Based on observation, interview, record review, and facility policy, the facility failed to maintain a quality assessment and assurance (QAA) committee consisting of the Medical Director or his/her representative. The facility failed to ensure or encourage real-time alternative methods of participation, such as videoconferencing and teleconference calls to include the Medical Director or his/her representative. The findings include: Review of the facility's policy titled, Quality Assessment and Assurance Committee, dated 10/2022, revealed the facility would maintain a QAA committee consisting of a minimum of the Administrator or representative, Director of Nursing (DON) or representative, Physician, Infection Preventionist or representative, and three facility staff. Further review revealed the QAA committee must meet at least quarterly and as needed to coordinate and evaluate activities under the Quality Assurance Performance Improvement (QAPI) program. During an interview with the Administrator, on 08/08/2024 at 4:30 PM, she stated the Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist (IP), Social Services Director (SSD), and Clinical Coordinator, Medical Director, and she were members of the QAA committee. She stated that the Medical Director or his representative had not attended the quarterly meetings. She stated the Medical Director had been provided the results of those meetings and would make recommendations as needed. She further stated the Medical Director was invited by the ADON prior to the QAPI meetings but since she had been in the Administrator position the Medical Director or his representative had not attended any meetings via phone, video-conferencing, or in-person. In an interview with the Medical Director, on 08/08/2024 at 5:16 PM, he stated he was not aware of the terms regarding QAA or QAPI. He further stated after he was provided a definition of what QAPI was and entailed, he had not understood what the QAA committee was or what his role was on the committee. He stated he was not aware of the quarterly meetings, but if the facility had invited him to a meeting he would generally have gone to the facility to attend. The Medical Director stated he was not aware of receiving any email or letter regarding QAA or QAPI meetings. In an interview with the ADON (Assistant Director of Nursing) on 08/08/2024 at 5:30 PM, she stated she had emailed the Medical Director for the last quarterly QAPI meeting (copy of email provided). She stated the prior two letters for the invitation for the previous two quarterly QAPI meetings were sent via postal mail (facility had not retained copies of those letters to provide). She stated she had never received a confirmation email or phone call that the Medical Director was planning to attend. The ADON stated she was not aware of any staff following up with the Medical Director related to attending the meetings. In an interview with the Administrator, on 08/08/2024 at 5:40 PM, she stated she was only aware that the Medical Director had been notified but had not understood the regulatory requirement for the Medical Director or his representative to attend the meeting because he was active in reviewing and making recommendations. She stated she was astonished when informed that the Medical Director stated he not aware of the QAA committee or the QAPI program. She stated she would ensure moving forward that the Medical Director was fully informed of the QAA committee and QAPI so that he understood his role and the importance of his participation in those meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility's policy and resident's medical record, the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infections for one of two sampled residents (Resident #22 (R22)). Staff failed to perform hand hygiene when indicated; contaminated residents' clothing and bed linens; and, failed to prevent the contamination of clean dressings. The findings include: Review of the facility's policy titled, Infection Control Practices in Maintaining Sanitary Environment in the Prevention of Development and Spread of Contagious Viruses and Pathogens, dated 12/2006 and revised 03/2019 revealed the facility will maintain infection control practices that promote a sanitary environment to prevent the development and spread of contagious viruses and pathogens. Review of the facility's policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 revised 08/2022 revealed the facility would ensure that optimal skin care was provided to all residents according to Clinical Practice guidelines as per the Agency for Health Care Research and Quality and The National Pressure Ulcer Advisory Panel. Further review revealed the clean technique would be utilized for dressing changes, unless otherwise indicated per physician's order. The facility would follow Standard Precautions in regards to wound care. Steps included: 1. Bring equipment to resident room; . 