Health inspection·March 8, 2023

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1.The facility failed to ensure food items in refrigerators, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best by', consume by or expiration dates. 3. The facility failed to ensure the ice machine vent/grate and outer surface was free from dust. 4. The facility failed to have Dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observations of Reach-in Refrigerator #2 on 03/06/23 at 09:21 AM revealed the following: -Left side door, bottom of the refrigerator: 1 large zip top bag with thawed chicken in a shallow metal pan, there was no label of item description, no pulled date, no consume by date. -1 full size sheet pan with thawing pork chops covered with loose fitting plastic wrap, dated 03/06/23, sitting on six stacked rectangle white boxes of raw bacon; the pan over-hanged the side of the boxes that drippings could drip onto the thawed chicken beneath it. -Center door: 1 large zip top bag of celery dated 3 6 (03/06/23), unsecured closed, no consume by or discard date. -Right door: 120 (10 bags with 12 each) defrosted/thawed waffles [out of box], dated 03/03/23 (on first stack), there was no label of item description, no consume by or discard date. -1 large zip top bag with cooked cheese omelettes, dated 03/06/23, there was no label of item description, no consume by or discard date. Page 1 of 11 455670 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0812 -2 extra-large bags of thawed scrambled egg mix, dated 03/06/23, there was no label of item description. Level of Harm - Minimal harm or potential for actual harm Observation of the Kitchen on 03/06/23 at 08:57 AM revealed the following: Residents Affected - Some - Ice Machine: inside the ice chest there was a long white plastic guard (stretched the length of the internal ice chest) in front of the ice chute; it had brown and light pink areas/smudges/smears/spots in various places on the guard. -Ice Machine: plastic vent, located on the right side of the machine, the vent slats had dust on them. - Handwashing sink #1's garbage receptacle: the garbage bag was not properly placed in receptacle; it was hanging down in the back. -Prep Table (between the stove and the reach-in Refrigerators) at 09:33AM: On the bottom of the prep. Table, 50 lbs. bag of onions in an extra-large plastic container, previously opened, there was a metal tablespoon with a thick dark orange colored substance on it. -1 extra-large cardboard box of approximately 6 -10 heads of cabbage, no date reflected. The cabbages were dried out and had browned ends to most of the leaves covering the heads of cabbage, there was no consume by date or discard date. -On the floor, slightly under the prep table was a slice of tomato, a wilted, shriveled dark leaf from a green leafy vegetable and a piece of skin (peel) from a yellow onion. -On the floor, under the prep. sink (next to the prep table) was a sliced off top of a fresh yellow onion. -On a large rolling Baker's Rack at 09:55 AM: On the 4th- 9th, row down from top, 5 sheet pans of baked chocolate chip and sugar cookies, uncovered; there was no label of item description, no open/pulled date, no consume by, or discard date. Observations of Reach-in Refrigerator#1 on 03/06/23 at 09:02 AM revealed the following: - Left side door: 1 large clear plastic bag for lettuce, previously opened and tied closed in a knot that had come undone. There was no label of item description, no open date, no received by date, and no consume by or discard date. -1 medium clear plastic container with green lid, dated 03/02/23, labeled tomatoes'; it had sliced tomatoes and lettuces leaves, there was no consume by or discard date reflected. -Center door: 10 small white foam bowls with lids labeled fish, dated 03/01/23, contained a thick yellow substance (yellow mustard consistency), there was no consume by or discard date. -1 small white foam bowl with lid, labeled fish, dated 03/01/23; the lid was not closed on the left side, there was no consume by or discard date. -1 small white foam bowl with lid, contained salad with croutons, there was no label of item 455670 Page 2 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0812 description, no open/pulled date, and no consume by or discard date. Level of Harm - Minimal harm or potential for actual harm -2-16.9 oz clear plastic bottles of water, no label of personal use or kitchen use, no pulled date and no discard date. Residents Affected - Some -1 large zip top bag with six premade chicken salad sandwiches, dated 03/03/23, there was no consume by or discard date reflected. - 1 large zip top bag with two pimento cheese sandwiches, dated 03/03/23, there was no consume by or discard date reflected. -1-5 lbs. white plastic tub with lid of low-fat cottage cheese with manufacturer expiration date of 02/18/23, there was no received by