Health inspection·January 16, 2020

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure effective overall operational systems were established for oversight of the Food and Nutrition Services department. This failure to ensure an effective system for day to day oversight of dietary operations may have placed 84 facility residents at health and nutritional risk of unsafe, unsanitary, and ineffective food practices that could further compromise their health status. (Cross reference F801, F802, F805, F812, F813, and F814) Findings: During the initial kitchen tour and review of operations in the food and nutrition services department from 1/13/20-1/16/20, multiple observations and concurrent interviews were conducted with kitchen staff of the overall food and nutrition services department regarding storage of unlabeled and undated foods, serving unpasteurized eggs unsafely for over a month, and kitchen sanitation. In addition, other deficient practices were identified during the survey in the areas of poor staff competence of food safety, equipment cleaning maintenance, and following recipes and menus. Storage of Unlabeled, Undated, and Expired Foods: During the initial kitchen tour observation on 1/13/20 at 8:41 A.M., several potentially hazardous foods/time control for food safety foods (PHF/TCS) were unlabeled, undated, or expired, were found in the walk-in refrigerators and dry storage rooms. These foods included meats, cheese, ready-to-eat foods, onions, and vinegar. A concurrent interview was conducted with the CKS on 1/13/20 at 8:41 A.M., during the kitchen tour. CKS stated the dietary staff should have dated the food products when they were opened, and followed the storage guidelines. The CKS stated if the dietary staff had followed the storage guidelines, they would have known when the food was to be discarded. On 1/15/20 at 8:26 A.M., an observation and interview was conducted of the patient's refrigerator in the Sun Room. Several expired, unlabeled and undated foods were found in the refrigerator, including meat sandwiches wrapped in plastic wrap, containers with red sauce, and beverages. On 1/15/20 at 4:55 P.M., an interview was conducted with the FSDRD. The FSDRD stated resident food stored in the Sun Room refrigerator should have been labeled and dated by kitchen staff. The FSDRD stated the food should have been thrown out after three days. Page 1 of 25 555806 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0800 Level of Harm - Minimal harm or potential for actual harm Proper storage of potentially hazardous foods (PHF)/time and temperature control for safety (TCS) foods could lead to the development of pathogens that contaminate the food and may cause foodborne illness if consumed. The facility staff failed to demonstrate an effective system for ordering safe food, storing meats, particularly fish, produce, and liquids; or sufficient knowledge to ensure that unsafe food was stored or served to residents. (cross refer F 812) Residents Affected - Many Unpasteurized eggs: On 1/13/20 at 8:45 A.M., an observation and interview was conducted with CKS in the walk-in refrigerator #1. Two cases of shell eggs, one case half used and one case unopened were stored in a walk-in refrigerator. The individual eggs did not have the letter P printed on them to indicate they were pasteurized, and the cases did not have the word pasteurized on them. CKS stated he was not sure if the eggs were pasteurized but they were used when residents requested fried and over-easy eggs. At 4:07 P.M., CKS stated the eggs were pasteurized because the vendor had told him they were when he ordered them, and the item number had CDFA on the invoice for the eggs. On 1/14/20 at 7:58 A.M., an observation and interview of the breakfast trayline was conducted. CK 1 prepared poached eggs for residents, and there were 11 poached eggs in a pan on the tray line. CK 1 stated he used the shell eggs in the walk-in refrigerator to make the poached eggs. On 1/14/20 at 8:17 A.M., an observation was conducted of the Dining Room for breakfast. Two residents had eaten half of the pouched eggs with runny yolks. On 1/14/20 at 8:50 A.M., an interview was conducted with the vendor who delivered the shell eggs to the facility. The vendor stated the shell eggs were unpasteurized eggs. A record review of the facility food invoices for June-December 2019 indicated unpasteurized eggs had been ordered and delivered to the facility since December 6, 2019. During an interview with the FSDRD on 1/14/20 at 10:48 A.M., the FSDRD stated CKS placed the food orders for the kitchen, and she assumed the shell eggs were pasteurized. Residents were placed at risk of food contamination that further compromised their health condition when unpasteurized eggs were served to them in an unsafe manner. The kitchen leadership and staff were unable to demonstrate competence in skills necessary to effectively cover the operations in the food and nutrition services department. Improper Storage of wet Pans and dirty Dishes: On 1/13/20 at 10:23 A.M., an observation and interview was conducted in the kitchen. Fifteen wet stainless steel pans with water dripping on the floor were stacked on top of each other on the dry dish storage rack. DA 1 stated he stacked the wet pans on the rack but acknowledged they should have been on the drying rack first. At 11:58 A.M., during a subsequent kitchen observation, there were 5 dirty serving scoops (3 number 8 scoops, 2 number 16 scoops) with dried crusted brown and green food debris inside them, and these scoops were stored with the clean scoops. There were also three wet scoops stored with the clean, 555806 Page 2 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dry scoops. DA 1 stated the scoops looked dirty, and three were wet. The FSDRD and CKS agreed the five dirty scoops and three wet scoops should not have been stored with the clean, dry scoops. Food and Nutrition Staff competence: On 1/13/20 at 9:14 A.M., an interview was conducted with CK 2 regarding thermometer calibration. CK 2 stated she would use ice water in a cup to calibrate the thermometer. When CK 2 was asked what temperature she was looking for the thermometer to have, CK 2 stated she was unsure. CK 2 also stated there was no calibration log in the kitchen. At 3:30 P.M., an interview was conducted with CK 3 about thermometer calibration. CK 3 stated he would place ice water in a cup, put the thermometer inside and the temperature on the thermometer should read less than 40 degrees Fahrenheit. At 4:13 P.M., an interview was conducted with CKS about thermometer calibration. CKS stated that the staff had an in-service on the procedure for the thermometer calibration, and they should have known how to calibrate the thermometer. On 1/14/20 at 7:56 A.M., a joint observation and interview was conducted of a thermometer calibration procedure with CKS and CK 2. CK 2 placed a digital thermometer in a cup of iced water (1/3 ice and 2/3 water). The thermometer read 42.4 degrees F. CKS stated there might have been a problem with the thermometer because it did not reach a lower temperature. CKS placed a new digital thermometer in the cup of iced water. The digital thermometer temperature read 41.8 degrees F. Neither CKS or CK 2 could explain why the thermometers did not reach the correct calibration temperature of 32 degrees F. On 1/15/20 at 4:55 P.M., an interview was conducted with the FSDRD. The FSDRD stated she was unaware the CKs did not know how to correctly calibrate the thermometers. The validation, verification reassessment section of the Hazard Analysis and Critical Control Point (HACCP) system stated in the Code of Federal Regulations (9CFR 3:417.4) specifies that instruments used for monitoring critical control points must be calibrated. All thermometers using an ice bath (more ice than water) calibration method should reach a temperature of 32 degrees Fahrenheit after at least two minutes. Therapeutic menu and recipe compliance: 1. On 1/13/20 at 11:25 A.M., an observation and record review was conducted of the lunch service meal tray line. Three residents did