TEXHOMA CHRISTIAN CARE CENTER INC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 7 residents (Residents #59 and #126) reviewed for comprehensive care plans. <BR/>1. Resident #59 developed cellulitis in her left forearm and a skin rash which covered her body. Physician ordered creams were applied to treat her skin. Resident #59's care plan was not revised and updated to address the development of skin conditions and the treatment of them. <BR/>2. Resident #126 was noted to have developed a skin rash during March 2024. Physician orders were obtained for creams to be applied to the affected areas. Resident #126's care plan was not revised and updated to address the development of skin conditions and the treatment of them.<BR/>These failures placed the residents at risk for not receiving necessary care and services to meet their individual needs and to promote a feeling of wellbeing during daily life within their living environment.<BR/>The findings included:<BR/>1. Review of Resident #59's Face Sheet, not dated, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: dementia; pruritis (itchy skin); contact dermatitis (an itchy rash caused by direct contact with a substance or an allergic reaction to it); and cellulitis of the left upper limb (bacterial skin infection characterized by swelling and redness).<BR/>Review of Resident #59's Annual MDS Assessment, dated 7/30/24, revealed in Section M - skin treatments - the application of ointment other than feet was selected.<BR/>Review of Resident #59's comprehensive care plan, dated as initiated 7/24/2023 and reviewed and revised on 8/05/2024, revealed it addressed the resident's risk for skin breakdown related to urinary incontinence. The care had not been revised and updated to address Resident #59's cellulitis or development of a rash/contact dermatitis.<BR/>Review of Resident #59's physician orders revealed the following:<BR/>- 5/02/24 triamcinolone acetonide cream 0.1%; apply a thin layer topical twice a day, continue until resolved. <BR/>- 6/19/24 clotrimazole cream 1%; apply a thin amount topical twice a day, administer with triamcinolone cream to hand until healed. <BR/>Review of Resident #59's Skin Integrity Event, dated 6/15/24, revealed the resident's left forearm had redness and was warm to touch and the skin to the palm of the hand was cracked and flaky with slight redness noted. <BR/>Review of Resident #59's Physician Progress Note, dated 6/20/24, revealed documentation that the resident had a diffuse rash on trunk and arms, itching and scratching. The note documented the resident was on Bactrim DS BID for one week for cellulitis. The note documented possible dermatology consult.<BR/>Review of Resident #59's Nursing Progress Notes revealed the following documentation: <BR/>- 6/29/24 In room at this time. Applied triamcinolone cream to chest, back, and bilateral upper extremities. Clotrimazole cream applied to palms of hands. Note rash fading. Skin palm of hands improving. Redness to left forearm is resolving.<BR/>- 7/01/24 Continue to monitor resolving rash to skin to abdomen, back, thighs, flanks. Resident denies pain or active itching, no redness to skin under breast or abdominal folds at this time, continues to receive triamcinolone cream to areas of affected skin. Clotrimazole cream to hands. <BR/>- 7/16/24 Continue to monitor extensive rash to bilateral upper extremities, chest, bilateral lower extremities, and torso. Scabs to scalp noted. <BR/>- 7/21/24 Refused shower, states I will later, not now. Compliant with triamcinolone cream treatment. Continue to note rash with picked scabs to upper bilateral extremities and shins. Red bumps to back of neck at hairline, torso, and chest. Scabs also noted to posterior scalp.<BR/>- 7/25/24 Continue to note rash to skin, picked areas with scabbing to abdomen, buttocks, flanks, bilateral upper extremities and bilateral lower extremities. Triamcinolone cream administered, tolerated well. Rash to hands resolved, no peeling or scaly skin. Scab to left forearm, no sign of infection.<BR/>During an interview and record review on 8/30/24 at 3:56 PM, the MDS Coordinator reviewed Resident #59's electronic health record documents and physician progress notes and stated she did not see a dermatology consult note. She reviewed Resident <BR/>#59's care plan and stated she did not see a care plan addressing the resident's skin rash. <BR/>2. Review of Resident #126's Face Sheet, not dated, revealed a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: dementia; tinea corporis (fungal infection of the skin); and pruritis (itchy skin). <BR/>Review of Resident #126's Annual MDS Assessment, dated 2/25/2024, revealed in Section M - skin treatments - the application of ointment other than feet was selected.<BR/>Review of Resident #126's Quarterly MDS Assessment, dated 8/04/2024, revealed it documented a BIMS score of 3 out of 15 (severe cognitive impairment) and in Section M - skin treatments - the application of ointment other than feet was selected.<BR/>Review of Resident #126's comprehensive care plan, dated as initiated 3/08/2023, revealed a care plan dated 2/28/2024 that addressed risk for skin break down related to urinary incontinence. The care plan was dated as reviewed and revised 8/05/2024 and had not been updated to address the resident's skin rash and physician ordered topical treatment.<BR/>Review of Resident #126's Physician Visit progress note, dated 1/09/2024, revealed documentation of a chief complaint of the resident picking the skin on his forearms causing bleeding and itching. The physician's assessment and plan documented pruritis on upper extremities and self-inflicted skin excoriations. An order was documented to start Hydroxyzine 25 mg every 6 hours PRN for 6 weeks and to redirect the patient to abstain from picking the skin on his upper extremities.<BR/>Review of Resident #126's physician orders revealed an order dated 4/23/2024 for miconazole nitrate cream 2% topical to all rash areas. Special Instructions: APPLY BID ON RASH AREAS TO (R) BILATERAL THIGHS. Twice A Day.<BR/>Review of Resident #126's Nursing Progress Notes revealed the following documentation [in part]:<BR/>- 3/06/24 SKIN: Redness noted to coccyx, red bumps noted to bilateral thighs. No other skin issues noted at this time. <BR/>- 3/21/24 SKIN: Red bumps noted to bilateral thighs. No other skin issues noted at this time. <BR/>- 8/16/24 Continue to note symptoms of rash to right thigh, Hydrocortisone cream applied, tolerated well. Diagnosis: pruritis.<BR/>- 08/25/24 Resident noted to have rash to right lower extremity, cream applied and small scab to right upper extremity with no signs or symptoms of infection.<BR/>During an interview and record review on 8/30/24 at 3:45 PM, the MDS Coordinator reviewed Resident #126's care plan. She stated she thought she had done a care plan for the resident's rash and stated she could not locate a care plan addressing the resident's rash.<BR/>Review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered, dated as revised March 2022, revealed the following [in part]:<BR/>Policy Statement<BR/>A comprehensive care plan is developed and implemented for each resident.<BR/>Policy Interpretation and Implementation<BR/>6. The comprehensive care plan:<BR/>g. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .<BR/>10. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes .

