**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to clean and maintain 1 of 1 walk-in refrigerator in the main kitchen free from debris. The facility also failed to refrigerate opened jelly containers stored in the dry food storage area, remove expired thickened beverages from the dry food storage area and expired thickened beverage from a dining area refrigerator ([NAME] dining room). This practice had the potential to affect food served to residents. Findings Included: a. On 2/17/25 at 9:46 AM an observation with the Dietary manager (DM) in the kitchen's walk-in refrigerator found a whiteish in color and fuzzy in appearance substance on the floor beneath the food storage rack on the left side of the refrigerator. The substance was concentrated in some areas and speckled in other areas on the floor and on the baseboard spanning the length of the wall. Further observation of the walk-in refrigerator found the ceiling area near the circulatory fan to contain grey fluffy matter. The grey matter was crumbly to touch. The DM stated during the observation that he mopped the refrigerator 2 times daily and had not noticed the substance under the storage rack and had overlooked the ceiling. b. On 2/17/25 at 9:50 AM an observation of the kitchen's dry food storage area with the DM found 2 opened jars of jelly located on the second shelf of the storage rack. The jelly jars did not contain an opened date, and the manufacturers label read refrigerate after opening. The observation also found one un-opened 48 ounce container of thickened beverage with an expiration date of 10/3/24 stored on the shelf. The DM removed the 2 jelly jars and thickened beverage container from the shelf. The DM stated during the observation he did not know how long the opened jelly jars had been on the shelf and stated they should have been refrigerated after they were opened. The DM also said the thickened beverage container was overlooked and that the dry food storage area was checked weekly on food delivery days. c. On 2/17/25 at 9:57 AM an observation of the [NAME] dining room refrigerator found one container of opened thickened beverage with an expiration date of 10/3/24. The DM stated during the observation the refrigerator was stocked regularly each day by the dietary staff and the container had been overlooked. The Administrator stated on 2/20/25 at 9:18 AM the facility had switched from using and purchasing 48 oz thickened beverage containers to individual sized containers the previous summer and fall. The 48 oz thickened beverage containers should have been removed at that time. The Administrator also said the walk-in refrigerator was mopped 2 times each day by the DM, and that all areas of the walk-in refrigerator should have been cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and staff interviews the facility failed to follow a resident's care plan when transferring 1 of 5 residents reviewed (Resident #307). Findings included: Resident # 307 was admitted into the facility on [DATE] with the diagnoses of: non- Alzheimer's dementia with mood disturbance, anxiety, bipolar disorder, and expired on [DATE]. Resident #307's quarterly Minimum Data Set, dated [DATE] revealed she was severely cognitively impaired, required extensive assistance with her bed mobility, toilet use and transfers. A review of Resident #307's most recent comprehensive care plan dated [DATE] stated two-person assistance with transfers. A review of Nurse #2 progress notes dated [DATE] at 8:04 AM revealed that at 6:00 AM she was alerted Resident #307 had a seizure episode during a transfer. A telephone interview was conducted with Nursing Assistant #1 on [DATE] at 7:45 AM who relayed that she had used a sit-to-stand lift by herself to take Resident #307 to the restroom on [DATE], she stated that during the transfer Resident # 307 became red in the face and would not respond when Nurse Assistant #1 called her name. Nurse Assistant #1 then stated that she laid Resident #307's head and upper body on the bed but could not get her legs on the bed because Resident #307 was so stiff, Nurse Assistant #1 then yelled for help and the nurse came into the room. Nurse Assistant #1 also revealed that at no time did Resident #307 fall either from the lift or off the bed. Nursing Assistant #1 indicated that Resident # 307 had become too heavy to transfer so she used the assist lift for the transfer. Nurse Assistant #1 also revealed that she knew that Resident # 307's care plan did not include using a sit-to-stand lift for transfers and had indicated two-person extensive assist with all transfers. An interview with the Director of Nursing on [DATE], at 2:00 PM revealed that during the transfer on [DATE] it appeared that Resident #307 had seizure like activity. The Director of Nursing further revealed that at the time of the incident that the facility investigation concluded Resident #307 had not been transferred by Nurse Assistant #1 in accordance with her care plan. An interview with the Administrator on [DATE], at 2:45 PM revealed that Nursing Assistant #1 did not transfer Resident #307 in accordance with the care plan. She further revealed that the facility had assessed Resident #307 and contacted the physician regarding her pain and seizure activity. When the facility had found out a plan of correction was established. The plan of correction initiated on [DATE] included: Root cause analysis: Resident's care plan stated 2-person assist with transfers. Certified Nursing Assistant transferred resident with a sit to stand lift with one person assist. Corrective Action: Certified Nursing Assistant was counseled and re-educated on facility transfer policy and following the care plan for transfers was completed on [DATE]. Corrective Action for Potential Deficient Practice: All current resident's care plans checked to assure they match the resident profiles was completed on [DATE]. Systematic Changes: Retraining of all staff in the facilities transfer policy, following the Resident's profile for all transfers was completed on [DATE]. Monitor Plan of Facility: The Staff Development Coordinator or designee will monitor transfers to ensure correct techniques and the transfer matches the plan of care and report to the facilities Quality Assurance Performance Improvement Committee for a 3-month period and then randomly thereafter to ensure compliance. Review of the plan of correction was completed on [DATE]. The facility's plan of correction was validated by observations of transfers during the survey that revealed transfers with and without mechanical lifts were completed by the staff in accordance with the care plan and resident profiles. Staff interviews were completed to verify they had received training on resident transfer status. And a review of staff training material regarding the proper procedures for transfers and audits completed by the facility was completed.