**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review facility staff failed to safely propel three residents (Resident #23, #263, and #5) in a wheelchair. Facility staff failed to safely store hazardous materials in a manner to prevent accidents in one shower room and one storage room. The facility census was 58. 1. Review of the facility's Wheelchair Mobility policy, dated 2023, showed staff were directed that if a resident needs to be propelled and does not generally move or propel the wheelchair on their own, proper foot positioning on wheelchair pedal will be maintained and provided. 2. Review of Resident #23's quarterly Minimum Data Set (MDS) a federally mandated assessment tool, dated 10/21/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Wheelchair dependent; -Diagnosis of Alzheimer. Observation on 02/04/25 at 11:30 A.M., showed an unknown staff propelled the resident on the 200 hall dinning area to the 300 hall living room. Observation showed the resident bilateral feet slid on the floor and his/her right wrist rubbed the wheelchair wheel. 3. Review of Resident #263's admission MDS dated [DATE] showed staff assessed the resident as follows: -Diagnosis of arthritis and Alzheimer's; -Impairment of both upper extremities; -Wheelchair dependent. Observation on 02/05/25 at 8:33 A.M., showed an unknown staff propelled the resident to the dining room. Observation showed the wheelchair did not have foot pedals and the resident lifted his/her feet. The staff member stopped in the hall and said to the resident he/she needed to find the resident's foot pedals before they continued. Observation showed another unknown staff person began to push the resident to the dining room. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Wheelchair dependent; -Diagnosis of Alzheimer and dementia. Observation on 02/05/25 at 10:30 A.M., showed the Activity Director propelled the resident from the 200 hall dinning area towards the hallway without foot pedals on the wheelchair and both feet slid and bounced off the floor. During an interview on 02/05/25 at 10:31 A.M., the Activity Director said he/she should have gone and got the pedals for the wheelchair before pushing the resident. He/She said normally they lift their feet up when being pushed. 5. During an interview on 02/06/25 at 2:10 P.M., Licensed Practical Nurse (LPN) C said pushing a resident in a wheelchair without foot pedals could cause an injury. During an interview on 02/07/25 at 8:51 A.M., the Director of Nursing (DON) said staff should put foot pedals on a wheelchair prior to pushing a resident. This will prevent injuries or falls. During an interview on 02/07/25 at 11:08 A.M., the administrator said staff should make sure foot pedals are on a wheelchair before pushing a resident for safety. If a residents foot hit the floor it could cause injury. 5. Review of the facility's Chemical Usage and Storage policy, dated 01/01/20, showed all chemicals should be stored in a secure location when not in direct use, and should never be left out in the open where others may accidentally come into contact with it. 6. Observation on 02/05/25 at 9:40 A.M., showed the medical supply room on the 200 hall, unlocked. Observation showed an unlocked cabinet below the sink contained a bottle of odor control solution, two bottles of cleaning solution and one bottle of calcium, lime and rust remover with precautionary statements which indicated hazards. During an interview on 02/05/25 at 9:45 A.M., the maintenance director said no one had ever asked him/her to place a lock on the supply room door so he/she never thought about the risks of the cleaning chemicals. 7. Observation on 02/06/25 at 1:50 P.M., showed the 100 hallway shower room door open. Observation showed an unlocked storage cabinet with an open box of disposable razors. Observation showed multiple residents walked by the open shower room door. During an interview on 02/06/25 at 1:50 P.M., CNA A said shower room doors are to be locked when not in use. He/She said the 100 hall shower room and cabinets can not be locked. Residents could be harmed if they came into contact with chemicals. 8. During an interview on 02/06/25 at 2:01 P.M., CNA B said storage cabinets and showers are supposed to be locked to prevent injury to the residents. During an interview on 02/06/25 at 2:10 P.M., LPN C said showers and cabinets should be locked because anyone could get in. Chemicals could injure a resident. During an interview on 02/07/25 at 8:51 A.M., the DON said residents should not have access to chemicals or other hazardous materials. He/She said hazardous materials should be locked up to prevent resident injury. During an interview on 02/07/25 at 11:08 A.M., the administrator said residents should not have access to any hazardous materials due to the risk to their health. These materials should be in a locked cabinet or room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain resident dignity for three dependent residents' (esidents #45, #32 and #35) when staff did not clean and maintain the residents fingernails. The facility census was 55. 1. Review of the facility's policy titled, Right to Dignity, undated, showed staff promote care for elders of the facility in a manner and in an environment that maintains and enhances each elder's dignity and respect in full-recognition of the elder's individuality. Elders will be groomed as they including nail care. Each elder will be provided with independence and dignity during all dining experiences regardless of the amount of assistance the elder requires. Review of the facility's policy titled, Activities of Daily Living (ADLs), dated 2023, showed the facility based on the resident's comprehensive assessment and consistent with resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable to include grooming. A resident who is unable to care out activities of daily living with receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 2. