Based on observations, staff interviews, and review of the policy titled Skilled Inpatient Services - Storage Areas, the facility failed to ensure that items were discarded after the use by/best buy/expiration date, that food on the steam table remained in safe temperature range during serving, items were placed in a clean container with a tight fitting lid when remove from the original packaging, chipped paint, and the kitchen was clean as evidenced by buildup on the back of stove, light covers, and a wall and door near a trashcan. This deficient practice impacted 40 of 42 residents who received oral diets. Findings include: Review of policy titled Skilled Inpatient Services - Storage Areas, dated 12/4/2021, revealed: Guideline - All items should be inspected for quality and temperature control upon receipt. Items should be covered, sealed, labeled, and dated appropriately. First in first out (FIFO) should be followed. Freezer - Area should be kept in good working condition. During initial kitchen tour and interviews on 8/18/2023 at 7:45 a.m. with the Assistant Dietary Manager and the Certified Dietary Manager (CDM) the following was identified: 1. In the main kitchen the can opener was noted to have a black sticky substance on the blade and holder. There were also food substances noted on the side of the table where the can opener was attached. 2. In the main kitchen there were two white containers with buildup on the front and top that contained sugar and corn meal. 3. In the main kitchen there was a door and wall near the trashcan that had food build up and spills noted. 4. In the dry storage food area there were plastic containers container penne pasta with a use by date of 7/4/2023 written on the label, egg noodles with 7/4/2023 written on the label, and cous cous with a use by date of 7/4/2023 written on the label. 5. In the microwave there was food splatter in the top and on the sides of the inside of the microwave. 6. In the walk-in cooler there were seven containers of heavy whipping cream with a use by date of 8/14/2023. 7. In the dry food storage there was a 12 pack of hot dog buns that were not dated with an expiration date. The CDM reported that the can opener should be cleaned on Wednesdays and confirmed the black build up and food. CMD reported that the items in the containers in dry storage were just ordered and staff are not putting the correct dates on the containers as they are refilled. Assistant Food Manager reported that he was responsible for updating the labels on the items in the kitchen and he had not done so. He explained that items should have expiration dates on them. He then reported that the hot dog buns should have been in the freezer and not in the dry food storage area but confirmed that there was no way to determine the expiration date of the hot dog buns. Servery Kitchen tour on 8/18/2023 at 8:16 a.m. revealed the following: 1. There were two containers of thickened apple juice with a best if used by date of 8/9/2023. 2. There were two containers of thickened water with a best if used by date of 6/19/2023. Interview and observations conducted on 8/19/2023 beginning at 10:30 a.m. with the CMD revealed the following: In the walk-in freezer there was an 80-ounce (oz) bag of blueberries with a label indicating that the bag was opened on 5/11/2023 and a use by date of 8/10/2023. CDM reported that she thought that the facility could leave frozen items in the freezer up to six months. CDM confirmed that based on the label it indicated an expiration date of 8/10/2023. During interview on 8/19/2023 at 1:05 p.m. the Director of Nursing (DON) reported that the facility does not have a policy specific to discarding foods by the expiration date. During an observation and interview with the DON and CDM on 8/19/2023 at 4:52 p.m. in the servery kitchen the following was revealed: 1. In the cooler there was a container with cream cheese that was not labeled or dated. 2. In the refrigerator there were two containers of thickened liquid apple juice (use by 8/9/2023) and two cartons of thickened water (used by 6/19/2023). 3. In the refrigerator there was a cup of tea in a cup that did not have a lid on it and was not dated. CDM reported that the refrigerator should be checked daily, by dietary staff, for expired items and items should be discarded once found. CDM reported that she was not sure if items could be used beyond the best by date. She reported that the date was the best buy date but it didn't say expired. She went on to say that she would have to follow up because she is not sure how they do things here. It was then questioned how the expiration date is identified if the use by or best by date is not used. The DON reported that her expectation is that items are used by the best by and used by dates. There was a sign on the refrigerator door that stated items in the refrigerator should be labeled, dated, and have a use by date prior to placing in the refrigerator. On 8/19/2023 at 6:20 p.m. temperature checks for dinner meal check began with the CDM and Dietary AA after the first cart of trays had been sent for delivery. The following was revealed: 1. Chicken parmesan was 123 degrees Fahrenheit (F). It was reheated in two batches to 178 F and 181 F. 2. Beef patties were 103 F. They were reheated but not used. 3. Roast beef was 120 F with a final reheat of 184 F. 4. Marinara sauce was 120 F with a final reheat 170 F. During