Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, and homelike environment as evidenced by a soiled privacy curtain, missing paint on the walls, strong odors, and flies present in the resident's room for one (1) of fourteen (18) sampled residents. Resident #14 Findings Include: A review of the facility's policy titled Safe and Homelike Environment, undated, revealed, .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . A review of the facility's Residents' Rights document, undated, revealed, .You have the right to live and receive care in a residential setting that is homelike, safe, clean, and comfortable. For example, you are entitled .to housekeeping and related services to keep your living spaces clean, uncluttered, and comfortable . During an observation on 10/07/24 at 12:15 PM, Resident #14's room was observed with a strong smell of urine and mildew. There were four (4) flies flying around the resident's bed, mattress, and pillow. There was paint missing from the wall to the left of the bed, and a spider web with a fly in it was observed behind the door in the upper left-hand corner. The privacy curtain had visible food and other stains. During an interview on 10/07/24 at 1:00 PM, Resident #14 expressed significant concerns regarding her living conditions within the facility. She reported that the persistent strong odor, which she described as moldy, has led her to spend most of her time outside of her room. Resident #14 also reported that recently the presence of flies in her room had increased significantly. During an observation on 10/08/24 at 11:47 AM, in Resident #14's room, there was a strong smell of urine and mildew. Four (4) flies were flying around her bed, mattress, and pillow. The paint was still missing from the wall to the left of the bed, and the spider web was still behind the door. The privacy curtain remained soiled with visible food and other brown, discolored stains. During an observation and interview on 10/08/24 at 12:00 PM, the Facility Administrator confirmed the presence of flies, the odor of mildew, the missing paint on the wall, and the stained privacy curtain in Resident #14's room. The Administrator stated that it was the responsibility of the housekeeping supervisor to ensure the facility, especially resident rooms, was cleaned thoroughly to maintain a homelike environment. He acknowledged that the cleanliness of the resident's room had not been maintained according to the facility's standards. During an observation and interview on 10/08/24 at 12:10 PM, Housekeeping Staff #1 confirmed the presence of flies, the smell of mildew, the stained privacy curtain, and the missing paint in Resident #14's room. He expressed that housekeeping staff are expected to clean resident rooms thoroughly to maintain a homelike environment. A record review of the admission Record revealed Resident #14 was admitted by the facility on 9/22/2023 with diagnoses including Overactive Bladder. A record review of the Optional State Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 8/29/24, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated her cognition was moderately impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement care plans interventions regarding wearing all Personal Protective Equipment (PPE) during perineal care and hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube care for two (2) of five (5) residents reviewed for care. Resident #24 and Resident #40. Findings Include: A review of the facility's policy titled Care Plan - Comprehensive, revised October 2016, revealed, An individualized (person-centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident . Policy Interpretation and Implementation . 3. Each resident's comprehensive care plan is designed to: . f. Identify the professional services that are responsible for each element of care . Resident #24 A record review of Resident #24's comprehensive care plan revealed Focus: I am on Enhanced Barrier Precautions .because I have a PEG Tube .Interventions/Task .WASH HANDS BEFORE AND AFTER PROVIDING CARE TO RESIDENT with a dated initiated of 10/2/2024. On 10/10/24 at 9:07 AM, during an observation Licensed Practical Nurse (LPN) #3 entered Resident #24's room to perform PEG tube care and did not perform hand hygiene prior to applying gloves and providing care. During the procedure, LPN #3 had to exit the room. When she re-entered the room, once again, she did not perform hygiene prior to gloving and providing care to the resident. On 10/10/24 at 9:42 AM, during an interview, LPN #3 admitted that she was nervous, forgot to wash her hands, and recognized her actions posed infection control risks. Resident #40 A record review of Resident #40's comprehensive care plan with a date initiated of 4/2/2024 revealed Focus: I am on Enhanced Barrier Precautions .because I have a PEG tube .Interventions/Task .Staff will use PPE (gown and gloves) during high contact resident care activities. During an observation on 10/09/24 at 9:14 AM, Certified Nursing Assistant (CNA) #1 was observed providing perineal care to Resident #40 without wearing the required gown as part of the required PPE for residents on Enhanced Barrier Precautions. During an interview on 10/10/24 at 9:50 AM, CNA #1 confirmed she did not wear a gown and admitted that not wearing proper PPE could spread germs to the resident. During an interview on 10/10/24 at 11:30 AM, the Director of Nursing (DON) confirmed that both Resident #24 and #40 were on Enhanced Barrier Precautions due to a PEG tube. The DON stated that the comprehensive care plans for both residents revealed that they were on Enhanced Barrier Precautions, with interventions that revealed hand washing was required before and after providing care to the residents and staff wearing PPE (gown and gloves) during high contact resident care activities. The DON stated that all staff should follow the comprehensive care plan. During an interview on 10/10/24 at 11:49 AM, LPN #5, the care plan nurse, confirmed that care plans should be followed by both nurses and CNAs and acknowledged that by not wearing a gown, as part of the requirements for Enhanced Barrier Precautions, and washing their hands before providing care to the resident, staff did not follow the care plan when they provided high-contact care for these two (2) residents.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident received a physician-ordered salad during the lunch meal for one (1) of eighteen (18) sampled residents. Resident #44 Findings Include: A review of the facility's policy titled Dining and Food Preferences, revised 10/2022, revealed: Individual dining, food, and beverage preferences are identified for all residents/patients. During an interview on 10/07/24 at 10:43 AM, Resident #44 stated that the kitchen does not provide her with food to her liking. She mentioned that she enjoys eating salads daily but has not received them in several months, despite requesting them through the nurses and Certified Nursing Assistants (CNAs). She added that she stopped asking because she became tired of repeating her request. During an observation on 10/07/24 at 12:31 PM, it was noted that Resident #44's lunch tray did not contain a salad. During an interview on 10/07/24 at 2:13 PM, Resident #44's sister expressed her frustration with the facility's failure to honor her sister's food preferences, specifically her desire to receive salads with meals. During an interview on 10/08/24 at 12:11 PM, the Dietary Manager stated that she collects resident food preferences upon admission but had not updated Resident #44's preferences in a while. She acknowledged that it was probably time to reassess the resident's preferences. During an observation on 10/08/24 at 12:17 PM, Resident #44's lunch tray again did not contain a salad. During a follow-up interview on 10/09/24 at 7:02 AM, the Dietary Manager admitted that she stopped purchasing salads a few months ago because of cost concerns. She also revealed that she was unaware of the physician's order requesting that Resident #44 receive a side salad with ranch at every lunch meal. The Dietary Manager stated that she had not received communication from nursing staff about the order. During an interview on 10/09/24 at 2:21 PM, the Director of Nursing (DON) confirmed that the Dietary Department had been notified of the doctor's order. The DON provided a copy of the diet requisition form, which included instructions for diet changes. During an interview on 10/10/24 at 9:21 AM, the Registered Dietician (RD) explained that with every nutritional assessment and recommendation for a resident, she emails a copy to the doctor, DON, and Dietary Manager. She also provides each of them with a hard copy of the diet requisition form, which indicates the same information included in the assessment. A record review of the admission Record revealed that the facility admitted Resident #44 on 11/22/23 with diagnoses including Hyperlipidemia and Type 2 Diabetes. