Health inspection·October 22, 2021

F 0755 Level of Harm - Minimal harm or potential for actual harm charge nurse when then go to the designated unit to obtain the Ativan from that unit's E-Kit and bring it back to the unit that needed it. Due to the time of taking the elevator, the nurse would use the stairway to transport the Ativan to be more expeditious. When asked why the Ativan would not be kept in the unit E-Kit to be readily accessible in an emergency situation which could place a resident in jeopardy, the DON stated Ativan was rarely used in the Barona unit. Residents Affected - Few The DON further indicated that the majority of the Ativan medication used was stored upstairs in the Sierra unit. The facility's plan was to keep the storage of emergency use Ativan in the center portion of the building units. This would enable the nurse to go to the designated unit quickly and obtain the medication. The DON was asked what the procedure would be in a situation where no Ativan was available in the nearest Unit, since this had been the situation in the Santa [NAME] Unit when the survey team did their observation. The DON indicated, the LN would call upstairs to the Charge Nurse to open the locked medication storage room and open the locked E-Kit and have the Ativan available. The LN would then take the stairs, obtain the medication and come back down to administer the medication. An interview was conducted with the facility's Pharmacist on 10/21/21 at 11:20 A.M. The Pharmacist indicated that Ativan was rarely used in the Barona Unit and if it were needed, it could be obtained by the Santa [NAME] unit. When asked what the procedure would be if no Ativan was available in the Santa [NAME] unit as was the case due to no refrigerator in the Santa [NAME] unit. The Pharmacist stated it would not have happened if the refrigerator had not broke. Although, rarely used on the Barona Unit, the procedure had the potential to place a Resident in jeopardy if and when it may have been needed and wasn't readily available. The Pharmacist acknowledged the potential hazard of not having the Ativan in each unit's E-Kit. An interview was conducted with the facility's Physician and ADM (Administrator) on 10/22/21 at 2:10 P.M. The ADM emphasized the locations of the units designated to have Ativan in the E-Kit was to be stored in Santa [NAME] Unit, for the Barona and Pico units use on the first floor. The Sierra Unit was to have Ativan stored for the [NAME] and Monte Vista's use on the second floor. There was no rationale provided to account for the potential issue of time to locate the charge nurse when she may not be readily available to open the medication storage room and open the E-Kit on the designated unit. A review of the facility's P&P (policy and procedure), titled, Emergency Drug Supply E-Kits Meds 007, dated 09/27/21, documented,Edgemoor provides supplies of drugs for use in medical emergencies. These drugs shall be immediately available at each nursing neighborhood or service as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055008 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgemoor Hospital 655 Park Center Drive Santee, CA 92071 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, and record review, the facility failed to ensure dietary staff were competent on the food cool-down process (bring food temperature down to 41 degrees °F [Fahrenheit] or below) for potentially hazardous foods [PHF] and the use of a cool-down log when preparing egg salad. This failure had the potential to place residents at risk of foodborne illness. Findings: According to the 1999 Federal Food and Drug Administration (FDA) Food Code, . 'Potentially hazardous food' means a food that is natural or synthetic and that requires temperature control because it is in a form capable of supporting: (i) The rapid and progressive growth of infectious or toxigenic microorganisms According to the 2009 FDA Food Code 3-501.14, Temperature and time control- Cooling: (1) Cooked Potentially Hazardous Food must be cooled: (a) Within two hours from 135 °F (57 °C) to 70 °F (21 °C); (b) Within a total of six hours from 135 °F (57 °C) to 41 °F (5 °C) or less On 10/21/21 at 2:42 P.M., an observation and interview was conducted with dietary staff (DS) 1, also present were the supervisor of dietary services (SDS) 2, SDS 3, and the chief of nutrition services (CNS). DS 1 described the process for making egg salad sandwiches. DS 1 stated after cooking the eggs he briefly placed them in an ice bath so he could remove the eggshells. DS 1 stated he then sliced the eggs and mixed them with the other ingredients and placed the egg salad mixture into the refrigerator. DS 1 stated he had placed the egg salad he had made into the refrigerator approximately 10 minutes ago. DS 1 stated he had not checked the temperature. DS 1 checked the temperature of the egg salad using the facility's thermometer. The temperature of the egg salad was 46 °F. DS 1 stated he made egg salad several times a week and has never done a cool-down. DS 1 stated he did not realize the cool-down process was required when making egg salad. SDS 2 stated there should have been a cool-down process performed when making egg salad because it was a PHF if the egg salad did not reach 41 °F or less within the appropriate timeframe. SDS 2 further stated the cool-down process had to be tracked and documented on the cooling record. On 10/21/21 at 2:30 P.M., an interview was conducted with the registered dietitian (RD). The RD stated egg salad was a PHF and should have gone through the cool-down process and the process should have been