**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification Survey from 09/16/2024 and 09/23/2024, the facility did not ensure that a resident who needs respiratory care including tracheostomy care, was provided such care consistent with professional standards of practice. This was evident in 1 resident (Resident #193) reviewed for tracheostomy care out of 38 total sampled residents. Specifically, Resident #193's family member was observed performing tracheostomy care to the resident without training and staff supervision. The findings are: The facility policy titled Tracheostomy with a revision date of 10/2023 documented that the purpose of the policy was to guide tracheostomy care and cleaning of reusable tracheostomy cannulas. The policy documented that aseptic technique must be used during tracheostomy dressing changes and enhanced barrier precautions must be followed. The procedure guidelines documented that resident's skin must be assessed and resident must be assessed for respiratory distress during tracheostomy dressing change. The policy documented that in cleaning the removable inner cannula, the supplies must be set-up in a sterile field. On 09/18/2024 at 09:49 AM, Resident #193's family member was observed performing tracheostomy care to the resident in the room without supervision or observation by any licensed staff. The family member used regular gloves to remove Resident #193's dirty tracheostomy collar, dirty dressing, tracheostomy mask, and inner cannula. The family member washed the dirty tracheostomy items in the sink inside Resident #193's room and placed them back on the resident's tracheostomy site without changing their gloves. Using the same gloves, the family member applied a new gauze on the tracheostomy site, replaced the inner cannula and the tracheostomy collar and mask. Resident #193 was admitted to the facility with diagnoses that included Coronary Artery Disease, Non-Alzheimer's Dementia, and Tracheostomy Status. The Quarterly Minimum Data Set, dated [DATE] documented the resident had severe impairment in cognition, is on suctioning, on oxygen therapy, on tracheostomy care, and was totally dependent on staff for all activities of daily living. A comprehensive care plan for tracheostomy related to impaired breathing mechanics was initiated on 02/01/2022. The facility interventions included tracheostomy / stoma care every shift and as needed and suction as necessary. A physician's order dated 06/07/2023 documented to apply gauze pads to neck topically every shift for tracheostomy care, to cleanse skin under trach collar with soap and water and apply gauze pads, and to change inner cannula every shift and as needed. A review of the Treatment Administration Record from 09/01/2024 - 09/17/2024 revealed that the physician's order on tracheostomy care was transcribed and were signed off by the licensed nurses. During an interview on 09/18/2024 at 09:50 AM, Resident #193's family member stated that they perform Resident #193's tracheostomy care every day because the staff were not doing it. The family member refused to answer when they were asked by the Surveyor if they had been trained by the licensed nurse in the facility on how to perform tracheostomy care. During an interview on 09/18/2024 at 02:24 PM, Certified Nursing Assistant #1 stated they had been assigned to Resident #193. They stated that Resident 193's family visits daily and that the family member performs the tracheostomy care for the Resident. During an interview on 09/18/2024 at 10:04 AM, Licensed Practical Nurse #1 stated that Resident #193's family member has been doing the Resident's tracheostomy care every day. They stated they do not know if the family member has been trained to perform tracheostomy care. During an interview on 09/18/2024 at 1:20 PM, Registered Nurse #1 stated that the unit nurse is responsible in performing tracheostomy care for Resident #193. They stated they had been seeing the family member visit daily but was not aware that they had been doing the tracheostomy care for the Resident. During an interview on 09/20/2024 at 09:26 AM, the Director of Nursing stated that the unit nurse is responsible in performing tracheostomy care. They stated they were not aware that Resident #193's family member had been doing the Resident's tracheostomy care. The Director of Nursing stated that if the family is interested in performing tracheostomy care, they need to be educated by the nurse on the proper way of doing it. 10 NYCRR 415.12(k)(5)(4)

Based on observations, record review, and interviews conducted during the Recertification Survey from 09/16/2024 to 09/23/2024, the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, there were multiple expired enteral feeding observed in the kitchen dry storage room. This was evident during the Kitchen Task. The findings are: The facility policy titled Food Storage with a revision date of 09/28/2023 documented that all stock must be rotated with each new order received. Old stock is always used first, first in - first out method. Routine checks on the storeroom will be conducted by the Food Service Director or designee to ensure that stock is rotating properly. An initial tour of the