**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the facility's policy titled, Abuse Prevention, and the Alabama Department of Public Health online Incident Reporting System, the facility failed to ensure Employee Identifier (EI) #2, Admissions Coordinator did not exploit Resident Identifier (RI) #1 for personal gain by becoming the beneficiary on RI #1's life/burial insurance policy (face value of $20,000). This deficient practice affected RI #1; one of three sampled residents reviewed for exploitation. Findings include: The facility's policy titled, Abuse Prevention with a revised date of [DATE], revealed, POLICY: . to promote a dignified existence for all residents; free from . exploitation . Exploitation- means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats and/or coercion. RI #1 was readmitted to the facility on [DATE]. and expired in the facility on [DATE]. The Alabama Department of Public Health Online Incident Reporting System form dated [DATE], documented, . Narrative summary of incident: (NAME OF GUARDIAN) AND RESIDENT REPRESENTATIVE OF (NAME OF RI #1), CALLED ADMINISTRATOR [DATE] INQUIRING AS TO IF FACILITY HAD A LIFE INSURANCE POLICY ON (NAME OF RI #1). EXPLAINED THAT WE DO NOT DO THAT. SHE THEN ASKED IF FACILITY WAS AWARE THAT (NAME OF EI #2) HAD A LIFE INSURANCE POLICY ON (NAME OF RI #1) WHERE SHE WAS THE BENEFICIARY. FACILITY WAS NOT AWARE OF SUCH AND TOLD HER THAT I WOULD BEGIN AN INVESTIGATION. TODAY, WHEN (NAME OF EI #2) WAS INTERVIEWED SHE STATED THAT SHE HAD PAID (NAME OF RI #1)'S POLICY PREMIUMS TO PREVENT IT FROM LAPSING AND CONFIRED THAT SHE WAS THE BENEFICIARY. SHE WAS TOLD IMMEDIATELY THAT WAS INAPPROPRIATE . On [DATE] at 9:48 AM, a phone interview was conducted with RI #1's Guardian ad litem (appointed) who has kids for RI #1. She stated she became aware EI #2 was the beneficiary of RI#1's policy when she was going through some paperwork and saw a suspicious piece of paper and called the insurance company. The Guardian stated EI #2 has not done anything for RI #1's kids since RI #1's death and she has not spoken with EI #2. On [DATE] at 10:21 AM, a phone interview was conducted with EI #2, (2nd Former admission Coordinator). EI #2 stated she had been knowing RI #1's family for years. EI #2 said RI #1's dad was paying the premium on the policy but had died that year and no one was paying the premium and the policy was about to lapse. EI #2 stated she called RI #1 in the office and asked him/her about the policy and was told that sisters had a policy on him/her. They (EI #2 and RI #1) called and verified that sister indeed had a policy. EI #2 stated RI #1 asked her if she would pay for the policy just in case his/her sisters fall through. EI #2 stated she asked RI #1 was he/she sure because policy was about to lapse, and they needed to let the insurance company know that he/she will pay it. EI #2 stated she told RI #1 that he/she would have to sign, and he/she stated no problem because he/she knew she would make sure everything would be taken care of. EI #2 stated she became the beneficiary and she started paying for the policy. EI #2 stated the amount of the policy was $20,000 and she had cashed it in. She admitted she had not done anything for RI #1 children at this time and she had paid off the balance of the funeral. A second phone interview was conducted with EI #2 on [DATE] at 4:30 PM. EI #2 stated she started paying the premium of RI#1s policy in May. She stated all RI #1 had to do to make her the beneficiary was to sign the beneficiary form. EI #2 admitted she did not talk to anyone at the facility about RI #1 wanting her to start paying the premium on the policy and becoming the beneficiary until after RI #1's death and funeral. EI #2 admitted she never told family she had an insurance policy on RI #1 and there were several opportunities to let them know. She stated RI #1's guardian called the facility and spoke with her and asked if the facility had a policy on RI #1. EI #2 stated she informed RI #1's Guardian the facility does not do such things like that, and she was going to call her because she had something to talk to her about. EI #2 stated the reason she did not say anything to Guardian at that time about her having a policy was because she had a family member in the office. She stated she did not tell the family the date of RI #1's death because there were other people in the room. EI #2 stated she went to the funeral to inform family of the policy; however, she did not get around to it. EI #2 stated RI#1's guardian was rude to her when she tried to talk with her. EI #2 admitted after the funeral she did not try to reach out to family anymore because she felt