**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure appropriate hand hygiene was completed during wound care for 1 (Resident #81) of 3 residents observed for wound care. Review of the facility's policy titled, Dressing Change - Clean, dated 1/2024 revealed .To protect wounds .prevent infection, and promote healing .All dressings will be done using clean technique, unless otherwise ordered sterile by the physician .Procedure .Perform proper hand hygiene .Put on clean gloves .remove and discard gloves. Perform proper hand hygiene .Put on clean gloves .Remove and discard gloves .perform proper hand hygiene . Medical record review revealed Resident #81 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease, Congestive Heart Failure, and Chronic Bronchitis. Review of a comprehensive care plan dated 2/29/2024, revealed Resident #81 had a Stage 3 pressure ulcer to the sacrum. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #81 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #81 had a Stage 3 pressure ulcer. Review of the Physician's Orders for Resident #81 dated 6/3/2024, revealed .Cleanse wound to sacrum with wound cleanser and pat dry. Apply collagen powder [specialized protein powder to aid in wound healing] to wound bed and cover with [specialized dressing] .one time a day . During an observation and interview on 6/11/2024 at 8:50 AM, revealed Licensed Practical Nurse (LPN) A set up the supplies needed for wound care administration, cleaned the hands with hand sanitizer, and put on gloves. LPN A removed the soiled dressing from Resident #81's sacrum and placed the soiled dressing into a garbage bag. LPN A proceeded to clean the sacral wound with gauze pads and wound cleansing spray. Continued observation revealed LPN A finished cleaning the pressure wound, applied the collagen powder to the wound bed, and covered the wound with a clean dressing. Further observation revealed Resident #81's sacral pressure wound did not show any signs or symptoms of infection during wound care. LPN A picked a marker up from the floor and dated the clean dressing applied to Resident #81's sacral pressure wound with the marker. LPN A removed the soiled gloves and went into the bathroom to wash the hands. LPN A confirmed she did not change her gloves or wash her hands after removing the soiled dressing and before applying the clean dressing. LPN A stated she should have completed appropriate hand hygiene and put on clean gloves before applying the clean dressing. During an interview on 6/12/2024 at 1:00 PM, the Infection Preventionist (IP) stated the facility protocol was the gloves are to be changed when going from dirty to clean. IP stated LPN A had received re-education on the dressing change protocol.

Based on facility policy review, observation, and interview, the facility failed to ensure expired foods were discarded and not available for resident use in 1 of 1 kitchen, which had the potential to affect 115 of 116 residents. The findings include: Review of the facility policy, Receiving Foods, dated 3/25/2012, showed .When receiving foods, the following will be done Inspect for damage, Check expiration and use by dates .Label all food items with date of delivery . Review of the facility policy, Cold Storage Areas, dated 3/26/2012, showed .It is the policy to store cold food under safe and sanitary conditions .Store cold foods until their use by date, expiration date . Review of the facility policy, Storage Periods, Use By Guidelines, dated 12/6/2016, showed .Food will be stored properly and used within the appropriate time period to ensure safe and quality food is served .when labeling opened or unopened food that must be used within a certain time frame .leftovers .guideline is for 3 days .Expired Food items will be disposed .Expiration date-the last day the product should be used for best quality .Milk, opened Manufacturer's use by date .Milk, unopened .Manufacturer's use by date .Adhere to best use by date on carton .Produce, fresh fruits and vegetables Check daily for freshness . Observation with the Registered Dietitian (RD) on 3/16/2020 at 10:20 AM, of the walk in cooler, milk cooler, and freezer showed the following available for resident use: *1 head of lettuce open to air dated 3/5/2020. *1 partially used head of lettuce open to air with a use by date of 3/15/2020. *1 of the 1/2 pints of chocolate milk with a use by date of 3/14/2020. *9 of the 1/2 pints of chocolate milk with a use by date of 3/15/2020. *5 of the 1/2 gallons of buttermilk with a use by date of 3/7/2020. *1 of the 1/2 gallons of buttermilk with a use by date of 3/8/2020. *3 loaves of white bread with a use by date of 12/11/2019. *3 loaves of white bread with no date of receipt or expiration date. During an interview on 3/16/2020 at 10:40 AM, the RD confirmed the foods and milk had expired and was available for resident use. The RD confirmed her expectation was for expired foods to be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview the facility failed to complete a discharge Minimum Data Set (MDS) discharge assessment timely for one resident (#2) of 1 resident reviewed for discharge MDS assessments of 26 sampled residents. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be completed .within 14 days after the discharge date . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Coronary Artery Disease, and Hypertension. Further review revealed the resident was discharged from the facility on 11/16/18. Medical record review of the MDS assessments revealed no documentation of a discharge MDS assessment. Interview with the MDS Coordinator on 3/05/19 at 10:41 AM, in the MDS office, confirmed resident #2 was discharged from the facility on 11/16/18 and had not returned to the facility. Further interview confirmed the facility failed to complete a discharge MDS for the 11/16/18 discharge from the facility.