date. -1- 5 lbs. white plastic tub with lid of low-fat cottage cheese, previously opened on 02/11/23, manufacturer expiration date of 02/18/23. -1-5.5 oz aluminum can of low sodium special blend tomato juice (for drinking), there was no received by date, no consume by, or discard date. -1-approximately 8 oz. plastic bottle of lactose free fat free milk with no received by date, no consume by or manufacturer expiration date reflected. -1 large zip top bag with sliced provolone cheese dated 02/16/23, there was no consume by or discard date. Observations of Reach-in Freezer #1 on 03/06/23 at 09:39 AM revealed the following: -Left door: - 1 large zip top bag with breaded chicken fillets, dated 03/04/23, unsecured closed, there was no consume by or discard by date. -1 large zip top bag, dated 02/28/23, with previously opened 5 lbs. bag of breaded okra, there was no received by date, no consume by or discard by date. -1 large zip top bag, dated 02/05/23, with previously opened, tied closed, 40 oz. bag of breaded okra, unsecured closed; there was no received by date, no consume by or discard date. -1 large zip top bag, dated 03/05/23, labeled ck, with breaded chicken fillets; there was no consume by or discard date. -1 extra-large blue plastic bag tied closed with mixed vegetables, there was no label of item description, no received by date, no consume by, or discard date. -1 extra-large bag tied closed with frozen beef patties, dated 03/06/23, there was no label of item description, no received by date, no consume by, or discard date. -Right door: -1 medium zip top bag, dated 02/17, containing a small ham, dated 02/15, there was a medium amount of ice crystals in the bag and the ham was darker near where the ice crystals had collected, on the bottom of the ham. 455670 Page 3 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0812 -at the bottom of the freezer was a frozen French fry. It remained in the same place during an observation on 03/08/23 at 01:15 PM. Level of Harm - Minimal harm or potential for actual harm Observations of the Reach-in Freezer#2 on 03/06/23 at 09:50 AM, revealed the following: Residents Affected - Some -1 large frozen slab of beef, dated 03/06/23, there was no label of item description. -2 previously opened, tied closed plastic bags of frozen Ranch dinner rolls, approximately 20 each; there was no label of item description, no consume by, or discard date. Observations of the Dry Storage room on 03/06/23 at 09:57 AM revealed the following: -Left side shelf: -1-1.34 oz box, previously opened oatmeal pies, there was no received by date, no opened date, no consume by or manufacturer expiration date. -1 large zip top bag of previously opened bag of shredded coconut, dated 08/17/22, there was no received by date, no consume by or discard date. -1-8 oz plastic bottle of dark brown thick liquid, there was no label of item description, no received by date, no open date, no consume by, or discard date. -Right side shelf: -1-1.36 oz. container with lid, containing Demi-[NAME] (a brown sauce used by itself or as base for other sauces), dated 08/29/22, no consume by date, manufacturer expiration/best by date 12/07/22. -1-16 oz bag of chicken flavor, dated 02/02/22, manufacturer expiration date 01/09/23. -5- 11.3 oz. bag of turkey gravy mix, there was no received by date. It was sitting outside of a box of similar items dated 02/02/22, with manufacturer best by date 12/19/22. Observations of the Kitchen on 03/08/23 at 10:50 AM revealed the following: -Handwashing sink #1 garbage receptacle garbage was full and had more than paper towels in it, foam/paper plates, gloves, were also noted. -At 11:00 AM: [NAME] C mask was noted to be beneath his nose. He pulled it up. It fell beneath his nose again while speaking with the surveyor, he was asked to pull it and pinch it at the nose to allow for a better fit. -At 11:10 AM: Lunch service was about to get started, [NAME] C's mask was once again under his nose, and he was talking to the staff about getting service underway. He started preparing plates and the mask slipped down beneath his mustache and top lip. -At 11:20 AM: Dietary Aides noted taking prepared plates of food to the dining room, with gloved hands, then coming back and grabbing another prepared plate to take back out to the dining room to give to a resident. The staff had on gloves but had to push the exit door outward to exit the kitchen and push the entrance door open to come into the kitchen and they were not changing gloves or washing hands upon re-entering the kitchen. (*Dietary Manager returned at 11:23 AM and observed a staff member push the entrance door with gloved hands to re-enter the kitchen then take another plate to go 455670 Page 4 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0812 back into dining room without changing gloves or washing their hands.) Level of Harm - Minimal harm or