Health inspection·November 9, 2023

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility policy, the facility failed to ensure appropriate care and services for urinary catheters were provided to prevent infection for one (Resident #455) of one resident sampled for urinary catheters. Findings included: A review of Resident #455's medical record revealed Resident #455 was admitted to the facility on [DATE] with diagnoses of urinary tract infection, retention of urine, and flaccid neuropathic bladder. A review of Resident #455's physician's orders revealed an order, dated 11/1/2023 for Ciprofloxacin 500 milligrams (mg) by mouth every 12 hours for 7 days for a diagnosis of urinary tract infection. An observation was conducted on 11/6/2023 at 10:04 AM of Resident #455 in his room. Resident #455 was observed resting in bed with his urinary catheter drainage bag stored inside of a privacy bag hanging from the left side of the bed. The privacy bag was observed resting on the floor and the tubing for Resident #455's urinary catheter was observed resting on the floor next to the resident's bed. An observation was conducted on 11/7/2023 at 1:17 PM of Resident #455 in his room. Resident #455 was observed resting in bed with his urinary catheter bag hanging from the left side of the bed. The catheter drainage bag and catheter tubing were not stored inside of the privacy bag hanging from Resident #455's bed and the tubing for Resident #455's urinary catheter was observed resting on the floor next to the resident's bed. An interview was conducted on 11/7/2023 at 1:21 PM with Staff B, Certified Nursing Assistant (CNA), Resident #455's assigned CNA for 11/7/2023 during the 7 AM to 3 PM shift. Staff B, CNA stated when she had a resident with a urinary catheter under her care, they were to ensure the catheter drainage bag and catheter tubing were kept off of the floor when hanging from the side of the resident's bed and should be stored in the privacy bag. Staff B, CNA observed Resident #455's urinary catheter tubing and addressed the catheter tubing was resting on the floor and she did not notice previously the urinary catheter tubing was resting on the floor. An interview was conducted on 11/7/2023 at 2:36 PM with Staff A, Registered Nurse (RN), Resident #455's assigned nurse on 11/7/2023 for the 7 AM to 3 PM shift. Staff A, RN stated when caring for a resident with a urinary catheter, they were to ensure the resident's catheter drainage bag and catheter tubing were kept off of the floor. Staff A, RN observed Resident #455's catheter tubing on the Page 1 of 11 105978 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few floor and stated the tubing should not be on the floor and should be stored in the privacy bag on the side of the bed. An interview was conducted on 11/9/2023 at 11:43 AM with the facility's Director of Nursing (DON). The DON stated if a resident with a urinary catheter was in their bed, the catheter drainage bag should be stored in the privacy bag provided with the catheter tubing tucked into the bag so it was not touching the floor. The DON also stated if the urinary catheter drainage bag and catheter tubing was stored inside of the privacy bag and the privacy bag was touching the floor it would be acceptable because the privacy bag is acting as a barrier to protect the catheter drainage bag and catheter tubing from any potential infection issues. The DON stated if catheter tubing or the catheter bag were observed resting on the floor she would expect it to be changed out by the nursing staff and it was best practice to ensure the catheter bag and catheter tubing were kept off of the floor. A review of the facility policy titled Catheter Care, Urinary, last revised in August 2022, revealed under the section titled Purpose the purpose of the procedure is to prevent urinary catheter-associated complications, including urinary tract infection. The policy also revealed under the section titled Infection Control staff are to ensure the catheter tubing and drainage bag are kept off of the floor. Photographic evidence was obtained. 105978 Page 2 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and review of facility procedures, the facility failed to ensure proper storage of respiratory equipment in accordance with professional standards of practice for two (Resident #92 and Resident #32) of two residents sampled for respiratory care. Residents Affected - Few Findings included: A review of Resident #92's medical record revealed Resident #92 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD) and pneumonia. A review of Resident #92's physician's orders revealed an order, dated 10/26/2023 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. A review of Resident #92's care plan revealed a focus area initiated on 6/27/2023, Resident #92 had a potential for complications of respiratory distress related to COPD and shortness of breath when lying flat with an intervention to store respiratory equipment in an infection control bag when not in use and change every week and as needed. An observation was conducted on 11/6/2023 at 12:46 PM in Resident #92's room. Resident #92 was observed sitting in a wheelchair in front of his bed and wearing a nasal cannula. Resident #92 stated he used oxygen because he had COPD and he also received breathing treatments when needed. A nebulizer mask was observed on Resident #92's bedside table, which was attached to a nebulizer machine. The nebulizer bag was not stored inside of an infection control bag. A nasal cannula attached to an oxygen concentrator was observed next to Resident #92's bed. The oxygen cannula and tubing were observed tucked between the bed rail and