Health inspection·August 7, 2024

§483.60(i) Food safety requirements. The facility must – §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. § 72637 General Maintenance (a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. (b) Buildings and grounds shall be free of environmental pollutants and such nuisances as may adversely affect the health or welfare of patients to the extent that such conditions are within the reasonable control of the facility. (c) All buildings, fixtures, equipment and spaces shall be maintained in operable condition. § 72523(a) Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 6/28/2024 at 3:24 p.m., the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a standard annual recertification survey. During recertification survey CDPH has determined the facility failed to ensure three freezers and one refrigerator in the facility’s kitchen and food pantry were maintained in a safe operating condition and food items stored under proper temperature. This failure had the residents’ food items stored in an unsafe condition placing the residents at risk for food-borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, and toxins). During an observation on 6/28/2024 at 3:24 p.m. in the facility’s food pantry with the Dietary Supervisor (DS), the following was observed: a. Freezer #1 had no thermometer to monitor the freezer’s temperature. There were several bags of frozen tortilla. There was one opened bag of tortilla with no date of opening and another bag of tortilla, unopened, with ice crystals ([freezer burn] happens when food is not stored properly in the freezer, causing moisture to escape and turn into ice crystals) inside the bag. b. Freezer #2 with packed bags of vegetables had a temperature of 2.0 degrees Fahrenheit (°F a temperature scale) and there was an ice buildup observed on the upper portion of the freezer. c. Freezer #3 with sliced carrots and French fries had a temperature of zero °F and there was an ice buildup at the bottom of the freezer. There was observed clear liquid on the floor outside of the freezer. During an observation on 6/28/2024 at 5:02 p.m., in the facility's kitchen the following were observed: a. Freezer #4 with frozen meat, ice cream, butter and popsicles had a temperature of 1 (one) one °F. b. Refrigerator #1 with milk and eggs had a temperature of 60 °F. During an observation on 6/29/2024 at 9:46 a.m. in the facility’s food pantry with the Maintenance Director (MD), the following was observed: a. Freezer #2 with packed bags of vegetables had a temperature of 4.0 °F. b. Freezer #3 with sliced carrots and french fries had a temperature of 4.0°F and there was an ice buildup at the bottom of the freezer and a clear liquid on the floor (outside of the freezer). During a concurrent observation and interview on 6/29/2024 at 9:46 a.m. with MD the following were observed: a. Refrigerator #1 with milk in it had a temperature of 38 °F, there were no other food items inside the refrigerator. b. Freezer #4 with meat, ice cream, butter, and popsicles in it, had a letter "D" noted on the outside temperature monitor. A letter D signified a defrosting was taking place in the freezer, which was confirmed by MD as a normal mechanism of the freezer to give the condenser coils to work. During an observation on 6/29/2024 at 10:11 a.m., of the facility's kitchen with the Administrator, the following was observed: a. Refrigerator #1 with milk in it had a temperature of 38 °F and there were no other food items inside the refrigerator. b. Freezer #4 with frozen meat, ice cream, butter and popsicles had a temperature of 1 °F. During an observation on 6/29/2024 at 12 p.m., of the facility's kitchen with the Administrator, Maintenance Supervisor and Dietary supervisor, the following was observed: a. Freezer #4 t with frozen meat, ice cream, butter and popsicles had an ice buildup on the upper section of the freezer with a temperature of 18.5 °F as checked by the Maintenance Supervisor utilizing the facility's thermometer gun. However, the thermometer inside the freezer indicated 16 °F. During an observation on 6/29/2024 at 12:52 p.m., in the facility's kitchen with the Administrator, Maintenance Supervisor and Dietary supervisor, the following was observed: a. Freezer #4 with frozen meat, ice cream, butter and popsicles had an ice buildup on the upper section of the freezer with a temperature of 5 °F as checked by the Maintenance Supervisor utilizing the facility's thermometer gun. However, the temperature inside the freezer was 4 °F. During an interview on 6/28/2023 at 5:20 p.m., the Dietary Supervisor (DS) stated the kitchen equipment such as the freezer and refrigerator must be operating at the proper temperature (freezer must have a temperature of 0 [zero] and below °F and refrigerator must operate with 40 °F and below) to ensure the residents' food was stored safely, prevent the growth of bacteria that can cause food borne illnesses, and the quality of the food was maintained. During an interview on 6/29/2024 at 9:46 a.m., the Maintenance Supervisor (MS) stated leakage and water condensation/ ice buildup inside the freezer signifies the equipment was not functioning properly and need to be replaced. During an interview on 6/29/2024 at 10:11a.m., the Administrator stated she was not aware of the concerns of the kitchen and pantry cold storage equipment. During an interview on 6/29/2024 at 5:06 p.m., the on-call Registered Dietician stated the temperature of the facility’s cold storage equipment, such as the freezer and refrigerator, will have fluctuating temperature depending on how often the kitchen staff were using them; however, the cold storage equipment must stay in the proper temperature and a thermometer must be delegated in each of the equipment to ensure the equipment temperature was monitored and functioning safely. A review, a facility's freezer equipment manual titled "Commercial Freezer Defrost Cycles Explained" undated, the equipment manual indicated defrost cycles of the freezer avoid problems caused by the buildup of ice and defrosting does not affect the interior temperature of the freezer cabinet and the food held in the freezer. A review, a facility's policy, and procedure (P&P) on "Equipment Operation" revised 11/ 2014, the P&P indicated appropriate and safe equipment are being used in the facility. A review, a facility's P&P on "Food Storage and Handling" revised 2/29/2024, the P&P indicated the residents' food items must be stored at a safe and appropriate temperature in the freezer at a temperature of 0-degree (zero) Fahrenheit and below and in the refrigerator at a temperature of below 41 degrees Fahrenheit. The facility failed to ensure three freezers and one refrigerator in the facility’s kitchen and food pantry were maintained in a safe operating condition and food items stored under proper temperature. This failure had the residents’ food items stored in an unsafe condition that could potentially place the residents at risk for food-borne illnesses. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of residents. 2 Bay Vista Healthcare & Wellness Centre “B Citation” Recertification EID: TC4i11