**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) for four cognitively impaired residents (Resident #11, #36, #39 and #41) after unwitnessed falls. The facility census was 51. 1. Review of the facility's policies showed staff did not provide a post fall policy for cognitively impaired residents. Review of the facility's Neurological Assessment Flow Sheet, showed neurological assessments are to be completed as followed: -Every 15 minutes for four times; -Every 30 minutes for two times; -Every 1 hour for two times; -Every 2 hours for two times; -Every 4 hours for two times; -Every 8 hours for four times. 2. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/12/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent with transfers, and toileting; -Has had two or more falls since admission, one fall with major injury; -Diagnosis of Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Review of the resident's nurse's notes, showed staff documented: -09/22/23 at 5:32 A.M., the resident had an unwitnessed fall; -09/30/23 at 9:10 A.M., the resident had an unwitnessed fall; -11/13/23 at 4:50 A.M., the resident had an unwitnessed fall. Review of the resident's medical record showed staff did not document a complete neurological assessment or document the continuous monitoring of the resident for 72 hours following the incident for the three unwitnessed falls. 3. Review of Resident #36's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Has had a fall with injury since admission; -Diagnosis of cerebral palsy (congenital disorder of movement, muscle tone, or posture, resulting in exaggerated reflexes, floppy or rigid limbs, and involuntary motions), epilepsy (a disorder of the brain characterized by repeated seizures), and intellectual disabilities (a term used when a person has certain limitations in cognitive functioning and skills, including conceptual, social and practical skills, such as language, social and self-care skills). Review of the resident's nurse's notes, showed staff documented the following: -08/27/23 at 4:11 A.M., the resident had an unwitnessed fall; -08/21/23 at 1:41 P.M., the resident had an unwitnessed fall; -09/07/23 at 1:28 A.M., the resident had an unwitnessed fall; -09/10/23 at 7:11 P.M., the resident had an unwitnessed fall; -10/20/23 at 11:00 A.M., the resident had an unwitnessed fall. Review of the resident's medical record showed staff did not document a complete neurological assessment or document the continuous monitoring of the resident for 72 hours following the incident for the five unwitnessed falls. During an interview on 02/16/24 at 11:08 A.M., the Assistant Director of Nursing (ADON)/Charge nurse said the resident has some cognitive deficit and might be a good historian post fall if asked right away if he/she was hurt. He/She said if the resident were asked 20-30 minutes later he/she would not be reliable. 4. Review of Resident #39's discharge MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Has had a fall with injury since admission; -Diagnosis of Ischemic stroke (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and dementia. Review of the resident's nurse's notes showed staff documented the following: -10/18/23 at 06:56 A.M., the resident had an unwitnessed fall; -12/21/23 at 09:47 P.M., the resident had an unwitnessed fall; -01/21/24 at 07:10 A.M., the resident had an unwitnessed fall. Review of the resident's nursing notes, dated 01/02/24, showed the resident had an Xray of his/her pelvis and bilateral hips and transferred to the hospital for an acute right hip fracture from the fall on 12/21/23. Review of the resident's medical record showed staff did not document a complete neurological assessment or document the continuous monitoring of the resident for 72 hours following the incident for the three unwitnessed falls. During an interview on 02/16/24 at 11:08 A.M., the ADON/Charge nurse said the resident is not cognitive enough to be reliable about events. He/She said he/she would initiate neuros if he/she had a fall. 5. Review of Resident #41's significant change MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Diagnosis of dementia, Hemiplegia (paralysis of on side of the body), and stroke (Damage to the brain from interruption of its blood supply). Review of the resident's nurse's notes showed staff documented the following: -08/13/23 at 4:26 P.M., the resident had an unwitnessed fall; -09/15/23 at 5:30 P.M., the resident had an unwitnessed fall; -12/11/23 at 6:14 A.M., the resident had an unwitnessed fall, found with head and neck on the pedals of his/her wheelchair, pupils were slow to respond and had complaints of neck and lower back pain, Resident was sent out to the hospital and returned at 12:30P.M.; -02/09/24 at 1:24 A.M., the resident had an unwitnessed fall. Review of the resident's medical record showed staff did not document a complete neurological assessment or document the continuous monitoring of the resident for 72 hours following the incident for the four unwitnessed falls. During an interview on 02/16/24 at 11:08 A.M., the ADON/Charge nurse said he/she would not consider this resident to be cognitive enough to recall if he/she hit his/her head. He/She said the resident has been getting more and more confused over the last 6 months. 6. During an interview on 02/16/24 at 11:08 A.M., the ADON/Charge nurse said basic falls require monitoring for 3 days post fall. He/She said that includes a full set of vital signs, including blood pressure, heart rate, pulse, respirations, oxygen saturation, temperature and pain, and general assessment. He/She said if the resident experienced any injury staff are expected to do a focused assessment on injury and if they hit their head then they also do neurological exams for the three days. He/She said when a fall occurs, they always call the family or responsible party and make sure they do not want the resident sent to the hospital for further evaluation. He/She said they notify the physician and verify there are no further orders needed. He/She said if they are a resident who is not cognitive, he/she likes to monitor them through his/her shift because resident who are not cognitive maybe be unsure of events and some may not even know they hit the floor. During an interview on 02/16/24 at 11:23 A.M., the DON said his/her expectation is that when a resident has fallen the charge nurse assessed the resident from head to toe, looking for any signs of broken skin, bones, or trauma, provides any first aide that is needed, and does a complete set of vitals including pain level. He/She said if the resident denies hitting his or her head and neuros are not warranted, based off of the nurse's assessment, then the resident is on a post fall assessment for 72 hours. If the resident shows signs of trauma to the head or neck and/or if the resident says they hit their head or was witnessed hitting their head, then the resident gets neuros and a post fall assessment for 72 hours. He/She said for residents who are not cognitive or reliable historians, the need for obtaining neurological exams is based off of nursing assessments. During an interview on 02/16/24 at 11:36 A.M., the administrator said his/her expectation post fall is that staff ensure the resident is safe for assessments, that they treat according to the type of injury, and follow nurse protocols and policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments for the use of bed rails for five residents (Resident #3, #6, #7, #27 and #30). The facility census was 51. 