not receive items from their meal ticket according to the facility's menu spreadsheet. A review of the Menu Daily Spreadsheet Week 5 - Day 2, 2019 December 15 to January 15, indicated for Monday 1/13/20, - Lunch: Regular Portion: Meat Loaf 3 oz., Gravy 1 oz., Yellow [NAME] #8 Scoop, Brussel Sprouts #8 Scoop. The Lunch - Mechanical Soft (level 3) included: Meat Loaf bite sized pieces, Gravy 1 oz., Yellow [NAME] with broth 1 oz., Brussel Sprouts soft and chopped ½ inch and smaller. An observation of three residents (71, 79 and 284) meal tickets was conducted. Resident 71 was 555806 Page 3 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many served a 1 ¾ oz. slice of uncut meat loaf, no gravy, no broth; Resident 79 was served a 1 ¾ oz. slice of uncut meat loaf with gravy, no broth; and Resident 284 was served 1 ¾ oz. slice of ground meat loaf, no broth and no gravy. On 1/13/20 at 12:15 P.M., an interview was conducted with CK 1 and FSDRD. CK 1 weighed a meat loaf slice and it was 1 ¾ oz. for the regular diets. CK 1 stated the slices should have been 3 oz. The FSDRD and CKS acknowledged the meatloaf slices should have been thicker. The 1 ¾ oz. slice of Meat Loaf provided less calories and protein than the requirements for the regular diet meal. The facility's policy titled Standard Menu Information Regarding Calorie and Protein Levels, dated 2015, included .General Information - Diet - Regular - Average Calories = 2500 - Average Protein = 90-100 grams. 2. On 1/13/20 at 3:51 P.M., an interview was conducted with CK 3. CK 3 stated CKS would tell CK 3 what ingredients were needed to cook the Sausage Jambalaya. CK 3 stated CKS would tell him what to use for the ingredients such as chopped white onion, six green and red bell peppers, and two long andouille sausages. CK 3 stated he did not know how long the andouille sausages were. CK 3 stated he made about 80 to 90 servings for dinner but was not sure how accurate that was. CK 3 stated he did not use a recipe for the Sausage Jambalaya which was on the dinner menu for 1/13/20. A review of the facility's recipe for Sausage Jambalaya was conducted. The recipe included . Portion Size 8 oz., Number of Servings - 60, .14 ¾ pounds of Sausage (bulk), 2 pounds 1 ¾ oz. Onions, medium, fresh, yellow, 2 pounds 1 ¾ oz. Pepper, bell, green, fresh, medium . In an interview with the FSDRD on 1/15/20, the FSDRD stated she was unaware the CKs had not followed the recipes or the menus. The FSDRD stated the expectation was that the recipes and menus be followed. The facility's policy titled Food Production Sheets, dated 2016, included .3. Production of all diets, regular, therapeutic and texture modified are produced by following recipes. The production process is observed and supervised by Dietary Management staff. These duties are planned, prepared, and served with supervision or consultation from a Registered Dietitian . Lack of Cool down process for PHF/TCS foods: On 1/13/20 at 4:10 P.M., an interview was conducted with CKS about cooling down foods. CKS stated they used the cool down process and log a long time ago, but they did not use it anymore since the food was cooked the day the food was to be served. CKS further stated We don't have a cool down log. We cook everything fresh the day of. On 1/13/20 at 4:14 P.M., an observation and interview was conducted with CK 4 about chicken and tuna salad preparation. CK 4 was setting up the cold side of the tray line station for dinner. CK 4 placed the tuna and chicken salad on the station. CK 4 stated he made the chicken salad yesterday and he never checked the temperature when he made it. CK 4 stated he used packages of chicken and tuna from the dry storage when he made the salads. CK 4 further stated he was not sure there was a cool down log and he had not used one since he started working at the facility three months ago. 555806 Page 4 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0800 Level of Harm - Minimal harm or potential for actual harm At 4:20 P.M., an interview was conducted with the FSDRD about cool down process for ambient temperature foods. The FSDRD stated the tuna, chicken, and egg salads were made fresh daily. The FSDRD further stated We never have left overs. We don't have a cool down log for chicken, tuna, or egg salad. The FSDRD stated she was unaware the kitchen staff made tuna and chicken salad the day before. The FSDRD further stated she was unaware of a cool down process for ambient temperature foods. Residents Affected - Many According to the Food and Drug Administration (FDA) Food Code 2017, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5 degrees C (41 degrees F) or less if prepared from ingredients at ambient temperature, such as .canned tuna. Use of unsafe cleaning chemicals in the kitchen: During an observation and interview on 1/13/20 at 3:19 P.M., in the kitchen with CK 3 about the use of sanitizer to clean food preparation surfaces. CK 3 stated he used a peroxide multi surface cleaner and disinfectant solution. CK 3 stated he sometimes poured the solution in a green bucket because it was small. CK 3 further stated he would use a kitchen towel to wipe the surface with the solution and a scrub brush if necessary. When asked if he tested the strength of the sanitizer, CK 3 stated No, it did not need to be tested. On 1/16/20 at 1:05 P.M,, an interview was conducted with the FSDRD and ADM. The FSDRD stated she thought there were test strips for the solution to test the strength but further stated she was unsure. The ADM and FSDRD stated they did not know the solution was not approved as safe to use on food contact surfaces in kitchens. A review of the manufacturer's guidelines for the kitchen cleaning solution indicated, .cleaner is formulated to be a true multi-surface solution effective on a wide range of non-food contact surfaces . According to the 2017 US Food and Drug Administration (FDA) Food Code, section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate . The standard of practice was to ensure that chemical cleaning and sanitizing agents met specified criteria and were used in accordance with the EPA (Environmental Protection Agency) registered label use instructions (Food Code, 2017). 555806 Page 5 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure effective oversight of dietetic services was provided to the food and nutrition services department, as evidenced by lapses in the delivery of food services associated with tags 800, 802, 803, 805, 812, 813 and 814. This failure to ensure effective oversight of day to day food and nutrition services operations placed 84 facility residents at nutritional risk, and in turn, may have further compromised their health and nutrition status. Findings: During the initial kitchen tour on 1/13/20 at 7:49 A.M., multiple observations and interviews were conducted about food and nutrition services operations with the kitchen staff. The CKS stated he was primarily in charge of ensuring kitchen staff performed their duties such as labeling and dating, dishwashing, and food preparation. On 1/13/20 at 4:20 PM, an interview was conducted with the FSDRD about the cool down process for ambient temperature foods. The FSDRD stated the tuna, chicken, and egg salads were made fresh daily. The FSDRD further stated We never have left overs. We don't have a cool down log for chicken, tuna, or egg salad. The FSDRD was told the kitchen staff stated they prepared the tuna and chicken salad the day before and placed it in the refrigerator. The FSDRD stated she was unaware the kitchen staff made tuna and chicken salad the day before. The FSDRD further stated she was unaware of a cool down process for ambient temperature foods. According to the Food and Drug Administration (FDA) Food Code 2017, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5 degrees C (41 degrees F) or less if prepared from ingredients at ambient temperature, such as .canned tuna. On 1/14/20 at 10:48 A.M., an interview was conducted with the FSDRD. The FSDRD stated she was unaware the kitchen was using unpasteurized shell eggs. The FSDRD stated the CKS did the food ordering