Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety. Food items were not dated at the time of storage. Food that had been opened were not covered and/or sealed to prevent contamination. The deficiency had the potential to affect 47 of the facility's 47 residents who consumed food from the kitchen. The findings include: Review of the facility's undated policy titled, Dry Food Storage, revealed dry food should be stored in a manner that ensures food safety, optimum nutrient, and optimum aesthetic quality. Dry food products should be labeled and dated when received. All leftovers were dated with the open date and stored accordingly ensuring that food was covered completely in the original box to prevent air exposure. Review of the facility's undated policy titled, Refrigerated Food Storage, revealed refrigerated food should be stored in a manner that ensures food safety, optimum nutrient, and optimum aesthetic quality. All refrigerated products should be labeled indicating product name and dated when product was received, and dated when product was opened. Food should be covered completely in the original box to prevent air exposure. Review of the facility's undated policy titled, Frozen Food Storage, revealed refrigerated food should be stored in a manner that ensures food safety, optimum nutrient, and optimum aesthetic quality. All frozen products should be labeled indicating product name and dated when product was received, and dated when product was opened. Food should be covered completely in the original box to prevent air exposure. a. Observation of Freezer 2, on 06/23/2025 at 10:25 AM, revealed sausage patties, pancakes, egg omelets, and biscuits were in their original container/box with flaps opened, and the food items were not covered in the plastic bag and was not dated potentially exposing the foods to air contaminants. Continued observation revealed sausage links out of the original container/box without a label and was undated. Additionally, three bags of diced celery and one bag of green beans were opened and placed into a plastic storage bag but had not been dated. b. Observation of Refrigerator 3, on 06/23/2025 at 10:40 AM, revealed a large clear bag of shredded cheddar cheese out of the original container/box with no open date or expiration date. In an interview with Dietary Aide 1, on 06/24/2025 at 2:00 PM, she stated her general duties included distributing food/snack carts on the units, preparing drinks and desserts in the kitchen, and then passing drinks and desserts during meal times for the dining room. She stated she was also responsible for putting away stock when delivered, and those food items were dated with a received by date before being stored. She stated she was aware that refrigerated and freezer food items stored in their original container / box with an inner plastic bag was tied or sealed and the outer flaps on the box was closed and opened by date was included. She further stated if staff had not followed food safety guidelines to prevent freezer burn and/or contamination, food could be ruined and potentially make residents sick. Additionally, she stated all dietary staff should be checking labels and dates and ensuring food items were sealed and covered, noting she would discard any food items that were stored and undated as there was no certain way to know when it had been opened. In an interview with Dietary Aide2, on 06/24/2025 at 2:10 PM, she stated she had worked in the facility for eleven years. She stated she had generally washed dishes but had helped where needed. She stated any food items that were received would be dated with the received date before being stored. She stated that food items that were left over from the steam table the cook would generally store those items. She stated if she was storing leftovers they would be covered, labeled and dated to ensure it was used within the appropriate time frame. She stated if she had stored any food items in its original container/box in the refrigerator or freezer that had previously been opened, the plastic bag would be covered and the box flaps would be closed and an open date would be marked. Food in the freezer that was not sealed could be freezer burned and would not be suitable for the resident because it would not taste good and would not be safe to serve. She stated any food items in the refrigerator that had been placed in a container or storage bag required a label, the open date and should be covered to prevent contamination. She stated if she found any food items without a date that item would be discarded because no one would know when it was opened or when it should be discarded and she would never serve that food to the residents. In an interview with Dietary Manager (DM), on 06/24/25 at 2:22 PM, she stated worked at the facility for thirty years and started out as a cook then moved into management later on. She stated the dietary aides were given a handbook, and they had access to a policy