Health inspection·December 19, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on record review, observation, and interview, the facility failed to provide privacy and confidentiality of resident's electronic health record (name, diagnosis, medication list and other personal information) for two unsampled residents (Resident 13 and 40). Residents 13 and 40's electronic health records were exposed to the public when staff left the facility's computer on. Residents Affected - Few This failure violated Resident 13 and 40's right to privacy. Findings: During an observation on 12/17/24, at 10:10 a.m., the Registered Nurse (LN4) left the medication cart at the Garden Court station with an open computer exposing the Resident 13 and 40's electronic health record. Further observation, two individuals passed by the medication cart while the electronic record were exposed out in public's view. During an interview on 12/17/24, at 10:25 a.m., with the LN 4, LN4 acknowledged Resident 13 and 40's electronic record were left exposed to the public when the computer was left open. LN4 further acknowledged after using residents' electronic medical record, it must be closed at all times. During a review of the facility's policy and procedure titled, Confidential Information, undated, the P&P indicated, Knowledge of confidential information is a trust to be honored. It is critical that all team members respect the resident's right to confidentiality .All team members should respect the confidentiality of residents' and co-workers' protected health information (PHI). In order to maintain the privacy of residents and ensure compliance with HIPAA (Health Insurance Portability Accountability Act - a federal law that protects sensitive health information from being disclosed without a patient's consent) regulations, team members are not to post electronic information about residents and/or family members. During a review of the P&P titled, Medication Administration General Guidelines, dated 2007, the P&P indicated in part, .18. Resident's health information needs to remain private. The pages of the MAR (Medication Administration Record) notebook containing resident health information must remain closed or covered when in not in direct use. During a review of the P&P titled, Resident's Rights, dated 02/2021, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to privacy and confidentiality. During an interview on 12/19/24 at 3:28 p.m. with the Director of Nursing (DON), the DON acknowledged that residents' rights on privacy and confidentiality of medical records must be followed and Page 1 of 13 555762 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0583 respected and for this incident it was not. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555762 Page 2 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 ensure two of two unsampled residents (Resident 31 and 37), had their Minimum Data Set (MDS - a core set of screening, clinical, and functional status data Evaluation System (iQIES) within the required timeframes. Residents Affected - Few These failures resulted in delayed validation of the assessment by iQIES and had the potential to result in errors in billing to CMS or payment to the facility and quality ratings of the facility. Findings: Resident Assessment Instrument (RAI) User's Manual, dated 10/2023, the RAI indicated, Timeliness Criteria . Completion Timing . must be no later than 14 days after the Assessment Reference Date . Assessment Transmission . All other MDS assessments must be submitted within 14 days of the MDS must be transmitted within 14 days of the Event Date. During a review of Resident 31's Face Sheet (FS), printed [DATE], the FS indicated, Resident 31 was discharged [DATE]. During an interview and record review on [DATE] at 11:02 a.m. with a licensed nurse (LN1), Resident 31's discharge assessment MDS transmission date was not available because it had not been transmitted. LN1 further stated it should have been transmitted within 14 days of their discharge date on [DATE]. During a review of Resident 37's FS, printed [DATE], the FS indicated, Resident 37 was admitted to the facility on [DATE] and discharged from the facility on [DATE] when Resident 37 expired. During a concurrent interview and record review on [DATE] at 11:02 a.m. with LN1, Resident 37's untitled record of transmitted MDS assessments (MDS record), was reviewed. The MDS record indicated: 1) MDS quarterly assessment reference date (ARD - the specific end date of the resident observation period) [DATE] that was transmitted [DATE], 39 days after the ARD date. 2) MDS quarterly assessment ARD [DATE] that was transmitted [DATE], 28 days after the ARD date. LN1 stated LN1 does not recall why they were late. During a concurrent interview and record on [DATE] at 9:40 a.m. with LN1, Resident 37's MDS, dated [DATE] was reviewed. The MDS indicated, Resident 37 was discharged [DATE] with a discharge status of deceased . LN1 stated this MDS should have been submitted within 14 days of the death in the facility and it wasn't. 555762 Page 3 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