RI #1's sisters and guardian were on the same accord. EI#2 stated she finally contacted the funeral home in February, and she paid the balance of $5,500 owed on RI #1's funeral. EI #2 stated reflecting back she guess her becoming beneficiary of RI #1's policy could be considered financial abuse. On [DATE] at 3:44 PM, a phone interview was conducted with EI #3, (1st Former admission Coordinator/Marketing). EI #3 said she became aware EI #1 had a policy on RI #1 when she told her it was something weighing heavy on her heart. EI #3 stated, EI #2 asked should she do anything for RI #1's daughters. EI #3 told her to talk with EI #1, Administrator but she did not report this to Administrator. EI #3 stated she remember RI #1 coming into the office and EI #2 talking with him/her about a policy lapsing. EI #3 said RI #1 stated he/she didn't think he/she needed it because his/her sisters had a policy. EI #3 said EI #2, and RI #1 call his/her sister and verified she indeed had a policy on RI #1. The admission Coordinator (EI #3) stated that was the last she knew of the concerns or conversation of the policy. EI #3 stated a facility staff member becoming beneficiary of a resident's policy could be considered taking advantage of a resident. EI #3, went on to say she knew RI #1 loved his/her daughters and would have wanted to make sure they were taken care of. On [DATE] at 5:14 PM, an interview was conducted with EI #4, Registered Nurse (RN)/ MDS Coordinator. EI #4 stated EI #2 mentioned to her after the funeral that she was the beneficiary of RI #1's policy. EI #4 stated EI #2 said RI #1 suggested that she become the beneficiary since she was paying the policy. EI #4 stated RI #1 was able to make competent decisions, however admitted that it was inappropriate for a staff member to become beneficiary of a resident's policy. EI #4 said at the time EI #2 told her about the policy, she (EI #4) did not see it as abuse. On [DATE] at 3:36 PM, a phone interview was conducted with funeral director. The funeral director stated EI #2 came to the funeral home and never disclosed she was in possession of a policy for RI #1. The funeral director said EI #2 finally reached out to him months later to notify him about the policy she had on RI #1. The funeral director stated at that time there was still a balance owed ($5,500) on RI #1's funeral which EI #2 paid. On [DATE] at 6:00 PM, an interview was conducted with EI #1, Administrator. She stated she became aware of EI #2 being beneficiary of RI #1's policy when his/her guardian called to asked if facility had a policy on RI #1. The Administrator stated she was then told that EI #2 had a policy on RI #1. The Administrator (EI #1) stated guardian informed her she found some papers in RI #1's belonging. EI #1 stated she went to talk to EI #2, and she admitted she was paying the premium on a policy for RI #1 and was the beneficiary. EI #1 stated EI #2 said she did it because she thought she was helping RI #1. EI #1 stated her concern was EI #2 was not upfront with the family when they came to pick up RI #1's things from facility and at the funeral. EI #1 stated even though RI #1 was competent to make decision, staff are not to become beneficiary of anything. EI #1 stated EI #2 was aware of the abuse policy pertaining to exploitation and part of her job was to review resident's rights with resident/families upon admission. EI #1 stated EI #2 made promises to RI #1 in exchange for being the beneficiary of his/her policy. This definition fits exploitation. ************************* Once the allegation of exploitation was reported to the facility's Administrator, the following corrective actions were implemented EI #2 was placed on suspension on [DATE]. EI #2 turned in her resigned effective [DATE]. On [DATE], the facility initiated an investigation into the allegation; the facility was able to substantiate the allegation of exploitation. Around [DATE], the Administrator began an audit of all admission files for all in-house residents and any files that were in the buildings for residents that may have been discharged (where EI #2 was designated power of attorney, any guardianship papers, insurance papers. On [DATE], held training with Service, Activities, and Business Office personnel regarding handling of residents' funds, the abuse policy and procedure- specifically the exploitation definition. ************************* After review of the facility's investigation file, in-service/education records and staff interviews, the facility implemented corrective actions from [DATE] to [DATE], thus past non-compliance was cited. This deficiency was cited because of the investigation of complaint/report number AL00042370.