New Friends Memory And Residential Care of Florence

1. What actions will be taken to correct the rule violation for each example/resident? Observation of the main facility kitchen and house 2 and 3 kitchen areas were reviewed on 08/15 from 1:30 pm through 3:00 pm and again on 8/18/25 from 10:30 am thru 1:15pm and found the following:
a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:

* Inside and outside of reach in coolers and freezers
* Outdoor storage space floors, walls, ceiling where refrigerators and freezers are stored
* Door thresholds to food storage areas
* Open shelving in dry storage
* Black plastic shelving
* Flooring of pantry
* Interior of microwaves
* Industrial can opener and housing
* Open shelving:
* Drawers and cabinets storing clean dishes and other equipment
* Cabinets, drawers, shelving holding/storing food
A. Executive Director hired new dietary Manager. Dietary Manager and Maintenance director completed deep clean in main facility kitchen and in house 2 and 3 kitchens. The Executive Director created a schedule with sign off for deep cleaning ALL areas of concern, to be completed weekly. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. Kitchen Consultant or designee has done a walkthrough of all kitchen areas to include dry storage/pantry areas/ equipment and food storage areas and provided direction as to what to clean, replace, or repair. Executive director or designee will update the kitchen checklist to include all items identified on the survey for cleaning/sanitation and storage.

* Dietary Manager and Maintenance Director cleaned inside and outside of reach in coolers, freezers.
* Maintenance Director pressure washed outdoor storage space floors, walls, ceiling where refrigerators and freezers are stored, and the refrigerators and freezers.. The Executive Director created a schedule with sign off for the maintenance department to audit the need for pressure washing in ALL areas weekly and as needed.
* Door thresholds to food storage areas cleaned, will be maintained by the maintenance department weekly and as needed for removal of dirt/debris.
* Dietary Manager or designee will clean open shelving in dry storage and will be monitored daily for compliance by Dietary Manager or designee. Dietary Manager or designee will replace all shelving paper in drawers/cabinets. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness.
* Black plastic shelving was cleaned by Dietary Manager and will be monitored daily for compliance by Dietary Manager or designee, Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness.
* The floor of the pantry was cleaned by the Dietary Manager and will be monitored daily for compliance by the Dietary Manager. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness.
* The interior of microwaves were ALL cleaned and will be monitored daily for compliance by Dietary Manager, Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness.
* Industrial can opener and housing, was cleaned by Dietary Manager and will be monitored for cleanliness with each use by Dietary Manager or designee. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness.
* Dietary Manager cleaned open shelving and will be monitored daily for compliance by Dietary Manager or designee, Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness.
* The Dietary Manager cleaned the drawers and cabinets, storing clean dishes and other equipment and will be monitored daily for compliance by the Dietary Manager. Daily meeting with dietary manager and Executive Director to discuss compliance, changes and effectiveness.
* Dietary Manager cleaned cabinets, drawers, shelving holding/storing food was cleaned and will be monitored daily for compliance by Dietary Manager or designee. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness.
* The Dietary manager or designee will bring the results of the above stated audits to QAPI monthly for 3 months or until deficient practice has resolved. The RD or designee will audit monthly to perform their kitchen sanitation and compliance audit monthly. Dietary Manager will bring results of the RD audit to QAPI monthly for 3 months or until deficient practice is resolved.