3. Prepare a clean, dry work area at bedside, use disinfectant solution to prepare the work surface, cover work surface with clean dry paper or cloth towel to prevent contamination of supplies; 4. Place a trash bag at the end of the bed or within easy reach of the work area; 5. Wash hands, apply gloves; 6. Prepare/open dressing items on table; 9. Remove soiled dressing and place in trash bag; 10. Remove gloves, wash hands, and apply new gloves; 12. Clean the wound with normal saline or prescribed cleanser; 13. Pat the tissue surrounding the wound dry with a 4 x 4. 15; Apply prescribed topical agent to wound; 16. Apply wound dressing, cover the entire wound; 20. Discard gloves and all used supplies in trash bag. Remove Equipment; 21. Wash hands; and 22. Discard trash bag in bio-hazardous waste receptacle. 1. (a.) Review of the Electronic Medical Record (EMR) revealed the facility admitted R 22 on 09/16/2015 with diagnoses which included: eating disorder, impaired cognitive status, chronic schizophrenia, erratic behavior leading to multiple falls with fractures, and Stage IV pressure wound to the left gluteal area. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 99. This score indicated the resident had moderate cognitive impairment. During an observation of wound care, performed by Licensed Practical Nurse #3 (LPN3) on 08/08/2024 at 8:53 AM, of R22's left gluteal area, revealed she had covered an over bed table with clean towels. LPN3 stopped and washed her hands and donned gloves. She then opened a sterile cup and poured Dakin's solution into the cup. LPN3 then opened 2 sterile four by fours and placed them into the Dakin's solution for the wound packing. She placed a plastic trash bag beside her dressings and solution. Further review revealed she removed the dirty dressing and placed it in the trash bag on top of her clean table beside her packing. She then took off her dirty gloves and donned clean gloves without washing her hands. She cleaned the wound with wound cleanser, a sterile gauze and a Q-tip. She took the dirty Q-tip and gauze and put them in the trash bag sitting beside her clean dressings. The trash bag at this time was laying over the top of the open Dakin's soaked gauze in the sterile cup. After placing the dressing on the wound, she pulled up the resident's pants and placed the resident in her broda chair with help from an aide with her. Prior to starting the dressing change, LPN #3 unhooked the resident's Gastric-tube feeding. She removed the gastric tube cap which was stuck to the top of the IV fluid pole. An interview with LPN3 on 08/08/2024 at 9:30 AM, after the dressing change, she stated she should have washed her hands more. She stated she was unaware she had contaminated the dressing with the trash bag on the clean table. LPN3 stated it was her practice to secure the cap of the G-tube on the IV pole for safe keeping. During an interview with the Infection Control Registered Nurse (IP/RN) on 08/07/2024 at 11:33 AM, she stated there was ongoing education regarding hand washing and infection control. The IP/RN stated on 08/08/2024 at 10:00 AM that she expected all staff to follow the hand washing and wound care policies as written. She further stated she expected the nurses to use clean technique and not contaminate the wound during the dressing change. During the interview, she stated she expected the cap of the feeding tube to be placed in a place where it would not be contaminated. During an interview with the Director of Nursing (DON) on 08/07/2024 at 3:40 PM she stated she expected all nursing staff to use proper handwashing practices and to follow the facility's polices regarding wound care and hand washing. She stated she expected nursing staff to place the cap of the feeding tubing in a clean area when removed for feeding. During an interview with the Administrator on 08/07/2024 at 4:40 PM she stated she expected all staff to use proper handwashing practices and provide wound care per policies.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents' right to privacy was honored (Resident #93). Staff were observed to walk by Resident #93's room while he/she was up in his/her wheelchair, in his/her doorway, with his/her gown pulled up exposing his/her incontinent brief; however, the staff failed to assist Resident #93 in covering him/herself up to ensure the resident's privacy per facility policy. The findings include: Review of the facility policy, Resident Rights, last revised March 2017, revealed the facility will protect and promote the rights of each resident. Resident rights will be recognized and honored to insure a dignified existence and self-determination. The policy further revealed the facility must promote care for residents in a manner that maintains and enhances each individuals dignity and respects his/her individuality. Record review revealed the facility admitted Resident #93 on 10/15/08, with diagnoses which included Schizophrenia and Depression. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/01/19, revealed the facility coded Resident #93's Brief Interview of Mental Status (BIMS) score as ninety-nine (99) and was unable to assess Resident #93's cognition level. Observations on 11/21/19 at 9:13 AM and 9:28 AM, revealed Resident #93 was sitting up in his/her wheelchair in the doorway of his/her room, with his/her shirt pulled up, and incontinent brief exposed. Continued observation revealed one (1) resident and two (2) staff members passed by the resident's room; however, neither staff took any action to ensure the resident's privacy. Interview with Certified Nurse Aide (CNA) #4 on 11/21/19 at 9:39 AM, revealed staff should assist in covering the resident up or change the resident's clothes. CNA #4 stated she had put pants on the resident after noticing he/she was in a gown. Interview with Licensed Practical Nurse (LPN) #2 on 11/21/19 at 9:40 AM revealed all staff should honor a resident's privacy. LPN #2 stated Resident #93 was care planned to have pants on when up because he/she leans forward so much causing a gown to slide upward, exposing his/her leg and brief. Interview with the Director of Nursing (DON) on 11/21/19 at 3:03 PM, revealed she expected staff to ensure residents have their right to privacy. She stated if staff noticed a resident was uncovered and possibly exposing themselves, staff should cover the resident or change his/her clothing.

Based on interview, record review and review of the facility policy, it was determined the facility failed to ensure a written notice of transfer/discharge, which included the reason for the resident's transfer, was sent to a representative of the Office of the State Long-Term Care Ombudsman for two (2) of twenty-two (22) sampled residents (Residents #80 and #88 ) Record review for Residents #80 and #88, revealed no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident transfers. The finding include: Review of the facility policy titled, Placement, Discharge, Planning, and Transfers, last reviewed July 2016, revealed while on leave/bed hold, the facility will notify the resident and/or representative of the transfer or discharge and the reasons for the move. 1. Record review revealed the facility admitted Resident #80 on 08/15/13, with diagnoses which included Seizure Disorder and Psychotic Disorder. Review of a Nurses Note dated 09/10/19, revealed Resident #80 was sent to the emergency room (ER) for evaluation and treatment. However; further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. 2. Record review revealed the facility admitted Resident #88 on 08/04/09, with diagnoses which included Hypertension and Peripheral Vascular Disease. Review of a Nurses Note dated 10/01/19, revealed Resident #88 was sent to the emergency room (ER) for evaluation and treatment. However; further review of the medical record revealed there was no documented evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. Interview with Social Service Director on 11/21/19 at 11:05 AM, revealed the Ombudsman requested to only be notified if a resident was officially discharged from the facility. She stated the facility had failed to follow the regulation, as they were not notifying the Ombudsman of all transfers. Interview with the Director of Nursing (DON) on 11/21/19 at 3:03 PM, revealed she was not aware the facility was to notify a representative of the Office of the State Long-Term Care Ombudsman office of all transfers and discharges. The DON further stated the facility would ensure this misunderstanding would be corrected.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents with wounds in the selected sample of twenty-two (22) residents received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan (Resident #41). Licensed staff failed to provide wound care in accordance with professional standards of practice for Resident #41. The findings include: Review of the facility policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 and reviewed June 2017 revealed, The facility will ensure that optimal skin care is provided to all residents according to Clinical Practice guidelines as per the Agency for Health Care Research and Quality and the National Pressure Ulcer Advisory Panel. Any resident identified with an actual skin care problem or identified as a high risk for pressure injury or skin injury with have an individualized plan of care developed and initiated per the licensed nurse to address specific goals and treatment protocols which implements individualized interventions, monitors effectiveness of interventions, and modifies interventions and approaches. An individualized monitoring or interventions for skin care will be according to the physician/clinician's order or resident's plan of care. Dressing and Treatment: Clean technique will be utilized for dressing changes unless otherwise indicted per physician orders. Routine injury cleaning is to be done with all dressing changes and as per physician orders. Normal saline will be used for cleansing unless otherwise