Based on observation, interview, and review of facility policy, the facility failed to store food in accordance with professional standards for food service safety. Observation revealed refrigerated foods were not dated, labeled, and/or discarded in a timely manner. Those failures had the potential to affect 86 of 87 residents in the facility who consumed food from the kitchen. The findings include: Review of the facility policy, Food Storage, Cold Foods, revised 02/2023, revealed, all Time Temperature Control (TCS) for safety foods, frozen and refrigerated, would be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further review revealed all foods were to be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination. Review of the facility's, Food Storage and Retention Guide, dated 2017, revealed, ready to eat prepared foods, such as leftovers, deli salads, and cut produce, when refrigerated at 41 degrees Fahrenheit (F) or less was good up to seven days and poultry or seafood, once thawed, was one-two (1-2) days. Observation on 02/12/2025 at 10:27 AM, during the initial kitchen tour with the Certified Dietary Manager (CDM), revealed two large ziploc bags of raw chicken breasts stored in a container that was dated 02/07/2025; one large bag of chopped meat that the CDM identified as chicken, not sealed with no label or date; and a large bag of deli meat (ham), dated 01/31/2025 with a use by date of 02/07/2025. Continued observation of the freezer revealed a ziploc bag with seven frozen hamburger patties that were not not labeled or dated. Further observation of an upright freezer revealed it contained a plastic bag labeled italian sausage that was dated 10/01/2024. In interview with the CDM and the Dietary District Manager on 02/14/2025 at 8:41 AM, the CDM stated the process for labeling stored foods was items were to have a label identifying what the item was, an opened date and a use by date. She stated foods could be dated for seven days. The CDM said she expected staff to label and date all food items before placing them in the coolers. She reported all staff were responsible for labeling and dating items as well as checking the coolers. The CDM further stated outcomes for residents eating out of date or expired foods could be be nausea and vomiting. In interview with the Director of Nursing (DON) and the Administrator on 02/14/2025 at 1:09 PM, the DON stated her expectations for the kitchen was for them to follow their guidelines for labeling and dating food items. She stated an outcome for residents was they could become sick with stomach issues. The Administrator stated he did not have any different expectation than the DON.

Based on interview, record review and review of the facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for one (1) of nineteen (19) sampled residents (Resident #43), and one (1) resident not in the selected sample (Resident #77). Record review for Resident #43 and Resident #77, revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of resident transfers. The finding include: Review of the facility policy titled, Transfer/Discharge Notice, last reviewed 12/06/16, revealed before the transfer or discharge occurs, the facility will notify the resident and, the resident's representative of the transfer or discharge and the reasons for the move in writing in a language and manner they understand. Send a copy of the transfer or discharge notice to a representative of the Office of the State Long Term Care Ombudsman. The facility's notice will include an explanation of the right of appeal to transfer to the State as well as the name, address, and phone number of the State Long-Term Care Ombudsman, and the facility will send a copy of the transfer or discharge notice to a representative of the State Long-Term Care Ombudsman. According to 42 CFR 483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. 1. Record review revealed the facility admitted Resident #43 on 10/25/13 with diagnoses which included Encephalopathy, Alzheimer's Disease, Transient alterations of awareness, Ataxia, Urinary Tract Infections, Parkinson's Disease, Major Depression, Anxiety Disorder, and Type two (2) Diabetes. Review of a Physician Order dated 06/12/18, revealed to send to emergency room (ER) for evaluation and treatment. However; further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the local hospital. 2. Record review revealed the facility admitted Resident #77 on 02/25/18, with diagnoses which included Ataxia, Anxiety Disorder, and Type Two Diabetes. Review of a Physician Order dated 05/10/18, revealed Resident #77 was to be discharged home with Home Health to follow up. However; further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the local hospital. Interview with the Business Office Manager (BOM) on 08/08/18 at 3:55 PM, revealed she was not aware she was required to notify a representative of the State Ombudsman office when a resident was transferred out of the facility. She stated she only notified a representative of the State Ombudsman office when they have involuntary discharges. Interview with the facility Administrator on 08/08/18 at 4:00 PM, revealed he was not aware the facility was to notify a representative of the Office of the State Long-Term Care Ombudsman office when a resident was transferred out. He was only aware the facility needed to make a representative of the State Ombudsman office aware of all involuntary discharges. He revealed he had recently had a conversation with the local Ombudsman regarding involuntary discharge notifications, and the local Ombudsman informed him she did not want a notification after every single involuntary discharge just to keep a list of the involuntary discharges and send the list of involuntary discharges to her periodically. Further interview at 4:49 PM, revealed after reading the interpretative guidance of F-623 and after our discussion regarding the new regulation, he did see that the Ombudsman's office was to be notified of all discharges, and not just involuntary discharges.

Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure medication administration met professional standards of quality for one (1) of nineteen (19) sampled residents (Resident #10). Observation on 08/07/18 of a medication cart revealed a syringe containing a dose of reconstituted Risperdal Consta that had not been administered. The findings include: Review of the facility policy, Medication Administration General Guidelines, last revised May 2016, revealed medications are to be administered at the time they are prepared and medications are administered in accordance with written orders of the prescriber. Further review of the policy revealed medications are administered within sixty (60) minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Record review revealed the facility admitted Resident #10 on 06/18/16, with diagnoses which included Major Depressive Disorder and other recurrent Depressive Disorders. Review of Resident #10's Physicians Orders dated August 2018, revealed an order for Risperdal Consta 25 mg syringe to be given intramuscularly every two (2) weeks at 9:00 AM . Observation of a medication care on A Hall, on 08/08/18 at 2:15 PM, revealed a syringe of reconstituted Risperdal Consta 25 milligram (MG) in the top drawer for Resident #10. Interview with Licensed Practical Nurse (LPN) #1 on 08/07/18 at 2:15 PM, revealed the resident should have received the injection earlier but was gone to Bingo and she did not want to interrupt the resident in activities. She stated medications are to be given an hour before or an hour after and she should have administered when the medication was prepared. Interview with the Pharmacist on 08/09/18 at 8:59 AM, revealed according to the manufacturers guidelines as long as Risperdal Consta is given within six (6) hours of reconstitution, there are no known effects. Interview with the Director of Nursing (DON) on 08/09/18 at 2:18 PM, revealed she expected the medications to be given as ordered and an hour before/after the scheduled time.

Based on observation, interview and review of the facility policy and procedure, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Dietary Aide #1 was observed touching his clothing and not washing his hands during the meal service. Review of the Census and Condition dated 08/07/18 revealed seventy-six (76) of seventy-six (76) residents received their food from the kitchen. The findings include: Review of the facility policy and procedure titled, Handwashing and Glove Use, last revised February 2014, revealed guidelines for handwashing and glove use are used to promote safe and sanitary conditions throughout the dietary department. Further review of the policy revealed employees should wash their hands following contact with any unsanitary surface i.e touching hair, sneezing, opening doors, etc Observation of a lunch meal, on 08/07/18 at 11:30 AM , revealed Dietary Aide #1 touched and pulled up his pants, with ungloved hands, then touched clean plates and towels and placed food into the clean dishes. Continued observation revealed he did not wash his hands after touching his clothing and prior to touching the clean dishes. Interview with Dietary Aide #1 on 8/08/18 at 9:30 AM, revealed he knew he should have washed his hands after touching his clothing and prior to touching clean plates because his hands were considered soiled after touching contaminated items. Interview with the Dietary Manager on 08/08/18 at 9:23 AM, revealed if staff's hands become contaminated by touching unclean objects such as their clothes, they should wash their hands prior to touching clean items such as plates during meal service.