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 two of three kitchens reviewed.<BR/>1. The South Building satellite kitchen had expired, unlabeled, and undated food in the walk-in refrigerator.<BR/>2. Dietary Aide H did not demonstrate a sanitary procedure while measuring food holding temperatures and sanitary use of disposable gloves in the North Building satellite kitchen. <BR/>These failures could place residents at risk for foodborne illness and a decline in health status.<BR/>The findings included:<BR/>1. South Building Satellite Kitchen<BR/>Observations on 06/13/22 at 9:00 AM, during the tour of the South Building satellite kitchen, revealed the walk-in refrigerator contained the following:<BR/>- an opened package with what appeared to be meat that was wrapped in cellophane and was dated 06/06/22;<BR/>- an opened plastic bag containing shredded cheese was wrapped with cellophane and was not labeled and dated;<BR/>- an opened bag containing shredded lettuce was undated; the lettuce was brown colored, and the bottom of the bag had collected a brown colored fluid. <BR/>In an interview on 06/13/22 at 9:10 AM, Dietary Aide H said he was not aware the articles of food in the walk-in refrigerator were expired and he would throw them away immediately. <BR/>In an interview on 06/14/22 at 2:30 PM, the Director of Nurses said they seldom used the South Building kitchen. She stated she suspected they had food in it and recognized the fact that food in the refrigerator should be dated and labeled regardless if the satellite kitchen was used or not. <BR/>In an interview on 6/16/2022 at 2:40 PM, the Dietary Manager stated his expectations were that all food in the refrigerator would be dated and properly stored and he as well as the dietary aides are responsible for checking dates and disposing out of date food. <BR/>2. North Building Satellite Kitchen <BR/>During and observation and interview on 6/13/22 at 10:48 AM, while in the North Building satellite kitchen, revealed pans covered with aluminum foil were being removed from hot carts brought from main kitchen in the [NAME] Building. The pans were placed on the steam table. The Dietary Manager stated no cooking was done in the satellite kitchen. He stated all residents were being served using foam containers. He stated regular eating utensils were being used and were washed in the low temperature dish machine with chlorine sanitizer. <BR/>Observation on 06/14/22 at 10:50 AM revealed 2 enclosed food carts from the main kitchen in the [NAME] Building arrived in the North Building satellite kitchen. The pans were covered with aluminum foil. The dietary aides placed the pans on the steam table. <BR/>During an observation and interview on 06/14/22 at 11:00 AM, [NAME] I began taking the food holding temperatures for foods on the left-hand side of the steam table. She stated she worked in the main kitchen in the [NAME] Building and the food temperatures had been taken in the main kitchen prior to being sent to the satellite kitchens in the North and South Buildings. [NAME] I used alcohol preparation pads to sanitize a digital food thermometer. [NAME] I stated she had been employed in the facility for 5 years. She stated she did not work in the North Building and was told to come to the North satellite kitchen and take the steam table food holding temperatures for lunch today. She stated the menu today was salmon croquettes, oven browned potatoes, sweet/green peas, and a brownie for dessert. <BR/>During an interview and observation on 06/14/22 at 11:02 AM, Dietary Aide H stated he had been employed in the facility for a little more than one month. He stated he worked during the breakfast and lunch meals and arrived to work about 6:20 AM. He stated the dietary aides usually checked the steam table food holding temperatures for the North Building and agreed to take over for the cook. Dietary Aide H proceeded to check the temperature of the salmon croquettes, which was measured at 151.3 degrees F. He wiped the food surface of the digital thermometer on a dry rag before measuring the cardiac diet croquettes at 154.9 degrees F. When asked how he cleaned and sanitized the digital thermometer between food items, he stated he wiped them on the rag. When asked where the dry rag came from he replied it had come from the main kitchen. When asked if he had been trained to take steam table food holding temperatures and when and who had trained him, Dietary Aide H stated another dietary employee who no longer worked here had trained him.<BR/>In an interview and observation on 06/14/22 at 11:10 AM, [NAME] I stated there was a stack of clean rags in the main kitchen. The rag appeared to be a piece of a towel that had once been white and was now a dingy light brown-gray color with darker brown and gray stains. [NAME] I was asked if Dietary Aide H was cleaning the digital thermometer correctly, and she said no. [NAME] I told Dietary Aide H to use the alcohol preparation pads that she had placed on the counter and to rub the thermometer food surface for 15 seconds with an alcohol pad. <BR/>During an observation and interview on 06/14/22 at 11:14 AM, Dietary Aide H started using the alcohol preparation pads to clean the digital food thermometer. He used his gloved hand and slid diced oven-browned potatoes, that were skewered onto the food thermometer, back into the pan. Dietary Aide H dropped meal tray diet order slips, held together with a paperclip, on the floor. He picked them up off the floor and placed them on the first tray, on the top of a stack of meal trays. Dietary Aide H said the trays were not used. He did not change his gloves until after he was asked if his gloved hand had touched the floor when he picked up the diet order slips from the floor.<BR/>In an interview on 06/14/22 at 11:20 AM, after the Dietary Manager entered the steam table area, he was asked what would be done after the meal tray diet slips had been on the floor. He said they probably should not be used. He stated they were for the people who lived in the cottages on the grounds/campus. The Dietary Manager instructed Dietary Aide H to serve the North Building meal trays first, and he would print new meal tray diet order slips to replace the ones that had been on the floor. The Dietary Manager stated Dietary Aide I knew how to take steam table holding temperatures and he would be trained again before the end of the day.<BR/>In an interview on 06/16/22 at 2:02 PM, the Dietary Manager stated the new dietary aides were usually trained by the experienced dietary aides, and the dietary manager followed-up with the new dietary aides later and observed them. He stated Dietary Aide H was trained by a dietary aide who worked in the facility for a couple of years, and no longer worked in the facility due to going to nursing school. The Dietary Manager stated sometimes staff did wipe the food thermometer on a paper towel to remove excess food before sanitizing with the alcohol pad, but he had never seen staff wipe it on a rag until Dietary Aide H did it at lunch the other day. He stated he had never seen Dietary Aide H do that before and had watched him take food holding temperatures. He stated Dietary Aide H knew how to do it. The Dietary Manager stated [NAME] I from the main kitchen in the [NAME] Building main kitchen had been sent to help Dietary Aide H with serving the lunch meal that day (06/14/22), and not to take the steam table food holding temperatures. He stated he would look for a policy and procedure for taking food holding temperatures and food thermometer use and sanitization. <BR/>Review of the facility's current employee list with hire dates, provided 6/13/22, revealed Dietary Aide H was hired on 4/27/2022. <BR/>[He had been measuring steam table food holding temperatures prior to serving breakfast and lunch meals for more than one month.]<BR/>Review of the facility's policy for Food Storage Procedure, not dated, revealed the following [in part]:<BR/>B. Cold Storage<BR/> .6. All items should be rotated on shelves so that older items are towards the front. If an item reaches its expiration or use by date it should be discarded immediately. <BR/>Review of the facility's policy and procedure for Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated October 2008, revealed the following [in part]:<BR/>Policy Statement<BR/>Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .<BR/>9. <BR/>Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness.<BR/>10. <BR/>Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper hand washing <BR/>[The facility did not provide a policy and procedure specifically for the sanitization and use of food thermometers as requested on 6/16/22 at 2:02 PM.]<BR/>The U.S. Food and Drug Administration, 2017 Food Code specified:<BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. <BR/>(A) <BR/>FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days.<BR/>4-701.10 Food-Contact Surfaces and Utensils. <BR/>EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. <BR/>Frequency 4-702.11 Before Use After Cleaning. <BR/>UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.

