Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food safety related to expired foods, overly ripe produce, and scoops stored in dry bins touching food items for one (1) of two (2) kitchen observations. Findings included: A review of the facility's policy titled Storing: Food and Equipment revealed, .Team members must store food in a manner that ensures quality, freshness, and safeguards against foodborne illness . Items to Label. Ensure all food items are labeled .How Long to Keep .Generally, food should be discarded or used by the use-by date. The use-by date is the last date the manufacturer recommends use of the food and also may be referred to as the expiration date .Containers .Cover, label, and date all leftovers . Store scoops in a covered area .not in food containers. A review of the facility's policy titled HACCP (Hazard Analysis and Critical Control Points) and Food Preparation Guidelines, revised 01/2024, revealed, Fruits and Vegetables . Inspect for signs of spoilage, bruises, and damage . On 11/18/2024 at 10:13 AM, during an observation with the Patient Service Manager (PSM) and the Food Services Director (FSD), in Refrigerator #1 there were three (3) aluminum pans with cut iced cake slices with no label or date, one (1) opened container of facility-made peanut butter with a prep date of 11/11/2024 and a use-by date of 11/17/2024, one (1) half bologna sandwich with no label or date, two (2) unopened packs of ham with a use-by date of 10/28/2024, and one (1) unopened pack of bologna with a use-by date of 09/29/2024. In Refrigerator #2, there was one (1) opened container of cooked cauliflower with no label or date, thirty-three (33) bell peppers with soft spots and black and/or white biological growth, and seven (7) tomatoes with soft spots and biological growth. In Refrigerator #3, there was one (1) aluminum foil-wrapped food item identified as pork loin with no label or date, and one (1) opened pack of bologna with a faded and unidentifiable date. In the pantry, a scoop was inside the sugar bin, touching the sugar. On the spice rack, scoops were stored inside the containers and touching the food items in a 4-pound container of kosher salt, a 4-pound container of black pepper, and a 4-pound container of onion powder. On 11/18/2024 at 11:30 AM, during an interview, the [NAME] stated that all kitchen staff are responsible for checking food for expiration and safety, and this monitoring should occur daily. The [NAME] confirmed that staff are in-serviced on food safety one (1) to two (2) times per month. On 11/18/2024 at 11:44 AM, during an interview, the PSM acknowledged the scoops left in the dry bins, overly ripe produce, expired foods, and unlabeled food items observed. The PSM stated that all staff are responsible for checking the food for quality, labeling, and expiration dates. On 11/18/2024 at 11:50 AM, during an interview, the FSD confirmed the findings, including overly ripe produce, scoops left in dry bins, and expired and unlabeled food. The FSD stated that it is everyone's responsibility to check foods for quality and expiration dates, which should take place daily. The FSD stated she conducts monthly in-services on food safety. On 11/21/2024 at 9:45 AM, during an interview, the Administrator acknowledged the concerns observed in the kitchen. The Administrator confirmed that the FSD and PSM are responsible for monitoring food expiration dates and proper storage. He stated that going forward, he expects the kitchen to be in complete compliance.

