**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Review of Resident #1's face sheet dated 07/24/25, revealed an 86- year- old male admitted to the facility on [DATE] with diagnoses including covid-19, acute upper respiratory infection, constipation, abnormalities of gait and mobility. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 are was dependent on staffs for most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was frequently incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 07/03/25 revealed Resident #1 was frequently incontinent of bowel most of the time. Its The goal was to manage episodes of bowel incontinence as needed. Observation of incontinence care for Resident #1 on 07/23/2025 at 10:42 a.m. revealed CNA A washed her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and fecal matter. CNA A wiped the resident from front to back. She changed her gloves and repositioned Resident #1. CNA A continued to clean the resident. CNA A's gloves were visibly soiled with urine and fecal matter. She did not wash her hands, change gloves or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. She removed her gloves and picked up the trash. CNA A washed her hands before exiting Resident #1's room. In an interview on 07/23/2025 at 10:50 a.m. with CNA A, she revealed she should have washed her hands and changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been employed in the facility for 16 years and received infection control training about 1 month ago. She stated cross contamination was mixing clean with dirty which happened while providing care to Resident #1. CNA A noted she was nervous which caused her not to follow standard precautions. She said the resident could acquire an infection when she did not follow good infection control practices including not changing gloves before retrieving Resident #1's clean brief. During an interview with the DON on 07/24/2025 at 11:49 a.m., he revealed he was aware of some of the concerns raised about infection control. He stated he expected the aides to follow the facility's protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. He noted CNA A has been in the facility a long time and one of the best staffs. He said she must have been nervous. The DON stated the employees receive infection control training annually and periodically as needed. He explained the facility monitors the employees by observing them give care to the residents. Review of the facility's Hand hygiene policy revised November 26, 2024, reflected, Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed:1) Upon arrival at the workplace and before going home2) After using the toilet, blowing nose, and covering a cough or sneeze3) Before and after eating4) Before and after client contact5) After removing gloves6) Before invasive procedures 7) After touching contaminated items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Residents #19's) reviewed for respiratory care. 1. The facility failed to ensure Residents #19's nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. The findings included: 1. Record review of Resident #19's face sheet, dated 09/18/2024, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #19 had diagnoses which included Hypertension (high blood pressure), Shortness of breath, Depression, Anxiety, chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe). Record review of Resident #19's MDS annual assessment, dated 10/31/2023, reflected a BIMS score of 06, which indicated severe cognitive impairment. Section I: Active diagnosis reflected chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. Record review of Resident #19's Physician Orders, dated 09/18/2024, reflected an order for Oxygen at 3 liters per minute via nasal cannula to maintain 02 saturation above 90% Change oxygen and nebulizer tubing weekly. Record review of Resident #19's quarterly Care Plan, 09/18/2024, reflected a care plan for has COPD (obstructive pulmonary disease) - Oxygen at 3 liters per minute continuously to keep oxygen saturation above 90%. The Care Plan did not have an intervention regarding when oxygen tubing needed to be changed. In an observation on 09/17/2024 at 10:30 AM revealed Resident #19 was sitting in the dayroom in his wheelchair. His nasal cannula was uncovered and hanging over the bed rail in his room with the nose prongs on floor. In an observation and interview on 09/18/2024 at 5:45 AM, during morning rounds, revealed Resident #19 was sitting in his wheelchair in his room and his nasal cannula was uncovered and hanging over the concentrator in his room with the nose prongs on floor . In an Interview on 09/18/2024 at 4:45 PM the DON stated oxygen tubing was changed weekly based on the resident's orders, or as needed if the tubing become contaminated or occluded. The DON said oxygen tubing and the humidifier bottle should be changed per doctor's orders and the nasal cannula should have been stored in a plastic bag when not in use to prevent cross contamination and infection. He said the charge nurses were responsible for seeing that it was done. In an Interview on 09/18/2024 at 5:00 PM the Administrator stated the resident care was handled by the nursing department and nasal cannulas should be