Health inspection·June 16, 2022

F 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident #46's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact. Review of Resident #46's medical record revealed Resident #46 required hospitalization on 04/05/22 for symptomatic bradycardia and insertion of a pacemaker. The medical record identified no evidence the resident or resident representative was given a bed hold notice by the facility as required. Resident #46 was re-admitted to the facility following the hospitalization. On 06/16/22 at 9:09 A.M. Corporate Nurse #394 verified the facility did not provide a bed hold notice to Resident #46. Based on record review and staff interview, the facility failed to ensure bed hold notices were given to Resident #28 and Resident #46 and/or their representatives upon transfer to the hospital. This affected two residents (Resident #28 and #46) of two residents reviewed for bed hold notices. Findings include: 1. Review of the medical record for Resident #28 revealed admission date of 03/22/17 and a discharge to the hospital on [DATE]. Review of Resident #28's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had cognitive impairment. Review of Resident #28's medical record revealed the resident required hospitalization on 06/12/22 for sepsis. The medical record identified no evidence the resident or resident representative was provided written notification of a bed hold upon Resident #28's transfer to the hospital. Interview on 06/16/22 at 9:09 A.M. with Corporate Nurse #394 verified the facility did not provide a bed hold notice to Resident #28. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide bed baths/showers routinely and as scheduled. This affected two residents (Resident #5 and Resident #21) of five residents reviewed for activities of daily living. Residents Affected - Few Findings include: 1. Review of Resident #5's medical record revealed an admission date of 01/15/21 and diagnoses including acute and chronic respiratory failure, prediabetes, lymphedema, morbid obesity, hypertension and depression. Review of Resident #5's quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #15 was cognitively intact and was totally dependent on two or more staff for bathing. Review of the undated 300/400 shower schedule revealed Resident #5 was to be bathed Mondays and Thursdays on evening shift. Review of 30 days of shower data for Resident #5 revealed one bed bath was recorded on 05/14/22 (Saturday). No refusals were marked on the shower sheet and no data was available for 05/16/22 (Monday), 05/19/22 (Thursday), 05/23/22 (Monday), 05/26/22 (Thursday), 05/30/22 (Monday), 06/02/22 (Thursday), 06/06/22 (Monday), 06/09/22 (Thursday) and 06/13/22 (Monday). Review of 30 days of nurses' notes for Resident #5 revealed no refusals were documented and no evidence pertaining to bathing was available for 05/16/22, 05/19/22, 05/23/22, 05/26/22, 05/30/22, 06/02/22, 06/06/22, 06/09/22 and 06/13/22. Interview on 06/13/22 at 10:21 A.M. with Resident #5 revealed he was not getting bed baths and did not get bathed last week (06/05/22 to 06/11/22). Resident #5 stated he was supposed to get bathed on second shift but there was not often a shower aide for second shift so he would not get bathed. Interview on 06/14/22 at 10:40 A.M. with State Tested Nursing Assistant (STNA) #343 indicated if there was just one STNA scheduled it was hard to get showers done. Interview on 06/14/22 at 3:13 P.M. with Registered Nurse (RN) #381 revealed if all of the scheduled staff showed up they would have a shower aide to do resident showers. However, on second shift there was not a shower aide so STNAs had to do their own showers. Interview on 06/15/22 at 4:20 P.M. with Licensed Practical Nurse (LPN) #318 indicated there was currently one STNA on the hall instead of two and indicated showers on second shift were not getting done. LPN #318 indicated Resident #5 did refuse showers at times but also indicated charting did not get done due to staffing levels. Interview on 06/15/22 at 4:33 P.M. with STNA #396 revealed showers were an issue and did not always get done three out of seven days of the week. STNA #396 indicated Resident #5 would refuse showers at times, it depended on him. Interview on 06/16/22 at 8:48 A.M. with Regional Nurse Consultant (RNC) #395 verified Resident #5's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0677 showers were not completed per schedule and Resident #5 was not bathed routinely. Level of Harm - Minimal harm or potential for actual harm Interview on 06/16/22 at 8:58 A.M. with RN #397 revealed if residents refused showers, this was to be documented in a progress note. RN #397 stated showers were only documented on the paper shower sheets at the facility. Residents Affected - Few Interview on 06/16/22 at 9:29 A.M. with Corporate Registered Nurse (CRN) #398 revealed there was no specific facility policy addressing showers. Shower preferences were obtained on admission and that drove the days and shifts listed on the facility's shower schedule. 