1. Review of facility's policies showed staff did not provide a bed rail policy. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/05/23, showed staff assessed the resident as: -Cognitively intact; -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's electronic medical record (EMR), showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/13/24 at 10:40 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/14/24 at 9:23 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/16/24 at 9:15 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. 3. Review of Resident #6's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of multiple sclerosis (A disease in which the immune system eats away at the protective covering of nerves resulting in nerve damage disrupts communication between the brain and the body); -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's EMR, showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/15/24 at 11:25 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/15/24 at 5:30 P.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/16/24 at 9:13 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. 4. Review of Resident #7's admission MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of stroke (Damage to the brain from interruption of its blood supply); -Required partial assistance for lying to sitting, sitting to lying, and rolling left to right; -Bed rails not used. Review of the resident's EMR showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/15/24 at 11:11 A.M., showed the resident's had bilateral bed rails in the upright position. Observation on 02/16/24 at 9:30 A.M., showed the resident in bed with bilateral bed rails in the upright position. 5. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of heart failure; -Required full dependence for assistance with sit to stand, lying to sitting, sitting to lying, and rolling left to right; -Bed rails not used. Review of the resident's EMR, showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/14/24 at 3:49 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/15/24 at 9:30 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/16/24 at 9:18 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. 6. Review of Resident #30's Significant change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease); -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's EMR, showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/13/24 at 11:32 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/15/24 at 11:36 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. Observation on 02/16/24 at 9:12 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. 7. During an interview on 02/16/24 at 10:55 A.M., the Assistant Maintenance Director said he only knows when to do entrapment assessments when told to do them by the Maintenance Director. He/She said he/she is unsure when or how often the assessment are to be done. During an interview on 02/16/24 at 11:08 A.M., Assistant director of nursing said residents must go through therapy to be evaluated to ensure the assistive bars are safe for the resident's mobility. He/She said once assessed and approved the Director of nursing (DON) obtains handles the rest. He/She is not sure of the process after that point. During an interview on 01/16/24 at 11:23 A.M., the Director of Nursing (DON) said if staff feel a resident can benefit from assistive bars therapy does an assessment and evaluates if a resident can safely use the bars for mobility. He/She said if the resident is approved by therapy, they fill an approval form and give it to him/her. He/She said after receiving the form he/she goes in and assesses the resident, puts a request for maintenance to put the bars on the bed in the TELS (a system used for maintenance that keeps track of their work orders and due dates) system and obtains an order from the physician to put in the resident's EMR. He/She is not sure how often maintenance does entrapment assessments. He/She knows he/she does do them when he/she installs the rails and if there is a change to the mattress or bed. He/She said he/she was not aware entrapment assessments were supposed to be done quarterly. He/She said if there is not an entrapment assessment in the resident's EMR then it is not done. During an interview on 02/16/24 at 11:36 A.M., the Administrator said in morning meetings they discuss the residents, therapy assessments and approving the device. He/She said the DON takes care of the nursing assessments and maintenance is responsible for the entrapment assessments and installation. He/She said maintenance does the entrapment assessments once the work orders are put into TELS, but he/she is not sure of how often maintenance is doing the entrapment assessments after that and he/she does not think he/she is doing them quarterly.

Based on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 51. 1. Review of the facility's Dining Services Manager Roles and Responsibilities policy, dated 2020, showed the policy directed for the dining services manager to comply with current public health and safety standards in all phases of the department's operation. Review showed the policy did not contain information related to the education and experience requirements for the dining services manager. Review of dietary manager's (DM) personnel records, showed a hire date of 05/11/23 as the Director of Food Services and an invoice for a certified dietary manager course enrollment dated 12/12/23. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 02/14/24 at 9:15 A.M., the administrator said the DM had been the DM for the last six to seven months. The administrator said the DM did not have prior dietary manager experience in a nursing facility or the certification or other education required to be the director of nutritional services, but they did enroll him/her into a certification course in December 2023. The administrator said they did not get the DM enrolled into the course until December because they had to figure out what course the DM needed to take and he/she believed the DM had started the course, but had not completed the first lesson to date. The administrator said the facility has a part-time registered dietician consultant and they did not have any certified or clinically qualified nutrition staff employed full-time. During an interview on 02/14/24 at 10:06 A.M., the DM said he/she had been employed as the facility's DM for eight months. The DM said he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or certification related to food service management. The DM said he/she started a food service management certification course about a month ago, but was still working on completion of the first lesson. The DM said it took so long to get him/her enrolled in the course, because they had to figure out what course he/she needed to take. The DM said the facility has a part-time consultant registered dietician that comes to the facility once a month and they did not have any certified or clinically qualified nutrition staff employed full-time.

