**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, it was determined the facility failed to store food in a safe and sanitary manner. Observation on 02/25/2025 at 8:50 AM and 02/26/25 2:49 PM, revealed the walk-in freezer had frost and ice accumulated throughout and food particles located on the freezer's floor, which had the potential to affect all residents consuming foods stored there. The findings include: Review of the facility policy titled, Food Storage: Cold Foods, revised 04/01/2018, revealed All Time and Temperature Control for Safety (TCS) foods, frozen and refrigerated, were to be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further policy review revealed all foods were to be wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation of the facility's walk-in freezer on 02/25/2025 at 8:50 AM, revealed it had large piles of frost and ice accumulation throughout the freezer. Further observation revealed food particles lying on the floor of the walk-in freezer. Observation of the facility's walk-in freezer on 02/26/25 at 2:49 PM, revealed the large piles of frost and ice accumulation continued to be present throughout the freezer. Observation additionally revealed the food particles continued to be present lying on the floor of the walk-in freezer. In interview on 02/27/2025 at 8:30 AM, [NAME] 1 stated she had worked at the facility a little over a year. She said she performed other duties such as cleaning, sanitizing dishwashing, as well as, cooking and followed a cleaning schedule. [NAME] 1 reported once the schedule had been completed she turned it into her manager. She stated the cleaning of the walk-in freezer and cooler was done by the kitchen manager and she was not responsible for that task unless it was assigned to her. During interview on 02/25/2025 at 8:50 AM, the Dietary Accounts Manager stated the walk-in freezer had been malfunctioning, and a work order had been placed on Saturday, (02/22/2025). She stated there was nothing they could do to stop the accumulation of the ice in the walk-in, and she was in the process of trying to tidy things up when the State Survey Agency (SSA) Surveyor arrived to inspect the kitchen. The Dietary Accounts Manager reported the walk-in freezer and cooler were scheduled to be cleaned weekly and she was the staff member responsible for cleaning it. She further stated if she ran into a problem with her schedule she assigned the task of cleaning the walk-in freezer and cooler to someone else. During interview with the Regional Dietary Accounts Manager (RDAM) on 02/26/2025 at 2:49 PM, she stated they used a chemical cleaner to get the ice up and that cleaner was specially formulated to not freeze. She said using that chemical cleaner must be done on a regular basis to keep it from allowing ice to build up. The RDAM reported they had been trying to clean the walk-in freezer at least once a week; however, she thought the dietary manger had gotten behind because of being short staffed a couple of days. She said her expectations were for the walk-in freezer to be cleaned at a minimum of once a week for a detailed cleaning. The RDAM explained at that time the problem with the walk-in freezer was that outside air was getting inside and was causing excessive moisture to buildup. She stated a technician from a local service repair company came out and looked at it, then followed up with them on Monday regarding the freezer. The RDAM additionally said the local service repair company's technician let them know the walk-in freezer was beyond repair and the facility planned to replace the freezer. In interview with the facility's Maintenance Director on 02/26/2025 at 4:17 PM, he stated he had been informed on Friday about the walk-in freezer. He said he had someone come out that day to look at the walk-in freezer. The Maintenance Director reported they had another freezer that was next to it they could use if needed. He stated he believed they were now waiting on a part to fix the freezer's issue. The Maintenance Director said he thought air was coming in but he was not for sure. He explained the service technician was supposed to schedule a time when they would come back and fix the walk-in freezer. The Maintenance Director reported he could not recall who came out to look at the freezer. He further stated the normal protocol for was to report to the Administrator his issue before he could get someone else to come and fix freezer issues. In interview with the Registered Dietician (RD) on 02/27/2025 at 8:23 AM, she stated she came to the facility at least one to two days a week and performed a monthly sanitation audit of the kitchen. She stated she last performed the sanitation audit on Friday (02/21/2025) and found nothing unusual during her audit. The RD said the food appeared good, and the floors of the walk-in freezer were just slick and hard to get around on due to the excess moisture that was coming in. She reported the walk-in freezer issue had been an ongoing problem they had been dealing with. The RD stated the Dietary Accounts Manager had been coming in and sweeping out the excess ice and frost accumulation in the walk-in freezer from time to time; however, it just came back so fast it was hard to keep up with. She explained when she was at the facility on Friday and did the sanitary audit she had not seen any food or excess ice on the walk-in freezer floor at that time. The RD said if she had seen the freezer in its current state she would be providing ongoing education with the staff on cleaning and keeping the excess frost and ice swept up. She stated she felt there was not much else they could really do to properly address the situation with the walk-in freezer now as they could not keep the large amount of frost and ice from accumulating inside. The RD