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/24, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating she was cognitively intact. A record review of the electronic health record Care Profile revealed Resident #44 had an active physician's order, with a start date of 3/19/24, Provide House side salad with Ranch dressing on lunch tray daily . A record review of Resident #44'sRD Assessment & Recommendations, dated 3/13/24, revealed, .Request side salad w/(with) ranch on lunch tray. Will inform dietary . A record review of the Diet Requisition Form, dated 3/18/24, revealed a Request for Services to provide side salad w/ranch on lunch tray daily . The form indicated the requisition was for Resident #44.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure proper infection control practices during the provision of care for residents on Enhanced Barrier Precautions (EBP) for two (2) of five (5) care observations. Residents #24 and #40. Findings Include: A review of the facility's procedure titled Procedure for Handwashing, revised 04/15, revealed .When to Wash Hands (at a minimum) . Before and after each resident content After handling any contaminated items (linens, soiled diapers, garbage, etc.) A review of the facility's policy titled, Enhanced Barrier Precautions revised 08/07/24, revealed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism. Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . A review of the facility's policy titled Infection Prevention and Control Program, (undated) revealed It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Resident #24 During an observation on 10/10/24 at 9:07 AM, Licensed Practical Nurse (LPN) #3 entered Resident #24's room to perform PEG tube care and did not perform hand hygiene prior to applying gloves and providing care. During the procedure, the supplies needed for continuation of care fell off the bedside table onto the floor. LPN #3 picked up the dirty supplies, and threw them away, however, when she re-entered the resident's room after securing additional supplies, once again, she did not perform hand hygiene prior to applying her gloves. During an interview on 10/10/24 at 9:41 AM, LPN #3 confirmed she forgot to wash her hands upon entering the room prior to applying gloves and beginning care. The nurse admitted that her actions was against infection control guidelines and could pose a risk for infection. A record review of Resident #24's Order Summary Report, with active orders as of 10/10/24, revealed orders, dated 05/20/24, to clean around the PEG tube site with normal saline gauze, pat dry, apply gentamycin ointment around the stoma, cover with split gauze, and secure with tape twice daily for a gastrostomy infection, until resolved, then discontinue. There was also an order, dated 04/08/24, for Enhanced Barrier Precautions related to PEG tube every day and night shift. A record review of Resident #24's admission Record revealed the facility admitted the resident on 12/11/19. The resident had diagnoses that included Unspecified Sequelae of Unspecified Cerebrovascular Disease, Epilepsy, and Dysphagia. A record review of the Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/27/24 revealed that Resident #24's cognitive skills was severely impaired. Section K indicated the presence of a feeding tube. Resident #40 During an observation on 10/09/24 at 9:14 AM, Certified Nursing Assistant (CNA) #1 provided peri care to Resident #40 without wearing the required gown, which was part of the Enhanced Barrier Precautions. During an interview on 10/10/24 at 9:50 AM, CNA #1 confirmed she did not wear the gown as required and acknowledged that not wearing proper PPE could result in the transmission of germs to the resident and others. During an interview on 10/10/24 at 11:23 AM, the Director of Nursing (DON) confirmed that hand hygiene before resident care and when a nurse changes gloves is an important part of infection control. The DON also confirmed that CNA #1 should have worn a gown when providing care to Resident #40, as that is a requirement for Enhanced Barrier Precautions to prevent the risk of cross-contamination. During an interview on 10/10/24 at 11:33 AM, LPN #4 (Infection Preventionist) stated that LPN #3 should have performed hand hygiene prior to providing resident care and when changing gloves. LPN #4 also confirmed that CNA #1 should have worn the required gown while performing care for Resident #40 to decrease the risk of germs being transferred to the CNA's uniform, which could for cross contamination, while providing care to other residents. A record review of Resident #40's Order Summary Report, with active orders as of 10/10/24, revealed an order, dated 04/08/24, for Enhanced Barrier Precautions related to the resident's PEG tube. A record review of Resident #40's admission Record revealed the facility admitted the resident on 01/23/24. The resident's diagnoses included Alzheimer's Disease, Vascular Dementia, and Dysphagia. A record review of the Quarterly MDS with an ARD of 07/25/24 revealed that Resident #40 was unable to complete the Brief Interview for Mental Status (BIMS) for cognitive status and was scored 99 on the assessment.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to serve meals to the residents that were palatable for two (2) of three (3) residents reviewed for palatable meals. Residents #2 and #3 Findings include: A record review of the facility's, Food: Quality and Palatability, revised 9/2017, revealed, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served and appetizing temperatures . Resident #2 On 8/28/23 at 4:40 PM, in an interview with Resident #2, she revealed that there are days in which the food is okay, but some days, it has no taste. The resident explained that it depends on who cooked the food. On 8/28/23 at 6:00 PM, in an interview, Resident #2 stated she had corn, rice, and a tortilla with cheese. The resident complained that the corn tasted very bland. Once again, the resident revealed that there are times in which the food has no taste and needs seasoning. However, she noted that the problem with periods of bland tasting food had been brought to the attention of the Dietary Department. On 8/29/23 at 3:30 PM, in an interview, Resident #2 he commented the food tasted better today. A record review of the Order Summary Report, with active orders as of 8/29/23, revealed Resident #2 had orders for a Consistent Carbohydrates diet, Regular texture, Regular liquids consistency, and No Salt Packet with Meals. A record review of Resident #2's admission Record revealed the facility admitted the resident on 12/25/22, with diagnoses that included Essential (Primary) Hypertension and Type 2 Diabetes Mellitus A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 5/26/23, for Resident #2, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #3 On 08/28/23 at 6:10 PM, in an interview with Resident #3, he stated his supper vegetables had no taste. He stated he ate the barbeque chicken on a bun, and it was okay. The resident revealed that most of the time, the food has no taste. He stated he ate it because he was hungry. On 08/29/23 at 11:50 AM, in an interview with Resident #3, he revealed the grits he was served at breakfast, had no taste. The resident stated he does not like food with no taste. A record review of the Order Summary Report, with active orders as of 8/29/23, revealed Resident #3 had orders for a HSG (limited calorie diet), CCD (carbohydrate-controlled diet), NAS (no added salt), Regular texture, and Regular liquids consistency. A record review of Resident #3's admission Record, revealed the facility admitted the resident on 4/16/23, with diagnoses that included Essential (Primary) Hypertension, Anemia, and Type 2 Diabetes Mellitus. A record review the MDS with an ARD of 7/20/23, for Resident #3, revealed a BIMS score of 13, which indicates the resident was cognitively Intact. On 08/28/23 at 5:30 PM, in an interview with the Dietary Manager (DM), she stated she there are several different cooks that she must schedule to cook the dinner meals. The DM revealed there has been a high turnover in the dietary department, and she has found that some of the cooks do not taste the food prior to serving the residents. The DM revealed that she believes tasting the food is important, as it helps the cook recognize which foods need additional seasoning. On 08/28/23 at 5:45 PM, during an observation and taste test of the evening meal along with the DM revealed the tray consisted of barbeque pulled chicken on a bun, tater tots, vegetable medley, confetti coleslaw, whole kernel corn, steamed rice, and a cheese quesadilla. The whole kernel corn and vegetable medley tasted very bland. The DM confirmed that they were bland and needed seasoning for taste. She noted that the cook has no salt alternatives for the food and if alternatives were used, it would improve the taste of the food. On 08/29/23 at 4:00 PM, in an interview with Dietary [NAME] #1, he revealed he uses chicken base to flavor the food when he cooks, as it gives the food a great flavor and is low in sodium.