mattress on Resident #92's bed and not stored inside of an infection control bag. An observation was conducted on 11/7/2023 at 1:15 PM in Resident #92's room. Resident #92 was observed resting in bed with an oxygen nasal cannula applied to his face. A nebulizer mask was observed on Resident #92's bedside table, which was attached to a nebulizer machine. The nebulizer bag was not stored inside of an infection control bag. A review of Resident #32's medical record revealed Resident #32 was admitted to the facility with diagnoses of COPD and traumatic brain injury. A review of Resident #32's physician's orders revealed an order, dated 3/14/2023 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. A review of Resident #32's care plan revealed a focus area initiated on 9/26/2023, Resident #32 had a potential for complications of respiratory distress related to COPD with an intervention to store respiratory equipment in an infection control bag when not in use and change every week and as needed. An observation was conducted on 11/7/2023 at 10:45 AM in Resident #32's room. Resident #32 was observed resting in bed. An oxygen concentrator was observed at Resident #32's bedside. An oxygen nasal cannula was observed inside of a storage bag hanging from the oxygen concentrator and resting on the floor. The storage bag was dated 11/2/2023. 105978 Page 3 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0695 Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 11/7/2023 at 2:44 PM with Staff A, Registered Nurse (RN). Staff A, RN stated respiratory equipment, such as nebulizer masks and oxygen tubing, were stored in a bag when not in use by the resident and were usually changed on a weekly basis or as needed. Staff A, RN also stated he ensured nebulizer masks were stored in the appropriate bag after administering a breathing treatment to a resident. Residents Affected - Few An interview was conducted on 11/9/2023 at 11:32 AM with the facility's Director of Nursing (DON). The DON stated oxygen tubing and nebulizer masks were changed out on a weekly basis by a third party company and on an as needed basis by the facility nursing staff if the item was soiled or dropped on the floor. Respiratory equipment was stored inside of an infection control bag when not in use, which was also changed out on a weekly basis. If facility staff observed a resident did not have an infection control storage bag for their respiratory equipment, it should be replaced. The DON stated if respiratory equipment was stored in an infection control bag and the bag was resting on the floor, there would not be any issues related to infection control because the bag was protecting the respiratory equipment. The DON also stated she would expect facility staff to ensure the infection control bags were kept off of the floor but they would not need to replace the bag if it had been on the floor as long as the infection control bag was not compromised. A review of the facility procedure titled Administering Medications through a Small Volume (Handheld) Nebulizer, last revised in October 2010, revealed under the section titled Purpose the purpose of the procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The procedure also revealed under the section titled Steps in the Procedure after obtaining post-treatment pulse, respiratory rate, and lung sounds, discard any left over solution and allow container to air dry. When equipment is completely dry, store in a plastic bag with the resident's name and date on it. A policy related to storage of oxygen tubing was requested on 11/8/2023 at 12:35 PM from the facility's Director of Nursing. A policy was not provided by the facility. 105978 Page 4 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and eleven errors were identified for one (Resident #355) of three residents. These errors constituted a 44% medication error rate. Residents Affected - Few Findings Include: On 11/08/23 at 10:55 a.m., an observation of medication administration with Staff C, Registered Nurse (RN) was conducted for Resident #355. Staff C dispensed the following medications: -Multivitamin tablet (one) -Aspirin 81 milligrams (mg) chewable (one) -Iron 65 mg tablet (one) -Lisinopril 5 mg tablet (one) -Plavix 75 mg tablet (one) -Cymbalta 30 mg tablet (one) -Meloxicam 7.5 mg tablet (one) -Miralax 75 grams (gr) (one) Ketoralac 0.5% eye drops (one drop in each eye) A review of Resident #355's November Medication Administration Record (MAR) revealed medications were scheduled for 9:00 a.m. An interview with Staff C was conducted immediately after medication administration of Resident #355. Staff C admitted the medications were outside the allotted time to give the medication, She stated the expectation was to administer medication one hour prior to and up to one hour after the scheduled time ordered by the physician. When asked what should be done if medications are out of the time allotted for medication, Staff C said the physician should be notified immediately prior to medication being administered for further update or orders. Staff C did not call the ordering physician prior to administration of late medications. Resident #355 swallowed the prescribed chewable Aspirin along with her other medications from one medication cup. The resident was never instructed to take the Aspirin as a chewable per physician orders. Staff C admitted to not following physician orders by instructing Resident #355 to chew the Aspirin. Resident #355 had a physician order for [brand name] oral capsule (Multiple Vitamins with Minerals). Resident #355 received a multivitamin tablet. An interview was conducted with Staff D, RN/Unit Manager (UM) for the [NAME] wing