b. The following areas were in need of repair:
* Small holes in walls in kitchens.
* Reach in refrigerator in house one not holding temperature at 41 degrees are below
* Multiple exteriors of refrigerators with dirt and/rust on exteriors or with no handles
* Multiple reach in refrigerators with large condensation and notable water leakage/build up
* Microwave in house 2 with dents/damage
* Flooring in house 3 with integrity flaws, chips, gouges yielding non-smooth surface
* Multiple cupboards/cabinets/shelving with exposed porous wood and/or non-smooth surfaces.
* Multiple refrigerators had water and/or excessive condensation in the refrigerators with water leakage/build up on shelves, food or beverage containers.
B. Executive Director and Maintenance Director have completed a walkthrough of all kitchens identifying any holes in the walls, porous surfaces that are not cleanable, or other environmental factors needing repair and have a plan in place to repair these areas by compliance date. Daily meeting with maintenance director and Executive Director to discuss compliance, changes and effectiveness.
* The Executive Director and Maintenance Director have completed a walkthrough of all kitchens identifying any holes, in the walls, needing repair and have a plan in place to repair these areas by compliance date.
* House one reach in the refrigerator adjusted by the Facility Manager and holding proper temps. Temp checking as directed to be in sufficient compliance daily by Dietary Staff.
* Will be repairing or replacing refrigerator units with rust or broken parts, Facility Manager to price and order replacements while Maintenance Director will price and order replacement parts.. The Maintenance Director has cleaned ALL units of dirt/debris/rust and will maintain cleanliness weekly and as needed. Oversight from the Executive Director weekly for compliance.
* Facility Manager and Interim Dietary Manager have done a full House audit of all kitchens and freezers to assess for any build up, standing water or condensation and have put a plan in place to monitor for a continued issue and then will seek repair or replacement by compliance date.
* Microwave in house 2 with dents/damage, has been removed. The facility manager has requested quotes for a commercial microwave to replace Microwave. Will be replaced by compliance date.
* The Executive Director and Maintenance Director have completed a walkthrough of all kitchens identifying any flooring with integrity flaws, chips, gouges yielding non-smooth surface or other environmental factors needing repair and have a plan in place to repair these areas by compliance date. Quotes for labor to be obtained by the Maintenance Director and reported the Facility Manager.
* Dietary Manger or designee will resurface all shelves and drawers to allow for cleanable surfaces by compliance date.
* Facility Manager and Interim Dietary Manager have done a full House audit of all kitchens and freezers to assess for any build up, standing water or condensation and have put a plan in place to monitor for a continued issue and then will seek repair or replacement by compliance date. The Maintenance Director or designee will bring the results of the above stated audit to QAPI monthly for 3 months.
c. Multiple food items found uncovered in reach in fridges. Multiple items without dates opened/prepared. Multiple items found past the manufactures use by dates and or facility date marking for use within 7 days. In house 3 a bag of hot dogs was observed that did not have a date and were visibly discolored and looked spoiled. A pan of dessert was loosely covered with plastic wrap where multiple areas of exposed food were noted. The pan of dessert was noted to have liquid contaminants from other areas of the fridge inside the food product where the open sections were. Staff was asked to discard the hot dogs and the dessert due to contamination and safety concerns.
C. House 3, hotdogs and the pan of dessert were disposed of immediately. Dietary Manager or designee will monitor daily for dates opened/prepared and weekly for manufactures use by date. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. RD will hold an all-staff in-service for Dietary and Nursing staff on the following topics altered texture diets, kitchen cleanliness, Fridge/Food temps, dating and discarding foods, cooling and reheating food, covering food when in kitchen/Fridge, or taking out of the dining area to a resident, Substantial snacks, Infection control and glove use.
d. Refrigerator in house 1 thermometer reading 48 degrees Fahrenheit on 08/15/25. Mayonnaise temperature was checked and found also at 48 degrees Fahrenheit. Multiple items were stored in the refrigerator and limited open space was observed potentially creating cold circulation concerns. Staff 2 (Cook) indicated some items in the fridge (near the back) were freezing. Staff 2 was instructed to check the temperature of all potentially hazardous foods and discard any found at greater than 41 degrees. Upon return to the facility on 08/18/25 the identified fridge was within acceptable temperatures (41 degrees) and was at maximum cold setting (7).
D. The Dietary Manager tempted everything and disposed of items that did not meet temperature requirements. Refrigerator adjusted by the Facility Manager and holding proper temps. Temp checking as directed to be in sufficient compliance daily by Dietary Staff.
e. Care giving staff were observed to not properly remove/change gloves and or wash hands when necessary during meals service on 08/18/25. Staff were observed to leave the kitchen with gloves on, touch residents and/or resident care equipment and return to the kitchen area without removing/changing gloves. Other staff were observed entering the kitchen from care areas and did not wash hands before donning gloves as required.