Based on observation, interview and record review, facility staff failed to store food in a manner to prevent contamination and outdated used. The facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to maintain the kitchen floors clean and in good repair to prevent the growth and harborage of bacteria. The facility staff also failed to ensure the ice machine, used to supply ice to residents, drained through an air gap to prevent cross-contamination. The facility census was 51. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded; -Rotate products so the oldest are used first. Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers; -Never leave any food item uncovered and not labeled. Review of the facility's Labeling and Dating Foods (Date Marking) policy, dated 2020, showed: -Unopened cases of dry food items will be dated with the date the case was received into the facility and will be using first in-first out method of rotation; -Once a case is opened, the individual food items from the cases are dated with the date the item was received in the facility and placed in/on the proper storage unit utilizing the first in-first out method of rotation; -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date. Observation on 02/13/24 at 8:50 A.M., showed the reach-in freezer contained opened and undated bags of steak fries and potato wedges. Observations on 02/13/24 at 9:06 A.M., showed the dry goods pantry contained: -A opened and undated 25 pound (lb) bag of nonfat dry milk; -Six 18 ounce (oz) cans of world horizons mushrooms pieces and stems with an expiration date of 06/19/23; -To large bags tortilla chips with an expiration date of 05/23; -Four large bags of tortilla chips with an expiration date of 08/23; -Two five lbs bags of biscuit mix with a date of 12/21 for the date received, but no expiration date; -A dented 6 lb 8 oz can of fruit cocktail; -A dented 6 lb 10 oz can of tropical fruit. During an interview on 02/13/24 at 9:34 A.M., the Dietary Manager (DM) said he/she and any staff put away food from the trucks are responsible to check for dented cans. The DM said he/she did not know why the two dented cans were on the shelf and dented cans are to be placed in the garage until the items can be returned to the supplier. The said he/she was responsible to check the dry goods room weekly for dented cans, expired foods and ensure opened items are dated with the date opened. The DM said he/she assumed the food received from the distributor was not expired, so he/she did not look at the manufacturer date. The DM said staff who open the food items are responsible to date the package with an opened date and the dry milk should have had an open date on it. The DM said if there is no used by date or date the item was received, those items should be discarded. Observation on 02/14/24 at 12:06 P.M., showed the reach-in freezer contained an undated bag of tater tots opened to the air and an undated and an open bag of hashbrown patties stored inside an undated plastic resealable bag. Observation on 02/14/24 at 2:16 P.M., the walk-in refrigerator contained: -A large pan of raw meat stored next to a pan of ready-to-eat fruit cocktail; -A container of previously prepared sage chicken dated 2/13 stored next to a pan of ready-to-eat tossed lettuce salad dated 2/14; -A container of previously prepared chicken gravy dated 2/13 and an undated container of previously prepared sausage gravy stored over prepared, ready-to-eat egg and cheese sandwiches. Observations on 02/14/24 at 12:00 P.M. and on 02/15/24 at 2:11 P.M., showed the glass-front reach-in refrigerator contained a five pound container of factory prepared chicken salad with a handwritten received date of 01/03, opened date of 2/13 and use by date of 3/13. Observation showed a manufacturer's expiration date of 02/02/24 printed on the container. During an interview on 02/15/24 at 2:37 P.M., the DM said staff should label opened food items with the opened and use by dates, store them in sealed containers, and they should not store raw or previously prepared food items near ready-to-eat food items and staff are trained on these requirements. The DM said the cooks are responsible to review the food storage in all areas at the end of their shifts to ensure foods are stored appropriately. The DM said staff probably do not think to check the use by or expiration dates from the manufacturer, but he/she would hope that they pay attention to those dates. The DM said he/she tries to audit food storage at least weekly when he/she prepares the food truck order. During an interview on 02/15/24 at 3:07 P.M., the administrator said staff should label and date opened food items with opened and used by dates and ensure they are stored covered and in a manner to protect them from contamination. The administrator said staff should not store food items that need cooked near ready-to-eat food items. The administrator said staff are trained on these requirements upon hire and as needed. 2. Review of the facility's Handwashing/Hand Hygiene policy, dated August 2019, showed the policy directed: -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Wash hands with soap when hands are visibly soiled; -Use an alcohol-based hand rub containing at least 62 percent alcohol or alternatively soap and water before and after coming on duty, eating or handling food, and assisting a resident with meals; -Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands; -Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers; -Rinse hands with water and dry thoroughly with a disposable towel; -Use a towel to turn off the faucet. Observation on 02/14/24 at 9:36 A.M., showed [NAME] A washed his/her hands at the handwashing sink. Observation showed the cook scrubbed his/her hands with soap for 10 seconds and then returned to prepare food items for service to residents. Observation on 02/14/24 at 9:42 A.M., showed [NAME] B washed soiled dishes in the mechanical dishwashing station and then he/she washed his/her hands at the handwashing sink. Observation showed the cook scrubbed his/her hands with soap under running water from the faucet for 15 seconds and then put dishes away from the clean side of the station. Observation on 02/14/24 at 9:53 A.M. and 9:56 A.M., showed the DM washed his/her hands at handwashing sink and scrubbed his/her hands with soap for five seconds. Observation showed the DM then obtained food items from the reach-in refrigerator and prepared a cheeseball in the mixer for service to the residents. 