Based on observation, interview, record review, and facility policy review, the facility failed to provide care and services consistent with professional standards of practice for a pressure ulcer for one (1) of two (2) pressure wound care observations. Resident #11. Findings Include: Review of the facility's procedure Wound Care, revised June 2018, revealed, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in Procedure .7. Use no-touch technique . A record review of the Physician Orders for February 2023 revealed a treatment order with an order date of 1/20/23 for Resident #11 for Wound care for RT (Right) buttock: Cleanse wound w/(with) wound cleanser. Pack wound w/dry gauze. Cover w/5x5 foam border. Change daily or PRN (as needed) or soilage or dislodgement. DX (Diagnosis): Stage 4 Pressure Ulcer Rt Buttock. A treatment order with an order date of 1/26/23 also revealed, Wound care orders for RT buttock: for 9 o'clock (position of area as related to the face of a clock) tunneling (passageway of tissue destruction underneath the skin) of wound: cleanse w/wound cleanser. Pack with Opticell AG silver ribbon and dry gauze change on MWF (Monday, Wednesday, Friday) or prn for soilage or dislodgement. Cover w/5x5 foam border Dx: Stage 4 Pressure Ulcer RT Buttock. On 2/21/23 at 1:35 PM, during an observation of wound care of Resident #11 with Registered Nurse (RN) #1/Treatment Nurse, assisted by Certified Nurse Aide (CNA) #1, RN #1 cleaned the wound bed of the right buttock with wound cleanser. While RN #1 was washing her hands, CNA #1 assisted the resident to turn onto her back, which allowed the clean wound bed to come in contact with the incontinence pad that was soiled with drainage from the wound. Resident #11 was positioned back onto her left side and RN #1 placed a cotton tipped applicator into the wound bed, removed it and used measuring paper to measure the depth of the wound. She then took the same cotton tipped applicator and placed it back into the wound to measure the tunneling at 1 o'clock. RN #1 then removed the applicator from that area of the tunneling wound and held it up to the measuring paper to obtain the depth of the tunneling. RN #1 used the same cotton tipped applicator and placed it into the tunneling at 9 o'clock and held it up to the measuring paper to obtain the depth of the tunneling. On 12/22/23 at 10:26 AM, during an interview with RN #1, she stated that at her previous job, she did not have to stage or measure pressure wounds. She confirmed that during the wound care for Resident #11, she used the same cotton tipped applicator to measure the wound depth, and both wound tunneling and that this could have caused cross contamination of the wound. She said that she was nervous during the observation and did not know why she did not use a different cotton tipped applicator to measure each area of the wound because she had brought several applicators into the room for that very reason. She also verified that CNA #1 allowed the resident's cleaned wound to come in contact with the contaminated incontinence pad and that she did not clean the wound again, but proceeded with packing the wound. On 12/22/23 at 11:00 AM, in an interview with the Director of Nursing (DON) and the Infection Preventionist (IP), they both confirmed that CNA #1 should not have allowed the resident's cleaned wound to come in contact with the contaminated incontinence pad. They also confirmed that the wound care nurse should have used a different cotton tipped applicator when measuring the depth at each tunnel of the wound to avoid cross contamination of the wound. A record review of the facility's document, Wound care reviewed with (Proper Name of RN #1), dated 2/1/23 revealed there were no issues identified during RN #1's wound care technique when observed by management staff. The steps reviewed (1-20) did not address measuring or staging wounds. Record review of the Face Sheet revealed Resident #11 was admitted by the facility on 10/14/2022 and had diagnoses including Hypertension, Encephalopathy, and Senile Degeneration of Brain. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/23 revealed that Resident #11 had severely impaired cognitive skills.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a licensed nurse had the specific competencies and skill set to stage pressure wounds for two (2) of two (2) residents reviewed for pressure wounds. Resident #11 and Resident #13. Findings Include: A review of the facility's policy, Competency of Nursing Staff, revised October 2017, revealed, Policy Statement .2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care .Policy Interpretation and Implementation 1. The staff development and training program is created by the nursing leadership .and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents 2. The following factors are considered in the creation of the competency-based staff development and training program .c. Specialized skills or training needed