for the kitchen and the last time she checked in June 2019, the shell eggs were pasteurized. The FSDRD stated she assumed that all facilities in healthcare used pasteurized eggs. The FSDRD stated she did not do all the monthly kitchen sanitation checks because a part-time consultant registered dietitian (RD) who worked once a week, did them. The FSDRD stated her typical day at the facility included most of the time on clinical nutrition care, which was 75 - 80 percent, and 20 percent in the kitchen. The FSDRD stated the clinical work included reviewing new admissions, annual assessments, MDS, care conferences, monthly weights, and other communications from nursing all on the skilled nursing side of the facility. She also stated she checked lunch trayline and trays when she was able to. The FSDRD stated overall, she spent 60-70 percent of her time on the skilled nursing side and the other 30-40 percent on the assisted living side. A review the Kitchen Sanitation audits completed by the FSDRD and consultant Registered Dietitian (RD) from June-December 2019 were conducted. The audits indicated labeling and dating had been areas of concern but did not identify following the menu or recipe, cool down for ambient temperature food, or storage of wet dishes on the audits. One audit dated 11/2019, completed by the consultant RD 555806 Page 6 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0801 indicated use all unpasteurized eggs in the recommendations section of the audit. Level of Harm - Minimal harm or potential for actual harm During the interview with the FSDRD on 1/14/20 at 10:48 AM, the FSDRD stated she was unaware the consultant RD wrote on the 11/2019 kitchen sanitation audit use all unpasteurized eggs. The FSDRD was asked if she and the consultant RD discussed or communicated their kitchen findings with each other, she stated they mostly did but it may not be enough. FSDRD stated she needed to communicate better, especially with the Dietary manager, who recently resigned a week ago. The FSDRD stated the Dietary Manager usually handled managing the dietary aides and the kitchen operations. But now, the CKS had to pick up the Dietary manager's tasks since the position is vacant. The FSDRD stated the CKS was responsible for managing the Cooks duties, the Cooks' work schedules, the Dishwashers, oversee the trayline, food ordering and inventory. Residents Affected - Many A review of the facility's job description titled Nutrition Services Manager, indicated .Qualifications: .Certificate in Dietary Services Management, a degree in nutrition or similar food service program .Knowledge of all Title 22 requirements . A review of the CKS's personnel file was conducted. CKS did not have a Certified Dietary Manager Certificate, or a Dietary Services Supervisor credential from an accredited program, or a degree in nutrition. Therefore, CKS was not qualified to perform the duties of the Dietary Manager's position. On 1/15/20 at 12:49 P.M., an interview was conducted with the ADM about the FSDRD's job duties at the facility. The ADM stated that the FSDRD worked with both the skilled nursing side and assisted living residents. However, the ADM stated his expectation is that the FSDRD spends more time with the skilled nursing residents than with the assisted living residents. On 1/15/20 at 5:01 PM, an interview was conducted with the FSDRD. The FSDRD what her expectation was for the Cooks when serving residents who had textured modified diets. The FSDRD stated when she reviewed the menu spreadsheet for Monday 1/13/20, the cook failed to follow the menu spreadsheet and residents on mechanical soft diets should have received the meatloaf chopped into bite sized pieces. The FSDRD also stated on that same day for lunch, the rice should have been served with 1 ounce of broth, not gravy. During the interview with the FSDRD on 1/15/20 at 5:01 PM, the FSDRD stated she was unaware of any maintenance concerns in the kitchen or of Quality Assurance (QA) projects in the food and nutrition services department. The FSDRD further stated she does not test tray audits at the facility but sometimes the consultant RD does them for temperature checks. The FSDRD stated she does do them because she's never heard of an issue with the food from the residents. The FSDRD was asked about the menus used by the facility and posted in the dining room. The FSDRD stated she thought the signature on the menus from the vendor Registered Dietitian was appropriate. The FSDRD was unaware the facility's menus had to be approved by the facility's Registered Dietitian, which is a state regulatory requirement. A review of the facility's job description titled Nutrition Services Director indicated, .1) Organizes, directs, and supervises all front-of-house food and nutrition activities; 2) Assures efficiency of food serving, compliance with local, state, and federal standards, sanitation and hygiene and health standards . The standard of practice and regulatory requirement is for the facility's Registered Dietitian to provide guidance, support, and oversight to staff in the Food and Nutrition Services Department to 555806 Page 7 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0801 Level of Harm - Minimal harm or potential for actual harm assure appropriate practices are met for routine food service operations. Additionally, a manager or supervisor of the Food and Nutrition Services department is required to have regularly scheduled consultations with the facility's Registered Dietitian, in order to meet regulatory requirements to effectively oversee the department operations. Residents Affected - Many 555806 Page 8 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure dietary staff were competent to carry out the functions of the food and nutrition services in a safe and sanitary manner when: Residents Affected - Many 1. Wet dish pans were stacked with clean dry pans in the storage area. 2. Dirty serving scoops with brown crusted food residue were stored with clean scoops. 3. Kitchen staff incorrectly demonstrated thermometer calibration. 4. Kitchen staff did not know the cool down process for ambient (room) temperature foods. These failures placed 84 residents at risk of widespread food borne illness. Cross reference 800, 812 Findings: 1. On 1/13/20 at 10:23 A.M., an observation was conducted of the pots and pans dry/clean storage area in the facility's kitchen. Fifteen wet stainless steel pans were stacked inside one another with clean dry pans. At 10:25 A.M., an interview was conducted with DA 1. DA 1 stated the pans should not have been stored wet. CK 16 stated the pans should have been air dried in the rack near the dishwasher before being stored on the dry/clean storage racks. According to the 2017 US Food and Drug Administration (FDA) Food Code, section 4-901.11, titled Equipment and Utensils, Air-Drying Required; indicated .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow . The facility's policy titled Dishwashing Procedure, updated November 2010, included, .13. Air dry dishes by racking or putting on single trays lined with mesh .14. Clean and soiled dishes, utensils and pots and pans must be separated. 2. On 1/13/20 at 11:59 A.M., an observation was conducted of the dry/clean storage area of the kitchen. Three #8 food scoops and two #16 food scoops had dried food residue adhered to the inside of each scoop. At 12 P.M., an interview was conducted with DA 1. DA 1 stated the food scoops were dirty and should have been cleaned of food residue before being stored in the dry/clean storage area. According to the 2017 US Food and Drug Administration (FDA) Food Code, section 4-601.11, titled Equipment, Food-Contact Surfaces .and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch . 3. On 1/13/20 at 9:14 A.M., an interview was conducted with CK 2. CK 2 stated she did not know what the temperature of the thermometer should read when calibrated correctly. On 1/13/20 at 3:51 P.M., an interview was conducted with CK 3. CK 3 stated he calibrated the 555806 Page 9 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many thermometer by placing the thermometer in a glass of iced water, and waited for the thermometer temperature to reach less than 40 degrees F (Farenheit). On 1/14/20 at 7:56 A.M., a joint observation and interview was conducted of a thermometer calibration procedure with CKS and CK 2. CK 2 placed a digital thermometer in a cup of iced water (1/3 ice and 2/3 water). The thermometer read 42.4 degrees F. CKS stated there might have been a problem with the thermometer because it did not reach a lower temperature. CKS placed a new digital thermometer in the cup of iced water. The digital thermometer temperature read 41.8 degrees F. Neither CKS or CK 2 could explain why the thermometers did not reach the correct calibration temperature of 32 degrees F. On 1/15/20 at 4:55 P.M., an interview was conducted with the FSDRD. The FSDRD stated she was unaware the CKs did not know how to correctly calibrate the thermometers. The validation, verification reassessment section of the Hazard Analysis and Critical Control Point (HACCP) system stated in the Code of Federal Regulations (9CFR 3:417.4) specifies that instruments used for monitoring critical control points must be calibrated. All thermometers using an ice bath (more ice than water) calibration method should reach a temperature of 32 degrees Fahrenheit after at least two minutes. According to the 2017 US Food and Drug Administration Food Code, section 4-204.112 titled Temperature Measuring Devices, .The importance of maintaining time/temperature control for safety foods at the specified temperatures requires that temperature measuring devices .be appropriately scaled per Code requirements to ensure accurate readings. The facility's policy dated 2014, titled Calibrating a Probe or Digital Thermometer, included, .digital thermometers should be calibrated weekly to assure accuracy .1. Fill a medium sized glass with ice. 2. Add ½ cup water to the ice. 3. Place thermometer in middle of the glass of ice water. 4. Wait three (3 minutes). 5. Stir water occasionally. 6. After three (3) minutes, thermometer should read 32 degrees F . 4. On 1/13/20 at 9:17 A.M., an observation of the cold food preparation, including tuna sandwiches, was conducted. There were three stainless steel pans inside the cold preparation unit, one pan each of tuna salad, egg salad, and chicken salad. At 4:12 P.M., an interview was conducted with CK 4 and CKS. CK 4 stated he was not sure dietary services used a cooling log. CK 4 stated he had never used a cooling log and never took the temperature of tuna and chicken salad when he prepared them. CK 4 further stated he prepared the chicken salad yesterday and that was being served today. CKS stated a long time ago the facility used the cool down process and cool down log, but they did not use it anymore because all the food was prepared the day the food was served. CKS stated therefore a cool down log was not needed. On 1/13/20 at 4:17 P.M., an interview was conducted with the FSDRD. The FSDRD stated the egg, tuna and chicken salads were made fresh every day. The FSDRD stated perhaps CK 4 made the chicken salad late last night, to be served today. The FSDRD stated she was not aware of a cool down log for food prepared and stored at ambient temperature. The 2017 US Food and Drug Administration (FDA) Food Code, Section 3-501.14, titled Cooling, 555806 Page 10 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0802 Level of Harm - Minimal harm or potential for actual harm includes, Time/Temperature Control for Food Safety shall be cooled within 4 hours to 50 degrees C (degrees Celsius) (41 degrees F) (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as .chicken salad and canned tuna. Residents Affected - Many 555806 Page 11 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and record review, the facility failed to ensure dietary staff followed recipes and menus accurately as printed when: Residents Affected - Many 1. The Daily Spreadsheet Menu for lunch was not followed when a CK served 1 ¾ oz. meat entrée portions instead of 3 oz. portions. 2. The recipe for Sausage Jambalaya was not followed 3. The lunch puree recipe for roast turkey was not followed. These failures resulted in a vulnerable resident population receiving inadequate and/or incorrect nutrition that could compromise their health status. The facility census at the time of survey was 84. Cross reference 800, 801, 805 Findings: 1. On 1/13/20 at 11:25 A.M., an observation and record review was conducted of the lunch service meal tray line. A review of the Daily Spreadsheet Week 5 - Day 2, 2019 December 15 to January 15 Monday 1/13/20 - Lunch Menu included: Regular Portion: Meat Loaf 3 oz., Gravy 1 oz., Yellow [NAME] #8 Scoop, Brussel Sprouts #8 Scoop. Small Portion: Meat Loaf 2 oz., Yellow [NAME] #16 Scoop, Brussel Sprouts #16 Scoop. Mechanical Soft (level 3): Meat Loaf bite sized pieces, Gravy 1 oz., Yellow [NAME] with broth 1 oz., Brussel Sprouts soft and chopped ½ inch and smaller. CCHO m/s: Meat Loaf bite sized pieces, Gravy 1 oz., Yellow [NAME] with broth 1 oz., Brussel Sprouts soft and chopped ½ inch or smaller. During the lunch trayline on1/13/20, an observation of three residents (71, 79 and 284) meal tickets was conducted. 1a. Resident 71's meal ticket stated regular diet, chopped meats to bite sized pieces, with gravy or broth, and rice. Resident 71's meal tray contained one, 1 ¾ oz. slice of uncut meat loaf, no gravy and yellow rice. 1b. Resident 79's meal ticket included CCHO mechanical, soft chopped (level 3), regular portion. Resident 79's meal tray included one slice of meatloaf uncut, with gravy, m/s Brussel Sprouts, yellow rice. The 1 oz. of broth to be added to the yellow rice was not on the meal tray - per the Daily Spreadsheet. 1c. Resident 284's meal ticket included mechanical soft ground . 555806 Page 12 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0803 Resident 284's meal tray included ground meatloaf, yellow rice, and no broth was added to the yellow rice. Level of Harm - Minimal harm or potential for actual harm On 1/13/20 at 12 P.M., an observation was conducted of CK 1. CK 1 used the Regular Portion size #8 scoop only to serve the yellow rice and Brussel Sprouts. The Small Portion size #16 scoop was not used. CK 1 scooped a smaller portion of the size #8 scoop for the Small Portion sized meal. CK 1 weighed a regular portion slice of meatloaf on a kitchen scale. The slice of meatloaf weighed 1 ¾ oz. The Daily Spreadsheet Menu indicated a 3 oz. portion of meatloaf was to be served for the regular portion meals. Residents Affected - Many On 1/13/20 a record review was conducted. The facility's recipe for Meat Loaf included, . Portion Size 3 oz.Directions .7. Slice into 3 oz. portions . The facility's policy titled Standard Menu Information Regarding Calorie and Protein Levels, dated 2015, included .General Information - Diet - Regular - Average Calories = 2500 - Average Protein = 90-100 grams. A 1 ¾ oz. portion of Meat Loaf provided less calories and protein than the regular diet portion required. 2. On 1/13/20 at 3:51 P.M., an interview was conducted with CK 3. CK 3 stated CKS would tell CK 3 what ingredients were needed to cook the Sausage Jambalaya. CK 3 stated CKS would tell him to use chopped white onion, six green and red bell peppers, two long andouille sausages. CK 3 stated he did not know how long the andouille sausages were. CK 3 stated he made about 80 to 90 servings for dinner but was not sure how accurate that was. On 1/13/20 a record review was conducted. The facility's recipe for Sausage Jambalaya included . Portion Size 8 oz., Number of Servings - 60, .14 ¾ pounds of Sausage (bulk), 2 pounds 1 ¾ oz. Onions, medium, fresh, yellow, 2 pounds 1 ¾ oz. Pepper, bell, green, fresh, medium . 