02/15/24 01:54 PM Observation showed DA D washed his/her hands at the handwashing sink. Observation showed the DA scrubbed his/her hands with soap under running water for five seconds, turned the faucet off with bare hands and put away dishes from the clean side of the mechanical dishwashing station. Observation on 02/15/24 at 1:55 P.M., showed the [NAME] C washed his/her hands at the handwashing sink and scrubbed his/her hands with soap for three seconds under running water and then turned faucet off with bare hands. Observation on 02/15/24 at 2:02 P.M. and 2:15 P.M., showed Dietary Aide (DA) D washed soiled dishes in the mechanical dishwashing station and then washed his/her hands at the handwashing sink. Observation showed the DA scrubbed his/her hands with soap for five seconds, turned faucet off with his/her bare hand and then put away dishes from the clean side of the station. Observation showed the DA used his/her bare hand to turn the door handle to exit the kitchen and then he/she returned to the kitchen and, without performing hand hygiene, continued to put away dishes from the clean side of the mechanical dishwashing station. During an interview on 02/15/24 at 2:15 P.M., DA D said he/she had worked at the facility for about four weeks, staff trained him/her on hand hygiene upon hire and staff are to wash their hands before they put away clean dishes. The DA said staff should also wash their hands when they enter the kitchen if they touched something dirty while out of the kitchen. The DA said he/she did not touch anything while out of the kitchen, but door handles would be considered dirty and he/she did not think about that. The DA said he/she did not remember being told how long he/she needed to scrub his/her hands with soap, but guessed he/she should do so for 20 or 30 seconds and he/she did not do so because he/she was in a hurry. The DA said staff should also turn the faucet off with paper towel when they wash their hands so they do not recontaminate their hands and he/she was just not good at thinking about that stuff before he/she does it. During an interview on 02/15/24 at 2:22 P.M., [NAME] C said he/she had worked at the facility since November 2023. The cook said staff should scrub their hands with soap for 20 seconds out of the water, rinse and then turn the faucet off with a paper towel. The cook said he/she had been trained to wash his/her hands the right way, but he/she just not do it the right way because he/she does not think about it and is just focused on making food. During an interview on 02/15/24 at 2:29 P.M., the DM said staff should wash their hands when they enter the kitchen, between dirty and clean dishes and anytime they go from touching something dirty to something clean and staff are trained on hand hygiene during their orientation. The DM said staff should scrub their hands with soap for 20 seconds out of the water, rinse and turn the faucet off with paper towel so they do not recontaminate their hands. The DM said he/she is responsible to monitor hand hygiene, probably did not do that as often as he/she should, and he/she could not remember the last time he/she monitored staff's hand hygiene practices. During an interview on 02/15/24 at 2:56 P.M., the administrator said staff should wash their hands when they enter the kitchen and after they touch anything dirty. The administrator said staff should scrub their hands with soap for 20 seconds out of the water and turn the faucet with a paper towel so they do not recontaminate their hands. The administrator said all staff are trained on hand hygiene upon hire, annually and as needed. 3. Review of the facility's Sanitation of Dining and Food Service Areas policy, dated 2020, showed: -The Dining Services Manager will record the necessary cleaning and sanitation tasks for the department; -Tasks ill be designated to specific departmental positions; -All staff will be trained on the frequency of cleaning; -Staff will be held responsible for all cleaning tasks. Review showed the policy did not contain information related specifically to the cleaning and maintenance of the kitchen floors. Observations on 02/15/24 at 2:34 P.M., showed: -an excessive build-up of food debris and a white dried liquid substance under the clean side of the mechanical dishwashing station; -broken and missing pieces of tile in the water pitcher storage area; -an excessive build-up of dirt and debris along the edges of the kitchen floor next to the walls. During an interview on 02/15/24 at 2:34 P.M., the DM said the night shift staff are responsible for maintenance of the kitchen floor daily as well as when needed during other times by the other dietary staff. The DM said the staff should sweep and mop the entire kitchen floor when they clean it and he/she struggles with staff cleaning the floor in the dishwashing area. The DM said if something is broken it should be reported to maintenance for repair, but he/she thought maintenance already knew about the broken tiles. During an interview on 02/15/24 at 3:01 P.M., the administrator said the DM is responsible over all for the cleanliness and maintenance of the kitchen, but the evening shift staff are responsible to clean all of the kitchen floor daily and dietary staff should clean them as necessary. The administrator said if something in the kitchen, including the flooring, is broken they should notify maintenance for repair and they were making plans to do some work on the kitchen floor around the dishwasher. The administrator said he/she knew the kitchen floors were not very clean and, while he/she had tried to clean them, they needed to scrubbed and deep cleaned. 4. Review of the facility's Ice Handling and Cleaning policy, dated 2020, showed the policy directed that ice storage bins shall be drained through an air gap. Observation on 02/15/24 at 10:35 A.M., showed the kitchen ice machine drain located adjacent to two other plastic unidentified lines. Observation showed all three plastic lines were inserted into a larger piece of white plastic pipe that connected to the drain. Observation showed the ice machine drain did not have an air gap. Observation on 02/15/24 at 12:05 P.M., showed the ice machine located behind nurse station one contained a drain connected to a sink drain with white plastic piping glued to the sink drain. Observation showed the ice machine drain did not contain an air gap. During an interview on 02/15/24 at 12:05 P.M., the maintenance assistant said the ice machines were used to provide ice to all residents. The maintenance assistant said he/she did not know what an air gap was and did not know an air gap was required on ice machine drains. During an interview on 02/15/24 at 2:36 P.M., the DM said the maintenance staff are responsible for the maintenance of the ice machine and he/she did not know the ice machine drain did not have an air gap. During an interview an 02/15/24 at 3:05 P.M., the administrator said the maintenance staff are responsible for the maintenance of the ice machine and he/she did not know ice machines were supposed to have an air gap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to electronically transmit quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments in a timely manner and in accordance with guidelines for three residents (Residents #5, #44, and #51). The facility census was 61. 