based on the resident population .4. Competency in skills and techniques necessary to care for residents' needs may include but is not limited to competencies in areas such as .h. Skin and wound care . A review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1 dated October 2019 revealed, .Definition Stage 2 Pressure Ulcer Partial thickness loss of dermis presenting as a shallow open ulcer .without slough . Review of the manual also revealed, .Once a deep tissue injury has opened to an ulcer, reclassify the ulcer into the appropriate stage . Resident #11 Record review of the Wound Assessment Report for Resident #11, dated 2/16/23, revealed Resident #11 had a Pressure Ulcer with the Wound Location of Left Buttock; Stage 2 pressure. The pressure ulcer was listed as a Stage 2 with measurements that indicated the length of the ulcer as 0.10 cm (centimeters), width of 0.20 cm, and depth of 8.30 cm. The wound bed was listed as having 10% slough (non-viable tissue) and the assessment was electronically signed by Registered Nurse (RN) #1 on 2/16/23. On 2/21/23 at 1:35 PM, the State Agency (SA) observed wound care for the left buttock pressure ulcer for Resident #11, with Registered Nurse (RN) #1. RN #1 measured the pressure ulcer depth as 6 cm, which is uncharacteristic of a shallow open ulcer. Record review of the Face Sheet revealed Resident #11 was admitted by the facility on 10/14/2022 and had diagnoses including Hypertension, Encephalopathy, and Senile Degeneration of Brain. Resident #13 Record review of the Wound Assessment Report for Resident #13, dated 2/16/23, revealed Resident #13 had a Pressure Ulcer with the Wound Location of Right Top of Foot: Right Lateral Foot. The pressure ulcer was listed as an Unstageable due to suspected deep tissue injury (DTI). Review of the Notes section revealed, Healing unstageable wound; new measurements are: approx. (approximately) 2.2 cm in length; 1.5 cm in width; 0.3 cm in depth. Wound bed is pink. The assessment was electronically signed by RN #1 on 2/16/23. On 2/22/23 at 10:07 AM, during an observation of wound care for Resident #13 with RN #1, she measured the wound as 1.3 cm length, 2.4 cm width, and 0.3 cm depth. The wound was opened, and muscle and granulated tissue were visible in the wound bed. The open wound was not characteristic of a deep tissue injury. A record review of the Face Sheet revealed Resident #13 was admitted by the facility on 5/21/20 and had diagnoses including Functional Quadriplegia and Contracture, Left Knee. On 12/22/23 at 10:26 AM, during an interview with RN #1, she stated that she previously worked in an acute care hospital for 17 years, in which she did not have the responsibility of staging pressure ulcers. She became employed at the facility at the end of September 2022 as the treatment nurse. Her job duties include performing treatments, conducting skin assessments, and completing weekly wound assessments for residents with pressure ulcers. The Infection Preventionist provided her training and worked with her during her orientation. She stated she had asked about possibly becoming wound care certified because she felt as though she would feel better and be more confident when staging wounds. She confirmed that she did not change the stage of the Stage 2 pressure ulcer for Resident #11 after it had progressed to include a depth of 9 cm. She stated the wound parameters were so small that she was unable to visibly assess the wound bed, so she left it staged as it was. She confirmed that she continued to classify the pressure injury for Resident #13 as an unstageable DTI even after it had opened up because she thought the nurse consultant had told her that she couldn't downstage the pressure injury. On 12/22/23 at 11:00 AM, in an interview with the Director of Nursing and the Infection Preventionist (IP), the DON stated that she had taken for granted that RN #1 would know how to stage wounds accurately. The DON and the IP acknowledged that wound care staging and assessments required a certain skill set and that RN #1's work history had been in an acute care setting in which there were specialized staff who were responsible for staging pressure wounds. The DON stated that there are so many nuances involved in staging pressure ulcers and cover a broad area. She confirmed that Resident #11's wound should have been staged as a Stage 4 as the wound progressed and became deeper and verified that a Stage 2 was not accurate. The DON stated that Resident #13's wound should have been reclassified once the wound became opened. She stated she would have classified his wound as a Stage 4. She confirmed that is it her responsibility to oversee the work of RN #1. A record review of the facility's document, Wound care reviewed with (Proper Name of RN #1), dated 2/1/23 revealed there were no issues identified during RN #1's wound care technique when observed by management staff. The steps reviewed (1-20) did not address measuring or staging wounds.