E. Executive Director posting signage in all kitchens, with reminders for hairnets, aprons, process for hand washing and glove use. Dietary manager or designee will monitor for compliance and enforcement of safe processes. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness. RD will hold an all-staff in-service for Dietary and Nursing staff on the following topics altered texture diets, kitchen cleanliness, Fridge/Food temps, dating and discarding foods, cooling and reheating food, covering food when in kitchen/Fridge, or taking out of the dining area to a resident, Substantial snacks, Infection control and glove use. Infection Preventionist or designee will audit week at different meals for hand hygiene and glove use. Infection Preventionist or designee will bring the results of the above stated audit to QAPI monthly for 3 months or until deficient practice has resolved.
F. On 08/15/25 at 2:00pm already prepared food items were observed in the oven. Staff 2 was interviewed and revealed the food items were for dinner at 4:30 pm that day. On 08/18/25 at 12:30 pm, Staff 1 (Administrator) was interviewed and confirmed that on multiple days there was no evening cook to prepare dinner meals and that the morning cook prepared evening meals and care staff served the meal. Staff 1 acknowledged the food was being held hot for greater than 2 hrs on those days with no evening cook. Staff 1 and Staff 3 (Facility Representative) acknowledged that practice could impact food quality and palatability, having food continue the cooking process for that extended amount of time.
F. Dietary Staff will now be prepping and plating all meals. The Executive Director has created a Dietary schedule that will allow for meals to be prepared and served prior to dinner rather than kept warm. Dietary Manager will hold a Dietary staff training on this process.
Dietary Manger will hold an all Dietary department in service on all of the changes in the kitchen for compliance to include prepping and plating meals.
The Executive Director or Designee will complete an audit weekly at different times of the day to ensure meals are plated, and served at scheduled meal times and proper diet is followed.
The Executive Director will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved.
g. Pans of food were observed in house 3 not held on or in a heat source and no covers or lids during service to keep hot food hot or food protected from potential contamination. Pans of food were observed uncovered for more than 20 minutes.
G. Executive Director has created a Dietary schedule that will allow for meals to be prepared and served prior to dinner rather than kept warm. Food warmers instituted and used by dietary staff to ensure that food temps are maintained at regulated temperature prior to and during the serving process. The Executive Director or designee will audit a meal weekly to ensure that residents are enjoying dignified dining, and that altered texture diets are followed as ordered.
The Executive Director will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved.
h. Staff were observed in house 3 putting food off the stove in plastic containers for “left overs”. Staff were asked about proper cooling methods and what the time/temperature steps were for proper cooling. Staff was not able to correctly demonstrate knowledge of cooling or reheating temperatures/processes.
H. RD will hold an all-staff in-service for Dietary and Nursing staff on the following topics altered texture diets, kitchen cleanliness, Fridge/Food temps, dating and discarding foods, cooling and reheating food, covering food when in kitchen/Fridge, or taking out of the dining area to a resident, Substantial snacks, Infection control and glove use.
The Dietary Manager will be monitored daily for compliance by the Dietary Manager. Daily meeting with dietary manager and Executive Director to discuss compliance, changes and effectiveness.
i. Facility had multiple residents on Mechanical soft diets. Staff were interviewed regarding items that are available to be provided to residents on mechanical soft diets. Varied answers were given. Staff did not have guidance to refer to in kitchen areas for appropriate foods for mechanical soft foods. Staff indicated they used to have a reference sheet to help them but didn’t know where it was. Multiple care staff indicated that they were the ones that would mechanicalize the food that the cook prepared for the residents and would “figure out” items as/if needed appropriate for the mechanical soft diet. Staff stated that if residents could not have a vegetable that was offered like lettuce for soft tacos, they would offer apple sauce or other fruit available. Staff 1 acknowledged that cook was not mechanicalizing food for mechanical soft diets. In house 3 a resident’s diet indicated Mechanical soft (ground) meat, resident was given cut up meat of various sizes/chunks none of which were ground. Vegetables on plate also included broccoli stems that were not fork mashable/soft. A whole roll with a hard/crusted bottom was also served. House 1 had a resident that was on mechanical soft on the list posted on the fridge however staff 4 (cook) was unaware any residents in that house were mechanical soft. Staff 1 was interviewed regarding the resident in house 1 on mechanical soft and indicated it was the resident’s preference to get a regular texture diet. Staff 1 acknowledged the diet order was still Mechanical soft and that the MD had not been informed of the resident’s preference to not follow mechanical soft diet. Staff 3 provided a typed sheet for Mechanical soft diets that included. “Tender meats (shredded or finely chopped), vegetables (soft, well cooked, pureed or smashed), breads (white bread, soft rolls or toast without crusts). None of the mechanical diets served for the lunch meal on 08/18/25 met criteria for mechanical soft.