on 11/08/23 at 11:24 a.m. regarding timeliness of medication administration. Staff D stated medications should be 105978 Page 5 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dispensed one hour up to scheduled time and up to one after scheduled time per physician orders. Staff D stated the ordering physician should be notified of the late time frame either for notification purposes or for new orders. Staff D stated time management should have been factored in and if this nurse was behind on medication administration, she, Staff D, would have assisted Staff C. A review of Resident #355's November Medication Administration Record (MAR) identified the following physician orders: Aspirin 81 mg Chewable, give one by mouth one time a day related to Transient Cerebral Ischemic Attack, [brand name] oral capsule (Multivitamin with Minerals), give one tablet by mouth one time a day for vitamins. An interview was conducted on 11/09/23 at 2:20 p.m. with the contracted pharmacist consultant. The pharmacy consultant was updated on the medication incident and stated the expectation was to administer medication on a timely basis. The pharmacy consultant also stated [brand name] was a special multivitamin which included Vitamin A added for vision health. An interview with the Director of Nursing (DON) was conducted on 11/09/23 at 12:17 p.m. regarding the timeliness of residents' medication administration. The DON's expectations were for the medications to be pulled based on the physician's orders and based on the Five Rights of Medication: Right resident, Right drug, Right time, Right dose, and Right route. The DON stated timeliness of medication administration was one hour prior to and up to one hour after scheduled ordered time. This time frame would be considered timely and any time after would warrant a call to the physician and family. The DON stated medications should be administered by the correct route in which case Resident #355's Aspirin should have been separated from the other medication with the instructions for the resident to chew the medication as ordered. The DON stated [brand name]oral capsule (Multiple Vitamins with minerals) was in the medication cart but Staff C, RN inadvertently gave a multivitamin. The DON stated she would run the Dashboard from the electronic charting to look to see how medication pass could be more effective and manageable. The DON stated Staff C should have asked for assistance from fellow coworkers. A review of the facility's policy, Administering Medication, revised April 2019, states the following in relation to medication administration: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one hour of their prescribed time unless otherwise specified, for example before and after meal orders. 10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method or route of administration before giving the medication. A review of the facility's policy, Medication Administration Schedule, revised December 2012 states the following in relation to scheduling of medication(s). Daily medications scheduled for 9:00 a.m. and medications that are two times daily are scheduled for 9:00 a.m. and 5:00 p.m. 105978 Page 6 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards by 1.) failing to ensure medications were securely stored and dispensed for two (Resident #83 and Resident #355) of thirty five sampled residents, 2.) failing to ensure one of six medication carts in the facility were kept locked when unattended by staff, 3.) failing to ensure medications were properly dated when opened in three of three medication carts, and 4.) failing to ensure medication carts were free of expired medications in one of three medication carts. Findings included: An observation was conducted on 11/7/2023 at 10:14 AM in Resident #83's room. A medication bottle containing over-the-counter medication was observed on Resident #83's bedside table. Resident #83 was not observed in the room at the time of the observation. An interview was conducted on 11/7/2023 at 1:27 PM with Resident #83. Resident #83 stated she brought the over-the-counter medication into the facility when she was admitted to the facility. An observation was conducted on 11/6/2023 at 11:46 AM on the 600 unit of the facility. A medication cart was in the unit hallway and was unlocked. No staff members were in the proximity of the unlocked medication cart. Staff A, Registered Nurse (RN), who was assigned to the medication cart, was observed at the unit nurse's station sitting in a chair. An interview was conducted on 11/7/2023 at 2:50 PM with Staff A, RN. Staff A stated all medications should be stored in the medication cart and if a resident brought a medication from home it would be stored inside of the medication room. Staff A also stated residents were not permitted to have medications in their rooms. Staff A stated medication carts should be locked if they were left unattended and should not be left unlocked. An observation was conducted on 11/8/2023 at 11:07 AM in Resident #355's room during medication administration with Staff C, RN. A medication bottle containing over-the-counter medication, a bottle of nasal spray, and a tube containing a topical medication was observed on Resident #355's bedside table during medication administration. Resident #355 stated she brought the medications from home when she was admitted to the facility. Staff C observed the medications on Resident #355's bedside table and informed the resident the medications needed to be taken out of the room and secured due to not having a physician's order to self-administer medications. Staff D, RN Unit Manager (UM) entered the room and informed Resident #355 she would