Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure partial loaf with over half of loaf used was dated with the opened date. 2. The facility failed to ensure opened bagged elbow pasta was dated with the opened date. 3. The facility failed to ensure twenty-five-pound opened bag of corn meal was sealed and dated with opened date. 4. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 06/03/2024 at 11:20 a.m. during the initial tour of the kitchen the pantry revealed a partial loaf of bread with over half the loaf used. The end of the bread bag was tied off in a knot without an open date. The pantry further revealed an opened bag of elbow pasta in a large zip lock bag with a received date of 04/29/2024, but no opened date. A twenty-five-pound bag of corn meal was observed open on the bottom shelf of pantry with top of bag open to air without an opened date. During an interview on 06/03/2024 at 11:36 a.m. [NAME] A stated the bread in the pantry should have been dated when it was opened and placed back in the pantry. She further stated it was used for sandwiches that morning. [NAME] A stated she was not sure when the pasta had been opened but an opened date should have been placed on the bag with a use by date. She further stated the corn meal usually was placed in a container after it was opened and dated. [NAME] A stated the corn meal being opened and not sealed could have allowed bugs to get in it and it could have caused cross contamination. [NAME] A stated dates are necessary so they know when something was opened and how long it had before it should be used. Observation and interview on 06/04/2024 at 4:57 p.m. of the kitchen revealed [NAME] B and the DA with facial hair restraints not worn properly. [NAME] B was observed with his mustache exposed and the right side of his beard not totally restrained while he demonstrated the preparation of the pureed meal. DA was observed with his mustache exposed and the facial hair restraint only covering his chin while he prepared drinks for dinner meal. [NAME] B stated the purpose of facial hair restraints were to keep hair from getting in the food and basically kept the food from being infected by hair or contaminated. The DA stated beard guards (facial hair restraints) were used to keep his hair from going into the food. The DA further stated it kept food from being contaminated. [NAME] B then asked the DS if it was necessary for the hair restraint to be over his mustache of which the DS replied yes. [NAME] B further stated he honestly did not know the beard guard (facial hair restraint) needed to be over his mustache. During an interview on 06/06/2024 at 9:52 a.m. the DS stated regarding items in the pantry found not dated or properly sealed during the initial tour of the kitchen that the pasta should have been in a closed zip lock bag, the used bread should have been dated with an open date and the corn meal should have been put in a container with an opened date all of which should have been done by kitchen staff. The DS further stated all items should have been dated by the kitchen staff with open dates and use by dates. The DS stated by sealing food items it kept bugs from going in the food and dust. The DS stated dating items when they are opened or dating with use by dates was so the kitchen did not serve something expired and so they would know when it had been opened. The DS further stated by serving expired foods it could cause residents to get sick. The DS stated the importance of beard restraints (facial hair restraints) was to keep food from being cross contaminated and it kept hair from going in the food. The DS further stated hair restraints should be worn entire time staff were in the kitchen. Review of facility's policy Food Receiving and Storage, dated approved October 2022, read Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices., Policy Interpretation and Implementation: #7 Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) Such foods will be rotated using a first in - first out system. Review of facility's policy Dietary Employee Dress Code Policy, date revised 10.22 and reviewed 5/21/2024, read Protocol: All employees will wear approved attire in order to perform their assigned duties., Procedure: 1. All staff will have their hair off the shoulders, confined in a hairnet or cap-facial hair covered properly. a. According to the Food Code, food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring posts or assembling the ingredients of a salad. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-402 Hair Restraints, 2-402.11, Effectiveness., (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices were complete, accurately documented, readily accessible and systematically organized for 1 of 12 residents (Resident #20) reviewed for accuracy of medical records, in that: The facility failed to obtain a physician's order for Resident #20's code status. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. The findings were: Record review of Resident #20's face sheet, dated 5/5/23 revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] and 3/9/23 with diagnoses that included orthopedic aftercare following surgical amputation, diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), heart failure and acquired absence of right leg above the knee. Record review of Resident #20's most recent Significant Change MDS, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required two-person physical assist with bed mobility and transfers. Record review of Resident #20's comprehensive care plan, revision date 4/23/23 revealed the resident was a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) with interventions that included to review advanced directive options quarterly and as needed and obtain a copy of full code status physician's order. Record review of Resident #20's Order Summary Report, dated 5/3/23 revealed there were no physician's orders for code status. During an observation and interview on 5/4/23 at 1:44 p.m., LVN A revealed a resident's code status could be determined by looking in the resident's electronic record under the resident profile which included a picture of the resident, the code status, admission information and date of birth . LVN A revealed she believed Resident #20 had a DNR code status. LVN A logged into Resident #20's profile in the electronic record and revealed, the subheading under code status was blank. LVN A revealed a physician's order for code status was required but did not know the reason why. LVN A revealed she believed the SW oversaw obtaining code status for the resident and the nurses were tasked with obtaining the