I. RCC or designee will reach out to all PCP of residents who are declining their altered texture diet and see if they would like to change the diet to regular texture. Diet cards to be made with all diet orders and preferences. The Executive Director posted Altered Texture directives in each Kitchen. RD will hold an all-staff in-service for Dietary and Nursing staff on the following topics altered texture diets, kitchen cleanliness, Fridge/Food temps, dating and discarding foods, cooling and reheating food, covering food when in kitchen/Fridge, or taking out of the dining area to a resident, Substantial snacks, Infection control and glove use. Dietary Staff will now be prepping and plating all meals. Dietary Manger will train all Dietary staff training on this process. The Executive Director or designee will audit a meal weekly to ensure that residents are enjoying dignified dining, and that altered texture diets are followed as ordered.
The Executive Director or designee will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved.
j. On 8/15/25 staff 2 informed surveyor that dinner meal times were at 4 pm. When asked why dinner was at 4 pm, staff 2 indicated “it has just always been that way since I started.” Staff 2 acknowledged they felt 4 pm was early time for dinner. A care staff in house 3 indicated that dinner was at 4:30pm for their house. Surveyor inquired on why dinner was at 4:30 pm and they also did not know why and that “it has always been at 4:30 pm.” On 08/18/25 at 10:30 am staff 1 was asked about meal times and confirmed dinner is served at around 4:30 pm. They indicated they were not sure why it was 4:30 pm as it has been that way since they started. Staff 1 indicated most likely was because residents go to bed fairly early like 7 pm. Staff 1 indicated a snack was offered to residents if they wanted one but was not able to determine if it was a substantial snack indicating a protein source was given with the snack. Staff 1 acknowledged that dinner meal and breakfast meal was 16 hrs apart exceeding recommended maximum of 14 hrs. Staff 1 acknowledged that the facility could not determine or provide information that having dinner early with an extended time between meals was resident driven.
J. Executive Director in coordination with the community and management has altered the mealtimes so that they will meet regulation and not exceed 14 hours between breakfast and dinner. Activity Director or designee will add a food Committee Component to the Monthly Resident Council meeting to encourage resident involvement in developing menus.
The Executive Director or designee will audit a meal weekly to ensure that residents are enjoying dignified dining, that it is being provided at scheduled times, and that diets are followed as ordered.
The Executive Director or designee will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved.
k. Staff food storage items were observed stored in house 3 with resident food. Staff acknowledged that was their food and that there was a space for staff to store their food and should not be stored in with resident food items.
K. Staff Fridges ordered and will be placed in each house.
l. On 08/15/25 at 2:38 a plate of food was observed sitting on the counter in house 3. Staff verified this was a plate of food for a resident from lunch. Staff indicated lunch was served at about 11:30 am.
L. Dietary Staff will now be prepping and plating all meals. Dietary Manager will train all Dietary staff training on this process. The Executive Director or designee will audit a meal weekly to ensure that residents are enjoying dignified dining, that it is being provided at scheduled times, and that diets are followed as ordered.
The Executive Director or designee will bring the results of these audits to QAPI for 3 months or until deficient practice has resolved.
m. On 08/15/25 at approximately 3:00pm a nonstaff member was observed in the house 2 kitchen. It was later determined this was a family member of a resident. This person was observed to be heating up some food brought in for the resident. The family member was using kitchen items/equipment and did not have a hair restraint and was not observed to wash hands. Family member did not check the temperature of the food warmed for resident to determine if reheated to correct safe temperatures. Facility staff was in the kitchen area with family member and surveyor.
M. Executive director or designee will distribute a letter to family on how to get food reheated by the staff when needed rather than entering the kitchen.
n. House 2 had a carpet/floor cleaning machine stored where food is prepared, stored, and served. Staff 1 acknowledged that piece of equipment should not be stored in the kitchen area.
N. This was moved and properly stored immediately.
o. The reach-in refrigerator located in the outdoor covered storage area was noted to have raw ground beef stored above pork(bacon) which is not according to proper storage of raw meat products.
O. Executive Director posted proper food storage processes on all refrigerators within the community. Dietary manager to monitor for compliance and adjust storage areas as necessary. Daily meeting with Dietary Manager and Executive Director to discuss compliance, changes and effectiveness.
p. Registered dietitian reports for July documented concerns for dating of foods, food being out of date, cleanliness, concerns with hand hygiene and glove use, staff not following diets, improper meat storage and resident complaints on food quality.
P. The RD or designee will audit monthly during meal prep to ensure the proper diet textures are being prepared as well as perform their kitchen sanitation and compliance audit monthly. Executive Director and Dietary Manager will discuss Kitchen sanitation and compliance daily via stand-up meeting to include reviewing the food/fridge/freezer temps, and cleaning checklist.

