**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure Care Plan conference meetings were held at least quarterly for 1 of 21 (Resident #33) sampled residents reviewed for care plan meetings. The findings include: Review of the facility's DOCUMENTATION GUIDELINES, dated October 2021, revealed .SECTION VII PATIENT CARE PLANS .Patient's goals for care and preferences will be determined and used to develop their plan of care .The patient care plan schedule will be developed first to accommodate the patients' and patient representative' schedule/ability to attend .All clinical assessments will be completed before the meeting is convened and will be used to inform the care plan development .Patient/patient representative participation will continue to be documented via [by way of] the care plan approval form in the EHR [Electronic Health Record] .Care plans are updated as needed but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of the completion of the clinical MDS assessment . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Gastroparesis, Anxiety, Schizophrenia, Neurogenic Bowel and Slow Transit Constipation. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The facility was unable to provide documentation a care plan conference was held with Resident #33 within 7 days of the completion of the 10/14/2021, 1/13/2022 or 4/12/2022 quarterly MDS assessments. During an interview on 9/28/2022 at 5:53 PM, the Director of Social Services confirmed there were no care plan meetings held with Resident #33 for the quarterly MDS assessments dated 10/14/2021, 1/13/2022 and 4/12/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to notify the resident representative of a skin tear for 1 of 2 sampled residents (Resident # 29) reviewed for non pressure related skin conditions. The findings include: Review of the facility's policy titled, Change in a Resident's Condition or Status, revised February 2021, revealed .Our facility promptly notifies the resident .and the resident representative of changes in the resident's medical/mental condition and/or status .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia, Heart Failure, Diabetes, and Long Term Use of Anticoagulant. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated she had severely impaired cognition. Review of a Resident Progress Note dated 9/17/2022 at 6:55 AM, revealed While CNA cleaning and changing patient's diaper and clothes, pt. [patient] became combative and suffered skin tears on both of her hands. Left hand has 2inch [2 inch] long tear and right hand has a small tear. Patient has been combative while doing Wound care and dressing. Patient also refused her medicines. The facility was unable to provide documentation the resident representative was notified of Resident #29's skin tears. During a telephone interview on 9/28/2022 at 5:53 AM, Licensed Practical Nurse #1 confirmed she did not notify Resident #29's resident representative about the skin tears. During an interview on 09/28/22 03:12 PM, the DON confirmed staff should have notified Resident #29's family immediately after finding the skin tear on her hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's contracted housekeeping proposal, Maintenance Supervisor's Job Description review, Housekeeping Supervisor Job Description review, policy review, observation, and interview, the facility failed to provide effective housekeeping services and maintenance services to maintain a sanitary, orderly, and comfortable environment as evidenced by trash and debris lying on the floors, sticky floors with a buildup of dirt and grime, dust and cobwebs in the corner behind a door, exposed wires, dirty fall mats and overbed table bases, telephones lying on the floor, dirty bathroom floors and toilet, missing privacy curtains, and a fan covered in thick gray dust in 7 of 46 resident rooms (room [ROOM NUMBER], #410, #411, #503, #507, #508, and #510) observed. The findings include: Review of the facility's contracted housekeeping proposal dated 6/9/2022 revealed, .keeping your property well-maintained and exceptionally clean is extremely important .