Based on review of the facility policy titled, In Service Training Program, Nurse Aide, document review and interview, the facility failed to ensure all nurse aide personnel has completed the required 12 hours of training per employment year based on hire date for 11 out of 32 Certified Nursing Assistants (CNAs). Findings include: Review on 11/15/22 at 3:00 PM of the facility policy titled, In Service Training Program, Nurse Aide, revealed the policy statement which reads, All nurse aide personnel shall participate in regularly scheduled in-service training classes. The Policy Interpretation and Implementation states: 1. All personnel are require to attend regularly scheduled in service training classes. 2. The facility will complete a performance review of nurse aides at least every 12 months. In-service training will be based on the outcome of annual performance reviews, addressing weakness identified in the reviews. 3. Annual in service must: a. Be no less than 12 hours per employment year; b. Address the special needs of the residents, as determined by the facility staff; c. Include training in dementia management and abuse prevention. 6. All training classes attended by the employee shall be entered on the respective employee's Employee Training Attendance Record by the department supervisor or other persons as designated by the supervisor. 7. Records shall be filed in the employee's personnel file or shall be maintained by the department supervisor. Review on 11/15/22 at 2:10 PM of the required 12 hours of in services and training for each employed CNA revealed that 11 out of 32 did not have documentation to ensure they had received the training per employment year based on their hire date. During an interview on 11/15/22 at 2:35 PM with the Director of Nursing (DON) confirmed the findings after acknowledging understanding and proceeded to find further documentation of the required 12 hours of in services for all CNAs. The DON was unable to provide the documention to ensure the training for the 12 hours for each CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and interviews, the facility failed to ensure expired medications and biologicals were removed from 2 of 3 medication storage rooms. Findings Include: Review of the facility policy titled, Drug Storage, revealed no indication on the disposal of expired medications and biologicals. Multiple requests were made for policies regarding disposition of expired medication with no documentation provided by the facility during the survey. Observation of the Arbor Unit medication storage room on 11/14/22 at 3:16 PM revealed, three (3) [NAME] I.V. Starter Kits with an expiration date of 08/05/22. Also, one (1) of the [NAME] I.V. Starter Kits was opened and no longer sterile. Licensed Practical Nurse (LPN)1 confirmed the expired biologicals. Observation of the Palmetto Unit medication storage room on 11/15/22 at 8:57 AM revealed, eight (8) cartons of Jevity Complete Balanced Nutritional Fiber 8 Fl ounces (oz) with an expiration date of 11/01/21. LPN2 confirmed the expired biologicals. In an interview with the Director of Nursing (DON) on 11/15/22 at 1:55 PM, she stated she was informed by her staff that the expired medical supplies and expired Jevity were found in the medication storage rooms. She revealed it is her expectation for staff to dispose of expired medications in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview, the facility failed to ensure: 1) Accurate labeling and dating of foods, 2) Removal of expired foods from refrigeration and storage. Findings include: Review of the undated facility policy and procedure titled, KITCHEN AND FOOD STORAGE AREA states: Policy: The skilled Health Center's kitchen and nourishment kitchen will meet the same standards for quality for sanitation, cleanliness, and health as required by state regulations for the main kitchen and food serving area. Procedure: 1) All rooms where food or drink is stored, prepared, or served or where utensils are washed shall be in good repair, clean, and protected from dust, flies, vermin, rodents, and other contamination. Review of the undated facility policy and procedure titled, FOOD DISPOSAL states: Policy: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy interpretation and implementation state 3) Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Dispose of foods on the use by date. 4)All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Disposal of foods on the use by date. 5) Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. During the initial kitchen tour on 11/13/22 at 11:31 AM, an observation revealed in freezer one contained beef; individually wrapped, on the floor, undated. There were also 5 cases of turkey thighs on the floor and 2 cases of lamb on the floor. In addition, there were 3 containers of Breyer's ice-cream noted to be placed on the floor. There was a box of Crabmeat, also on the floor. There were 3 cases of She Crab, 1 box of Cobbler, 1 case of Corn on the Cob, 1 case of Crab Cakes, 1 case of wheat bread and 1 bag of Hushpuppies, undated, all noted to be stored on the freezer floor. There was also a variety of frozen vegetables scattered on the floor. During an observation of the walk-in refrigerator/dairy cooler on 11/13/22 at 11:45 AM, an observation was verified by the Executive Chef (EC). Findings in this area included; uncovered tossed salad and cheese with a grayish black substance, undated and wrapped in unoriginal packaging. There was also unlabeled and undated, covered shrimp. There was also an undated, opened, container of cornbread, approximately 15-20 eggs in a metal bowl undated and 4 blocks of cheese, undated with a mold like substance present. There was a package of Brioche buns, opened and unlabeled, along with a package of hotdog buns, opened and unlabelled. There was a clear container of unlabeled coleslaw and unlabeled salad. There were 13 cases of Blackberries covered in a grayish-fur-like substance and 3 cases of Strawberries with the same substance present. During an observation of the dry storage on 11/13/22 at approximately 12:00 PM, an observation of was verified by the EC. Findings in the dry storage included; opened and undated, [NAME] cereal and an opened and undated bag of dry noodles. There was also a bag of yellow onions, with approximately 15 onions, with a mold-like substance on the floor, with flies flying around them. There was a bag of red onions, with approximately 15 onions, with a mold-like substance on the floor with flies, flying around them, also. The dry storage also contained an opened and undated box of grits, 6 boxes of pie shells opened and undated and two cases of beef gravy on the floor. There was also multiple items stored above the red line, close to the ceiling. During an observation on 11/14/22 at approximately 12:05 PM, there was a tray of dessert located in the food delivery room, uncovered and clean plates ready for service with food debris present. An observation of the kitchen on 11/14/22 at 12:30 PM revealed the walk-in refrigerator and walk in freezer, still in the same conditions as the 11/13/22 observations. On 11/15/22 at 12:56 PM, an interview with Director of Food and Beverages (DFB) verified the cases of food stored on the floor in the dry storage, walk in refrigerator, and walk in freezer. Also, verified the molded berries in the walk-in refrigerator and red onions in the dry storage. The DFB stated that facility is in the process of getting another fridge and cooler, since feeding two facilities. The DFB stated, The facility had a receiver staff member that cleans the fridge on Sundays and receives the new shipment, however, that staff member was fired this past month due to not completing her duties. The facility is currently trying to fill the position.

Based on review of facility policy, observation and interview, the facility failed to ensure proper disposal of refuse. Findings include: Review of the undated facility policy and procedure titled, KITCHEN AND FOOD STORAGE AREA states: Policy: The skilled Health Center's kitchen and nourishment kitchen will meet the same standards for quality for sanitation, cleanliness, and health as required by state regulations for the main kitchen and food serving area. 7) All garbage, trash, and rubberish shall be collected daily and taken to storage facilities. Wet waste which is not disposed of by mechanical means shall be kept in leak- proof nonabsorbent containers with close-fitting covers and be disposed of daily in a manner will prevent transmission of disease, a nuisance, a breeding place for flies, or a feeding place for rodents. During an observation on 11/13/22 at approximately 12 PM revealed 2 dumpsters with posted signage CARDBOARD ONLY with both doors opened. During an observation on 11/13/22 at approximately 12:05 PM revealed a 3 ft tall plastic bin with an abounding amount of grease, uncovered behind the grease trap, surrounded with flies. During an interview with the Director of Food and Beverages on 11/15/22 at 12:56 PM, when asked about the plastic bin with grease and flies, he stated,he wasn't sure what it was, but he would get staff to get rid of it.