put in a plastic bag when not in use. The facility was unable to provide a policy for Respiratory Therapy -Prevention of Infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #11) of two residents reviewed for infection control practices. CNA A failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #1 This failure could place residents at risk for cross contamination and the spread of infection. Findings included: Review of Resident #11's face sheet, dated 9/19/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of urinary tract infection, essential hypertension (high blood pressure), chronic kidney disease (loss of kidney function). Review of Resident #11's Minimum Data Set (MDS) assessment dated on 09/3/24, revealed Resident #11, BIMS score of 15 (cognitively intact), required partial/moderate dependence with most activities of daily living (ADL's) with two-person assistance. She was frequently incontinent of bowel and bladder. Observation on 9/18/24 at 5:56 PM of incontinence care for Resident #11 revealed CNA A assisted the resident to bed. CNA A put on gloves, removed the brief that was soiled with urine and feces from Resident #11. CNA A wiped the resident from front to back with wipes, cleaning both urine and feces. CNA A gloves were soiled with urine and feces, but she continued to use. CNA A did not change gloves or perform hand hygiene but proceeded to retrieve Resident #11's clean brief. CNA A placed the clean brief on the resident, fastened the brief, then pulled up pajama pants into position on the resident . In an interview on 9/18/24 at 6:06 PM CNA A stated that after performing pericare including cleaning urine and fecal material from the resident, her hands/gloves were dirty. CNA A further stated that when going from dirty to clean they should always perform proper hand hygiene and lack of doing so could cause infections . Interview on 9/18/24 at 6:16 PM with the DON revealed his expectation was for clinical staff to follow infection control policy and use proper hand hygiene. The DON further stated that not following proper hand hygiene could lead to cross contamination and infection. The DON also stated that the clinical staff was responsible for following infection control policy and that he was ultimately responsible infection control. Interview on 9/19/24 at 11:55 AM the Administrator revealed her expectation was for staff to follow infection control policy and to use proper hand washing including washing between dirty and clean. The ADM further stated that lack of doing so could cause infection. ADM also stated that everyone in facility is responsible for infection control and proper hand hygiene. Review of Hand Hygiene policy from BRS Operations and Service Standards Manual revised on July 16, 2024 indicated the following [in-part]: Service Standard: Handwashing is the most important procedure to follow to prevent the spread of infection. Associates are expected to follow the CDC guidelines related to hand hygiene. Hand hygiene is the most important procedure for preventing the spread of infections. Hand hygiene should be performed: After touching contaminated items Review of Clinical Safety: Hand Hygiene for Healthcare Workers from the Centers for Disease Control and Prevention (https://www.cdc.gov/handhygiene/providers/index.html ) accessed on 9/19/24 indicated the following: Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. When to change gloves and clean hands If gloves become damaged. If gloves become soiled with blood or body fluids after a task. If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. If moving from care on one patient to another patient. If they look dirty or have blood or body fluids on them after completing a task. Before exiting a patient room.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents for 1 of 1 wound care/treatment carts inspected for medication storage in that: There were several expired items found in the facility's wound care/ treatment cart. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: During an observation and record review on 07/19/23 at 3:28 PM the wound care/treatment cart was observed with LVN C present. Observation revealed the following expired supplies and medications: 2 catheter stabilization device kits expired 02/28/2021; 1 Antimicrobial 10 X 12.5 cm dressing expired 3/28/2022; 9 Absorbant wound dressings expired 03/2021; 1 Antimicrobial skin and wound gel (3 oz. tube) expired 05/28/2022; 1 Wound solution (16 fluid oz. bottle) expired 04/2021; 1 PICC line dressing change kit expired 11/30/2019; 2 Duoderm wound dressings expired 06/2022; 1 Non-adhering dressing (3 in. X 3 in.) expired 12/2022. During an interview on 07/19/23 at 3:45 PM, LVN C said that she usually checks the carts when she was working. LVN C stated that she was unaware that the expired supplies were in the cart. LVN C stated that she will throw them out immediately. During an interview on 07/20/23 at 08:45 AM, the DON stated that the nurse assigned to the unit should be checking their medication carts, treatment carts and medication room daily for expired medications and supplies. The DON stated that he rounds and checks the med carts but forgets about the treatment carts and