additionally stated her expectations were for dietary staff to do more frequent sweeping inside the walk-in freezer, but even then she was not still sure that would help with the issue. In interview with the Service Manager for the contracted Repair Services Company on 02/27/2025 at 9:14 AM, he stated he had been contacted and came out to the facility last week on 02/21/2025. He reported he found large amounts of ice building up because of there being a large amount of outside air coming into the freezer due to the seals and gaskets being compromised. The Service Manager said that caused water to get in between the foam panels and that those panels were most likely full of water. He stated the freezer had probably been doing that for a long time as the freezer was about [AGE] year. The Service Manager reported the seals and gaskets wore out and start going bad after about 10-15 years of usage and start losing their effectiveness. He explained in his opinion the amount of ice inside the walk-in freezer had taken weeks to accumulate that much in there. The Service Manager said, unless there had been a large amount of water inside or a leak of some sort which could have caused that much ice accumulation to be observed in the freezer. He reported if it was just humidity coming in from outside air, that would take a long time for the ice to accumulate the way it had in the freezer. The Service Manager stated in his opinion he thought the ice had to have been there awhile. He also stated he had service men coming back out to the facility today to take measurements for the new freezer that was to be ordered to replace the current one. In interview with the Administrator on 02/27/2025 at 8:00 AM, he stated he would consider the ice accumulation away from the food since it was mainly on the floor and that it posed no risk to the food stored in it at that point. He explained if the ice was accumulating on the food, then he would have it removed and replaced and would use the emergency food supply in the meantime until the replacement food got here. The Administrator further stated his expectations was for the excess ice to be swept out daily, but since it was located on the floor it should be okay.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with the manufacturer's specifications, and accepted professional nursing principles and practices for one (1) of four (4) medication carts audited out of a total of seven (7) medication carts. Observation on 05/24/2024 at 9:40 AM, of the medication cart (Cart 1) that serviced rooms #15-27 on The City hall, revealed seven (7) cards of medications were beyond the expiration date printed on the label as well as the beyond use date identified on the affixed pharmacy-generated label. This affected Residents (R3), R23, R36 and R91. The findings include: Review of the facility's policy titled, Medication Administration, General Guidelines, dated 09/2018, revealed medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices. Further review revealed the person administering the medication is to, check expiration date on package/container. No expired medications will be administered to a resident. Additional guidelines included, the beyond use dating, which only lists month/year, fall to the last day of the month. Observation on 05/24/2024 at 9:40 AM, of the medication cart (Cart 1) that serviced rooms #15-27 on The City hall, revealed seven (7) cards of medications were beyond the expiration date printed on the label as well as the beyond use date identified on the affixed pharmacy-generated label. The expired medications prescribed to R3, R23, R36 and R91 included the following: Resident (R3) Pantoprazole 20 mg tablets (medication used to treat gastroesophageal reflux disease) expired 03/15/2024 with eight (8) tablets remaining. R23 Meclizine 12.5 mg tablets (antihistamine) expired 04/18/2024 with 25 tablets remaining. Amlodipine 2.5 mg tablets (medication used to treat high blood pressure) expired 05/15/2024 with 25 tablets remaining. R36 Olanzapine 2.5 milligrams (mg) half tablets (antipsychotic) expired 03/14/2024 with 27 tablets remaining. Olanzapine 2.5 mg half tablets expired 04/24/2024 with 30 tablets remaining. R 91 Cetirizine 5 mg tablets (antihistamine) expired 02/28/2024 with 1 tablet remaining. Vitamin D3 50 microgram tablets expired 03/16/2024 with seven (7) tablets remaining. During an interview on 05/24/2024 at 9:40 AM, with Licensed Practical Nurse (LPN) 3, she stated she was not usually on this medication cart, but was assigned to it this day. LPN3 further stated the nurses assigned to the medication cart should check the expiration dates of the medications and remove them if expired. In continued interview, she stated the contracted pharmacy checked for expired medications, but she was unsure of how often pharmacy completed this audit. In an interview with the Assistant Director of Nursing (ADON), on 05/29/2024 at 4:25 PM, she stated it was her expectation medications be removed from the medication cart if expired or discontinued, by the nurses assigned to the carts. The ADON further stated she audited the medication carts as often as every two (2) weeks, monthly, and as needed. In an interview with the Director of Nursing (DON), on 05/29/2024 at 3:06 PM, she stated a representative from the pharmacy checked the medication carts and medication storage monthly. She stated the pharmacy representative tried to get to the facility early enough to check all medication carts and was at the facility just last week. The DON further stated it was her expectation the floor nurses assigned to the medication carts would pull the medication from the cart if it was discontinued or expired. Further, she stated she expected the pharmacy medication cart audits to catch any expired medications.