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/26/24, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Rejection of care not exhibited; -Required set up assistance from staff member with eating; -Dependent on staff for personal hygiene and transfers; -Always incontinent of bowel and bladder; -Diagnosis of Stroke (damage to the brain from interruption of its blood supply). Review of the resident's care plan, dated 02/05/24, showed staff documented the resident required assistance from one staff member for personal hygiene and independent with eating. Observation on 03/05/24 at 11:35 A.M., showed the resident in bed in his/her room. Observation showed the resident's fingernails long with a built up black substances under then nail. Observation showed the resident rubbed his/her lips and eyes with his/her fingers. Observation on 03/05/24 at 12:26 P.M., showed the resident ate in bed in his/her room. Observation showed the resident fed himself/herself with long fingernails long with black a substances under them. Observations on 03/06/24 at 8:12 A.M., showed the resident fed himself/herself breakfast in bed. The resident's fingernails are long with a black substances built up under them. Observation on 03/06/24 at 1:24 P.M., showed the resident's fingernails long with a black substance built up under them. Observation on 03/07/24 at 8:20 A.M., showed the resident ate breakfast in bed. The resident touched his/her mouth with his/her fingers. The resident's fingernails are long with a built up black substance under them. Observation on 03/07/24 at 11:52 A.M., Certified Nursing Assistant (CNA) E sat the resident's lunch tray on the bedside table. Observation showed the resident's fingernails long with a built up black substance under them. Observation showed the resident picked up a piece of food from the table with his/her fingers and put it in his/her mouth. During an interview on 03/07/24 at 11:30 A.M., the resident said his/her fingernails are to long and they hurt his/her arm. The resident pointed to scratches on his/her arm. The resident said he/she want's his/her fingernails cut. During an interview on 03/07/24 at 11:57 A.M., CNA E said he/she served the resident breakfast and lunch. The CNA said he/she had not tried to clean the resident's fingernails. The CNA said he/she does not know why he/she did not check the resident's fingernails. During an interview on 03/07/24 at 12:01 P.M., Certified Medication Technician (CMT) F said the resident's fingernails need to be cleaned. The CMT said the resident just told him/her his/her nails are cutting his/her arms. The resident scratches a lot. 2. Review of Resident #32's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Rejection of care not exhibited; -Required moderate assistance from staff with eating; -Dependent on staff for personal hygiene and transfers; -Always incontinent of bowel and bladder; -Range of Motion (ROM) impairments on both sides of upper extremities; -Diagnosis of stroke. Review of the resident's care plan, dated 01/9/24, showed staff documented the resident requires assistance from one staff member for personal hygiene and independent with eating. Observation on 03/05/24 at 11:45 A.M., showed the resident sat at a table in the dining room. Observation showed the resident's fingernails long and have brown debris under them. Observation showed the resident picked up cornbread and fed himself/herself with his/her fingers. Observation on 03/06/24 at 1:33 P.M., showed the resident's fingernails long, jagged and full of a brown substance. Observation showed the resident rubbed his/her lips and eyes with his/her finger tips. Observation on 03/07/24 at 8:28 A.M., showed the resident fed himself/herself breakfast in the dining room. Observation showed the resident's fingernails are long and have built up brown debris under them. 3. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Rejection of care not exhibited; -Required maximal assistance from staff with eating; -Dependent on staff members for personal hygiene and transfers; -Always incontinent of bowel and bladder; -Diagnosis of Dementia (persistent or progressive loss of intellectual functioning, especially impairment of memory and abstract thinking). Review of the resident's care plan, dated 02/17/24, showed staff documented the resident requires assistance from one staff member with eating and personal hygiene. Observation on 03/05/24 at 3:35 P.M., showed the resident's fingernails long, jagged, and with a brown substance built up under them. Observation on 03/06/24 at 1:36 P.M., showed the resident in bed. The resident's fingernails are long, jagged, and with built up brown substance under them. Observation on 03/07/24 at 8:47 A.M., showed the resident sat in his/her chair. The resident's fingernails are long, jagged and have brown debris under them. 4. During an interview on 03/07/24 at 11:57 A.M., CNA E said staff are supposed to clean resident fingernails when they are dirty. Staff should check resident's fingernails all the time. During an interview on 03/07/24 at 12:01 P.M., CMT F said he/she checks resident fingernails when he/she gives showers and when he/she sees they are dirty. The CMT said staff should check resident fingernails when providing care. The CMT said if a resident feeds themselves staff should ensure the residents' fingernails are cleaned prior to meals so the resident does not get bacteria in their mouth. During an interview on 03/07/24 at 12:05 P.M., Registered Nurse (RN) G said staff should check resident fingernails during all care. The RN said staff should check resident's fingernails before and after each meal. During an interview on 03/08/24 at 8:41 A.M., Director of Nursing (DON) said staff should check resident fingernails when they get the resident up in the morning or when care is provided. The DON said staff should trim resident fingernails as needed and on shower days. The DON if a resident feeds themselves, staff should check the residents' fingernails before food is served. The DON said a resident putting dirty nails in his/her mouth put them at risk for infection, and also a dignity issue. The DON said all residents should be offered hand hygiene before meals.