supplies in certain areas. The DON stated he needs to ensure that expired medications were removed from the medication room and medication carts for residents safety. During an interview on 07/20/23 at 9:00 AM, the Administrator stated that DON and ADON should be rounding each unit and checking for expired meds and supplies. The Administrator stated that staff were expected to work as a team to ensure resident safety. Record review of the facility's policy titled Storage of Medications revised 04/02/2018 indicated in part: The facility may not use medication that has been discontinued, outdated, or has deteriorated. In these cases, medication is returned to the dispensing pharmacy or destroyed by the pharmacist and licensed nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 16 residents (Residents #2, #24, #30 and #45) reviewed for care plans in that: Resident #2 had no care plan in place to address his oxygen use. Resident #24 had no care plan in place to address her oxygen use. Resident #30 had no care plan in place to address the need for palliative care. Resident #45 had no care plan in place to address his Out-Of-Hospital-Do-Not-Resuscitate status. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of Resident #2's Face Sheet, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included quadriplegia (unable to use arms or legs), malaise (general feel bad for unknown reason), and respiratory disorders. Review of Resident #2's Annual MDS Assessment, dated [DATE], revealed: He scored a 15 of 15 on his mental status exam with no signs or symptoms of delirium (indicating he was cognitively intact). He received special treatments while a resident that included oxygen. Review of Resident #2's Order Summary, dated [DATE], revealed orders dated [DATE] for oxygen at 2 - 4 L/min per nasal cannula as needed. Observation on [DATE] at 9:30 a.m. showed Resident #2 in bed with the head of bed raised. Resident #2 had oxygen on. Review of Resident #2's Care Plan, revision undated, revealed no care plan for the oxygen use. Resident #24 Review of Resident #24's Face Sheet dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included respiratory failure with hypoxia (low levels of oxygen in the blood) and congestive heart failure. Review of Resident #24's admission MDS assessment, dated [DATE], revealed: She had active diagnoses of heart failure and respiratory failure. She received special treatments prior to admission and as a resident that included oxygen therapy. Review of Resident #24's Physician Order Sheet, dated [DATE], revealed the following: Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler (2 puffs) as needed every 4 hours (order date [DATE]) Oxygen at 2 L/min per nasal canula continuous (order date [DATE]) Observation on [DATE] at 2:49 PM revealed Resident #24 sitting in her wheelchair in her room after returning from an appointment. Resident #24 was waiting to be assisted to her bed and was wearing a nasal canula attached to a portable oxygen tank set to 2 L/min. Observation on [DATE] at 3:03 PM revealed Resident #24 resting in bed with oxygen via nasal canula attached to her in room oxygen machine at 2 L/min. Review of Resident #24's Care Plan, revision undated, revealed no care plan for oxygen use. Resident #30 Review of Resident #30's Face Sheet dated [DATE] revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included diabetes, dementia, altered mental status, pain, and muscle weakness. Review of Resident #30's quarterly MDS Assessment, dated [DATE], revealed. He scored a 3 of 15 on his BIMS and showed no signs of delirium (indicating severe cognitive impairment). He needed extensive assistance of one or two staff for all ADLs except eating. Review of Resident #30's Nurse's Notes, revealed notes dated [DATE]: Resident #30's son has now signed Out of Hospital Do Not Resuscitate for elder. Resident #30's son also sent an email expressing the following In light of my conversation with Nurse Practitioner in [DATE], Resident #30's nurse yesterday, Resident #30's latest BIMS score of 3, and after consultation with Resident #30's daughter who is in agreement with this action, [the son] has signed his OOH-DNR order. I've included the Palliative Care form I signed in January as well. Resident #30's son had previously signed Palliative Care back in January however, soon after signing, he expressed he wanted to retract it. Resident #30's son is now in agreement with palliative care services for elder. Review of Resident #30's Care Plan, revision date unknown, revealed: Problem: Advanced Directives: Resident #30 has the following advanced directives; (DNR/OOHDNR, POA Medical or POA Financial, Living Will or Directive to Physicians) Palliative Care signed Goal: Resident #30 /or Family will have wishes respected regarding Directives over next 90 days. Interventions: Hospice referral for Resident #30 as needed. Resident #30 will have DNR/OOHDNR available in the chart. Resident #30's chart will be designated with the appropriate DNR/Full Code status. Support Resident #30 and family with their decisions and respect choices made. Interview on [DATE] at 3:30 PM the ADON stated she was part of the care plan process. She stated when a resident was