Based on observation, interview, review of facility policy, and review of the Kentucky Food Guide 2013 Food Code guidance, it was determined the facility failed to provide foods at a safe and appetizing temperature on 05/24/2024 for the noon meal, to the residents of Serenity Hall. Observation on 05/24/2024 at 12:09 PM, revealed during kitchen tray line for Serenity Hall, the cole slaw, cucumber salad and banana pudding was left out sitting on a tray, and was not placed in an ice bath. Following the completion of the tray line for Serenity Hall, at 12:25 PM, the State Surveyor requested a temperature check on all foods on the tray line and the following temperatures were observed: coleslaw, seven (7) servings at 61 degrees Fahrenheit (F); cucumber and onion salad, two (2) servings at 66 degrees F, and banana pudding 15 servings at 71 degrees F. The findings include: Review of facility policy titled Food Preparation, dated 02/2023, revealed all foods would be prepared in accordance with the Food and Drug Administration (FDA) food code. Continued review revealed all foods will be held at appropriate temperatures of less than 41 degrees Fahrenheit (F) for cold food holding. Review of the Kentucky Food Guide 2013 Food Code, revealed cold foods should be held at 41 degrees F or less. Review of the Service Line Checklist, dated 05/24/2024, revealed temperatures for all hot and cold foods should be taken prior to service and recorded. Temperature of cold food should be at or less than 41 degrees F. Continued review of the Checklist recorded temperatures for the 05/24/2024 noon meal prior to serving, revealed the coleslaw was 33 degrees F, cucumber and onion salad was 36 degrees F and the banana pudding was 35 degrees. Observation on 05/24/2024 at 12:09 PM, revealed during tray line for Serenity Hall, the cole slaw, cucumber salad and banana pudding was left out sitting on a tray, and was not placed in an ice bath. Following the completion of the tray line for Serenity Hall, on 05/24/2024 at 12:25 PM, the State Surveyor requested a temperature check on all foods on the tray line and the following temperatures were observed: coleslaw, seven (7) servings at 61 degrees F; cucumber and onion salad, two (2) servings, at 66 degrees F; and banana pudding 15 servings at 71 degrees F. During an interview with the Dietary Manager on 05/24/2024 at 12:27 PM, she stated the cold foods should be held at 41 degrees F. The Dietary Manager who was assisting with tray line proceeded to replace the coleslaw, salad and pudding and placed these food items in an ice bath. In a follow up interview with the Dietary Manager, on 05/24/2024 at 5:08 PM, she stated the banana pudding was canned and was refrigerated prior to the noon meal being served. She further stated she could not speak to the food temperatures during tray line and the State Surveyor would need to speak to the cook. In an interview with the Dietary Cook, on 05/24/2024 at 5:24 PM, she stated the dining cart for Serenity Hall was the fourth cart that left the kitchen. She stated the trays of pudding, coleslaw and salad were not placed in an ice bath prior to serving. She further stated dietary staff typically used an ice bath for cold food, but they were in a rush because a staff member had to leave due to a family emergency. The Dietary [NAME] stated the banana pudding was canned and they added bananas to the regular diet. She further stated she could not recall what the tray line food temperatures were prior to serving the noon meal. The State Surveyor shared that the recorded temperature for the banana pudding was 35 degrees Fahrenheit (F), the coleslaw was 33 degrees F, and the cucumber and onion salad was 36 degrees F. The cook stated based on those temperatures she would assume the food items had been in the cooler prior to her taking the temperatures. The Dietary [NAME] stated the temperatures taken of the cold foods following the completion of the tray line for Serenity Hall were not at a safe temperature and residents could potentially become sick if foods were not kept at safe temperatures. During an interview with the Director of Nursing (DON), on 05/24/2024 at 4:32 PM, she stated she expected kitchen staff to check food temperatures before and while serving food. She stated the cold foods at the noon meal tray line maybe should have been placed in an ice bath. She further stated she could not provide an answer for potential outcomes if food was served at inappropriate temperatures as she really could not answer a hypothetical question. During an interview with the Administrator, on 05/24/24 at 4:40 PM, he stated he expected cold foods to be kept cold. He stated the food code mentioned food should be palatable and served at a safe temperature.