**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of a facility policy titled Policy and Procedure for Oxygen Administration the facility failed to ensure the oxygen tubing for Resident Identifier (RI) #4 was changed weekly. This affected one of one resident sampled for respiratory care. Findings Include: A review of a facility policy titled Policy and Procedure for Oxygen Administration with a date of 07/2016 revealed, .Procedure: . Change the . cannula/mask tubing at least weekly, date and initial the bottle on 3-11 PM and as needed (PRN) whenever it is changed. Resident Identifier (RI) #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Adult Failure to Thrive and Cardiomegaly. A review of RI #4's Physician Orders for the month of April 2021 revealed, . Oxygen (O2) at two liters (2L) per nasal cannula (NC) as needed for shortness of breath (SOB) . On 04/12/21 at 5:21 PM, the surveyor observed the resident's oxygen in use at 2 liter. The tubing was dated 03/31/21. On 04/13/21 at 11:16 AM, an observation was made of RI #4's oxygen in use. The date on the tubing remained 03/31/21. On 04/13/21 at 2:55 PM, another observation was made of RI #4's oxygen in use with the tubing dated 03/31/2021. On 04/15/21 at 8:30 AM, an interview with Employee Identifier (EI) #15, a Registered Nurse (RN) Supervisor was conducted. EI #15 was asked, what date did she observe on RI #4's oxygen tubing the day before (04/14/21). EI #15 replied, March 31, 2021. EI #15 was asked, according to the facility's policy how often should the oxygen tubing be changed. EI #15 stated, weekly. EI #15 was asked, what should have been done regarding RI #4's oxygen tubing. EI # 15 said, the tubing should have been changed on the 6th. EI #15 was asked, why was it important to change the tubing on the oxygen concentrator. EI # 15 replied, to prevent infection. On 04/15/21 at 9:23 AM, an interview with EI #14 a Licensed Practical Nurse (LPN) Charge Nurse was conducted. EI #14 was asked, what date did she observe on RI #4's oxygen tubing. EI #14 said, March 31, 2021. EI #14 was asked when should RI #4's oxygen tubing be changed. EI #14 stated, every Wednesday on 3-11 PM shift by the Charge Nurse. EI #14 was asked, when should RI #4's oxygen tubing have been changed. EI #14 replied, April 7, 2021. EI #14 was asked, why was it important to change out the oxygen tubing timely. EI #14 stated, it could become infected with germs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of facility policy titled Incontinent Care and Catheter Care Using Disposable Wipes the facility failed to ensure Employee Identifier (EI) #16 , Certified Nursing Assistant (CNA) changed gloves after removing the soiled brief and before applying a clean brief while providing incontinent care to Resident Identifier (RI) # 58. This affected RI #58, one of one sampled residents reviewed for bladder and bowel incontinence. Findings include: A facility document titled Incontinent Care and Catheter Care Using Disposable Wipes with a revised date of 12/2012 revealed . PROCEDURE: .2. Apply gloves . 4. Female- clean entire perineal area . 9. Remove and dispose of gloves, wash hands. Apply new gloves. 10. Apply new dry incontinence pad . 12. Remove gloves and wash hands . RI #58 was admitted to the facility on [DATE]. On 4/13/21 at 9:17 AM, an observation was made of EI #16, CNA providing incontinent care to RI #58. EI #16 did not change gloves after removing the soiled brief and before applying the clean brief. EI #16 touched the resident's bed covers, call light, and curtain while wearing the same soiled gloves. On 4/14/21 at 12:09 PM an interview was conducted with EI #16. EI #16 was asked, while providing incontinent care for a resident with a brief wet or soiled with urine, when did the staff providing care change gloves. EI #16 replied, after finishing the procedure and if staff have touched anything outside of the resident's brief, then staff changed gloves. EI #16 was asked, should she change gloves after removing a wet or soiled brief and before applying the clean brief. EI #16 replied, yes. EI #16 was asked, on 4/13/21 while providing incontinent care to RI #58, when did she change gloves. EI #16 replied, she did not change gloves during the procedure. EI #16 was asked, why was it important to change gloves after removing a wet or soiled brief and before applying the clean brief. EI # 16 replied, infection control, to stop the spread of infection and germs. EI #16 was asked, who was responsible to ensure incontinent care was provided according to policy and infection control standards. EI #16 replied, herself and supervisor, which was EI #17, Registered Nurse (RN), Assistant Director of Nursing (ADON). EI #16 was asked, what was the potential harm to a resident when a staff member removed a soiled brief and provided perineal care and with same gloves applied clean brief and touched the call light. EI #16 replied, re-spread germs from dirty brief to clean brief. On 4/14/21 at 12:28 PM an interview was conducted with EI #17, ADON/ RN Supervisor for the Hall. EI #17 was asked, when providing incontinent care, when should staff change gloves. EI #17 replied, when the gloves get soiled or moving from dirty to clean. EI #17 was asked, when should a staff member providing incontinent care not change gloves after removing a brief wet with urine and before applying the clean brief. EI #17 replied, never. EI #17 was asked, what was the potential harm to a resident when a staff member removed a soiled brief and provided perineal care and then with the same gloves applied a clean brief and touched the call light. EI #17 replied, contamination, she touched clean areas with dirty gloves. EI #17 was asked, why was it important to change gloves after removing a wet or soiled brief and before applying the clean brief. EI #17 replied, they did not want to contaminate or do anything that might cause infection.