Based on record review, staff interview, and facility policy review, the facility failed to convey to the receiving provider, the basis for the transfer from the facility for one (1) of six (6) residents with hospital transfers, Resident #3 Findings Include: Review of a statement on facility letterhead, dated 9/19/19, and signed by the Director of Nursing (DON) revealed,We do not have a policy and procedure that specifically addresses the information that is sent out with the resident to the hospital at time of discharge/transfer. Review of a document, provided by the facility, and signed by the DON, dated 9/19/19, revealed Sending residents to the ER- Transfer/discharge sheet once you fill it out in the computer (print). Record review of physician's orders, dated 8/8/19, 8/13/19, and 8/16/19, revealed Resident #3 was transferred from the facility to the hospital for evaluations. Record review of Resident #3's paper and computer chart revealed no documentation that a transfer summary containing Resident #3's medical status/ Resident Representative Contact information was sent to the receiving facility when Resident #3 was transferred to the hospital three (3) times. An interview on 09/17/19 at 1:25 PM, with the Director of Nursing (DON), revealed, We do not have a transfer summary that was sent to the hospital for Resident #3. We are supposed to send a transfer summary including the reason for transfer to the hospital, Medication Administration Record, Resident Representative contact information, allergies, etc. but there was not one sent that I can find.

Based on record review, staff interview, and facility policy review, the facility failed to notify the resident and/or resident representative of the facility policy for bed hold, for two (2) of six (6) hospitalizations reviewed, Resident #23, and Resident #30. Findings Include: A review of facility policy titled Bed-Holds and Returns, dated March 2017, revealed Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Resident #23 Record review of a physician's order, dated 6/28/19, revealed Resident #23 was transferred from the facility to the hospital. Record review of Resident #23's medical record revealed no evidence of a bed hold letter delivered to Resident #23 or the Resident Representative. The facility failed to provide evidence of a documented bed hold letter for Resident #23. Res #30 Record review of a physician's order, dated 6/04/19, revealed Resident #30 was transferred from the facility to the hospital. Record review of Resident #30's medical record revealed no documented evidence of a bed hold letter delivered to Resident #30 or the Resident Representative. The facility failed to provide evidence of a bed hold letter for Resident #30. An interview on 09/17/19 at 12:00 PM, with the Social Service Director, regarding Resident #23 and Resident #30's transfers, revealed that she did not know of any transfer/bed hold letter that the facility mailed to the Resident Representative when the resident was transferred to the hospital. An interview on 09/17/19 at 1:25 PM, with the Director of Nursing (DON), regarding Resident #23 and Resident #30's transfers, revealed there was no documented transfer/bed hold sheet for the residents for when they went out of the facility to the hospital. The DON stated, We don't have any written transfer/bed hold letters that were given to the resident or mailed to the Resident Representative. We don't have proof we mailed anything.

Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of 18 MDS assessments reviewed, Resident #21. Findings include: Review of a facility statement, regarding the Resident Assessment Instrument (RAI) Policy: A comprehensive assessment of a resident's needs shall be made within 14 days of the resident's admission. According to the M0210: RAI Version 3.0 Manual, If a resident had a pressure ulcer/injury that healed during the look-back period of the current assessment, do no code the ulcer/injury on the assessment. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2019, Section M revealed documentation that Resident #21 had a Stage 2 Pressure Ulcer. Record review of the Physician's Progress note, revealed documentation that the Pressure Ulcer for Resident #21 was Healed on 6/20/19. Record Review of the Wound/Skin Management Documentation Record, revealed on 06/24/2019, the wound for Resident #21 was intact. On 09/17/19 at 11:24 AM, an interview with Director of Nursing (DON) revealed Resident #21 had no Pressure Ulcer. During an interview on 09/17/19 at 11:25 AM, Register Nurse #1 confirmed Resident #21's physician documented that #21's Stage 2 ulcer was healed on 6/20/19. On 09/17/19 at 3:30 PM, observation of Resident #21 revealed no pressure ulcers. On 09/18/19 at 09:08 AM, an interview with Licensed Practical Nurse #1/MDS Coordinator, and the Director of Nursing, revealed the Stage 2 wound for Resident #21 healed on 6/20/2019, and the MDS was inaccurately coded. Licensed Practical Nurse #1, stated, I did not observe the wound. On 09/18/19 at 10:56 AM, an interview with Resident #21's Physician revealed Resident #21's wound had healed on 6/20/2019, and orders should have been written to discontinue the treatment.