Based on observation, interviews, and facility policy review, the facility failed to remove expired, refrigerated medications from the medication storage room for one (1) of two (2) observations. Findings include: A record review of the facility's policy titled, Checking Stock Medication for Manufacturer Expiration Dates, with a revision date of 4/17, revealed, It is the policy of this facility to check for medication expiration dates monthly for manufacturer's expiration dates and as needed prior to dispensing to residents . During the process, if any medication is found to be expired, it will immediately be removed from the med cart or stock room and given to the Director of Nursing for proper disposal . On 3/9/23 at 10:02 AM, in an observation of the medication room, with Registered Nurse #2 (RN), revealed a refrigerated bottle of labeled Influenza Vaccine Flucelvax Quadrivalent 2021-2022 Formula, with an opened date of 12/17/21, and an expiration date of June 30, 2022. The opened vaccine bottle was half full. On 3/9/23 at 10:12 AM, in an interview with RN #2, she explained it is the responsibility of the Charge Nurse to dispose of the expired medications. She stated expired vaccines could be less effective. On 3/9/23 at 1:00 PM, in an interview with the Director of Nursing (DON), she revealed the Charge Nurse should check for expired medications in the medication refrigerator, as she monitors the refrigerator temperature. She confirmed expired Influenza vaccine could potentially be less effective in protecting the residents from influenza.

Based on interview, record review, and facility policy review, the facility failed to resolve repeated group dietary complaints voiced by residents during Resident Council Meetings for five (5) of six (6) months of resident council meeting minutes reviewed. Findings include: Review of the Healthcare Services Group (HCSG) policy titled, Food: Quality and Palatability, revised 9/2017, revealed, Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature. Foods and liquids are prepared and served in a manner, form, and texture to meet resident's needs . Review of the Healthcare Services Group (HCSG) policy titled Meal Distribution: Infection Control Consideration, revised 9/2017, revealed . All food items will be transported promptly for appropriate temperature maintenance . Record review of the Resident Council Meeting Minutes reviewed for the past six (6) months revealed varied dietary complaints of food being salty at times, and bland at other times. However, there were repeated complaints of cold food during five (5) of the six (6) months reviewed. Meeting minutes revealed residents complained of cold food during the meetings held on 9/27/22, 10/25/22, 12/20/22, 1/24/23, and 2/21/23. An interview and observation of a test tray with the Dietary Consultant on 3/06/23 at 12:14 PM, revealed the pork loin had a good taste and was warm, the collard greens were warm and extremely salty, and the rice pilaf was warm and bland with no taste. During a meeting on 3/7/23 at 10:00 AM, with 13 Resident Council Members, they revealed that have complained about the food for months during their monthly meetings. The members also stated that they have met with the Administrator and Dietary Manager to voice their concerns. During an interview on 3/9/23 at 10:09 AM, with the Activity Director, she revealed she records the Resident Council Meeting minutes. She stated the residents continue to complain every month that the food is cold and bland. The Activity Director confirmed she had forwarded the complaints to the Administrator and Dietary Director. During an interview on 3/9/23 at 11:18 AM, the District Manager confirmed the residents had complained several months in resident council meetings about the food being cold, salty, and bland. The District Manager also confirmed the collard greens were salty and the rice pilaf was bland on the test tray. During an interview on 3/9/23, at 11:26 AM, with the Administrator she confirmed the residents had complained for several months about the food, however, she had talked to the Regional Managers about the food complaints, as the kitchen staff is contracted through a private company. An interview on 3/9/23 at 12:30 PM, with the Dietary Manager, revealed she was aware of the food complaints. The Dietary Manager confirmed there had been some improvements in dietary, but they are still trying to find ways to keep the food warm and improve the taste.

Based on observation, interviews, and facility policy review, the facility failed to prevent the possible spread of infection by leaving an unattended ice chest in the hallway for one (1) of four (4) days of observation. Findings include: A review of the facility policy, titled Infection Prevention and Control Program, dated 6/6/22, revealed, It is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections . All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . An observation on 3/7/23 at 9:30 AM, revealed Resident #35 getting ice out of the ice chest left unattended in the hallway. The resident scooped ice and water out of the ice chest into his personal mug, then poured the excess out of his mug back into the ice chest. During an interview on 3/7/23 at 9:40 AM, with Registered Nurse (RN) #3/IP (Infection Preventionist), she confirmed the ice chest was left on the hallway unattended but should have been taken to the kitchen after the nurse aides filled the resident's mugs with ice. The IP confirmed this was an infection control issue, as other residents could be exposed to infectious substances if they received ice from the contaminated ice chest. During an interview on 3/9/23 at 11:29 AM, with the Director of Nursing (DON), she confirmed the Certified Nurse Aide (CNA) should have removed the ice chest from the hallway after passing out ice to the residents. The DON confirmed the actions of Resident #35 contaminated the ice chest and the remaining ice could lead to cross contamination and be a potential source of infection.

Based on record review, staff interview, and facility policy review, the facility failed to protect the resident from misappropriation of funds for one (1) of four (4) resident records reviewed for Trust Fund accounts, Resident #51. Findings include: A review of the facility's policy titled, Abuse and Neglect Prohibition, dated July 2018, revealed each resident has the right to be free from abuse and misappropriation of resident property. A record review of the Facility Reported Incident (FRI) revealed Resident #51 stated Housekeeper #1 had borrowed $20.00 from him until payday, but had not paid the $20.00 back. The report showed the Administrator completed an investigation by interviewing the resident, staff members, and the Resident Representative. The FRI also indicated the Administrator replaced the $20.00 to the resident. The Administrator also indicated, misappropriation of Resident #51's funds was substantiated with the funds replaced, and Housekeeper #1 was suspended and terminated. On 8/5/19 at 10:45 AM, an interview with Resident #51, revealed he does not remember letting anybody have any money. He stated he has not let anyone have any money, and if he did he would remember. On 8/5/19 at 2:15 PM, an interview with Resident #51's Resident Representative (RR) revealed, she does not recall the resident loaning an employee any money. She stated the facility told her not to give the resident large sums of money. The RR also stated the facility has been doing good with taking care of the resident. On 8/05/19 at 2:26 PM, an interview with the Administrator, revealed Resident #51 was the person who reported his money was missing and she informed the RR. She stated the employee does not work at the facility any longer and has termination papers in the investigation packet. She stated his name was (Name of Housekeeper #1). She stated the previous employee did admit to borrowing the money and the facility paid the money back. On 8/06/19 at 8:18 AM, the surveyor attempted to call the previous employee, Housekeeper #1 with no answer received. On 8/06/19 at 8:36 AM, an interview with the Housekeeper #2, revealed he was not aware of the previous employee borrowing money from the resident. He stated he was notified at home and came to the facility upon notification. He also stated he first placed Housekeeper #1 on suspension and after a couple of days he let the employee go. On 8/07/19 at 3:42 PM, an interview with the Director of Nurses (DON), revealed she became aware of the resident loaning Housekeeper #1 money after it was reported to the Administrator. She stated she helped to in-service staff on abuse, but the Administrator handled the investigation for Housekeeper #1 borrowing the money from Resident #51. On 8/08/19 at 10:32 AM, the surveyor attempted to call Housekeeper #1 and no answer was received.