Based on observation, interview and review of facility policies titled Labeling & Dating, Use and Storage of Food Brought in by Family and Visitors, Policy-Expired Foods in Refrigerator, and a facility document titled Labeling & Dating Rules, the facility failed to ensure: 1. that Bacon and Sausage Links in the walk-in cooler were dated with open date and in a sealed package; 2. broken eggs were not placed on top of unbroken eggs and 3. the air conditioning exhaust vent above clean trays and cups used for resident meals was not covered with a thick layer of dust. The facility further failed to ensure all food items in the unit refrigerators contained a name and date and that refrigerators were clean. These deficient practices had the potential to affect all 115 residents that received meals from the facility kitchen. Findings Include: A review of a facility document titled Labeling & Dating revealed, .2. Refrigerated storage- a. All items must have a received date and to be used or discarded by the appropriate expiration date of the product. d. Every item which has been opened must have an opened date and use by date. Find the appropriate use by date from the Label & Dating Rules chart. A review of a facility document titled Labeling & Dating Rules revealed All Items Must be Sealed, Dated Labeled . Every item which has been opened must have an opened date. Every item which has been removed from the freezer to thaw, must have a thaw date. A review of a facility policy titled Use and Storage of Food Brought in by Family and Visitors with a date of 6/18 revealed Policy Explanation and Compliance Guidelines: . 2. All food items that are . brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator.d. If not consumed within 3 days, food will be thrown away by facility staff. A review of a facility document titled Policy-Expired Foods in Refrigerator with a date of 1-5-17 revealed Housekeeping will check for expired items in refrigerator. Fridays are the assigned day for inspection . No name items will be discarded when checked. No date items discarded when checked. Refrigerator will be wiped out at this time. On 04/12/21 at 5:12 PM, during the initial kitchen tour an observation was made of a ceiling vent covered with a solid layer of dark gray dust with clumps of dust hanging in between vent slots. Air was noted to be blowing through the vent as evidenced by hanging clumps of dust were moving. Below the vent were drying racks containing bowls and coffee mugs. On 04/12/21 at 5:15 PM, an observation was made of the walk-in cooler. In the cooler was a cardboard box containing bacon. The surveyor lifted the lid of the box and observed bacon in plastic packaging that was opened and unsealed. There was no open date on the box or plastic packaging. Employee Identifier (EI) #19, a cook, was asked when the box of bacon was opened. EI #19 replied, she could not tell but it was probably opened that day when kitchen staff were prepping bacon for breakfast the next day. EI #19 was asked to look in the box of bacon and tell surveyor what she saw. EI #19 replied, that the package of bacon was open and there was no open date. EI #19 was asked what should be done when a box of bacon was opened. EI #19 replied, it needed to be wrapped and dated with open date. An observation was made of a box of Country Sausage links. The box was open, and the plastic packaging was unsealed and there was no open date. EI #19 was asked when the box of sausage was opened. EI #19 replied, she did not know but when they opened things they wrap it up and put a date sticker on it. An observation was made of a box of pasteurized eggs. Inside the box, on top was a gray divider with moist egg yolk on it, under the divider on top of a layer of eggs, were two broken eggs leaking egg white and yolk. An observation was made of a box of 37 yogurt cups in the original box, the box read Best if used by March 21, 2021. EI #19 was asked what does Best if used by March 21, 2021 mean. EI #19 replied, that was the expiration date and the yogurt cups should have been thrown out. On 04/13/21 at 8:15 AM, an observation was made of the unit 3E refrigerator. Inside the refrigerator there was a 2 liter bottle of soda partially filled that did not have a date or name on it, one bottle of salad dressing that had been opened with there was no date or name on it and a plastic grocery bag that contained an opened