need to consider the addition of Aricept to see if this would help with the behaviors. 1/13/26- Alzheimer's dementia. Agitation. Anxiety. She will continue on the Seroquel. She was oriented times 0 this morning. the gabapentin should have also helped to provide some relief for the patient. 1/28/26-Alzheimer's dementia. Agitation. Anxiety. She will continue on the Seroquel and gabapentin. Pleasant with me today. During an interview on 2/12/26 at 8:16 A.M. with the facility's consultant pharmacist (CP), the CP stated she reviewed Resident 3's medications on 2/9/26 and sent a letter for the physician on 2/10/26 to re-evaluate the use of seroquel. The CP stated the use of Seroquel was contraindicated for residents with dementia (an impairment of brain function, such as memory loss and judgment). The CP further stated the facility can do trial to discontinue the medication. During an interview on 2/13/26 at 8:13 A.M. with the DON, the DON stated the facility's interdisciplinary team (IDT-team members with various areas of expertise who work together toward the goals of their residents) did not conduct a psychotropic medication review to discuss the appropriate use antipsychotics. The DON stated the pharmacist reviewed residents' medications monthly and recommended if GDR was needed. The DON stated the use of antipsychotic medication such as seroquel for residents with dementia was contraindicated. A review of the facility's policy and procedure (P&P) titled, Psychotropic Medication, dated 3/25/24 was conducted. The P&P indicated, It is the policy of Meadowbrook Village to promote each resident's rights to be free from chemical restraints [such as antipsychotics, to restrict a patient's movement, manage a behavior or sedate them rather than treat a specific medical symptom]. A review of the facility's P&P titled, Behavior Management Policy, dated 7/17/24 was conducted. The P&P indicated, The interdisciplinary team [IDT] will evaluate.Medical causes [pain, infection, delirium, medications.Cognitive and mental health status.Environmental and psychological triggers.

Based on observation, interview and record review the facility failed to identify a resident's (Resident 10) need for occupational therapy for one of four residents reviewed for specialized rehab services (physical therapy, occupational therapy or speech therapy). This failure had the potential for a decline in the resident's functional status.Findings: Resident 10 was admitted to the facility on [DATE] with diagnoses including muscle weakness and other abnormalities of gait (walking) and mobility according to the facility's Resident Face Sheet. A review of Resident 10's Minimum Data Set (MDS- a federally mandated resident assessment tool) was conducted. The MDS dated [DATE] section C0500 indicated Resident 10's Brief Interview for Mental Status (BIMS- evaluates cognition, the ability to remember and think clearly) score was 15, intact cognition. During an observation and interview on 2/10/26 at 9:24 A.M., Resident 10 was sitting up in a wheelchair next to her bed. Resident 10 stated she did not have meals in the dining room because she needed assistance with eating. Resident 10 stated she spilled food while eating and made a mess which was the reason for not going to the dining room. Resident 10 stated she did not have occupational therapy. During an observation and interview on 2/10/26 at 12:28 P.M., Resident 10 was having lunch in her room. Resident was observed to pick up noodles from the plate using a fork and very slowly placed the food in her mouth. An interview on 2/11/26 at 9:58 A.M. was conducted with Certified Nurse Assistant (CNA) 3. CNA 3 stated Resident 10 ate her meals in the room because Resident 10 declined to eat in the dining room. CNA 3 stated she was not aware of Resident 10 needed assistance during meals. An interview on 2/11/26 at 2:52 P.M. was conducted with the facility's occupational therapist (OT). The OT stated Resident 10's prior level with eating was set up assistance. The OT stated Resident 10 was referred to OT in January due to inability to reach her food during meals. The OT stated the rehab staff worked on Resident 10's positioning in the wheelchair during meals and staff were trained. The OT stated Resident 10's concern with spilling food while eating was a new issue and she was not aware of the problem. The OT stated resident screening was only completed upon admission and when referred by the nursing staff. During an interview on 2/13/26 at 8:13 A.M. with the Director of Nursing (DON), the DON stated she was not aware of Resident 10's concern with eating. The DON stated it was important to identify the problem and refer to rehab to keep the resident's independence and dignity as much as possible.A review of the facility's policy and procedure (P&P) titled, Rehabilitation Services, dated 10/20/24 was conducted. The P&P indicated, The Skilled Nursing Facility [SNF] provides comprehensive rehabilitation services including Physical Therapy [PT], Occupational Therapy [OT], and Speech-Language Pathology [SLP], to assist residents in attaining and maintaining their highest practicable physical, mental, and psychosocial well-being.

