**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, resident record reviews, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, the facility failed to ensure Resident Identifier (RI) #64's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2023 was accurately coded for weight loss or gain and RI #114's quarterly MDS assessment with an ARD of 10/24/2023 was accurately coded to reflect RI #114 did not receive an anticoagulant medication during the assessment period. This had the potential to affect two of 29 sampled residents whose MDS assessments were reviewed. Findings include: The Long-Term Care Facility Resident Assessment Instrument User's Manual documented: . Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. K0300: Weight Loss . Code 2, yes, .: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, . K0310: Weight Gain . Code 2, yes, .: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, . N0415: High-Risk Drug Classes: Use and Indication . E. Anticoagulant ( . warfarin, heparin, or low-molecular weight heparin) . Do not code antiplatelet medications such as aspirin . as N0415E, Anticoagulant . 1.) RI #64 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #64's annual MDS assessment with an ARD of 11/15/2023 reflected RI #64 had experienced both weight loss and weight gain. RI #64's weights were reviewed and from June 2023 to November 2023 RI #64 gained five percent or more from October to November and had not lost five percent in one month or 10 percent in six months. On 11/30/2023 at 2:18 PM an interview was conducted with the MDS Coordinator. The MDS Coordinator said, the annual MDS with an ARD of 11/15/2023 for RI #64 should not have been coded for both weight loss and weight gain. The MDS Coordinator said, when the MDS was completed RI #64 had a weight gain and the MDS was not coded accurately and the significance of accurately coding the MDS was to reflect the resident's current condition. 2.) RI #114 was admitted to the facility on [DATE]. RI #114's quarterly MDS assessment with an ARD of 10/24/2023 documented the use of anticoagulant medication. Review of RI #114's October 2023 physician orders revealed an order for aspirin but no orders were found for anticoagulants that would need to be coded on the MDS assessment. On 11/30/2023 at 2:25 PM, an interview was conducted with the MDS Coordinator who said, the quarterly MDS with an ARD of 10/24/2023 for RI #114 was coded for the use of anticoagulant medication. The MDS Coordinator stated, RI #114 was not actually receiving anticoagulant medication and the MDS assessment was coded incorrectly. The MDS Coordinator said, RI #114 was prescribed aspirin, which was not classified as an anticoagulant medication and the significance of accurately coding the MDS was to reflect the resident's current condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, resident record review, and review of the facility policy Promoting/Maintaining Resident Dignity During Mealtimes, the facility failed to ensure Resident Identifier (RI) #38's lunch meal was not served on Styrofoam on 11/27/2023 and the staff delivering laundry gained permission to enter residents' rooms before entering on 11/27/2023. This had the potential to affect RI #38, one of 10 sampled residents observed at mealtime and residents residing on the 200 hall. Findings include: On 11/27/2023 at 12:53 PM, Laundry Aide (LA) #18 was observed delivering resident's clothing to room numbers 213, 211, 210, 208, 207, 204, 203, and 202, entering each room without knocking, announcing herself, or waiting for permission before entering. On 11/28/2023 at 8:40 AM during an interview with LA #18, she said, she should knock or ask to enter a resident room before going in. When the laundry aide was asked if she knocked on residents' doors before entering, she said, she did not. When asked why she did not knock or announce herself, she said she did not think about it. When the LA #18 was asked what was the harm in not knocking or asking for entry to residents rooms, she said, it would be a dignity issue. On 11/29/2023 at 9:40 AM the Laundry Supervisor #8 said, before staff enter resident rooms they should knock on the door and the concern of not knocking before entering was that it was disrespectful. A facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes, with a review date of 5/2021, documented: Policy: It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. RI #38 was admitted to the facility on [DATE]. During the lunch observation on 11/27/2023 at 12:15 PM, RI #38's meal was served on Styrofoam or plastic. RI #38 explained, they had previously switched to Styrofoam or plastic due to a recent medical diagnoses, but it was supposed to have been temporary. RI #38 expressed a preference for having meals served on a regular plate and using plastic utensils could sometimes be challenging. On 11/29/2023 at 10:00 AM the Director of Nursing (DON) was interviewed and she said RI #38's lunch meal on 11/27/2023 should have been served on a regular plate instead of an isolation tray. The DON said, the isolation tray should have ended on 11/21/2023 and it could be a dignity issue for residents to receive meals on Styrofoam instead of plates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, the Resident Council Meeting on 11/29/2023, a test tray on 11/29/2023, and a facility policy titled, Food Service, the facility failed to ensure food was served warm, palatable and enjoyable. This had the potential to affect 114 of 114 residents receiving meals from the kitchen. Findings include: The facility's undated policy, Food Service documented: . PROCEDURES: . 