Based on record review, facility policy review, and staff interview, the facility failed to revise the Comprehensive Care Plan to reflect a soft wrist splint and interventions, for Resident #3 and the use of an indwelling catheter for Resident #38, for two (2) of 18 care plans reviewed. Findings Include: A review of facility policy titled, Care Plans-Comprehensive, (no date) revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care-Planning interdisciplinary team is responsible for the review and updating of care plans. Resident #3 Record review of the Working Care Plan on the chart, and the most current care plan, initiated 12/12/18, through the review date of 9/30/19, revealed Resident #3's care plan was not revised to include a soft wrist splint and/or interventions related to the splint. Review of an incident report timeline, provided by the facility, revealed Resident #3 had a right wrist splint placed, per Primary Care Provider, on 8/13/19, for a non-displaced distal radial fracture. An observation on 09/16/19 at 8:53 AM, revealed a soft wrist splint noted on Resident #3's right wrist. During an interview on 09/18/19 at 11:07 AM, the Director of Nursing (DON) stated, after reviewing the current care plan and the working care plan on the chart, The right wrist splint interventions are not on the Resident's current care plan or on the working care plan in the chart. An interview on 09/18/19 at 11:20 AM, with LPN #1 MDS/Care Plan Nurse, revealed the soft wrist splint and interventions were not care planned, and they should have been. LPN #1 stated, The nurse who checks the orders when a resident returns from an appointment, is responsible to write the order and care plan the order if needed. An interview on 09/18/19 at 1:37 PM, with the DON, revealed, It is the RN Supervisor or the LPN's responsibility to check a resident back in after an appointment and they are supposed to write any orders that return with the resident. Then, whoever writes the order, is supposed do to create or update the care plan specific to the order. Resident #38 Review of Resident #38's comprehensive care plan, with a target date of 11/30/19, revealed a care plan related to the resident's incontinence, however, there was no care plan for an indwelling urinary catheter. On 9/17/19 at 9:19 AM, an observation revealed Certified Nursing Assistant (CNA) #1, assisted by CNA #2, performed catheter care for Resident #38. The resident was observed to have an indwelling urinary catheter. On 9/17/19 at 11:00 AM, an interview with the Director of Nurses (DON) revealed there was no physician's order or care plan for the indwelling urinary catheter for Resident #38. On 9/17/19 at 11:10 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed a care plan had not been developed for the resident's indwelling urinary catheter. She also stated the current care plan did not reflect the resident's current status regarding the indwelling urinary catheter. During an interview on 09/18/19 at 8:54 AM, Registered Nurse (RN) #3 revealed Resident #38 returned from the hospital (8/19/19) with the catheter and had not had any complications from the urinary catheter.