Based on interviews and record review, the facility failed to implement standardized data collection and reporting for their Quality Assurance Performance Improvement/Quality Assessment and Assurance (QAPI/QAA) program.This failure had the potential for facility areas of improvement to not be recognized and not progress toward resolution. During the Quality Assurance and Performance Improvement (QAPI) interview on 2/13/2026 at 12:30 p.m. with the facility Administrator (ADMIN), the ADMIN stated that each participant in the QAPI program brings forward concerns in their areas. The individual area leader decides the scope of their project and how data is recorded and shared. The ADMIN further stated .standardization would help everyone see and understand the results.During a review of the facility's policy and procedure titled Quality Assurance and Performance Improvement Plan dated April 2014, indicated .The objectives of the QAPI Plan are.3. Provide structure and processes to correct identified quality and /or safety deficiencies. and further indicated .Implementation.3. The QAPI Committee shall oversee and authorize QAPI activities, including data-collection tools, monitoring tools, and the basis for appropriateness and effectiveness.

Based on interview and record review, the facility failed to implement Performance Improvement Plans (PIPs). The facility was not aware of the deficient practices identified during the recertification process for an unknown amount of time. This failure had the potential to not address high volume, high risk occurrences impacting residents' health and safety.During the Quality Assurance and Performance Improvement (QAPI) interview on 2/13/2026 at 12:35p.m. with the Director of Nursing (DON) and the facility Administrator (ADMIN), the DON stated, We do not have any performance improvement projects.During a review of the facility's policy and procedure titled Quality Assurance and Performance Improvement Plan dated April 2014, indicated .Authority.2. The administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, local regulatory agency requirements.

Based on observation, interview, and record review, the facility failed to: 1. Store foods appropriately in the dry storage room and freezer. 2. Cover facial hair while preparing food. These failures had the potential for food contamination and spoilage of residents' food. Findings: 1. On 10/29/24 at 8:47 A.M., an initial tour of the kitchen and an interview was conducted with the [NAME] (C1). During an observation of the dry storage room the following were noted: -Chocolate flavored syrup bottle had brown sticky liquid all over the bottle. -Rice cereals were in an unsealed bag and not labelled with the open date. -Bran cereal bag was sealed, but not labelled with the open date. -Flour, thickener, and panko breadcrumbs were stored in large white bins with a large gaps, approximately 1-2 inches between the container and the lids of all three bins. The label on the thickener was very faded and unreadable. During the observation of the facility's freezer, two small containers of ice cream were found unlabeled with open date. C1 stated that if food containers were not sealed, the product could have been contaminated by pests or not preserved its quality. C1 stated that the gaps between lid and top of container could allow contamination from pests. C1 stated that it was important to label all food clearly with open dates, to provide information when the products were past the expiration date. 2. On 10/29/24 at 8:40 A.M., during the initial tour of the kitchen, [NAME] (C1) and Dietary Aide (DA 1) were observed to have beards, and were not wearing beard nets while preparing food. DA 1 was cutting fruits. An interview was conducted. DA 1 stated he just started to grow his facial hair and forgot to wear his beard net. C1 stated the policy was staff with facial hair were required to wear beard nets while in the kitchen. C1 and DA 1 both applied beard nets. DA 1 stated that he was supposed to wear a beard net when working with food to prevent facial hair from falling into food and contaminating it. C1 stated it's important to wear beard nets to not contaminate the food with their facial hair. On 10/30/24 at 12:30 P.M., an observation of kitchen task related photos and an interview was conducted with the Certified Dietary Manager (CDM). There were photos taken during the initial tour of the kitchen, dry storage room and the freezer. The CDM stated the expectation for the dry food storage was that food should be in a sealed container and labeled. The CDM stated that the importance of proper food storage was to prevent contamination and to ensure the food was not past the expiration date. The CDM stated the expectation for food service staff with facial hair was that when they choose to have facial hair, they were required to wear beard net while working with food. The CDM stated the importance of using beard nets was to prevent contamination of food from the food service worker's facial hair. On 10/31/24 at 10:30 A.M., an observation of kitchen task related photos and an interview was conducted with the Administrator (ADM). The ADM stated his expectation for food storage was that all food should be labelled and in a sealed container. The ADM stated the importance of sealing and labelling was to prevent contamination and spoilage of food. The ADM stated his expectation of food service staff was all hair, including facial hair should be covered while working with food or in the kitchen. The ADM stated the importance of covering hair was to prevent food contamination from the hair. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 3-501.17 (A) (B) (C) (D), .required food labeling and dating .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 2017 4-601.11) Equipment .Non-food contact surfaces .Non-food contact surfaces of equipment shall be kept free from accumulation of dust, dirt, food residue, and other debris. Additionally, 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. Review of facility policy titled FOOD SERVICE MANAGEMENT, dated 2023 indicated .All food and nonfood items purchased for the Food and Nutrition Services Department will be properly stored .All open food items will have an open date and use-by-date per manufacturer's guidelines .1.Food storage areas shall be clean at all times .2 .All packaged food .or food items shall be kept clean and dry at all times . Review of facility policy titled PERSONNEL MANAGEMENT, dated 2023 indicated .5. All Food and Nutrition Services staff are required to wear hairnets or caps or other suitable coverings to confine all hair when required to prevent the contamination of food, equipment, or utensils .7. Beards, sideburns, and mustaches shall be covered .