kitchen and emergency food storage area was conducted on 09/16/2024 from 09:48 AM to 10:42 AM with the Food Service Director and Dietary Aide. During the observation, 3 boxes of 1 liter bottle enteral feedings, a total of 24 bottles, were found with a past due use by date. Two boxes of enteral feeding had a use by date of 08/01/2024 and 1 box had a use by date of 07/01/2024. During an interview on 09/16/2024 at 10:43 AM, the Dietary Aide stated they rotate the food items and that they put old food items in the front and new items behind the old items. During an interview on 09/23/2024 at 01:25 PM, the Food Service Director stated they look for expired food products during daily rounds. They stated they noticed the expired enteral feedings and instructed the dietary aide to remove them, but it slipped the dietary aide's mind. 10 NYCRR 415.14(h)

2.) A review of the facility's Legionella Water Management Plan with a revision date of 04/10/2024 documented that the facility would maintain and monitor the water system for Legionella. A review of the facility's Water Management Program revealed that it was missing the range specifying acceptable pathogen levels. During an interview on 09/23/2024 at 01:30 PM, the Assistant Administrator stated they would ensure that the Water Management Plan includes the range of acceptable pathogen levels. 415.19(a)(1-3) Based on observation, record review, and interview conducted during the Recertification Survey from 09/16/2024 to 09/23/2024, the facility did not ensure infection prevention and control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) Certified Nursing Assistant #5 did not perform hand hygiene in between residents while assisting residents with hand hygiene prior to lunch being served. 2.) The facility did not have acceptable pathogen levels identified in the Water Management Plan for Legionella. 1.) The undated facility policy titled Dining documented the facility adheres to strict hand hygiene protocols to prevent the transmission of infections among residents, staff, visitors and other stakeholders. Hand hygiene procedure that reduces the risk of transmission of infection in the nursing home facility ensuring the safety and health of all residents and staff members. Hand hygiene must be performed before and after touching a resident, and before handling food and feeding a resident. During dining observation on the 7th floor on 09/19/2024 from 12:55 PM to 1:08 PM, Certified Nursing Assistant #5 was observed assisting residents in the dining room with hand hygiene prior to meals. Certified Nursing Assistant #5 assisted Resident #223 with hand hygiene and then assisted Resident #244 without performing hand hygiene and changing gloves. During an interview on 09/18/2024 at 02:29 PM, Certified Nursing Assistant # 5 stated they realized they did not clean their hands and changed their gloves in between residents. They stated they were supposed to perform hand hygiene after each helping each resident in cleaning their hands. During an interview on 09/18/2024 at 02:38PM, Licensed Practical Nurse #3 stated there is no reason for the staff not to perform hand hygiene the right way since they had received in-service and hand sanitizers are available. During an interview on 09/23/2024 at 12:37PM, the Infection Preventionist stated Certified Nursing Assistants must assist residents in cleaning their hands before meals using hand wipes. They stated that staff must perform hand hygiene as a safety precaution, so they do not transfer anything from one resident to another. During an interview on 09/23/2024 at 12:49 PM, the Director of Nursing stated that for infection control purposes, the staff should not use the same gloves and must wash their hands before they proceed to helping the next resident with hand hygiene. 415.19 (b)(4)

Based on observations, record review, and interviews conducted during the Recertification and Complaint (NY00270919) survey from 8/15/22 to 8/19/22, the facility did not ensure safe food storage was practiced. This was evident during kitchen observation. Specifically, expired nutritional supplements and enteral feeds were observed in the kitchen's Dry Storage Room (DSR) and basement Overflow Storage Room (OSR). The findings are: The facility policy titled Food Storage last revised 2/2022 documented all stock should be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. Old stock should be used first (first in- first out method). Supervise the person designated to put stock away to make sure it is rotated properly. Food should be dated as it is placed on the shelves. As a final measure, to ensure that expired food, drinks, and nutritional supplies do not reach a resident area, the supply aide or designee will do a final check for the date before bringing the item to the units. On 08/15/2022 at 08:31 AM, the DSR was observed, and 3 expired bottles of liquid nutritional supplements were observed on a shelf amidst boxes of the kitchen's active food supply: a 1.6-quart bottle of Glucerna with Carbsteady labeled with a use by date 4/1/2022, a 1.58-quart bottle of Osmolite labeled with a use by date 8/01/2022, and a 1.05 quart of Nepro-carb-steady labeled with a use by date 