indicated per the physician. Record review revealed the facility admitted Resident #41 on 01/10/14 with diagnoses which included Schizophrenia, Paranoid Type, Dementia with Behavioral Disturbances, Psychosis and Mood Disorder. Review of the Quarterly MDS assessment, dated 09/25/19 revealed the facility coded the BIMS score as ninety-nine (99) which indicated the resident was severely cognitively impaired and unable to be interviewed. Further review of the MDS revealed the resident was totally dependent of care with ADL's. Review of the Comprehensive Care Plan for Impaired Skin Integrity dated 04/25/17 revealed an interventions to provide wound care as ordered.; however, observation of wound care to Resident #41's skin tear/wound/surgical wound on 11/21/19 at 9:00 AM revealed LPN #1 failed to clean over bed table prior to laying down barrier or after care, to wash hands between glove changes, and to wear gloves when she opened and removed dressings with fingers and placed on abdomen prior to placing on leg. Interview on 11/21/19 at 2:00 PM with LPN #1 revealed she should have washed her hands between glove changes and used clean gloves to open dressings. She stated she also should have put clean dressing on a barrier. Interview with the Director of Nursing (DON) on 11/21/19 at 3:00 PM revealed she expected the nurse to use good hand hygiene during wound care and dressing changes.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents with pressure ulcers in the selected sample of twenty-two (22) residents received the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection. Licensed staff failed to provide pressure ulcer care for Resident #30 according to professional standards of practice which resulted in the Nurse contaminating the wound with feces. The findings include: Review of the facility policy, Nursing Interventions: Skin/Wound Care Protocol dated 12/1998 and reviewed June 2017 revealed, The facility will ensure that optimal skin care is provided to all residents according to Clinical Practice guidelines as per the Agency for Health Care Research and Quality and the National Pressure Ulcer Advisory Panel. Any resident identified with an actual skin care problem or identified as a high risk for pressure injury or skin injury with have an individualized plan of care developed and initiated per the licensed nurse to address specific goals and treatment protocols which implements individualized interventions, monitors effectiveness of interventions, and modifies interventions and approaches. An individualized monitoring or interventions for skin care will be according to the physician/clinician's order or resident's plan of care. Clean technique will be utilized for dressing changes unless otherwise indicated per physicians's orders. Record review revealed the facility admitted Resident #30's on 03/16/18 with diagnoses which included Bipolar I with Psychotic Features, Type II Diabetes Mellitus, Pressure Ulcer to Bilateral Heels and Coccyx, and Convulsions. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/09/19 revealed the facility coded the Brief Interview of Mental Status score (BIMS) as ninety-nine (99) which indicated the resident had severe cognitive impairment and was unable to be interviewed. Further review of the MDS found the resident to be totally dependent of care for Activities of Daily Living. Review of the Comprehensive Care Plan for Impaired Skin Integrity dated 03/19/18 with an interventions for wound treatments as ordered; however, observation of wound care on 11/21/19 at 9:14 AM revealed License Practical Nurse (LPN) #1 failed to provide wound care according to professional standards of practice. LPN #1 failed to clean table prior to laying down barrier, opened dressings without washing hands nor did she have gloves on, did not wash hands after removing the dirty wound dressing on left hip, and cleaned the wound with normal saline, with same dirty gloves. LPN #1 then stated she forgot to get skin prep so she removed her gloves, obtained the skin prep out in hallway, then put on clean gloves without washing his/her hands, then put on skin prep. She placed the clean dressing on with stool surrounding area where resident had a BM. LPN #1 then removed the dressing to coccyx with that had stool on it and contaminated the coccyx wound with feces. LPN #1 went to sink to wet wash clothe to clean and removed gloves and replaced without washing hands. There was stool on the gloves she removed. She then prepared for the coccyx dressing. She cleaned the wound with normal saline and applied dressing. Further observation revealed dirty soiled wash cloths were still under resident touching clean dressings. Interview with LPN #1 on 11/21/19 at 2:00 PM revealed she should have washed hands during, before, and after wound care. She stated she also should have stopped dressing change when resident had a BM and completely cleaned before continuing with wound care so that the wound would not have been contaminated. Interview with the Wound Care Nurse on 11/21/19 at 1:57 PM revealed she expected the over bed table to be cleaned prior to placing barrier. She stated she expected the nurse to wash hands and don gloves and not touch the dressings with bare hands. She also revealed she expected all staff to follow the resident's care plan as written. Interview with the Director of Nursing (DON) on 11/21/19 at 3:00 PM revealed she expected the nurse to wash her hands between glove changes and not to contaminate the bedding. The DON stated she also expected good hand hygiene to be used during wound care and staff to follow care plans as written.