Health inspection·June 23, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan for anticoagulant therapy for one of 13 residents (R19) reviewed for care plans in the sample list of 25. Findings include: The facility's Care Plan - Comprehensive policy dated 3/28/19 documents, Policy Statement(:) An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set). 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; 5. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. It is recognized that care planning individual symptoms or Care Area Triggers in isolation may have little, if any, benefit for the resident. 7. The resident's comprehensive care plan is developed within seven (7) days of the completion so the resident's comprehensive assessment (MDS). 8. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. R19's Order Summary dated 6/21/22 documents diagnoses including Chronic Embolism and Thrombosis of Unspecified Vein, History of Falling and Dementia without Behavior Disturbances. R19's Order Summary documents orders to obtain PT/INR (Prothrombin Time/International Normalized Ratio) on 7/7/22, one time only. This Order Summary documents orders for Coumadin (anticoagulant) 2 mg (milligrams) by mouth, every evening on Monday, Tuesday, Wednesday, Thursday and Friday. This Order Summary also documents an order for Coumadin 3 mg by mouth every evening on Saturday and Sunday. R19's Minimum Data Set (MDS) dated [DATE] documents resident is moderately cognitively impaired and this MDS documents that R19 receives an anticoagulant seven days a week. R19's Care Plan provided on 6/22/22 by V3 Director of Nursing does not document anticoagulant therapy for the treatment of Chronic Embolism and Thrombosis or the risk of bleeding and any interventions to prevent bleeding. On 6/23/22 at 9:05 AM, V9 Clinical Care Coordinator/Care Plan Coordinator confirmed that R19's anticoagulant therapy is not on R19's Care Plan. V9 stated that it should be on there because R19 has a history of having an Embolism. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 2 of 10 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to keep a resident's oxygen tubing off the floor and failed to label portable oxygen tubing according to facility policy. This failure affects two of three residents (R14 and R16) reviewed for respiratory care on the sample list of 25. Residents Affected - Few Findings include: 1.) On 06/21/22 at 11:22 AM R14 was seated in a wheelchair at the side foot area of R14's bed. R14 had an oxygen bedside concentrator that was plugged into the wall outlet at the head of the bed. R14 had a portable oxygen tank on the back of R14's wheelchair. The bedside oxygen concentrator tubing was stretch out on the floor three feet from the concentrator to reach R14's wheelchair. The oxygen concentrator tubing had several feet of oxygen tubing coiled on the floor at the side of R14s wheelchair. R14 stated R14 just changed over to the portable oxygen in preparation to leave R14's room. R14 stated The oxygen tubing dangles from the concentrator and onto the floor sometimes. R14's portable oxygen with the nasal cannula tubing was not dated to indicate when it was last changed. R14 stated R14 is not sure when the portable concentrator tubing was last changed. R14's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 13 out of 15, indicating no cognitive impairment R14's Diagnoses Sheet dated 4/8/22 documents the following: Pulmonary Fibrosis Unspecified. R14's Physician Order Summary Report Sheet dated as active 6/13/22 documents the following: Resident (R14) uses O2 (oxygen) per NC ( nasal cannula) at 2L (two liter per minute) when at rest. Increase oxygen) to 3L (three liter per minute) with activity. 2.) R16's Physician Order Summary Report Sheet (POS) dated June 1/30/22 documents the following diagnoses and oxygen order: Acute Respiratory Failure Unspecified Whether Hypoxia or Hypercapnia, Down Syndrome Unspecified, Muscle Weakness Generalized, and Chronic Obstructive Pulmonary Disease. The same POS documents: May use O2 (oxygen)per NC (nasal cannula) at 2.5L (2.5 liters per minute) when at rest and up to 4L (four liters) with walking to keep SpO2 (oxygen saturation) greater than 90%. Active 12/14/2021. On 06/21/22 12:15 pm - 12:40 pm R16 was feeding herself in dining room. R16's portable oxygen tank was attached to the back of R16's wheelchair and was in the on position, administering 2.5 liters per minute via nasal cannula. The oxygen tubing that attached the nasal cannula to the portable oxygen tank had several feet of excess oxygen tubing that dropped to the floor. The oxygen tubing on floor was directly behind R16's wheelchair tire and was partially coiled. On 6/21/22 at 12:40 pm R16 's oxygen tubing continued to lay on the floor. Several unidentified staff members passed by R16. V5, Registered Nurse acknowledged R16's oxygen tubing