Resident #3 Review of Physician orders for August 2019, revealed no Physician's order for a soft wrist splint to Resident #3's right wrist on 8/13/19. Review of an incident report timeline, provided by the facility, documented on 8/13/19, revealed Resident #3 received a right soft wrist splint, placed per Primary Care Provider, due to a nondisplaced distal radial fracture. An observation on 09/16/19 at 8:53 AM, revealed a soft wrist splint noted on Resident #3's right wrist. An interview on 09/18/19 at 11:00 AM, with the facility Medical Director, revealed he applied the soft splint to Resident #3's wrist in the emergency room on 8/13/19. An interview on 09/18/19 at 11:07 AM, with the Director of Nursing (DON), revealed there should have been an order written for Resident #3's splint when she returned from the hospital. The DON confirmed the medical record was inaccurate because there was no order written for the wrist splint. An interview on 09/18/19 at 1:37 PM, with the DON, revealed the RN Supervisor or the LPN who checks a resident back in after an appointment are supposed to write any orders that return with the resident. She stated whoever writes the order, is supposed to create or update the care plan, specific to the order. The DON confirmed there was no Physician's order written for Resident #3's splint, nor a care plan updated with written interventions for the soft right wrist splint. Based on observation, record review, staff interview and facility policy review, the facility failed to ensure accuracy of the medical record, related to a soft wrist splint and an indwelling urinary catheter, for two (2) of 18 resident medical records reviewed, Resident #3 and Resident #38. Findings include: A review of the facility's policy titled Medication Orders with a revision date of November 2014, revealed a current list of orders must be maintained in the clinical record of each resident. A review of the facility's documented statement, signed by the Director of Nursing (DON), not dated, revealed the facility does not have a policy and procedure that specifically addresses the input of orders after a hospital return. Resident #38 A record review of the physician's orders for September 2019, revealed there was no order for Resident #38's indwelling urinary catheter. The most recent Discharge-Return Anticipated Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/27/19, was coded to include an indwelling urinary catheter. The resident had a catheter for entire seven (7) day look-back period. On 9/17/19 at 9:15 AM, an observation revealed Resident #38 lying in bed with his eyes open. Resident #38 was observed with an indwelling urinary catheter. On 9/17/19 at 11:00 AM, an interview, with the Director of Nurses (DON), confirmed the medical record was inaccurate related to no physician's order for the indwelling urinary catheter for Resident #38. She also stated the physician orders did not reflect the resident's current status regarding the indwelling urinary catheter. The DON stated Resident #38 had the catheter upon his hospital return (8/19/19). On 9/18/19 at 8:54 AM, an interview, with Registered Nurse (RN) #3, revealed the resident returned from the hospital with the catheter, had poor kidney function, and is unable to urinate on his own. She also stated she would have to look at the chart to make sure of the diagnoses. She stated the resident had not had any complications from the urinary catheter that she is aware of.

Resident #21 Review of Resident #21's medical record revealed the resident was transferred to the hospital on 5/27/19, and returned to facility on 5/31/2019, for observation of Pneumonia. Review of Resident #21's medical record revealed no documented evidence of a written transfer notice to the Resident and/or Resident Representative for the 5/27/19 transfer to the hospital. During an interview on 09/17/19 at 1:37 PM, the DON confirmed the facility did not notify the Responsible Party of Resident #2, in writing, for transfer to hospital on 5/27/19. Resident #28 Record review revealed Resident #28 was transferred to the hospital on 9/3/2019, and returned on 9/7/2019, for diagnoses of Sepsis, Acute Kidney Infection, and Urinary Tract Infection (UTI). Review of Resident #28's medical record revealed no documented evidence of a written notice of transfer to the Resident and/or Resident Representative. On 09/18/19 at 3:03 PM, interview with the DON revealed a written notice of transfer was not provided to the Resident Representative regarding the transfer to the hospital on 9/3/19. Resident #3 Record review of physician's orders dated 8/8/19, 8/13/19, and 8/16/19, revealed Resident #3 was transferred from the facility to the hospital for evaluations. Review of Resident #3's medical record revealed no documentation of a transfer letter to the Resident Representative regarding Resident #3's transfers from the facility to the hospital, prior, during, or shortly after the transfers. The