4. A conscientious effort is made to make the food, trays, and service as attractive as possible. Resident Identifier (RI) #22 was admitted to the facility on [DATE]. During tour of the facility on 11/27/2023 at 12:06 PM, RI #22 stated, most of the time food was cold, especially breakfast. RI #27 was admitted to the facility on [DATE]. On 11/28/2023 at 5:15 PM RI #27 was eating dinner in his/her room. When asked about the food, RI #27 said, the food was cold but he/she was going to eat it because of being hungry. RI #27 said, the food was served cold frequently. During the Resident Council Meeting, held on 11/29/2023 10:00 AM, three of 15 residents in attendance stated food was cold by the time it got to the units. A tray line observation on 11/29/2023 revealed the following: At 12:30 PM kitchen staff started plating cart one of seven. At 1:25 PM the last tray was placed on Cart seven and the test tray was placed on the cart. At 1:35 PM the last tray was served from the cart. Temperatures on the test tray were as follows: Regular: fish 103° (degrees) Farnehiet (F), Corn 110°F hushpuppies 88°F Mechanical soft meal: fish 88° F, Corn 113° F, hushpuppies 88°F Puree meal: Roast beef 114° F, Carrots 116° F, mashed potatoes 102° F. The meals were tasted and were not warm. An interview was conducted with the Dietary Manager (DM) on 11/30/2023 at 9:45 AM. The DM stated food should be served at a temperature of at least 135°. The DM stated the concern of serving cold food was it could allow bacteria to grow. A telephone interview was conducted with Registered Dietitian (RD) on 11/30/2023 at 11:50 AM. The RD stated the concern of serving cold food was the food was less palatable, less enjoyable, and there may be less intake of food if not warm.

Based on observations, interviews, the facility policy Proper Labeling of Food items , and the 2022 Food Code from the United State (U.S.) Food and Drug Administration (FDA); the facility failed to ensure: 1) food stored in the freezer was covered and sealed properly, outdated food was discarded and; 2) the temperature of blended (puree) foods was measured before serving to residents. This had the potential to affect 114 of 114 resident receiving food from kitchen. Findings Include: 1. The 2022 U.S. FDA Food Code included the following: 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: . (2) Where it is not exposed to splash, dust, or other contamination . On 11/27/2023 at 10:45 AM, during the initial kitchen tour an observation was made of food stored in the freezer. Salisbury steak was exposed to the air in an unsealed aluminum container. The lid to the container was not sealed properly and there was ice observed on the meat. The freezer contained roast beef in a plastic eight-quart container with use by 11/26/2023 date and four-quart plastic container of plain pork with use by date of 10/25/2023. An interview was conducted with Dietary Aide (DA) #20 on 11/27/2023 during the initial tour. DA #20 stated the Salisbury steak should have been covered with lid sealed. DA #20 stated the concern of the Salisbury steak not being sealed was freezer burn and further said the food had ice on it. DA #20 stated the pork with the use by date of 10/25/2023, should have been discarded before 10/25/2023 and the roast beef with the use by date of 11/26/2023 should have been discarded on 11/26/2023. DA #20 stated both foods items should not have been in the freezer beyond the use by dates. DA #20 stated the concern of outdated food being in freezer was staff could use it and food could make residents sick. An interview was conducted with the Dietary Manager (DM) on 11/30/2023 at 9:45 AM. The DM stated Salisbury steak should have been stored in its original container and properly sealed. The DM stated the concern of lid not being sealed was food poisoning and freezer burn. The DM stated outdated food should have been discarded. The DM stated the concern of outdated food being in freezer was staff could not look at date and serve food to residents. A telephone interview was conducted with the Registered Dietitian (RD) on 11/30/2023 at 11:50 AM. The RD stated food should be stored in sealed intact container. The RD stated the concern of stored food not being sealed was a reduced quality of food and opened to the risk of contamination. She stated it could be a food safety issue. The RD stated food should be discarded by use by date. RD stated the concern of outdated food being in freezer was risk of foodborne illness. 2. The 2022 U.S. FDA Food Code included the following: . 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57°C [Centigrade/Celsius] (135°F [Fahrenheit]) or above . During the tray line observation on 11/29/2023 at 11:20 AM the surveyor observed that the temperature was not measured for the prepackaged blended items on the steam bar. An interview was conducted with the Dietary Manager (DM) on 11/30/2023 at 9:45 AM. The DM stated food should be served with a temperature of at least 135 degrees Fahrenheit (F). He stated the concern of serving cold food was it could allow for bacteria to grow. The DM stated the reason the temperature for blended food was not measured was because it was prepackaged, and staff were not to pierce the containers. A telephone interview was conducted with Registered Dietitian (RD) on 11/30/2023 at 11:50 AM. RD stated prepackaged food temperature should be checked by piercing the package immediately before serving. RD stated the concern of not checking the temperature on prepackaged food is food safety, staff did not know if food was heated properly.