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the anticoagulation medication for Resident Identifier (RI) #31 was coded on the Quarterly Minimal Data Set (MDS) dated [DATE]. RI #31 was admitted to the facility 8/2/18 and readmitted [DATE] with a diagnosis of Acute embolism and thrombosis deep veins of right lower extremity. A review of RI #31's February 2019 Physician Orders revealed: . 9/14/18 .APIXABAN (Eliquis) 5 MG (milligrams) tablet give one tablet PO (by mouth) BID (two times a day) This medication was indicated for acute deep vein thrombosis of the right lower extremity. A review of RI #31's April 2019 Physician Orders revealed: . 9/14/18 .APIXIABAN tablet 5 MG give one tablet PO BID . A review of RI #31's Quarterly MDS, with an Assessment Reference Date of 2/3/19, revealed under Section N . Medications Received Anticoagulant . not checked as resident receiving. On 4/24/19 at 12:00 PM, an interview was conducted with EI # 6, Registered Nurse (RN) MDS Coordinator. The surveyor and EI #6 reviewed the MDS dated [DATE] and EI #6 was asked if RI #31 was currently receiving an anticoagulation medication. EI #6 replied, yes Eliquis. EI #6 was asked how long the resident had been receiving the Eliquis. EI #6 replied, since 9/14/18. EI # 6 was asked when the MDS was completed on 2/3/19, was RI #31 receiving the Eliquis. EI #6 replied, yes. EI #6 was asked if the anticoagulation medication was coded on the 2/3/19 MDS. EI #6 replied, no. EI #6 was asked if the Eliquis should have been coded on the MDS. EI #6 replied, yes. EI #6 was asked who was responsible for coding the anticoagulation medication on the MDS. EI #6 replied, she was. EI #6 was asked if the MDS dated [DATE] was an accurate assessment. EI #6 replied, no, not that part. EI #6 was asked what was the risk in the MDS not coded accurately. EI #6 replied, no harm to the resident, it was only not accurately coded for those that review the record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of facility policies titled, Medication Administration Oral Medications and Medication Administration NG/G Tube, the facility failed to ensure : 1. Licensed staff did not handle the scoop inside the Questran Powder medication with her bare hand then return the scoop inside the container when preparing the medication for Resident Identifier (RI) #45; 2. Licensed staff did not touch the inside of the crush medication bag with his bare hand during medication pass for RI #99, and 3. Licensed staff did not place RI #55's eye drop medication on the glove box in the bathroom without a barrier, while he washed his hands and then place the top of the eye drop container on the resident bedside table while he administered the medication without a barrier, then returned the top to the eye drop container. This affected two of five licensed staff observed for medication pass; one of one resident observed for medication by mouth, one of one resident observed for medication by gastrostomy tube and one of two residents observed for eye drop medication. Findings Include: 1. A review of a facility policy titled, MEDICATION ADMINISTRATION ORAL MEDICATIONS with a reviewed date of 2/2013 revealed: .PROCEDURE: .6.Do not touch medication with fingers or hands . RI # 45 was readmitted to the facility 4/1/19 with diagnosis of unspecified noninfective gastroenteritis and colitis. A review of a Physician Order Sheet revealed .1/11/19 Questran Powder Light give one dose daily . On 4/24/19 at 8:43 AM the surveyor observed Employee Identifier (EI) #4, Licensed Practical Nurse (LPN) prepare and give medications to RI #45. Among the medications EI #4 prepared was Questran Powder light. EI #4 opened the container of Questran Powder and took the scoop, that was inside the container, with her bare hand and placed one scoop full in a medication water cup. EI #4 then returned the scoop to the inside of the container, on top of the remaining Questran Powder. On 4/24/2019 at 9:36 AM, an interview was conducted with EI #4. EI #4 was asked where was the scoop for the Questran Powder stored. EI #4 replied, inside container. EI #4 was asked how should she handle the scoop stored inside a medication container. EI #4 replied, with gloves. EI #4 was asked if she wore a glove to handle the scoop. EI #4 replied, no. EI #4 was asked what was the harm in not wearing gloves to handle the scoop stored inside the medication containers. EI #4 replied, contamination. 2. A review of a facility policy MEDICATION ADMINISTRATION NG/G TUBE (Nasogastric/gastrostomy) with a revised date of 1/2017 revealed: . PROCEDURE: .2. Wash hands. Prepare medication and supplies. 4 Apply gloves. Explain procedure to resident. 