**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to maintain a closet door and trash can in good repair. This was evident in 1 of 4 rooms reviewed for environment (room [ROOM NUMBER]). Findings included: On 6/19/2023 at 1:16 PM an observation of room [ROOM NUMBER] was conducted. A closet with two doors that swung open was located on the right-hand side of the room at the entrance to the room. One of two doors on the closet was broken. The door on the left side of the closet was observed to be hanging loosely from the top hinge and was completely disengaged from the bottom hinge. There was a trash can in the bathroom with about 6 inches of broken jagged edges that were approximately 4 - 5 inches long around the top corner rim of the trash can. It was covered by a plastic trash can liner. On 6/20/2023 at 2:00 PM an observation of room [ROOM NUMBER] revealed the closet door was attached to the top hinge and completely disengaged from the bottom hinge. There was a broken trash can in the bathroom with jagged edges along the top. It was covered by a plastic trash can liner. On 6/21/2023 at 10:12 AM an observation and interview were conducted with Nurse Aide #1 (NA#1) while in room [ROOM NUMBER]. NA#1 revealed she had worked at the facility for about 3 months and that the closet door had had been broken the entire time she worked at the facility. She further revealed she had submitted a work order for the closet door to be repaired about 1 to 1.5 months ago. NA #1 was observed as she removed the trash from the broken trash can and lined the trash can with a new bag. When informed that the trash can was broken, she stated she did not realize it because she was focused on the trash. She indicated if she had known the trash can was broken, she would have asked for it to be replaced. She further indicated she needed to remove the trash can immediately as it could cut her residents if they fell against it. NA #1 removed the trash can from the room and filed a work order for the broken closet door. In an interview at 10:31AM on 6/21/2023, the Maintenance Director observed the broken closet door in room [ROOM NUMBER]. He stated he had not received a work order for the closet door to be repaired. There was no log of a request for the closet door to be repaired. The Maintenance Director stated there is a logbook at each nursing station where problems were signed in, and he and his assistant reviewed them every morning. He further stated he did a walk through every morning to assess for any problems, including closets, and fixed hazards immediately. He said that needed repairs were prioritized and emergent repairs were made as needed. He indicated the broken closet door was a hazard and would be repaired immediately. An interview was conducted on 6/22/2023 at 7:52 AM with the Account Manager for the housekeeping contract company. She revealed she was the head housekeeper in charge of housekeeping, laundry, and the floor technicians. She further revealed that resident rooms were cleaned every day and that trash cans were emptied when the room was cleaned. She explained that the NAs emptied trash cans if needed after they provided resident care. She further explained housekeeping staff should remove a broken trash can, put it in dirty linen, notify her and she would put in a work order for maintenance. On 6/22/2023 at 4:40 PM an interview was conducted with the facility Administrator and the Director of Nursing (DON). The Administrator stated that the broken trash can should have been thrown away and replaced. She further stated the closet door could have been removed and replaced or repaired if a work order had been submitted. The DON stated that the NA who stated that the closet door had been broken the entire time she worked at the facility did not submit a work order and that the NA was disgruntled. She stated staff are expected to write a work order for needed repairs and that work order boxes are located at each nursing station. A Resident and Room Audit Form was provided that revealed on 6/13/2023 an audit of resident rooms revealed the closet was orderly and there were no clothes on the floor in room [ROOM NUMBER].

Based on observations and staff interviews the facility failed to maintain a clean walk-in refrigerator from an accumulation of a brownish/blackish matter for 1 of 1 walk-in refrigerators. Additionally, the facility failed to remove expired liquids stored ready for use in 1 of 1 walk-in refrigerators. This practice had the potential to affect food served to residents. The findings included: 1a. An observation completed with the Dietary Manager (DM) in the walk-in refrigerator on 3/28/2022 at 9:39 AM revealed a brownish/blackish matter on the ceiling of the walk-in refrigerator which included the cage covering the circulatory fan and the light protector. b. An observation completed with the DM in the walk-in refrigerator on 3/28/2022 at 9:41 AM revealed 1 opened box of honey thick consistency milk with a use by date of 1/16/22 on the top shelf. The box contained 12 un-opened cartons of honey thick consistency milk. The DM stated in an interview on 3/28/22 at 9:43 AM that the brownish/blackish matter on the ceiling of the walk-in refrigerator was from condensation from opening the door. The DM stated that he checked expiration dates weekly on delivery days and that the milk was delivered from the food supplier expired. The DM was not certain as to why the honey thick consistency milk was still in the walk-in refrigerator. The DM communicated he last checked the walk-in refrigerator for expired items on 3/25/2022. In a follow up interview with the DM on 3/29/22 at 2:32 PM, he verbalized the walk-in refrigerator was cleaned Monday, Wednesday, and Fridays. The DM expressed the walk-in refrigerator would be scrubbed clean and Maintenance would be notified. The Administrator stated in an interview on 03/30/22 04:32 PM that the walk-in refrigerator should be cleaned on a regular basis to prevent buildup of debris on the ceiling. Additionally, the Administrator voiced that any foods or beverages coming into the building needed to be checked for the expiration date before storing.