Based on observations, interviews, and review of a facility policy titled Hand Hygiene, Laundry/Linen Distribution, and Handling Clean Linen the facility failed to ensure: 1) staff performed hand hygiene when a Certified Nursing Assistant (CNA) delivered meal trays, picked an item off the floor, and touched a resident's food, when a Laundry Aid (LA) delivered clean linen to eight different resident's rooms on the 200 hall, and before a Laundry Assistant (LAS) handled clean linen; 2) a LAS did not hold clean linens against her personal clothing; and 3) clean linen was covered while being transported on the 200 hall. These failure had the potential to affect Resident Identifier (RI) #53, RI #25, residents on the 200 hall, and all residents in the facility who received linen from the laundry room. Findings include: The facility policy with an effective date of 02/2001 and a review/revision date of 05/2021 titled Hand Hygiene revealed . POLICY: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. PROCEDURE: . 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. An undated facility document titled Hand Hygiene Table revealed . Condition . Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred) . Between resident contacts . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled . linens . An undated facility policy titled Laundry/Linen Distribution revealed . PURPOSE: To provide guidelines for the proper distribution of laundry, linen, and resident clothing to appropriate areas . POLICY: All laundry, linen and resident clothing will be distributed and stored appropriately . PROCEDURE: 1. Use only clean laundry hampers to transport clean laundry, linen, etc. 3. Keep clean laundry carts covered with covers at all times. A facility policy with a revised date of 05/2021 titled Handling Clean Linen revealed .POLICY: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. DEFINITIONS . Linen includes sheets . and similar items . PROCEDURE: . 2. Linen can become contaminated with pathogens from contact with intact skin . or contaminated hands. 3. Separate carts will be used for transporting clean and contaminated linen. Carts will be cleaned when visibly soiled, and routinely according to facility schedule. 6. Carry clean linen with clean hands away from your body. On 11/27/2023 at 12:28 PM an observation was made of CNA #13 delivering meal trays. After CNA #13 delivered a meal tray to RI #42 and without performing hand hygiene, he entered RI #53's room, picked up a chip from the floor, picked up a blanket from a wheelchair, placed the blanket over the RI #53, and then positioned the bedside table in front of RI# 53. CNA #13 then walked to the meal tray cart, did not perform hand hygiene, picked up tray for RI #25, and then delivered and set up the meal tray for RI #25. While setting up the tray for RI #25, CNA #13 took the cover off of the plate, touched the cornbread on the tray with his bare hands, and then exited the room without performing hand hygiene. On 11/27/2023 at 12:35 PM an interview was conducted with CNA #13. CNA #13 stated that he did not perform hand hygiene by sanitizing or washing his hands after picking up the chip that was on the floor, after leaving RI #53's room, or before picking up and setting up RI #25's tray. CNA #13 stated that there was a risk for infection control for not washing or sanitizing his hands after picking up the chip off of the floor. CNA #13 stated that he should have washed his hands in between each resident. On 11/29/2023 at 08:50 AM during an observation of the laundry room, LAS #17 picked up a pillowcase from the floor and placed on a cart with cleaned linen and designated for clean linen. LAS #17 removed the pillowcase from the cart, took the pillowcase to the dirty linen room, and cleaned the linen cart. After cleaning the linen cart LAS #17 did not perform hand hygiene before she began handling clean clothing from the dryer. LAS #17 began folding sheets without gloves and without performing hand hygiene. While folding the sheets LA #17 held the sheets against her body and clothing. LA #17 folded eight flat sheets and two fitted sheets by holding the clean sheets against her clothing and without performing hand hygiene. On 11/29/2023 at 09:09 AM during an interview with LA #17 she stated she should wash or sanitize her hands between each load especially if she handled something that was dirty. LA #17 said, she did not wash or sanitize her hands after cleaning the contaminated linen cart. LA #17 stated, her gloves were considered to be dirty after cleaning the