Based on observations, record reviews, and staff interviews, the facility failed to implement infection control policies and procedures when the Nurse did not don a gown to provide wound care for a resident on enhanced barrier precautions (EBP). In addition, Nurse #1 failed to follow the facility's policy and procedure for clean dressings which included changing gloves and performing hand hygiene after removing the old dressing. The deficient practice occurred for 1 of 3 staff observed for infection control practices. The findings included: Review of the facility's policy for Enhanced Barrier Precautions (EBP) dated 04/01/2024 revealed the EBP will be implemented for the prevention of transmission of multidrug-resistant organisms. EBP employs gown and glove use during high resident care activities such as: Dressing Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting, Device Care or use: central line, urinary catheter, feeding tube and tracheostomy, Wound Care: any skin opening requiring a dressing. Review of the facility's policy and procedure on clean dressings last revised in March 2022 revealed the following procedure: - Use disposable cloth (paper towel is adequate) to establish a clean field on residents' overbed table. Place all items to be used during the procedure on the clean field. - Wash and dry your hands thoroughly. - Position resident. Place disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen. - Put on gloves. Loosen tape and remove dressing. - Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. - Put on new gloves. - Pour liquid solutions directly onto gauze sponges on their papers. - Wear gloves while holding gauze to catch irrigation solutions that are poured directly over the wound. - Apply treatments as indicated. - Dress wound. - Discard disposable items into the designated container. Discard all soiled laundry, linen, towels and washcloths into the soiled laundry container. Remove disposable gloves and discard them into designated containers. Wash and dry your hands thoroughly. Review of the facility's policy and procedure on handwashing last revised in August 2022 revealed the following procedure: - Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: - Before and after coming on duty. - Before and after direct contact with the residents - Before performing any non-surgical invasive procedures - Before handling clean or soiled dressing, gauze pads, etc. - After handling used dressing, contaminated equipment, etc. On 11/06/24 at 12:04 PM an observation was made of Nurse #1 entering Resident #3's room to provide wound care. Resident #3 was under EBP for a wound located on his left heel. The EBP signage located on Resident #3's door instructed staff to wear a gown and gloves during high contact resident care activities such as wound care for chronic wounds. Gowns were available directly outside of the resident's door in the hall in a three-compartment container. She was observed entering the resident's room, performing hand hygiene and applying gloves. Nurse #1 had Resident #3's wound care supplies in a container placed on the resident's bedside dresser. Resident #3 was observed sitting in a recliner chair and he placed the footrest up so his heels were in the air. Nurse #1 removed the old dressing and discarded the dressing in the trash can. The Nurse was observed using the same gloves to cleanse the wound with normal saline, paint the wound with betadine and apply calcium alginate (used in wound care to absorb drainage and promote wound healing). Nurse #1 was then observed wrapping Resident #3's heel with gauze. Nurse #1 then removed the gloves and discarded them into the trash can. She gathered the supplies and returned to the medication cart where she sanitized her hands. An interview on 11/06/24 at 12:15 PM with Nurse #1 revealed the facility did not have a wound nurse, it was up to the nurses working on the hall to complete and provide wound care. She stated she worked 4 days a week and every other weekend, so she changed Resident #3's dressing frequently. Nurse #1 was asked if Resident #3 was under any kind of precautions and replied yes, Enhanced Barrier Precautions which meant she needed to wear a gown and gloves before entering the resident's room. Nurse #1 stated she would typically wear a gown while providing wound care however it had just slipped her mind to put it on. She stated she would normally put on a gown while providing any wound care in the building. Nurse #1 stated she had also forgotten to wash her hands and change gloves in between removing the soiled dressing and applying new treatment to the wound and, after removing her gloves in the room. She stated she had just become nervous during the encounter and had forgotten. She stated she knew the policy and knew the process of wound care. An interview on 11/06/24 at 12:43 PM with the Director of Nursing (DON), who was also the Infection Preventionist (IP), revealed it was her expectation for the Nurse to follow infection control guidelines and wound care guidelines while providing wound care. She stated they were auditing staff to ensure they were following infection control guidelines and procedures and said she would be adding the Nurse and wound care to the auditing tool. She stated Nurse #1 should have worn a gown during the wound care for Resident #3. An interview on 11/06/24 at 12:50 PM with the Administrator revealed Nurse #1 should have followed the infection control policy and guidelines regarding wound care and Enhanced Barrier Precautions.

Based on observations and staff interviews, the facility failed to label and date leftover food items stored for use and failed to discard a dented can stored for use. These practices occurred in 1 of 1 walk-in cooler and 1 of 1 dry goods storage area and had the potential to affect food served to the residents who resided in the facility. The findings included: An initial tour of the kitchen occurred on 11/5/24 at 9:54 AM. The following concerns were identified: a. Items in the walk-in cooler that were labeled with a preparation date, but no use-by date included: -a resealable container of sliced red onion dated 11/1/24. -a resealable container of scallions dated 11/1/24. -a bag of shredded carrots, opened and resealed with plastic wrap dated 11/1/24. -a bag of cheddar cheese cubes, opened and resealed with plastic wrap dated 11/1/24. -a bag of shredded white cheddar cheese, opened and resealed with plastic wrap dated 11/1/24. b. An unopened bag of chopped cabbage dated 10/25/24 was observed in the walk-in cooler with a manufacturer's use-by date 10/29/24. c. A 6-pound, 12 ounce can of sweetened applesauce dented on the bottom seal was observed in the dry goods storage area ready for use. An interview with the Executive Chef on 11/5/24 at 11:39 AM was conducted. The Dietary Manager was out on vacation. He stated the facility used a three-day system for food storage. The Executive Chef indicated the date on the label was a preparation date and the staff needed to fill out the entire label, to include the use-by date on opened and prepared items. He stated cans with a dent on the edge or seal should not be used. An interview with the Administrator on 11/6/24 at 3:50 PM revealed he expected staff to follow the policy and procedures for labeling food items and proper storage for canned goods. He added the Dietary Manager typically checked the dates for stored food and stated when she was not working, the staff needed to follow the policies and procedures.