admitted to the facility there was a care plan that was completed within 48 hours of the initial admission, and it was just part of the admission a RN had to complete. She said by day 20 the resident would have a comprehensive care which was completed by the nursing department, social work, activities, and the dietician. The ADON stated she expected to see ADL status, pain, skin issues, nutrition, hydration, mood, behaviors, cognition, fall risk and just about anything else you would think was pertinent to the resident's care. The ADON stated if the Resident had the oxygen all the time, she would expect a care plan. The ADON reviewed Resident #2's chart and said she did not see a care plan for his oxygen use. Interview on [DATE] at 11:23 AM, the ADON stated an interdisciplinary team did the care plans. The ADON stated Social Work, Activities, and the Dietician were also involved with care plans. The ADON said the expectation for what should be on the care plan included ADL status, pain, falls, skin conditions, psychosocial wellbeing, nutrition, advanced directives, mood, and behaviors. The ADON said specific diagnoses would be care planned if the resident took a medication for it, she added she did not care plan every medication the resident was on. The ADON elaborated that she would care plan a medication if it was about pain, or stuff at affected the resident's continence status. She said respiratory stuff could be care planed . should be care planned if the resident had cardiac diagnoses that affected the oxygen saturations. The ADON stated Resident #24 did have continuous oxygen and an as needed inhaler. The ADON said Resident #24 had not received the as needed inhaler since her admission. The ADON stated she could see why respiratory issues were separate from cardiovascular disfunction. The ADON said palliative care was care planned under advanced directives and did not require its own category. Then the ADON stated she did not know if it would require its own category, she said Palliative Care had its own EMR section and a place information would be scanned in. The ADON stated a resident would have a separate care plan for hospice. Interview on [DATE] at 11:44 AM the DON stated the OOHDNR was the residents CPR status while palliative care was about the resident or family's end of life wishes. The DON said a resident could have an OOHDNR and not be on palliative care so they would require separate care plans. The DON stated the facility would put the approaches together because it was about what the resident's wishes were. The DON read Resident #30's care plan on advanced directives and agreed the care plan did not cover services provided about the palliative care. The DON stated the facility did have a corporate nurse who would come to the facility and audit the care plans at least annually. Resident #45 Review of Resident #45's admission Record, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Disorder of the autonomic nervous system, Encounter for surgical aftercare following surgery on the digestive system, Other Secondary Parkinsonism, Torticollis, Ataxia, Drug induced subacute dyskinesia, Major Depressive Disorder, Anxiety Disorder, Polyosteoarthritis, Hyperlipidemia, Retention of urine, Essential Hypertension, Gastroesophageal Reflux Disease without Esophagitis, Chronic Diastolic Heart Failure, Pain, Constipation, Benign Prostatic hyperplasia with lower urinary tract symptoms, Malnutrition, and Polyneuropathy. Review of Resident #45's admission MDS, dated [DATE], revealed: -He had clear speech and had no difficulty in normal conversation, social interaction, listening to TV. He did wear hearing aids. -He scored a 10 of 15 on his mental status exam showing moderate signs of impairment. Review of Resident #45's Physician Order Summary Report, dated [DATE], revealed orders: -Out-of-Hospital-Do-Not-Resuscitate (OOH-DNR) (order dated [DATE]) Review of Resident #45's Care Plan dated [DATE] revealed no care plan in place for the Out-of-Hospital-Do-Not-Resuscitate Order. In an interview on [DATE] at 9:00 AM, the DON and ADON stated the facility will always address Out of Hospital Do Not Resuscitate Orders in Care Plans. The ADON stated that she completes the Care Plans, and this was always addressed. Review of facility policy Resident Plan of Care, revised [DATE], revealed, in part: Utilizing the resident assessment (MDS) an interdisciplinary team will develop a plan of care for each resident with input from the resident and/or family. 1. An initial care plan will be developed within 48 hours of the resident's admission. This will address immediate care needs, including, but is not limited to, dietary needs, medications, and routine treatments. 2. A comprehensive care plan will be developed within 7 days of completion of the resident's comprehensive assessment (MDS). The Interdisciplinary Team develops it. 3. The plan of care will include input, if given, from the resident and/or the resident's a. family, or the resident's legal representative. All are encouraged to participate in the development of the care plan and subsequent changes to the care plan. 4. The care plan will identify problem areas and interventions needed to meet the needs of the resident. 