6/01/2022. On 08/15/2022 at 08:42 AM, the basement OSR in the basement contained the following expired items: 24 cartons of Jevity 1.5 (8-ounce) supplements with use by date of 11/01/2021, 6 bottles of Osmolite with expiration date on 08/01/2022, 4 bottles (1.6 quart)of Glucerna with Carbsteady with expiration date 04/01/2022, 6 bottles (1.6 quart) Glucerna Carbsteady 1.2 with expiration date of 02/01/2022, 24 cartons of Two Cal HN with use by date of 05/01/2022, and 6 bottles of 1-liter bottles of Nepro with Carbsteady 1.8 with expiration date of 06/01/2022. On 8/15/2022 at 09:29 AM, an interview was conducted with Dietary Aide (DA) #2 who stated they are the backup storeroom person and when new items are delivered, the DA the new items in the back and pulls the older items forward. DA #2 checks the dates of food items every day, puts expired items in the trash, and informs the kitchen supervisor. DA #2 stated hey were receiving deliveries this morning and did not check the dates. On 8/15/2022 at 10:05 AM, the Dietary Supervisor was interviewed and stated, most of the time, the storerooms are checked every morning and every other day for expired foods. The OSR was checked last Thursday, and the Dietary Supervisor did not get to complete checking the whole area for expired items. The Dietary Supervisor did not check the DSR for expired foods this morning. On 08/16/2022 at 03:29 PM, the Food Service Director (FSD) was interviewed and stated they do rounds three times a week to check for spoiled and expired foods. On 08/19/2022 at 10:55 AM, the Administrator was interviewed and stated that the food service clerk keeps a log and checks food items to ensure no expired food items are brought to the kitchen or resident floors. 415.14 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, during the Recertification survey, the facility did not ensure that residents received services that accommodated the resident's needs and preferences. Specifically, the call light was not kept within reach of the resident. This was evident for 1 of 4 residents reviewed for the Environment (Resident #523) out of 38 sampled residents. The finding is: The facility's policy and procedure titled Call Lights revised 04/2010 documented each resident has a functional call bell at the bedside within their reach to communicate need for assistance with the nursing staff. Position the call light on the resident's strong side. Resident #523 was admitted to the facility on [DATE] with diagnoses which include Dementia, Alzheimer's Disease, Hypertension, and Diabetes Mellitus. On 10/25/19 at 11:05 AM and 10/25/19 at 12:40 PM, the resident's call bell was observed tied to the bedrail and hanging down out of the resident's reach. On both occasions, Resident #523 asked the surveyor for a nurse. On 10/28/19 at 12:32 PM, 10/28/19 at 03:59 PM, and 10/29/19 at 12:04 PM, the call bell was observed tied to bedrail and hanging off bedrail not within reach of resident. On all three occasions Resident #523 asked the surveyor for a nurse. On 10/28/19 at 12:32 PM, Resident #523 was interviewed. The resident stated she has been paralyzed for 20 years. She cannot reach the call bell and cannot reposition/move herself. Resident #523 stated that staff infrequently comes to check in on her. On 10/29/19 at 12:10 PM, the Certified Nursing Assistant (CNA #2) was interviewed. She worked with Resident #523 the week of 10/15/19 and today 10/29/19. CNA #2 stated Resident #523 alerts staff when she needs assistance at times by the call bell, and most of the time, Resident #523 has used the call bell. CNA #2 stated the call bell is always within reach and was placed within reach of Resident #523 today. CNA #2 stated Resident #523 has a bad right hand, but the left hand is good. CNA #2 stated the tv remote, bed remote, and the call bell were placed on Resident #523's chest. CNA #2 stated the resident used the call bell twice today. CNA #2 and the surveyor walked to Resident #523 room and observed the call bell wrapped around the bedrail. CNA #2 stated she had just returned from her break and she did not know how the call bell got wrapped and was not in reach of Resident #523. CNA #2 stated Resident #523 cannot reposition herself without assistance. On 10/29/19 at 12:23 PM, Resident # 523 stated the call bell was not placed on her stomach, and she did not use the call bell today. On 10/29/19 at 12:31 PM, an interview was conducted with the Registered Nurse (RN #3). RN #3 supervises the 2 LPNS and 5 CNAS. RN # 3 stated she conducted rounds in the morning by going into each room to check on the status of the residents. During the rounds, she checks for call bells and remotes being within reach of the residents. RN # 3 stated when Resident #523 needs something she will use the call bell, and she may ring the call bell 3 to 4 times during the shift. RN # 3 stated the call bell was within reach for Resident # 523. RN # 3 stated she was not sure if it was used today. RN # 3 stated the call bell was clipped on the left side of the pillow and that Resident #523 is able to move her arm. When the surveyor showed RN #3 the resident's call bell, RN #3 stated the call bell should not be wrapped around the bedrail and unwrapped the call bell. On 10/29/19 at 02:20 PM, CNA #2 was re-interviewed. She stated Resident #523 cannot lift her left arm. She did not clip the call bell to the resident's pillow, and that was the reason why she placed the call bell on the resident's chest. CNA #2 stated the resident's call bell does not have a clip. She did not wrap the call bell around the bedrail this morning, but sometimes, if there is no clip attached to the call bell, the CNAs wrap the call bell chord around the bedrail, so it is not on the floor. 