[Named Housekeeping Company] uses the very latest cleaning technologies to provide an unsurpassed level of clean .so every square foot of your business conveys quality and value .The objective of our cleaning process is not only to clean well, but also to clean for improved health .Cleaning Schedule .Patient Rooms .Thoroughly vacuum all carpeted areas including mats and rugs .Thoroughly damp mop all hard surface floors being sure to get into all corners and edges .Pull out any moveable furniture and décor to clean behind .High dust all surfaces not reached during regular cleaning . Review of a Maintenance Supervisor job description revised on 1/2010 revealed, .Inspects all equipment and systems regularly for proper functioning and safety .Regular inspection of property and equipment for compliance with safety regulations . Review of a Housekeeper job description revised on 1/2010 revealed, .This position is responsible for the cleanliness of the patient rooms .Clean patient bathrooms including sinks, toilets, tubs and showers .Clean patient rooms, including mopping and/or buffing floors, dusting furniture both on top and underneath .sweeping up debris .clean walls, furniture and equipment .to provide a clean pleasant environment for patients . Review of the facility's undated policy titled, .General Environmental Cleaning revealed, .Clean spills of blood or body fluids immediately .Use fresh cleaning cloths at the start of each cleaning session . Observation in room [ROOM NUMBER] on 9/26/2022 at 11:05 AM and 2:41 PM, and on 9/27/2022 at 7:59 AM, revealed a medicine cup, spoon, and cup, and 2 telephones lying on the floor, the floor was sticky and covered with a buildup of black scuff marks, and brown and gray substances, the fall mat was covered in black and gray grime and gray dust, and the overbed table base had a layer of built-up brown grime and gray dust. Observation in room [ROOM NUMBER] on 9/28/2022 at 9:52 AM, revealed 2 telephones lying on the floor, the floor was sticky and covered with a buildup of black scuff marks, and brown and gray substances, the fall mat was covered in black and gray grime and gray dust, and the overbed table base had a layer of built-up brown grime and gray dust. During an interview on 9/28/2022 at 9:53 AM, in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the floor and fall mat were dirty, the overbed table base needed to be cleaned, and telephones should not be in the floor. Observation in room [ROOM NUMBER] on 9/26/2022 at 11:38 AM, on 9/27/2022 at 8:26 AM, and on 9/28/2022 at 9:41 AM, revealed a cable cover torn away from the wall with the cable wires exposed, the floor was covered with dust, and a buildup of crumbles and dust, and the fall mat had a buildup of dark gray grime and black marks. During an interview on 9/28/2022 at 9:42 AM, in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the floor and fall mat were dirty and needed to be cleaned. The Maintenance Supervisor confirmed the cable wires should not be exposed and the cable cover should be replaced. Observation in room [ROOM NUMBER] on 9/26/2022 at 11:40 AM, and on 9/28/2022 at 9:44 AM, revealed black scuff marks and a buildup of a brown substance on the floor in the room and in the bathroom, and the overbed table base had a buildup of a brown substance and gray dust. During an interview on 9/28/2022 at 9:45 AM, in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the floor in the room and bathroom were dirty and needed cleaning, and the overbed table needed to be cleaned. Observation in room [ROOM NUMBER] on 9/26/2022 at 11:43 AM and 2:50 PM, on 9/27/2022 at 8:45 AM, and on 9/28/2022 at 9:25 AM, revealed a tan colored substance splattered on the floor near the doorway in the room, the toilet had a tan substance on the inside of the toilet bowl, on the water closet of the toilet and across the toilet seat, the floor had a buildup of a dark gray substance and black scuff marks. During an interview on 9/28/2022 at 9:26 AM, in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the floors needed to be cleaned and the bathrooms and toilets should be clean. Observation in room [ROOM NUMBER] on 9/26/2022 at 11:45 AM, on 9/27/2022 at 8:30 AM and 4:35 PM, and on 9/28/2022 at 9:34 AM, revealed a buildup of gray dust and grime along the edges of the base boards, the floor had a build up of a brown and gray substance and was sticky, there was a pile of gray dust and cobwebs behind the door, and the privacy curtain was missing for the bed beside the door. During an interview on 9/28/2022 at 9:35 AM, in room [ROOM NUMBER], the Housekeeper confirmed the floor next to the baseboards had the build up of gray dust and grime, and the floor needed to be cleaned. She confirmed there should not be a pile of gray dust and cobwebs behind the door and the privacy curtain should be replaced. Observation in room [ROOM NUMBER] on 9/27/2022 at 8:22 AM, 11:15 AM, and 2:16 AM, and on 9/28/2022 at 9:32 AM, revealed a fan covered in dark gray dust blowing in the room, the overbed table base was covered in a build up of brown grime and gray dust, the fall mats were covered in black and gray marks and grime, and the floor was covered in black and gray marks and grime. During an interview on 9/28/2022 at 