5. Assessments of residents are on-going and care plans are revised as information about the resident and his/her condition changes. 6. The Interdisciplinary Team is responsible for updating the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the nursing community from a hospital stay; and d. At least quarterly. The Discharge Plan of Care will be developed in coordination with the resident/resident representative to provide for an effective transition to the post-discharge location.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 2 of 4 medication carts reviewed for medication storage in that: MA B failed to ensure the medication cart was secured when it was left unattended. LVN A failed to ensure the treatment cart was secured when it was left unattended. These failures could place residents at risk for drug diversion or accidental ingestion. Findings included: During an observation on 07/18/23 at 09:10 AM the medication cart for hall 200 was seen unlocked and unattended. Inside the cart were several medication packets and pill bottles. During an interview on 07/18/23 at 09:14 AM MA B said if she did not push all the cart drawers then they would not all lock. MA B said she thought she had locked the medication cart before she had stepped away. MA B said she knew that she had to make sure the cart was locked because there were some residents that might try to open the drawers on the medication cart and could get access to the medications. During an observation and an interview on 07/19/23 at 10:15 AM the treatment cart for hall 200 was seen unlocked and unattended for approximately 10 minutes. Inside the cart were several medications, ointments and scissors. LVN A said whenever they stepped away from the carts, they were supposed to make sure they were locked. LVN A said he must have forgotten to lock the cart when he stepped away. LVN A said it could be possible for some residents to get into the items in the cart and injure themselves and that he would be more careful to make sure and lock the cart when leaving it unattended. During an interview on 07/20/23 at 11:14 AM the DON said if the medication or treatment carts were out of the staff's eyesight that they had to be locked. The DON said if the carts were left unlocked and unattended a resident could get access of the medications, items that were in the carts and could ingest them. The DON also said staff that were not authorized to the carts could have access to them. The DON said the failure probably occurred because staff got in a hurry and forgot to lock the cart. During an interview on 07/20/23 at 11:36 AM the Administrator said if the staff stepped away from their medication cart or treatment cart, they were supposed to make sure the carts were locked, and nothing left out on the top of the carts. The Administrator said residents could get into the medication cart and possibly ingest medications or ointments due to staff leaving the carts unlocked and unsupervised. Record review of the facility policy titled storage of medications dated 4/8/18 indicated in part: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Any compartments containing drugs and biologicals shall be locked when not in use and are not to be left unattended if open. Only persons authorized to prepare and administer medications should have access to the medication room and medication cart including any keys.

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 in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure that expired foods were discarded. These failures could affect residents who received meals prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on 7/18/23 at 9:10 AM of the kitchen dry storage room revealed: -8, 5lb bags of deluxe cornbread mix with no expiration or best by date -1, 7lb6oz container of sliced strawberry topping with no expiration or best by date -4, 6lb bags of chocolate flavored brownie mix with no expiration or best by date -1, 5lb bag of graham cracker crumbs with no expiration or best by date -1, 5lb bag of snowflake sweetened coconut with no expiration or best by date -12, 16oz bags of whipped topping mix with no expiration or best by date -2, 24oz bags of cherry gelatin mix with no expiration or best by date -3, 24oz bags of banana instant pudding/pie filling with no expiration or best by date -1, 24oz container of caramel flavored sauce with no expiration or best by date -1, 1-gallon jar of dill slices with no expiration or best by date -1, 1-gallon jar of dill spears with no expiration or best by date -1, 1-gallon jug of rice wine vinegar with no expiration or best by date -11, 24oz bags of orange gelatin mix with no expiration or best by date -8, 24oz bags of instant lemon pudding/pie filling with no expiration or best by date -8, 24oz bags of chocolate pudding/pie filling with no expiration or best by date -3, 5lb bags of white cake mix with no expiration or best by date -17 boxes of individually wrapped oatmeal cream pies (12 pies per box) with no expiration or best by date -13, 36oz boxes of long grain wild rice with no expiration or best by date -3, 1-gallon containers of mayonnaise with no expiration or best by date -7, 20.35oz bags