documented. The RD stated not doing the cool-down process when making egg salad could cause foodborne illness. On 10/21/21 at 3:35 P.M., an interview was conducted with SDS 2. SDS 2 stated the cool-down had not been implemented when making egg salad and there were no cool-down logs kept for egg salad. On 10/21/21 at 7:45 A.M., an interview was conducted with the CNS. The CNS stated the facility should have been doing the cool-down process when making egg salad and cool-down logs should have been kept. The CNS stated there had been no in-services provided to dietary staff on the cool-down process when making meat-based salads such as egg salad. The CNS stated there were no staff competencies done to ensure staff were knowledgeable on the cool-down process for egg salad. The CNS stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055008 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgemoor Hospital 655 Park Center Drive Santee, CA 92071 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 cool-down in-services and assessment of staff competency should have been done. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled Nutrition Services: Food Safety 614, dated 10/8/18, indicated, .e. For each potentially hazardous food (PHF) item that is cooked for later use (whether refrigerated or frozen), a cool down temperature graph shall be mandatory . h. All PHF items cooled must have a starting and ending temperature taken to determine if the cooling guidelines are met. Items which do not have either of these temperatures recorded shall be discarded The policy did not provide guidance related to inservices and competency assessment. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055008 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgemoor Hospital 655 Park Center Drive Santee, CA 92071 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed when: Residents Affected - Some 1. Prepared egg salad was not cooled-down to ensure food safety. 2. Spoiled produce items were not removed from the refrigerated storage area. 3. Food items were not labeled and dated. 4. Washed food storage containers were stacked and stored wet. In addition, one of the food storage containers had a crack through it. These failures to mitigate potential food contamination may result in food borne illness. Findings: 1. According to the 1999 Federal Food and Drug Administration (FDA) Food Code, . 'Potentially hazardous food' [PHF] means a food that is natural or synthetic and that requires temperature control because it is in a form capable of supporting: (i) The rapid and progressive growth of infectious or toxigenic microorganisms According to the 2009 FDA Food Code 3-501.14, Temperature and time control- Cooling: (1) Cooked Potentially Hazardous Food must be cooled: (a) Within two hours from 135 °F (57 °C) to 70 °F (21 °C); (b) Within a total of six hours from 135 °F (57 °C) to 41 °F (5 °C) or less On 10/21/21 at 2:42 P.M., an observation and interview was conducted with dietary staff (DS) 1, also present were the supervisor of dietary services (SDS) 2, SDS 3, and the chief of nutrition services (CNS). DS 1 described the process for making egg salad sandwiches. DS 1 stated after cooking the eggs he briefly placed them in an ice bath so he could remove the eggshells. DS 1 stated he then sliced the eggs and mixed them with the other ingredients and placed the egg salad mixture into the refrigerator. DS 1 stated he had placed the egg salad he made into the refrigerator approximately 10 minutes ago. DS 1 stated he had not checked the temperature. DS 1 checked the temperature of the egg salad using the facility's thermometer. The temperature of the egg salad was 46 °F. DS 1 stated he made egg salad several times a week and has never done a cool-down. DS 1 stated he did not realize the cool-down process was required when making egg salad. SDS 2 stated there should have been a cool-down process performed when making egg salad because it was a PHF if the egg salad did not reach 41 °F or less within the appropriate timeframe. On 10/21/21 at 2:30 P.M., an interview was conducted with the registered dietitian (RD). The RD stated egg salad was a PHF and should have gone through the cool-down process and the process should have been documented. The RD stated not doing the cool-down process when making egg salad could cause foodborne illness. On 10/21/21 at 3:35 P.M., an interview was conducted with SDS 2. SDS 2 stated the cool-down had not been implemented when making egg salad and there were no cool-down logs kept for egg salad. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055008 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgemoor Hospital 655 Park Center Drive Santee, CA 92071 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 10/21/21 at 7:45 A.M., an interview was conducted with the CNS. The CNS stated the facility should have been doing the cool-down process when making egg salad and cool-down logs should have been kept. The facility's policy titled Nutrition Services: Food Safety 614, dated 10/8/18, indicated, .e. For each potentially hazardous food (PHF) item that is cooked for later use (whether refrigerated or frozen), a cool down temperature graph shall be mandatory. f. Manual temperatures shall be recorded at a minimum of every two hours (but preferably every hour) . h. All PHF items cooled must have a starting and ending temperature taken to determine if the cooling guidelines are met. Items which do not have either of these temperatures recorded shall be discarded 2. On 10/19/21 at 8:45 A.M., a kitchen storage observation was conducted with