5. Check tube placement . RI # 99 was admitted to the facility on [DATE] with a diagnosis of Spastic Quadriplegic Cerebral Palsy. A review of RI #99's Physician Orders for April 2019 revealed: . Tylenol 10 CC (cubic centimeters) Elixir, . Baclofen 10 MG (milligram Tablet, . Phenobarbital 32.4 MG Tablet, . Depakote (Valproic Acid) . Give 10 cc by Tube . On 4/24/19 at 4:05 PM, the surveyor observed EI #5, LPN prepare RI #99's medication. EI #5 prepared the following medication to be given by gastrostomy tube: Depakote (Valproic acid) liquid 10 cc, Tylenol (Acetaminophen) Liquid 10 cc, Phenobarbital 32.4 mg Tablet and Baclofen 10 mg tablet. EI #5 prepared the liquid medication. EI #5 took a medication crush bag and placed each tablet in a separate bag and crushed each tablet. EI #5 was observed putting his finger in each of the medication crush bags after crushing the tablet as he opened the bag to place each crushed tablet in the medication cups. EI #5 took the medication in the resident's room, washed his hands and put on gloves. EI #5 then pulled the privacy curtain, turned off the feeding pump, checked for tube placement, administered the medications and then flushed water in the tube, with the same gloves he touched the privacy curtain and feeding pump with. On 4/24/19 at 4:40 PM, an interview was conducted with EI #5, LPN. EI #5 was asked what was the practice on crushing medication. EI #5 replied, he should place the medication in a bag and crush it. EI #5 was asked how should he handle the bag. EI #5 replied, he should touch only the outside. The surveyor explained observing him touching the inside of the bag when he opened the bag to pour the medication in the medication cup. EI #5 was then asked if he should have touched the inside of the bag. EI #5 replied, no. EI #5 was asked what was the harm in touching the inside of medication crush bag. EI #5 replied, contamination. EI #5 was asked when should he put on gloves then close the privacy curtains and administer the medications, with the same gloves he touched the privacy curtain and feeding pump. EI #5 replied, he should not. EI #5 was asked what was the harm in touching the inside of a medication crush bag with his bare hand and touching the privacy curtain with the same gloves, then give medications. EI #5 replied, cross contamination. 3. RI #55 was readmitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. A review of RI #55's April 2019 Physician Orders revealed: . 4/15/19 .Artificial Tears to Both Eyes 1 Drop in Each Eye tid (Three times a day) For Dry Eyes . On 4/24/19 at 4:29 PM, EI #5 was observed preparing Artificial Tears eye drops for RI #55. EI #5 took the Artificial Tears bottle from the medication cart and entered the resident's bathroom. EI #5 placed the bottle of Artificial tears in the bathroom on top of a glove box, without a barrier, and washed his hands. EI #5 put on gloves, removed the top from the eye drop bottle and placed it on RI #55's bedside table, without a barrier. EI #5 administered one drop to each eye. EI #5 then picked up the top from the bedside table and placed it back on the Artificial Tears eye drop bottle. EI #5 removed his gloves, washed his hands and returned the medication to the medication cart. On 4/24/19 at 4:40 PM, an interview was conducted with EI #5. EI #5 was asked what was the procedure on where to place an eye drop bottle while washing your hands. EI #5 replied, on a barrier. EI #5 was asked where did he put the eye drop bottle while he washed his hands. EI #5 replied, on top of the glove box in the bathroom. EI #5 was asked what was procedure on where to place the top of eye drop container while he administered the drops. EI #5 replied, he placed it on RI #55's bedside table. EI #5 was asked if he placed the top on a barrier. EI #5 replied, no. EI #5 was asked should the top have been placed on a barrier. EI #5 replied, yes. EI #5 was asked what was the harm in placing the eye drop container on the glove box in the bathroom and the top for the eye drop container on the resident table without a barrier. EI #5 replied, contamination from the glove box and from the table to the top and the container of the eye drop bottle. On 4/25/19 at 11:04 AM, an interview was conducted with EI #1, Director Of Nursing, in the absence of the infection control nurse. EI #1 was asked what was the best practice for handling the scoop that was inside a medication container. EI #1 replied, put gloves on to remove it. EI #1 was asked should a nurse handle the scoop with bare hands. EI #1 replied, no. EI #1 was asked what was the harm in the nurse handling the scoop with a bare hand. EI #1 replied, contamination. EI 31 was