1. Review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual, Version 1.17.1 dated October 2019 showed the following: -An Omnibus Budget Reconciliation Act of 1987 (OBRA) assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments; -Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). 2. Review of Resident #5's medical record showed: -An accepted quarterly MDS dated [DATE]; -A quarterly MDS dated [DATE] as in process; -The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date. 3. Review of Resident #44's medical record showed: -An accepted significant change MDS dated [DATE]; -A quarterly MDS dated [DATE] as in process; -The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date. 4. Review of Resident #51's medical record showed: -An accepted admission MDS dated [DATE]; -A quarterly MDS dated [DATE] as in in process; -The facility failed to ensure the quarterly MDS assessment was submitted within 14 days of the MDS completion date. During an interview on 11/04/22 at 11:20 A.M., the MDS coordinator said he/she tries to review and submit MDS data at least every other week. He/She said in process means the MDS is open and available for completion but not finished. He/She said he/she uses a dashboard to review MDS status' and all three residents' MDS submissions are late. During an interview on 11/04/22 at 11:42 A.M., the administrator said nursing staff sign off on the MDS and the MDS coordinator is responsible to ensure timely submissions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to provide safe mechanical lift transfers for four residents (Resident #3, #10, #12, and #16) in a manner to prevent accidents. Additionally, staff failed to safely store medications by leaving the medication cart unlocked and unattended. The facility census was 61. 1. Review of the facility's Storage of Medications policy, revised April 2019, directed staff to do the following: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner; - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use; - Unlocked medication carts are not left unattended. Observation on 11/01/22 at 4:11 P.M., showed a medication cart in the Covid isolation unit with the lock in the open position, with several layers of tape on it. The top drawer was able to be opened with little difficulty, and was stocked with over-the-counter medications. Further observation showed the remaining seven drawers could be opened, with the second drawer containing medication packets for residents on the unit; one packet identified contained trazodone, (an antidepressant and sedative medication used to treat depression). There were four residents in the Covid isolation unit without staff present. Observation on 11/04/22 at 9:00 A.M. showed the medication cart on the Covid isolation unit unlocked and without staff present. During an interview on 11/04/22 at 9:02 A.M., Certified Medication Aide/Certified Nurse Assistant (CMT/CNA) A said medication carts go into the med room when not in use, behind a locked door, and when in use, should be locked before leaving the cart. He/She said he/she was aware the medication cart was broken, and he/she notified other staff including maintenance. He/she said he/she did not know how long the medication cart has been broken. During an interview on 11/04/22 at 9:07 A.M., Registered Nurse (RN) F said medication carts should always be locked when staff are not with them. He/She said the medication cart in the Covid unit cart has tape around the lock and the lock is broken. RN F said staff use the TELS system (a building management software platform to track Life Safety tasks) to notify maintenance to repair broken items. He/She said he/she believed a key was locked in the cart and the lock had to be drilled out, and was unaware the lock was still not working. During an interview on 11/04/22 at 9:22 A.M., CMT/CNA C said medication carts should be locked all the time, especially if they are out in the open, otherwise they should be behind a locked med room door. CMT/CNA C said he/she would notify the DON, put the medication cart into a locked medication room, and enter a request into the TELS system for maintenance. He/She said the last time he/she worked in the Covid unit was a month ago and the lock was broken at that time. During an interview on 11/04/22 at 9:27 A.M., RN G said staff should always lock medication carts when staff are not with them, or should be locked in the medication storage room. He/She said staff should talk to maintenance to get it fixed as soon as possible, or use an extra medication cart that can be locked. The RN said if an extra cart is not available, then staff should keep the medication cart in a locked medication room. He/She said it has been several weeks since he/she last worked on the unit, and he/she was aware the medication cart lock was broken because maintenance had to drill the lock because keys were locked into it. During an interview on 11/04/22 at 9:34 A.M., the Director of Nursing (DON) said medication carts should always be locked when not in use or staff are away from them. If a cart needs repair, staff notify maintenance. He/She said he/she was aware of the medication cart in the Covid unit not locking, but thought maintenance fixed it. He/She was not aware it was still unable to be locked. During an interview on 11/04/22 at 11:25 A.M., the administrator said medication carts should remain locked at all times, and should only be accessible by appropriate certified personnel. The administrator said he/she was unaware the medication cart in Covid unit did not lock and just found out about it. He/She said staff should use TELS to notify maintenance, and the maintenance director should have followed up with company that owns the cart. During an interview on 11/04/22 at 11:28 A.M., the maintenance director said staff put requests into the TELS system and he/she checks every morning to see if there are any requests. He/She said the lock was drilled out after keys were locked in it, and he/she did not replace the lock. The maintenance director said it was an extra cart that had been in storage, and was supplied by the previous pharmacy the facility used. He/She said he/she should have called the company to get a new medication cart. He/She said he/she would dispose of the cart since it is unable to be repaired by the new pharmacy company. 