Based on observation, interview and record review, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. Kitchen staff had beard hair exposed and uncovered while preparing food. This had the potential to affect all 39 of 39 residents residing in the facility. Findings include: The facility policy, titled Personal Hygiene states, Hair must be kept clean and kept restrained with a hair net or cap covering all hair. Beards must be restrained using a beard net. On 05/05/25 at 8:20 AM, Surveyor conducted initial tour of kitchen and observed [NAME] C standing at breakfast steam table with beard net on that did not cover facial hair along both sides of face or mustache. On 05/05/25 at 12:35 PM, Surveyor observed [NAME] C preparing and serving food at steam table with beard net on that did not cover facial hair along both sides of face or mustache. On 05/06/25 at 9:44 AM, Surveyor interviewed [NAME] C regarding observation of beard net not fully covering facial hair along sides of face and mustache during food service. [NAME] C stated being unaware the side facial hair needed to be covered and indicated the beard net provided does not stay positioned to cover mustache. On 05/06/25 at 9:45 AM, Surveyor interviewed Dietary Manager (DM) D regarding observations of improper facial covering. DM D stated the expectation would be to have all facial hair covered and looked at [NAME] C and stated DM D will immediately start looking into more appropriate facial hair covering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not 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. This had the potential to affect 17 residents (R) on the 200 Hall. The facility did not ensure the standards of practice for applying and removing Personal Protective Equipment (PPE) to prevent the spread of infection while providing high contact care for COVID-19 positive R4. Housekeeper observed not sanitizing hands between resident rooms when delivering clean linens. Findings include: Surveyor requested and reviewed the facility policy titled Personal Protective Equipment, which stated in part, .c. Face/eye protection: ii. Wear goggles or face shield as added face/eye protection. Personal eyeglasses with side protectors are not a substitute for goggles or a face shield . Surveyor requested and reviewed the facility policy titled Infection Prevention and Control Program, which stated in part, .11. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . R4 was admitted on [DATE] with diagnoses which included in part: COVID-19 positive, dementia, and diabetes. R4's Minimum Data Set (MDS) assessment, dated 06/23/24, identified R4 scored 4 during a Brief Interview for Mental Status (BIMS), indicating impaired cognition. On 09/04/24 at 11:50 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D sanitize hands and apply fluid shield 3 N95 particulate filter respirator mask, gowns, and gloves. CNA D applied goggles and CNA C kept personal glasses on and entered R4's room. Surveyor did not observe CNA C apply protective goggles before entering COVID-19 positive room. On 09/04/24 at 12:07 PM, Surveyor observed CNA C exit R4's room and doff PPE. CNA C sanitized CNA C's regular glasses. On 09/04/24 at 12:11 PM, Surveyor observed CNA D doff PPE. CNA D laid contaminated goggles on the top of the PPE cart outside R4's room to wipe goggles down with sanitizing wipe. Surveyor did not observe CNA D wipe down the top of the PPE cart after contaminated goggles were touching the PPE cart. On 09/04/24 at 12:20 PM, Surveyor observed Housekeeper E remove clean linens from linen cart. Housekeeper E placed a pile of clean linens underneath Housekeeper E's arm pit and placed another set of clean linens under the other arm while holding the clean linens against Housekeeper E's scrubs. Then Housekeeper E approached PPE cart outside R4's door. Housekeeper E moved items around with bare hands and then placed R4's clothes on top of the contaminated PPE cart. Housekeeper E went directly into R5 and R8's room, opened the closet door and delivered the other clean linens that were being held under Housekeeper E's arm. Housekeeper E exited R5 and R8's room. Surveyor did not observe hand hygiene being performed before or after entering or exiting R5 and R8's room. Housekeeper E walked down hallway and grabbed more residents' clean linens and held clean linens against Housekeeper E's body touching Housekeeper E's scrubs. Housekeeper E ambulated down the hallway to R6 and R7's room and delivered clean linens to R6 and R7's closet. Surveyor did not observe hand hygiene performed before or after entering and exiting R6 and R7's room. On 09/04/24 at 1:10 PM, Surveyor interviewed Housekeeper E and asked Housekeeper E what expectation for hand hygiene and infection control practices were during clean linen delivery. Surveyor indicated to Housekeeper E that Surveyor observed Housekeeper E carry clean linens against Housekeeper E's body and then deliver clean linens, and Surveyor observed no hand hygiene between Housekeeper E entering, exiting, and delivering clean linens to residents' rooms. Housekeeper E indicated that Housekeeper E was never really taught that Housekeeper E needed to sanitize hands between rooms after touching closets and clean linens. Housekeeper E indicated that Housekeeper E should not let clean linens touch Housekeeper E's clothes. On 09/04/24 at 1:12 PM, Surveyor interviewed CNA C and asked if