Based on staff interview, record review, and facility policy review, the facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days of determining the resident had a significant change for one (1) of 20 resident Minimum Data Set (MDS) assessments reviewed, Resident #57. Findings include: A review of the facility's policy titled, Resident Assessment Instrument (RAI) Process, dated February 2017, revealed the RAI was used at the facility to provide the caregiving staff with ongoing assessment information necessary to develop a resident care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status. The MDS provides a core set of screening, clinical, and functional status elements that forms the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicare or Medicaid. The RAI is completed by an interdisciplinary team that includes facility staff with varied backgrounds. Each interdisciplinary team member completes his/her assigned sections of the MDS within the designated time frame. The Resident Assessment Coordinator is required to sign the MDS certifying the assessment is complete. Resident #57 Review of the Physician's Order, dated 6/24/19, revealed Resident #57 was admitted to hospice care. Review of Resident #57's Progress Notes-Nursing Note, dated 6/25/19 at 1:10 PM, revealed the IDT (Interdisciplinary Team) Risk Meeting was held. Resident #57's recent hospital return, on 6/24/19, was discussed. Hospice services had been elected, peg (PEG-Percutaneous Endoscopic Gastrostomy) feedings, and psychotropic medication use. Psychotropic meds monitoring in place. Recent weight loss s/p (status post) hospital stay. RD to change feeding formula due to discontinuation of dialysis. Upcoming Significant Change MDS scheduled for 7/1/19. The MDS Coordinator's electronic signature was identified as the author of the note. Review of the most recent Significant Change MD revealed the assessment was dated 7/2/19. Further review of the MDS revealed the MDS Coordinator's signature to confirm completion of the MDS was dated 7/16/19, which was 22 days after the MD order was written for Hospice. On 8/6/19 at 12:07 PM, an interview with the Director of Nurses (DON), revealed she would expect the MDS to be completed timely, within the time period that is expected for the MDS to be completed. On 8/6/19 at 12:10 PM, an interview with Registered Nurse (RN) #2/MDS Coordinator, revealed Resident #57's MDS should have been completed within 14 days of determining that the resident had been admitted to hospice services. RN #2 stated the MDS was not completed within the 14 day window. A review of the facility's Face Sheet revealed, the facility admitted Resident #57 on 4/8/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to discharge and accurately code the comprehensive MDS assessment related to hospice services for two (2) of 20 MDS assessments reviewed, Resident #57 and Resident #58. Findings include: A review of the facility's policy titled, Resident Assessment Instrument (RAI) Process, dated February 2017, revealed the RAI was used at the facility to provide the caregiving staff with ongoing assessment information necessary to develop a resident care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident's status. The MDS provides a core set of screening, clinical, and functional status elements that forms the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicare or Medicaid. The RAI is completed by an interdisciplinary team that includes facility staff with varied backgrounds. Each interdisciplinary team member completes his/her assigned sections of the MDS within the designated time frame. The Resident Assessment Coordinator is required to sign the MDS certifying the assessment is complete. Resident #57 Review of the Physician's Order, dated 6/24/19, revealed Resident #57 was admitted to hospice care. Review of the most recent Significant Change MD assessment, dated 7/2/19 with a completion date of 7/16/19, revealed hospice was checked in the Special Treatments, Procedures, and Programs section. On 8/6/19 at 12:07 PM, an interview with the Director of Nurses (DON), revealed she would expect the MDS to reflect the condition of the resident at the time the MDS was completed. On 8/6/19 at 12:10 PM, an interview with Registered Nurse (RN) #2/Care Plan Nurse, revealed Resident #57 was admitted to hospice services on 6/24/19 and the MDS assessment with an ARD of 7/2/19 was not coded to include hospice services. RN #2 stated the MDS should have been coded to include hospice. A review of the facility's Face Sheet revealed, the facility admitted Resident #57 on 4/8/19. Resident #58 Review of the most current Minimum Data Sheet (MDS) revealed Resident #58 was admitted on [DATE], and discharged on 07/23/2019 to an Acute Hospital. Review of Resident #58's Physician Orders, dated 07/23/2019, revealed the resident was discharged to home with home health services. Review of Resident #58's Progress Notes-Nursing, dated 07/23/2019, revealed the resident was being discharged at this time. The Nurses Notes revealed Resident #58's daughter was with her and understood all that needed to be done and taken care of, the resident ambulated to a private vehicle. On 08/06/19 at 12:06 PM, an interview with the Director of Nursing (DON), revealed the resident was discharge to home. On 08/06/19 at 12:11 PM, an interview with Registered Nurse #2/MDS Coordinator, revealed the MDS was coded incorrectly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to revise the Resident #48's Comprehensive Care Plan related to weight loss for one (1) of 20 resident care plans reviewed. Findings include: A review of the facility's policy titled, Comprehensive Care Plan, with a revision date of November 2017, revealed the care plan was to be reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or change in condition. A review of Resident #48's Comprehensive Care Plan revealed the resident had a care plan Focus of, I have a nutritional problem of weight loss. Further review of the care plan revealed there was no diagnoses or risks documented related to the weight loss. The Goal stated the resident would maintain adequate nutritional status as evidenced by no signs/symptoms (s/s) of malnutrition, consuming 50% of at least three meals daily through review date, 9/11/19. The Interventions included: Administer medications as ordered. Determine individual like and dislikes. IDT (Interdisciplinary Team) referral as needed. Provide supplements/snacks as ordered. Attend activities that promote additional intake. Provide and serve diet as ordered and observe intake and record every (q) meal. RD evaluate as needed. Weigh as ordered. Review of the Minimum Data Set (MDS), with an Assessment Reference Date of August 03, 2019, revealed the Swallowing/Nutritional Section K. K0300 was coded a 2, which indicated Resident # 48 had weight loss not on a physician's prescribed weight loss regimen. A review of Resident #48's Nurse Practitioner's Progress Note, dated 7/22/19, revealed the resident had a diagnosis of malignant neoplasm of the sigmoid colon. Resident #48 was with significant weight loss upon return from the hospital, on 6/23/19. Resident #48 was admitted to the hospital on [DATE], and per Computerized Tomography (CT) scan, on 6/20/19, calcified granulomas, pleural effusion and possible metastatic disease were found. On 08/07/19 at 9:22 AM, an interview revealed the Registered Dietician (RD) said she was aware of the weight loss and it was addressed in her notes with the resident's diagnosis of cancer and fluid overload with the hospitalization where she had fluid removed from her lungs. The RD said she did not do the care plans and the care plans were the responsibility of the MDS/Care Plan Nurses. A review of the RD note for Resident #48 titled, Nutrition Data Collection, dated 6/25/19, revealed Resident #48 had a weight loss of 14.6% and the resident had been diuresed in the hospital and the weight loss was likely related to the resident's diagnosis of malignant neoplasm of the sigmoid colon, edema, recent hospital stay, and the resident's continued poor intake. A review of the Diagnosis Information list for Resident # 48 revealed Malignant neoplasm of the sigmoid colon and chronic congestive heart failure. Both were dated 5/29/19. An interview with the Administrator (ADM), on 08/07/19 at 3:12 PM, revealed information from the initial hospitalization for Resident #48 did not mention the cancer, but they were trying to find information from the Onocologist. An interview, on 08/08/19 at 9:31 AM, with Registered Nurse (RN) #1/MDS Coordinator/ Care Plan Nurse, revealed the care plans would be updated for the residents as status changes occur. The information would come from the orders and daily meetings. She said she was responsible to update the care plans in the computer and that the facility