facility failed to provide proof of a written transfer letter mailed to Resident #3's Resident Representative (RR). An interview on 09/17/19 at 11:45 AM, with the Business Office Director (BOD) revealed, We have no documentation that we mailed the Resident Representative written notice of the hospital transfer on any of the days. An interview on 09/17/19 at 11:55 AM, with the DON revealed, The process is that the hospital written transfer sheet should be mailed out the next day after a Resident is transferred out of the facility. It should be mailed by the Social Service Department. An interview on 09/17/19 at 12:00 PM, with the Social Service Director (SSD), confirmed that she did not know of any transfer/bed hold letter that the facility mailed to the Resident Representative when the resident was transferred to the hospital. An interview on 09/17/19 at 1:25 PM, with the DON, revealed the facility did not have a transfer/bed hold sheet for Resident #3 for transfers to the hospital. The DON stated, We don't have any written transfer/bed hold letters that were mailed to the Resident Representative. We don't have proof we mailed anything. Res #23 Review of a physician's order, dated 6/28/19, revealed Resident #23 was transferred from the facility to the hospital. Review of Resident #23's medical record revealed no written transfer letter to the Resident Representative regarding Resident #23's transfer from the facility. The facility failed to provide proof of a written transfer letter mailed to Resident #23's Resident Representative. Res #30 Review of a physician's order, dated 6/04/19, revealed Resident #30 was transferred from the facility to the hospital. Review of Resident #30's medical record revealed no written transfer letter to the Resident Representative regarding Resident #30's transfer out of the facility. The facility failed to provide proof of a written transfer letter mailed to Resident #30's Resident Representative. Based on record review, staff interview, and facility policy review, the facility failed to provide written documentation to the resident and/or resident's representative, of the reason for transfer/discharge to the hospital, for six (6) of six (6) hospitalizations reviewed out of 18 residents sampled, Residents #3, #21, #23, #28, #30, and #36. Findings include: A review of the facility's policy titled, Bed-Holds and Returns, with a revision date of March 2017, revealed: Prior to a transfer, written information will be given to the residents and the resident representatives that explains the details of the transfer. Resident #36 Record review of the physician orders, dated 9/4/19, revealed an order to send Resident #36 to a local Behavior Hospital. The Nurse Progress Note, dated 9/4/19, indicated Resident #36 was observed walking up and down the hallway yelling and cursing staff, and when staff was trying to get the resident back to her room, the resident refused to put clothing on and refused to take medications as well. There was no documented evidence that a written notice was provided to the resident/resident representative regarding information of Resident #36's transfer to the hospital on 9/4/19. On 9/17/19 at 1:45 PM, an interview with the Director of Nurses (DON) revealed the facility had not been notifying the resident or the Resident Representatives, in writing, of the reason for transfer to the hospital. On 9/17/19 at 2:07 PM, an interview with Resident #36's Resident Representative revealed no written notice of the reason for transfer to the behavior facility was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #23 An observation on 09/17/19 at 9:45 AM, revealed RN #1/Wound Care Nurse, entered Resident #23's room, washed and dried her hands, and then turned the faucet off with her clean hand. RN #1 left the room, pulled keys out of her pocket, and opened the wound care cart, then returned the keys to her pocket. RN #1 placed several gauze dressings onto a Styrofoam plate, using her bare hands, then opened the drawer of the wound cart, took out a spray bottle of wound cleanser, wet the gauze, and returned the cleanser to the drawer. RN #1 sanitized her hands, gloved, grabbed the side of Resident #23's geri-chair, and pushed the chair to the side, so she could get to the Resident's stoma. RN #1 pulled up Resident #23's shirt, removed the soiled dressing, and cleaned and dried the resident's stoma. RN #1 pulled the resident's shirt over the stoma between intervals, allowing the shirt to touch the dirty and clean stoma. With gloves on, RN #1 pulled Resident #23's shirt down after applying a new dressing, then, picked up Resident #23's baby doll and handed it to the resident, prior to removing her gloves and washing her hands. An interview on 09/18/19 at 11:50 AM, with RN #1 revealed, I do remember reaching in and getting the gauze with my ungloved hands. It is an infection control issue. RN #1 stated she remembered pulling the shirt back down over the