bag of pizza rolls that was not dated and had no name on it. On 04/13/21 at 9:05 AM, a second observation was made of the air conditioning vent in the kitchen. The vent was still covered with dust and clumps of dust observed moving due to air movement. EI #9, Kitchen Manager was asked what the area under the vent was used for. EI #9 replied, it was part of the tray line where they put clean trays. There was also several crates of glasses and bowls in the same area. On 04/14/21 at 5:09 PM, an interview was conducted with EI #10, District Kitchen Manager regarding the dirty air conditioning vent over the dishes on the tray line. EI #10 was asked to look at the vent and describe what he saw. EI #10 replied, he saw lots of dust accumulated. EI #10 was asked what was under the vent. EI #10 replied, dishes. EI #10 was asked who was responsible for cleaning the vent. EI #10 replied, maintenance but kitchen staff must tell them it needs cleaning. EI #10 was asked what the risk was by having a dirty vent over the serving area. EI #10 replied, the dust could drop in the dishes. EI #10 was asked how the dirty vent above the clean trays and dishes could affect the residents. EI #10 replied, it could contaminate the dishes food was served on. On 04/15/21 at 7:20 AM, an observation was made of the 2nd Hall unit refrigerator. Inside the refrigerator was a dried yellow substance on the back of the refrigerator, as well as the bottom. There was a glass jar of dip that had a name on it but no date, and a stainless-steel drink container with a glove over the top of it. EI #11, a Registered Nurse (RN) was asked what should be done when putting food items in the refrigerator. EI #11 replied, it should have the name and date on it and it should be wrapped or covered. EI#11 was asked who was responsible for cleaning the refrigerator. EI #11 replied, 11p-7a shift nurse and it was supposed to be done weekly. EI #11 was asked what should be done with items with no labels. EI #11 replied, the items should be thrown out. 04/15/21 at 8:10 AM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked who the refrigerators on the units were for. EI #2 replied, the residents and staff. EI #2 was asked what the policy was on cleaning the unit refrigerators. EI #2 replied, the refrigerators should be defrosted and cleaned weekly and as needed. EI #2 was asked what should be done when putting outside food and drinks in the unit refrigerators. EI #2 replied, food should have a name on it and dated. 04/15/21 at 9:10 AM, an interview was conducted with EI #13, Maintenance Manager. EI #13 was asked who was responsible for cleaning the air conditioning vent in the kitchen. EI #13 replied, dietary notified them when it needed cleaning. EI #13 was asked when it was supposed to be cleaned. EI #13 replied, there is nothing on the cleaning tier to say when it must be cleaned. EI #13 was asked why it was important to have a clean air conditioning vent. EI #13 replied, for the air that comes flowing through it. EI #13 was asked how a dirty air conditioning vent in the kitchen could affect the residents. EI #13 replied, it would not affect the residents because it was not over the food or anything. 04/15/21 at 10:00 AM, an interview was conducted with EI #9. EI #9 was asked What should be done after a box of bacon is opened and the plastic packaging is opened. EI #9 replied, put an open date on it and wrap up so it is not exposed. EI #9 was asked why it was important for the plastic packaging to be sealed. EI #9 replied, so air would not get in it, and no cross contamination. EI #9 was asked what should be done with broken eggs. EI #9 replied, discard, throw them away, cannot be used if broken. EI #9 was asked what the risk was if broken eggs were leaking yolk and egg white. EI #9 replied, Salmonella was possible. EI #9 was asked who was responsible for checking expiration dates on food. EI #9 replied, she was. EI #9 was asked what should be done with expired food. EI #9 replied, should be thrown away. EI #9 was asked how it could affect the residents if served expired yogurt. EI #9 replied, it could make them sick. EI #9 was asked who was responsible for ensuring that food stored in the cooler is stored properly. EI #9 replied, the stock person or the kitchen manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A review of the facility's policy titled, Hand Hygiene Policy and Procedure, with a revised date of 06/17 revealed: Purpose: Hand hygiene is recommended to reduce the transmission of infection to residents, staff and visitors in the health-care setting. Procedure: . 3. Perform hand hygiene after contact with blood, body fluids, mucous membranes, . between resident contacts, . prior to donning and after gloves are removed. and when otherwise indicated to avoid transfer of organisms to other residents or environments. 