415.5 (e)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs was developed. Specifically, comprehensive care plans were not developed for a resident on Contact Isolation for Methicillin-resistant staphylococcus aureus (MRSA) in the respiratory tract. This was evident for 1 of 38 sampled residents (Resident #213). The findings is: The facility's policy and procedure titled Comprehensive Care Plan Policy and Procedure, revised 04/2010, documented each resident will have a Comprehensive Care Plan developed that includes the resident's problems, strengths and needs identified through the MDS assessment process and other assessment processes. Each care plan will have a specific measurable and realistic goals based upon the problem identified, and will include interventions developed by the CCP team to assist resident entertaining those goals. Resident #213 was admitted to the facility on [DATE] with diagnoses which include Unspecified Diabetes Mellitus, Thyroid Disorder, and Arthritis. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The Physician Orders dated 10/30/2019 documented an order for Contact Isolation for MRSA in the respiratory tract with a start date of 10/16/2019. Review of medical records revealed that there was no comprehensive person-centered care plan that addressed care for Contact Isolation for MRSA in the respiratory tract. On 10/30/19 at 01:42 PM, an interview was conducted with Registered Nurse (RN #2). RN #2 stated a care plan is developed upon admission, believes within the first 24 hours. RN # 2 stated she did not have the chance to add the MRSA to the care plan of Resident #213. RN #2 stated every morning staff are informed that Resident #213 is on contact precaution and personal protective equipment needs to be used. RN #2 also stated there is a sign on the resident's door for the isolation. RN #2 apologized for the error. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) The facility policy entitled Standard Precautions dated created 1/2017 and dated last revised 1/2017. The facility policy entitled Transmission-Based Precautions dated created 1/2016 and dated last revised 3/2017. The facility policy entitled Candida Auris dated created 5/1/2017 and have no revised or revision date listed on policy. The facility policy entitled Clostridium Difficile (C. diff) Candida Auris (C. Auris) dated created 9/2015 and dated last revised 7/2017. The facility Policy entitled Antibiotic Stewardship Program dated created 3/2017 and have no revised or reviewed date listed on policy. The facility policy entitled Influenza Vaccine - New York State Employees and Affiliates dated created 5/2008 and dated last revised 12/2017. The facility policy entitled Influenza and Pneumococcal Vaccinations dated created 5/2008 and dated last revised 12/2017 The Infection Prevention and Control Program Policies (IPCP) were not updated and reviewed annually. On 10/29/19 at 09:13 AM, an interview was conducted with the Direction of Nursing (DON) and Infection Control Preventionist for the facility. The DON stated the date on the policies did not change because there was nothing to change, and she was not aware that the policies needed to be reviewed or revised annually and as needed. The DON stated all the information on the policies meet the current regulations, and nothing had changed. The DON went to state she reviewed all the policies recently, although the policy it is not dated as such. The DON added all departments are educated on infection control. 415.19(b)(l) 2) The facility's policy and procedure titled Candida Auris documented HCP Should still perform hand use guns and gloves when performing tasks that put them at risk of contaminating hands or clothing. These include wound treatments, linen change etc . Resident #167 was admitted to the facility on [DATE] with diagnoses that included Anemia and Hyperlipidemia. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 10/25/19 at 12:57 PM, the Surveyor observed the Certified Nursing Assistant (CNA #1) going back and forth into the resident's room delivering the lunch tray, a clothing protector, and a cup of coffee without Personal Protective Equipment (PPE) on. Physician's Orders dated 10/30/2019 documented orders to maintain contact precautions for C-Auris, revised dated 10/25/19. A laboratory report dated 10/16/19 documented results for Candida auris Surveillance testing. The report documented Candida auris DNA was detected. The facility's document Mandatory In-service Topics for CNA #1 documented Infection Control and Blood Bourne Pathogens, Tuberculosis, and use of PPE was signed by CNA #1 on 07/26/2019. On 10/25/19 at 12:57 CNA #1 was interviewed immediately