handbook in the kitchen to refer to if needed. She stated they would have new hires train with a preceptor, then they will get official orientation from the Registered Dietician. The RD instructed on allergies, handwashing, food storage, temps, etc. and were completed monthly. The RD had instructed on the International Dysphagia Diet Standardization Initiative (IDDSI) diet which was used to determine meal textures and consistencies. She stated all dietary staff were responsible for the food storage and labeling. She stated she expected staff to store the food items the proper way, if they are storing leftovers in containers to use small containers, label and date correctly. She stated if the food item was opened, it should be labeled with an opened and expiration date. She stated when new stock was received it had been rotated moving the older products to the front and the new to the back. She further stated food items that were not properly stored and labeled would potentially need to be discarded. Additionally, resident outcomes if the food items had been stored for a long period of time but not dated, may cause sickness for anyone but noted staff were aware not to use undated foods in the facility because the residents could potentially get sick and that was not acceptable. In an interview with the Administrator, on 06/25/2025 at 10:00 AM, she stated her expectations for dietary staff members were to follow the policies and procedures of the facility and guidelines set forth by the Registered Dietitian which were in compliance with the Food and Drug Administration (FDA) food service code and Center for Medicare & Medicaid Services (CMS) regulations. She stated all dietary staff were responsible for the foods stored in the pantry, refrigerator, or freezer to be covered, labeled, and dated properly. Additionally, she stated it was important for dietary staff to follow food safety guidelines in order to avoid foodborne illness noting resident safety and satisfaction was among the facility and staff's greatest concern.

Based on observation, interview, record review, and facility Protocol review, it was determined the facility failed to ensure that one (1) of one (1) residents in the facility with an indwelling urinary catheter (Resident #50) received appropriate treatment and services to prevent urinary tract infections (UTI). Observations on 03/24/2021 revealed Resident #50's urinary catheter drainage bag was on the floor. Observation of State Registered Nursing Assistant (SRNA) #1 at 1:41 PM on 03/24/2021 revealed the SRNA picked the catheter bag up off the floor, moved it closer to the resident, but put it back on the floor without ensuring the catheter bag was maintained off the floor to prevent UTIs. The findings include: Review of the facility policy titled Foley Catheter Protocol, revised 02/04/2014 revealed SRNAs were to check residents with an indwelling catheter every two (2) hours to ensure the catheter bag was maintained off the floor. Record review revealed the facility admitted Resident #50 on 12/03/2020 with diagnoses that included Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms. Review of the admission Minimum Data Set (MDS) Assessment with a reference date of 12/10/2020 revealed the resident had an indwelling urinary catheter on admission. Review of the most recent physician's orders, revealed an order for the indwelling catheter due to the diagnosis of BPH and to utilize a leg drainage bag when the resident was out of bed. Further review of physician's orders revealed a telephone order dated 03/24/2021 that stated the bedside drainage bag could be used when a leg drainage bag was not available. Further review of the record revealed a care plan for the risk of infection related to the use of an indwelling catheter, dated 12/16/2020, revealed interventions to include for the resident to utilize a bedside drainage bag at night and a leg drainage bag while out of bed. The care plan was revised on 03/24/2021 to include an intervention that it was acceptable to utilize the bedside drainage bag temporarily when a leg drainage bag was not available. Further review of the resident's medical record revealed no evidence the resident had experienced a UTI since admission. Observations of Resident #50 on 03/23/2021 at 10:06 AM, 1:20 PM, and 4:50 PM, revealed the resident moved from the chair to the bed independently in the room and was utilizing a urinary leg drainage bag for the indwelling catheter. Observations on 03/24/2021 at 10:45 AM revealed the resident was sitting on the bed with a bedside drainage bag lying on the floor beside the bed. Further observation of Resident #50 on 03/24/2021 at 12:05 PM revealed the resident was sitting in a chair at the counter in his/her room with the bedside drainage bag hanging on the chair. At 1:28 PM on 03/24/2021, Resident #50 was feeding him/herself lunch with the urinary catheter drainage bag noted lying on the floor next to the chair. On 03/24/2021 at 