Refer to C240

*Based on observations and staff interviews, it was determined the facility administration failed to provide necessary oversight of the food service program to achieve and maintain compliance with food sanitation rules. Findings include, but are not limited to: On 04/15/25 at 10:15 am, a revisit kitchen survey was conducted which found multiple areas that remained out of compliance. This was the third failed revisit for the kitchen survey. o New labeling and cleaning processes put in place, several trainings provided on new processes. Daily oversight from Executive Director and Dietary Manager for compliance.Monthly RD oversight to ensure compliance for at minimum 90 days.

C2401. All of the listed items have been or are in process of being deep cleaned: * Inside and outside of reach in coolers and freezers; * Fans blades, cages and screen of open window in house 1; * Ceiling vents; * Walls; * Interior of microwaves; * Interior of ovens; * Industrial can opener housing; * Underneath, between and behind equipment; * Floor mats: * Kitchen floors; * Open shelving: * Drawers and cabinets; * Metal legs of tables/prep spaces; * Interior and exterior of Rubbermaid drawers; and * Drains under sinks.The following items have been or are being repaired:* Small holes in walls throughoutkitchens;* Reach in refrigerator with large crack indrawer;* Significant floor damage under sink inKitchen 2:* Multiple cupboard/cabinets/shelvingwith exposed porous wood;* Window seal in house 1 kitchen withnon smooth surface for cleaning;* Countertops with visible damage andsigns of ware in multiple areas;* Dining room chairs with un-smoothsurfaces with damage to outer layer ofseating surfaces;These items have been discarded and new ones purchased:c. Multiple sauté pansd. Multiple plastic spatulas, other utensils and hot pads in poor repair are ordered and being replaced. e. All undated food and expired food has been discarded.f. Thermometer purchased for the refrigerator in dining room of house 1g. All dry good items will be stored in secure bins to ensure that they are free from contamination. All dry goods without open dates have been discarded. Expired dry goods have been discarded. The scoops are no longer stored in the bins.h. Aprons have been ordered and caregiving staff have all been trained to wear aprons during meal service to create aclean barrier as a mechanism to preventpossible spread of infectious agents.i. Additional staff have been hired to relieve PIC and to ensure that all food and supplies are put away immediately and are not on the floor according to food code.2. All staff will go through training on proper cleaning, food storage, and infection prevention control.All supplies will be closely monitored to ensure they are in good repair, and if not, will be discarded immediatley.Kitchen cleaning task sheets are being implemented immediately.3. Daily walk throughs and weekly monitoring of Kitchen Book w/temps, task sheets, etc.4.The Dietary Manager and the Executive Direcor1. What actions will be taken to correct the rule violation for each example/resident? 1. All listed items have/are in the process of being repaired or replaced:? Cabinets, cupboards and shelving with exposed porous wood, all Houses. ? Windowsill in House 1 non-smooth surface for cleaning.? Countertops with visible damage and signs of wear all Houses. ? Dining room chairs with un-smooth surfaces and damage to the outer layer of seating surface all Houses. ? Will be replacing the refrigerator/freezer, non-working unit removed.? Marking facility date, for use within 7 days. ? All resident food items will be dated with open/expiration date and resident identifier. ? All staff food items will be placed in a designated refrigerator for staff with an open/expiration date and staff identifier. ? Weekly menus will be posted in designated areas with alternative menu. Copy of weekly menu and alternative menu will be offered to each resident. ? Aprons readily available for all staff, prior to entering the kitchen area. Education with documentation of date, training and sign off.? Hairnets readily available for all staff, prior to entering the kitchen area. Education with documentation of date, training and sign off.2. All-Staff Meeting will be held to review Kitchen Binder: Cleaning schedule- ways to identify and report uncleanable surfaces, Food Safety/Handling: Proper labeling, wearing of hairnets, beard nets, and aprons. Monitoring will occur regularly.3. We will monitor with daily spot checks and weekly audits.4. The RCC, Dietary Manager, Executive Director and Regional Director will be responsible for monitoring. ????? All listed items below are/have been replaced/repaired/purchased or moved: * Cupboards/cobinets/shelving with exposed porpus wood. (being update with material that provides a cleanable surface)* Refridgerator H2 (not same as freezer from initail visit) being replaced. * Thermometer purchesed* All eggs moved to bottom shelf* Raw meats moved/seperated to prevent potential cross contamination while being stored. Items listed below have been added to daily task sheets. To be monitored for compliance by dietary manager 3x weekly.