cleaned wound, and stated I mean, what's the point of cleaning the wound if your going to put the shirt back on it. It was contaminated and should have been re-cleaned after the shirt touched it, and before putting a clean dressing on it. I know you probably seen me move the chair with my gloves on, but I don't remember it. I probably did it self-consciously. The wound definitely should have been re-cleaned, prior to putting a clean dressing on. An interview on 09/18/19 at 12:06 PM, with the Director of Nursing (DON), revealed the nurse should not have gotten the gauze with her bare hands, because of cross contamination. The DON stated, If she pulled the shirt back over the wound after cleaning it, and before applying a clean dressing, it was cross contamination also. An interview on 09/19/19 at 9:45 AM, with RN #2, revealed she would possibly consider it an infection control issue with the nurse pulling the shirt back over a cleaned stoma, before applying a clean dressing. She stated she would also consider it a possible infection control issue with the nurse picking up the 4 x 4 gauze with her ungloved hands and placing it onto the plate. She stated, You need a barrier between the clean gauze and your hands. You wouldn't want hand to hand contact with something you're going to use on a resident. You could pass germs to a resident. Record review of a facility document titled, JD-ECF treatment check log Nurse Check off, dated 3/16/16, revealed RN #1 received training in Any cross contamination with treatment. Based of observation, record review, staff interview, and facility policy review, the facility failed to provide a Percutaneous Endoscopic Gastrostomy (PEG) tube dressing change in a manner to prevent cross contamination for two (2) of two (2) resident PEG tube care sites observed, for Resident #23 and Resident #38. This was evidenced by allowing resident clothing to touch/cover the PEG site, after cleaning and prior to applying a dressing, during treatment for Resident #23 and the RN touching items with ungloved hands prior to the PEG care for Resident #38. The facility also failed to provide wound care in a manner to prevent cross contamination for one (1) of four (4) resident wound care observations, Resident #31. This was evidenced by the RN touching items with ungloved hands prior to performing the treatment. Findings include: A review of the facility's policy titled, Infection Control Guidelines for all Nursing Procedures, with a revision date of May 2017, revealed: Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. A review of [NAME] and [NAME] Nursing Skills and Procedures, eighth edition, page 123, revealed: use of personal protective equipment reduces transmission of microorganisms. A review of facility policy titled, Policies and Practices-Infection control, dated May 2017, revealed, The facility's infection control policies are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of facility policy titled, Gastrostomy/Jejunostomy Site Care, dated March 2018, revealed: The purpose of this procedure is to promote cleanliness and to protect the Gastrostomy or Jejunostomy site from irritation, breakdown and infection. Resident #31 On 9/18/19 at 9:48 AM, observation of wound care revealed RN #1 used her ungloved hands to place 10 dry 4 x 4 gauze dressings on a Styrofoam plate, sprayed the dressings with normal saline that she had gotten out of her treatment cart, then gloved and performed the wound care on Resident #31, using the 4 x 4 gauze. Resident #31's soiled dressing was observed to have a moderate amount serosanguious drainage. Resident #31's wound bed was pink with scattered red tissue. Resident #38 On 9/18/19 at 11:28 AM, an observation revealed, while RN #1 set up her supplies, she retrieved the 4 x 4 gauze dressings with her ungloved hands and placed them on a Styrofoam plate. She washed her hands, turned on the overbed light, and applied clean gloves, without washing her hands. She removed the soiled tube feeding dressing, washed her hands, applied clean gloves and performed the site care. On 9/18/19 at 11:48 AM, an interview with RN #1 revealed it was a habit for her to retrieve the 4 x 4 gauze with her bare hands and not use gloves. She also stated it made total common sense, that not wearing gloves while handling the 4 x 4 gauze dressings with bare hands, would cause cross contamination. On 9/18/19 at 11:50 AM, an interview with the Director of Nurses (DON) revealed RN #1 should have used gloves, because she had touched a lot of other things in her treatment cart. The DON stated not using gloves to handle the 4 x 4's could cause cross contamination. On 9/19/19 at 9:56 AM, an interview with RN #2 revealed that RN #1 should have used gloves and not her bare hands, while handling the 4 x 4 gauze dressings, to prevent hand to hand contact with the supplies. She also stated RN #1 could pass germs to the residents by using her bare hands to handle the 4 x 4 gauze dressings.