CNA C knows what type of eye protection is supposed to be used in a droplet precaution room. CNA C indicated that CNA C was never really told that CNA C could not wear CNA C's personal glasses. On 09/04/24 at 1:14 PM, Surveyor interviewed CNA D and asked what the correct process was for doffing PPE when exiting droplet precautions room. CNA D stated, I know I placed my dirty goggles on PPE cart outside the COVID-19 positive room and didn't mean to. I should have wiped goggles down right away and not placed them on the PPE cart contaminated. On 09/04/24 at 1:17 PM, Surveyor interviewed Infection Preventionist (IP) F and asked IP F what guidelines does IP F follow to implement and educate staff on current standards of practice. IP F indicated that IP F follows the CDC guidelines and facility protocols. Surveyor asked IP F if IP F can walk Surveyor through the process for donning and doffing PPE. IP F indicated that staff are to don gown, mask, eye protection, and gloves. Surveyor asked was it normal for staff to doff PPE on the outside of the COVID-19 positive room. IP F indicated that IP F has never been taught any other way. Surveyor indicated to IP F that Surveyor observed staff doffing PPE outside COVID-19 positive room and throwing PPE into trash located on outside door in common hallway. IP F indicated that IP F was not aware that trash can needed to be in the COVID-19 positive room. Surveyor asked IP F what expectation is for staff when doffing PPE and how do they sanitize goggles after being contaminated. IP F indicated that staff are to doff PPE and sanitize goggles before placing goggles down on any surface. Surveyor indicted to IP F that Surveyor observed CNA D exit COVID-19 positive room, doff gown, gloves, and then grabbed goggles and placed contaminated goggles on the PPE cart outside R4's room before wiping contaminated goggles down. CNA D then opened PPE cart drawers and grabbed a wipe to clean contaminated goggles. Surveyor did not observe CNA D wipe down the PPE cart. IP F indicated that CNA D should have not laid contaminated goggles on PPE cart. IP F indicated that CNA D should have wiped the goggles down with sanitizing wipe before laying directly on the PPE cart. Surveyor asked IP F what expectation of hand hygiene between Housekeeper E delivering clean linens room to room. IP F indicated that Housekeeper E is expected to be using hand sanitizer between rooms when delivering clean linens. Surveyor indicated to IP F that Surveyor observed Housekeeper E grab clean linens, press clean linens against scrubs, walk down hallway to COVID-19 positive room and rearrange contaminated items on top of PPE cart to make room for clean linens. Housekeeper E then walked across the hall to another resident room and delivered the other clean linens that were being held under Housekeeper E's arm. Surveyor did not observe Housekeeper E sanitize hands or use any hand hygiene practices. IP F indicated that Housekeeper E should be practicing good hand hygiene between delivering clean linens and expectation would be to sanitize or wash hands between rooms.

Based on observation and interview, the facility did not ensure the privacy and confidentiality of resident medical records. Staff left the Medication Administration Record (MAR) open and visible when unattended during medications administration. This occurred for 1 of 8 residents (R) during medications administration. (R19). Findings: The facility policy titled, COMPLIANCE-HIPAA Sanctions date implemented 7/15/22 states in part: 6. Examples of violations include, but not limited to: .d. The intentional or negligent mishandling, altering or destruction of confidential information or media/workstations that house such information. e. Leaving a secured application unattended while logged on . On 04/08/24 at 9:01 AM, Surveyor approached the medication cart located outside of the nurses station. No one was present by the cart. Surveyor noted that R19's MAR was up on the screen and visible to anyone who walked by the medication cart. Several facility staff walked by the medication cart. R18 was in a wheelchair sitting in the hallway, having the ability to see R19's MAR. On 04/08/24 at 9:09 AM, Registered Nurse (RN) K returned to the medication cart 8 minutes later and logged off of R19's MAR. On 04/10/24 at 11:04 AM, Surveyor interviewed RN K about the observation made the first day. RN K replied, I know I left the screen up on the computer, I saw you there. Thank you for pointing this out. On 04/10/24 at 11:17 AM, Surveyor interviewed RN K regarding HIPPA training the facility provided staff. RN K replied, I get training in Relias about not having personal information up on the computer screen at least every year. On 04/10/24 at 12:41 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor informed DON B of the observations made of the computer screen and asked what the expectation is. DON B replied, I tell them if they have the computer screen facing the resident's room in a private room that is fine, but it is better if you close the screen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not 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. Staff did not perform hand hygiene during 1 of 3 observations (R7) of personal care. Staff did not perform hand hygiene during 1 of 7 residents (R29) observed during medication pass. Findings include: Surveyor requested and reviewed the facility policy titled Hand hygiene dated last review November 2022. The policy in part reads: .