* Drawers, cabinates, cupboards cleaned/wiped out. * Wipe out inside/ouside of refridgators (including under the drawers. * Items found without date marking use in 7 days. * Items found in refidgerator without dates and identifiers for staff or residents.* Access to resident menues in Houses 2/3.All items listed below reviewed with staff via ALL staff meeting 2/25/25:*Importance of having a clean enviornorment, dating all items with experation date * List of experation date durations posted in each kitchen. * (A) The following areas were in need of repair; * Large hole/damage to wall behind the door in the kitchen of house 2 oRepaired and new door stopper installed.* Large area in ceiling above the reach in refrigerator with water damage, paint and ceiling peeling/cracking. o Area has been inspected, repaired and repainted. (B) The following items were needing cleaning; * Reach in refrigerators and/or freezers in house 1, house 2 and house 3 o Tasks ares part of cleaning task sheets and will be monitored for compliance by Excutive Director and/or Dietary Manager daily.(C) Multiple items were found in refrigerators without facility date marking for use within seven days. Multiple potentially hazardous food items were observed opened and did not contain open dates as required per rule. (D) Multiple items were found in refrigerators, identified by staff as for specific residents, without dates or resident identifiers. Multiple food items were found past seven days or were observed without dates but with noticeable decomposition indicating they were well past seven days or not safe for for residents. o New labeling process. Labels will be placed upon arrivel. Once item is pulled/opened, label will be filled out with identifier/date open/use by date. This process will address C, D and F . Dietary Manager and Excutive Director to check daily for proper labeling. o Training to be provided to all staff on new process. (E) Refrigerator in house one thermometer was checked at 10:30 am and was found at 50 degrees Fahrenheit. Staff 2 indicated the facility had just been putting away stock about one hour before. Surveyor placed their thermometer in the refrigerator and when checked at 11:00 am both the facility thermometer and the surveyor's thermometer both read well above 41 degrees at 50 degrees and 51.5 degrees respectively. A food item was checked and the temperature was at 49.3 degrees. Facility logs were reviewed and no temperature was documented for that refrigerator for that morning. Staff 1 (Administrator) and Staff 2 (Dietary Manger) were instructed that any potentially hazardous non shelf stable food products stored in that refrigerator that were found above 41 degrees would need to be discarded. Staff 1 and Staff 2 voiced understanding. o All items were disposed of. Tempature monitoring was done for 48hrs before restalking to ensure tempature was maintaining. Once restocked no further issues have been noted. (F) Open package of hard boiled eggs was not closed and were stored open to potential contamination. There was no date opened on the package. Multiple items were observed in reach in refrigerators that did not have a label of what the food product was and the product was not clearly identifiable. o New labeling process. Labels will be placed upon arrivel. Once item is pulled/opened, label will be filled out with identifier/date open/use by date. This process will address C, D and F . Dietary Manager and Excutive Director to check daily for proper labeling. o Training to be provided to all staff on new process. Monthly RD oversight to ensure compliance for at minimum 90 days.

Refer to C240 Refer to C240Refer to C 240.

Refer to C240Refer to C240 Refer to C240Refer to C 150 and C 240.

What actions will be taken to correct the ruleviolation? Incident was reported to local APD. · How will the system be corrected so this violation willnot happen again?In-service to be held regarding proper procedure forabuse reporting, incident report completion andtemporary service plan/alert charting.· How often will the area needing correction beevaluated and who is assigned to evaluating thechanges?The progress notes will be reviewed weekly, Incidentreports each business day, and TSPs each business day.· Who on your staff will be responsible to see that allthe corrections are completed and monitored?The RCC and Executive Director will be responsible.