Based on observation, interview, and record review, the facility failed to adequately clean the area around their kitchen dumpster. This failure had the potential to attract pests and rodents. Findings: On 10/30/24 at 11:40 A.M., an observation of the food dumpster and interview with the [NAME] (C1) was conducted. The kitchen dumpster for food was located behind the main building of the facility campus. A putrid smell was noticeable around dumpster. The area around the dumpster had remnants of oily, grimy liquid spills on the concrete near the dumpster and on the side of the dumpster. Multiple used gloves were observed on the floor around the dumpster. Two small white bags of garbage were observed under the dumpster. C1 stated the expectation was the area around the dumpster should be cleaned regularly and to not have stray trash below or around outside of the dumpster. C1 stated that the importance of cleaning around the dumpster area was to prevent attracting pests and rodents to the trash. C1 stated he had seen a possum at the dumpster a week ago. On 10/30/24 at 12:30 P.M., an observation of photos of kitchen's dumpster and an interview with Certified Dietary Manager (CDM) was conducted. The CDM stated the expectation was garbage should be contained within the dumpster, and the area around the dumpster should be cleaned. The CDM stated the importance of cleaning the area around the dumpster was to prevent pests and rodents from infesting the area. On 10/31/24 at 10:30 A.M., an observation of photos of the kitchen's dumpster and an interview with the Administrator (ADM) was conducted. The ADM stated his expectation was the area around the dumpster should be kept cleaned, no loose trash around or under the dumpster to prevent pest and rodent infestations. Review of policy title Cleaning Procedure - Garbage cans and lids, dated 2023 indicated 'When to be cleaned: weekly .Maintain high standards of cleanliness .

Based on observation, interview and record review, the facility failed to ensure: 1. Medications (med) were stored properly. 2. Medication Refrigerator temperatures were documented consistently for one of one medication refrigerator. 3. Medication room temperatures were documented consistently for one of one medication room. These failures had the potential for unsafe storage, contamination of medication and altered efficacy of resident medications. Findings: 1. On 10/30/24 at 4:27 P.M., a joint observation of the med cart in the back hall and an interview was conducted with Licensed Nurse (LN) 1. There were oral medications in liquid forms, tablet, and capsule forms, comingled with eye drops in the second drawer of the med cart. LN 1 stated, There should be no liquid medication form and eye drops there. LN 1 stated the medications should not be mixed up. On 10/31/24 at 7:48 A.M., an interview was conducted with LN 1. LN 1 stated the importance of keeping the med cart organized was to prevent contamination and ease of med identification. On 10/31/24 at 9:43 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the importance of organizing the med cart was to prevent spillage of liquid medications to the tablet forms. A review of the facility's policy, titled Storage of Medications, revised 10/2018, indicated, .B. External use drugs in liquid, capsule .shall be restored separately .a. Example: Separate oral tablets/ capsules from oral liquids .from ophthalmic drops . 2. On 10/30/24 at 4:27 P.M., an observation of the med refrigerator and review of log for the med refrigerator, and an interview was conducted with Licensed Nurse (LN) 1. Inside the med refrigerator, there were tubersol (solution used for skin testing for tuberculosis [TB, respiratory infection]), flu (respiratory virus) vaccines and a vancomycin (antibiotic) eye ointment for a resident. A review of the med temperature log was conducted. There was a missed temperature check on 10/19/24. LN 1 acknowledged there was a missed temperature check on the med refrigerator log. On 10/30/24 at 5:04 P.M., a review of the med refrigerator temperature log from January 2024 to October 2024 and an interview was conducted with the Director of Nursing (DON). The log indicated, there were missed documentation of temperatures of the med refrigerator on the following dates: - Morning shift on 4/8/24, 4/15/24, and 4/16/24. - Afternoon shift on 4/18/24, 5/20/24, 6/1/24, 7/16/24 and 10/19/24. The DON stated it was important to monitor and document the temperatures of the med refrigerator especially when there were vaccines to maintain integrity of the vaccines. A review of the facility's policy, titled Temperature of Medications, revised 10/2018, indicated, Drugs should be stored in appropriate temperatures .B. Drugs requiring refrigeration shall be stored in a refrigerator between .36 degrees Fahrenheit and .46 degrees Fahrenheit .1. If storing vaccines .temperature will be documented on log twice daily (AM & PM) . 3. On 10/30/24, a review of the med room temperature log from January 2024 to October 2024 was conducted. On 10/31/24 at 1:01 P.M., a review of the medication room temperature log and an interview was conducted with the Director of Nursing (DON). There were missing documentation of temperatures of the med room on the following dates: - 4/6/24, 4/8/24, 4/13/24, 4/15/24, and 4/16/24. The DON stated the expectation was for the Licensed Nurses (LNs) to take and document med room temperatures daily to maintain integrity of the medications. A review of the facility's policy, titled Temperature of Medications, revised 10/2018, indicated, Drugs should be stored in appropriate temperatures, A. Drugs required to be stored at room temperature shall be stored at a temperature between .59 degrees Fahrenheit .and 86 degrees Fahrenheit. 1) Recommend a temperature log for daily documentation .