had no paper care plans in the charts. RN #1 also said that Resident #48's care plan did not address the weight loss related to the cancer diagnosis or edema. RN #1 said the thought process was because she was so swollen when she came from the hospital initially that the weight loss was from lose of the fluid. She said the care plan should have been specific to the resident's cancer and edema. An interview, on 08/08/19 at 11:05 AM, with the Director of Nursing (DON) revealed she expected the care plan to be specific to Resident #48's needs and concerns and the care plan should have listed the weight loss related to the severe edema and her diagnosis of cancer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent the possibility of infection and/or cross contamination for one (1) two (2) catheter care observations, Resident #16. Findings include: Review of a typed document on the facility's letterhead, dated 8/8/19 and signed by facility's Administrator, revealed:Countrybrook Living Center as an affiliate of (Name of Corporation), uses [NAME]'s Nursing Procedures as a resource for policy and procedures regarding nursing care including current resident requirements of enteral feedings, catheter care and handwashing. A review of a document provided by the Administrator from the [NAME] website's [NAME]'s Nursing Procedures titled, Suprapubic Catheter Care, dated February 15, 2019, revealed: Stabilize the catheter with your non-dominant hand. With your dominant hand clean the skin around the catheter insertion site using a washcloth that contains mild soap and water, moving outward in concentric circles. Avoid aggressive cleaning which can lead to skin irritation or local skin infection. Gently dry the area around the insertion site with a towel or gauze. Remove and discard gloves. Perform hand hygiene. A review of a document obtained from the [NAME] website site [NAME]'s Nursing Procedures was provided by the facility's Administrator. The document was titled, Hand Hygiene, dated June 14,2019, and revealed, The hands are the conduit for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Hand Hygiene, therefore, is the single most important procedure in preventing infection. A review of a 'facility's document titled, Licensed Nurse Competency Checklist, dated 11/27/18 revealed Registered Nurse (RN) #3 was competent to provide Suprapubic Catheter Care. An observation, on 08/07/19 at 8:40 AM, revealed Registered Nurse (RN) #3 entered Resident #16 room to perform catheter care. RN #3 had already placed the catheter care supplies on the over bed table using a towel as a barrier. RN #3 washed and dried her hands. RN #3 obtained a basin and filled the basin with warm water. RN #3 obtained DermaVera skin and hair soap from a shelf and put the soap into the water in the basin. RN #3 used her anterior wrist area and turned faucet off. RN #3 left the rest room but returns to wash her hands again stating, I touched the faucet with my wrist. RN #3 returned to the bedside and picked up a red biohazard bag and a clear bag that were lying on the foot of Resident #16's bed. RN #3 opened the bags and then placed them at the foot of Resident #16's bed. RN #3 gloved without washing her hands and removed the dirty dressing from around Resident #16's suprapubic stoma site and discarded the dressing in the red bag. RN #3 washed her hands, gloved and took a wash cloth an put it into basin containing the water and soap. RN #3 squeezed the cloth out and wadded the cloth up in her right gloved hand. RN #3 wiped the catheter stoma site in a circular motion with one wipe and discarded the cloth into the clear bag. RN #3 obtained a second cloth, wet the cloth in the basin and wiped the catheter stoma site in a circular motion and discarded the cloth into the clear bag. RN #3 obtained a third cloth, wet the cloth in the basin, took the tubing into her left gloved hand and begin to clean the tubing with cloth in her gloved right hand starting at the catheter stoma site. RN #3 stated, there is something on the tubing and she wiped the tubing in the same area for several moments in a circular motion using the same spot on the cloth and then continued upwards on the tubing using the same cloth. RN #3 discarded the cloth into the clear bag. RN #3 washed her hands, gloved, opened a split gauze dressing and applied it to the stoma site. RN #3 took a piece of cloth tape and applied the tape to the dressing and skin stating, this is to hold the dressing in place. RN #3 did not date or initial the clean dressing. RN #3 removed her gloves, applied new gloves without washing her hands and picked up the basin and discarded the water into the toilet. RN #3 washed her hands, gloved and tied the red bag up and placed it back on the foot of the bed. RN #3 removed the towel used as a barrier and placed it into the red bag and tied the bag up leaving it on the foot of the bed. RN #3 removed her gloves and placed Resident #16's things back onto the over bed table without washing her hands or cleaning the over bed table with sanitizer. RN #3 picked up the red biohazard bag and exited the room without washing her hands. RN #3 stated after exiting the room, I didn't wash my hands when I took my gloves off and before leaving the room. An interview, on 08/08/19 at 9:02 AM, with RN #3 revealed, Wiping the tube several times with the same cloth and then continuing up the catheter tubing is an infection control issue. This could have caused germs to spread. I do think it was an infection control issue. I knew better and I thought about it after the fact. An interview, on 08/08/19 at 9:43 AM, with the Director of Nursing (DON)/Interim Infection Control Nurse, revealed, It was contamination with the RN rubbing the catheter tube several times with the same cloth and then moving on up the catheter tube with the same cloth. It was an infection control issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide Resident #207's Percutaneous Endoscopic Gastrostomy (PEG) site care in a manner to prevent the possibility of infection and/or cross contamination. This concern was identified for one of one (1 of 1) PEG tube site care observations. Review of the facility's Resident Census and Resident Conditions (671) revealed the facility had identified two residents with tube feedings. Findings include: Review of a typed document on the facility's letterhead, dated 8/8/19 and signed by the facility's Administrator revealed:Countrybrook Living Center as an affiliate of (Name of Corporation), uses [NAME]'s Nursing Procedures as a resource for policy and procedures regarding nursing care including current resident requirements of enteral feedings, catheter care and handwashing. A review of [NAME]'s Nursing Procedures titled, Enteral Feeding Tube Exit Site Care, Gastrostomy and Jejunostomy, dated December 14, 2018, revealed, Clean the exit site with soap and water moistened gauze pads and allow it to dry completely. Label the dressing with the date, the time, and your initials. This information was provided by the facility's Administrator she obtained from the [NAME] website. A review Nursing Procedures titled, Hand Hygiene, dated June 14,2019, revealed, The hands are the conduit for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Hand Hygiene, therefore, is the single most important procedure in preventing infection. This information was provided by the facility's Administrator she obtained from the [NAME] website. A review of a facility document titled Licensed Nurse Competency Checklist, dated 11/27/18, revealed Registered Nurse (RN) #3 was competent to provide Enteral Tube Care. An observation, on 08/07/19 at 09:00 revealed Registered Nurse (RN) #3 gathered supplies from the wound care cart, obtained a towel from the linen cart to use as a barrier and entered Resident #207's room to perform Percutaneous Endoscopic Gastrostomy (PEG) tube care. RN #3 placed a towel on the over bed table, without cleaning the over bed table, and laid the unopened bottle of normal saline, unopened gauze and a drain gauze on the barrier. RN #3 moved the over bed table, containing the supplies, with her foot to the side of the bed. RN #3 washed her hands, turned the lights on in the room and then left the room to obtain a red biohazard bag. RN #3 entered Resident #207's room with the red bag and placed the unopened red bag on the foot of the bed. RN #3 removed her gloves and left the room stating she had to go to the linen cart and get some gloves. RN #3 removed an open box of gloves from the linen cart and returned to the room taking several pair of gloves out of the box and placing them on the barrier. RN #3 put the remaining box of gloves in the bracket on the wall. RN #3 washed her hands, gloved, turned off Resident #207's feeding pump and then unhooked the tubing from the stoma site. RN #3 removed her gloves, washed