contaminated linen cart and she should have washed her hands. LA #17 stated, when folding linen, the linen should be held away from her body. LA #17 stated, clean linen should never be held against her clothing because it was a risk for germs. LA #17 stated, a pillowcase that was on the floor should not have been placed on the clean linen cart. LA #17 stated, there was a risk for spreading germs by putting the dirty pillowcase on the clean linen cart. LA #17 stated, she should have washed or sanitized her hands after picking up the pillowcase from the floor and after cleaning the linen cart. On 11/29/2023 at 09:24 AM an interview was conducted with the Housekeeping and Laundry Service Manager (HSM). The HSM stated, staff should wash or sanitize their hands before taking clothes or linen out of the dryer, and after they touched something dirty or something on the floor. The HSM stated staff should wash or sanitize hands after taking off gloves because there was a risk of infection control. The HSM stated, staff should hold clean linen at least a foot away from their body and linen should not touch their body. The HSM stated there was a risk of infection control issues if staff held clean linen against staff clothing. The HSM said staff should not pick up linen off of the floor and put it on the clean cart because there was a risk for infection. The HSM stated, clean linens should be transported covered with plastic. On 11/27/2023 at 12:53 PM, Laundry Aid (LA) #18, was observed staff bringing an uncovered clothing rack (or cart) inside the building. The front flap was up leaving the clothing uncovered. LA #18 distributed resident's clean clothing by entering residents' rooms, using hands to open the closet doors, and placing the clothing in their closets. LA #18 entered four resident's rooms without performing hand hygiene. After the fourth delivery, LA #18 returned clothes hangers from the resident's closet to the clean clothing rack. LA #18 delivered clothing to two more resident's rooms without performing hand hygiene. LA #18 returned clothes hangers from a resident's room to the clean clothing rack and then delivered clothing to two more resident's rooms without performing hand hygiene. During the surveyor's observations, LA #18 did not perform hand hygiene and did not cover the clean clothing rack. LA #18 delivered clothing to resident rooms 213, 211, 210, 208, 207, 204, 203, and 202, a total of eight residents' rooms without performing hand hygiene. On 11/28/2023 at 08:40 AM during an interview with LA #18, she said while distributing resident's clothing, she touched the closet doors and clothes hangers. LA #18 said she should have sanitized her hands before and after touching dirty items. LA #18 said carts should be covered when transported to the units and the front flap was up while she transported and distributed residents' clothing 11/27/23. The laundry aide said the harm in transporting clothing uncovered was a risk for contaminating the clean laundry. On 11/29/2023 at 09:40 AM during an interview with the Laundry Supervisor (LS), she said the laundry staff should use hand sanitizer when they entered or exited a resident's room. The LS said linens and clothing should be covered when on the hall. The LS said the risk of not washing or sanitizing hands was infection control issues, and the risk of not covering the laundry in the hallways was concerns of germs. On 11/29/2023 at 04:45 PM during an interview with the Infection Preventionist (IP), she stated, clean laundry should be held away from the staff's body and with clean hands. The IP stated, the risk of holding laundry against the body was cross-contamination. The IP said, laundry staff should perform hand hygiene before they touch laundry, after and in-between doing the laundry, and after taking off the gloves, because there was a risk for infection. The IP stated staff not washing or sanitizing their hands after cleaning a linen cart created a risk of contaminating laundry with chemicals and dirt. The IP said staff should never pick something up from the floor and put it on a clean cart while clean linen was on the cart, because it was a risk of contamination. The IP stated staff should wash their hands before and after entering a room, because there was a risk of contamination. The IP stated while serving meal trays staff should perform hand hygiene before they picked up the tray and after exiting a resident's room. The IP said staff should wash their hands when they picked up anything from the floor, because cross-contamination.