potential for actual harm -At 11:39 AM: Dietary Aide E stood on the line, next to [NAME] C and passed the plates [NAME] C fixes to the other Dietary Aides on the receiving side of the steam table, was noted with gloved hands touching her smart watch when it alarmed and not changing gloves. She then touched her clothes but did not change her gloves. Residents Affected - Some In an interview on 03/08/23 at 11:00 AM with [NAME] C. He stated he had worked at the facility for 7 months and that he was in-charge when the Dietary Manager was not present. He stated an understanding of the purpose of the presence of the surveyor in the kitchen today. (The Dietary Manger was in a facility staff meeting). When [NAME] C was informed of an observation of a staff member not practicing hand hygiene in the kitchen, he stated that that could cause illness in the residents and make someone real sick. He was also asked about wearing one's mask incorrectly. He stated they wear their masks to protect the residents and need to have it pulled up over their mouth and nose. He stated they are not supposed to touch it and not wash their hands or put on new gloves. In an interview on 03/08/23 at 11:15 AM with [NAME] D. She stated she had worked at the facility for 15 years and along with cooking duties also does inventory on Mondays, Wednesdays and Fridays. She said, Dietary Manager gives me a sheet on of what is supposed to be in here then I try to add with my menu. The sheet is supposed to have everything we need for the kitchen. We get sheets every week. [NAME] D stated she submits her finished sheets to the Dietary Manger then he places the orders. He orders on Mondays, the orders go out on Tuesdays, the truck delivers on Wednesdays and Fridays. She also restocks and rotates inventory. She said, the reason for rotating stock was because items will expire. The harm is it could cause food poisoning, if used. In an interview on 03/08/23 at 11:25 AM with the Dietary Manager. He was informed of the observations made by the surveyor regarding hand hygiene. When asked the risk /harm of staff touching the doors going in and out of the kitchen with gloves or ungloves hands and not changing them or washing their hands. He stated maybe he could open the doors to the kitchen (to keep staff from touching the door going out and returning to kitchen from serving the ALF dining room). He stated hand hygiene was important to keep down the opportunities to introduce germs to the food being prepared and later served. He also stated they had just had an in-service on this prior to survey. In an interview and observation on 03/08/23 at 12:45 PM with Dietary Aide-D. She stated she had worked at the facility for one month and that hand hygiene was important to prevent making residents ill. When asked did she know why or understand why when we touch any surface other than food when working the line, gloves should be changed. She stated yes and nodded her head up and down. In an interview and observation on 03/08/23 at 12:50 PM with the Dietary Manager. He stated he had not seen the brownish and pink spots/smudges inside the ice machine, but he would get that cleaned up. As the walk through of the kitchen and interview continued, the Dietary Manager said, opened/leftover items are kept in the refrigerator for 3 days and prepackaged items are kept 7-10 days once they are opened. Canned goods with no expiration dates . I do not know; I would have to find that out. Canned goods with expiration dates, we go by the expiration dates, but other items once opened are kept 6-8 weeks. We go by expiration dates to discard food items. He stated items in the dry storage room, once opened are kept until expiration date. He asked if the French fry that was shown to him in freezer during the walk through was there on Monday. When asked about the staff member that walked into the kitchen and had the kitchen staff distracted 455670 Page 5 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some trying to find out what she wanted, the Dietary Manager stated the staff member was a Housekeeper for the ALF side and non-dietary staff knows they are not to just walk in here. He also stated he was unsure why the housekeeper came inside the kitchen today to place her personal lunch order. He stated he understood how her repeated touching of her mask was an issue and she should not have been in the kitchen, especially doing the thing (repeated touching of her mask) he was just trying to remind his staff not to do because it puts the residents at risk for cross contamination. Review of facility's Shelf Life of Refrigerated Food List (provided by Dietary Manager) on 03/08/23: Meat & Seafood: Meat and Seafood: .Chicken or Turkey 1-2 days Ground Meats 1-2 days Lunch Meats 2 weeks unopened, 3-5 days opened .Dairy: Cheese, hard 6 months unopened, 3-4 weeks opened Cheese, soft 1 week .Leftovers: Meat or Poultry 3-4 days Salads 3-5 days . Review of the U.S. Public Health Service Food Code, dated 2017, reflected: 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A food specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; P (2) Is in a container or package that does not bear a date or day; P or 455670 Page 6 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A). (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section; or Review of the facility's Nutrition Services Policy & Procedures: Food Preparation and Service, not dated, reflected: Policy Statement: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: Food Preparation Area 1. The food preparation area is large enough to meet the needs of the facility. 