**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 #1) of 2 residents reviewed for infection control practices in that:<BR/> RN A failed to perform hand hygiene, wash hands, change gloves and prevent cross contamination while providing wound care for Resident #1.<BR/>These failures could affect the residents by placing them at risk for the spread of infection. <BR/>Finding included:<BR/>Review of Resident #1's Face Sheet dated 02/08/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of non-pressure ulcers, urinary tract infection, exposure to covid-19, and candidiasis.<BR/>Review of Resident #1's Minimum Data Set (MDS) Assessment undated revealed Resident #1 required total assistance with most activities of daily living (ADLs) and was always incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan dated 08/03/22 revealed he was at risk pressure ulcers and skin breakdown related poor intake, abnormal labs, incontinence, and impaired mobility.<BR/>Observation of wound care on Resident #1 on 02/08/24 at 11:30 a.m. revealed RN A did not wash hands but donned gloves before the start of care. She prepared a clean field on a paper spreader. RN A communicated and positioned Resident #1. She removed old dressing revealing a thin reddish clear dry wound on the left heel. RN A cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean kerlix gauze bandage roll. As RN A was covering the wound with the kerlix gauze, it fell on the floor. She picked it up and continued to use it to cover the wound. RN A did not change or replace the dressing. <BR/>In an interview on 02/08/24 at 11:46 a.m. with RN A, she said he had been employed in the facility for one year. She noted she received infection control training in November 2023. RN A stated she should have washed her hands, performed hand hygiene before retrieving the clean kerlix gauze. She said cross contamination was mixing clean with dirty and the resident could get sick if good infection practice was not followed. <BR/>During an interview with the ADON on 02/08/24 at 4:23 p.m. she acknowledged he was aware of some of the concerns raised about infection control practices. The DON stated she expected the nurses to wash hands and change gloves at appropriate times while providing wound care. <BR/>Review of the facility's hand washing/hand hygiene policy revised August 2019 reflected, The facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and implementation:<BR/>1) <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2) <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .<BR/>3) <BR/>Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>a) <BR/>When hands are visibly soiled and<BR/>b) <BR/>After contact with a resident with infectious diarrhea including, but not limited to infections caused norovirus, salmonella, shigella and C. difficile.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 or 3 Residents (Resident #18, Resident #94, and Resident #125) reviewed for accommodation of needs. <BR/>The facility failed to provide dining tables with the appropriate height to accommodate residents' needs and preferences for Resident #18, Resident #94, and Resident #125.<BR/>This failure could place residents at risk of decreased nutritional intake and weight loss.<BR/>Findings include:<BR/>1. Record review of Resident #18's, undated, face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included senile degeneration of brain (dementia - a group of symptoms that affects memory, thinking and interferes with daily life) and idiopathic scoliosis (an abnormal curvature of the spine). <BR/>Record review of Resident #18's Quarterly MDS, dated [DATE], revealed a BIMS score of score of 1, which indicated (severe impairment). Section G revealed Resident #18 required extensive assistance with transfers and used a wheelchair for mobility . <BR/>2. Record review of Resident #94's, undated, face sheet, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included unspecific dementia (a group of symptoms that affects memory, thinking and interferes with daily life), repeated falls, dizziness and giddiness, fracture of unspecified part of neck and right femur - right hip pinning (broken right hip). <BR/>Record review of Resident #94's Quarterly MDS, dated [DATE] revealed a BIMS score of score of 3, which indicated (severe impairment). Section G revealed Resident #94 required total dependence with transfers and used a wheelchair for mobility. <BR/>3. Record review of Resident #125's, undated, face sheet, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. The resident had diagnoses which included unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life), anterior dislocation of right hip, osteoporosis of right hip (a skeletal disorder characterized by low bone mass leading to bone fragility and increase in bone fracture), generalized muscle weakness, and abnormal posture.<BR/>Record review of Resident #125's admission Assessment MDS, dated [DATE], revealed a BIMS score of score of 2, which indicated (severe impairment). Section G revealed Resident #94 required extensive assistance with transfers and used a wheelchair for mobility. <BR/>In an observation on the 800-hallway dining room, on 07/03/23 at 12:20 PM revealed, Resident #18 was sitting at a table eating her lunch in a low wheelchair. The height of the table was to the resident's upper chest. The resident's plate of food was sitting on the table which required the resident to reach up her arms above her shoulders to get the food off her plate. The resident was eating unassisted. The resident was not interviewable and failed to answer if the table was too high for her . Resident #94 was observed sitting at a table eating her lunch in a low wheelchair. The height of the table was to the resident's neck. The resident's plate of food sat in her lap. The resident was eating unassisted. The resident was not interviewable and failed to answer if the table was too high for her. <BR/>In an observation in the 800-hallway dining room, on 07/06/23 at 11:47 AM revealed, Resident #18 was sitting in a low wheelchair with the height of the table to the resident's chin. The resident's plate of food was on the table, which required the resident to reach up to eat her food. The resident was not interviewable and failed to state if the table was too high. At that time, a CNA came and raised up her wheelchair which changed the height of the table to the resident's upper chest. The resident still had to lift her arms to eat her food. The resident was eating unassisted. Resident #94 was observed sitting at a table eating her lunch in a low wheelchair. The height of the table was to the resident's chin. The resident had her plate of food sitting in her lap. The resident was eating unassisted. The resident was not interviewable and failed to answer if the table was too high for her. <BR/>In an interview on 07/06/23 at 11:48 AM, LVN E said Resident #18's wheelchair could be raised up which helped. Resident #94 always ate with her plate of food in her lap. She was unsure if the height of the tables could be lowered. <BR/>In an observation and interview in the dining room in the north building, on 07/06/23 at 11:55 AM, Resident #125 was observed sitting in a low wheelchair. The height of the table went up to her neck. The resident's plate of food was sitting on the table, which required the resident to reach up to eat her food. The resident was eating unassisted. The State Surveyor asked Resident #125 if the table was too high, she stated probably . <BR/>In an interview on 07/06/23 at 1:37 PM, the DON said the tables were adjustable in the dining rooms. She said it was her expectation that the tables would be placed at the appropriate height as not to be an obstruction to the resident's ability to feed themselves. She said a possible negative outcome would be a dignity issue as the resident's would not be able to feed themselves which could result in a possible decline in functioning and health. A facility policy was requested but the DON stated there was no policy regarding this situation . <BR/>A policy was requested but not provided by the time of exit. The Administrator said there was not a policy that addressed table height of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment prepared by an interdisciplinary team for 6 of 12 residents (Resident #30, Resident #47, Resident #84, Resident #90, Resident #110, and Resident #119) reviewed for care plan timing and revision.