after the observation. CNA #1 stated when a resident is on contact precautions you don't go inside the room without a gown or mask. CNA #1 stated she did not see the sign the on door. CNA #1 stated she was supposed to put on a gown, gloves and mask, but she did not put on anything. CNA #1 stated she is floater for the week, and she was informed about contact precautions for another room. CNA #1 stated she made a mistake. On 10/29/19 at 12:48 PM, an interview was conducted with a Registered Nurse (RN #3) who stated if a resident is on contact precautions, orders are placed, the resident is placed on the 24 hour report to inform the other shifts, the precaution signs are placed on the resident's door, and the resident and/or family is made aware. RN #3 stated whoever is entering the resident's room has to don the PPE. RN # 3 stated she informs staff through huddles where they discuss residents who tested positive for C Auris. She handed out information sheets about C Auris and placed the stop sign instructing visitors to refer to the nurse before entering room. She posted a sign regarding how to don and remove the PPE on Resident's 523 door. RN #3 stated staff who are floaters are informed during the morning huddles daily. RN #3 stated she stresses the importance of donning/removing PPE, hand washing and tells the LPNs to monitor the CNAs as well. RN # 3 stated PPE should be applied when giving care and when providing meal trays to the resident. Based on observations, record review and interview during the recertification survey, the facility did not ensure that the infection prevention and control program (IPCP) was maintained and reviewed annually. Specifically, staff members did not wear appropriate PPE supplies when entering the room of residents on contact precautions for Methicillin Resistant Staphylococcus Aureus (MRSA) and Candida Auris, and the IPCP was not reviewed and/or revised since 2017. This was evident for 2 of 8 residents reviewed for Infection out of a total sample of 38 residents (Resident #167 and #424) and the Infection Control facility task review. The Findings are: 1) Resident #424 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Cerebral Infarction, and Methicillin Resistant Staphylococcus Aureus (MRSA) in the nares on contact isolation. On 10/28/19 the following observations were seen during a medication pass and fingerstick observation: At 11:31 AM, the Licensed Practical Nurse (LPN #1) entered the resident's room and only donned a mask over her nose and mouth, with no usage of a gown. Two gloves were taken out of the glove box with her right hand and remained in her closed hand as she entered the resident's room to take the blood pressure (B/P). She checked the resident's identification band and applied the cuff to the residents left arm without the use of the gloves in her hand. After obtaining the B/P she proceeded to throw the glove in the trash bin and washed her hands. The nurse exited the room and prepared the medication (meds). She reentered the room wearing a mask and gloves carrying the meds in a cup and the resident's inhaler, which was placed on the table. The resident coughed and covered her mouth with her right hand. The resident then picked up the Proventil inhaler using both hands, inhaled 1 puff, and placed the inhaler back on table. The resident was not encouraged or reminded to wash her hands after coughing into her hand. At 12:28 PM, LPN #1 donned a mask and gloves and proceeded to the resident's room to obtain fingerstick results. After much coaxing, the resident agreed to have the fingerstick done and proceeded to wipe her nose with a tissue that was placed on the table. The resident then extended her fingers to the nurse for testing. The nurse did not encourage the resident to wash her hands after wiping her nose and before doing the fingerstick test. The physician's (MD) order dated 10/23/19 documented orders for Infectious Disease (ID) consult, pt with MRSA in nares, contact/isolation. The comprehensive care plan dated 10/23/19 documented that the resident is alert and oriented with intact cognition. The CCP further documented the resident had a potential for complications related to the diagnosis of MRSA. The interventions were to maintain contact precautions when providing resident care, observe standard precautions for infection control, and to educate res/fam/caregivers to wear PPE prior to and before leaving the patient room. An ID consult dated 10/27/19 documented the resident was seen due to resident being on contact isolation for MRSA in nares. The resident had a positive nasal swab in the hospital and treated with Mupirocin ointment nasally for 7 days. The resident was placed on contact precautions at the hospital and in the facility after discharge. The resident was afebrile with no signs of active rhinitis/sinusitis. The ID impression was MRSA colonization of nose that was treated at the hospital. They recommended repeating the nasal swab from each nostril for MRSA. If the results are negative, the physician may discontinue contact precautions. A Mandatory form of the inservices LPN #1 attended upon hire dated 3/6/19 documented that she received inservice on infection control