of sliced scalloped potatoes with no expiration or best by date -28, 4oz containers of mixed fruit in pear juice with no expiration or best by date -10, 12oz bottles of tartar sauce with expiration date of 7/19/23 -3, 64oz bottles of 100% prune juice with expiration date of 6/1/23 In an interview on 7/18/23 at 10:00 AM, the Dietician and Dietary Manager, both were advised of expired food items and lack of expiration/best by dates on food items found during initial inspection of the kitchen. The DM stated that the expired prune juice and the tartar sauce would be disposed of immediately. The Dietician stated that the supplier had been sending the facility items that were very close to the expiration date all the time and they tried to make sure the dates were good before they put anything in the storage areas. The Dietician stated the staff just overlooked the dates on the last delivery. The DM stated that they did not have a system for writing use by dates on food items that were delivered without expiration or use by dates on the label. The DM acknowledged that the staff did have stickers with an area for the date the item was received and a use by date to be written in and then placed on the food item prior to putting it on the shelf. The DM stated the stickers do not always get placed on items. Both stated there should have been a better system in place to prevent expired foods from remaining in the kitchen past their expiration dates. Observation of unit refrigerator #1 on 7/19/23 at 10:10 AM revealed: -4, 12oz bottles of tartar sauce with expiration date of 7/19/23 -2, 3.5L containers of apple juice concentrate with no expiration or best by date -2, 3.5L containers of orange juice concentrate with no expiration or best by date -1, 3.5L container of cranberry juice concentrate with no expiration or best by date -1, 12oz bottle of squeeze vegetable oil spread with expiration date of 12/14/22 -2, 12oz bottles of squeeze vegetable oil spread with expiration date of 6/27/23 Observation of unit refrigerator #2 on 7/19/23 at 10:20 AM revealed: -2, 3.5L containers of apple juice concentrate with no expiration or best by date -1, 3.5L container of cranberry juice concentrate with no expiration or best by date -1, 3.5L container of orange juice concentrate with no expiration or best by date -3, 12oz bottles of tartar sauce with expiration date of 7/19/23 In an interview on 7/19/23 at 10:35 AM, the Dietician was advised of expired and undated items in unit refrigerators. The Dietician stated that the juice concentrate containers were supposed to be dated when they were removed from the freezer for use. She stated she did not know why the concentrate containers were not dated. She stated that the expired food items would be disposed of immediately. Review of undated facility policy titled Food Storage & Time Guidelines, revealed, in part: To maintain food quality and prevent foodborne illness, food should be stored for a limited amount of time. Always follow these general storage guidelines: - Label food with its expiration date. - If there is a question about a product's storage or expiration, discard it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 3 (Residents #51) reviewed for infection control. The facility failed to ensure: Resident #51's SVN mask and oxygen nasal cannula tubing was bagged when not in use. This failure placed residents at risk for infection. Findings included: Record review of Resident #51's face sheet dated 05/21/2022 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, chronic obstructive pulmonary disease and shortness of breath. She was [AGE] years of age. Record review of Resident #51's care plan dated 05/12/2022 indicated in part: Focus: the resident needs to wear oxygen during the day, the resident likes to come out for meals and then go back to her room to rest. Goal: The resident will wear her oxygen during the day, resident will come out for meals and then rest after she eats during the day, the resident will be invited and reminded when the daily activities are going on. Interventions: Staff will remind the resident to wear her oxygen daily x 7. Record review of Resident #51's medication profile dated 05/19/2022 indicated in part: May use oxygen 1-2L via NC at bedtime related to shortness of breath. Ipratropium 0.5 mg-albuteroL 3 mg (2.5 mg base)/3 mL nebulization PRN Every 4 Hours related to shortness of breath. During an observation on 05/17/22 at 10:20 AM Resident #51's oxygen tube cannula was on the floor and the SVN mask was lying on the top of the bedside dresser next to some hair from an elastic hair tie and hair brush. During an interview on 05/17/22 at 10:25 AM RN A said Resident #51's oxygen tubing cannula and SVN mask were supposed to be stored in a plastic bag when not in use. The RN said it was the CNA's responsibility to place the supplies in the bag when it was removed from the resident. The RN said the resident was not able to remove the cannula herself, so it was the CNA's responsibility to store the cannula in the bag. RN A said it was the nurse's responsibility to place the SVN mask in the bag after the resident received her breathing treatment. The RN said Resident #51 was currently using