<BR/>The facility failed to ensure Resident #30, Resident #47, Resident #84, Resident #90, Resident #110, and Resident #119 had a comprehensive care plan developed and updated within 7 days following the completion of the admission comprehensive assessment. <BR/>This failure could place residents at risk of not having their care plans completed, accurately and timely. <BR/>Findings include: <BR/>1. Record review of Resident #30's face sheet, dated 07/05/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #30's primary diagnosis included senile degeneration of the brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia).<BR/>Record review of Resident #30's Annual MDS Assessment, dated 05/28/2023, revealed the resident had a BIMS score which was blank, which indicated the resident was not able to complete the assessment. <BR/>Record review of Resident #30's care plans revealed the facility developed a care plan on 04/27/2023 and conducted an IDT Care Conference on 04/27/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS dated [DATE].<BR/>2. Record review of Resident #47's face sheet, dated 07/06/2023, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47's primary diagnosis included senile degeneration of the brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia).<BR/>Record review of Resident's #47's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 3 which indicated severe impairment.<BR/>Record review of Resident #47's care plans revealed the facility developed a care plan on 02/15/2023 and conducted an IDT Care Conference on 02/15/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated [DATE].<BR/>3. Record review of Resident #84'sface sheet, dated 07/05/2023, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #84's primary diagnoses included unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), psychoactive disturbance (changes in mood, awareness, thoughts, feelings and behaviors), and anxiety (state of anxiousness). <BR/>Record review of Resident's #84's Annual MDS, dated [DATE], revealed the resident had a BIMS score of 3, which indicated severe impairment.<BR/>Record review of Resident #84's care plans revealed the facility developed a care plan on 02/15/2023 and conducted an IDT Care Conference on 02/23/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated [DATE].<BR/>4. Record review of Resident #90's face sheet, dated 07/05/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #90's primary diagnoses included Pneumonia (an inflammation of the lungs) and seizure Disorder (a sudden uncontrolled burst of electrical activity in the brain).<BR/>Record review of Resident #90's Significant Change MDS Assessment, dated 05/01/2023, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. <BR/>Record review of Resident #90's care plans revealed the facility developed a care plan on 05/16/2023 and conducted an IDT Care Conference on 05/16/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Significant change MDS, dated [DATE].<BR/>5. Record review of Resident #110's face sheet, dated 07/06/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #110's primary diagnosis included senile degeneration of the brain (a decline in cognitive abilities that impacts a person's ability to do everyday activities - dementia).<BR/>Record review of Resident's #110's Annual MDS, dated [DATE] revealed the resident had a BIMS score of 3, which indicated severe impairment.<BR/>Record review of Resident #110's care plans revealed the facility developed a care plan on 06/30/2023 and conducted an IDT Care Conference on 06/08/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Annual MDS, dated [DATE].<BR/>6. Record review of Resident #118's face sheet, dated 07/06/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #118's had diagnoses which included vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), psychotic disturbance (a condition of the mind that results in difficulties determining what is real and what is not real), mood disturbance (a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature), and anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events). <BR/>Record review of Resident's #118's Significant Change in Condition MDS, dated [DATE], revealed the resident had a BIMS score of 1, which indicated severe impairment.<BR/>Record review of Resident #118's care plans revealed the facility developed a care plan on 06/29/2023 and conducted an IDT Care Conference on 06/29/2023. There was no documentation to show the facility developed a care plan or conducted an IDT care conference within 7 days after the Significant Change in Condition MDS, dated [DATE].<BR/>In an interview on 07/05/2023 at 2:55 PM, the MDS Coordinator revealed the care plan schedule and care plans did not go along with the MDS schedule. She said they always conducted the care plans before the MDS was completed and she did not realize their policy stated to complete it after the comprehensive MDS was completed. She said she could see how the failure would place the residents at risk of not having the care plan reflect what the MDS assessment showed, which would result in an inadequate care plan. <BR/>Record review of the facility's care planning policy, dated 2001, and revised in December 2016, titled Care Plans, Comprehensive Person- Centered revealed: The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #30) reviewed for unnecessary psychotropic medications.<BR/>Resident #30 had an order and administered Depakote (an anticonvulsant medication) and Risperdal (antipsychotic) for a diagnosis of unspecified psychosis not due to a substance or known physiological condition, which was not an appropriate indication for use. <BR/>This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms.<BR/>The findings include:<BR/>Record review of Resident #30's face sheet, dated 07/05/2023, revealed a [AGE] year-old female who's most recent admission to the facility was 10/22/2020. The resident had a diagnosis which included unspecified dementia with behavioral disturbance (a group of symptoms that affects memory, thinking and interferes with daily life with behavioral and psychological symptoms such as agitation, anxiety, and psychosis).<BR/>Record review of Resident #30's Physician Order Report, for 06/07/2023 to 07/06/2023, revealed an order for Depakote (divalproex), 500 mg, twice a day, for unspecified psychosis not due to a substance or known physiological condition, with a start date of 05/14/2023. Risperdal (risperidone) 1 mg at bedtime, for unspecified psychosis not due to a substance or known physiological condition, with a start date of 05/14/2023 .<BR/>Record review of Resident #30's Care Plan, last reviewed/revised 06/02/2023, revealed a care plan for Psychotropic Drug Use - Risk for adverse psychotropic side effects., Resident #30 was treated with an antipsychotic. <BR/>Record review of Resident #30's Annual MDS, dated [DATE], revealed in Section C, a Brief Interview of Mental Status was not conducted due to the resident was rarely/never understood., Section N revealed, the resident received antipsychotic medications 7 of 7 days and antipsychotics were received on a routine basis only. <BR/>In an interview on 07/06/2023 at 2:21 PM, the DON said her expectation was for nursing to communicate with the doctor to ensure a medication had a correct diagnosis. She said possible negative outcomes would be a resident would receive an unnecessary medication and experience side effects to the medication . <BR/>Record review of the website drugs.com, https://www.drugs.com/depakote.html, accessed on 07/07/2023, revealed Depakote therapeutic class is an anticonvulsant that can be used as an adjunctive therapy to treat manic episodes associated with bipolar disorder; and revealed, https://www.drugs.com/risperdal.html, Risperdal therapeutic class is an antipsychotic used to treat schizophrenia and bi-polar disorder. <BR/>Record review of the facility's policy titled Antipsychotic Medication Use, dated as revised December 2016, revealed the following [in part]:<BR/>Policy Interpretation and Implementation: <BR/>1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.