Based on interview and record reviews, the facility failed to implement a water system that included Legionella testing for thirteen out of thirteen residents affected. This failure had the potential of affecting the health and safety of residents in the facility. Findings: During an interview on 11/29/2023 at 2:46 P.M., with the Maintenance Supervisor (MS), MS stated that the facility used solar water heating. The MS stated water was heated up to 140 degrees Fahrenheit. The MS further stated he did not know of any policies and procedures on Legionella prevention, and it should be the Director of Nursing (DON) handling it under the infection control program. During an interview on 11/29/2023 at 4:00 P.M., with the DON, the DON stated the facility did not have a policy on water management in accordance with Legionella testing. As of this date 11/29/2023, the facility has no documented policy on Water management regarding Legionella.

Based on interview and record review, the facility did not staff a Registered Nurse (RN) for eight consecutive hours per 24 hour period for 14 days. This failure had the potential to negatively impact Resident care due to lack of RN supervision. Findings: A review of an untitled staffing document provided by the Facility indicated there were no RN's staffed on the following dates: 4/1/23; 4/15/23; 4/29/23; 5/6/23; 5/13/23; 5/20/23; 5/27/23; 6/3/23; 6/10/23; 6/17/23; 6/24/23. The untitled staffing document indicated a RN was staffed for less than eight hours on the following dates: 6/28/23; 6/29/23; 6/30/23. On 11/29/23 at 11:37 A.M., an interview with the Director of Nursing (DON) was conducted. During the interview the DON stated the Facility used a staffing agency, however the agency was not contacted to provide RN coverage on 4/1/23; 4/15/23; 4/29/23; 5/6/23; 5/13/23; 5/20/23; 5/27/23; 6/3/23; 6/10/23; 6/17/23; 6/24/23, 6/28/23; 6/29/23; and 6/30/23.

Based on observation, interview and record review, the facility failed to store a medication according to manufacturer instructions. This failure had the potential for the facility residents to receive a less potent medication resulting in diminished effectiveness in an emergent situation. Findings: During an inspection of the facility medication storage room, on 11/28/2023 at 12:05 P.M. a review was done of the medication room refrigerator with Licensed nurse (LN) 1. During an inspection of the emergency medication kit (a case containing medication used in an emergency) which was a clear/translucent kit, an unopened vial of Ativan (a medication used for anxiety) was noted to be stored in a clear vial, within a clear plastic bag, in the kit The manufacturer's instruction printed on the label of the vial indicated protect from light. LN 1 confirmed facility's policy is for medications to be stored according to manufacturer instructions. During an interview on 11/29/2023 at 9:18 A.M., LN 3 viewed a photograph of the manufacturer's instruction on the Ativan vial. LN 3 stated the medication was to be stored according to manufacturer instructions. She further stated the Ativan vial indicated the Medication needed to be protected from light, which while the refrigerator offered some protection, the clear vial, bag, and container would not be considered enough protection from light. LN 3 stated it was important to follow the manufacturer instructions for storage of the medication to ensure its effectiveness. During a telephone interview with the Pharmacist (PH), on 11/30/2023 at 10A.M., the PH stated she was unaware Ativan needed to be protected from light. She further stated this medication should have been placed in a light protected bag according to manufacturer instructions. The PH acknowledged it was important to follow the manufacturer instructions to protect the potency of the medication. During an interview with the Director of Nursing (DON), on 11/30/23 at 10:00 A.M., the DON stated facility policy was for medications to be stored according to the manufacturer instructions. She acknowledged the Ativan was not protected adequately from light, and this could diminish the potency of the medication. On review of facility policy titled, Medication Labeling & Proper Storage, revised 10/2018, manufacturer storage instructions for medications not located.