contact the resident's physician to get approval for having the medications with her in the room and the medications would be secured in the medication cart until then. An interview was conducted following the observation with Staff D, RN UM. Staff D stated residents who wish so self administer medications must be assessed for their ability to self administer the medications and the resident's care plan must be update. Staff D also stated medications must be kept secured at all times, even if the medications were approved to be located in the resident's room. An inspection of a medication cart on the 200 unit was conducted on 11/9/2023 at 9:42 AM with Staff 105978 Page 7 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0761 E, RN. The inspection of the medication cart revealed the following: Level of Harm - Minimal harm or potential for actual harm - An open Humalog insulin KwikPen stored in a plastic bag with a hand written date of 10/11/23 on a label affixed to the bag. Pharmacy directions on printed on the label read once opened, store at room temperature for 28 days. Staff E verified the KwikPen was opened on 10/11/2023 and the medication expired after 28 days. Staff E addressed the insulin KwikPen expired on 11/8/2023 and the insulin pen should be removed from the medication cart. Residents Affected - Few - A card containing seven tablets of Alprazolam 1 milligram (mg) with a printed expiration date of 10/31/2023. Staff E verified the medication was expired and should be removed from the medication cart. An inspection of a medication cart on the 300 unit was conducted on 11/9/2023 at 10:07 AM with Staff F, Licensed Practical Nurse (LPN) UM. The inspection revealed an open insulin glargine KwikPen stored inside of a plastic bag with a white Date Opened label affixed. No date was documented on the Date Opened label. Staff F was not able to state when the insulin KwikPen was opened and stated the medication should be dated when opened. An inspection of a medication cart on the 500 unit was conducted on 11/9/2023 at 10:22 AM with Staff G, LPN. The inspection revealed an open Lantus insulin pen stored inside of a plastic bag with a white Date Opened label affixed. No date was documented on the Date Opened label. Staff G was not able to state when the insulin pen was opened and stated the medication should be dated when opened. An interview was conducted on 11/9/2023 at 11:47 AM with the facility's Director of Nursing (DON). The DON stated when a resident was admitted to the facility, an inventory of the resident's belongings was taken and the resident's nurse would ask the resident or representative if any medications had been brought into the facility. If a resident brought medications into the facility, the medication was sent home with the resident's family unless the resident was assessed and was able to self administer the medications. If a resident wished to self administer medications, the resident's physician was notified and an order for the medication would be obtained. The resident was provided a locked box or drawer to ensure the medications were secured inside of the room because medications could not be left out at the resident's bedside. The DON stated she would expect nursing staff to keep the medication carts clean, ensure medications were not expired, and to discard medications appropriately if an expired medication was discovered. Insulin vials and pens should be dated when they were opened and the expiration date of the medication should also be documented. Expired medications should be returned to the pharmacy and expired controlled medications should be taken to the DON's office after the pharmacy was notified. The DON also stated she would expect nursing staff to ensure medication carts were locked at all times. An telephone interview was conducted on 11/9/2023 at 3:08 PM with the facility's Consultant Pharmacist (CP). The CP stated a nurse from the pharmacy conducted regular visits to ensure medication carts were clean, medications were all dated when opened, and no expired medications were in the medication carts. All insulins were good for 28 days after they were opened with the exception of Levemir, which had a 42 day expiration window. Expired medications should be removed from the medication cart and reordered from the pharmacy. The CP stated medications should not be left out in a resident's room and should be stored securely. The CP also stated medication carts should not be left unlocked unless the nurse is present at the medication cart. A review of the facility policy titled Administering Medications, last revised in April 2019, 105978 Page 8 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed under the section titled Policy Statement medications are administered in a safe and timely manner, and as prescribed. The policy also revealed the following under the section titled Policy Interpretation and Implementation: - The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. - During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. - Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary team, has determined that they have the decision-making capacity to do so safely. A review of the facility policy titled Self-Administration of Medications, last revised in February 2011, revealed under the section titled Policy Interpretation and Implementation self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. A review of the facility policy titled Medication Labeling and Storage, last revised in February 2023, revealed under the section titled Policy Statement the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. The policy also revealed the following under the section titled Policy Interpretation and Implementation: - If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. - Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. - Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 105978 Page 9 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