1:39 PM, Resident #50 transferred himself/herself from the chair back to the bed with the catheter bag remaining on the floor. SRNA #1 was observed to enter the resident's room at 1:41 PM, clean the resident's face, and pick up the catheter drainage bag and move it closer to the bed; but put the catheter drainage bag back on the floor. SRNA #1 then took the resident's lunch tray and left the room. At 1:46 PM on 03/24/2021, SRNA #2 entered Resident #50's room and picked the catheter drainage bag up off the floor and hung it on the bed frame. Observation of Resident #50 on 3/24/2021 at 4:40 PM revealed the resident was utilizing a leg bag instead of the bedside drainage bag. Interview with SRNA #2, on 03/24/2021 at 1:50 PM revealed she noticed Resident #50's catheter bag on the floor and picked it up because catheter bags are not to be left on the floor. She further stated that she had asked about the leg drainage bag for Resident #50 and was told that there were no leg bags available that day and that was why the resident did not have a leg bag in place. Interview with SRNA #1, on 03/24/2021 at 2:01 PM revealed she was the SRNA assigned for Resident #50 that day. She stated when she entered Resident #50's room and saw the urinary drainage bag lying on the floor, she forgot to move it off the floor because Resident #50 usually had a leg drainage bag and she just didn't think about it. She stated when she got Resident #50 up this morning, she could not find a leg drainage bag and reported it to the nurse. Interview with Licensed Practical Nurse (LPN) #1 on 03/24/2021 at 4:40 PM revealed SRNA #1 reported to her that they did not have a leg urinary drainage bag for Resident #50 that morning. She stated she spoke with the supply person and they got one as soon as possible. LPN #1 stated that all staff were trained to maintain catheter bags off the floor to prevent urinary tract infections. Interview with the Director of Nursing (DON), on 03/26/2021 at 9:54 AM revealed the facility expected all staff to ensure catheter bags were maintained off the floor due to the risk for infection if a catheter bag was on the floor. The DON further stated that care audits were done on a daily basis through daily rounds and she had not identified this to be a concern.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions. Observation of two (2) of four (4) medication carts revealed one (1) cart had 2 boxes of expired medications. The findings include: Review of the facility policy titled. Medication Storage, dated 08/17/2017, revealed medications will be dated at time of opening as appropriate (ie. Insulin, TB Solution, etc.). Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, unlabeled or without secure closures are immediately removed from stock, and disposed of according to procedures for medication destruction and reordered from the pharmacy if a current order exists. Observation of Medication Cart #1 on 03/25/2021 at 11:15 AM, revealed the following expired medications: Resident #45 - Colace 100 milligrams (mg) capsules - fourteen (14) capsules with an expiration date of 06/27/2020. Resident #22 - Colace 100 mg capsules - twenty-seven (27) capsules with an expiration date of 10/29/2020. Interview with Director of Nursing (DON) on 3/25/2021 at 11:15 AM revealed she expected nurses and medication techs to check the carts daily and remove any expired medications. The DON further stated she and the Assistant Director of Nursing (ADON) randomly checked carts but revealed she had no documentation of audits. She revealed Pharmacy typically completed monthly reviews but had not been in the building since the pandemic started

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain sanitary conditions related to dirty, soiled kitchen floors. Observation revealed the kitchen floor was not clean with black soiled marks on the floor as the base of the entrance doorway; and, black areas and dust particles to the floor to the left of the steam table and beside the hot water heater. The findings include: Review of facility policy titled, Food preparation and Handling, not dated, revealed the kitchen and equipment are to be clean and the kitchen to be neat and orderly. Observation of the kitchen floor, on 03/23/2021 at 12:14 PM, revealed there were black, soiled marks on the floors at the entrance door to the kitchen at the bottom where the door frame meets the door at the floor. In addition, there were black areas to various areas of flooring in the kitchen to include to the left of the steam table which also had dust particles, and was beside the hot water tank. Interview with the Dietary Director, on 03/25/21 at 2:15 PM revealed the kitchen floors were cleaned every night. She stated she was not aware of the soiled floor to the left of the steam table nor at the base of the entry door to the kitchen. Interview with the Administrator on 03/25/2021 at 3:30 PM revealed she was aware of the concerns regarding the floors in the kitchen.