Based on observation, staff interviews and record review the facility failed to remove expired food stored for use from the walk-in refrigerator, failed to date meat that was thawing, failed to allow clean dishes to air dry before they were stacked (placed on top of each other while still wet). The failures had the potential to affect food served to residents. The findings included: 1. An initial observation of the walk-in refrigerator conducted on 2/13/23 from 11:25 AM to 11:50 PM with the Dietary Director (DD) revealed the following food items stored past the use by date and/or without a date to indicate how long the item was good for: - A 10-quart container of bean soup which was ¾ full dated 2/9/23. - 20 ham slices in a zip lock bag dated 2/8/23. - ¼ of a 2-pound pre-packaged ham was wrapped in plastic wrap without a date. - A metal container of ham slices with an unreadable date. The DD confirmed this was unreadable. - A plastic container containing approximately 2 cups of egg salad dated 2/7/23. - A plastic container containing approximately 5 cups of tuna salad dated 2/8/23. - A 12-quart container of cooked meatballs in sauce dated 2/3/23. - Canned peaches in a plastic container dated 2/7/23. - A metal pan of 12 thawed chicken breast with no date on the pan. The DD stated the chicken breast were served on Saturday 2/10/23. - A 10-pound box of mushrooms which had ¼ remaining that were covered in brown spots and were dated 1/18/23. - A 10-pound thawed, uncooked pork roast with no date. The DD stated the pork roast had been pulled from the freezer on Friday 2/10/23 and pork roast was served on Sunday 2/12/23 and this was pork was not used. - 5 pounds of thawed ground beef with no date. During the initial tour the DD stated that all food without an expiration date such as cooked food is kept for three days, and frozen food is pulled from the freezer to thaw in the refrigerator 48 hours prior to being cooked. A follow-up interview was completed with the dietary director on 2/13/23 at 3:16 PM who stated that she did not know why there had been expired food in the walk-in refrigerator. The DD stated that food that was cooked should have had a label with the day it was made and a use by date. The DD director explained that items like the raw ground beef should have had a date it was put in the refrigerator to thaw. An interview was completed with [NAME] #1 on 2/13/23 at 3:34 PM who stated that the process for labeling food was for example, if the food had been mixed vegetables he would have put a date the mixed vegetables were put in the refrigerator with plastic wrap over them. [NAME] #1 stated for ham slices he would had put the date of prepping and for raw chicken he would have put the date it had been put in the metal bin and placed in the refrigerator. [NAME] #1 stated that the policy is prepared food is thrown out after 3 days. 2. During a follow up visit to the kitchen of the dishwashing area on 2/13/23 at 3:40 PM revealed four, 4-quart plastic containers were stacked inside each other and 3 of the containers had noticeable condensation (water) inside the containers. The DD was made aware of the plastic containers at 3:46 PM and stated these were wet nested (containers stacked inside each other while still wet) and should have been left to air dry on the dish rack. An interview was completed with Dishwasher #1 on 2/13/23 at 3:50 PM who stated that dishes were to be put on a rack to air dry. Dishwasher #1 was shown the wet containers and he stated that some containers may be a little wet and he would still stack them or would get a clean towel to dry them off. An interview was completed with the Administrator on 2/15/23 at 2:42 PM who stated that it would be her expectation that food is labeled and dated and thrown away if expired and dishes are dry when stacked.

Based on record review and staff interviews, the facility's Quality Assurance and Performance Improvement committee (QAPI) failed to maintain implemented procedures and monitor these interventions the committee put into place in May 2021. This was for 1 re-cited deficiency which was originally cited on 5/26/2021 (F812) and on the current recertification/complaint survey on 2/15/2023 (F812). The continued failure of the facility during the two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program. The findings included: This tag is cross referred to: F812: Based on observation, staff interviews and record review the facility failed to remove expired food stored for use from the walk-in refrigerator, failed to date meat that was thawing, failed to allow clean dishes to air dry before they were stacked (placed on top of each other while still wet). The failures had the potential to affect food served to residents. During the Federal Monitoring Comparative Survey conducted on May 26, 2021, the facility failed to ensure sanitary practices were carried out in the kitchen. The facility failed to discard buttermilk by its use by date; failed to perform hand hygiene to prevent cross contamination of clean dishes during dishwashing and while plating food; failed to ensure gloves used while temping and plating food, were not cross contaminated by the food thermometer which had been improperly stored in a staff members pocket; and failed to allow clean dishes to air dry when they were wet stacked (placed on top of each other while still wet). The failures had the potential to affect three (3) of three (3) residents. The Administrator was interviewed on 2/15/2023 at 1:57 PM and she explained the facility conducted quarterly QAPI meetings that included the dietary director. The Administrator reported staff turnover in the dietary department was the cause of the breakdown in the system related to sustaining the corrective actions that were put in place in May 2021.