#6 Additional considerations: -a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Surveyor reviewed the facility policy titled Hand Hygiene Table dated last review November 2022. The table in part reads: .Either soap and water or Alcohol Based Hand rub (ABHR is preferred) -Between resident contacts. -Before applying and after removing personal protective equipment (PPE), including gloves/ -Before preparing or handling medications. -After handling potentially contaminated blood, body fluids, secretions, or excretions. -When, during resident care, moving from a contaminated body of the site to a clean body site. -After assistance with personal body functions (e.g., elimination, hair grooming, smoking). Example 1 R7 was admitted on [DATE] and the current diagnoses, in part: non-Alzheimer's dementia, diabetes mellitus, stroke with hemiparesis, anemia, hypertension, and heart failure. Surveyor completed record review of the Minimum Data Set assessment (MDS), dated [DATE], which indicates the resident's most recent Brief Interview for Mental Status (BIMS) score was a 15 out of 15 total points. According to the BIMS assessment, a score of 15 indicates the resident has intact cognition. The MDS documents R15 is dependent on staff for activities of daily living and maximum assistance of staff to roll in bed. R15 is dependent on staff for transfers with a Hoyer lift assist of 2. On 04/09/24 at 9:17 AM, Surveyor observed Certified Nursing Assistant (CNA) E and CNA F take Hoyer lift into R7's room to transfer to bed for incontinent care. Surveyor observed CNA E used gloved hands to clean incontinent BM off R7's bottom. Surveyor observed CNA F roll R7 to the left side of the bed and CNA F used a wipe to clean R7's bottom off once rolled. CNA F tucked the dirty incontinent pad under R7's bottom to the left side. CNA F then rolled R7 back to his back. CNA E grabbed the dirty incontinent pad and threw it in the garbage. CNA E requested CNA F to go grab R7's urinal out of the bathroom. CNA F grabbed the urinal from the bathroom with soiled gloved hands and repositioned the urinal between R7's legs. CNA F grabbed R7's penis with CNA F's left gloved hand and placed R7's penis in the urinal. R7 requested CNA F to take R7's glasses from R7's eyes and place them on the bedside table. R7 also requested the head of the bed be raised. CNA F grabbed R7's glasses from R7's face with both soiled gloved hands and placed them on the bedside table. Surveyor did not observe CNA F take her soiled gloves off before removing R7's glasses. CNA F continued with R7's care, readjusting bed height, and turning the bedside light off by pulling the light string on the wall with both soiled gloved hands. Surveyor observed CNA F reposition the bedside table closer to R7's bed and then CNA F removed soiled gloves and threw them in the trash. CNA F exited R7's room, grabbed an antibacterial wipe, and wiped down the Hoyer lift. CNA F walked down the hallway, pushed the keypad on the door, and then pushed the Hoyer lift into the storage room. CNA F exited the storage room and relocked the doorknob on the keypad. Surveyor did not observe hand hygiene being performed by CNA F before exiting R7's room or after exiting R7's room. Surveyor did not observe hand hygiene being performed before or after sanitizing the Hoyer lift and entering the locked keypad storage room. CNA F then entered back into R7's room and sanitized hands. On 04/09/24 at 9:34 AM, Surveyor interviewed CNA F and asked about hand hygiene and glove use practices during R7's care. CNA F indicated that gloves are supposed to be changed as needed, changed often and hand sanitizer is used before and after resident care. On 04/10/24 at 11:02 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C and asked about hand hygiene during peri care and other care during resident care. ADON C indicated that CNA F should be changing gloves often and using good hand hygiene. ADON C indicated it was not correct for CNA F to use soiled gloves to take R7's glasses off and place them on the bedside table. ADON C indicated the correct process is for staff to change gloves often and sanitize hands going from peri care to other tasks. Example 2 On 04/09/24 at 7:12 AM, Surveyor observed Registered Nurse (RN) J administer medications to R29. Proper hand hygiene was performed using Alcohol Based Hand Rub (ABHR) before entering R29's room. After medication administration was finished, RN J did not perform hand hygiene, put on a pair of single use gloves, rinsed R29's dentures in the sink and attempted to put R29's dentures in R29's mouth. R29 refused the denture. RN J put the dentures back in the denture cup. RN J removed gloves and performed hand hygiene using soap and water at the sink in R29's room. On 04/10/24 at 11:13 AM, Surveyor asked RN K, What is the expectation for hand hygiene? RN K replied, Before I put on gloves I sanitize my hands. I also sanitize my hands when I am passing medications and before and after leaving a resident room, or I wash them. On 04/20/24 at 12:42 PM, Surveyor interviewed Director of Nursing (DON) B regarding observations made of no hand hygiene performed during medication pass between residents. DON B replied, They know better. They know that hand hygiene is expected between residents' cares and before and after glove use.