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. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055022 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 055022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mary Health of the Sick Convalescent & Nursing Hos 2929 Theresa Drive Newbury Park, CA 91320 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)