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 two of three kitchens reviewed.<BR/>1. The South Building satellite kitchen had expired, unlabeled, and undated food in the walk-in refrigerator.<BR/>2. Dietary Aide H did not demonstrate a sanitary procedure while measuring food holding temperatures and sanitary use of disposable gloves in the North Building satellite kitchen. <BR/>These failures could place residents at risk for foodborne illness and a decline in health status.<BR/>The findings included:<BR/>1. South Building Satellite Kitchen<BR/>Observations on 06/13/22 at 9:00 AM, during the tour of the South Building satellite kitchen, revealed the walk-in refrigerator contained the following:<BR/>- an opened package with what appeared to be meat that was wrapped in cellophane and was dated 06/06/22;<BR/>- an opened plastic bag containing shredded cheese was wrapped with cellophane and was not labeled and dated;<BR/>- an opened bag containing shredded lettuce was undated; the lettuce was brown colored, and the bottom of the bag had collected a brown colored fluid. <BR/>In an interview on 06/13/22 at 9:10 AM, Dietary Aide H said he was not aware the articles of food in the walk-in refrigerator were expired and he would throw them away immediately. <BR/>In an interview on 06/14/22 at 2:30 PM, the Director of Nurses said they seldom used the South Building kitchen. She stated she suspected they had food in it and recognized the fact that food in the refrigerator should be dated and labeled regardless if the satellite kitchen was used or not. <BR/>In an interview on 6/16/2022 at 2:40 PM, the Dietary Manager stated his expectations were that all food in the refrigerator would be dated and properly stored and he as well as the dietary aides are responsible for checking dates and disposing out of date food. <BR/>2. North Building Satellite Kitchen <BR/>During and observation and interview on 6/13/22 at 10:48 AM, while in the North Building satellite kitchen, revealed pans covered with aluminum foil were being removed from hot carts brought from main kitchen in the [NAME] Building. The pans were placed on the steam table. The Dietary Manager stated no cooking was done in the satellite kitchen. He stated all residents were being served using foam containers. He stated regular eating utensils were being used and were washed in the low temperature dish machine with chlorine sanitizer. <BR/>Observation on 06/14/22 at 10:50 AM revealed 2 enclosed food carts from the main kitchen in the [NAME] Building arrived in the North Building satellite kitchen. The pans were covered with aluminum foil. The dietary aides placed the pans on the steam table. <BR/>During an observation and interview on 06/14/22 at 11:00 AM, [NAME] I began taking the food holding temperatures for foods on the left-hand side of the steam table. She stated she worked in the main kitchen in the [NAME] Building and the food temperatures had been taken in the main kitchen prior to being sent to the satellite kitchens in the North and South Buildings. [NAME] I used alcohol preparation pads to sanitize a digital food thermometer. [NAME] I stated she had been employed in the facility for 5 years. She stated she did not work in the North Building and was told to come to the North satellite kitchen and take the steam table food holding temperatures for lunch today. She stated the menu today was salmon croquettes, oven browned potatoes, sweet/green peas, and a brownie for dessert. <BR/>During an interview and observation on 06/14/22 at 11:02 AM, Dietary Aide H stated he had been employed in the facility for a little more than one month. He stated he worked during the breakfast and lunch meals and arrived to work about 6:20 AM. He stated the dietary aides usually checked the steam table food holding temperatures for the North Building and agreed to take over for the cook. Dietary Aide H proceeded to check the temperature of the salmon croquettes, which was measured at 151.3 degrees F. He wiped the food surface of the digital thermometer on a dry rag before measuring the cardiac diet croquettes at 154.9 degrees F. When asked how he cleaned and sanitized the digital thermometer between food items, he stated he wiped them on the rag. When asked where the dry rag came from he replied it had come from the main kitchen. When asked if he had been trained to take steam table food holding temperatures and when and who had trained him, Dietary Aide H stated another dietary employee who no longer worked here had trained him.<BR/>In an interview and observation on 06/14/22 at 11:10 AM, [NAME] I stated there was a stack of clean rags in the main kitchen. The rag appeared to be a piece of a towel that had once been white and was now a dingy light brown-gray color with darker brown and gray stains. [NAME] I was asked if Dietary Aide H was cleaning the digital thermometer correctly, and she said no. [NAME] I told Dietary Aide H to use the alcohol preparation pads that she had placed on the counter and to rub the thermometer food surface for 15 seconds with an alcohol pad. <BR/>During an observation and interview on 06/14/22 at 11:14 AM, Dietary Aide H started using the alcohol preparation pads to clean the digital food thermometer. He used his gloved hand and slid diced oven-browned potatoes, that were skewered onto the food thermometer, back into the pan. Dietary Aide H dropped meal tray diet order slips, held together with a paperclip, on the floor. He picked them up off the floor and placed them on the first tray, on the top of a stack of meal trays. Dietary Aide H said the trays were not used. He did not change his gloves until after he was asked if his gloved hand had touched the floor when he picked up the diet order slips from the floor.<BR/>In an interview on 06/14/22 at 11:20 AM, after the Dietary Manager entered the steam table area, he was asked what would be done after the meal tray diet slips had been on the floor. He said they probably should not be used. He stated they were for the people who lived in the cottages on the grounds/campus. The Dietary Manager instructed Dietary Aide H to serve the North Building meal trays first, and he would print new meal tray diet order slips to replace the ones that had been on the floor. The Dietary Manager stated Dietary Aide I knew how to take steam table holding temperatures and he would be trained again before the end of the day.<BR/>In an interview on 06/16/22 at 2:02 PM, the Dietary Manager stated the new dietary aides were usually trained by the experienced dietary aides, and the dietary manager followed-up with the new dietary aides later and observed them. He stated Dietary Aide H was trained by a dietary aide who worked in the facility for a couple of years, and no longer worked in the facility due to going to nursing school. The Dietary Manager stated sometimes staff did wipe the food thermometer on a paper towel to remove excess food before sanitizing with the alcohol pad, but he had never seen staff wipe it on a rag until Dietary Aide H did it at lunch the other day. He stated he had never seen Dietary Aide H do that before and had watched him take food holding temperatures. He stated Dietary Aide H knew how to do it. The Dietary Manager stated [NAME] I from the main kitchen in the [NAME] Building main kitchen had been sent to help Dietary Aide H with serving the lunch meal that day (06/14/22), and not to take the steam table food holding temperatures. He stated he would look for a policy and procedure for taking food holding temperatures and food thermometer use and sanitization. <BR/>Review of the facility's current employee list with hire dates, provided 6/13/22, revealed Dietary Aide H was hired on 4/27/2022. <BR/>[He had been measuring steam table food holding temperatures prior to serving breakfast and lunch meals for more than one month.]<BR/>Review of the facility's policy for Food Storage Procedure, not dated, revealed the following [in part]:<BR/>B. Cold Storage<BR/> .6. All items should be rotated on shelves so that older items are towards the front. If an item reaches its expiration or use by date it should be discarded immediately. <BR/>Review of the facility's policy and procedure for Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated October 2008, revealed the following [in part]:<BR/>Policy Statement<BR/>Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .<BR/>9. <BR/>Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness.<BR/>10. <BR/>Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper hand washing <BR/>[The facility did not provide a policy and procedure specifically for the sanitization and use of food thermometers as requested on 6/16/22 at 2:02 PM.]<BR/>The U.S. Food and Drug Administration, 2017 Food Code specified:<BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. <BR/>(A) <BR/>FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days.<BR/>4-701.10 Food-Contact Surfaces and Utensils. <BR/>EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. <BR/>Frequency 4-702.11 Before Use After Cleaning. <BR/>UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.