Based on observation, interview, and record review, facility staff failed to obtain orders for one resident's (Resident #22's) Continuous Positive Airway Pressure (CPAP), a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure, and failed to assess and document the resident's respiratory status and response to therapy. Facility census was 54. 1. Review of the policies provided by the facility showed they did not contain a policy for CPAP, or Bi-level positive airway pressure (Bipap), a non-invasive ventilation machine that is capable of generating two adjustable pressure levels use. 2. Review of Resident #22's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/29/23 showed staff assessed the resident as: -Cognitively intact; -Did not reject care; -Required supervision and touch assist from one staff member for upper body dressing; -Uses non-invasive mechanical ventilator; -Did not receive respiratory therapy; -Diagnoses of heart failure, Parkinson's disease, asthma, respiratory failure, and acute respiratory failure with hypoxia (decreased oxygen to tissue). Review of the resident's care plan, dated 01/25/24, showed staff documented the resident diagnosis of Obstructive Sleep Apnea (OSA), apnea (breathless) syndromes due primarily to collapse of the upper airway during sleep and uses a CPAP/BiPAP. Resident will adhere to CPAP/BiPAP regimen. Review of the Physician's Order Summary (POS), dated March 2024, showed it did not contain an order for the use of a CPAP/BiPAP/Automatic self-adjusting positive airway pressure (APAP), a non-invasive ventilation machine that automatically adjusts the air pressure according to the patient's requirement at a particular time, settings or required respiratory assessments. Review of the nurse's notes, dated March 2024, showed staff documented: -03/1/24- Oxygen Saturation (oxygen in blood) 94 percent (%); -03/4/24- 91%; -03/5/24- 93%; -03/6/24- 94%; -03/8/24- 95%. Review showed it did not contain further documentation in regard to the resident's respiratory status including response to therapy. Observation on 03/6/24 at 1:32 P.M., showed the resident in his/her room with a CPAP/BiPAP on his/her bedside table. During an interview on 03/06/24 at 1:32 P.M., the resident said he/she uses the CPAP for sleep apnea and has used it for over 20 years. The resident said he/she can put the mask on but he/she needs help because the machine is sat on a table behind his/her bed, and he/she is not always able to reach it. During an interview on 03/07/24 at 11:25 A.M., Licensed Practical Nurse (LPN) O said he/she knows the resident wears a CPAP or oxygen at night. The LPN said he/she does not know much about the resident's CPAP because he/she does not work nights, but he/she thinks the resident applies the CPAP himself/herself. During an interview on 03/07/24 at 11:49 A.M., LPN O said he/she would expect a resident with a diagnosis of OSA to use CPAP. The LPN said the resident was admitted with his/her CPAP. The LPN said CPAP use should be listed on the resident's care plan and there should be a physician order for use. The LPN said if a resident is admitted with a CPAP staff should ensure there are physician orders for the settings, and for cleaning. The LPN said sometimes the settings are in the orders and other times staff have to call the physician for orders, or the company who supplies the machine. LPN O said the resident should have a physician order for his/her CPAP, and he/she does not. The LPN said he/she did not know why the resident did not have orders for his/her CPAP. LPN O said the nurse is responsible for obtaining orders, and if they did not see orders they should notify the Director of Nursing (DON) or someone else to figure out the next steps. The LPN said he/she would also expect CPAP settings in the care plan. The LPN said when the resident came back from the hospital staff listened to his lung sounds, but now they check his oxygen saturation every day. The LPN said staff does not complete a respiratory assessment everyday for the resident. During an interview on 03/14/24 at 1:33 P.M., the DON said the resident uses an APAP. The DON said the settings are not set by the staff but set remotely by the resident's pulmonologist's (physician specializing in lung function) office. The DON said there should be an order for the APAP on the resident's POS. The DON said there is currently not a daily respiratory assessment conducted on the resident, but one should be completed daily. The DON said the facility does not have a policy for CPAP/BiPAP/APAP use. During an interview on 03/15/24 at 10:58 A.M., Registered Medical Assistant (RMA) P, who works with the resident's pulmonologist, said the resident uses a CPAP set at 14. The RMA said the pulmonologist would expect the resident to have a physician's order for the CPAP and order should contain the settings. The RMA said the last linked report showed the resident used his/her CPAP on 03/14/24. The RMA said the resident has not been seen by their office since 2019.