and blood bourne pathogens, tuberculosis, and use of PPE supplies. The Lesson plan for infection prevention & control/bloodborne pathogens, revised 10/23/17, documented: To prevent the spread of infection, proper handwashing is the most single most important means of preventing the spread of infection. Observing standard precautions of Personal Protective Equipment (gloves, mask, gowns) must be worn when providing care to all residents. Contact precautions is defined as meaning that direct and indirect contact with the resident is considered a potential source of infection; therefore, PPE must be worn for all interactions (gloves and gowns) On 10/28/19 at 02:30 PM, LPN #1 was interviewed. She stated she has been working at the facility for 7 months floating, on different units. LPN #1 stated RN #8, the educator, provides inservices on infection control. She stated she did not receive an infection inservice since working at the facility. She stated if the resident is on contact precaution in nares and she is just passing meds and not giving care, then she should wear gloves and mask. When she is done, she should remove the mask and wash hands. If the resident sneezed, she would change gloves and wash hands. She should wipe down equipment with the wipes with the blue tops. LPN #1 stated she should have worn gloves when she did the B/P. She was nervous. She stated she should have told the resident to wash her hands after wiping her nose. If a resident is on contact precautions for MRSA in nares, and she is responsible for wearing PPE and resident education. The resident is alert and oriented x 3 and looks like she is independent. The RN charge nurse on duty would inform her of any infections and precautions during morning report. LPN #1 stated she knew the resident had something in nares, but didn't know the specific organism which is why she looked it up. The unit charge nurse (RN #2) spoke to her regarding the precautions. If the resident has a urinary infection she should wear gowns because urine is liquid. She only administers meds when assigned to the unit, unless the Certified Nursing Assistant (CNA) is not on the unit and she has to assist a resident to the bathroom. LPN #1 stated she received universal precautions education from school. LPN #1 stated when the resident coughed, should have encouraged/instructed the resident to wash her hands and wiped the inhaler with bleach before leaving the room. After the resident wiped her nose with the tissue, she should have instructed her to wash her hands. She read the signs posted on door, but she was so nervous about not wearing the gown. On 10/29/19 at 10:19 AM, the charge nurse (RN#2) was interviewed. She is responsible for making sure nurses and CNAs provide appropriate care and notifying the physician of changes. Staff were given report in morning, and all staff are aware of what residents are on contact precaution for, what have to do, and what PPE they need to wear at all times when entering room. Contact precautions for nares means that staff must wear gloves, gown, and mask. The PPE supplies is on each side and signs are posted on residents' doors. RN #2 stated that she and the Supervisor do education and check when aides and nurses are doing care. She has not found any concerns. She stated she observed LPN #1 giving meds on a previous day. RN #2 stated she made sure everyone was educated on infection control. LPN #1 had an inservice on infection control and there are signed inservice papers for the training, which was done by herself and RN #8. For Resident #424, the nurse should wear a gown, gloves, and mask before going into the room. From the time the resident used the tissue, the nurse should have told the resident to wash her hands before proceeding. LPN #1 should not have left the room with the inhaler. She should have gotten a wipe and wiped the inhaler in the room before coming out of the room with it. The resident was admitted with this infection. The resident and family were educated on the infection, how it is spread and what to do when they visit. They were educated about hand washing, wearing a gown, gloves, and mask prior to entering the room, and how to remove the PPE when leaving. They were told to take gloves off first, then gown, then mask and discard them in the special bin in the room. They should then wash hands before they leave the room. The resident was educated on hand washing and wearing a mask before coming out of the room. All staff on unit monitor to make sure the resident is wearing mask and compliant. On 10/29/19 at 11:21 AM, the Infection Control Preventionist (RN #8) was interviewed. RN # 8 stated that there is a chance of soiling, therefore gown, mask, and gloves should be worn. An inservice for infection control has been done for all staff and departments within the building. All mandatories, including infection control & contact precaution, are done when hired. The nurse should have worn the PPE supplies provided each time she entered the room. Hand washing is constant. When the resident wiped her nose with the tissue, the nurse should have encouraged her to wash her hands before proceeding. The inhaler should have been wiped clean with the