Based on observation interview and record review, the facility did not ensure confidentiality of the medical records for 12 of 12 sample residents (1, 2, 3,4, 6,7, 9, 10, 11,12, 116, 166). This failure had the potential to result in unauthorized access to confidential and protected health information. Findings: During a concurrent observation and interview on 11/28/2023 at 10:25 A.M., the narcotic administration logbook was noted to be sitting on top of medication cart 1. Licensed nurse (LN) 2 stated the narcotic administration logbook was allowed to be placed on the medication cart 1 shelf, if it was closed. She further stated it was a crazy hectic morning. During an observation on, 11/29/2023 at 8:40 A.M., the computer screen was noted to be open with a resident's medication record visible. During an observation and interview with LN 3, on 11/29/2023 at 10:30 A.M., LN 3 was shown a photograph of medication cart 2 with the computer screen on, showing the facility medication record. LN 3 stated the computer screen was not left open on purpose, she had been distracted, and facility policy was to have computer screens locked when not in use. LN 3 also reported medication cart 1 had a shelf where the closed narcotic administration logbook could be kept. LN 3 agreed that an unauthorized person could look at the logbook when the cart was unattended. During an interview with the director of nursing (DON), on 11/30/23 at 10:48 A.M., the DON's stated the narcotic administration logbook was to be kept in the bottom drawer of the medication cart unless the licensed nurse was currently passing medication. The narcotic administration logbook was not to be left unattended on top of the medication cart and it was important to secure it to maintain resident confidentiality. The DON confirmed facility policy was to protect resident confidentiality, with locked computer screens when not in use. On review of the facility policy, titled Electronic Medical Records, revised 3/2014, the facility will . make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary .

Based on observation, interview and record review, the facility failed to administer an unexpired medication to one of 4 residents (Resident 3). This failure had the potential for Resident 3 to receive a less potent medication resulting in diminished effectiveness. Findings: During a review of Resident 3's Admission Record, dated 10/29/23, Resident 3 was readmitted to the facility on [DATE], with diagnoses which included but was not limited to right hand fracture (break), vitamin deficiency, and osteoporosis (weakening of the bones) with fracture of right ankle and foot. On observation, interview and record review , on 11/28/23 at 8:45 A.M., Licensed Nurse (LN) 1 was observed taking Centrum (multi vitamin) from Medication Cart 1. LN 1 poured and administered one oral tablet of Centrum to Resident 3. Label on Centrum designated it was opened by staff on 8/2/23 and expired per manufacturer on 7/23. After Centrum given, LN 1 reviewed label with surveyor. LN 1 confirmed Centrum was opened on 8/2/23 and expired 7/23. LN 1 stated policy was for unexpired medications to be given to residents. LN 1 stated expired medications could be less potent and less effective. During medical record review on 11/28/23 , the physician orders dated 10/29/23 indicate Centrum Woman one tablet was to be given orally once a day. Per Resident 3's medical administration record, Centrum Woman one tablet daily was recorded as given from 9/1/23 to 11/28/23. During an interview with the pharmacist (PH), on 11/30/23 at 10:48 A.M., the PH stated medications are reviewed monthly and the nurse consultant was responsible for confirming expired medications were discarded. The PH further stated she performed spot checks to review the facility pharmacy medication and it was unfortunate the medication had expired. The PH stated expired medications were not to be given to residents, as they could be less potent and less effective. The PH stated expired medications should be discarded. During an interview with the Director of Nursing (DON) on 11/30/23 at 10:00 A.M., the DON stated the facility policy is to give unexpired medications to the residents. The DON further stated the expired Centrum Woman should not have been given and could be less effective.