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents received the appropriate care and services to prevent urinary tract infections to the extent possible (Resident #30) related to poor hand hygiene during indwelling catheter care. The findings include: Review of the facility policy Care of the Indwelling Catheter to Prevent Infections dated March 2001 and revised April 2017 revealed the facility will closely monitor all residents with long term indwelling catheter placement for signs and symptoms of infection and urosepsis. A resident will not be catheterized unless their clinical coneition demonstrates that the catheterization is necessary. Residents with an indwelling catheter will receive perineal and catheter care every shift and following every bowel movement. Catheter care includes cleaning at least the first four inches of the catheter closest to the insertion site plus the perineal area with soap and water. The tubing will be assessed after care to ensure it is not kinked, clamped, and ensure tubhing is not touching the floor and the appropriate drainage bag is in place. Review of the procedure for Giving Female Perineal Care revealed to perform hand hygiene, put on disposable gloves, separate the labia and clean downward from front to back with one stroke. Repeat steps until area is clean. Use a clean part of the washcloth for each stroke. Rinse and pat dry. Assist resident on side away from you. Wash from the vagina to the anus with one stroke. Repeat as necessary until clean with a clean area of the washcloth. Rinse and pat dry. Remove and discard the gloves. Perform hand hygiene and report and record observations. Record review revealed the facility admitted Resident #30 on 03/16/18 with diagnoses which included Bipolar I with Psychotic Features, Type II Diabetes Mellitus, Pressure Ulcer to Bilateral Hels and Coccyx, and Convulsions. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/09/19 revealed the faciltiy coded the Brief Interview of Mental Status score (BIMS) as ninty-nine (99) which indicated the resident had severe cognitive impairment and was unable to be interviewed. Further review of the MDS found the resident to be totally dependent of care for Activities of Daily Living. Observation of Resident #30's catheter care by Certified Nurse Aide (CNA) #2 and #3 on 11/21/19 at 1:25 PM revealed the resident's catheter bag was laying on the floor. Further observation revealed the CNA's failed to wash hands between soiled glove changes. Interview with CNA #2 and CNA #3 on 11/21/19 at 1:42 PM revealed they should have washed hands in between soiled glove changes. CNA #2 stated she knew the catheter bag should not be on the floor. Interview with Director of Nursing (DON) on 11/21/19 at 3:00 PM revealed she expected the staff to followthe facility policy and procedures. She stated she expected catheter bags to not be touching the floor.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure to help prevent the development and transmission of communicable diseases and infections for two (2) of twenty-two (22) sampled residents (Residents #30, and #89). In addition, the facility failed to ensure linens were transported so as to prevent the spread of infection. Observation revealed staff failed to perform handwashing to prevent infections during pressure ulcer care and catheter care for Resident #30 and catheter care and gastrostomy care for Resident #89. In addition, observation revealed staff carried a resident's clothing protector under his arm prior to placing it around a residents neck during meal service. The findings include: Review of the facility policy titled, Handwashing, last revised October 2018 revealed, handwashing is considered the single most important procedure for preventing infection or the spread of infection. Indications: when you arrive at work, before and after touching wounds, after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood or body fluids, secretions, or excretions, after touching inanimate sources that are likely to be contaminated with virulent or epidemiological important microorganisms of special clinical or epidemiologic significance; for example: multiple drug resistant bacteria, between resident contact, after handling soiled or used linens, bed pans, catheters, and urinals and after handling soiled equipment or utensils. Gloves should be used for hand contamination activities. Gloves should be removed to prevent contamination of hands during removal. Hands should be washed when the activity is completed. Gloves should be changed between residents, and may need to be changed during the care of a single resident. 