asked where should the nurse place an eye drop container while in the bathroom washing their hands. EI 31 replied, on a barrier. EI #1 was asked when should a nurse place a container of eye drops on the glove box in the bathroom. EI #1 replied, they should not without a barrier. EI #1 was asked what was the harm in placing a container of eye drops on the glove box in the bathroom without a barrier. EI #1 replied, possible contamination with bathroom-feces, urine, or other. EI #1 was asked where should the nurse place the top of the eye drop container while administering the drops. EI #1 replied, anywhere, with a barrier. EI #1 was asked when should the nurse place the top on the bedside table without a barrier. EI #1 replied, never. EI #1 was asked what was the harm in placing the eye drop container/top without a barrier. EI #1 replied, contamination. EI #1 was asked how should a nurse handle the crush bag when crushing medication. EI #1 replied, near the bottom or center of the bag on the outside. EI #1 was asked when should a nurse touch the inside of a bag for crushing medications. EI #1 replied, never. EI #1 was asked what was the harm in the nurse touching the inside of the bag medication was crushed in. EI #1 replied, contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of a facility policy titled, Conducting an Accurate Resident Assessment, the facility failed to ensure Resident Identifier (RI) #59's admission Minimum Data Set (MDS) assessment, dated 02/13/18, was coded for the diagnosis of Depression and RI #59's use of the antidepressant medication Prozac. This affected RI #59, one of 22 residents whose MDS assessments were reviewed. Findings Include: A review of a facility policy titled, Conducting an Accurate Resident Assessment, with a revised date of 11/17 revealed: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, . RI #59 was admitted to the facility on [DATE], with a diagnosis to include Dementia in other Diseases without Behavioral Disturbances. A review of RI #59's admission MDS assessment, with an Assessment Reference Date (ARD) of 02/13/18, did not reveal the diagnoses of Depression and RI #59's use of an Antidepressant was not coded. A review of RI #59's May 2018 Physician Orders revealed the following: . PROZAC 10 MG (milligram) GIVE ONE CAPSULE PO (by mouth) QDAY (every day) . This order had a start date of 02/06/18. A review of RI #59's February, March and April Medication Administration Records (MARs) for 2018, were reviewed and indicated RI #59 had received Prozac every day. On 05/24/18 at 8:55 a.m., Employee Identifier (EI) #5, a RN (Registered Nurse)/MDS Coordinator was asked if RI #59 was receiving an antidepressant medication. EI #5 replied, yes. EI #5 was asked what antidepressant was RI #59 receiving and when was it started. EI #5 replied, RI #59 was receiving Prozac every day and it started on 02/06/18. EI #5 was asked should the Prozac be coded on the MDS. EI #5 replied yes. EI #5 was asked if the Prozac was coded on the MDS. EI #5 replied no. EI #5 was asked why was the Prozac not coded on the MDS. EI #5 replied, it was an oversight. EI #5 was asked would RI #59's MDS be considered accurate if the antidepressant was not coded on the MDS. EI #5 replied no, not in the medication section.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #63's Skin Breakdown care plan was revised after RI #63 was identified to have redness around his/her sacral area. This deficient practice affected RI #63, one of 22 sampled residents whose plans of care were reviewed. Findings Include: RI #63 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of Hemiplegia Following Cerebral Infarct Affecting The Left Nondominant Side. RI #63's Physician's Order dated 03/30/18, documented: . 2) Clean reddened area around sacral area c (with) wound cleanser, apply TAO (Triple Antibiotic Ointment) & (and) cover c gauze pads & Duoderm qd (every day) . On 05/23/18 at 2:15 p.m., the surveyor reviewed RI #63's care plans. There was no care plan noted which addressed the redness to RI #63's sacral area or the use of a Duoderm dressing to the area. On 05/23/18 at 2:24 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Treatment Nurse. The surveyor asked EI #2 did RI #63's Skin Breakdown care plan address the redness and use of the Duoderm to his/her sacral area. EI #2 looked at RI #63's care plans and stated, No Ma'am. When asked should there be a care plan addressing the redness, EI #2 replied yes. The surveyor asked EI #2 what would be the purpose of having a care plan to address the redness to RI #63's sacral area. EI #2 said so people would be aware that RI #63 had the redness and know what treatment was to be provided.