9:33 AM, in room [ROOM NUMBER], the Housekeeping Supervisor in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the fan was dirty and dusty, the overbed table base needed to be cleaned, and the fall mats and the floor was dirty. Observation in room [ROOM NUMBER] on 9/26/2022 at 11:49 AM, on 9/27/2022 at 8:30 AM, and on 9/28/2022 at 9:35 AM, revealed the fall mats had a build up of a black and gray substance, 2 telephones were lying on the floor, and the floor was sticky and had a buildup of a brown and gray substance. During an interview on 9/28/2022 at 9:36 AM, in room [ROOM NUMBER], the Housekeeping Supervisor confirmed the fall mats needed to be replaced, the floor was dirty, and stated, .phones should be on the bedside tables or the overbed table, not in the floor . During an interview on 9/29/2022 at 12:23 PM, the Administrator was asked when she last made a tour of the resident rooms. She stated, .the week of August the 8th . She confirmed every resident should have a privacy curtain. She confirmed the floors in the Resident rooms and bathrooms should be clean and free of debris, cobwebs, and layers of dust should not be built-up behind the doors. She confirmed overbed table bases and floor mats should be clean. She was asked if telephones should be in the floor. She stated, No. They should not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure interventions were implemented to maintain nutritional status for 2 or 2 residents (Resident #29 and #65) reviewed for nutrition and failed to ensure skin assessment documentation was not completed for 1 of 2 residents (Resident #49) reviewed for non-pressure related skin conditions. The findings include: Review of the facility's policy titled, .Weight Monitoring, revised 3/2021, revealed .Interventions will be determined by the Dietician or designee based on the individual patient needs .The interdisciplinary team will play an active role in combating insidious .weight loss through routine involvement in the patient's plan of care . Review of the facility's policy title, .Obtaining Weights, dated 3/2021, revealed .Weights will be obtained upon admission, weekly times four weeks, and then monthly . Review of the medical record, revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia, Heart Failure, Chronic Kidney Disease, and Diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was severely cognitively impaired, required extensive assistance of staff for eating, and received a mechanically altered diet. Review of a Registered Dietician (RD) Note dated 9/7/2022 revealed, .Resident continues with current diet .Pt [Patient] seems to have had a decline in the past couple of weeks aeb [as evidenced by] increased weakness and more lethargic during meals. Pt is very slow with self feeding and tends to drop a lot of food in her lap. CBW [Current Body Weight] this week is 137# [137 pounds] indicates a 4# loss x [times] 2 weeks d/t [due to] decreased intake .Let patient eat food first, then offer supplements/shakes . Observation in the resident's room on 9/27/2022 at 7:59 AM, revealed Resident #29 was sitting up in bed and her breakfast tray was on the overbed table in front of her. Resident #29 was confused and talking about past events and reaching for items on the breakfast tray but was unable to hold them. Resident #29 tried to pick up a half of a biscuit with jelly and dropped it in her lap, attempted to drink her cranberry juice but couldn't hold the container and dropped it in her lap. Resident #29 attempted to take a drink from her water jug and dropped it in her lap and attempted to hold her fork and dropped it in her lap. The facility failed to ensure staff assisted Resident #29 with her breakfast meal between 7:59 AM and 8:45 AM. Observation in the resident's room on 9/27/2022 at 8:45 AM, revealed Certified Nursing Assistant (CNA) #1 asked Resident #29 if she was finished with her breakfast. CNA #1 picked up all the items from the resident's lap, placed them on the tray, and put the tray on the dirty tray cart. CNA #1 did not attempt to assist Resident #29 to take a bite of the breakfast food or take a drink of her supplement. Observation in the resident's room on 9/28/2022 at 8:27 AM, revealed Resident #29 was sitting up in bed and there was no breakfast tray in her room while her roommate was eating breakfast in the room. Resident #29's breakfast tray was found on the dirty tray cart. None of the beverages, including the supplement had been opened and one bite of scrambled eggs appeared to have been eaten. The RD confirmed the breakfast tray was put on the dirty cart and confirmed Resident #29 had taken one bite of scrambled eggs and the drinks had not been