the chief of nutrition services (CNS). The CNS stated the produce inside the walk-in refrigerator was ready to be used in resident meals. Inside the walk-in produce refrigerator, there were: -A jalapeno pepper with a soft, circular area covered with fuzzy gray material resembling mold. -A green bell pepper that was soft and misshapen. The top half of the pepper was discolored and covered in fuzzy gray and black material resembling mold. -An orange that was soft and dented inward when gently pressed. The orange was discolored and had a section of smooth gray material on it that resembled mold. -A large plastic bin containing fresh parsley leaves. The green parsley leaves had several other leaves that were wilted and yellow and black in color. -A large bag of spinach with several areas in the bag where the spinach was wilted, slimy, and had produced an orange liquid in the bag. -A large box of approximately 100 limes. Approximately 50 of the limes were yellow in color and were covered in soft brown spots. The CNS stated it was his expectation that the produce inside the walk-in refrigerator was checked daily for spoiled items. The CNS stated there should not have been spoiled produce mixed in with non-spoiled produce. On 10/21/21 at 11:10 A.M., an interview was conducted with the supervisor of dietary services (SDS) 4 and SDS 5 in the presence of the CNS. SDS 4 stated there should not have been any spoiled produce in the walk-in produce refrigerator. SDS 4 stated the refrigerators were assigned to dietary staff to check for any spoiled food at the start of their shift. SDS 4 stated the dietary staff signed a form each day that indicated the refrigerator had been checked. SDS 4 and SDS 5 both stated the supervisors of dietary services were responsible for ensuring that the refrigerators had been checked by dietary staff. On 10/21/21 at 11:58 A.M., an interview was conducted with dietary staff (DS) 2. DS 2 stated she had been assigned to check the walk-in produce refrigerator on 10/19/21 for cleanliness and to make sure the produce was fresh. DS 2 stated this was to be done at the start of her shift at 6:30 A.M. DS 2 stated she did not check the walk-in produce refrigerator on 10/19/21 and stated she was aware that she should have. DS 2 stated she also did not sign the log for performing refrigerator checks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055008 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgemoor Hospital 655 Park Center Drive Santee, CA 92071 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm On 10/21/21 at 2:17 P.M., a joint interview and record review was conducted with SDS 2 and SDS 3 in the presence of the CNS. The logs for the refrigerator and food storage checks titled Positions Responsible for Noted Storage Areas were reviewed. SDS 2 stated he reviewed all the logs from 10/17/21 through 10/21/21 and that there were missing logs and incomplete entries on the logs that were turned in. SDS 2 stated food storage checks to include the walk-in produce refrigerator had not been consistently done. Residents Affected - Some On 10/21/21 at 3:20 P.M., an interview was conducted with the registered dietitian (RD). The RD stated the refrigerators should have been checked daily, and any spoiled food should have been promptly removed. The RD stated this was done to prevent foodborne illness. The facility's policy titled Nutrition Services: Food Safety 614, dated 10/8/18, indicated, .To prevent food borne illnesses, food and beverages are to be received, stored, prepared and served under sanitary conditions The facility's policy titled Nutrition Services: Food Storage 610, dated 4/23/18, indicated, . M. Food items are rotated with stock on hand using FIFO (first in, first out) principle 3. On 10/19/21 at 8:45 A.M., a kitchen storage observation was conducted with the chief of nutrition services (CNS). Inside the walk-in refrigerator, there were: - A large package of approximately 24 dinner rolls. They were not labeled or dated. -A large package of approximately 24 hamburger buns. They were not labeled or dated. -A large plastic bin containing fresh parsley leaves. The green parsley leaves had several other leaves that were wilted and yellow and black in color. It was not labeled or dated. -A large bag of spinach with several areas in the bag where the spinach was wilted, slimy, and had produced an orange liquid in the bag. It was not labeled or dated. -A plastic bag filled with approximately 12 large zucchinis. They were not labeled or dated. Inside the walk-in freezer, thawing section, there was a food storage container with what resembled cooked ground meat that had been covered with plastic wrap. On top of the plastic wrap, was a gallon sized zip lock bag with what resembled uncooked pink ground meat inside. The zip lock bag had caused the plastic wrap to cave-in so that the zip lock bag was directly on top of what looked like cooked ground meat. The zip locked contents were not labeled or dated. The CNS stated that the contents of the zip locked bag were cooked ground ham. The CNS stated all food items in the walk-in refrigerators or freezers should have been appropriately labeled and dated. On 10/19/21 at 9:15 A.M., an interview was conducted with cook (CK) 1. CK 1 stated all food items in the refrigerators or freezers had to be labeled and dated. CK 1 stated there had been ground cooked ham in the gallon sized zip lock bag. CK 1 stated he threw it away because it was not labeled or dated and he could not determine how long it had been in the thawing section of the freezer. CK 1 further stated the ground ham should not