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 observation, interview, and record review, the facility failed to develop a care plan for urinary catheter (foley catheter flexible rubberized tube inserted into the urinary tract to drain the urine out) care in one of two sampled residents (Resident 36). This failure has the potential for Resident 36's to have the urinary catheter in place with no follow up or plan of care resulting to urianry tract infections (UTI), dislodgement and other bladder issues. Findings: During an observation on 12/16/24 at 10:45 a.m., Resident 36 was observed in bed with a urinary catheter connected to a urine bag. During a concurrent interview and record review of Resident 36's clinical record, on 12/19/24 at 07:30 a.m., with Licensed Nurse (LN2), the face sheet indicated an admission date of 9/19/24, and a condition of urinary indwelling catheter for obstructive and reflex uropathy ( inability to completely drain urine out of the urinary tract). The Progress notes indicated Resident 36 was hospitalized for UTI on 10/31/24 and re-admitted back to the facility on [DATE], on antibiotic treatment, which resolved the UTI . Further review of the clincial record for Resident 36 indicated no careplan for the urinary catheter was developed for the care. LN2 acknowledged no careplan was in place for the urinary catheter. During a review of facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated March 2022, P&P indicated, The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident, which describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .reflects currently recognized standards of practice for problem areas and conditions. 555762 Page 4 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to failed to review and update the plan of care (CP) after a fall for one of 16 sampled residents (Resident 18). This failure placed Resident 18 at a higher risk for recurring falls secondary to no updated plan in place for staff to follow and implement for prevention. Findings: During an interview on 12/16/24, at 12:15 p.m. with Resident 18, Resident 18 verbalized having a fall two weeks prior; which resulted to a week stay in the hospital . The resident further verbalized while at the hospital an antibiotic treatment was started due to an infection. During a review of Resident 18's hospital Discharge summary, dated [DATE], the discharge summary indicated, Resident 18 was admitted to the hospital after a ground level fall and a diagnosis of septic joint (infection of the joint). Resident was discharged with an intravenous antibiotic administered through the vein) treatment. During a concurrent record review and interview on 12/18/24, 12:05 p.m. with the Director of Nursing (DON). The interdisciplinary ( IDT) notes and CP for fall, dated 11/14/24 were reviewed. The IDT notes indicated Resident 18 had a fall incident and CP will be updated upon return to the facility to include resident teaching on using call button for assistance. Upon review of the fall CP, the last updated date was 10/20/24, no update was entered when resident returned to the facility on [DATE]. The DON acknowledged the care plan for fall was not updated when the resident returned to the facility from the hospital on [DATE]. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2011, the P&P indicated, 1. The interdisciplinary team (IDT - group of people with different areas of expertise to solve a problem or care for a patient) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change. 555762 Page 5 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to provide an eye drop medication for glaucoma ( degenerating of eye condition leading to vision loss or blindness) as ordered by the physician when supply runned out for one of 16 sampled residents (Resident 12). This failure resulted to Resident 12, not receiving the eye medication as ordered with the potential and risk for rapid vision loss /blindness. Findings: During the medication pass observation on 12/18/24, at 9:00 a.m. with the Registered Nurse (LN5), LN5 indicated Resident 12's eye drop medication for glaucoma will not be adminsitered as ordered as currently the medication is being reordered. During a review of physician's order (PO), dated 7/10/24, the PO indicated, Resident 12 is to receive Timolol Maleate 0.5% (percent) eye drops to both eyes for glaucoma daily. During a concurrent record review and interview on 12/19/24, at 2:15 p.m. with the Minimum Data Set Coordinator (LN1). Resident 12's current Medication Administration Record (MAR) was reviewed and indicated the eye medication Timolol Maleate 0.5% (percent) was not administered 12/17 and 12/18/2024. LN1 acknowledged the non administration of the eye medication on Resident 12 on 12/17 and 12/18/24. During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated in part, .c. Certain products or package types such as multi-dose vials and ophthalmic (eye) drops have specific shortened end-of-use dating, once opened, to ensure medication purity and potency .Position statements from American Society of Ophthalmic Registered Nurses and American Society of Cataract & Refractory Surgery (ASCRS) state that the multi-use eye drops and ointments should be disposed of 28 days after