Health inspection·February 26, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document and policy review, the facility failed to ensure foods were stored in accordance with professional standards for food safety. Specifically, the facility failed to ensure warm milk placed into the refrigerator to cool was loosely covered to facilitate heat transfer; failed to ensure food items, including frozen carrots and frozen fish, were stored in closed containers and protected from exposure to the air; and failed to ensure a utensil storage rack was free of an accumulation of dust and debris. These failures had the potential to affect all residents receiving meals from the dietary department. Findings included: 1. A facility policy titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, indicated, Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety. The policy specified, When PHF or TCS food will not be served right away, it must be cooled as quickly as possible and Food should be loosely covered, or uncovered if protected from overhead contamination, during the cooling period to facilitate heat transfer from the surface of the food. An observation of the walk-in cooler on 02/24/2025 at 9:37 AM revealed a pan of warm milk stored with plastic wrap that tightly covered the pan. During an interview on 02/24/2025 at 9:37 AM, [NAME] #1 stated that she placed the pan of warm milk in the walk-in refrigerator to cool on the morning of 02/24/2025. [NAME] #1 stated that she knew to leave the plastic open a little bit so that the milk could cool, but she forgot and covered the milk so that the milk would not spill. During an interview on 02/24/2025 at 9:39 AM, the Director of Food and Nutrition Services (DFNS) stated that dietary staff were trained to store warm foods so that they were vented; otherwise, the food item may not cool to appropriate temperatures quickly enough. During an interview on 02/26/2025 at 10:57 AM, the Director of Nursing (DON) stated she expected dietary staff to follow the policy on cooling foods to prevent the potential for resident illness. 2. A facility policy titled, Procedure for Freezer Storage, dated 2023, indicated, 5. Store foods in an air-tight, moisture resistant wrapper such as a plastic bag or freezer wrapper to prevent freezer burn. Page 1 of 2 055022 055022 02/26/2025 Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many A concurrent interview and observation of the walk-in freezer on 02/24/2025 at 9:49 AM revealed one 20-pound box of crinkle cut carrot coins and one 10-pound box of pressed Alaskan [NAME] fish fillets were stored in open boxes with the contents exposed to air. The Director of Food and Nutrition Services (DFNS) stated that he expected dietary staff to store frozen foods in tightly sealed containers. During an interview on 02/26/2025 at 10:57 AM, the Director of Nursing (DON) stated that foods stored in the walk-in freezer should be stored per the facility policy in a closed container. 3. A facility policy titled, Shelves, Counters, and other Surfaces Including Sinks (handwashing, food preparation, etc. [et cetera, other similar things]), dated 2023, specified, 1. Remove any large debris with warm detergent solution following manufacturer's instructions and 2. Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth. A facility document titled, Daily/Weekly Cleaning Schedule, for the week of 02/24/2025 through 03/02/2025, revealed a list of cleaning tasks for staff to initial as the tasks were completed; however, the log did not include a cleaning task that specified to clean utensil storage racks. An observation on 02/25/2025 at 12:10 PM of the lunch meal tray line in progress revealed a utensil storage rack, which was adjacent to the tray line, stored multiple serving utensils. The storage rack was observed with an accumulation of dust and debris. During an interview on 02/25/2025 at 1:14 PM, the Director of Food and Nutrition Services (DFNS) stated that dietary staff followed the cleaning schedule that included daily and weekly tasks. After reviewing the cleaning schedule, the DFNS stated, We don't [do not] have the utensil racks on the schedule; I will have to add that. The DFNS then observed the utensil storage racks and stated he saw streaks and specks of debris and dust. The DFNS stated the utensil storage rack should have been cleaned better. 055022 Page 2 of 2