47466 Based on interview and record review, the facility failed to ensure non-pharmacological interventions (actions or treatments that do not include the use of medicine) were implemented for three of five sampled residents (Residents 1, 2 and 6) that had been given psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 6 was administered Seroquel (a medication for bipolar disorder, depression, and schizophrenia) without documented evidence for the implementation of non-pharmacological behavioral interventions. 2. Resident 1 was administered Seroquel (a medication for bipolar disorder, depression, and schizophrenia) without documented evidence for the implementation of non-pharmacological behavioral interventions. 3. Resident 2 was administered Ativan (a medication to treat anxiety) without documented evidence for the implementation of non-pharmacological resident-centered behavioral interventions. These failures had the potential to result in unnecessary psychotropic medications for Resident 1, 2, and 6, thus increasing the risk of breathing difficulties, sedation (severe sleepiness), anxiety (extreme uneasiness), agitation (extreme emotional disturbance) and memory loss. Findings: 1. During a review of Resident 6's Admission Record, Resident 6 was readmitted under Hospice Care to the facility on [DATE], with diagnoses that included but was not limited to stroke, severe vascular dementia (decline in brain function) with agitation, restlessness, and insomnia . Per Resident 6's Minimum Data Sheet Section C, dated 4/6/23, Resident 6 had a Brief Interview Mental Score (method of evaluating mental status) of 00, indicating severe mental impairment. Per Resident 6's physician order, on 10/26/23, Resident 6 was to receive Seroquel 25 mg amt 1/2 tab orally once an evening, for agitation with diagnosis: restlessness and agitation. During an interview, on 11/29/23 at 11:02 A.M., Licensed Nurse (LN) 3 stated Resident 6 was receiving Seroquel 12.5 mg for agitation. LN 3 further stated Resident 6's agitated behavior included refusing all care including any skin care or cleaning, striking at staff during care and becoming very upset while reaching for invisible objects. LN 3 stated if nurses attempted redirection this should be documented in Resident 6's medical record. During a concurrent interview and record review with LN 2, on 11/29/23 at 12:12 P.M., LN 2 stated Resident 6 had occasional episodes of confusion and agitation. LN 2 stated Resident 6 had been prescribed Seroquel for the agitation. LN 2 acknowledged it was important to ensure non-pharmacological interventions were documented to help prevent unnecessary use of psychotropic medications and their potentially dangerous side effects. On review of resident 6's medical record, LN 2 was unable to locate documentation of what non-pharmacological interventions had been done since Resident 6's admission. During a review of Resident 6's medical record, on 11/30/23, no documentation of non-pharmacological staff interventions related to the Seroquel administration was located. During a phone interview with the pharmacist (PH) on 11/30/23 at 10:38 A.M., PH reported she monitored Resident 6's physician order for Seroquel since this medication had potentially dangerous side effects. During an interview and record review on 11/30/23 at 10:00 A.M., the Director of Nursing (DON), confirmed non-pharmacological interventions for psychotropic medications should be documented in Resident 1, 2 and 6's medical record. She further acknowledged prior to 11/29/23 there was no documentation of these interventions being done. The DON agreed it is important to include non-pharmacological interventions to help decrease the use of unnecessary psychotropic medications . 2. A review of Resident 1's face sheet indicated Resident 1 was admitted from the memory care facility on 6/8/2021 with diagnoses that included dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (a mental disorder characterized by feelings of worry, anxiety or fear) and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a joint observation and interview in the dining room on 11/28/2023, at 8:00 A.M., Resident 1 was sitting up in the wheelchair, assisted by Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 1 usually ate 50% of meals and was dependent with his care. CNA 1 stated Resident 1 liked to touch and grab things, and clapped his hands when awake. CNA 1 further stated she tried to keep Resident 1's hands occupied by giving Resident 1 something to hold on to. CNA 1 stated Resident 1 had episodes of agitation and struck out during care. During a joint interview and record review on 11/29/2023, at 11:24 A.M., with the Licensed nurse (LN) 3, LN 3 stated there was no documneted evidence of non-pharmacological interventions. 3. A review of Resident 2's face sheet indicated Resident 2 was admitted from home on 3/26/2021 with diagnoses that included major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning). During an observation on 11/28/23, at 8:30 A.M., Resident 2 was sitting in the wheelchair in the dining room being assisted by Certified Nursing Assistant (CNA) 2. During a joint interview and record review on 11/29/2023, at 11:24 A.M., with the Licensed nurse (LN) 3, LN 3 stated the Medication Administration Record (MAR) and care plan did not have non-pharmacological interventions prior to use of Ativan (a medication used to treat anxiety). LN 3 stated non-pharmacological interventions should have been documnted as implemented prior to administration of Ativan. An interview with the Director of Nursing (DON) on 11/30/2023, at 9:42 A.M., the DON confirmed non-pharmacological interventions were not documented as implemented prior to administration of Ativan. A review of the facility policy and procedure titled Psychotropic Medication, dated 9/30/2015 was conducted. The policy indicated the facility was responsible to ensure the .Documentation of the specific type and frequency of medication, will be completed in the resident's care plan, nursing progress notes and added to the medication record .