initial use. During a review of the pharmacist recommendation titled, Executive Summary of Consultant Pharmacist's Medication Regimen Review (MMR), dated 6/29/24, pharmacist notes indicated, Per P&P, most eye drops should be discarded after 2 months from the open date for infection control, regardless of the manufacturer expiration date. During a concurrent record review and interview on 12/19/24, at 3:33 p.m. with the Director of Nursing (DON). The pharmacist MMR recommendation and the facility's P&P, both provided by the DON were reviewed. The DON was unaware of the pharmacist MMR recommendation for the eye drop medication. The DON acknowledged, the conflicting information on eye drops medication administration from the pharmacist and the facility's policy. The DON further acknowledged, that as a result Resident 12 did not receive the medication for two days. 555762 Page 6 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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, facility failed to ensure residents were free of unnecessary medications for two sampled residents (Resident 54 and 57) when: Residents Affected - Few 1. A. Resident 54 was not properly assessed and provided with the correct medication per physician's order. B. Resident 54's blood pressure parameter per physician order was not followed. 2. Resident 57's pain level was not assessed and the pain level parameter per physician order was not followed. These failures resulted in Resident 57 and 54 to receive unnecessary medication and not in accordance with what the physician had ordered. Findings: 1. A. During a review of Resident 54's physician's visit notes (PVN), dated 8/28/24, the PVN indicated, Resident 54 is an 82-years old with the diagnosis of hypertension (high blood pressure), Stroke (brain attack), and left femur (thigh bone) fracture, and thoracic vertebral compression fracture (a break in a bone in the spine where bone collapses). During a review of Resident 54's physician's order (PO), dated 12/24, the PO indicated, Resident 54 is to receive an Acetaminophen 325 mg (milligram - unit of measurement) tablet, two tablets orally (by mouth) as needed every four hours for mild pain and Tramadol 25 mg orally for moderate to severe pain. During a review of the document titled, Universal Pain Assessment Tool (UPAT), undated, the UPAT indicated, pain scale 0 = no pain, 1-2 = mild pain, 3-5 = moderate pain, 6-8 severe pain, and 9-10 = worst pain. During a review of Resident 54's Medication Administration Record (MAR) dated, 12/2, 12/5, and 12/18, Resident 54 had a pain scale of seven out of 10, and six out of 10 on 12/9 and 12/10. Resident 54 was administered Acetaminophen 325 mg (milligram - unit of measurement) tablet, two tablets orally (by mouth) as needed every four hours for mild pain for a pain scale of seven, instead of Tramadol 25 mg orally for moderate to severe pain on 12/2,/12/5,12/18, and 12/9,and 12/10/24 for a pain scale of six . During a concurrent record review and interview on 12/19/24, at 11:15 a.m. with Minimum Data Set Coordinator (LN1), LN1 confirmed that an Acetaminophen was given when Resident 54 was assessed to have seven out of 10 pain on 12/2, 12/5, and 12/18, and six out of 10 pain on 12/9 and 12/10. During an interview on 12/19/24, at 3:50 p.m. with the Director of Nursing (DON). The DON acknowledged that the physician's order was not followed on the administration of Resident 54's pain medication. The DON was unable to provide additional proof of documentation that support why the pain medication was administered to the resident without following the physician's order and if the physician had been notified. 555762 Page 7 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated in part, .1. Medications are administered in accordance with written orders of the prescriber. If dose seems excessive .or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate .3. Medication administration timing parameters include the following: e. Any additional facility specific policies and procedures. B. During a review of Resident 54's PVN, dated 8/28/24, the PVN indicated, Resident 54 is an [AGE] years old with the diagnosis of hypertension (high blood pressure (BP)), Stroke (brain attack), and left femur (thigh bone) fracture, and thoracic vertebral compression fracture (a break in a bone in the spine where bone collapses). During a review of Resident 54's physician's order (PO), dated 12/2024, the PO indicated, Resident 54 is to receive Irbesartan 300 mg, one tablet orally at hour of sleep and to hold the medication if the SBP (systolic blood pressure - the pressure in the arteries when the heart beats) is less than 110. During a review of the Medication Administration Record (MAR), dated 12/13 and 12/17, Resident 54's SBP was recorded as 109 and 99. During a concurrent record review and interview on 12/19/24, at 11:15 a.m. with LN1, LN1 confirmed that BP medication was administered to Resident 54 despite of the SBP was below the parameters the physician had ordered. During an interview on 12/19/24, at 3:50 p.m. with the DON. The DON acknowledged that the physician's order was not followed for BP medication. The DON was unable to provide additional proof of documentation that support why the BP medication was administered to the Resident 54 below the parameters as instructed on the physician's order and if the physician had been notified. During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated in part, .1. Medications are administered in accordance with written orders of the prescriber. 