Based on interview, document review and a facility policy titled, Continuing Education, the facility failed to ensure 27 CNA's (Certified Nursing Assistants) had the required 12 hours of CEUs ( Continuing Education Units) training per year. This deficient practice affected 27 out 29 CNA's whose training records were reviewed. Findings Include: A review of a facility policy titled, Continuing Education, with an review/revision dated of 6/2001 documented: PURPOSE: To maintain sufficient continuing competence of Nurses Aides. POLICY: All Nurses Aides will be offered twelve (12) hours of continuing education per year .PROCEDURE: .3. Each must receive .twelve(12) hours .training per year . On 8/22/19 at 11:00 a.m, the Surveyor reviewed the CEU's training records for the CNA's employed by the facility from the last twelve months between their hire date (month/date). There was no documentation of the required 12 hours of CEU's, during a twelve month span, for 27 CNAs. On 8/22/18 at 11:23 a.m., an interview was conducted with EI (Employee Identifier) #1, DON (Director of Nurses). EI #1 was asked who was responsible for ensuring the CNA's had the required 12 hours of CEUS. EI #1 said the DON. EI #1 was asked what was the facility's policy regarding the CNA's having 12 hours of CEUs. EI #1 said they(CNA's) are required to have 12 hours of CEU's per year. EI #1 was asked how many of CNA's did not have the required 12 hours of CEU's. EI #1 said 26 EI #1 was asked if she had any documentation of the CNA's having the required 12 hours of CEU's. EI #1 said, No Ma'am. EI #1 was asked what was the potential concern with CNA's not having required 12 hours of CEU's per year. EI #1 said, Failure of the CNA's to provide appropriate up to date care.

Based on observations, interviews and a review of facility policies titled, Steamtable temperatures, Cleaning of food carts, and Handwashing Guidelines-Dietary Employees, the facility failed to ensure: 1) the temperatures were taken of all foods on the tray line; 2) food carts used to transport residents meals were not dirty and; 3) staff washed their hands when entering the kitchen. This had the potential to affect 113 of 113 residents who received meals from the kitchen. Findings Include: 1) Review of a facility policy titled, Steamtable temperatures, with no date revealed: .POLICY: All steamtable temperature will be checked and documented prior to food service. PROCEDURES: 1. All foods held on the steamtable will be checked and all temperature will be documented by the assigned dietary personnel prior to service. On 7/11/18 at 11:54 rice was brought to the steam table by (Employee Identifier) EI #4. Dietetic Assistant. EI #4 did not take the temperature of the rice, nor did EI #1, the Cook. On 7/11/2018 at 2:46 p.m., the surveyor conducted an interview with EI #1, the Productive Supervisor/Cook. EI #1 was asked who took the temperature of the second pan of rice. EI #1 replied, no one. EI #1 was asked how often were temperatures taken on the tray line. EI #1 replied, every time they ran out of something and had to get something else. EI #1 was asked why was it important to take food temperatures. EI #1 replied, to make sure the food was hot for the residents. EI #1 was asked what did the facility policy say regarding taking food temps on the tray line. EI #1 replied, make sure they are at the right temperature and serve the proper way. EI #1 was asked when they replenished food on the tray line should the food temperature be taken. EI #1 replied, yes ma'am. EI #1 was asked what was the potential harm to the residents when all food temperature were not taken on the tray line. EI #1 replied, she would not know the temperature of the foods. On 7/12/18 at 10:12a.m., an interview was conducted with EI #4, Dietetic Assistant. EI #4 was asked who was responsible for taking the temperatures of foods that were placed on the tray line. EI #4 replied, the cook and production supervisor. EI #4 was asked who checked the rice temperature before placing it on the steamtable on 7/11/18. EI #4 replied, EI #6, Dietary Cook. EI #4 was asked what was the potential harm to the residents when food temperatures were not taken. EI #4 replied, it would make the residents sick. EI #4 was asked did she take the temperature of the second pan of rice. EI #4 replied, no she did not. On 7/12/18 at 10:57 a.m. an interview was conducted with EI #6, dietary cook. EI #6 was asked who took the temperature of the second pan of rice when it came out of the steamer. EI #6 replied, no one took it. EI #6 was asked when foods were brought from the warmer to the tray line who took the temperatures. EI #6 replied, the cook. EI #6 was asked should food temperatures be taken when foods were brought from the steamer to the tray line. EI #6 replied, yes ma'am. EI #6 was asked why was it important that food temperature be taken. EI#6 replied, because she did not want to make anyone sick. EI #6 was asked when should food temperatures be taken. EI #6 replied, after it come out of the steamer/oven, before you get to the tray line, and every time you bring it out of the warmer, the temperatures need to be taken. 