the oxygen only while in bed and PRN breathing treatments. The RN said they would replace the tubing and SVN mask and place them in the bags. During an observation on 05/18/22 at 09:32 AM observed Resident #51's oxygen tubing cannula wrapped around the bedside dresser drawer. During an interview on 05/18/22 at 09:35 AM RN A said Resident #51's oxygen tubing cannula was supposed to be stored in a plastic bag when not in use. The RN said they had just placed it in a bag yesterday 05/17/22 but the staff had not stored it in the bag as they were supposed to. RN A said they would replace the tubing and get a bag to store it in again. The RN said the charge nurses would usually do rounds throughout the day and monitor to see the oxygen items were stored in the bags. RN A said the failure occurred because the staff did not store the oxygen cannula and the nurse did not store the SVN mask in the bag. The RN said if the items were not stored correctly it could lead to respiratory infections and possibility of bacteria being inhaled by the resident. During an interview on 05/18/22 at 11:04 AM CNA B said Resident #51 only used the oxygen cannula when she was in bed. The CNA said whenever they got the resident out of the bed, they stored the cannula tubing in a plastic bag. CNA B said she was not sure who got the resident out of bed that morning. During an interview on 05/19/22 at 3:20 PM the DON said the SVN masks and nasal cannulas were supposed to be cleaned and stored when not in use. The DON said the nurses would monitor that the oxygen items were stored properly. The DON viewed a photo of the SVN mask taken by the surveyor where it showed the mask lying next to the hair and hairbrush and he said that was not the ideal way to store the mask. The DON said if the oxygen cannula was left on the floor and then used again it could lead to respiratory infections. The DON said the failure occurred due to lack of staff education or them just forgetting to store the supplies in the bag. During an interview on 05/19/22 at 3:25 PM the Administrator said they did not have a policy for storing oxygen nasal cannulas or SVN masks. The Administrator said the expectation was for staff to store the cannulas and SVN masks in an area that was considered clean. The Administrator said it was everyone's responsibility to make sure the items were stored safely. The Administrator said the oxygen items left on the floor could lead to respiratory infections. The Administrator said the failure occurred due to lack of staff education or them just forgetting to store the supplies in the bag. Record review of the facility's undated policy titled Surveillance for infections indicated in part: Process surveillance reviews practices related directly to resident care, such as monitoring of compliance with transmission-based precautions, hand hygiene, use of disposable gloves, ensuring sterile procedures are appropriately followed, ensure that reusable equipment is appropriately cleaned, disinfected, or reprocessed.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure dietary staff performed hand washing/sanitation, and appropriate glove and hairnet use to reduce the risks of cross-contamination. These failures could place residents at risk of food-borne illness. Findings include: Observations in Kitchen 05/18/22 10:30 AM - 12:00 PM: An unknown female staff came in the back door of kitchen, which was left ajar, with a rolling ice chest. She was not wearing a hairnet. She donned gloves without first washing her hands. She scooped ice from the ice machine into the rolling ice chest. She removed her gloves and exited the back door. DA C made salad in a large metal bowl while wearing gloves, touching multiple surfaces, and handling salad ingredients (lettuce, tomatoes) She tossed the salad by pushing her contaminated gloved hands and bare lower arms into the salad to mix the ingredients. Still wearing the same gloves, she wrapped some remaining lettuce in clear wrap, labeled it, and placed it in refrigerator. DM and [NAME] D lined chafing pans with plastic liners by pushing the plastic down into the pans with bare, unwashed hands, then putting hush puppies into the lined pans. DA C transferred salad from the large bowl into 4 foil pans using her hands, still wearing the same contaminated gloves. DA C changed gloves without washing/sanitizing her hands. DM changed gloves without washing her hands, . She opened drawers, got a spoon, and scooped corn from a large pan on the stove into a chafing pan and put into the food processer. Cook D got chaffing pans and lined with plastic. She changed gloves without washing her hands. She poured pureed corn into the lined pans. DA C doffed her gloves. She loaded dirty cookware that DM had previously rinsed into the dishwasher. DA C donned gloves without washing her hands. She pushed the cart to a storage rack and put away the clean colanders and cutting board. She changed gloves without washing her hands. She used gloved hands to transfer salad from the large bowl into 2 orange bowls and a Styrofoam plate. She placed the bowls and plate into refrigerator. She went to dry storage, gathered items, and went to baking station. Still wearing same gloves, she