have been stored directly on top of the ground turkey in the same container. The undated signage posted on nourishment refrigerator (R4) indicated, .All food must be covered, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055008 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgemoor Hospital 655 Park Center Drive Santee, CA 92071 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 labeled, dated Level of Harm - Minimal harm or potential for actual harm On 10/21/21 at 11:10 A.M., an interview was conducted with the supervisor of dietary services (SDS) 4 and SDS 5 in the presence of the CNS. SDS 4 stated all food items should have been labeled and dated so everyone could tell what the item was and how long it had been in the refrigerator. SDS 4 stated food was kept for specific amounts of time depending on what the food was, and the food had to be labeled and dated so staff would know when to dispose of it. Residents Affected - Some On 10/21/21 at 3:20 P.M., an interview was conducted with the registered dietitian (RD). The RD stated food items should have been labeled and dated in order to ensure food could be accurately identified and it would be safe to serve to the residents. The RD stated thawed meat items were generally kept for three days, and if they were not dated, staff would not know when to remove them. The facility's policy titled Nutrition Services: Food Storage 610, dated 4/23/18, indicated, . a. Stored items should be covered, labeled and dated when received, opened, or when leftover 4. On 10/19/21 at 8:45 A.M., a kitchen storage observation was conducted with the chief of nutrition services (CNS). At 9 A.M., the dishware and food storage containers section was observed. A metal rack held several plastic food storage containers that were stacked in groups, one container fitting tightly into the other container. The CNS stated this rack of food storage containers were clean and ready to be used. A stack of approximately 10 plastic food storage containers were stored wet. The CNS stated the containers were clean and should not have been stored wet. One of the food storage containers had an approximate two inch long crack from the rim down. The CNS stated the crack in the food storage container could not be effectively cleaned or sanitized and could possibly harbor bacteria. The CNS stated all cracked food storage containers or dishware had to be removed from circulation. On 10/21/21 at 11:10 A.M., an interview was conducted with the supervisor of dietary services (SDS) 4 and SDS 5 in the presence of the CNS. SDS 5 stated all broken or cracked dishware or food storage containers had to be given to the SDS so they could remove them and reorder new items to replace them. Both SDS 4 and SDS 5 stated storing food storage containers while wet could contribute to food contamination. On 10/21/21 at 3:20 P.M., an interview was conducted with the registered dietitian (RD). The RD stated clean dishware and food storage containers should not have been stored wet. The RD stated cracked dishware or food storage containers had to be removed from circulation. The RD stated storing food storage containers wet and keeping cracked containers in use could lead to bacterial growth and contamination. The facility's policy titled Nutrition Services Employee Safety Guidelines 607, dated 3/19/18, indicated, .viii. Discard chipped and/or cracked dishes FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055008 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055008 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edgemoor Hospital 655 Park Center Drive Santee, CA 92071 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure kitchen equipment was maintained in a safe operating and fully functioning manner when, the salad [NAME] had a chipped lid and the mechanical crank handle was held together with blue tape. Residents Affected - Few This failure had the potential to impact the ability of dietary staff to prepare food in a safe and sanitary manner. Findings: On 10/19/21 at 8:45 A.M., a kitchen storage observation was conducted with the chief of nutrition services (CNS). At 9 A.M., the dishware and food storage containers section was observed. On the metal storage rack, there was a large salad [NAME]. The salad [NAME]'s lid was chipped and had missing pieces along the rim of the lid. The top of the lid had a metal crank and handle. The handle was secured to the crank with frayed blue tape. When the handle was lightly touched, it fell apart and pieces slipped down the crank. The CNS stated the salad [NAME] was still in circulation for use and that it should have been removed and fixed or replaced. On 10/21/21 at 11:10 A.M., an interview was conducted with the supervisor of dietary services (SDS) 4 and SDS 5 in the presence of the CNS. SDS 5 stated broken equipment was supposed to be given to the SDS for removal from circulation so it could be repaired or replaced. SDS 5 stated the salad [NAME] should have been removed from circulation as the tape or the handle could have fallen off and gone into the residents' food. On 10/21/21 at 3:20 P.M., an interview was conducted with the registered dietitian (RD). The RD stated broken equipment should have been removed from circulation and given to the SDS. The RD stated broken equipment was a safety hazard. The facility's policy titled Nutrition Services Employee Safety Guidelines 607, dated 3/19/18, indicated, . i. Ensure that all tools, including knives, etc. are adequate and are properly maintained FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055008 If continuation sheet Page 9 of 9