1. Record review revealed the facility admitted Resident #30's on 03/16/18 with diagnoses which included Bipolar I with Psychotic Features, Type II Diabetes Mellitus, Pressure Ulcer to Bilateral Heels and Coccyx, and Convulsions. Observation of wound care on 11/21/19 at 9:14 AM revealed License Practical Nurse (LPN) #1 failed to wash hands prior to opening dressings, and failed to wear gloves; did not wash hands after removing the dirty wound dressing on left hip; and, cleaned the wound with normal saline, wearing the same dirty gloves. Further observation revealed LPN #1 removed her gloves to go out in the hallway to obtain skin prep and returned putting on clean gloves without washing his/her hands, then she applied skin prep to wound. LPN #1 went to sink to wet wash cloth, then removed gloves and replaced them without washing hands. There was stool on the gloves she removed. She then prepared for the coccyx dressing. She cleaned the wound with normal saline and applied dressing. Further observation revealed dirty soiled wash cloths were still under resident touching clean dressings. Interview with LPN #1 on 11/21/19 at 2:00 PM revealed she should have washed hands during, before, and after wound care. She stated she also should have stopped dressing change when resident had a BM and completely cleaned before continuing with wound care so that the wound would not have been contaminated. Interview with the Wound Care Nurse on 11/21/19 at 1:57 PM revealed she expected the nurse to wash hands and don gloves and not touch the dressings with bare hands. Observation of catheter care by Certified Nurse Aide (CNA) #2 and #3 on 11/21/19 at 1:25 PM revealed the catheter bag was laying on the floor. Further observation revealed the CNA's failed to wash hands between soiled glove changes and did not use appropriately good hygiene practices. Interview with CNA #2 and CNA #3 on 11/21/19 at 1:42 PM revealed they should have washed hands in between soiled glove changes. CNA #2 stated the catheter bags should not be on the floor. 2. Record review revealed the facility admitted Resident #89 on 07/29/19 with diagnoses which included Alzheimer's Disease and Schizophrenia. Observation of incontinent care for Resident #89 by CNA #1 with the assistance from LPN#1 on 11/21/19 10:35 AM revealed CNA #1 did not wash her hands prior to peri care, nor did she wash hands between glove changes. She then cleaned the front and placed all laundry in a trash bag on top of bed. Observation of gastrostomy tube care on 11/21/19 at 10:35 PM revealed LPN #1 failed failed to wash her hands during the procedure and after glove changes and also contaminated the dressing when she placed it on the resident's bedding prior to putting it at the site. Further observation revealed she also placed the soiled dressing on the bedding and the wound cleanser on the resident's bedding with no barrier in place. Interview with CNA #1 on 11/25/19 at 10:50 AM revealed she should have cleaned Resident #89 from clean to dirty. She revealed she did not realize she did not wash her hands. She revealed she should not have placed her dirty linen on the bed as the dirty linen fell out of the bag onto the bedding. Interview with LPN #1 on 11/25/19 at 1:55 PM revealed she should have used proper hand washing and knows to change gloves when they are soiled. She also revealed she should have not contaminated the resident's bedding by placing the soiled dressing on the bed. She revealed she needed a couple more hands to help since the resident was contracted and difficult to keep the area clean. Interview with the Director of Nursing (DON) on 11/21/19 at 3:00 PM revealed she expected the nurse to wash her hands between glove changes and not to contaminate the bedding. The DON stated she also expected good hand hygiene to be used during wound care, gastostomy tube care, catheter care, and peri care. 3. Interview with the Director of Nursing (DON) on 11/21/19 at 3:03 PM, revealed the facility did not have a policy that addressed handling of linens. She stated the facility followed state and federal regulations related to the handling of clean linens. Observation of a meal service on 11/19/19 at 12:28 PM, revealed CNA #5 transported a clothing protector under his right arm prior to placing it around a residents neck prior to meal service. Interview with CNA #5 on 11/21/19 at 2:51 PM, revealed he should not have carried the clothing protector under his arm. CNA #5 stated he should have held the clothing protector away from his body to keep it clean. Further interview with the DON on 11/21/19 at 3:03 PM, revealed she would have expected CNA #5 to carry linens away from his body as to not contaminate it.