was on the floor. V5, Registered Nurse stated All oxygen tubing and humidifier bottle are dated when they are changed weekly. The oxygen tubing is never supposed to be on the floor. It can be a trip hazard as well as an infection control issue. On 6/23/22 at 3:15 pm V2, Director of Nursing (DON) stated residents' oxygen tubing should never be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 3 of 10 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 0695 on the floor. Level of Harm - Minimal harm or potential for actual harm The facility policy Oxygen Procedures dated January 12, 2018, documents the following: 5. Date the humidifier bottle and tubing. Residents Affected - Few 6. Ensure there is a storage bag attached to the concentrator for storage of unused nasal cannula and excess tubing. 7. Change tubing and nasal cannula /mask every two weeks ,or as needed. 8. Change the humidifier bottle every two weeks, or as needed. 9. Place nasal cannula/mask and excess tubing in the storage bag attached to the concentrator when not in use. Tubing should not rest on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 4 of 10 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure PRN (as needed) medications were not ordered for more than 14 days maximum duration permitted for PRN medications without justification, failed to complete a psychotropic medication assessment prior to starting a psychotropic medication, and failed to care plan non-pharmacological interventions to assist with behavior management for three of five residents (R27, R30, and R36) reviewed for psychotropic medications on the sample list of 25. Findings include: 1.) R36's Physician Order Summary Report Sheet (POS) dated June 1-30, 2022, documents the following diagnosis: Unspecified Dementia Without Behavioral Disturbance, Anxiety Disorder Due to Known Physiological Condition, and Delusional Disorder. R36's Physician Order Summary Report Sheet (POS) dated February 1-28, 2022, documents the following psychotropic medication order: Lorazepam Tablet 0.5 MG( milligram) Give 1(one) tablet by mouth as needed (PRN) for Anxiety take every 12 hours. Active 2/01/22. There is no physician order to discontinue or change the as needed (PRN) Lorazepam medication order after the maximum required duration for prn psychotropic medications. R36's Note To Attending Physician/Prescribe documented by V12, Pharmacist, signed by V11, Physician on 03/24/22, documents the following: Resident was started on Lorazepam 0.5 milligrams q (every) 12 hours added 2/8/22 (actual order as noted on February 2022 POS above has a start date of 2/1/22). The same Note To Attending Physician/Prescribe documents: Please provide a rational and duration for a PRN psychotropic order that exceeds 14 days per CMS requirements as indicated above. V11, Physician documented duration updated as 180 days for intermittent anxiety (dated 3/24/22). As documented below, R36 received 31 doses after the 14 day maximum duration. R36's Medication Administration Record dated February 1-28, 2022, documents R36 received prn Lorazepam 0.5 mg, 31 times after the 14 day maximum prn order permits. R36 Lorazepam administration occurred on the following dates: February 15-19, 21-24, and the 27, 2022. R36's Medication Administration Record dated March 1-31, 2022, documents R36 Lorazepam was also administration on the following dates, March 1-13th, March 15-23, 2022. On 6/23/22 at 9:45 am V10, Director of Clinical Services/ Registered Nurse and V2, Director of Nursing (DON) confirmed R36 was admitted to the facility on [DATE] with an order for Lorazepam 0.5 mg by mouth, as needed every 12 hours. V2 and V10 acknowledged R36's Lorazepam order did not document the 14 day maximum duration. V2, DON and V10, Director of Clinical Services/RN also confirmed R36 continued to receive administration of Lorazepam 0.5 mg po every 12 hours until V11, Physician responded to V12, Pharmacist request to provide a rational and duration for a psychotropic order that exceeds 14 days as required by CMS.2. R30's Physician Order Recap dated June 2022 documents the following orders: 5/13/22 Cymbalta {Antidepressant} 30 mg (milligrams) daily for depression (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 5 of 10 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 6/3/22-6/16/22 Lorazepam Concentrate {Benzodiazepine} 2 mg/ml (milliliters) - give 0.25 ml every 4 hours PRN for agitation 5/13/22 Trazodone {Serotonin Modulator} 50 mg - give 0.5 tablets every HS (bedtime) for sleep R30's medical record does not contain a psychotropic medication assessment prior to starting the above medications. R30's Care Plan dated 5/11/22 documents R30 requires mood/behavior monitoring due to yelling out and situations of anger. This Care Plan documents interventions of implementing the above medications but does not include any non-pharmacological interventions. On 6/22/22 at 3:13 PM, V7 RN (Registered Nurse)/Psychiatric Nurse explained that when R30 returned from the hospital on 4/28/22, R30 was not on any psychotropic medications but then hospice recommended R30 be started on the above medications. V7 stated there should have been a justification assessment completed at that time but V7 doesn't see that one was completed, (after checking the computer). V7 also confirmed R30's psychotropic care plan does not include any non-pharmacological interventions. 