2. During a review of Resident 57's Medication orders, dated 8/10/24, order indicated, Oxycodone 5 mg tablet (1 tablet) as needed for mild (pain level 1-3) or shortness of breath (SOB). Oxycodone 5 mg tablet (2 tablets) as needed for moderate (pain level 4-6) to severe (pain level 7-10) or shortness of breath (SOB). During an interview on 12/19/24 at 11:15 a.m. with Licensed Nurse (LN3), she stated that there was no pain evaluation or assessment prior to administering Oycodone 1 tablet for mild pain (pain level 1-3) per physician order. During the record review of Resident 57's Medication Administration Record (MAR) dated 12/9, 12/11, and 12/16/24, record indicated Oxycodone were administered without pain assessments on these dates 555762 Page 8 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0757 and results were marked effective. Level of Harm - Minimal harm or potential for actual harm During a review of facility's policy and procedure (P&P), titled Medication Management dated 2007, P&P indicated in part There are various opportunities during the care process to evaluate the effects of medications on a resident's physical, mental and psychosocial well-being, and to consider whether the medications should be continued, reduced, discontinued, or otherwise modified, opportunities include during the monthly medication regimen review, the pharmacist evaluates resident-related information for dose, duration, continued need, and the emergence of adverse consequences for all medications. and each resident's drug regimen is reviewed to ensure it is free from unnecessary medication that includes any drug without adequate monitoring. Residents Affected - Few 555762 Page 9 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on interview and records review, the facility failed to ensure psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were not used unnecessarily for two of seven sampled residents (Resident 57 and 12) when 1. There was no justification from the physician for continued use beyond 14 days of the drug Ativan and/or Lorazepam (a medication used to help control anxiety) for Resident 57. 2. No monitoring for side effects and hours of sleep was done for trazodone (an antidepressant medication used to treat depression, anxiety [feelings of tension, worried thoughts, and physical changes like increased blood pressure], and insomnia [trouble sleeping]) for Resident 12. These failures had the potential to result in use of unnecessary psychotropic drugs and the potential to develop unrecognized side effects due to the inadequate monitoring of efficacy of the medication. Findings: 1.During a review of physician order for Resident 57, the order indicated medication orders of: a. Ativan 0.5 mg tablet (1 tablet) as needed every four hours for anxiety and shortness of breath (SOB) starting 7/18/24 with no STOP date. b. Lorazepam 0.5 mg tablet (2 tablets) as needed every four hours for moderate anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. c. Lorazepam 0.5 mg tablet (4 tablets) as needed every four hours for severe anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. d. Lorazepam 2 mg/ml oral concentrate (0.25 ml) as needed every four hours for mild anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. e. Lorazepam 2 mg/ml oral concentrate (0.5 ml) as needed every four hours for moderate anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. f. Lorazepam 2 mg/ml oral concentrate (1 ml) as needed every four hours for severe anxiety, SOB, or nausea/vomiting starting 8/10/24 with no STOP date. During the interview on 12/19/24 at 1:30 p.m. with the Director of Nursing (DON), DON acknowledged there was no Stop date nor physician's justification for continued use beyond 14 days of Ativan and/or Lorazepam. During a review of facility's policy and procedure (P&P) titled Medication Monitoring, Medication Management, dated 1/24, P&P indicated, Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order and attending physician or prescribing practitioner should document the rationale for the extended time period in the 555762 Page 10 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0758 medical record and indicate a specific duration. Level of Harm - Minimal harm or potential for actual harm 2. During a review of Resident 12's Clinical Record (CR), dated 12/19/24, the CR indicated Resident 12 has a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Residents Affected - Few During a review of Resident 12's Physician Order Sheet (POS) for December 2024, dated 12/19/24, the POS indicated an order for trazodone 100 mg (milligram) tablet as needed for sleep for 90 days was renewed on 12/4/24. Current order was compared to previous order that had monitoring for hours of sleep and side effects. There was no order to monitor side effects or hours of