2. Equipment is arranged to facilitate food preparation, 3. Areas for cleaning dishes and utensils are located in a separate area from the food service line to assure that a sanitary environment is maintained. 4. Appropriate measures are used to prevent cross-contamination. These include: a. Storing raw meat separately and in drip-proof containers in a manner that prevents cross-contamination from other foods in the refrigerator; . d. Cleaning and sanitizing work surfaces and food-contact equipment between uses, following food code guidelines. 5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Thawing Frozen Food .1. a. Thawing in the refrigerator in a drip-proof container; . 17. Food served once is not served again. 18. Residents are discouraged from saving anything from their meals for later consumption. Food Service/Distribution 4. All staff wash their hands before serving food to residents. Staff will also wash their hands after collecting soiled plates and food waste prior to handling food trays. 6. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Food Receiving and Storage Policy: Policy Statement: Foods shall be and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Dietary staff, or other designated staff, will maintain clean food storage areas at all times. 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 11. Wrappers of frozen foods must stay intact until thawing. 14. b. All foods belongings to residents must be labeled with the resident's name, the item and the use by date. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. E. Other opened containers must be dated and sealed or covered during storage. Review of the U.S. Public Health Service Food Code, dated 2017, reflected: Section 2-301.14 FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation 455670 Page 7 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in ¶ 2-403.11(B); (D) Except as specified in ¶ 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. 455670 Page 8 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for five (Residents #1, #12, #16, #36 and #70) of six residents reviewed for infection control. Residents Affected - Some MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #1, #12, and #70. MA B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #16 and #36. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review on 03/07/23 of Resident #1's EHR revealed the resident was an [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including Hypertension, (elevated blood pressure), Atherosclerotic Heart Disease, (lack of adequate blood supply to the heart), and congestive heart failure, (constriction of the airway and difficulty in breathing). Review of Resident #1's five-day MDS, dated [DATE], revealed a BIMS score of 12, indicating moderate impairment for decision making, his functional status indicated he needed one person assist only with his ADLs. Record review of Resident #1's physician orders dated 03/01/23 reflected, losartan potassium tablet; 50 mg, give 1 tablet by mouth one time a day for elevated blood pressure. Review of Resident #12's EHR revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE], with diagnosis including essential Hypertension (elevated blood pressure), congestive heart failure (constriction of airway and difficulty in breathing), and atrial fibrillation (irregular beat of the heart). Review of Resident #12's quarterly MDS, dated [DATE] revealed a BIMs score of 99, indicating severe impairment for decision making, her functional status indicated she needed assist of two staff with her ADLs. Record review of Resident #12's physician orders dated 03/01/23 reflected, metoprolol tartrate tablet; 50 mg, give 1 tablet by mouth in the morning and the evening for elevated blood pressure. Review on 03/07/23 of Resident #16's EHR revealed the resident was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses including Hypertensive urgency, (an elevated very high blood pressure with no symptoms), and atrial fibrillation (irregular beat of the heart). Review of Resident #16's quarterly MDS, dated [DATE] revealed a BIMs score of 13, indicating she was cognitively intact for decision making, her functional status indicated she needed assist of one 455670 Page 9 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0880 staff with her ADLs. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #16's physician orders dated 03/01/23 reflected, metoprolol succinate ER; tablet extended release 24-hour 25 mg give one tablet by mouth one time a day for elevated blood pressure. Residents Affected - Some Review on 03/07/23 of Resident #36's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including essential Hypertension (elevated blood pressure). Review of Resident #36's quarterly MDS, dated [DATE] revealed a BIMs score of 12, indicating moderate impairment for decision making, his functional status indicated he needed assist of one staff with his activities of daily living. Record review of Resident #36's physician orders dated 03/01/23 reflected, lisinopril tablet; 10mg give one tablet by mouth in the morning for elevated blood pressure. Review on 03/07/23 of Resident #70's EHR revealed the resident was a [AGE] year-old male that was admitted to the facility on [DATE] with diagnoses including essential Hypertension (elevated blood pressure), and atrial fibrillation (irregular beat of the heart), paroxysmal atrial fibrillation (irregular beat of the heart), nonrheumatic aortic valve stenosis (clogging of the aortic valve not related to childhood disease process), and acute diastolic congestive heart failure (left sided heart failure). Review of Resident #70's quarterly MDS, dated [DATE] revealed a BIMs score of 15, indicating he was cognitively intact for decision making, his functional status indicated he needed assist of two staff with his activities of daily living. Record review of Resident #70's physician orders dated 03/01/23 reflected, lisinopril tablet; 10mg give one tablet by mouth one time a day for elevated blood pressure. Observation on 03/07/23 at 7:07 AM revealed MA A performing morning medication pass, during which time he checked the blood pressures on Resident #12. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #12. Observation on 03/07/23 at 7:17 AM revealed MA A performing morning medication pass, during which time he checked the blood pressures on Resident #1. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #1. Observation on 03/07/23 at 7:20 AM revealed MA A performing morning medication pass, during which time he checked the blood pressures on Resident #70. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #70. Observation on 03/07/23 at 7:25 AM revealed MA B performing morning medication pass, during which time she checked the blood pressures on Resident #16. MA B failed to sanitize the blood pressure cuff before or after using it on Resident #16. Observation on 03/07/23 at 7:30 AM revealed MA B performing morning medication pass, during which time she checked the blood pressures on Resident #36. MA B failed to sanitize the blood pressure cuff 455670 Page 10 of 11 455670 03/08/2023 Ridgecrest Retirement and Healthcare Community 1900 W State Hwy 6 Waco, TX 76712

F 0880 before or after using it on Resident #36. Level of Harm - Minimal harm or potential for actual harm Interview on 03/07/23 at 10:30 AM, MA B stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use to prevent transmitting an infection from one resident to another. She stated if she forgot to wipe the cuff it was because of the presence of the surveyor made her more nervous. And sometimes she just did not have time to sanitize between each resident. Residents Affected - Some Interview on 03/07/23 at 11:15 AM, MA A stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use to prevent transmitting an infection from one resident to another. He stated if he forgot to wipe the cuff it was because of the presence of the surveyor made him more nervous. He stated that he knew he should have, and it was in his head to do it, but he just forgot. Interview on 03/07/23 at 2:15 PM with the DON she stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. Interview on 03/07/23 at 7:15 AM with the Administrator he stated that his expectation was that staff would sanitize all reusable equipment between each resident use. He stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. He felt the DON needed to be more aggressive with her training and her follow-up concerning infection control . Review of facility's Policies and Procedure titled: cleaning and disinfection of resident care items and equipment, undated, reflected the following: Resident Care equipment, including reusable items Will be cleaned and disinfected according to the . current recommendations .c non-critical reusable items are those that come in contact with initial skin but not mucus membranes . (1) non-critical resident-care items include Blood press cuffs . reusable items are cleaned and disinfected . between residents . 455670 Page 11 of 11