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to distribute and serve food in accordance with professional standards for food service safety related to staff not washing hands or changing gloves after leaving the meal tray prep area and prior to returning to area. Review of the Census and Condition, dated 11/19/19, revealed eighty-three (83) of ninety-three (93) residents received their meals from the kitchen. The findings include: Review of the facility's policy titled, Handwashing, last reviewed 10/2018, revealed routine hand washing should be completed after situations during which microbial contamination of hands is likely to occur and after touching inanimate sources that are likely to be contaminated with virulent or epidemiological important microorganisms of special clinical or epidemiological significance; for example: multiple drug resistant bacteria. Observation on 11/19/19 at 11:30 AM, revealed the dietary cook left the tray line three (3) times, once she touched a tray cart, the second time she touched the handles of drawers, and the third time she left the kitchen area and returned; however, she did not wash her hands or change gloves and returned to the tray line to handle food with the same gloves. Interview with the Dietary [NAME] and the Dietary Manager on 11/19/19 at 11:51 AM, revealed the Dietary [NAME] stated she should have changed her gloves and washed her hands after each time she left the tray line. The Dietary Manager revealed she expected the dietary staff to wash their hands and change their gloves.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one (1) of twenty-one (21) sampled residents (Resident #27). Observation on 08/29/18 revealed Registered Nurse (RN) #2 failed to wash her hands and change her gloves after removing the soiled dressing and before applying the new dressing during wound care for Resident #27's pressure ulcer. The findings include: Review of facility policy titled, Skin/Wound Care Protocol. last reviewed June 2017 revealed the facility will ensure optimal skin care is provided to all residents according to Clinical Practice guidelines per the Agency for Health Care Research and Quality (AHRQ) and the National Pressure Ulcer Advisory Panel (NPUAP). #15-d revealed clean technique will be utilized for dressing changes unless otherwise indicated per physician's orders. Record review revealed the facility admitted Resident #27 on 03/16/18 with diagnoses which included Diabetics, Urge Incontinence, Pressure Ulcer to the sacral area, and Bipolar Disorder. Review of Resident #27's Quarterly Minimum Data Set (MDS) assessment, dated 06/18/18, revealed the facility assessed Resident #27's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable. Further review revealed the resident has a stage III pressure area on admission. Observation on 08/29/18 at 10:00 AM revealed Registered Nurse (RN) #2 performed a dressing change to the sacral area. RN #2 washed her hands and don clean gloves, removed the old dressing that was soiled with feces, and then applied the clean dressing without washing her hands or changing her gloves. Interview with RN #2 on 08/29/18 at 10:30 AM revealed she realized she did not use proper hand hygiene during the dressing change but thought she had uses one gloved hand to remove the dirty dressing and the other gloved hand to apply the clean dressing. Interview with the Director of Nursing (DON) and the Infection Control Nurse on 08/30/18 at 3:16 PM revealed RN #2 should have changed gloves and washed her hands when going from the dirty dressing to the clean dressing.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure eye drops and ear drops used in the facility were labeled in accordance with currently accepted professional principles, on two (2) of four (4) units at the facility. The findings include: Review of the facility's policy titled, Psychobiological /Pharmacological Interventions Medication Administration and Documentation, last revised June 2018, revealed all multi-dose medications must bear an expiration date. At the time a multi-dose medication is opened it must be labeled with the date and staff initials. Observation of Unit 331 and Unit 332 medication carts on 08/29/18 at 8:15 AM, revealed the following medications had been opened with no date as to when they were opened: Medication Cart A for Unit 332: Ear Drops: NeoPolyDex ear ointment Eye Drops: Dorzolanide Opth Solution x 2 bottles Pilocarpine Opth Sol Lantanoprost x 2 bottles Medication Cart A Unit for 331: Combigan eye drops Interviews on 08/29/18 with Licensed Practical Nurse (LPN) #2 at 8:30 AM, LPN #1, at 9:50 AM, Registered Nurse (RN) #1 at 8:15 AM, and RN #2 at 10:00 AM, revealed medications were to be dated when opened and all nurses were responsible for dating the medications when they were opened. Interview with the Director of Nursing (DON), on 08/30/18 at 3:15 PM, revealed she expected the medication to be dated when opened by whichever nurse opened it.