her hands, gloved and let the head of the bed down. RN #3 attempted to turn Resident #207 over as he was lying on his left side. RN #3 voiced that the red unopened biohazard bag had fallen onto the floor and she reached down, picked it up and opened it at the foot of the bed. RN #3 reached over Resident # 207's right side and removed the dirty dressing from the stoma site. RN #3 discarded the soiled dressing into the red biohazard bag. RN #3 removed her gloves, washed hands, re-gloved, opened the normal saline bottle and sat it on the barrier and then opened the gauze. RN #3 picked up the gauze, the bottle of normal saline, and then touched the gauze to the opening of the normal saline bottle to wet the gauze. RN #3 took the gauze and wiped the PEG stoma area in a circular motion going all the way around the stoma twice and then folded the gauze and continued to wipe the stoma area in a circular motion. RN #3 discarded the dirty gauze into the red bag, removed her gloves and washed her hands. RN #3 gloved and took a dry gauze and dried the stoma area in a circular motion wiping twice with the same gauze without lifting the gauze. RN #3 removed her gloves, washed her hands and applied clean gloves. RN #3 opened the drain sponge and applied the sponge to the stoma securing it with paper tape. RN #3 did not date or initial the clean bandage. RN #3 pulled the covers up on Resident #207 without removing her gloves or providing hand hygiene. RN #3 tied the red biohazard bag up and placed it on top of the towel that was used as a barrier. RN #3 removed her gloves, washed her hands and picked up the red bag leaving the towel on the over bed table. RN #3 left the room, walked down the hall to the biohazard room and discarded the red bag. RN #3 washed her hands and returned to the room. RN #3 opened a clear bag and placed the towel used as a barrier into the bag and tied the bag up. RN #3 washed her hands, picked up the clear bag and exited the room without cleaning the over bed table and stated I'm finished and I'm going down the hall to discard the dirty linen. An interview, on 8/8/19 at 9:06 AM, with RN #3 revealed, I remember picking up the red bag off of the floor and not changing my gloves, but I wasn't sure what to do. I should have changed my gloves. I was nervous I thought about wiping the stoma site twice with the same gauze and then folding the gauze and wiping the stoma site again. I knew it was not correct after the fact, but I was just nervous. It was an infection control issue. I know I did that, but I also know it wasn't correct. An interview, on 8/8/19 at 9:43 AM, with the Director of Nursing (DON)/Interim Infection Control Nurse, revealed It was contamination with the RN picking the red bag up off of the floor and continuing care with the same gloves. It was contamination with the RN wiping the PEG tube stoma site several times with the same gauze and then folding it over and wiping with the gauze again. It was an infection control issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to perform hand hygiene at the appropriate times during Resident #52's wound care, and therefore increased the risk for the possibility of cross contamination and/or infection. This was identified for one (1) of four (4) wound care observations, Resident #52. Findings include: Review of a typed document on the facility's letterhead, dated 8/8/19 and signed by the facility's Administrator revealed:Countrybrook Living Center as an affiliate of (Name of Corporation), uses [NAME]'s Nursing Procedures as a resource for policy and procedures regarding nursing care including current resident requirements of enteral feedings, catheter care and handwashing. A review Nursing Procedures titled, Hand Hygiene, dated June 14,2019, revealed, The hands are the conduit for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Hand Hygiene, therefore, is the single most important procedure in preventing infection. This information was provided by the facility's Administrator she obtained from the [NAME] website. A review of the facility's policy titled, Infection Prevention Program Overview, dated 2012, revealed the goals of the infection prevention programs are to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infection. On 8/6/19 at 2:30 PM, an observation revealed Resident #52 lying in bed awake, and consent obtained for the surveyor to observe his wound care. The head of bed (HOB) was up at least 45 degrees. On 8/06/19 at 2:32 PM, an observation revealed Licensed Practical Nurse (LPN) #1 organized her supplies on the wound care cart. With her ungloved hands, she opened the Comfort-foam Border dressing, and wrote the current date on it with a permanent marker and placed the dressing back in the packet. LPN #1 then removed three (3) Microkill wipes and placed two (2) of the Microkill wipes in a plastic cup and one (1) Microkill wipe into another plastic cup. LPN #1 then poured Normal Saline (NS) into a plastic cup 1/4 full, and removed the one (1) Microkill wipe from the plastic cup, and put it in the plastic cup that she had the 2 wipes in. She washed her hands and finished setting up her supplies on the resident's over-bed table. LPN #1 dropped the unopened Dermacol dressing on Resident #52's floor, picked it up, and went into the resident's bathroom and washed her hands. She applied clean gloves, lowered the resident's HOB, turned the resident onto his left side, and cleaned his coccyx wound area with the NS moistened 4x4 gauze. She dropped a clean 4x4 gauze on the resident's over-bed table, picked it up, and used it to pat the resident's wound dry. LPN #1 removed her gloves, washed her hands, applied clean gloves, and applied the foam dressing. She removed her gloves, fastened the resident's brief, let the HOB back up, and cleaned the over-bed table with the Microkill wipes then she sat the red bag that was full of the soiled items back on top of the table while she washed her hands. The resident's wound bed was pink, with no odor or active drainage, no signs of infection were present. (Wound care observation was also completed in reference to complaint number: MS00015773. ) Record review of the Physician Order, with a start date of 7/11/19, revealed wound care: Clean wound to sacral area with normal saline, pat dry with 4x4 gauze, pack undermining with collagen sheet, cover with collagen sheet. Cover with Eclipse Border or comfort foam daily and as needed if dressing becomes soiled or wet. Review of the most recent 14 Day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment was coded to include pressure ulcer. The most recent Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 6/3/19, was coded to include pressure ulcer. The most recent comprehensive admission Minimum Data Set (MDS) assessment, with an ARD of 12/17/18 was coded to include pressure ulcer. Review of the Comprehensive Care Plan, with an onset date of 12/10/18, included interventions for the pressure ulcer care. On 8/08/19 at 8:15 AM, an interview with LPN #1, revealed she should have washed her hands before setting up her supplies and should have worn gloves while setting up her supplies. She stated when she sat the red biohazard bag on the resident's over-bed table after wiping the table off caused cross contamination of the over-bed table. On 8/08/19 at 9:05 AM, an interview with the Director of Nurses (DON), revealed when LPN #1 did not wash her hands before setting up her wound care supplies and opening the dressing, writing the date on it and putting it back into the wound packet, that was cross contamination. She stated when LPN #1 sat the red biohazard bag on the resident's over-bed table after she had cleaned it was cross contamination. The DON also stated these were infection control issues. A review of the Face Sheet revealed the facility admitted Resident #52 on 4/8/15.