4. It may be necessary to perform hand hygiene between tasks and procedures on the same resident to prevent cross contamination of different body sites. Resident Identifier (RI) #18 was re-admitted to the facility on [DATE], with diagnoses of Alzheimer's Disease, Diabetes Mellitus II, and Gastrostomy. RI #109 was re-admitted to the facility on [DATE], with diagnoses to include Encephalopathy, Alzheimer's Disease, and Dementia. On 10/9/19 at 3:46 p.m., Employee Identifier (EI) #7, a Licensed Practical Nurse, was observed leaving the medication cart to get lancets. EI #7 returned to the medication cart and placed the lancets inside the medication cart. EI #7 did not wash her hands prior to preparing medications for RI #109. On 10/9/19 at 3:58 p.m., EI #7 entered RI #109's room. EI #7 did not wash her hands before or after touching the resident, before or after applying gloves, after giving eye drops or before administering nasal spray. EI #7 did not wash her hands after she left the room and returned to the medication cart. EI #7 placed the eye drops and the nasal spray inside the medication cart. EI #7 touched the computer, the mouse, and the medication cart. EI #7 proceeded to move over to the other medication cart and started preparing medications for RI #18. EI #7 went into RI #18's room and did not wash her hands prior to applying gloves or after giving an injection. On 10/09/19 at 4:42 p.m. an interview was conducted with EI #7. EI #7 was asked, what should have been done when she returned to the medication cart each time, before preparing medications. EI #7 stated, I need to wash my hands. After third time of sanitizing, I wash my hands. EI #7 was asked, what should have been done before she put gloves on. EI #7 stated, I should wash my hands. EI #7 was asked, what should be done after removing gloves. EI #7 stated, Wash my hands. EI #7 was asked, did she do that every time. EI #7 stated, Not in (RI #109's) room, I took my gloves off after each eye (drop) and didn't wash hands before doing nasal spray. EI #7 was asked, what should be done before touching the resident. EI #7 replied, Wash Hands. EI #7 was asked, if she had done that. EI #7 stated, No I didn't. Based on observations, interviews, record review and review of a facility policy titled Incontinent Care and Catheter Care Using Disposable Wipes and Hand Hygiene Policy and Procedure, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA), Employee Identifier (EI) #9 did not place a blanket on the bare floor to use as a barrier for soiled washcloths when providing incontinent care to (Resident Identifier) RI #133 on 10/09/19; and 2) a medication nurse washed her hands after removing soiled gloves, before and after touching RI #18 and RI #109, and before returning to the medication cart to prepare medications on 10/09/19, during the evening medication pass administration. These deficient practices affected RI #133, one of one sampled resident observed for incontinent care and RI #'s 18 and 109, two of five residents observed during medication administration. Findings Include: 1) Review of a facility policy titled, Incontinent Care and Catheter Care Using Disposable Wipes, with a revised date of 12/12, revealed the following: . PROCEDURE : . 7. Place soiled items in/on a bag/barrier . RI #133 was admitted to the facility on [DATE], with the diagnoses of Muscle Weakness and Dementia. RI #133's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/28/19, revealed RI #133 was assessed as having a score of 5 on the Brief Interview for Mental Status, indicating severely impaired cognition. RI #133 was also assessed as being totally dependent on staff, with one person physical assist, for personal hygiene. On 10/09/19 at 2:59 p.m., the surveyor observed a staff member push RI #133 in his/her wheelchair into RI #133's room. The staff member assisted RI #133 to bed and placed a blanket over RI #133. On 10/09/19 at 3:03 p.m., RI #133's assigned CNA, EI #9, entered RI #133's room with several washcloths. EI #9 placed the washcloths at the foot of RI #133's bed along with a box of gloves and a clean adult brief. EI #9 gloved, removed the blanket from off of RI #133 and placed the blanket at the foot of the bed. After removing RI #133's sweat pants and retrieving a basin of water from RI #133's bathroom, EI #9 removed the blanket from the foot of the bed, placed it on the bare floor, then proceeded to provide incontinent care for RI #133, placing the soiled washcloths on top of the blanket. On 10/09/19 at 3:23 p.m., the surveyor conducted an interview with EI #9. The surveyor asked EI #9 where did she place the washcloths after she finished cleaning RI #133 during the incontinent care. EI #9 said on the blanket on the floor. The surveyor asked EI #9 where should the blanket and used washcloths have been placed. EI #9 said they could have been placed at the foot of the bed. On 10/10/19 at 1:46 p.m., the surveyor conducted an interview with EI #10, the Registered Nurse Unit Manager/ADON (Assistant Director of Nursing). The surveyor asked EI #10 where should the CNAs place dirty linen and washcloths after they have provided incontinent care. EI #10 said there should have been something on the bed to place the dirty linen in. The surveyor asked EI #10 should the linen and washcloths be placed on the floor. EI #10 said no. The surveyor asked EI #10 what could this be considered when placed on the bare floor. EI #10 said an infection control issue.