2. Review of the facility's Lifting Machine, Using a Mechanical procedure guide, revised July 2017, showed staff are to check for proper sling placement, make sure the lift is stable and locked, and to gently support the resident during the transfer. Review of the mechanical lift instruction guide, undated, showed the guide instructed operators of the mechanical lift to keep the legs in the maximum opened/locked position while transferring the resident. 3. Review of Resident #16's quarterly Review Minimum Data Set (MDS) a federally mandated assessment tool, dated 8/5/22, showed staff assessed the resident as follows: -Cognitively intact; -Totally dependent on two staff for transfers, toileting, and personal hygiene; -Diagnosis of Parkinson disease. Observation on 11/1/22 at 2:08 P.M., showed CNA K and NA L transferred the resident from his/her wheelchair to a bed with a mechanical lift. CNA K and NA L placed the lift sling under the resident and attached the sling to the lift. The CNAs used the mechanical lift to transfer the resident from the wheelchair without spreading the legs of the lift to the fully open position as instructed. NA L did not assist with the guidance of the resident from the wheelchair to the bed. 4. Review of Resident #3's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers, toilet use, and personal hygiene; - Diagnosis of non-traumatic brain dysfunction and Alzheimer's disease. Observation on 11/2/22 at 10:00 A.M., showed Certified Nurse Assistant (CNA) J and Nurse Aide (NA) L transferred the resident from his/her wheelchair to a bed with a mechanical lift. CNA J and NA L placed the sling under the resident and attached the sling to the lift. The CNAs used the mechanical lift to transfer the resident from the wheelchair without spreading the legs of the lift to the fully open position as instructed. NA L did not assist with the guidance of the resident from the wheelchair to the bed. During an interview on 11/2/22 at 10:15 A.M., CNA J said he/she does not spread the legs of the mechanical lift because the legs have to go under the wheelchair from the side. 5. Review of Resident #10's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers, toilet use, and personal hygiene; -Diagnosis of non-traumatic brain dysfunction. Observation on 11/3/22 at 9:30 A.M., showed CNA K and NA L transferred the resident from his/her wheelchair to a bed with a mechanical lift. CNA K and NA L placed the sling under the resident and attached the sling to the lift. The CNAs used the mechanical lift to transfer the resident from the wheelchair without spreading the legs of the lift to the fully open position as instructed. NA L did not assist with the guidance of the resident from the wheelchair to the bed. 6. Review of Resident #12's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate Cognitive impairment; -Totally dependent on two plus staff for transfers, and toilet use; -Diagnosis of multiple sclerosis. Observation on 11/3/22 at 11:39 A.M., showed CNA K and NA L transferred the resident from his/her bed to a wheelchair with a mechanical lift. CNA K and NA L placed the sling under the resident and attached the sling to the lift. The CNAs used the mechanical lift to transfer the resident from the wheelchair without spreading the legs of the lift to the fully open position as instructed. NA L did not assist with the guidance of the resident from the wheelchair to the bed. 7. During an interview on 11/04/22 at 9:11 A.M., NA L said the hoyer lift should be done with two staff, one will guide the lift, one staff helps support or steady the resident. Staff should not walk away and leave only one staff controlling the lift. Staff are to close the legs of the lift when staff move away form the wheelchair to add more movability. During an interview on 11/04/22 at 9:15 A.M., CMT C said staff should get the sling organized correctly then hook it to the mechanical lift, then lift the resident and transport the resident to the bed or chair and while staff guides the resident. He/She said staff spread the mechanical lift legs when they get to the wheelchair. During an interview on 11/04/22 at 9:27 A.M., the DON said staff should get the resident ready to be transported, position the sling and use two staff. The mechanical lift goes under the bed with legs opened, staff then attach the sling to the lift. Staff should lift the resident, one staff drives the lift, and one staff supports the resident. He/She said staff go to the next position to lower the resident. The DON said the lift legs should remain open at all time with the resident is on the lift. During an interview on 11/04/22 at 9:47 A.M., the administrator said staff should put the sling on the resident correctly. Two staff operate the lift, one guides the resident and another operates the lift, and they should lower the resident. The mechanical lift legs should be open when moving the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for three residents (Residents #11, #19 and #27). The facility census was 61. Review of American Geriatrics Society (AGS) 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults showed: -Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. -Strength of recommendation - Strong Review of Seroquel (quetiapine) product monograph (a factual, scientific document on a drug product that, devoid of promotional material, describes the properties, claims, indications and conditions of use of the drug and contains any other information that may be required for optimal, safe and effective use of the drug) revised 11/29/2021 showed: -Seroquel indications for use include schizophrenia and bipolar disorder; -Seroquel is not indicated for the treatment of elderly patients with dementia-related psychosis. Review of the prescribing information for Aripiprazole/Abilify (antipsychotic) showed: -Abilify is an atypical antipsychotic indicated for treatment of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), Bipolar I disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and as an add on treatment for Major Depressive Disorder; -Elderly people with dementia-related psychosis (a mental disorder characterized by a disconnection from reality) treated with antipsychotic drugs are at an increased risk of death; -Abilify is not approved for the treatment of patients with dementia-related psychosis. Review of FDA prescribing information showed Trileptal (Oxcarbazepine - an anticonvulsant) is indicated for single or add on therapy in the treatment of partial seizures. Review of the facility's Antipsychotic Medication Use, revised December 2016, showed the following: -Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective; -Diagnoses alone do not warrant the use of psychotropic medications; -Antipsychotic medications shall generally be used only for the following conditions: schizophrenia, schizo-affective disorder, schizophreniform disorder, Tourette's disorder, psychosis in the absence of dementia, and Huntington's disease; -Residents who are admitted from the community or transferred from a hospital and who are already receiving psychotropic medications will be evaluated for the appropriateness and indications for use; -The interdisciplinary team will: re-evaluate the use of psychotropic medication at the time of admission to consider whether or not the medication can be reduced, tapered, or discontinued. 