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. Based on observation, record review, and staff interview, the facility failed to ensure the sanitizer solution reached the low temperature dish machine by way of pump and tubing, failed to maintain the chlorine concentration between 50-100 ppm (parts per million) per manufacturer recommendations, and failed to maintain the ice machine in one of two nourishment rooms in a clean and sanitary manner. Findings included: On 11/06/2023 at 9:07 a.m., a general tour of the kitchen was conducted. While conducting the tour, the Dietary Manager was observed operating the dish machine. The dish machine log was reviewed for the week of (10/30-11/05) and revealed daily water temperatures as well as sanitizer concentration logged three times a day except for 11/05 at 1:00 p.m. and 7:00 p.m. The log revealed water temperatures of 150 degrees F and sanitizer concentration of 200 ppm (parts per million) for each day the log was completed. The instructions at the bottom of the form showed chlorine concentration must be between 50-100 ppm. Per the instructions, the logged sanitizer concentration was outside of range requirements. The Dietary Manager revealed they have and operate a Low temperature dish washing machine with wash temperatures to reach at least 120 degrees F and the rinse temperatures to reach at least 120 degrees F. The dish machine was observed with the Dietary Manager running empty crates through the dish washing machine. The Dietary Manager stated you must prime the dish machine three or four times to reach the required range for the sanitizer concentration and she was usually the one to get it started in the morning. Observations of the front of the machine revealed the specification place which indicated the sanitizer requirement was 50 ppm. The first dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The second dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The third dish machine operation demonstration revealed the paper used to test the chlorine sanitizer changed to a very dark black/purple and did not meet the color requirement to show there was sanitizer reaching 50-100 ppm. The Dietary Manager stated that was too high. The fourth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The fifth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The sixth dish machine operation demonstration revealed the Dietary Manager placed the paper used to test the chlorine sanitizer on a plastic container and the color changed to a very light color of purple and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The seventh dish machine operation demonstration revealed the paper used to test the chlorine sanitizer changed to a very dark black/purple and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The eighth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The Dietary Manager stated she had never had the machine not reading accurately this many times and that she would give the dish machine company a call. The Dietary Manager stated they would not use the dish machine 105978 Page 10 of 11 105978 11/09/2023 Gulf Shore Care Center 6767 86th Ave N Pinellas Park, FL 33782

F 0812 and they would use the three compartments sink to wash dishes. Level of Harm - Minimal harm or potential for actual harm On 11/06/2023 at 10:53 a.m., the Dietary Manager reported the dish machine was fixed. There was a crack in the line, and it was causing negative pressure. The sanitizer was getting to the machine, but the machine was not allowing it to flow through. Residents Affected - Many On 11/06/2023 at 11:33 a.m., dining was observed in the main dining room. Staff H, Dietary Aide, was observed placing utensils (spook, fork, and knife) on the table and on a white napkin for each resident. The utensils were observed wet. Staff H, Dietary Aide, stated the utensils were wet because they had just finished washing dishes because the dish machine was broken. We had to rush rush, stated Staff H, Dietary Aide. The utensils were observed in a crate, and they were all wet. The cart that the crate was sitting on was wet also. On 11/08/2023 at 11:45 a.m., a tour of the nourishment room on the east wing was conducted with the Dietary Manager. A pink and black buildup was observed underneath the dispenser on the ice machine (photographic evidence obtained). This was confirmed by the Dietary Manager. On 11/09/2023 1:44 p.m., an interview was conducted with the Dietary Manager and the Administrator. The Dietary Manager reported they switched to a new form to document water temperatures and sanitizer concentration so that was probably where the confusion came in and why staff were documenting 200 ppm. She said she was responsible for checking the forms to ensure staff were documenting and testing sanitizer accurately. The policy provided by the facility Ware Washing revised October 2019 revealed the following: 3. The Dining Services Director is responsible for insuring appropriate completion of temperature and/or sanitizer concentration logs as appropriate. 4. The Dining Services Director ensures that all dishware is air dried and properly stored. The policy provided by the facility Ice Machines and Ice Storage Chests revised January 2012 revealed the following: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation 3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. 105978 Page 11 of 11