3. R27's Order Summary Report dated June 22, 2022, documents an order for Lorazepam { Benzodiazepine} 0.5 mg - one tablet every three hours PRN for anxiety and shortness of breath until 7/14/22 due to resident being on Hospice. R27's Progress Notes dated 4/25/22 by V5 RN (Registered Nurse) documents R27 has been discharged from hospice due to no longer being terminally ill, and R27's condition is stable. On 6/22/22 at 3:13 PM, V7 RN/Psychiatric Nurse stated when a resident comes off of hospice, they should be re-evaluated for the use of the PRN psychotropic medication, to ensure they still need them and to adjust the length of time medications are ordered for. R27's medical record does not contain a psychotropic medication assessment since being discharged from hospice services. The facility Psychotropic Medication Use Policy dated May 13, 2022, documents the following: Physicians and mid-level providers will use psychotropic medications appropriately, working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Psychotropic medication refers to drugs which are used for anti-psychotic, anti-depressant, anti-anxiety, and/or hypnotic purposes. It is the policy of this facility to keep each resident's medication regime free from unnecessary drugs, yet we support the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. Psychotropic medications will not be administered for the purpose of discipline, staff convenience and will only be used when it is necessary to treat a specific condition. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. The resident's need for the psychotropic medication will be monitored by the Psychotropic Drug Monitoring Team. The monitoring will include: * Identification and daily monitoring of the resident's behaviors that the psychotropic drug could conceivably address (i.e., target behaviors). * Assessment of potential causes of the behaviors that , if addressed, could eliminate the behaviors without the use of psychotropic drugs.* Discussion of non-medical behavior management strategies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 6 of 10 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 0758 Level of Harm - Minimal harm or potential for actual harm that could be implemented in an attempt to reduce/eliminate the behaviors prior to the initiation of drug treatment as well as on an ongoing basis. This policy also documents, Policy Interpretation and Implementations number 8. Orders for PRN (as needed) psychotropic medications will be time limited (i.e., times two weeks) and only for specific clearly documented circumstances. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 7 of 10 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to administer medications according to Manufacturers Recommendations and facility policy for one (R35) of six residents reviewed for medication administration in the sample list of 25. The facility had 2 errors out of 33 opportunities for a medication error rate of 6.06%. Residents Affected - Few Findings Include: R35's June 2022 POS (Physician Order Sheet) documents orders for Lantus {Long Acting Insulin} 10 units SQ (Subcutaneously) every morning and Novolog {Rapid Acting Insulin} 100 units /ml per sliding scale coverage SQ before meals and at bedtime{based on blood glucose level}: 151-175 = 1 unit, 176-200 = 2 units, 201-225 = 3 units, 226-250=5 units, 251-275=7 units, 276-300 = 9 units, 301-325 = 12 units, 326-350=15 units, and if greater than 351, call physician On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) stated V7 had already checked R35's blood glucose level, which was 162, therefore R35 would be receiving one unit of Novolog. V7 pulled an unlabeled Novolog Flexpen from the medication cart and prepared the ordered Novolog. At this time, V7 stated V7 knew it was R35's as it was in the bag with R35's name on it. V7 pulled a bag from the medication cart that contained needles for the Flexpen and an unlabeled Lantus pen. The bag had a worn pharmacy label on it which included R35's name, which was barely legible and no other information, due to it being worn. V7 then pulled up 10 units of Lantus from the unlabeled Lantus Pen that was in the bag. At 8:44 am, after the medication was prepared, V7 administered the medications to R35. R35 had R35's breakfast plate on the table in front of R35, which was empty. R35 stated