1. Review of Resident #11's quarterly Minimum Data Set (a federally required assessment tool), dated 8/16/22, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Verbal behaviors directed toward others, one of three days of the look back period (seven day period of time before the assessment is completed to capture the status of a resident); -Received antipsychotic, antianxiety, antidepressant, and opioid medications seven out of seven days in the look back period; -Diagnoses of non-Alzheimer's dementia (a group of symptoms that can affect thinking, memory, reasoning, personality, mood and behavior), anxiety (feelings of worry, anxiety or fear that are strong enough to interfere with one's daily activities), depression, high blood pressure, and non-traumatic brain dysfunction (injuries to the brain that are not caused by an external physical force to the head). Review of the resident's Physician Order Sheets (POS), dated November 2022, showed an order on 1/10/20 for Abilify (aripiprazole - antipsychotic) 2 milligram (mg) tablet at bedtime for generalized anxiety disorder. Review of the resident's medical record showed it did not contain an appropriate diagnosis for the use of the psychotropic medication Abilify. 2. Review of Resident #19's significant change MDS dated [DATE] showed staff assessed the resident as follows: -Moderate cognitive impairment -Minimal depression -No behaviors -Diagnoses included stroke, dementia, depression, coronary artery disease, peripheral vascular disease, kidney disease, diabetes, atrial fibrillation (rapid beating of upper heart chambers) -Received antidepressants six of the last seven days Review of the resident's POS, dated November 2022, showed an medication order on 9/29/22 for Trileptal (anticonvulsant) 300 mg twice a day for occlusion and stenosis of left carotid artery. Review of the resident's medical record showed it did not contain a documented history or diagnosis of seizures or an appropriate diagnosis for the use of the psychotropic medication. 3. Review of Resident #27's quarterly MDS dated [DATE] showed staff assessed the resident as follows: -Moderate cognitive impairment -Minimal depression -No behaviors -Diagnoses included Parkinson's disease, dementia, depression, prostate cancer, coronary artery disease -Received antipsychotics and antidepressants for seven of the last seven days. Review of the resident's POS, dated November 2022, showed an order on 7/15/22 for Seroquel (quetiapine - antipsychotic) 50 mg tablet at bedtime for unspecified dementia with behavioral disturbance. Review of the resident's medical record showed it did not contain documentation to show an appropriate diagnosis for the use of the psychotropic medications. 5. During an interview on 11/04/22 at 9:07 A.M., Registered Nurse (RN) F said for psychotropic and antipsychotic medications it is not appropriate to have a diagnosis of anxiety or dementia. He/She said appropriate diagnoses would be schizoaffective, Huntington's disease and psychosis. During an interview on 11/04/22 at 9:27 A.M., RN G said it would be inappropriate to have a diagnosis of disruptive behaviors or anxiety as an indication for antipsychotic medications. It would be appropriate to have antipsychotic medications for hallucinations and delusions. RN G said he/she would look to see if the resident has an appropriate diagnosis, and if there were not an appropriate diagnosis, he/she would contact the physician to get an appropriate diagnosis for the medication. During an interview on 11/04/22 at 9:34 A.M., the Director of Nursing (DON) said appropriate diagnoses for psychotropics and antipsychotics would be bipolar disorder, schizophrenia, manic depression, major depressive disorder. It would not be appropriate for diagnoses of anxiety or dementia. The DON said he/she would investigate if an error occurred with the diagnosis; did the resident have the appropriate diagnosis, and would then talk to the facility physician to get it corrected. He/She said the pharmacy review usually catches it and the facility physician is good about following gradual dose reductions and titration recommendations from the pharmacy. During an interview on 11/04/22 at 11:25 A.M., the administrator said he/she did not have a clinical background, but there should be appropriate diagnosis for pyschotropic and antipsychotic medication use. He/She said the DON is responsible for updating and checking to ensure the appropriate diagnosis is in place.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. Facility staff also failed to maintain food storage equipment clean and in good repair. The facility census was 61. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. -Rotate products so the oldest are used first. Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date. -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. -Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. -Store raw animal foods such as eggs, meat, poultry, and fish separately from cook and ready-to-eat food. If they cannot be stored separately, place raw meat, poultry and fish items on shelves beneath cooked and ready-to-eat items. If multiple shelves are available, the raw animal food with the highest final cooking temperatures should be stored on the lowest level, i.e. poultry and stuffed foods. -Never leave any food item uncovered and not labeled. Review of the facility's Labeling and Dating Foods (Date Marking) policy, dated 2020, showed: -Unopened cases of dry food items will be dated with the date the case was received into the facility and will be using first in-first out method of rotation. -Once a case is opened, the individual food items from the cases are dated with the date the item was received in the facility and placed in/on the proper storage unit utilizing the first in-first out method of rotation. -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date. Review of the facility's Maintenance Service policy, dated December 2009, showed: -The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. -Functions of the maintenance personnel include, but are not limited to: a. Maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines. b. Providing routinely scheduled maintenance service to all areas. Observation on 11/01/22 at 9:30 A.M., showed the service station with the cereal and beverage dispensers contained a plastic container of fruit whirls cereal removed from the original packaging undated on top of the microwave and a dispensing