2. Review of Resident #21's medical record revealed an admission date of 01/19/21 and diagnoses including metabolic encephalopathy, depression, anemia, hypertension, type two diabetes and anxiety. Review of Resident #21's quarterly MDS assessment dated [DATE] revealed Resident #21 was cognitively impaired. Bathing was coded as did not occur on the MDS assessment. Review of the undated 300/400 shower schedule revealed Resident #21 was to be bathed Tuesdays on day shift and Fridays on evening shift. Review of 30 days of shower data for Resident #21 revealed showers were provided on 05/10/22 (Tuesday) and 05/24/22 (Tuesday); a bed bath was provided on 05/31/22 (Tuesday); a shower was provided on 06/07/22 (Tuesday) and a bed bath was refused on 06/14/22 (Tuesday). No data was available for 05/13/22 (Friday), 05/17/22 (Tuesday), 05/20/22 (Friday), 05/27/22 (Friday), 06/03/22 (Friday) and 06/10/22 (Friday). Review of 30 days of nurses' notes for Resident #21 revealed no refusals were documented and no evidence pertaining to bathing was available for 05/13/22, 05/17/22, 05/20/22, 05/27/22, 06/03/22 and 06/10/22. Interview on 06/13/22 at 12:03 P.M. with Resident #21 revealed she did not get bathed and could smell herself. Interview on 06/14/22 at 10:40 A.M. with STNA #343 indicated if there was just one STNA scheduled it was hard to get showers done. Interview on 06/14/22 at 3:13 P.M. with RN #381 revealed if all of the scheduled staff showed up they would have a shower aide to do resident showers. However, on second shift there was not a shower aide so STNAs had to do their own showers. Resident #21 refused showers at times. Interview on 06/15/22 at 4:20 P.M. with LPN #318 indicated there was currently one STNA on the hall instead of two and indicated showers on second shift were not getting done. LPN #318 indicated Resident #21 did refuse showers at times so staff would need to go back and reapproach her. LPN #318 also indicated charting did not get done due to staffing. Interview on 06/15/22 at 4:33 P.M. with STNA #396 revealed showers were an issue and did not always get done three out of seven days of the week. Interview on 06/16/22 at 8:48 A.M. with RNC #395 verified Resident #21's showers were not completed per schedule and Resident #21 was not bathed routinely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 06/16/22 at 8:58 A.M. with RN #397 revealed if residents refused showers, this was to be documented in a progress note. RN #397 stated showers were only documented on the paper shower sheets at the facility. Interview on 06/16/22 at 9:29 A.M. with CRN #398 verified there was no specific facility policy addressing showers. Shower preferences were obtained on admission and that drove the days and shifts listed on the facility's shower schedule. Event ID: Facility ID: 366011 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement appropriate fall interventions related to assistance with toileting to prevent Resident #49's falls. This affected one resident (#49) of four residents reviewed for falls. Findings include: Review of the medical record for Resident #49 revealed admission date of 05/27/20 with diagnoses including fracture of left femur, left femur intramedullary nailing, unspecified falls, muscle weakness, difficulty walking, lack of coordination, altered mental status, vascular dementia, restlessness and agitation, age related osteoporosis, and history of left hip fracture in 2016. Review of care plan initiated 06/05/20 revealed Resident #49 was at risk for falls related to confusion, history of falls, incontinence, medications, and impaired gait. Interventions included bed against wall, deep perimeter mattress to bed, encourage resident to wear bilateral hipsters, non-skid strips by bed, reinforce use of call light, utilize pillows to position in bed, bed in lowest position, non-skid socks, half side rail on right side of bed, identify non-compliance, monitor resident when in room for safety, and monitor for side effects from medications. Resident #49 had urinary incontinence. Interventions included assess quarterly for changes in elimination patterns, check and provide incontinence care as needed, refer to restorative for toileting program or scheduled toileting if applicable, and provide physical support or assistance for toileting safety as indicated. Review of Fall Risk assessment dated [DATE] revealed Resident #49 was at high risk for falls related to disorientation, required use of assistive devices, use of antidepressant and antipsychotic medications, and cardiovascular/cognitive/orthopedic/perceptual contributing factors. Review of physician's orders dated 04/07/22 revealed order for bed against wall and half side rail on right side. Physician's orders dated 04/19/22 revealed an order for bed in lowest position when in use. Physician's order dated 04/27/22 revealed an order for bilateral hipsters daily. Physician's orders dated 04/28/22 revealed orders for deep perimeter mattress. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had impaired cognition. Resident #49 required extensive one staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment indicated Resident #49 had falls since prior assessment and a recent major surgical repair of fracture. Review of progress notes from June 2021 to June 2022 revealed Resident #49 had falls on 03/21/22, 04/03/22, 04/11/22, and 04/25/22. Review of progress note dated 03/20/22 revealed Resident #49 was noted to wander around unit, redirection with limited success, and self-transferring. Review of progress note dated 03/21/22 revealed Resident #49 was found sitting on bathroom floor. Resident #49 reported I fell asleep and fell off the toilet. Resident #49 complained of back pain and was noted to be anxious. Resident #49 was noted not to be bearing weight on left side. There was slight rotation and shortening of left leg. Resident #49 was sent to hospital for evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of facility Fall with Injury Event report dated 03/21/22 revealed at 7:20 A.M. Resident #49 was found on floor in the bathroom. The fall was unwitnessed and Resident #49 had ambulated unassisted to bathroom. Resident #49 reported she must have fallen asleep and fell off the toilet. Resident #49 was found to have abnormal alignment of left leg, Resident #49 was alert, range of motion was painful and limited in lower extremity, and Resident #49 reported 10 out of 10 excruciating pain. Resident #49 had history of orthopedic conditions and use of antipsychotic medications. Resident #49 was transferred to hospital via ambulance. Hospital report revealed Resident #49 had left hip fracture and was scheduled for surgical repair on 03/22/22. Interventions upon return to facility were identified as refer to therapy services, monitor and manage pain, and room assignment closer to nursing station for monitoring. Review of progress note dated 03/24/22 revealed Resident #49 returned to facility post left hip surgery for fracture. Review of progress note dated 04/03/22 revealed Resident #49 was found on the floor in room stating, I have to go to the bathroom. No injuries were noted. Physician gave order to complete neurological checks and obtain a stat x-ray of left hip. Interventions included three-day bowel and bladder program. Review of facility Fall without Injury Event report dated 04/03/22 revealed at 5:15 P.M. Resident #49 was found lying on floor on right side next to bed. The fall was unwitnessed. Resident #49 was alert, normal extremity movements, and no pain or injury was noted. Interventions included hip x-ray related to recent fracture, utilize pillows for positioning when in bed, and monitor neurological status. Review of progress note dated 04/04/22 revealed Resident #49's left hip x-ray was negative. Resident #49 was assisted to bathroom and incontinence care provided. Review of progress note dated 04/11/22 revealed Resident #49 continued to be restless and making attempts to self-transfer. Resident #49 was offered toileting, snacks, and fluids. Redirection ineffective. Resident #49 had episode of incontinence. Resident #49 was having severe pain to left hip and back and was medicated with as needed pain medication. At 9:00 P.M. Resident #49 was found on bathroom floor and stated she was trying to go to bathroom, with no injuries noted. Review of facility Fall without Injury Event report dated 04/11/2 revealed at 9:00 P.M. Resident #49 was found on floor in bathroom. The fall was unwitnessed and Resident #49 has ambulated unassisted to bathroom. Resident #49 was alert, normal extremity movements, and no pain or injury was noted. Interventions included to reinforce use of call light. Review of progress note dated 04/20/22 revealed Resident #49 was found to be sitting on toilet in bathroom and the floor was noted to be covered in urine. Resident #49 had transferred unassisted and ambulated to bathroom without use of mobility devices or call light. Review of progress note dated 04/25/22 revealed Resident #49 was observed on floor in front of bed stating she was trying to go to bathroom. Post fall Resident #49 was noted to continue to attempt to self-transfer. No injuries were noted. Review of facility Fall without Injury Event report dated 04/25/22 revealed at 4:00 A.M. Resident #49 was found on floor in room. The fall was unwitnessed and Resident #49 had attempted to transfer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few without assistance from staff. Resident #49 was alert, normal extremity movements, and no pain or injury was noted. Interventions included to place non-skid strips in front of bed. Review of Occupational Therapy (OT) Discharge summary dated [DATE] revealed Resident #49 was started on OT services on 04/13/22. Resident #49 was noted to have been hospitalized after unwitnessed fall in bathroom and found to have hip fracture. Resident #49 had OT goal to safely complete all toileting tasks. Resident #49 was discharged from therapy with stand by assistance required for toileting. Review of Physical Therapy (PT) Discharge summary dated [DATE] revealed Resident #49 was started on PT services on 04/25/22. Resident #49 had PT goal to safely perform all functional transfers. Resident #49 was discharged from therapy with improvements to transfers however goals were not met as assistance levels