R35 had already finished breakfast as it was served around 7:45 am {an hour prior}. R35 stated this is not unusual, they always give me (R35) insulin after eating. The Manufacturers Recommendations for NovoLog dated March 2008 documents Novolog should be given immediately (within 5-10 minutes) prior to the start of a meal. The facility's undated Administering Medications Policy documents medications must be administered in accordance with the orders, including any required time frame. This policy also documents the individual administering the medications must verify the right medication, right dosage, right time and right method before giving the medications. The facility Labeling of Medication Containers Policy dated June 2020 documents medication labels must be legible at all times. Labels shall include all necessary information such as: the resident name, prescribers name, pharmacy information including name/address/telephone number, the name/strength/quantity of the medication, prescription number, and expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 8 of 10 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 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 medications are labeled appropriately for one of six residents (R35) reviewed for medication labeling in the sample list of 25. Findings Include: The facility Labeling of Medication Containers Policy dated June 2020 documents medication labels must be legible at all times. Labels shall include all necessary information such as: the resident name, prescribers name, pharmacy information including name/address/telephone number, the name/strength/quantity of the medication, prescription number, and expiration date. On 6/22/22 at 8:34 AM, V7 RN (Registered Nurse) prepared R35's morning medications which included insulin's: Novolog {Rapid Acting Insulin} and Lantus {Fast Acting Insulin}. V7 pulled the unlabeled Novolog and Lantus from a bag in the medication cart that had a worn pharmacy label on it. The label had R35's name on it, which was barely legible due to being worn and no other information. V7 stated, V7 knew that the Novolog and Lantus belonged to R35 due to being in the bag that was labeled for R35. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 9 of 10 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 145794 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/23/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fairview Haven 605 North 4th Street Fairbury, IL 61739 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 - Many 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 maintain equipment and utensils in a safe, clean, sanitary condition to prevent the potential for cross-contamination of food from physical contaminants. These failures have the potential to affect all 47 residents in the facility. Findings include: 1.) On 6/21/2022 at 9:45 am on tour of the kitchen, accompanied by V8, Dietary Manager, there was a manual tabletop can opener. The tabletop can opener had thick, dark brown grease-like build-up on the blade and an accumulation of metal shavings in gears. V8, Dietary Manager stated I see the metal shavings. I will get that taken care of right away. That is bad and is a potential hazard that could affect all the residents in the facility. 2.) On 6/21/2022 at 9:50 am continuing on the tour of the kitchen accompanied by V8, there was one large 24 inch by 18 inch acrylic cutting board and two smaller 18 inch by 12 inch acrylic cutting boards. The three cutting boards each had deep slice-like divots over the majority of the boards The center sliced divot had imbedded builds-up of brown and yellow food-like debris in the slice-like crevices. V8, Dietary Manager stated These (cutting boards) need to be thrown out. I will replace them. They can't be used in that condition. 3.) On 6/21/22 at 9:55 am continuing on the tour of the kitchen accompanied by V8, there were four large rubber spatulas. The four large rubber spatulas had slice-like divots with food-like debris. The same four rubber spatulas had uneven chew-like pieces of the rubber missing at the edges. V8, Dietary Manager stated I have to throw those (spatulas) away too. They can't be used. The facility policy Cleaning Instruction: Can Opener dated 2020 documents the following: 2. Protocol for counter-mounted can openers: * Remove can opener shaft from the base; wash in sink with soap and water. * Pay close attention to the blade and other moving parts. * Rinse, sanitize and air dry. * Wash the base carefully with mild detergent and hot water; be sure to get rid of all food particles from the blade and the base. * Sanitize and then air dry. * Reassemble can opener once dry. The Resident Census and Conditions of Residents report dated 6/21/22 documents 47 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145794 If continuation sheet Page 10 of 10