order from the doctor. During an observation and interview on 5/4/23 at 1:58 p.m., the DON revealed, the first-place nursing staff would look for a resident's code status would be in the electronic record under the resident's profile. The DON revealed she believed Resident #20 had a DNR code status. The DON logged into Resident #20's profile in the electronic record and revealed, the subheading under code status was blank. The DON stated it was necessary to have a physician's order for code status in case something happened to the resident, such as if the resident should code (slang for a cardiopulmonary arrest, when the heart suddenly and unexpectedly stops pumping) so staff would know how to treat the resident and respect their rights and the resident's/family's wishes. The DON revealed since there was no active order for code status, Resident #20 would have to be considered to have had a full code status until a physician's order could be obtained. The DON revealed it was the nurse's responsibility to obtain the physician's order for code status. Record review of the facility policy and procedure titled, Physician Services, revision date February 2021 revealed in part, .A physician must recommend in writing that an individual be admitted to the facility. This can be accomplished through .d. a physician's admission orders for the resident's immediate care .Once a resident is admitted , orders for the resident's immediate care and needs can be provided .6. Physician orders and progress notes are maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act) regulations and facility policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #20) reviewed for infection control practices, in that: LVN A did not perform hand hygiene between glove changes when providing wound care to Resident #20 These failures could place residents with wounds at risk for infection, slow wound healing and or a decline in health. The findings were: Record review of Resident #20's face sheet dated 5/5/23 revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] and 3/9/23 with diagnoses that included orthopedic aftercare following surgical amputation, diabetes (a chronic (long-lasting) health condition that affects how your body turns food into energy), heart failure, acquired absence of right leg above the knee and peripheral vascular disease (a slow and progressive circulation disorder. Narrowing, blockage or spasms in a blood vessel.) Record review of Resident #20's most recent Significant Change MDS, dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required two-person physical assist with bed mobility and transfers. Record review of Resident #20's comprehensive care plan, revision date 5/3/23 revealed the resident had developed pressure ulcers due to immobility with interventions that included to administer treatments as ordered and follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #20's Order Summary Report, dated 5/3/23 revealed the following: -Cleanse Stage I to right buttock with normal saline and 4x4 gauze. Pat dry with 4x4 gauze. Apply Duoderm dressing to affected area and change every 72 hours and as needed until healed with order date 5/2/23 and no end date. -Cleanse Stage II to left buttock with normal saline and 4x4 gauze. Pat dry with 4x4 gauze. Apply Duoderm dressing every 72 hours and as needed until healed every night shift every 3 days with order date 5/2/23 and no end date. -Wound #12 cleanse arterial wound (also known as an arterial ulcer, a painful injury in the skin caused by poor dicrulation) to top of left great toe with normal saline, pat dry, apply skin prep every shift with order dated 3/15/23 and no end date. -Wound #13 cleanse arterial wound to left toe (2nd digit) with normal saline, pat dry, paint with betadine, leave open to air every day and evening every shift with order date 4/4/23 and no end date. Observation on 5/4/23 at 9:48 a.m., during wound care revealed LVN A, after applying the Duoderm dressing to Resident #20's wound to the right buttock, removed her gloves, did not perform hand hygiene and put on a new pair of gloves. LVN A then took a second Duoderm dressing and applied it to Resident #20's wound on the left buttock. LVN A then removed her gloves, did not perform hand hygiene, put on a new pair of gloves and assisted Resident #20 onto her back, fastened the incontinent brief on the resident and took a blanket and covered the resident. LVN A then continued with wound care to Resident #20's lower extremities. LVN A, after pulling back Resident #20's blanket to expose her lower extremities then removed the resident's offloading boot and then removed the resident's sock to the left foot. LVN A then removed her gloves, did not perform hand hygiene, put on a new pair of gloves and cleaned the resident's left great toe and 2nd toe with normal saline. LVN A then removed her gloves, did not perform hand hygiene and put on a new pair of gloves. LVN A then applied betadine to Resident #20's left great toe, then removed her gloves but did not perform hand hygiene, put on a new pair of gloves and placed the resident's sock and boot back on the left foot. During an interview on 5/4/23 at 10:28 a.m., LVN A revealed she thought she had done well during wound care but then stated, Now that I think about it, I skipped (not performing hand hygiene between glove changes) that once or twice. LVN A revealed, hand hygiene was necessary between gloves changes to prevent cross contamination and was considered an infection control issue. LVN A revealed not performing hand hygiene between gloves changes could cause Resident #20 to get an infection or sepsis (condition resulting from presence of harmful microorganisms in the blood or other tissues and the body's response to their presence) from cross contamination. During an interview on 5/4/23 at 2:07 p.m., the DON revealed it was best practice to perform hand hygiene, either by sanitizing the hands or washing with soap and water, during glove changes. The DON revealed, hand hygiene would be performed before and after changing gloves to prevent cross contamination. The DON revealed, if there was cross contamination the resident could get sick. Record review of the facility's In-Service Training Report, dated 12/1/22 revealed LVN A had satisfied the requirements for proper hand hygiene protocol. Record review of the facility policy and procedure, titled Handwashing/Hand Hygiene, revision date was illegible, revealed in part, .This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .before donning .gloves .i. After contact with a resident's intact skin .m. after removing gloves .