Based on interview and record review, facility staff failed to provide notice to the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) related to a transfer or discharge to a hospital, including the reason for the transfer for two residents (Resident #51 and #307). The facility census was 49. 1. Review of the facility policies provided showed staff did not provide a policy for resident transfers and discharges. Review of the facility's Discharge to Facility Check Off form, undated showed the form did not include direction to notify the ombudsman. Review of the Discharge to Home Check off form, undated showed the form did not include direction to notify the ombudsman. 2. Review of Resident # 51's Discharge Return Anticipated Minimum Data Sets (MDS), a federally mandated resident assessment, dated 10/19/22, showed staff documented they discharged the resident to a hospital. Review of the resident's medical record showed the record did not contain documentation the staff informed the ombudsman of a transfer and/or reason for the transfer. Review of the resident's Discharge Return Not Anticipated MDS, date 11/14/22, showed staff documented they discharged the resident home. Review of the resident's medical record showed the record did not contain documentation the staff informed the ombudsman of the discharge and/or reason for the discharge. 3. Review of Resident # 307's medical record showed staff documented they transferred the resident to a hospital on 1/6/22. Review of the resident's medical record showed the record did not contain documentation the staff informed the ombudsman of the transfer and/or reason for the transfer. 4. During an interview on 1/13/23 at 10:28 A.M., the Director of Nursing said he/she developed a check list for discharges and transfers and the checklist included notifying the ombudsman. He/She said the checklist serves as the policy and procedure. During an interview on 1/13/23 at 10:31 A.M., Social Services Director said he/she has not been notifying the ombudsman of transfers or discharges. He/She said she is now aware that he/she is required to do so and will be notifying the ombudsman of all transfers and discharges from now on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide safe mechanical lift transfer for two residents (Residents #35, and #46) in a manner to prevent accidents. The facility census was 49. 1. Review of the facility's Safe Lifting and Movement of Residents Policy, dated June 2019, showed staff were directed as follows: -Staff responsible for direct resident care will be trained in the use of mechanical lifting devices; -Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to the policies and procedures regarding use of equipment and safe lifting techniques. 2. Review of Resident #35's quarterly review minimum data set (MDS) a federally mandated assessment tool dated, 12/8/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for assistance with transfers. Observation on 1/10/23 at 2:31 P.M., showed Licensed Practical Nurse (LPN) I and Nurse Assistant (NA) J transferred the resident from his/her bed to a wheelchair. LPN I pushed the mechanical lift under the resident's bed with the legs of the mechanical lift closed. The LPN and NA then connected the mechanical lift sling to the lift. The resident was lifted off the bed by the LPN while the NA supported the resident. LPN I then moved the resident away from the bed and turned the mechanical lift without opening the legs of the lift for stability. The resident was then lowered to the wheelchair with the NA supporting the resident without opening the legs of the mechanical lift. 3. Review of Resident #46's quarterly MDS, dated [DATE] showed facility staff assessed the resident as follows: -Unable to complete brief interview for mental status; -Totally dependent for transfers, locomotion and eating. Observation on 1/10/23 at 2:24 P.M., showed Certified Nursing Assistants (CNAs) D and E transferred the resident from a chair to his/her bed. The CNAs lifted the resident from his/her chair, rotated the mechanical lift 180 degrees and lowered the resident to his/her bed with the lift legs in the closed position. Observation on 1/12/23 at 8:50 A.M., showed CNA F and G transferred the resident from a chair to his/her bed. The CNAs lifted the resident from his/her bed, rotated the mechanical lift 90 degrees and lowered the resident to his/her bed with the lift legs in the closed position. During an interview on 1/13/23 at 8:26 A.M., CNA G said the resident is lifted with a two person assist. The mechanical lift sling is connected to the lift and the resident lifted and moved. The mechanical lift legs should be spread to the widest position for stability. During an interview on 1/12/23 at 8:55 A.M. CNA G said he/she had mechanical lift training around October of 2022. CNA G said the lift legs should be spread, because the lift gets wobbly if you don't spread the legs. CNA G said he/she did not spread the lift legs because the space is so small. 4. During an interview on 1/13/23 at 8:30 A.M., Registered Nurse (RN) A said during a Hoyer lift the resident should be secured by two staff during the transport. The mechanical lift legs should be at the widest position when moving the resident. During an interview on 1/13/23 at 8:42 A.M., CMT H said two staff are involved with a mechanical lift and transfer. The legs should be open during the lift for stability. During an interview on 1/13/23 at 8:44 A.M., the Administrator and the director of nursing said two staff assist during a mechanical lift. The lift pad is hooked to the lift with the wheels locked on the lift. While transferring the resident the legs of the lift should be at the widest position.