an interview with the CDM and Dietary AA on 8/19/2023 at 6:32 p.m. it was revealed that items on the steam table should be holding at 125 F. Dietary AA then said it should be holding 145 F and if reheated should be reheated to 165 F. It was discovered that the second holding well on the steam table was not getting hot enough. The light was not illuminated to indicate that it was on, but they reported the light does not work but it should still get hot. On 8/20/2023 at 7:23 a.m. the Assistant DM confirmed the seven cartons of heavy whipping cream in the walk-in cooler with a use by date of 8/14. Assistant DM reported that he was responsible for checking for expired items and he missed those items. He also confirmed that the use by and best by dates are used as the expiration dates and items should not be used beyond those dates. Assistant stated, You got me again and then discarded the items. On 8/20/2023 at 7:30 a.m. the CDM confirmed the container for the sugar and corn meal with lids that were not tightly fitting (gap) and also confirmed build up on the containers. A final kitchen tour and interviews were conducted on 8/20/2023 at 9:17 a.m. with the CMD and Dietary staff with the following being confirmed: 1. The food buildup and spills on wall and door near trashcan were confirmed. [NAME] CC reported this area is supposed to wiped down daily. She reported that she did not work on last night. A wet paper towel was used on the door and the staining was removed in the area that was wiped. 2. Food splatter in microwave. 3. There was flaking paint on pipes at the top entry into the kitchen. 4.There was build up on light covers in kitchen. 5. There was buildup of grease and oil on the back of the stove in the kitchen. Cook BB, [NAME] CC, and [NAME] DD all reported that everyone should be cleaning daily as spills happen. However, each Wednesday someone was supposed to provide a deep cleaning of the kitchen. CDM also confirmed that everyone should be responsible for cleaning, but she is still learning how things are done in this facility and she has only been in her role for two weeks. It was reported that they would have to notify Maintenance about the grease/oil on the back of the stove, flaking paint, and light covers as those are areas that Maintenance would have to address.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy titled Reporting and Investigating Abuse, the facility failed to reported abuse timely related to a resident-to-resident incident (R#6 and R#290) for one of four facility reported incidents reviewed. Findings include: Review of abuse police titled, Reporting and Investigating Abuse (2020), revealed: Procedural Guidelines - Reporting d. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and/or misappropriation of patient property and is reported to the Administrator, the incident will be immediately reported (within 2 hours) to the State. R#6 admitted to the facility on [DATE] with diagnoses that included, but not limited to, Parkinson's disease, cerebral infarction due to embolism of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and major depressive disorder. R#290 admitted to the facility on [DATE] with diagnoses that include, but not limited to, degenerative nervous system due to alcohol, chronic obstructive pulmonary disease, monoplegia of upper limb following unspecified cerebrovascular disease affecting left non-dominant side, and hypertensive heart disease with heart failure. Review of Nurse's Note dated 1/5/2022 revealed the Medical Doctor (MD) was notified of an incident from the previous evening in which R#290 entered another male resident's room and made unwanted sexual advances. The family was notified of MD's instructions for a psych evaluation of R#290 and made the decision to discharge R#290 from the facility. Review of Facility Report dated 1/5/2022 indicated an abuse incident between two residents took place on 1/4/2022 at 6:30 p.m. which consisted of verbal and physical aggression but no injuries. Interview and observation on 2/8/2022 at 2:42 p.m. revealed R#6 was sitting in wheelchair in his room. R#6 does not recall the incident with R#290. Interview on 2/10/2022 at 6:55 a.m. with Licensed Practical Nurse (LPN) CC who reported that she remembered the incident between R#6 and R#290. She explained that the incident took place just before shift change and R#6 was visibly upset about the situation with R#290. She reported that the Administrator was notified of the incident shortly after it happened. She further reported that hourly rounds were done to assure that R#6 was ok and that R#290 did not go back to the room to bother R#6. She further reported that R#290 discharged from the facility the day after the incident. During an interview on 2/10/2022 at 9:19 a.m. with the Administrator it was reported that if there is an allegation of abuse that resulted with an injury abuse is reported within two hours but if there is no injury it is reported within 24 hours. During an interview on 2/10/2022 at 3:30 p.m. with the Interim Director of Nursing (DON), Registered Nurse (RN) DD, and Consultant all reported that if there is no injury related to abuse the report is submitted within 24 hours. Interview on 2/10/2022 at 5 p.m. with RN DD who revealed that the facility has always sent any reports of abuse within 24 hours and had they realized it needed to be sent in within two hours it would have been done.