3. On 1/15/20 at 10:24 A.M., an observation and interview was conducted with CK 2. CK 2 was pureeing the roast turkey for the lunch service that day. CK 2 pureed 21 ounces of cut turkey in the blending machine. CK 2 stated there were three ounces of turkey per serving for six people. CK 2 stated she pureed 21 ounces of turkey meat which gave one additional serving portion. CK 2 stated the puree included one ounce of turkey broth. CK 2 added turkey broth to the pureed meat but did not measure the amount of broth added. CK 2 stated the consistency of the pureed turkey looked too thick, and proceeded to add more turkey broth to the blender without measuring the amount of broth added. On 1/15/20 at 5 P.M., an interview and record review was conducted with FSDRD. The FSDRD stated after reviewing the Daily Spreadsheet, CK 2 failed to follow the Spreadsheet and Resident's 19, 20, and 21 did not receive their modified diet as indicated on the Daily Spreadsheet. The FSDRD stated CK 3 failed to follow the recipe for Sausage Jambalaya and CK 2 did not follow the recipe for the pureed diet. The FSDRD stated the CKs should have followed the recipes and the CKS should have supervised the food preparation. The facility's policy titled Food Production Sheets, dated 2016, included .3. Production of all diets, regular, therapeutic and texture modified are produced by following recipes. The production process is observed and supervised by Dietary Management staff. These duties are planned, prepared, and served with supervision or consultation from a Registered Dietitian .These failures had the potential to result in a vulnerable resident population receiving inadequate and/or incorrect nutritional requirements necessary to sustain optimal health. 555806 Page 13 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and departmental document review, the facility failed to ensure the appropriate food texture was served to 11 residents who were on mechanical soft diets (a diet with a soft and chopped texture for one who had difficulty chewing or swallowing) when they received a whole meatloaf slice instead of meatloaf chopped into bite size pieces. This deficient practice had the potential for residents to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway) on unchopped food, which could further compromise their medical and nutritional status. Findings: During a lunch meal tray line service observation in the kitchen on 1/13/20 at 11:25 A.M., residents with regular and mechanical soft diets received whole slices of meatloaf. During a concurrent review of facility document titled, Daily Spreadsheet: Monday-1/13/2020, it indicated .meatloaf with bite size pieces for the mechanical soft diet. During an interview and concurrent review of the daily spreadsheet with the FSDRD on 1/15/20 at 5:01 P.M., the FSDRD stated the residents with the mechanical soft diets should have received meatloaf chopped into bite size pieces after she reviewed the daily spreadsheet for the Monday lunch meal. The FSDRD stated the CK failed to follow the recipe and daily spreadsheet for the meatloaf. A review of an undated facility document titled, Recipe name: Meat Loaf, showed the meatloaf should be chopped into bite size pieces for mechanical soft diet. A review of the facility document dated 10/17/16, titled Mechanically Altered Diet Explanation (3 levels), indicated .Mech Soft .meats .must be ground or chopped into less than 2 inch pieces . 555806 Page 14 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review the facility did not ensure food was stored and prepared in safe and sanitary conditions according to professional standards of practice; and kitchen equipment was maintained according to manufacturer's guidelines in the Food and Nutrition Services department when: 1) Unpasteurized eggs were served to residents; 2) The hot water in the hand wash sink at the main kitchen entrance was 80.6 degrees; 3) Unlabeled, undated, and expired food items were stored in kitchen refrigerators and the dry storage area, and in the nursing unit; 4) Pots, pans and dishes were stacked and stored wet; 5) The ice machine had blackish-brownish smudge inside the condenser of the ice making section; 6) Lack of cool-down process for ambient temperature foods; 7) Use of a non-food grade approved chemical to clean food-contact surfaces; 8) [NAME] nets were not worn by five kitchen employees. These deficient practices had the potential to jeopardize the health and safety of 84 residents and place them at risk to foodborne illnesses. (Cross reference F800, 801, 802, F813, and F814) Findings: 1) During an observation and interview of the meat walk-in refrigerator on 1/13/20 at 8:45 AM, there were two cases of hard shelled eggs on the floor next to the walk-in freezer entrance door. One case was half full and the other case unopened. Neither case had the word pasteurized printed on it and the eggs did not have the purple letter 'P' stamped on them. CKS was asked if the eggs were pasteurized and he said I believe so. CKS said he ordered the cases of eggs and would confirm with the vendor they were pasteurized. CKS further stated the shelled eggs were used to make fried eggs when residents requested them. On 1/13/20 at 4:18 PM, an interview was conducted with CKS. CKS stated the vendor informed him the cases of shelled eggs were pasteurized because they had a CDFA on the invoice. CKS initially stated he did not know what CDFA stood for but later stated it meant California Department of Food and Agriculture. On 1/14/20 at 7 A.M., an observation and interview of the breakfast meal service was conducted. CK 1 had prepared poached and fried eggs for residents. The poached eggs were resting in a pan on the tray line. CK 1 stated he used the unpasteurized shell eggs from the case in the walk-in refrigerator 555806 Page 15 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0812 to make the eggs. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Resident Breakfast Meal Ticket List, dated 1/14/20, indicated, eleven residents requested poached eggs for breakfast. Residents Affected - Many On 1/14/20 at 8:05 A.M., an observation of the dining room was conducted. Two residents were eating poached eggs with runny yolks for breakfast. On 1/14/20 at 8:15 A.M., an interview was conducted with the vendor who provided the eggs. The vendor stated the eggs ordered on the invoice with the CDFA and invoice number on the case were not pasteurized eggs. A review of facility's kitchen food vendor invoices dated June 2019 - January 2020 was conducted. The invoices indicated pasteurized shell eggs were last ordered and delivered to the facility on [DATE]. On 1/14/20 at 9:48 A.M., an interview was conducted with the FSDRD. The FSDRD stated she thought the eggs were pasteurized because CKS always ordered pasteurized eggs. A Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter dated 5/20/14, titled Advanced Copy of Revised F371; Interpretive Guidance and Procedures for Sanitary Conditions, Preparation of Eggs in Nursing Homes, indicated Skilled nursing facilities should use pasteurized shell eggs or liquid shell eggs to eliminate the risk of Salmonella Enteriditis (SE). The use of pasteurized eggs allows for the use of resident preference soft-cooked, undercooked or sunny-side up eggs while maintaining food safety . According to the 2017 US Food and Drug Administration (FDA) Food Code, section 3-302.13, titled Pasteurized Eggs, Substitute for Raw Shell Eggs for Certain Recipes, Raw or undercooked eggs that are used in certain dressings or sauces are particularly hazardous because the virulent organism Salmonella Enteritidis may be present in raw shell eggs. Pasteurized eggs provide an egg product that is free of pathogens and is a ready-to-eat food. The pasteurized product should be substituted in a recipe that requires raw or undercooked eggs. 2) On 1/13/20 at 7:54 A.M., an observation and interview of the hand wash sink at the kitchen entrance was conducted. The hot water tap was turned on and cold water ran for one minute and twelve seconds before the water felt lukewarm. On 1/13/20 at 10:04 A.M., the hot water tap was turned on at the kitchen entrance hand wash sink and cold water ran for 54 seconds before it felt lukewarm. The surveyor took the temperature of the water and it was 80.6 degrees. CKS stated the hot water usually only took a few seconds to warm up. The FSDRD stated she was unaware it took so long for the water in the hand wash sink to warm up. According to the 2017 US Food and Drug Administration Food Code, section 5-202.12 Handwashing Sink, Installation; Warm water is more effective than cold water in removing the fatty soils encountered in kitchens. An adequate flow of warm water will cause soap to lather and aid in flushing soil quickly from the hands. The American Society for Testing and Materials (ASTM) .specify a safe water temperature of 40°C ± 2°C (100 to 108°F). An inadequate flow or temperature of warm water may lead to poor handwashing practices by food employees . 