opened. During an interview on 9/28/2022 at 3:51 PM, the Director of Nursing (DON) confirmed the CNA should assist Resident #29 with her meals. Review of the medical record, revealed the Resident #65 was admitted to the facility on [DATE] with diagnoses of Left Hip Fracture, Methicillin-Resistant Staphylococcus Aureus, Pressure Ulcer Sacral Stage 2, and Malignant Neoplasm of the Prostate. Review of the admission MDS dated [DATE] revealed Resident #65 was severely cognitively impaired, required extensive assistance with Activities of Daily Living and had a diagnosis of Malnutrition. Review of the Care Plan dated 9/4/2022, revealed .Obtain weight weekly and intervene if significant weight change . Review of the Physician's Order dated 8/16/2022, revealed .Weekly weights on Wednesday day shift . Review of the 8/1/2022 to 8/31/2022 Medication Administration Record (MAR) revealed .Weekly weights on Wednesday .8/31 weight .199 . Review of the facility's Vital Results Weight sheet from 8/26/2022 to 9/26/2022 revealed .9/1/2022 .Weight admission .198.4 . Review of the 9/2022 MAR revealed the facility failed to obtain weights on 9/7/2022 and 9/14/2022. During an interview on 9/28/22 at 3:11 PM, the DON confirmed a weight should be obtained on admission and then weekly for 4 weeks. The DON confirmed Resident #65 should have had weights on 9/7/2022 and 9/14/2022. Review of the facility's Documentation Guidelines Section VII: Nursing Services, dated October 2021, revealed The goal of nursing documentation is to provide a timely recording of pertinent information regarding the safe and appropriate treatment, interventions, and responses in the patient's individual medical record . Review of the facility's undated Weekly Skin Assessments guidelines revealed .When should weekly Skin Assessments be completed .On admission .within 24 hours, as part of the nursing assessment . Review of the medical record, revealed Resident #49 was admitted to the facility on [DATE] with diagnoses of Right Tibia and Fibula Fracture, History of Falling, and Long Term Use of Aspirin. Review of the Care Plan dated 9/28/2022, revealed .to observe for signs and symptoms of .excess bruising . Review of the facility's Progress Note dated 9/23/2022 and was recorded as a late entry on 9/28/2022, revealed the facility failed to document the bruise to Resident #49's left arm upon the resident's admission to the facility. Review of the facility's Weekly Skin Observation assessment dated [DATE] revealed, .Bruising/Discoloration .Yes .If YES, bruise /discoloration location required .(blank) . The facility failed to complete the Weekly Skin Observation assessment to reflect the bruise to Resident #49's left arm. Observation in the resident's room on 9/26/22 at 11:21 AM, 9/27/22 at 8:31 AM 9/28/22 at 8:09 AM, and on 9/28/22 at 12:09 PM, revealed a large dark deep purple and blue bruise extending from the top of the resident's left wrist to the middle of the resident's left upper arm. Observation in the resident's room on 9/28/22 at 4:45 PM, revealed Registered Nurse #1, washed her hands, donned clean gloves, measured the bruise to the resident's left arm with results of 31.5 cm (centimeters) x 26 cm and stated That is pretty big . During an interview on 9/27/22 at 10:59 AM, Resident #49 confirmed the bruise to her left arm was present when she was admitted to the facility on [DATE]. During an interview on 9/28/22 at 12:22 PM, the DON confirmed that staff should have documented that the bruise was present on admission and should be documenting on the bruise until it starts to show signs of subsiding. The DON confirmed that the bruise should have been captured on the resident's Weekly Skin Observation assessment with the location completed on the assessment sheet and documentation in the medical record to support the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to obtain a physician's order, provide catheter care, and record urinary output for the use of an indwelling urinary catheter (a plastic tube inserted into the bladder used to drain urine into a plastic bag) for 1 of 2 sampled residents (Resident #58) reviewed for the use of an indwelling urinary catheter. The findings include: Review of the facility's policy titled Catheter Care, revised September 2014, revealed .The purpose of this procedure is to prevent catheter-associated urinary tract infections . Review of the medical record, revealed Resident #58 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Dysphagia, Hemiplegia and Hemiparesis, and Urinary Retention. Review of the admission Minimum Data Set, dated [DATE] revealed Resident #58 was assessed with a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact, had