Based on observation, interview, and facility policy review, it was determined the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect sixteen (16) of sixteen (16) residents residing in the facility. Observations, during initial tour of the kitchen on 10/03/2023, revealed three (3) food items which were not labeled or dated after being removed from their original container; a five (5) pound bag of okra, a five (5) pound bag of chicken, and a five (5) pound bag of potato wedges. The findings include: Review of the facility's policy, Food and Supply Storage, last revised 01/2023, revealed all food items were to be stored in a manner to maintain the safety and wholesomeness of the food for human consumption. Continued review of the policy revealed staff were to cover, label and date unused portions and open packages. Observation, on 10/03/2023 at 12:57 PM, during the kitchen tour revealed a 5 pound bag of Okra that had been received as part of a box of four (4) 5 pound bags on 09/11/2023, a 5 pound bag of chicken was received in a box of two (2) 5 pound bags on 09/28/2023, and a 5 pound bag of potato wedges received in a box of six (6) five pound bags on 09/15/2023. However, the food items were not dated when removed from their original package. In an interview with the Executive Chef on 10/04/23 at 12:52 PM, he stated when freezer items were removed from their original package, items were to be labeled, dated, and discarded if not used within three months. In an interview on 10/04/23 at 9:00 AM with the Interim Director Food Service (IDFS), she stated all three identified food items were outside of their original containers. She stated if a food item was pulled from it's original box, it needed to stay with the box, or was to be labeled indicating an expiration date. The IDFS stated she expected any unused food portions to be labeled on returned to the freezer with identifying information with a use by date. She stated it was important to identify an expiration date on food items, as the danger would be items could be pulled after their expiration date. In an interview with the Administrator on 10/05/23 at 10:16 AM, she stated she expected all food items to be dated with an expiration date and an opened date. She stated she would expect that everything have a date, and staff to routinely go through those items and discard expired items. The Administrator further stated not knowing if a food item is expired could present a danger.

Based on observation, interview, review of the facility's policy, and review of the Centers for Disease Control and Prevention (CDC) Guidelines, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases, including Coronavirus Disease (COVID-19). Upon arriving to the Transitional Care Unit, on 06/14/2022 at 6:15 AM, Certified Nursing Assistant (CNA) #1 opened the door, and failed to screen three (3) State Surveyors prior to the Surveyors entering the unit. Observation at the time, revealed a visitor log at the entrance and signage posted stating the unit followed CDC guidelines and all visitors must be screened. Further, Life Safety Code (LSC) Surveyors were not screened upon arriving to the Transitional Care Unit entrance on 06/14/2022 at 10:30 AM. The findings include: Review of the memo titled, The Transitional Care Center Notice to Residents' Representatives and Family Members, revealed the facility was following guidance from the Centers for Disease Control (CDC) and Center for Medicare and Medicaid Services (CMS) to reduce the spread and impact of COVID-19, such as: Screening residents, staff, and visitors for symptoms. Review of the Transitional Care Center Visitor Screening form, dated 03/29/2020, revealed visitors were to complete the form and answer several questions related to signs and symptoms of COVID-19. Observation on 06/14/2022 at 6:15 AM, upon arrival to the Transitional Care Unit, revealed Certified Nursing Assistant (CNA) #1 opened the door, and failed to screen three (3) State Surveyors prior to the Surveyors entering the unit. Further observation upon entering the unit, revealed a visitor log at the entrance and signage posted stating the unit followed CDC guidelines and all visitors must be screened. Observation on 06/14/2022 at 10:30 AM, by the Life Safety Code Surveyors, revealed upon arrival to the Transitional Care Unit, they were not screened at the unit entrance. LSC Surveyor #1 revealed Guest Relations (Greeter) #1 informed him state surveyors did not have to be screened. Interview with Greeter #1, on 06/14/2022 at 10:39 AM, revealed all visitors were to be screened when visiting the unit. Per interview, visitors filled out a symptom sheet and had their temperatures taken. However, Greeter #1 confirmed she did inform Life Safety Surveyors the state surveyors did not have to be screened. Interview with Greeter #2, on 06/14/2022 at 10:42 AM, revealed everyone was to be screened upon entering the unit. She further revealed state surveyors should have been screened upon entering. Interview with Certified Nursing Assistant (CNA) #1, on 06/15/2022 at 9:50 AM, revealed visitors should be screened by staff when entering the unit. She stated, on 06/14/2022 she failed to screen surveyors upon entry to the unit. She stated failure to screen visitors could lead to COVID positive staff or residents. Interview with Licensed Practical Nurse (LPN) #1, on 06/15/2022 ay 9:07 AM, revealed staff and visitors were to be screened prior to entering the unit. She stated different forms were used for staff and visitors to complete and anyone entering the unit had to have their temperature taken. Interview with Registered Nurse (RN) #1, on 06/15/2022 at 10:05 AM, revealed all staff and visitors were to be screened when entering the unit. She stated staff and visitors were to review and sign a questionnaire form and have their temperatures taken. Interview with Manager of Nursing #1/Director of Nursing (DON), and Manager of Nursing #2, who was in training, on 06/16/2022 at 10:30 AM, revealed it was their expectation that all staff and visitors entering the unit be screened by the Greeter or a staff member. They revealed failure to screen could lead to residents or staff being exposed to COVID 19. Further interview revealed the Infection Preventionist for the Transitional Care Unit had resigned and therefore was unavailable for interview.