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to implement the Comprehensive Care Plan for Resident #16's suprapubic catheter care, Resident #207's Percutaneous Endoscopic Gastrostomy (PEG) tube site care, and to develop a Care Plan for Resident #54's coagulant medication therapy. This concern was identified for three (3) of 20 resident care plans reviewed. Findings include: A review of the facility's policy titled, Comprehensive Care Plan, revised November 2017, revealed the facility would develop a comprehensive person-centered care plan that identifies each resident's medical, nursing, mental and psychosocial needs. The care plan is developed with the resident goals, wishes, and preferences. The plan includes measurable objectives and timetables agreed to by the resident to meet such objectives. The purpose of the Comprehensive Care Plan is to provide effective and person-centered care. Review of the [NAME]'s Nursing Procedures, obtained from the [NAME] website by the Administrator, revealed: Hand Hygiene, dated June 14,2019, the hands are the conduit for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Hand Hygiene, therefore, is the single most important procedure in preventing infection. Resident #54 A review of Resident #54's Order Summary of Physician Orders, dated 8/9/19 at 10:50 AM, revealed an order, dated 07/17/19, for Xarelto (Anticoagulant/Blood Thinner) 15 milligrams (mg) one (1) by mouth in the evening related to Atrial Fibrillation. A review of the admission Minimum Data Set (MDS), with an Assessment Reference date of 7/24/19, revealed Resident #54 was on anticoagulant medication for seven (7) days of the seven (7) day look back period. A review of Resident #54's Comprehensive Care Plan revealed a care plan was not developed related to anticoagulant therapy. An interview, on 08/08/19 at 9:45 AM, revealed Registered Nurse (RN) #1/MDS Coordinator, said the care plan should be developed for the anticoagulant use by Resident #54 because it was one of the medications that is closely monitored. She said Xarelto was a high risk medication and was monitored daily by the nurses. An interview, on 08/08/19 at 11:03 AM, revealed the Director of Nursing (DON) said she expected the care plan to be specific to the resident and Resident # 54 should have a care plan related to Xarelto use and concerns. Resident #16 Record review of Resident #16's Comprehensive Care Plan revealed a Focus for a Suprapubic Catheter, with a revision date of 10/05/18. The Interventions included: Clean suprapubic tube site every shift as ordered and suprapubic catheter care with soap and water as ordered. An observation, on 08/07/19 at 8:40 AM, revealed Registered Nurse (RN) #3 entered Resident #16's room to perform catheter care. RN #3 had already placed the catheter care supplies on the over bed table using a towel as a barrier. RN #3 washed and dried her hands. RN #3 obtained a basin and filled the basin with warm water. RN #3 obtained DermaVera skin and hair soap from a shelf and put the soap into the water in the basin. RN #3 used her anterior wrist area to turn the faucet off. RN #3 left the rest room, but returned to wash her hands again stating, I touched the faucet with my wrist. RN #3 returned to the bedside and picked up a red biohazard bag and a clear bag that were lying on the foot of Resident #16's bed. RN #3 opened the bags and then placed them at the foot of Resident #16's bed. RN #3 gloved without washing her hands and removed the dirty dressing from around Resident #16's suprapubic stoma site and discarded the dressing in the red bag. RN #3 washed her hands, gloved and took a wash cloth and put it into the basin containing the water and soap. RN 3 squeezed the cloth out and wadded the cloth up in her right gloved hand. RN #3 wiped the catheter stoma site in a circular motion with one wipe and discarded the cloth into the clear bag. RN #3 obtained a second cloth, wet the cloth in the basin and wiped the catheter stoma site in a circular motion and discarded the cloth into the clear bag. RN #3 obtained a third cloth, wet the cloth in the basin, took the tubing into her left gloved hand and begin to clean the tubing with the cloth in her gloved right hand starting at the catheter stoma site. RN #3 stated, there is something on the tubing and she wiped the tubing in the same area for several moments in a circular motion using the same spot on the cloth and then continued upwards on the tubing using the same cloth. RN #3 discarded the cloth into the clear bag. RN #3 washed her hands, gloved, opened a split gauze dressing and applied it to the stoma site. RN #3 took a piece of cloth tape and applied the tape to the dressing and skin stating, this is to hold the dressing in place. RN #3 did not date or initial the clean dressing. RN #3 removed her gloves, applied new gloves without washing her hands, picked up the basin and discarded the water into the toilet. RN #3 washed her hands, gloved and tied the red bag up and placed it back on the foot of the bed. RN #3 removed the towel used as a barrier and placed it into the red bag and tied the bag up leaving it on the foot of the bed. RN #3 removed her gloves and placed Resident #16's things back onto the over bed table without washing her hands or cleaning the over bed table with sanitizer. RN #3 picked up the red biohazard bag and exited the room without washing her hands. RN #3 stated after exiting the room, I didn't wash my hands when I took my gloves off and before leaving the room. An interview, on 08/07/19 at 12:06 PM, revealed Registered Nurse (RN) #1/Minimum Data Set (MDS)/Care Plan Nurse stated, the care plan is created for staff to care for a resident. My expectations is for staff to follow the care plan. The care plan is used as a guide in the care of the resident. RN #1 revealed the Care Plan was not followed if correct care was not provided. An interview, on 08/08/19 at 9:43 AM, with the Director of Nursing (DON)/Interim Infection Control Nurse revealed the care plan should have been followed to provide proper catheter care for Resident #16. An interview, on 08/08/19 at 10:06 AM, revealed RN #1 stated, What I mean by providing suprapubic care on the care plan is that I expect staff to follow the catheter care policy and procedure to help prevent the spread of infection. The nurse should not have used the same cloth to rub the tubing and then continue up the tubing. The nurse should follow what she knows is infection prevention. Resident #207 Record review of Resident #207's Comprehensive Care Plan revealed a Focus for a Percutaneous Endoscopic Gastrostomy (PEG) tube, with a revision date of 8/06/19. The Interventions included: PEG tube care daily as ordered. An observation, on 08/07/19 at 9:00 AM, revealed Registered Nurse (RN) #3 gathered supplies from the wound care cart, obtained a towel from the linen cart to use as a barrier and entered Resident #207's room to perform Percutaneous Endoscopic Gastrostomy (PEG) tube care. RN #3 placed a towel on the over bed table, without cleaning the over bed table, and laid the unopened bottle of normal saline, unopened gauze and a drain gauze on the barrier. RN #3 moved the over bed table, containing the supplies, with her foot to the side of the bed. RN #3 washed her hands, turned the lights on in the room and then left the room to obtain a red biohazard bag. RN #3 entered Resident #207's room with the red bag and placed the unopened red bag on the foot of the bed. RN #3 removed her gloves and left the room stating she had to go to the linen cart and get some gloves. RN #3 removed an open box of gloves from the linen cart and returned to the room taking several pair of gloves out of the box and placing them on the barrier. RN #3 put the remaining box of gloves in the bracket on the wall. RN #3 washed her hands, gloved, turned off Resident #207's feeding pump and then unhooked the tubing from the stoma site. RN #3 removed her gloves, washed her hands, gloved and let the head of the bed down. RN #3 attempted to turn Resident #207 over as he was lying on his left side. RN #3 voiced that the red unopened biohazard bag had fallen onto the floor and she reached down, picked it up and opened it at the foot of the bed. RN #3 reached over Resident # 207's right side and removed the dirty dressing from the stoma site. RN #3 discarded the soiled dressing into the red biohazard bag. RN #3 removed her gloves, washed hands, re-gloved, opened the normal saline bottle and sat it on the barrier and then opened the gauze. RN #3 picked up the gauze, the bottle of normal saline, and then touched the gauze to the opening of the normal saline bottle to wet the gauze. RN #3 took the gauze and wiped the PEG stoma area in a circular motion going all the way around the stoma twice and then folded the gauze and continued to wipe the stoma area in a circular motion. RN #3 discarded the dirty gauze into the red bag, removed her gloves and washed her hands. RN #3 gloved and took a dry gauze and dried the stoma area in a circular motion wiping twice with the same gauze without lifting the gauze. RN #3 removed her gloves, washed her hands and applied clean gloves. RN #3 opened the drain sponge and applied the sponge to the stoma securing it with paper tape. RN #3 did not date or initial the clean bandage. RN #3 pulled the covers up on Resident #207 without removing her gloves or providing hand hygiene. RN #3 tied the red biohazard bag up and placed it on top of the towel that was used as a barrier. RN #3 removed her gloves, washed her hands and picked up the red bag leaving the towel on the over bed table. RN #3 left the room, walked down the hall to the biohazard room and discarded the red bag. RN #3 washed her hands and returned to the room. RN #3 opened a clear bag and placed the towel used as a barrier into the bag and tied the bag up. RN #3 washed her