a diagnoses of Urinary Retention and the use of an indwelling urinary catheter. Review of the facility's Progress Note dated 8/22/2022, revealed .Placed a 16 F [French]/30ml [milliliter] cath [catheter] . Review of the Physician's Orders dated 8/19/2022 to 9/28/2022 revealed no order for the use of an indwelling foley catheter for August 2022. Review of a Physician's Order dated 8/23/2022, revealed .Received date .8/23/2022 .Start Date 8/23/2022 .End Date .Open Ended .Catheter Care once per shift and document output twice day . Review of the August 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the facility failed to document catheter care for the use of an indwelling urinary catheter from 8/23/2022 to 8/25/2022. Review of a Physician's Order dated 9/9/2022, revealed .Change Indwelling Catheter every 30 days .on the 9th of the Month .16 fr with 10 ml bulb . Review of the September 2022 MAR and TAR revealed the facility failed to document catheter care for the use of an indwelling urinary catheter from 9/9/2022 to 9/28/2022. Review of the facility's Output sheet from 8/22/2022 to 9/28/2022 revealed the facility failed to obtain urinary output for the use of an indwelling urinary catheter for Resident #58 on 9/9/2022, 9/10/2022, 9/11/2022, 9/12/2022, 9/13/2022, 9/16/2022, 9/17/2022, 9/18/2022, 9/19/2022, 9/20/2022 9/22/2022, 9/23/2022, 9/24/2022, 9/25/2022, 9/27/2022, and 9/28/2022. Observations on 9/26/22 at 11:27 AM, 2:46 PM, 4:32 PM, and 9/27/2022 at 8:33 AM, 1:11 PM, and 9/28/2022 at 8:11 AM, revealed an indwelling urinary catheter contained in a privacy bag draining dark amber colored urine. During an interview on 9/28/22 at 3:11 PM, the Director of Nursing (DON) was asked should there be an order for the use of an indwelling urinary catheter. The DON stated, Yes . The DON confirmed that indwelling catheter care should be performed every shift by the certified nursing assistant and the nurses should document it on the MAR or TAR. The DON confirmed that the Certified Nursing Assistant should obtain the urinary output for the use of an indwelling urinary catheter and it should be recorded every shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to monitor oxygen administration and oxygen tubing maintenance for 1 of 3 residents (Resident #56) reviewed for respiratory services. The findings include: Review of the facility's policy titled, Respiratory [NAME], dated 1/2005, revealed .Assessment Focus .oxygen monitoring .change .maintenance of equipment . Review of the medical record, revealed Resident #56 was admitted to the facility on [DATE] with diagnoses of Senile Degeneration of Brain, Palliative Care, and Heart Failure, and Dementia. Review of the Physician Order dated 8/31/2022, revealed .02 [oxygen] at 2-3L [liters] to keep sats [saturations] above 92 % [percent] . Review of the Medication Administration Record (MAR) dated 9/1/2022 - 9/28/2022, revealed there was no documentation for monitoring of oxygen administration and binasal cannula maintenance. Observation in the resident's room on 9/26/2022 at 11:25 AM, revealed Resident #56 was receiving oxygen through a binasal cannula. Observation in the resident's room on 9/27/2022 at 8:30 AM, revealed Resident #56's oxygen humidification bottle was empty and was dated 8/13. During an interview on 9/28/2022 at 3:00 PM, the Director of Nursing confirmed oxygen was not being monitored and they should have orders to maintain the binasal cannula tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of fall investigation reports, and interview, the facility failed to ensure that fall investigations were completed for 1 of 18 (Resident #57) sampled residents reviewed for falls. The findings included: 1. The facility's PROTECTION/PREVENTION PROGRAMS-FALLS PREVENTION PROGRAM policy revised 8/13/13 documented, . [Named facility] takes a person centered approach to falls prevention. Comprehensive assessment and root cause analysis are two very important tools in the prevention of falls and the recurrence of falls .a Falls Committee .monitors falls and utilizes data to systemically address falls . 2. The facility's INCIDENT AND ACCIDENT PROCESS revised 8/13/13 documented, .Investigation into the incident/accident: -Obtain information on what happened-what was actually seen or heard. If not witnessed, get patient's statement about what happened .Document all known facts, results of assessment including complete description of injuries, treatment, notification of physician and family. Gather statements from persons having information that may be pertinent . 