Based on observation, interview, and record review, the facility failed to ensure the food and nutrition services staff maintained current competency in dietetic task operations to safely carry out the kitchen functions in a sanitary manner according to facility policies and standard of practice when: 1. The Dietary Aide (DA) could not correctly demonstrate how to test the dishwashing machine for sanitation. 2. No temperature log for the dishwashing machine These failures had the potential to result in contamination of food leading to widespread food borne illness for 16 residents who consume food from the kitchen. Findings: 1. On 9/14/22 at 10:00 A.M., an interview with DA 1 was conducted. DA 1 stated, she was the assigned dishwasher for the shift. DA 1 stated, she would check the temperature of the dishwasher machine before starting the wash. DA 1 further stated, she would test the machine water by using a test strip; if the color of the test strip was dark the machine was good if not dark, add solution and run the machine again. DA 1 stated I do not record the temperature or the test strip, no one told me that it needed to be recorded. On 9/15/22 at 9:00 A.M., an observation and interview with DA 2 was conducted. DA 2 demonstrated how he tested the sanitizer strength in the dishwasher machine. DA 2 took a test strip from a test strip container, he placed the strip in the machine water, waited for 15-30 seconds and removed the test strip from the water. DA 2 compared the test strip color against the sanitizer color indicator. DA 2 stated, the deep green color test strip indicated 300-400 parts per million (ppm) and that was the proper sanitizing level. DA 2 checked the temperature gauges on the dishwashing machine. The temperature reading was 150 degrees. DA 2 stated, I think the machine temperature is ok, I do not know what the temperature is supposed to be, so I do not know if it is not ok. 2. On 9/15/22 at 9:10 A.M., an interview with DA 2 was conducted. DA 2 stated, he did know that he had to record the dishwasher machine temperature. There was no record of temperatures logged. On 9/15/22 at 9:15 A.M., an observation and interview with DA 1 was conducted. DA 1 started to use the dishwasher. The first run was a rack of serving trays. DA 1 did not checked the temperature gauges before, during or after the wash. DA 1 then placed a rack of glassware and did not checked the temperature gauges before, during, or after the wash. DA 1 stated, she did not remember receiving an in - service from the vendor. DA 1 stated another DA trained her how to use the dish machine. DA 1 stated, I do not touch any knobs on the machine. DA 1 stated, I do not record the temperature of the machine or the test strip. DA 1 further stated, she did not know about the machine sanitization. On 9/15/22 at 10:24 A.M., a concurrent observation and interview with the DM was conducted. The DM stated, it was the expectation that staff follow the facility policy and procedure for the dishwasher machine. The DM stated, the dishwashing machine is a high temperature dishwashing machine and the temperature needs to be 180 degrees. The DM stated, DA 2 should have placed the test strip onto the wet plate and not in the dish machine water. The DM further stated, there was a different test strip for the dish washer machine. The DM stated, the vendor came every 2 weeks to check the machine but could not what speak to what the vendor was checking or provide a log from the vendor of what was being checked. The DM further stated, we do not have temperature logs for the dishwashing machine. The DM stated, it was important for dishes to be sanitized to prevent residents from getting potential food borne illnesses from dirty dishes. There was no competency, in-service, or education provided by the facility regarding the dishwashing machine when requested. A review of the facility policy and procedure, dated 01/01/18, Dishwashing machines: Temperature ., the document indicated, .To record temperatures on a daily basis for all three meals times. 1. Temperatures shall be recorded after the first rack goes through the dish machine for each meal.4. For high temperature dish machines record the final rinse temperature, which must be at minimum of 180 degrees .

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained during food storage when: 1) A container of opened pitted prunes was not discarded. 2) A gallon of tea concentrate had no label. 3) An opened container of cottage cheese and an opened container of maraschino cherries were not discarded after the best use by date. 4) A gallon of light unsulphured molasses was not discarded after the best by date. 5) A quart of thickened lemon-flavored water was not discarded after the best used date and uncovered liquids were stored in the refrigerator. These failures had the potential to cause widespread food borne illness among residents who consume food from the kitchen. Findings: 1. On 9/14/22 at 9:30 A.M., an observation and interview was conducted with the Dietary Manager (DM) inside the main kitchen. Inside the single door refrigerator, a container with a container of pitted prunes with a prepared date of 8/9/22 was found. The DM stated, the prunes should have been discarded after a month. Per the facility's Produce shelf life (processed or bag) documentation posted in the main kitchen dated 3/14/14, pitted prunes once opened it was good for 4 days. 2. On 9/14/22 at 9:35 A.M., an observation and interview with the DM was conducted inside the main kitchen. A gallon of tea concentrate was found inside the refrigerator, no label or date of when the tea was opened. The DM stated, the staff should labeled all food items when opened to ensure food safety. 3. On 9/14/22 at 9:40 A.M., an observation and interview with the DM was conducted in the main kitchen. The Deli refrigerator had a container of maraschino cherries labeled with a used by date of 9/8/22 and a 5 pound container of cottage cheese, labeled with a best by used date of 9/7/22 were found. The DM stated, the staff should have discarded the cherries after 9/8/22 and the cottage cheese should have been taken out after the best used by date, to ensure residents were served safe food items. 4. On 9/14/22 at 9:45 A.M., an observation and interview with the DM was conducted in the main kitchen. Inside the standing freezer, a container of unsulphured molasses labeled best by 4/8/21 was found. The DM stated, the staff should have checked the shelf life of the molasses and discard accordingly. Per the facility's Dry Storage Life of Foods 2019 posted in the main kitchen, molasses could be used for 2 months from the opened date. 5. On 9/14/22 at 10:10 A.M., an observation and interview with the Registered Dietitian (RD) was conducted in the dining area. Inside the refrigerator, an opened container of thickened lemon water labeled best if used by 9/13/22. The RD stated, the thickened lemon water should have been discarded. In addition, inside the refrigerator, there were 4 double handled cups filled with liquid and no lid cover. The RD stated, staff should have covered the cups to ensure food safety. On 9/14/22 at 10:15 A.M., an interview with the RD was conducted. The RD stated, the kitchen staff should follow and discard foods according to the manufacture's best by or best used by dates to ensure food served to the residents were safe and to avoid food borne illness. Per the facility's policy and procedure dated 2018, titled Labeling / date Marking and Safe Storage of Refrigerated and Frozen Foods, . 1. Any foods removed from original container will be properly labeled .3(c) .commercially processed foods must be dated when opened and are good for 7 days, or until the expiration date .