fluctuate. Observation on 06/15/22 at 11:29 A.M. of Resident #49 revealed resident was sitting at edge of bed then stood up and self-transferred to wheelchair. Resident #49 then came out of room and headed down to dining room with no staff assistance or intervention. Interview on 06/15/22 at 11:33 A.M. with Registered Nurse (RN) #332 revealed Resident #49 was not on a toileting program. RN #332 indicated Resident #49 knows when she has to go to the bathroom and the aides take her. RN #332 indicated Resident #49 was commonly known to self-transfer. Interview on 06/16/22 at 12:11 P.M. with Licensed Practical Nurse (LPN) #326 and Regional Nurse #403 revealed Resident #49 had fascination with bathroom and she had a three-day bowel and bladder evaluation when she fell on upstairs unit. LPN #326 indicated they believe it would be helpful to Resident #49 to have some sort of toileting program. LPN #326 indicated they have a routine with Resident #49 and have been trying to keep closer to nurses' station but there was no scheduled routine for toileting in place. Regional Nurse #403 indicated the Director of Nursing (DON) would typically go over each fall and complete a root cause analysis then implement appropriate interventions, however there had been an interim DON so they were unable to confirm if any review of Resident #49's falls were completed. LPN #326 and Regional Nurse #403 verified the noted pattern for Resident #49 falls surrounding bathroom use and there were no interventions in place for toileting to prevent further falls. Follow up interview on 06/16/22 at 12:44 P.M. with LPN #326 and Regional Nurse #403 revealed Resident #49 was noted to continue to be up late at night and have periods of restlessness. Resident #49 continued to need reminders to use call light however Resident #49 had difficulty remembering reminders related to impaired cognition. Review of facility policy Fall Investigation dated 06/03/19 revealed post falls a root cause analysis would be conducted by interdisciplinary team and safety interventions would be implemented based on findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 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 366011 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/16/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concord Ridge Health and Rehabilitation 9901 Johnnycake Ridge Rd Mentor, OH 44060 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 a clean and sanitary kitchen area. This had the potential to affect 88 residents who received meals in the facility. The facility identified Residents #22 and #26 as receiving no food from the kitchen. Findings include: Observation of the kitchen during the initial tour with Corporate Certified Dietary Manager (CDM) #399 on 06/13/22 at 9:55 A.M. revealed the steamer and stove range with food debris and splatter running down sides. Dark blackened grease build up was observed on stove top grates. There was a dark sticky substance on the floor around and behind the steamer, oven, and grill top. Behind the equipment was a food preparation container three quarters full of dark grease like substance on floor and two pieces of foil. Interview with Corporate CDM #399 on 06/13/22 at 10:00 A.M. confirmed all observations. Corporate CDM #399 indicated there was no current dietary manager as the previous manager had quit unexpectedly last week. Follow up observation of the kitchen on 06/14/22 at 12:05 P.M. revealed the convection oven, pellet warmer, and plate warmer with floor residue and splatter running down outsides of equipment. The lower shelves of preparation tables had food particles and sticky residue. The floors under preparation tables and kitchen equipment had a dark residue and food particles. There was an unidentified brown substance dripping from bottom of preparation table by can opener and the substance was observed dripping down the leg of preparation table. Interview with Corporate CDM #399 on 06/14/22 at 12:12 P.M. confirmed all observations. Interview with Registered Dietitian (RD) #400 on 06/15/22 at 3:14 P.M. revealed they had no time for routine oversight in the kitchen and routine sanitation audits had not been completed. Review of a list of resident diets provided by the facility revealed Residents #22 and #26 as receiving no food from the kitchen. Review of facility policy, Dietary Department Cleaning Schedule, dated March 2016, revealed the dietary manager was responsible for ensuring cleaning schedules are completed, cleaning schedules shall be posted and available to all dietary employees, and all cleaning assignments shall be reviewed by dietary manager. Review of facility policy, Operation and Cleaning Procedures, dated March 2022, revealed the director of food services or designee was responsible for developing operating and cleaning procedures for all dietary equipment. All areas of the kitchen were to be cleaned daily to insure proper sanitation in the operation. Director shall conduct weekly audits of all areas and ensure proper sanitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366011 If continuation sheet Page 9 of 9