Based on observation, interviews, and record review, the facility staff failed to change gloves and perform hand hygiene as often as necessary, to cover trash cans when not in use, and to properly store open food to prevent cross contamination and outdated usage. This had the potential to affect all facility residents. The census was 49. 1. Review of the facility's Proper Hand Washing and Glove Use policy, dated 2020, showed: - All employees will wash hands upon entering the kitchen from any other location and between all tasks. Handwashing should occur at a minimum of every hour. - Employees will wash hands before and after handling foods, after touching any part of the uniform, face or hair; - Gloves are to be used whenever direct food contact is required; - Hands are washed before donning gloves and after removing gloves; - Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform, or other non-food contact surface, such as door handles and equipment; - When gloves must be changed, they are removed, handwashing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. Observation on 1/11/23 at 11:40 A.M., showed dietary aide (DA) K prepared resident lunch plates. DA K used his/her gloved hands to touch a bratwurst and place it on a resident plate. Further observation showed the DA touched serving utensils, resident plates, and a food cart. DA K used the same gloved hands to push the cart to the dining room, touching the door handles on both sides of the door. The DA returned to the kitchen, and he/she used the same gloved hands to prepare more resident lunch plates, and touched the bratwurst to place them on the plate. DA K did not change his/her gloves and wash his/her hands after he/she touched the bratwurst, the cart, and the door handles. Observation on 1/11/23 at 11:58 A.M., showed DA L prepared a grilled cheese sandwich for a resident's lunch. The DA took the pan to the dishwashing area, and he/she rinsed the pan with his/her gloved hands. He/She returned to the food preparation area, touched an ice cream container, resident bowl with gloved thumb on the food surface, lettuce, cheese, and nine resident drinks with gloved hands on the lip of the cups. The DA touched the front of his/her facemask with his/her gloved hand. He/She touched the doors to the freezer and the refrigerator, an ice cream container, and the lip of a glass. DA L did not change his/her gloves or wash his/her hands after he/she touched the dishwashing sink and his/her facemask. Observation on 1/11/23 at 12:20 P.M., showed [NAME] M entered the kitchen, washed his/her hands, adjusted his/her facemask with his/her bare hand to the front of his/her facemask, and the donned gloves. The cook used his/her gloved hand to rinse a dirty spoon, touch baking pans, parchment paper, and bacon slices. The cook also touched the refrigerator handles and sausage patties. He/She changed his/her gloves and used the gloved hands to touch various food related items while he/she prepared the resident's dinner meal. The cook opened a 15 pound package of hamburger and used his/her gloved hands to break up the hamburger log. [NAME] M did not change his/her gloves or wash his/her hands after he/she touched his/her facemask, the dirty spoon, the bacon, and the sausage. The cook did not wash his/her hands after he/she removed his/her gloves or before he/she put on new gloves. During an interview on 1/13/23 at 10:12 A.M., the dietary manager said it is expected dietary staff would change their gloves between food products and when changing tasks. She said staff are to wash their hands before they put on and when they take off gloves, when going from a dirty task to a clean task, after touching their face, and whenever they enter the kitchen. The dietary manager said the facility has a glove use and hand washing policy, and staff have been trained on the policy. She said it is expected staff would change gloves and wash hands as outlined in the policy. During an interview on 1/13/23 at 11:30 A.M., the administrator said the dietary manager is responsible to ensure dietary staff change gloves and wash their hands according to facility policy. She said the dietary staff have been trained on the policy. The administrator said it is expected staff would use gloves when preparing food, and they should change their gloves between different foods. She said dietary staff should wash their hands when they enter the kitchen, after touching their face, before and after glove use, and when moving from a dirty task to a clean task. 2. Review of the facility's Garbage and Rubbish Disposal policy, dated 2020, showed: - All containers will be provided with tight-fitting lids or covers, and will be leak-proof and water-proof; - All garbage and rubbish