Based on observations, interviews and a review of facility policies titled, Cleaning Instructions: Food Preparation Appliances, and Handwashing Guidelines-Dietary Employees, the facility failed to ensure: 1) crumbs were not in the bottom of the mixer bowl; 2) the bottom of the Robo Coupe blender was free of water; and 3) a dietary staff member washed her hands when entering the kitchen. This had the potential to affect 95 of 105 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Cleaning Instructions: Food Preparation Appliances, with no date revealed: Policy: It is the policy of this facility to handle small food preparation appliances, such as blenders, food processors, and mixers, will be cleaned and sanitized following each use . On 05/22/18 at 4:09 p.m., during the initial tour of the kitchen, the surveyor observed a mixer bowl with crumbs in the bottom of it and around the protective covering of the mixer. On 05/24/18 at 2:22 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Dietary Manager. EI #3 was asked what was inside of the mixer bowl. EI #3 replied, a few crumbs. EI #3 was asked why were crumbs in the mixer bowl. EI #3 replied, it was an oversight. EI #3 was asked who was responsible for making sure the mixer bowl was cleaned. EI #3 replied, the person that used it. EI #3 was asked what did the facility's policy say regarding the cleanliness of equipment. EI #3 replied, after they used the equipment it was supposed to be properly washed, sanitized and air dried. EI #3 was asked what was the potential harm when dirty equipment was used to prepare food for the residents. EI #3 replied, it could cause cross contamination. 2) On 05/22/18 at 4:09 p.m., during the initial tour of the kitchen, the surveyor observed the Robo Coupe blender on the base with water in the bottom of it. On 05/24/18 at 2:28 p.m., the surveyor conducted an interview with EI #3. EI #3 was asked what was in the bottom of the Robo Coup blender. EI #3 replied, water. EI #3 was asked why was there water in the bottom of the Robo Coup blender. EI #3 replied, a dietary aide did not allow it to air dry. EI #3 was asked who was responsible for making sure the Robo Coup blender was free of water. EI #3 replied, the person who used it was responsible for washing it, sanitizing and allowing it to air dry. EI #3 was asked what did the facility's policy say regarding the cleanliness of equipment. EI #3 replied, it was supposed to be washed, sanitized and air dried. EI #3 was asked was the equipment put away for future use. EI #3 replied, it was. EI #3 was asked what was the potential harm when dirty equipment was used to prepare food for the residents. EI #3 replied, contamination. 3) A review of a facility policy titled, Handwashing Guidelines-Dietary Employees, with no date, revealed: Policy: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink located within the kitchen that is specifically for handwashing. Procedures: . 6. Frequency of Handwashing: . a. Every time an employee enters the kitchen; . On 05/23/18 at 11:23 a.m., during the lunch meal tray line, when food temperatures were being taken, EI #4, a Dietary Aide came into the kitchen and did not wash her hands. EI #4 was observed by the three compartment sink with the tray cards. EI #4 left the kitchen and returned with the food carts. EI #4 did not wash her hands when re-entering the kitchen. On 05/24/18 at 2:34 p.m., an interview was conducted with EI #3. EI #3 was asked when should staff wash their hands in the kitchen. EI #3 replied, after using the bathroom; from one task to another; when touching any part of the body; when leaving the kitchen and coming back in; when changing gloves and when handling raw food products. EI #3 was asked how often should hands be washed when entering the kitchen. EI #3 replied, every time staff entered the kitchen staff were supposed to wash their hands. 05/24/18 at 02:45 pm., an interview was conducted with EI #4. EI #4 was asked when should she wash her hands in the kitchen. EI #4 replied, any time she finished something, and before she started something else she was supposed to wash her hands. EI #4 was asked how often should she wash her hands when entering the kitchen. EI #4 replied, every time she came into the kitchen she was supposed to wash her hands. EI #4 was asked what did the facility's policy say regarding washing hands in the kitchen. EI #4 replied, staff were supposed to wash their hands anytime they entered the kitchen and anytime they started something else. EI #4 was asked what was the potential harm to the residents when she did not wash her hands in the kitchen. EI #4 replied, her hands could pick up germs.