555806 Page 16 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 3) During the initial kitchen tour on 1/13/20 at 8:26 A.M., an observation and interview of the walk-in refrigerators and dry storage area was conducted. Inside the walk-in refrigerator #2 there were following items: a. One stainless steel pan contained an opened bag of raw diced butter squash. The bag containing the butter squash did not have a product description label, a date when the butter squash was opened, or a date when it was due to be discarded. b. A plastic bag of French Fries, a plastic bag of raw shrimp, and a plastic bag of fresh mussels in the shell had no labels of content, date of opening or use by date on them. c. An opened bottle of seafood cocktail sauce was not dated. d. A plastic bag of smoked salmon had no description label. The smoked salmon was dated 12/22/19. e. An opened block of Mozzarella cheese was dated 1/5/20 and a plastic bag of shredded Mozzarella cheese was dated 1/11/20. On 1/13/20 at 8:41 A.M., an interview was conducted with CKS. CKS stated the DS should have dated the food products when they were opened, and following the storage guidelines, would then know when the food was due to be discarded. On 1/13/20 at 8:50 A.M., an observation underneath the preparation table in the kitchen was conducted. A box of fresh onions was stored at room temperature. The box of onions included a peeled ½ cut white onion wrapped in plastic wrap. There was no label or opened date on the onion. A moldy half red onion was wrapped in plastic wrap. The red onion was not labeled or had a date of opening on it. A plastic container holding white powder was sitting on the food preparation bench. The container was labeled thickener. The food thickener had a use by date on the container of 1/6/20. The container had a pulled date of 1/11/20. At 8:57 A.M., an interview was conducted with CKS. CKS stated the box of fresh onions was usually checked by himself or one of the cooks once a week or week and a half. CKS stated a CK must have wrongly labeled the container of food thickener, but the thickener powder could be used for three months before being discarded. On 1/13/20 at 9:02 A.M., an observation of the dry food storage area was conducted. The dry storage area contained various food items that included: a. A bottle of distilled vinegar, a bottle of soy sauce, and a bottle of sesame oil were opened but did not have an opened date written on them. b. A bottle of red wine vinegar, dated 9/1/19, soy sauce, dated 12/3/19, sesame oil, dated 6/30/19, apple cider vinegar, dated 11/20/19, white truffle oil, dated 12/17/19, a container of honey, dated 12/10/19, extra virgin olive oil, dated 12/30/19, liquid smoke, dated 3/20/19, and a bottle of rice vinegar, dated 1/1/20. At 9:15 A.M., an interview was conducted with CKS. CKS stated the containers of food should have the opened and use by dates written on them. 555806 Page 17 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 1/13/20 at 9:21 A.M., an observation was conducted of the salad and sandwiches cold preparation unit in the Kitchen. A refrigerator under the cold preparation unit contained an opened bag of Monterey cheese cubes with a date of 1/8/20 on the bag. Boxes of fresh fruit were also stored in the cold preparation unit. At 9:25 A.M., an interview was conducted with CK 2. CK 2 stated she did not know the boxes of fruit stored in the cold preparation unit, needed to be dated. CK 2 stated the date written on the Monterey cheese cubes was the date the cheese was opened. CK 2 stated she followed the manufacturer's used by date when discarding food. On 1/13/20 at 3:07 P.M., an observation of the patient food refrigerator in the Sun Room was conducted. The refrigerator contained a plastic container of red beets with a label on it. The label said 1A/1B dinner snacks, one for each resident. The container had no opened date or use by date on it. On 1/15/20 at 8:44 A.M., a subsequent observation of the Sun Room refrigerator was conducted. The Sun Room refrigerator contained: a. Five bottles of nutritive drink. One bottle had an expiration date of 10/1/18, a second bottle had an expiration date of 7/25/19, and a third had an expiration date of 8/20/19. b. Three sandwiches wrapped in plastic and sitting on a plate. The sandwiches were not named or labeled and had no date of preparation or expiration. c. An undated plastic bag of four containers of food. The containers had no date of when they were opened or when they should have been discarded. d. A jar of dill pickles with no date of when the jar was opened. On 1/15/20 at 8:55 A.M., an interview was conducted with the AD. The AD stated the activity staff, the nursing staff and the dietary staff checked the temperature and cleanliness of the refrigerator every day. At 9:09 A.M., an interview was conducted with the DON, and the FSDRD. The DON stated the nutritive drinks were expired and needed to be discarded. The FSDRD stated the DA's needed to check the refrigerators for expired foods. On 1/15/20 an observation of the sign posted on the Sun Room refrigerator was conducted. The sign read, Help ensure the safety of our residents, any food items placed in this refrigerator must have a resident name and date present. All nursing and activities: food items must be securely covered and dated. On 1/15/20 at 4:55 P.M., an interview was conducted with the FSDRD. The FSDRD stated food brought in to the facility from the outside for residents should have been labeled and dated. The food should have been thrown out after three days. According to the 2017 US Food and Drug Administration (FDA) Food Code, section 3-501.17, Labeling and Dating Food; .For commercially prepared, refrigerated, ready-to-eat TCS food, the food is to be marked with the time the container is opened. If the food will be held for more than 24 hours it is to indicate the date or day it will be consumed or discarded. 555806 Page 18 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many According to the 2017 US Food and Drug Administration (FDA) Food Code, section 3-302.12; .Except for food that can be readily and unmistakably recognized such as dry pasta, containers holding food such as cooking oils, flour, herbs, potato flakes, salt, sugar are to be labeled with the common name of the food. The facility's policy titled Food Storage, dated 2016, included, .Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded . All products should be dated upon receipt and when they are prepared. Use use-by-dates on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Chart found in this section . Any opened products should be placed in seamless plastic or glass containers with tight fitting lids and labeled and dated . 4) On 1/13/20 at 10:23 A.M., an observation of the clean dry pots and pans storage rack was conducted. Fifteen wet stainless steel pans were stacked inside one another with clean dry pans. At 10:25 A.M., an interview was conducted with DA 1. DA 1 stated the pans should not have been stored wet. CKS stated the pans should have been air dried in the rack near the dishwasher before being stored on the dry/clean storage racks. According to the 2017 US Food and Drug Administration (FDA) Food Code, section 4-901.11, titled Equipment and Utensils, Air-Drying Required; indicated .Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow . The facility's policy titled Dishwashing Procedure, updated November 2010, included, .13. Air dry dishes by racking or putting on single trays lined with mesh .14. Clean and soiled dishes, utensils and pots and pans must be separated. On 1/13/20 at 11:59 A.M., an observation was conducted of the dry/clean storage area of the kitchen. Three #8 food scoops and two #16 food scoops had dried food residue adhered to the inside of each scoop. At 12 P.M., an interview was conducted with DA 1. DA 1 stated the food scoops were dirty and should have been cleaned of food residue before being stored in the dry/clean storage area. According to the 2017 US Food and Drug Administration (FDA) Food Code, section 4-601.11, titled Equipment, Food-Contact Surfaces .and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch . 5) On 1/13/20 at 9:46 A.M., a joint observation of the ice machine and concurrent interviews were conducted with the CKS, the MDR and MW 1. CKS stated the machine was cleaned monthly by maintenance. MW 1 stated he cleaned the inside of the ice machine coils and bin monthly. MW 1 stated he used a brush and cleaning solution to clean the ice machine. MW 1 then opened the cover of the ice machine, and there was large black smudge throughout the filters where the water runs and forms ice. The MDR stated he had to solder (a metal [NAME] used when melted to join metal surfaces) the coils that were leaking to seal them so it caused some black smearing on the filter covers. The MDR acknowledged the black smearing on the filter covers could get into the water running through the filters to form ice and could cause potential danger to the residents who may consume it because ice is food. The FSDRD acknowledged the black smudge and also agreed the black smudge could potentially get in the running water that formed ice. On 1/16/20 at 1:05 P.M., an interview was conducted with MW 1 and the AMS. MW 1 stated he did not 555806 Page 19 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0812 Level of Harm - Minimal harm or potential for actual harm use the manufacturer's guidelines to clean the ice machine because a previous maintenance worker taught him how to clean it. MW 1 stated he used a scrubbing brush to clean the sides and under the walls of the ice machine. MW 1 stated he was unaware the manufacturer's guidelines did not mention use of a scrubbing brush to clean the inside of the ice machine. The AMS stated it was his expectation that manufacturers guidelines for cleaning the ice machine were followed Residents Affected - Many A review of the ice machine manufacturer's guideline instructions for cleaning was conducted. The ice machine cleaning instructions did not require a brush during the cleaning of the filters or inside the machine. According to the 2017 US Food and Drug Administration (FDA) Food Code, section 4-602.11, titled Equipment Food-Contact Surfaces and Utensils, indicated .equipment contacting food .such as .ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms . 6) During the initial kitchen tour on 1/13/20 at 12:01 P.M., an observation of the lunch meal tray line service was conducted. CK 2 was loading the cold foods station to prepare sandwiches for lunch. There was a pan of tuna salad and chicken salad on the station. CK 2 was asked when the tuna and chicken salad was prepared and CK 2 stated yesterday. CK 2 also stated the tuna used to make the salad was stored in the dry storage room. CK 2 stated she did not take temperatures of the tuna or chicken salad while preparing it. CK 2 stated she takes the temperatures when the tuna and chicken salad are placed on the cold prep station. CK 2 stated a log was not kept of the temperatures. On 1/13/20 at 4:10 P.M., an interview was conducted with CK 4 and CKS. CK 4 stated he never used a cool down log since he started working at the facility months ago. CK 4 also stated the chicken salad placed on the cold prep station for dinner trayline was from yesterday. CK 3 was asked did he ever check temperature of the tuna or chicken salad while preparing it and he stated No. On 1/13/20 at 4:14 P.M., an interview was conducted about cool down logs with CKS. CKS stated we used to use a cool down log a long time ago when we had leftovers. CKS further stated now, we don't have a cool down log because we cook everything fresh the day of. On 1/13/20 at 4:20 P.M., an interview was conducted with the FSDRD. The FSDRD stated her expectation was that the tuna and chicken salads were made fresh daily and since we do not have leftovers, we do not have a cool down log. According to the Center for Disease Control and Prevention (CDC) report for 1993 - 1997, titled Surveillance for Food-borne Disease Outbreaks - United States, improper cool down was identified as one of the most significant factors contributing to food borne illness. Improper holding temperatures was identified as a contributing factor directly related to food safety concerns. A review of the 2017 US Food and Drug Administration (FDA) Food Code, Section 3-501.14 Cooling, indicated Time/Temperature control for Safety Food shall be cooled within 4 hours to 5 degrees Celsius (41 degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as .canned tuna. 7) On 1/13/20 at 3:19 P.M., an observation of the sanitizer solution used in the kitchen was conducted. A concurrent interview was conducted with CK 3. CK 3 stated he used a peroxide multi surface cleaner and disinfectant solution in a spray bottle instead of a red bucket with sanitizing solution 555806 Page 20 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0812 Level of Harm - Minimal harm or potential for actual harm and gray towel to wipe the food preparation counters. CK 3 also stated he used a wire scrubber to scrape tough areas on the counter along with more peroxide multi surface cleaner and disinfectant. A review of the manufacturer's safety guidelines of the peroxide cleaner solution indicated it was designed to clean windows, glass, floors, and other hard surface materials; and not registered to sanitize or disinfect. Residents Affected - Many During an interview with the ADM and FSDRD on 1/16/20 at 2:15 P.M., the FSDRD and ADM stated they were unaware the cleaning solution used in the kitchen may not have been safe to use in the kitchen because it did not sanitize surfaces. A review of the 2017 US Food and Drug Administration (FDA) Food Code, section 4-601.11, titled Equipment Food-Contact Surfaces and Utensils, indicated .food service equipment and surfaces contacting food .be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms . The standard of practice is to ensure that chemical cleaning and sanitizing agents meet specified criteria and are used in accordance with the EPA (Environmental Protection Agency) registered label use instructions (Food Code, 2017). 8) During the initial kitchen tour on 1/13/20 at 8 A.M., an observation was conducted in the facility's kitchen. CKS and CK 1 wore beard nets which did not cover their moustaches. On 1/13/20 at 9:17 A.M., an observation and concurrent interview was conducted in the kitchen. A food delivery employee walked through the kitchen and was not wearing a hair net. The FSDRD stated the food delivery employee should have been wearing a hair net when he entered the kitchen. On 1/13/20 at 12:02 P.M., during the lunch tray line meal observation, CK 1 wore a beard net which did not cover his moustache. On 1/13/20 at 3:25 P.M., an observation of the trash disposal process was conducted in the kitchen. DW 1 did not wear a beard net over his beard and moustache while working in the kitchen. During an interview with the FSDRD on 1/15/20 at 5:01 P.M., the FSDRD stated kitchen hair nets and beard nets should be worn by kitchen staff and visitors while working or entering the kitchen. The 2017 US Food and Drug Administration (FDA) Food Code; Section 2-402.11, titled Hair Restraints, included, .(A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food . The facility's policy titled Personal Hygiene, dated 2016, included .3. Head Covering Worn: a. Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered . 555806 Page 21 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and departmental document review, the facility failed to follow the policy on Food from Outside Sources that included provisions on how they will provide safe food handling practices for resident food brought from the outside. Residents Affected - Many This failure had the potential to lead to food borne illnesses in a medically compromised population of 83 out of 84 residents who could consume food. Cross reference 800, 801, 812 Findings: On 1/13/20 at 3:07 P.M., an observation of the refrigerator located in the Sun Room was conducted. The refrigerator had a poster on the outside door that read, Help ensure the safety of our residents, any food items placed in this refrigerator must have a resident name and date present . During an observation inside the refrigerator, there was a plastic lunch box with beets, and a resident's room number but no date. During an interview on 1/15/20 at 8:41 A.M., CNA 27 stated she would put the resident's food brought from outside in the refrigerator in the Sun Room which was designated for resident's food only. She stated she would put resident's name and date on the food. CNA 27 was not aware of how long the food should stay in the refrigerator and was not aware of the policy on food brought from outside sources for the residents. During an observation of the resident's refrigerator located in the Sun Room on 1/15/20 at 8:44 A.M., there were six containers of food and five nutritional drinks (three out of five nutritional drinks were expired by manufacturer's used by date) had residents' names but no dates, and a plate of three plastic wrapped half sandwiches had no resident's name and no date. During an interview on 1/15/20 at 9:04 A.M., CNA 28 stated when food was brought by visitors he would confirm with the charge nurse for permission to put it in the resident's refrigerator. He stated he would put the resident's name and a date on the food container. He also stated he would let the charge nurse check the food before resident consumed it because he did not know if the food was still fresh. CNA 28 stated he did not know how long the food should kept in the refrigerator and was not aware of the policy on food brought from outside sources for the residents. During an interview with DA 2 on 1/15/20 at 9:20 A.M., DA 2 stated the nursing staff were responsible for putting residents' names and dates on the residents' food, and then they put in the refrigerator located in the Sunroom. He stated dietary aides were responsible for checking the food and throwing them away if they were bad. DA 2 stated the food could be kept three to five days in the refrigerator but not sure if there were any guidelines regarding the time frame. He stated the dietary aides usually checked the refrigerator every other day or sometimes every two days. During an interview with the FSDRD on 1/15/20 at 5:01 P.M., she stated most often nursing staff manage residents' outside food and they should be labeled with residents' names and dates when put in the refrigerator. She confirmed that the current Food from Outside Sources policy had no guideline for how long the food could keep in the refrigerator. The FSDRD stated the facility did not have a system to manage residents' food brought in from the outside. 555806 Page 22 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the departmental policy titled, Food from Outside Sources, updated July 2013, showed, .the community does have the responsibility to help staff and visitors understand safe food handling practices .food is brought in by visitors .the community should help them understand safe food handling practices .Perishable food should be sealed and dated with a used-by-date and placed in refrigerator .the community will also designate who be responsible . discard outdated or uneaten foods .nursing staff will be trained also in safe food handling . It did not show any guidelines for the staff about how long the food could be kept in the refrigerator and when to discard it. 555806 Page 23 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and departmental document review, the facility failed to dispose of garbage and refuse properly when a dietary staff did not cover the garbage receptacles with lids when removing trash from the kitchen to the dumpster. Residents Affected - Some This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: On 1/13/20 at 3:55 P.M., an observation and interview of the garbage disposal process was conducted with DW 1. DW 1 was preparing to take the garbage bin full of trash bags with tied knots to the dumpster without a lid covering it. DW 1 stated yes when asked if he always transported the garbage bin to the dumpster without a lid. During an interview with DW 1 after the garbage was disposed of, on 1/13/20 at 4:05 P.M., he stated there was only one lid for four garbage bins in the kitchen, and that was why he did not use a lid to cover the garbage bin when taking it to the dumpster. DW 1 further stated the garbage bin with the lid had to stay in the kitchen. During an interview with the FSDRD on 1/13/20 at 4:20 P.M., she stated she was not aware there was only one garbage bin lid for the large garbage bins. During a follow up interview with the FSDRD on 1/15/20 at 5:01 P.M., she stated the garbage bin needed to be covered with a lid when transporting it from the kitchen to the dumpster. During a review of departmental policy titled, Garbage and Trash Cans, revised February 24, 2016, showed that trash cans need to be covered when transporting to the dumpster. Per the 2017 US Food and Drug Administration Food Code, section 5-501.113 Covering Receptacles, .Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils.receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse . the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available .so that unsanitary conditions can be eliminated. 555806 Page 24 of 25 555806 01/16/2020 Glenbrook 1950 Calle Barcelona Carlsbad, CA 92009

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 implement correct infection control practices when a licensed nurse did not consistently perform hand hygiene (hand washing or use of hand sanitizer) after glove removal during a gastrostomy tube (g-tube - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) dressing change on Resident 50. Residents Affected - Few This failure had the potential to transmit infectious agents to Resident 50. Findings: Resident 50 was readmitted to the facility on [DATE], with diagnoses which included malnutrition and diverticulum of the esophagus (a pouch that protrudes outward in a weak portion of the esophageal lining), per the facility's admission Record. Per Resident 50's H & P (History & Physical), dated 11/30/19, Resident 50 was oriented to person, place, and time. On 1/16/20 at 10:49 A.M., an observation of a g-tube dressing change by LN 11 on Resident 50 was conducted. LN 11 performed hand hygiene and put on gloves, then removed the old dressing on Resident 50. LN 11 removed the gloves, and put a new pair of gloves without performing hand hygiene. LN 11 put a new dressing on, removed the gloves, put on a new pair of gloves without performing hand hygiene, and placed a tape on the edges of the new dressing. On 1/16/20 at 10:50 A.M., an interview with LN 11 was conducted. LN 11 stated she should have washed her hands between glove changes to prevent infection. On 1/16/20 at 12:52 A.M., an interview with the DSD was conducted. The DSD stated the expectation was for LN 11 to perform hand hygiene between glove changes. On 1/16/20 at 3:14 P.M., an interview with the DON was conducted. The DON stated LN 11 should have performed hand hygiene between glove changes. The DON also stated there was no guarantee hands were clean especially between dressing changes. A review of the facility's policy titled, Hand Washing and Hand Hygiene, revised 8/26/19, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .Guidelines and Implementation: 5. Employees must wash their hands .using antimicrobial or non- antimicrobial soap and water .6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub .h. After handling used dressings .j. After removing gloves .8. The use of gloves does not replace handwashing/ hand hygiene. 555806 Page 25 of 25