2) A review of a policy titled, Cleaning of food carts, with no date, revealed: PURPOSE: To ensure food carts are cleaned properly.PROCEDURES: Daily: 1. Clean all spills right away . On 7/10/2018 at 12:17 p.m., the surveyor observed dirty carts with food debris on them. EI #2 tray hostess, wiped food debris from the cart and a brown like substance. EI #5 wiped food debris from the cart and a white looking substance. The resident trays were being placed on the carts. After leaving the kitchen and going to the 200 hall, the surveyor observed a dirty cart with died white food substance on the hall. On 7/11/18 at 3:01 p. m., an interview was conducted with EI #2, tray hostess. EI #2 was asked what was on the food cart that she wiped down on 7/10 and 7/11. EI #2 replied, food. EI #2 was asked why was it there. EI #2 replied, they did not have time to wipe them off. EI #2 was asked how often were carts cleaned. EI #2 replied, after breakfast they washed them, after lunch they washed them and the evening shift were supposed to wash them off. EI #2 was asked why was it important that carts were cleaned. EI #2 replied, so the residents would not get sick or get germs. EI #2 was asked who was responsible for making sure carts were cleaned. EI #2 replied, the person who washed pots and pans and the 3-7 staff. EI #2 was asked were resident trays being placed on the carts. EI #2 replied, yes. EI #2 was asked where was the food debris located on the carts. EI #2 replied, on the shelves and on the side of the carts. On 7/11/18 at 3:18 p.m., the surveyor conducted an interview with EI #3, CNA (Certified Nursing Assistant). EI #3 was asked what did she observe on the carts on 7/10/18. EI #3 replied, a lot of different spots and dried food. EI #3 was asked were the carts clean. EI #3 replied, no ma'am. EI #3 was asked should resident trays be on dirty carts. EI #3 replied, no ma'am. EI #3 was asked what was the potential harm to the residents when food carts were dirty. EI #3 replied, cross contamination and germs. EI #3 was asked were the carts with resident trays on them dirty. EI #3 replied,yes ma'am. On 7/12/18 at 10:43 a.m., an interview was conducted with EI #5 Dietary Manager/Dietician. EI #5 was asked what did she observe on the carts on 07/10 and 7/11. EI #5 replied, it looked like they missed some spots of food when they cleaned it. EI #5 was asked how often were carts cleaned. EI #5 replied, after each meal service. EI #5 was asked who was responsible for cleaning carts. EI #5 replied, tray hostess', ladies who did the beverages. EI #5 was asked why was it important that food carts were cleaned. EI #5 replied, a risk of cross contamination. 3) A review of a policy titled, Handwashing Guidelines-Dietary Employees, with a date of 5/8/2017 revealed: Policy: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses.1. Frequency of Handwashing: Hands should be washed in the following situations: a. Every time an employee enters the kitchen; . On 7/9/2018 at 5:02 p.m., the surveyor met the Dietary Manager (DM) EI #5, in the hallway. When entering the kitchen the DM did not wash her hands. The following observations were made of EI #7, tray hostess, on 07/10/18: 12:12 p.m., EI #7, was observed leaving the kitchen with gloves on. 12:17 p.m., EI #7 returned to the kitchen pulling carts in. She did not wash her hands when coming back in the kitchen. 12:19 p.m., EI #7 left the kitchen again. 12:20 p.m., EI #7 returned to the kitchen and did not wash her hands. On 7/12/18 at 10:49 a.m., an interview was conducted with EI #5, DM. EI #5 was asked when coming into the kitchen on 7/9/18, did she wash her hands. EI #5 replied she did not remember if she did. EI #5 was asked why was it important that she wash her hands in the kitchen . EI #5 replied, for infection control purposes. EI #5 was asked what did the facility policy say on washing hands when entering the kitchen. EI #5 replied, hands should be washed every time an employee entered the kitchen. EI #5 was asked who should wash their hand when entering the kitchen. EI #5 replied, everyone. On 7/12/18 at 11:10 a.m., an interview was conducted with EI #7, tray hostess. EI #7 was asked when going in and out of the kitchen to deliver carts to the hall did she wash her hands when returning to the kitchen. EI #7 replied, no ma'am. EI #7 was asked why she did not wash her hands when entering the kitchen after returning from the hall. EI #7 replied, she did not know she was suppose to wash her hands. EI #7 was asked did she turn the kitchen door knob to get to the hallway with gloves on. EI #7 replied, yes ma'am. EI #4 was asked what did the facility policy say regarding washing hands in the kitchen. EI #7 replied, scrub them, use warm water, make sure you wash for 15 second, do not touch the paper towel box, use paper towel to turn water off and use a paper towel to open the door and put the paper towel in the trash. EI #7 was asked what was the potential harm to the residents when you touch dirty carts and kitchen doors with gloved hands and do not change your gloves or wash your hands. EI #7 replied, cross contamination.