bleach blue top wipes. RN #8 stated that he goes on the unit at times during care and checks to make sure the signs are posted and that staff are following appropriate infection control practices. When concerns are found, they are reported to the DNS. On 10/30/19 at 12:01 PM, the Registered Nurse Supervisor (RN #5) was interviewed. RN #5 stated there are orders in the system for contact precautions and signs posted on doors. Upon admission or positive lab result, unit coordinators are notified and told to give report to all staff on the unit of the infection control precautions. The staff should wear gloves, gown, and mask upon entering the room, and the PPE should be removed before coming out with proper hand washing before & after. She has observed staff for handwashing. She last met with the unit coordinators about a month ago because residents were being admitted on contact precautions. RN #5 said they do rounds to make sure signs are hanging on doors and that the PPE rack/box are stocked on side A/B on each floor on a daily basis. She last received an inservice on infection control from the educator about 1 month ago regarding C auris, and when the Department of Health came in to test revisions on infection control and contact precautions. For residents on contact precautions staff, should don mask, glove and gown depending on type of infection. RN #5 stated they would not wear a gown if a resident had MRSA in nares. The staff could wear a mask and gloves without having to wear gown. The nurse should have encouraged resident to wash her hands after coughing into her hand and wiping her nose with a tissue. On 10/30/19 at 12:43 PM, the Director of Nursing (DNS) was interviewed. The DNS stated that she last met with staff, RN coordinators, and supervisors during morning meeting in regards to the antibiotic stewardship policy, orders and completeness of orders, transmission based precautions and signage. Contact/droplet and signs for usage were redistributed. For a resident with MRSA in the nares and contact precautions that came from hospital, staff will continue with contact precautions. Whenever they have direct contact or are going into the room, staff must have gown and glove and remove PPE and wash hands before exiting room. If resident is incontinent of urine, the CNA must wear gown/glove to give care. Gown and gloves are worn while caring for residents with respiratory infections, unless deemed as droplet precaution. They look at care needs depending on acuity and would increase staff for the unit if needed. The resident's unit is already staffed higher and no increase done of staffing. They have residents with C. auris all over the facility, and there was no need for increase in staff. The DNS stated she ensures staff are compliant by doing rounds, and RN #8 is her eyes on the unit.

Based on observation and staff interviews during the recertification survey, the facility did not ensure that internal temperatures of cold foods were maintained at professional standards of food safety practice. This was observed during the Kitchen Observation Task. The findings are: On 10/25/19 beginning at 11:41 AM, a tray line observation was conducted. The temperatures of the hot and cold foods held for service on the serving line were checked by the Food Service Director (FSD) and the following temperatures were taken: Tuna sandwich 49 degrees F (Fahrenheit) Ham sandwich 46 degrees F On 10/28/19 at 11:27 AM, a second tray line observation was conducted. The following temperatures were taken: Turkey and cheese 53 degrees F Chopped Ham and cheese sandwich 57 degrees F Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety Food (TCS) is food that requires time/temperature control for safety to limit the growth of pathogens (i.e. bacterial or viral organisms capable of causing a disease or toxin formation). PHS/TCS foods must be maintained at or below 41 degrees F, unless otherwise specified by law. On 10/28/19 at 11:37 AM, an interview was conducted with the Dietary Aide (DA) responsible for preparing and labeling the sandwiches. The DA stated it takes 3 hours to make the sandwiches. The DA stated she does not take the temperatures while the sandwiches are being made. The whole pan of sandwiches are made then is placed back into the fridge. The DA stated the sandwiches were made today from 6:00 AM to 9:30AM. Afterwards, the sandwiches were placed in the refrigerator without ice because the refrigerator is cold. On 10/28/19 at 11:57 AM, the FSD was interviewed. The FSD stated sandwiches are made for lunch around 10:30am. The pan with product (turkey, ham, tuna) must be submerged in ice. The FSD stated staff were informed to prepare 10 sandwiches at a time and put them into the refrigerators. The FSD stated at around 8/8:30am, he observed how sandwiches were made, 10 at a time, labeled and dated and placed back in the refrigerator. The FSD stated the sandwiches were removed from the refrigerator to the freezer after 11:10am. The FSD stated the sandwiches are tested daily right before 11:30am service, but he does not document the temperatures. The FSD stated the sandwiches should be stored in the 2 inch pan shingles in the refrigerator. 415.14(h)