Based on observation, interview and record review, the facility failed to ensure food safety practices were followed in the kitchen when: 1. Staff who handled and prepared food for the facility did not wear protective hair coverings. 2. An acceptable thawing process was not used when thawing food for lunch service. 3. Food stored in a refrigerator and a freezer was not dated and labeled. 4. A daily refrigerator temperature log was not consistently maintained. These failures had the potential to cause contamination of food, and increased risk of food borne illnesses, in food served to a vulnerable population. Findings: 1. On [DATE] at 8:15 [NAME]M., a tour of the facility's SNF Kitchen was conducted with the Dietician. At 8:35 [NAME]M., an observation was conducted of KS 1 entering the SNF Kitchen. KS 1 walked over to a kitchen counter without putting on a hair net. At 8:37 [NAME]M., an interview was conducted with the Dietician. The Dietician stated KS 1 should have worn a hair net. On [DATE] at 11 [NAME]M., an observation was conducted in the Main Kitchen. Three KS (including KS 2) were not wearing beard coverings while preparing food. On [DATE] at 11:02 [NAME]M., an interview was conducted with KS 2. KS 2 stated it was important to wear a net over his beard to ensure facial hair would not fall into food. KS 2 stated wearing a hair net was for infection control. 2. On [DATE] at 8:50 [NAME]M., a tour of the Main Kitchen was conducted. At 8:51 [NAME]M., an observation was conducted of two steam tables that held hot water. Six containers of cream colored soup were placed in the hot water. The six containers of soup were partially thawed. On [DATE] at 8:52 [NAME]M., an interview was conducted with KS 3. KS 3 stated she had just put the frozen soup in the steam tables to thaw. KS 3 stated the soup had been taken out of the freezer two days before and had been thawing in the refrigerator. KS 3 stated the soup should have been thawing in the refrigerator for three days, but it was taken out of the freezer only two days ago. KS 3 stated the soup needed to be thawed quickly for the lunch service today. On [DATE] at 8:54 [NAME]M., an interview was conducted with the Dietician. The Dietician stated the correct thawing process was not followed. The Dietician stated the soup should have been thawed under cold running water or thawed in the refrigerator for another day. 3. On [DATE] at 8:56 [NAME]M., an observation of a freezer and a refrigerator in the Main Kitchen was conducted. Inside a freezer were two opened bags of frozen potato wedges, and two opened bags of frozen mixed vegetables. None of the opened bags of food were dated or labeled. Inside a refrigerator, a container held two thirds of a dessert pie. The pie was covered in plastic wrap but was not dated or labeled. On [DATE] at 8: 57 [NAME]M., an interview was conducted with KS 3. KS 3 stated all food put in the freezer and refrigerator should be labeled and dated. KS 3 stated there was no way to know how long the food had been in the refrigerator or freezer if it was not dated. KS 3 stated there could have been contamination of the food if the food was not dated. KS 3 stated kitchen staff would not know how long the food had been stored in the refrigerator or freezer. KS 3 stated the expired food could have been served to residents, and might have made residents ill. On [DATE] at 9 [NAME]M., an interview was conducted with the Dietician. The Dietician stated the food in the refrigerator and freezer should have been labeled and dated to ensure it was still fresh enough to use. 4. On [DATE] at 9:05 [NAME]M., an observation and record review was conducted in the Main Kitchen. The refrigerator temperature log indicated there were no daily temperatures recorded for [DATE], [DATE], and [DATE] through [DATE]. On [DATE] at 9:07 [NAME]M., an interview was conducted with the Dietician. The Dietician stated the food in the refrigerator could have been spoiled because there were missing log entries of the refrigerator temperatures for (MONTH) 2019. The facility's policy titled Dietetic Services, dated 2014, included Personal Hygiene and Appearance .Dietary staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food ., Freezer Storage .8. Frozen food should be left in the refrigerator to thaw ., Storage of Food and Non-Food Supplies . All open food items will have an open date and use-by-date per manufacturer's guidelines . Perishable Storage . e. the temperature of all cold storage equipment is checked and recorded daily . The (YEAR) Federal FDA Food Code; Hair Restraints, Section ,[DATE].11, included . (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS . The (YEAR) Federal FDA Food Code; Thawing, Section ,[DATE].13, included .Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less; or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41oF) .