scoop inside the coffee ground container with the handle of the scoop touching coffee grounds. Observation on 11/01/22 at 9:32 A.M., showed the first glass front reach-in refrigerator contained: -an opened one gallon bottle of italian dressing with a received date of 09/28/22; the bottle did not contain an opened date; -an opened 138 ounce (oz.) bottle of picante sauce with a received date of 07/27/22; the bottle did not contain an opened date. Observation on 11/01/22 at 9:33 A.M., showed the second glass front reach-in refrigerator contained an opened and undated one quart carton of half and half. Observation on 11/01/22 at 9:36 A.M., showed the reach-in freezer contained: -two opened and undated bags of tater tots; -a case of beef country fried steaks opened to the air and undated. Further observation showed a case of vanilla ice cream cups stacked on top of steaks where the bottom of the box touched the exposed steaks; -a case of seasoned beef patties opened to the air and undated; -a plastic bag of chicken tenders opened to the air and undated; -an opened and undated plastic bag of french fries; -an opened and undated plastic bag of hashbrowns; -a torn left facing door gasket seal. Observation on 11/01/22 at 9:47 A.M., showed the aide's preparation station contained: -two opened and undated five pound containers of peanut butter; -an opened and undated 20 oz. bottle of strawberry spread. Review of the product label showed instruction to refrigerate the product after it is opened; -a 24 oz. bag of gelatin dessert, dated 10/18/22, opened to the air; -an opened and undated 24 oz. bag of gelatin dessert; -an opened and undated 8.5 oz. bag of cheese puffs; -four opened and undated 16 oz. bags of classic potato chips. Observation on 11/01/22 at 9:50 A.M., showed the nonfunctional reach-in refrigerator used for the storage of dry goods with an accumulation of food debris on the bottom shelf. Review also showed the refrigerator contained: -an opened one gallon bottle fine red wine vinegar with a received date of 10/18 and an opened date of 4/15; -a second opened one gallon bottle fine red wine vinegar with a received date 10/18; the bottle did not contain an opened date; -an opened and undated one gallon bottle imitation vanilla flavoring; -two opened and undated one gallon bottles of apple cider vinegar; -an opened one gallon bottle of balsamic vinegar dated 12/21; -two opened one gallon bottles of corn syrup dated 11/24; -an opened one gallon bottle of soy sauce with a received date of 06/15/22; the bottle did not contain an opened date. Observation on 11/01/22 at 10:12 A.M., showed the cook's station contained: -a bulk container which contained an opened 25 pound bag of brown sugar. Observation showed a dispensing scoop inside the bag with the handle of the scoop in the brown sugar. Observation also showed the exterior of the container excessively soiled with food debris; -a bulk container which contained an opened 50 pound bag of granulated sugar. Observation showed a measuring cup inside the bag with the handle of measuring cup in the sugar. Observation showed the exterior of the container excessively soiled with food debris; -a bulk container which contained flour removed from the original packaging. Observation showed a dispensing scoop inside the bin and the handle of of scoop in the flour. Observation also showed the exterior of the container excessively soiled with food debris; -a bulk container which contained bread crumbs removed from the original packaging, dated 09/13/21. Observation also showed the exterior of container excessively soiled with food debris; -a bulk container which contained an opened 50 pound bag of yellow cornmeal. Observation showed both the container and bag were undated. Observation also showed the exterior of container excessively soiled with food debris; -a bulk container which contained an opened 50 pound bag of oats. Observation showed a measuring cup inside the bag with the handle of measuring cup in the oats. Observation also showed the exterior of the container excessively soiled with food debris; -a bulk container which contained corn starch removed from the original packaging, dated 10/20/21 with a dispensing scoop buried in the cornstarch. Observation also showed the exterior of container excessively soiled with food debris; -a bulk container, which contained navy beans, with the exterior of the container excessively soiled with food debris. Observation at this time also showed the exterior of the convection oven and the upper portion of the stand mixer, where attachments are inserted, covered with dried food debris and an accumulation of dirt, food debris and trash on the floor beneath the cooking equipment. Observation on 11/01/22 at 10:34 A.M., showed raw eggs stored above gallons of milk in the walk-in refrigerator. Further observation showed the door gasket seal torn and covered with an unidentifiable black substance. Observation on 11/01/22 at 10:37 A.M., showed the door gasket seal to the walk-in freezer torn and covered with an unidentifiable black substance. During an interview on 11/01/22 at 2:05 P.M., the administrator said he/she had trained one of the cooks to do some of the kitchen management duties, but he/she was currently in charge of the kitchen since the facility had not had a dietary manager since September 2022. The administrator said he/she was working on developing a cleaning schedule and felt the condition of the kitchen was a lot better than it was considering they had experienced staffing issues and most of the kitchen staff were new. The administrator said during his/her last visit, the registered dietician recommended someone to come in a do a deep cleaning of the kitchen just so they could get caught up. The administrator said opened food items should be covered, dated with a use by date, which is three days for prepared food items, or an opened date for already prepared items, like gallons of milk. The administrator said staff should use one thing before opening another like another so they ensure what came in or was opened first is used first. The administrator said raw food products that requiring cooking should not be stored by or above ready to eat food products. The administrator said he/she monitors the food storage a couple times a week when he/she puts the truck away and looks to see if food items are labeled, dated and sealed. The administrator said he/she does not look in the nonfunctioning reach-in refrigerator that is used for storage nor does he/she look at the bulk containers. The administrator said scoops should not be stored in the foods inside the bulk containers, but he/she did not think that he/she had trained staff on that requirement. The administrator also said he/she and the maintenance director work together to access things that need to be fixed and, while he/she knew about the gasket seal on the freezer door, he/she did not know about the other maintenance issues.