removed wrapping from a block of cream cheese and placed it on the food scale. She picked up the recipe book with both gloved hands and looked at recipe. She took the block of cream cheese from food scale and placed it in a large bowl. She picked up the recipe book again. She said she was making (chilled) blueberry cheesecake pies. The 11 baked pie crusts were observed uncovered on a 3-tier cart during this 1 1/2-hour observation period. The pie crusts were on the bottom 2 shelves. The top shelf of the cart was used to transport various things around the kitchen. Cook D got a wet cleaning rag from sanitizer bucket, wiped a work surface, picked up a food thermometer and wiped the stem with same rag and put it away. She donned gloves without washing her hands and transferred fried shrimp from fryer basket and placed in a lined pan. She doffed the gloves. DA C went to the dishwasher room and got clean measuring cups, then went into dry storage and got a bag of powdered sugar and placed them at the baking station. She removed her gloves and used scissors to cut the top of the plastic bag containing whipped cream. She squeezed whipped cream into a measuring cup and transferred it into the large bowl. A white glob was noticed in the whipped cream. She fished it out with a fork and said it was the lid off the whipped cream container. DM reminded DA C she did not put on gloves. DA C donned gloves without washing her hands. She wiped spilled powdered sugar from the baking station and the top of a 3-tiered cart with a rag. She washed her hands and donned gloves. While transferring the pie filling into baked pie shells, she touched the pie crust edges and the pie filling with her gloved fingers. Cook D left kitchen with the loaded food cart for the 2 cottages, separate from the main building. When she returned to the kitchen, she donned an apron and put away clean pots/pans/utensils without washing her hands/donning gloves. When she picked up/held the items her bare fingers touched the food contact surfaces. DM got celery and onion from refrigerator. She donned gloves without washing her hands. She pulled apart the stalks and rinsed the celery. She placed a cutting board on the work surface and got a knife out of a drawer. She changed gloves without washing her hands and diced the celery then scraped the celery into a bowl. During an interview with the RD and DM on 05/18/22 at 1:00 PM they both agreed there was a definite lack of hand washing and appropriate glove use during the preparation of lunch today. They said the back kitchen door was not supposed to be left ajar as this would allow pests to enter the kitchen. They said the person who had entered with the rolling ice chest was from one of the ALF buildings. One of their ice makers was broken and the other one did not make enough ice for both houses. They said the back door had been left ajar so ALF staff could come get ice. If closed all the way the door locks automatically. They said the kitchen staff are unlikely to hear someone knocking due to the noise in the kitchen. There was a small window in the door, but the ALF staff would have to wait until someone in the kitchen noticed them through the window. The said anyone entering the kitchen is required to wear a hairnet or other appropriate hair cover/restraint. They said there should be no hand or soiled glove contact with food or food-contact surfaces. They said the cooked pie crusts should have been covered. They said anytime staff leave kitchen they must wash hands upon return. They agreed that the above failures could cause cross-contamination and place residents at risk of food-borne illness. Review of Dietary/Food Service Personnel Policy and Procedures, revised 07/10/19, included the following, in part: WORK CONDUCT: 6. Only dietary employees are allowed in the kitchen or food/supply storage areas. Residents, visitors, salesmen and other facility employees are not permitted in the department unless requested or approved by the Dietary Manager/designee. PERSONNEL APPEARANCE: 6. Employees must wash their hands whenever they may be dirty such as: a. Immediately before beginning food preparation including working with exposed food, clean equipment and utensils, and unwrapped single serve and single use items. b. After touching human body parts (including touching of hair or face) other than clean hands, and clean, exposed portion of the forearms, g. before handling food, i. whenever hands become soiled, j. after handling soiled dishes or utensils, l. when returning to kitchen after making a delivery to another area, m. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, o. before putting on gloves when starting a new task; when changing gloves; removed soiled gloves, wash hands using proper procedure then put on new gloves p. at all other times when working with or activity that could contaminate the hands. 7. ABSOLUTELY NO BARE HAND CONTACT WITH FOOD. 8. When to change gloves: as soon as they become dirty or torn, before beginning a new task, after any interruption (taking a phone call, leaving the serving area, etc.); 12. Employees will not handle food with their hands, (sic) disposable gloves or utensils will be used at all times.