3. Medical record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses of Fracture of Right Femoral Neck, History of Falling, Dementia, Peripheral Neuropathy, Depression and Insomnia. Review of fall investigations for resident #57 dated 11/13/18, 12/2/18, and 12/10/18 revealed the fall investigation was incomplete. Interview with the Director of Nursing (DON) on 12/20/18 at 6:17 PM, in the 300 hall, the DON confirmed that the fall scene investigation was not attached to the 11/13/18, 12/2/18, and 12/10/18. The DON was asked if the fall investigations were complete. The DON stated, .no these are not complete .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure practices were maintained to prevent the potential spread of infection when 1 of 3 (Registered Nurse (RN) #1) nurses failed to properly clean the nebulizer equipment after use during medication administration, 2 of 16 (Certified Nursing Assistant (CNA) #1) and (Licensed Practical Nurse (LPN) #2) staff members touched the residents' food during dining, and Respiratory Therapist (RT) #1 failed to perform appropriate infection control practice during tracheostomy care. The findings included: 1. The facility's SPECIFIC MEDICATION ADMINISTRATION PROCEDURES policy dated 6/2016 documented, .Rinse and disinfect the nebulizer equipment .Wash pieces (except tubing) with warm, soapy water .Rinse with hot water .Allow to air dry completely on paper . Observations in Resident #174's room on 12/18/18 at 8:34 AM, RN #1 washed her hands and performed the nebulizer treatment as ordered. RN #1 failed to clean the nebulizer equipment after use, and placed the uncleaned nebulizer equipment into a plastic bag at the resident's bedside. Interview with the Director of Nursing (DON) on 12/18/18 at 2:24 PM, at the nursing station, the DON was asked if it was acceptable to not clean the nebulizer equipment after use during medication administration. The DON stated, .No. 2. Observations on the 200 hall during dining on 12/17/18 at 11:51 AM, CNA #1 set up Resident #9's meal tray. CNA #1 removed a roll with his bare hands from the resident's meal plate and placed it on the tray. Observations in the restorative dining room on 12/17/18 at 12:23 PM, revealed Resident #27 was seated at the table when LPN #2 put the chicken patty on the bun with a fork and then with her bare hands, LPN #2 cut the chicken sandwich in half. LPN #2 picked up half of the sandwich with her bare hands and placed the sandwich in Resident #27's hand. Interview with the DON on 12/20/18 at 6:36 PM, on the 300 hall, the DON was asked if it was appropriate for the staff to touch the resident's food with their bare hands. The DON stated No, it is not, never. 3. The facility's .Tracheotomy Care policy revised 7/14 documented, .procedures are sterile and are performed by the RT, RN or LPN .Put a sterile glove on the dominant hand and a nonsterile glove on the nondominant hand . The facility's policy .Using Gloves revised 9/2010 documented .To prevent the spread of infection .Putting on Sterile Gloves .with one hand, grasp a glove by the inside of the cuff. Insert the opposite hand into the glove .Pick up the remaining glove with gloved hand. Insert ungloved hand into the second glove .Pull up cuffs of the glove .Removing Gloves .Wash hands. The facility's policy Handwashing/Hand Hygiene with a revised date of 8/2015 documented, .When applying, remove one glove from the dispensing box at a time . 4. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Hypertension, Thyroid Disorder, Arthritis, Multiple Sclerosis, Depression, Tracheotomy, Trigeminal Neuralgia, Fibromyalgia, and Peripheral Neuropathy. The physician's orders dated 3/9/18 documented, .CLEAN WITH TRACHE [Tracheostomy] CARE KIT ONCE DAILY AND AS NEEDED . Observations in Resident #8's room on 12/19/18 at 9:25 AM, RT #1 removed the breakfast tray and other items from the bedside table, laid her tracheostomy care kit and a package containing a split 4 x 4 gauze dressing on the bedside table without sanitizing the table and putting down a barrier. RT #1 removed a pair of gloves from her jacket pocket, donned the pair of unsterile gloves, opened the pack of sterile gloves, donned the sterile gloves on top of the unsterile gloves and continued with tracheostomy care. Interview with the DON on 12/20/18 at 4:12 PM, in the DON's office, the DON was asked if it was acceptable when preparing for tracheostomy care not to sanitize the bedside table and not to lay a barrier down before putting supplies down for tracheostomy care. The DON stated, .No. The DON was asked if it was acceptable to pull a pair of gloves out of your pocket and use them. The DON stated No. The DON was asked is it acceptable to don sterile gloves over a pair of unsterile gloves. The DON stated, No.