What actions will be taken to correct the ruleviolation? All areas of concern are being addressed, parts ordered, etc. Maintenance Director working on corrections.· How will the system be corrected so this violation willnot happen again?Regular walk throughs will be performed to observe environmental concerns by the Maintenance Director as well as the Executive Director· How often will the area needing correction beevaluated and who is assigned to evaluating thechanges? Maintenance Director will review each working day and report to Executive Director. Both the Maintenance Director and Executive Director will do weekly walk throughs together.· Who on your staff will be responsible to see that allthe corrections are completed and monitored?The Executive Director will ensure walk throughs are occurring and areas needing addressed are taken care of.

What actions will be taken to correct the ruleviolation? All TSPs and progress notes reviewed to ensure proper documentation being done. ED/LPN will be making weekly notes on all temporary and significant change of conditions. Staff training provided on TSPs, Incident Reports as well as daily documentation.· How will the system be corrected so this violation willnot happen again? The Executive Director/LPN will review TSPs and progress notes weekly, as well as ensure that she provides a weekly nursing note on all short term and significant changes of conditions.· How often will the area needing correction beevaluated and who is assigned to evaluating thechanges? Daily review of TSPs and Incident Reports by the RCC and ED, Weekly progress notes review and documentation by the ED.· Who on your staff will be responsible to see that allthe corrections are completed and monitored? The Executive Director

What actions will be taken to correct the ruleviolation? Fire Drill forms reviewed and Maintenance Director instructed on appropriate documentation as well as instruction on how to evacuate. Fire Safety training done at the all staff meeting.· How will the system be corrected so this violation willnot happen again? All Fire Drills/Evacuations will be documented. The Maintenance Director will then turn the form into the Executive Director who will determine if all of the required information is there and then sign off if so. If not, the drill will be re-done in the same month.· How often will the area needing correction beevaluated and who is assigned to evaluating thechanges? Drills and Fire Life Safety will be reviewed monthly.· Who on your staff will be responsible to see that allthe corrections are completed and monitored? The Maintenance Director and Executive Director

What actions will be taken to correct the ruleviolation? All doors in house 1 and 3 will be painted and repaired.· How will the system be corrected so this violation willnot happen again?Regular walk throughs will be performed to observe environmental concerns by the Maintenance Director as well as the Executive Director· How often will the area needing correction beevaluated and who is assigned to evaluating thechanges? Maintenance Director will review each working day and report to Executive Director. Both the Maintenance Director and Executive Director will do weekly walk throughs together.· Who on your staff will be responsible to see that allthe corrections are completed and monitored?The Executive Director will ensure walk throughs are occurring and areas needing addressed are taken care of.

What actions will be taken to correct the ruleviolation? Door chimes installed on all exit doors, Call lights will be tested regularly.· How will the system be corrected so this violation willnot happen again? Maintenance Director will test all door chimes to ensure that they are working monthly, each call light will be tested monthly as well and data kept on a log.· How often will the area needing correction beevaluated and who is assigned to evaluating thechanges? All chimes and call lights will be checked monthly.· Who on your staff will be responsible to see that allthe corrections are completed and monitored? The Maintenance Director and Executive Director

Refer to POC for: C 231, C 240, C 420, C 513, and C 555

What actions will be taken to correct the rule violation?Letters sent out to individuals needing training with the policy and annual training requirments per OAR's, and all employees training will be completed. · How will the system be corrected so this violation willnot happen again? New staff will not be permitted to work the floor until all pre-service trainings are complete. Training Completion Spreadsheet will be reviewed prior to scheduling any new staff. Training spreadsheet will be reviewed each month to ensure monthly trainings are being completed and a total of 16 hours of training will be done annually.· How often will the area needing correction beevaluated and who is responsible for the evaluation?RCC will review the staff training spreadsheet prior toscheduling any new staff. The BOM will enter dates oftraining completion into the spreadsheet and alert RCC of those staff members who have not completed the monthly training.· Who on your staff will be responsible to see that allcorrections are completed/monitored? The RCC and Executive Director

Refer to POC for C 270