**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 #1) of 2 residents reviewed for infection control practices in that:<BR/> RN A failed to perform hand hygiene, wash hands, change gloves and prevent cross contamination while providing wound care for Resident #1.<BR/>These failures could affect the residents by placing them at risk for the spread of infection. <BR/>Finding included:<BR/>Review of Resident #1's Face Sheet dated 02/08/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of non-pressure ulcers, urinary tract infection, exposure to covid-19, and candidiasis.<BR/>Review of Resident #1's Minimum Data Set (MDS) Assessment undated revealed Resident #1 required total assistance with most activities of daily living (ADLs) and was always incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan dated 08/03/22 revealed he was at risk pressure ulcers and skin breakdown related poor intake, abnormal labs, incontinence, and impaired mobility.<BR/>Observation of wound care on Resident #1 on 02/08/24 at 11:30 a.m. revealed RN A did not wash hands but donned gloves before the start of care. She prepared a clean field on a paper spreader. RN A communicated and positioned Resident #1. She removed old dressing revealing a thin reddish clear dry wound on the left heel. RN A cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean kerlix gauze bandage roll. As RN A was covering the wound with the kerlix gauze, it fell on the floor. She picked it up and continued to use it to cover the wound. RN A did not change or replace the dressing. <BR/>In an interview on 02/08/24 at 11:46 a.m. with RN A, she said he had been employed in the facility for one year. She noted she received infection control training in November 2023. RN A stated she should have washed her hands, performed hand hygiene before retrieving the clean kerlix gauze. She said cross contamination was mixing clean with dirty and the resident could get sick if good infection practice was not followed. <BR/>During an interview with the ADON on 02/08/24 at 4:23 p.m. she acknowledged he was aware of some of the concerns raised about infection control practices. The DON stated she expected the nurses to wash hands and change gloves at appropriate times while providing wound care. <BR/>Review of the facility's hand washing/hand hygiene policy revised August 2019 reflected, The facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and implementation:<BR/>1) <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2) <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .<BR/>3) <BR/>Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>a) <BR/>When hands are visibly soiled and<BR/>b) <BR/>After contact with a resident with infectious diarrhea including, but not limited to infections caused norovirus, salmonella, shigella and C. difficile.

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 two of three kitchens reviewed.<BR/>1. The South Building satellite kitchen had expired, unlabeled, and undated food in the walk-in refrigerator.<BR/>2. Dietary Aide H did not demonstrate a sanitary procedure while measuring food holding temperatures and sanitary use of disposable gloves in the North Building satellite kitchen. <BR/>These failures could place residents at risk for foodborne illness and a decline in health status.<BR/>The findings included:<BR/>1. South Building Satellite Kitchen<BR/>Observations on 06/13/22 at 9:00 AM, during the tour of the South Building satellite kitchen, revealed the walk-in refrigerator contained the following:<BR/>- an opened package with what appeared to be meat that was wrapped in cellophane and was dated 06/06/22;<BR/>- an opened plastic bag containing shredded cheese was wrapped with cellophane and was not labeled and dated;<BR/>- an opened bag containing shredded lettuce was undated; the lettuce was brown colored, and the bottom of the bag had collected a brown colored fluid. <BR/>In an interview on 06/13/22 at 9:10 AM, Dietary Aide H said he was not aware the articles of food in the walk-in refrigerator were expired and he would throw them away immediately. <BR/>In an interview on 06/14/22 at 2:30 PM, the Director of Nurses said they seldom used the South Building kitchen. She stated she suspected they had food in it and recognized the fact that food in the refrigerator should be dated and labeled regardless if the satellite kitchen was used or not. <BR/>In an interview on 6/16/2022 at 2:40 PM, the Dietary Manager stated his expectations were that all food in the refrigerator would be dated and properly stored and he as well as the dietary aides are responsible for checking dates and disposing out of date food. <BR/>2. North Building Satellite Kitchen <BR/>During and observation and interview on 6/13/22 at 10:48 AM, while in the North Building satellite kitchen, revealed pans covered with aluminum foil were being removed from hot carts brought from main kitchen in the [NAME] Building. The pans were placed on the steam table. The Dietary Manager stated no cooking was done in the satellite kitchen. He stated all residents were being served using foam containers. He stated regular eating utensils were being used and were washed in the low temperature dish machine with chlorine sanitizer. <BR/>Observation on 06/14/22 at 10:50 AM revealed 2 enclosed food carts from the main kitchen in the [NAME] Building arrived in the North Building satellite kitchen. The pans were covered with aluminum foil. The dietary aides placed the pans on the steam table. <BR/>During an observation and interview on 06/14/22 at 11:00 AM, [NAME] I began taking the food holding temperatures for foods on the left-hand side of the steam table. She stated she worked in the main kitchen in the [NAME] Building and the food temperatures had been taken in the main kitchen prior to being sent to the satellite kitchens in the North and South Buildings. [NAME] I used alcohol preparation pads to sanitize a digital food thermometer. [NAME] I stated she had been employed in the facility for 5 years. She stated she did not work in the North Building and was told to come to the North satellite kitchen and take the steam table food holding temperatures for lunch today. She stated the menu today was salmon croquettes, oven browned potatoes, sweet/green peas, and a brownie for dessert. <BR/>During an interview and observation on 06/14/22 at 11:02 AM, Dietary Aide H stated he had been employed in the facility for a little more than one month. He stated he worked during the breakfast and lunch meals and arrived to work about 6:20 AM. He stated the dietary aides usually checked the steam table food holding temperatures for the North Building and agreed to take over for the cook. Dietary Aide H proceeded to check the temperature of the salmon croquettes, which was measured at 151.3 degrees F. He wiped the food surface of the digital thermometer on a dry rag before measuring the cardiac diet croquettes at 154.9 degrees F. When asked how he cleaned and sanitized the digital thermometer between food items, he stated he wiped them on the rag. When asked where the dry rag came from he replied it had come from the main kitchen. When asked if he had been trained to take steam table food holding temperatures and when and who had trained him, Dietary Aide H stated another dietary employee who no longer worked here had trained him.<BR/>In an interview and observation on 06/14/22 at 11:10 AM, [NAME] I stated there was a stack of clean rags in the main kitchen. The rag appeared to be a piece of a towel that had once been white and was now a dingy light brown-gray color with darker brown and gray stains. [NAME] I was asked if Dietary Aide H was cleaning the digital thermometer correctly, and she said no. [NAME] I told Dietary Aide H to use the alcohol preparation pads that she had placed on the counter and to rub the thermometer food surface for 15 seconds with an alcohol pad. <BR/>During an observation and interview on 06/14/22 at 11:14 AM, Dietary Aide H started using the alcohol preparation pads to clean the digital food thermometer. He used his gloved hand and slid diced oven-browned potatoes, that were skewered onto the food thermometer, back into the pan. Dietary Aide H dropped meal tray diet order slips, held together with a paperclip, on the floor. He picked them up off the floor and placed them on the first tray, on the top of a stack of meal trays. Dietary Aide H said the trays were not used. He did not change his gloves until after he was asked if his gloved hand had touched the floor when he picked up the diet order slips from the floor.<BR/>In an interview on 06/14/22 at 11:20 AM, after the Dietary Manager entered the steam table area, he was asked what would be done after the meal tray diet slips had been on the floor. He said they probably should not be used. He stated they were for the people who lived in the cottages on the grounds/campus. The Dietary Manager instructed Dietary Aide H to serve the North Building meal trays first, and he would print new meal tray diet order slips to replace the ones that had been on the floor. The Dietary Manager stated Dietary Aide I knew how to take steam table holding temperatures and he would be trained again before the end of the day.