Based on interviews, observations and the facility's policy titled, Foods Brought by Family/ Visitors, the facility failed to ensure food and drink items, that were in the resident's refrigerators' on the East and Wing West, were clearly distinguishable from faciity-prepared food. Specially, the resident's food was not labeled with the resident's name, and the use by date. This deficient practice affected 41 out 41 residents, who resided in the facility. Findings Included: A review of the facility policy titled, Foods Brought by Family/ Visitors, with a revised date of October 2017, revealed: . Policy Interpretation and Implementation . 7. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. b. Containers will be labeled with the residents's name, the item and the use by, date On 05/05/22 at 10:29 AM, the surveyor observed the resident's refrigerator on the East Wing accompanied by Employee Identifer (EI) #1, LPN, Licensed Practical Nurse. The surveyor observed a black bowl with a plastic lid covering with fish and hush puppies, a Snap Apple Juice 16 ounces, and a Snap Water 16 ounces. The food and drink items were not labeled. An interview was conducted with EI #1 at 10:29 AM. EI #1 was asked if the bowl with the fish and hush puppies were labeled with a name and date. EI #1 said no, it was not. EI #1 was asked if the Snap Apple Juice and Snap Water was labeled with a name and date. EI #1 said no, it was not. EI #1 was asked if the food and drink items belong to a resident. EI #1 said, yes. EI #1 was asked if the food and drink items should be labeled. EI #1 said yes. EI #1 was asked what should be on the label. EI #1 said the resident's name and the date the food was put in the refrigerator. EI #1 was asked who was responsible for ensuring the food items was labeled. EI #1 said the Nurses, CNAs (Certificate Nursing Assistant), and who ever put the food in the refrigerator. EI #1 confirmed the name and date was supposed to be put on the food and drinks. On 05/05/22 at 10:38 AM, the surveyor observed the resident's refrigerator on the [NAME] Wing accompanied by EI #2, Registered Nurse (RN)/Director of Nurses (DON). The surveyor observed a Ritz, Balance cheese and crackers snack bowl, a hot pocked in a plastic wrap and a French Vanilla monster triple shot drink 15 ml (milliters). The food and drinks items were not labeled. An interview was conducted with EI #2 at 10:38 AM. EI #2 was asked if the food and drink items, a Ritz Balance Cheese and Crackers snack bowl, a hot pocket and a French Vanilla monster triple shot drink was labeled. EI #2 said, no they were not labeled. EI #2 was asked should the food and drink items be labeled. EI #2 said they should have been labeled. EI #2 was asked what should be on the label. EI #2 said the resident's name and the date the food was put in the resident's refrigerator. EI #2 was asked what was the harm with food and drink items not being labeled. EI #2 said you do not know how long it has been in the refrigerator and the owner of the food and drink items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interviews and review of the facility policy titled, Perineal Care, the facility failed to ensure staff washed their hands between glove changes during incontinent care. This affected RI #37, one resident observed during incontinent care. Findings Include: A review of an undated facility policy titled, Perineal Care revealed: .Policy Explanation and Compliance Guidelines: All staff members involved in performing perineal care to residents will promote cleanliness, prevent infections . RI #37 was readmitted to the facility on [DATE] with a diagnosis to include Urinary Tract Infection. On 6/20/18 at 10:47 AM, Employee Indentifer (EI) #2 and EI #3, both Certified Nursing Assistants (CNA) were observed performing perineal care for RI #37. Both EI #2 and EI #3 washed their hands and put on gloves. EI #2 removed the brief from RI #37 and cleaned RI #37's front area with wipes. EI #2 removed her gloves and put on a clean pair of gloves. Both CNA's assisted to turn RI #37 on the right side. EI #3 took wipes and wiped the buttock with a smear of bowel movement. EI #3 changed gloves without washing her hands and completed the task. Both CNAs, when changing gloves, did not wash their hands. On 6/20/18 at 11:05 AM an interview was conducted with EI #2 and EI #3. Both were asked what was the policy on when to wash hands. EI #2 replied, before, after and in between care. Both were asked when should you wash your hands with glove changing. EI #3 replied, in between the glove changes. Both were asked if they washed their hands between glove changes. Both EI #2 and EI #3 replied, no. Both were asked what was the harm in changing gloves and not washing their hands before putting on new gloves. EI #2 replied, passing germs. On 6/21/18 at 8:42 AM an interview was conducted with EI #1, Director of Nursing (DON). EI #1 was asked what was the policy on washing hands with glove changes. EI #1 replied, staff should wash their hands before putting on clean gloves. EI #1 was asked what was the risk of not washing hands between glove changes. EI #1 replied, spread of infection.