sleep. During a review of Resident 12's Care plan (CP), undated status active (current), the CP indicated, Monitor for side effects of medication (constipation [condition in which stool becomes hard, dry, and difficult to pass], dry mouth, anxiety, agitation, headache, falls). During a concurrent interview and record review on 12/19/24 at 6:07 p.m., with the Director of Nursing (DON), the Medication Administration Record (MAR) for December 2024 was reviewed for Resident 12. The last dose of trazodone administered was on 12/6/24 at 1:16 a.m. The DON stated hours of sleep and side effects monitoring are documented when Trazodone is administered. No documented evidence of hours of sleep or side effect monitoring on 12/6/24 was found. The DON stated, it was missed. During a review of the facility's Policy and Procedure (P&P) titled Psychotropic Medication Use, dated July 2022, the P&P indicated, Psychotropic medication management includes: .d. adequate monitoring for efficacy and adverse consequences . 555762 Page 11 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility to failed to remove: 1. Expired medical supplies in the medication storage room. 2. Expired unopen box of medication. These failures had the potential for the residents to receive expired, and ineffective medications and medical supplies. Findings: 1. During An observation on [DATE] 10:15 a.m. the Garden Court station medication room, the following medical supplies were found inside the intravenous (IV - a medical procedure involving inserting a needle through a vein) starter bin: - One expired medical supply: [NAME] IV start kit, expiration date: [DATE]. - One filter needle 19-gauge (unit of measurement), expiration date: 05/2020. - One opened box of bio patch disc (a medical supply that is applied to the IV catheter insertion site on the skin), expiration date: [DATE]. 2. One box, unopened, anti-diarrheal (loose, watery, bowel movements) medication, expiration date: 11/2024 located in the garden court station medication cart. During an interview on [DATE], 10:45 a.m. with the Registered Nurse (LN4), the LN4 verified the expired medication and medical supplies. During an interview on [DATE] 3:40 p.m. with the Director of Nursing (DON). The DON acknowledged the expired medication and medical supplies. The DON further acknowledged, that expired items must be removed and discarded. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, dated 4/2019, the P&P indicated in part, .Medications are administered in a safe and timely manner and as prescribed .12. The expiration/beyond use date on the medication label is checked prior to administering. During a review of the P&P titled, Medication Storage, dated 2007, the P&P indicated in part, .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . 555762 Page 12 of 13 555762 12/19/2024 Samarkand Skilled Nursing Facility 2566 Treasure Drive Santa Barbara, CA 93105

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 follow professional food standards for food safety , when facility : Residents Affected - Many 1. Failed to label food items as to date prepared and expiry date 2. Failed to provide adequate concentration of sanitizing solution in red buckets These failures has the potential for food borne illnesses to the residents. Findings : 1.During an observation on 12/16/24 at 9:50 AM at the kitchen, the following food items were beyond the expiry date: One (1) pack of Ground Beef with a discard date of 12/15/24; six (6) bags of potato wedges with expired date of 11/19/24; One (1) bag of hamburger buns with expiry date of 12/15/24; One (1) bag of diner rolls, unlabeled and undated. During an interview on 12/16/24 at 9:50 AM with Dietary Manager (DM) validates the findings that the identified food were expired. During an observation on 12/17/24 at 10: 36 AM at the kitchen, 4 bags of grapes brought in from the independent living kitchen had no labels with one of the four bags having mold. During an interview on 12/17/24 at 10:36 AM with DM, DM validates the findings that the identified food are expired. 2. During an observation on 12/17/24 at 2:16 PM at the kitchen, two (2) red buckets were tested. Dietary Aide (DA1) tested the solutions and the result with the comparator chart with both buckets having a result of 170 ppm (parts per million / a unit of measure). During a concurrent interview with DA on and review of the comparator chart on 12/17/24 at 2:16 PM, the recommended concentration of the sanitizing solution is 272-700 ppm. During an interview on 12/17/24 at 2:16 PM with DM, DM validates the findings and verbalized that a consult on how to adjust the concentration of the sanitizing solution and the solution is not as effective based on concentration. During a review of Policies and Procedures (P&P) titled Sanitation and Infection Control: Sanitation Buckets, the Sanitation and Infection Control indicates in part: d. Test sanitizer solution when buckets are filled and ensure that the concentration is 272-700 parts per million (ppm). e. Sanitizer solution in the buckets should be changed at minimum of 4 hours or more as needed to keep the water clean and maintain effectiveness of the sanitizer. 555762 Page 13 of 13