<BR/>In an interview on 06/16/22 at 2:02 PM, the Dietary Manager stated the new dietary aides were usually trained by the experienced dietary aides, and the dietary manager followed-up with the new dietary aides later and observed them. He stated Dietary Aide H was trained by a dietary aide who worked in the facility for a couple of years, and no longer worked in the facility due to going to nursing school. The Dietary Manager stated sometimes staff did wipe the food thermometer on a paper towel to remove excess food before sanitizing with the alcohol pad, but he had never seen staff wipe it on a rag until Dietary Aide H did it at lunch the other day. He stated he had never seen Dietary Aide H do that before and had watched him take food holding temperatures. He stated Dietary Aide H knew how to do it. The Dietary Manager stated [NAME] I from the main kitchen in the [NAME] Building main kitchen had been sent to help Dietary Aide H with serving the lunch meal that day (06/14/22), and not to take the steam table food holding temperatures. He stated he would look for a policy and procedure for taking food holding temperatures and food thermometer use and sanitization. <BR/>Review of the facility's current employee list with hire dates, provided 6/13/22, revealed Dietary Aide H was hired on 4/27/2022. <BR/>[He had been measuring steam table food holding temperatures prior to serving breakfast and lunch meals for more than one month.]<BR/>Review of the facility's policy for Food Storage Procedure, not dated, revealed the following [in part]:<BR/>B. Cold Storage<BR/> .6. All items should be rotated on shelves so that older items are towards the front. If an item reaches its expiration or use by date it should be discarded immediately. <BR/>Review of the facility's policy and procedure for Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated October 2008, revealed the following [in part]:<BR/>Policy Statement<BR/>Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness.<BR/>Policy Interpretation and Implementation<BR/>1. <BR/>All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .<BR/>9. <BR/>Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness.<BR/>10. <BR/>Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper hand washing <BR/>[The facility did not provide a policy and procedure specifically for the sanitization and use of food thermometers as requested on 6/16/22 at 2:02 PM.]<BR/>The U.S. Food and Drug Administration, 2017 Food Code specified:<BR/>Food storage/labelling<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. <BR/>(A) <BR/>FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days.<BR/>4-701.10 Food-Contact Surfaces and Utensils. <BR/>EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED. <BR/>Frequency 4-702.11 Before Use After Cleaning. <BR/>UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.

**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 #1) of 2 residents reviewed for infection control practices in that:<BR/> RN A failed to perform hand hygiene, wash hands, change gloves and prevent cross contamination while providing wound care for Resident #1.<BR/>These failures could affect the residents by placing them at risk for the spread of infection. <BR/>Finding included:<BR/>Review of Resident #1's Face Sheet dated 02/08/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of non-pressure ulcers, urinary tract infection, exposure to covid-19, and candidiasis.<BR/>Review of Resident #1's Minimum Data Set (MDS) Assessment undated revealed Resident #1 required total assistance with most activities of daily living (ADLs) and was always incontinent of bowel and bladder. <BR/>Review of Resident #1's care plan dated 08/03/22 revealed he was at risk pressure ulcers and skin breakdown related poor intake, abnormal labs, incontinence, and impaired mobility.<BR/>Observation of wound care on Resident #1 on 02/08/24 at 11:30 a.m. revealed RN A did not wash hands but donned gloves before the start of care. She prepared a clean field on a paper spreader. RN A communicated and positioned Resident #1. She removed old dressing revealing a thin reddish clear dry wound on the left heel. RN A cleansed the wound with normal saline and patted dry. She did not wash hands, change gloves, or perform hand hygiene before retrieving the clean kerlix gauze bandage roll. As RN A was covering the wound with the kerlix gauze, it fell on the floor. She picked it up and continued to use it to cover the wound. RN A did not change or replace the dressing. <BR/>In an interview on 02/08/24 at 11:46 a.m. with RN A, she said he had been employed in the facility for one year. She noted she received infection control training in November 2023. RN A stated she should have washed her hands, performed hand hygiene before retrieving the clean kerlix gauze. She said cross contamination was mixing clean with dirty and the resident could get sick if good infection practice was not followed. <BR/>During an interview with the ADON on 02/08/24 at 4:23 p.m. she acknowledged he was aware of some of the concerns raised about infection control practices. The DON stated she expected the nurses to wash hands and change gloves at appropriate times while providing wound care. <BR/>Review of the facility's hand washing/hand hygiene policy revised August 2019 reflected, The facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Policy Interpretation and implementation:<BR/>1) <BR/>All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.<BR/>2) <BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .<BR/>3) <BR/>Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:<BR/>a) <BR/>When hands are visibly soiled and<BR/>b) <BR/>After contact with a resident with infectious diarrhea including, but not limited to infections caused norovirus, salmonella, shigella and C. difficile.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured, stored, and labeled in accordance with currently accepted professional principles for 2 of 4 medication carts: <BR/>A. Medication cart #1 had intravenous heparin, intravenous tubing, air freshener spray, Lysol spray, drug destruction liquid , (a liquid to destroy medications of all routes of administration) and pudding stored together in the bottom drawer. The drawers of the cart had oral medications, nasal inhalants, and oral inhalants all stored in one compartment<BR/>B. The bottom drawer of the Medication cart #1, contained a soiled package of Intravenous tubing, a soiled bottle of medication destruction liquid and loose pills. The bottom drawer was soiled and covered with a sticky, dried brown substance. <BR/>C. Medication cart #2 had oral medications in individual bottles, nasal inhalant medications, and oral inhalant medication stored together in a plastic zip lock bag. A one-half gallon bottle of oral drug destruction liquid was stored in the bottom of the cart. <BR/>These failure could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications, medication via an incorrect route or ineffective therapeutic dosage and possible contamination by another agent or medication. <BR/>The findings include:<BR/>On 06/15/22 at 9:28 AM an observation of Medication cart #1 revealed the drawers of the cart had oral medications, nasal inhalants, and oral inhalants all stored in one compartment together. Medication cart #1 also had Lysol disinfectant spray, vanilla pudding, one package of labeled, unused heparin flush syringes, and a package of soiled intravenous tubing stored in the drawer with a bottle of drug destruction liquid. There were 2 unidentified yellow pills laying loose in the bottom of the drawer. The bottom of the drawer and the label and side of the drug destruction liquid container were soiled with a dried, brown sticky substance. <BR/>On 06 /15/22 at 9:35 AM an observation of Medication Cart #2 revealed bottle prescription and over the counter medications (nasal inhalants, oral inhalant, and oral medications) all belonging to one resident were stored together in a plastic bag. The half-gallon bottle of drug destruction liquid was stored in the bottom drawer with two loose, yellow pills laying there . <BR/> An interview on 06/15/22 at 9:42 AM with LVN B revealed she had accepted Medication cart #1 when she came on duty. She stated she had used the drug destruction liquid during the medication pass and should have cleaned the cart when she accepted it. She stated storing pudding, disinfectant spray, loose pills, and oral inhalers of different routes of administration in the same compartment could result in the medications being given via the wrong route or result in cross contamination and the spread of infection. She stated it was each