containing food waste are covered when not in immediate use so as to be inaccessible to vermin. Observation on 1/11/23 at 10:24 A.M., showed a trash can located in the dishwashing area uncovered and not in use. The trash can located next to the clean dish drying rack, and a crockpot on the drying rack near the trashcan visibly dirty with chunks of an unidentified substance. Observation also showed the dishwashing area did not contain a lid for the trash can. During an interview on 1/13/23 at 10:12 A.M., the dietary manager said trash cans should be covered at all times. She said the facility has a policy regarding trash cans, and staff have been trained on the policy. The dietary manager looked for the lid to the trash can in the dishwashing area, but she was unable to locate it. During an interview on 1/13/23 at 11:30 A.M., the administrator said it is expected the trash can would be covered at all times, unless staff are throwing something away. She said the dietary manager is responsible for ensuring the trash cans stay covered. 3. Review of the facility's Food Storage policy dated 2020, showed all food items will be labeled. The label must include the name of the food. Observation on 1/11/23 at 9:45 A.M., of the two door refrigerator, showed one open bag of a brown crumble substance not labeled. Observation on 1/11/23 at 10:45 A.M., of the three door freezer, showed: - Four open bags of breaded patties unlabeled; - One package labeled 14 slices with no other identifiers of contents; - Seven bags of chunked white substance unlabeled; - Two bags of meat patties unlabeled; - One bag of breaded nuggets unlabeled. During an interview on 1/13/23 at 10:12 A.M., the dietary manager said all food containers should be labeled with the contents before they are placed into storage. It is expected staff would label any food they see without a label. The dietary manager said the facility has a policy on food storage, and staff is trained on the policy. During an interview on 1/13/23 at 11:30 A.M., the administrator said it is expected all food containers would be labeled before they are placed into storage. She said the dietary manager is responsible for ensuring the food is identified and stored correctly. The administrator said the facility has a policy on food storage, and the dietary staff is trained on the policy.

Based on observation, interview, and record review, the facility staff failed to ensure proper hand hygiene was performed during medication pass for four (Residents #13, #39, #29, and #46) out of nine sampled residents. The facility census was 49 residents. 1. Review of the facility's Handwashing Policy and Procedures, undated, showed the policy directed staff to wash hands in the following situations: -When coming on duty; -When hands are obviously dirty; -Between handling of individual residents; -Before and after touching one's face; -Before and after use of toilet; -Before and after eating; -After handling dressings, used sputum containers, soiled urinals, catheters and bedpans or being exposed to body fluids; -Before leaving work. Review of the facility's Medication Pass Policy, dated May 2012, showed the policy did not contain direction regarding hand hygiene during medication pass. 2. Observation on 1/11/23 at 3:39 P.M., showed Licensed Practical Nurse (LPN) B did not perform hand hygiene before or after he/she administered medications to Resident #13. 3. Observation on 1/11/23 at 3:45 P.M., showed LPN B did not perform hand hygiene before or after he/she administered medication to Resident #39. 4. Observation on 1/11/23 at 3:55 P.M., showed LPN B did not perform hand hygiene before or after he/she administered medication to Resident #46. 5. Observation on 1/11/23 at 4:03 P.M., showed LPN B did not perform hand hygiene before or after he/she administered medications to Resident # 29. During an interview on 1/13/23 at 9:21 A.M., LPN C said he/she would use hand sanitizer between every medication pass and would wash his/her hands with soap and water on every fifth administration. During an interview on 1/13/23 at 9:32 A.M., Certified Medication Tech (CMT) H said he/she used hand sanitizer between every resident and he/she would wash hands with soap and water after every two residents unless soiled. During an interview on 1/13/23 at 11:38 A.M., Registered Nurse (RN) A said hands should be sanitized between every two residents when passing medications and washed with soap and water after every two residents or when soiled. During an interview on 1/13/23 at 12:57 P.M., the Director of Nurses said hand sanitizer should be used prior to administering medicine, between each resident and when soiled. He/She said soap and water should be used after every fifth resident.