hands, picked up the clear bag and exited the room without cleaning the over bed table and stated I'm finished and I'm going down the hall to discard the dirty linen. An interview, on 08/07/19 at 12:06 PM, with RN #1/MDS/Care Plan Nurse, revealed The care plan is created for staff to care for a resident. My expectations is for staff to follow the care plan. The care plan is used as a guide in the care of the resident. RN #1 revealed the Care Plan was not followed if proper care was not provided. An interview, on 08/08/19 at 9:43 AM, with the Director of Nursing (DON)/Interim Infection Control Nurse, revealed the care plan should have been followed to provide proper PEG tube care for Resident #207. An interview, on 08/08/19 10:12 AM, with RN #1 revealed What I mean by providing Enteral Feeding care on the care plan is that I expect the staff to follow the care plan for Enteral Feeding care for Resident #207. The nurse should first look at the physicians orders, the care plan, and policy and procedure of doing the care before beginning care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff intervention, record review, Manufacturer's Instructions for Digital Thermometer Calibration and facility policy review, the facility failed to prevent the possibility for the spread of food borne illness during tray line temperature checks and wet stacking of juice glasses, for one (1) of three (3) kitchen observations. Findings include: A review of facility's policy titled, Infection Prevention Program Overview dated 2/2018, revealed The goals of the infection control prevention program are to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by; decreasing the risk of infection to residents and personnel, identifying and correcting problems relating to infection prevention practices and maintaining compliance with state and federal regulations relating to infection prevention. Prevention of spread of infection is accomplished by use of hand hygiene, standard precautions, transmission based precautions, as indicated, and other barrier. A review of a typed document on the facility's letterhead, signed and dated August 8, 2019 by the Administrator, revealed, Countrybrook Living Center contracts with (Name of Healthcare Business) to provide dietary services, and thermometer calibration is to be done prior to each meal with the standard of use following manufacturers' instruction manual. A review of the Waterproof Digital Thermometer Instructions Manual provided by the facility revealed, If recalibration is necessary, for best results, calibrate within the temperature range most commonly used. Always utilize a reliable source as a benchmark when calibrating. If a verified reference temperature cannot be achieved in the usage range, then calibrate in an ice bath. An observation, on 8/5/19 at 3:53 PM, revealed 18 Juice glasses, were wet and stacked on top of each other, sitting on a rack with other clean dishes. A review of the [NAME]'s Nursing Procedures titled, Hand Hygiene, dated June 14,2019, revealed, The hands are the conduit for almost every transfer of potential pathogens from one patient to another, from contaminated object to a patient, and from a staff member to a patient. Hand Hygiene, therefore, is the single most important procedure in preventing infection. This information was provided by the Administrator she obtained from the [NAME] website. An observation, on 8/6/19 at 11:50 PM, revealed the Dietary [NAME] came from an area in the back of the kitchen wearing gloves and holding a metal pan containing food. The Dietary [NAME] approached the holding table where the food warms until it is served and sat the pan in the holding table. The Dietary [NAME] did not change gloves or wash her hands. The Dietary Manager handed the Dietary [NAME] a thermometer that he had been holding in his bare hand. The Dietary Manager went to the back of the kitchen, washed his hands and then returned to watch the Dietary [NAME] check the temperatures of the different food. The Dietary [NAME] began to check the temperature of the foods on the holding line without washing hands or changing gloves after brining the pan of food from the back of the kitchen. Neither the Dietary [NAME] nor the Dietary Manager calibrated the thermometer. The Dietary [NAME] wiped the thermometer probe with an alcohol prep pad and checked the temperature of the pork tenderloin (temp 169 degrees). The Dietary [NAME] wiped the thermometer probe with an alcohol prep pad and checked the temperature of the zucchini with onions (tempted 185 degrees). The Dietary [NAME] wiped the thermometer probe with an alcohol prep pad and checked the temperature of the potatoes (173 degrees). The Dietary [NAME] checked the temperature of the [NAME] garlic chicken (149 degrees) and then wiped the thermometer probe with an alcohol prep pad. The Dietary Manager then checked the temperature of the green beans (168 degrees). The Dietary [NAME] then wiped the probe of the thermometer with an alcohol prep pad and checked the temperature of the pureed pork tenderloin (143 degrees., The Dietary [NAME] wiped the thermometer probe with an alcohol prep pad and checked the temperature of the pureed chicken (141 degrees). The Dietary [NAME] wiped the probe and then tempted the green beans at 150 degrees. The Dietary [NAME] wiped the probe with an alcohol prep pad and checked the temperature of the mechanical soft pork tender loin (134 degrees). The Dietary Manager took the metal pan with the pork loin in it over to a preparation surface behind the holding table. The Dietary Manager gloved, took a spoon and poured the mechanical soft pork loin into a plastic container, and placed the plastic container containing the pork loin into the microwave to reheat. The Dietary Manager removed the plastic container containing the pork loin from out of the microwave and took a different digital thermometer, which he did not calibrate and the probe had not been cleaned, and began to stir the pork loin with the thermometer. The handle of the thermometer went into the pork loin touching the meat. The Dietary Manager checked the temperature of the pork loin at 193 degrees and then covers the pork loin and replaces it in the holding table to serve. The Dietary [NAME] checked the temperature of the buttered noodles at 134 degrees and could not obtain the desired temperature. The Dietary Manger, without changing gloves or doing hand hygiene, takes the digital thermometer from the Dietary [NAME] and stirs the noodles with the thermometer again getting the handle of the thermometer into the noodles. The Dietary Manager covered the pan of noodles and places them on the holding table to be served. The contaminated noodles and mechanical soft pork loin were observed being served. An interview, on 8/6/19 at 12:10 PM, with the Dietary Manager revealed, I did stir the mechanical pork loin and buttered noodles with the thermometer but I don't remember the handle getting into the mechanical soft pork loin or the buttered noodles. When asked if the thermometer had been calibrated the Dietary Manager stated the thermometer is digital it doesn't need calibrating. Do you really have to do it every day? I do think that if I touched the food with the handle it would be an infection control issue. This was my first survey and I was nervous. Not calibrating the thermometer could cause the temperature of the foods to be inaccurate. An interview, on 8/6/19 at 12:12 PM, with the Dietary [NAME] revealed, I saw the Dietary Manager stir the buttered noodles with the thermometer, but I didn't see the handle in the food. I also saw him stir the pork with the thermometer, but I didn't see the handle in the food. If he did touch the food with the handle of the thermometer then it would be an infection control issue. I didn't calibrate the thermometer before using it. I did wear my gloves from the back of the kitchen. I should have changed my gloves before starting to do the temperatures. I just didn't think about it. An interview, on 8/7/19 on 11:14 AM, with the Dietary Manager revealed, I did not throw the food away yesterday after we discussed that I stirred it with the thermometer, and it was said the handle touched the food. I served it. We did not calibrate the thermometer. An interview, on 08/07/19 at 03:50 PM with the Director of Nursing (DON), revealed not calibrating the thermometer could have allowed the food to be too hot or too cold. The Dietary manager stirring the food with the thermometer and allowing the handle of the thermometer to get into the food is an infection control issue. Stacking the wet glasses is an infection control issue. An interview, on 8/7/19 at 3:51 PM, with the Administrator revealed, Food is contaminated with the handle getting into the food. The Dietary Manager should have thrown it away. It was a Infection Control Issue.