nurse's responsibility, during their shift, to see that med carts were kept clean and medications of different routes were not stored in the same compartment She stated the medications and the soiled package of tubing should not be used due to possible contamination by another substance. <BR/>An interview on 06/15/22at 10:00 AM with LVN C, who was responsible for medication cart #2 revealed she knew that carts should be cleaned, and medications of different routes should not be stored in the same compartment. She stated storing medications together could result in the wrong route of administration or contamination by another substance. She stated each nurse was responsible for keeping the medication cart that they were assigned to clean and that she would not use intravenous tubing in soiled packaging, she would discard it immediately. She stated medication carts shoudlbe cleaned when they became soiled. She stated that she understood chemicals should not be stored with food and medications, and the drug destruction liquid should probably be stored in a different location. <BR/>In an interview on at 10:00 AM ADON F stated under no circumstances should pudding, disinfectant spray, loose pills, and oral inhalers for different residents be in the same compartment. She stated those items should be stored separately due to the risk of cross contamination and the spread of infection. She stated it was each nurse's responsibility to see that med carts were kept clean, and medications of different routes were not stored in the same compartment during their shift. She stated the heparin injectable syringes and the loose pills and the soiled package of tubing should be discarded immediately. She stated she did not monitor the med carts for cleanliness, but she would begin to do so. <BR/>In an interview on at 11:10 AM the DON revealed it was each nurse's responsibility and her expectation that medication carts be kept clean, and drugs should be stored according to the appropriate route and use. She stated storing medications of different routes and chemical agents could cause the spread of infections and unwanted medical side effects. She stated it was her expectation that nurses be responsible for cleaning their own carts and keep the medications stored according to the route they are administered. She stated ADON F trusted the LVN's to monitor themselves and keep the carts clean, but the ADON'S would be responsible for monitoring to ensure the carts were kept clean on a regular basis from this point forward. <BR/>Record review of the facility policy titled Storage of Medications dated revised April 2007, revealed in part:<BR/>2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. <BR/>5. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from regular medications. <BR/>8. Drugs shall be stored in an orderly manner in cabinets, rooms, refrigerators, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility mixing medications of several residents. <BR/>The policy did not address medications of different routes being kept separate. <BR/>Review of the SDS (safety Data Sheet) for the drug destruction liquid provided by the DON revealed in part:<BR/>Trade Name: Rx destroyer <BR/>2. Hazardous Identification. - Classification of the substance or mixture: The product does not need classification according to OSHA Hicom Standard 29 CFR paragraph (d) of Sec1910.122(g) and GHS (Globally Harmonized System Revision 3) <BR/>NFPA Rating (National Fire Protection Association) scale (0 - 4). HMIS H<BR/>Health + 1<BR/>Fire+0<BR/>Reactivity = 0 <BR/>HMIS Rating (Hazardous Materials Identification) = 1 (low risk for health) <BR/>First aide skin contact: generally, the product does not irritate the skin, After eye contact: rinse open eyes for several minutes under running water.<BR/>If ingested and symptoms occur notify the physician. <BR/>The usual precautionary measures for handling chemicals should be used. No hand protection required.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured, stored, and labeled in accordance with currently accepted professional principles for 2 of 4 medication carts: <BR/>A. Medication cart #1 had intravenous heparin, intravenous tubing, air freshener spray, Lysol spray, drug destruction liquid , (a liquid to destroy medications of all routes of administration) and pudding stored together in the bottom drawer. The drawers of the cart had oral medications, nasal inhalants, and oral inhalants all stored in one compartment<BR/>B. The bottom drawer of the Medication cart #1, contained a soiled package of Intravenous tubing, a soiled bottle of medication destruction liquid and loose pills. The bottom drawer was soiled and covered with a sticky, dried brown substance. <BR/>C. Medication cart #2 had oral medications in individual bottles, nasal inhalant medications, and oral inhalant medication stored together in a plastic zip lock bag. A one-half gallon bottle of oral drug destruction liquid was stored in the bottom of the cart. <BR/>These failure could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications, medication via an incorrect route or ineffective therapeutic dosage and possible contamination by another agent or medication. <BR/>The findings include:<BR/>On 06/15/22 at 9:28 AM an observation of Medication cart #1 revealed the drawers of the cart had oral medications, nasal inhalants, and oral inhalants all stored in one compartment together. Medication cart #1 also had Lysol disinfectant spray, vanilla pudding, one package of labeled, unused heparin flush syringes, and a package of soiled intravenous tubing stored in the drawer with a bottle of drug destruction liquid. There were 2 unidentified yellow pills laying loose in the bottom of the drawer. The bottom of the drawer and the label and side of the drug destruction liquid container were soiled with a dried, brown sticky substance. <BR/>On 06 /15/22 at 9:35 AM an observation of Medication Cart #2 revealed bottle prescription and over the counter medications (nasal inhalants, oral inhalant, and oral medications) all belonging to one resident were stored together in a plastic bag. The half-gallon bottle of drug destruction liquid was stored in the bottom drawer with two loose, yellow pills laying there . <BR/> An interview on 06/15/22 at 9:42 AM with LVN B revealed she had accepted Medication cart #1 when she came on duty. She stated she had used the drug destruction liquid during the medication pass and should have cleaned the cart when she accepted it. She stated storing pudding, disinfectant spray, loose pills, and oral inhalers of different routes of administration in the same compartment could result in the medications being given via the wrong route or result in cross contamination and the spread of infection. She stated it was each nurse's responsibility, during their shift, to see that med carts were kept clean and medications of different routes were not stored in the same compartment She stated the medications and the soiled package of tubing should not be used due to possible contamination by another substance. <BR/>An interview on 06/15/22at 10:00 AM with LVN C, who was responsible for medication cart #2 revealed she knew that carts should be cleaned, and medications of different routes should not be stored in the same compartment. She stated storing medications together could result in the wrong route of administration or contamination by another substance. She stated each nurse was responsible for keeping the medication cart that they were assigned to clean and that she would not use intravenous tubing in soiled packaging, she would discard it immediately. She stated medication carts shoudlbe cleaned when they became soiled. She stated that she understood chemicals should not be stored with food and medications, and the drug destruction liquid should probably be stored in a different location. <BR/>In an interview on at 10:00 AM ADON F stated under no circumstances should pudding, disinfectant spray, loose pills, and oral inhalers for different residents be in the same compartment. She stated those items should be stored separately due to the risk of cross contamination and the spread of infection. She stated it was each nurse's responsibility to see that med carts were kept clean, and medications of different routes were not stored in the same compartment during their shift. She stated the heparin injectable syringes and the loose pills and the soiled package of tubing should be discarded immediately. She stated she did not monitor the med carts for cleanliness, but she would begin to do so. <BR/>In an interview on at 11:10 AM the DON revealed it was each nurse's responsibility and her expectation that medication carts be kept clean, and drugs should be stored according to the appropriate route and use. She stated storing medications of different routes and chemical agents could cause the spread of infections and unwanted medical side effects. She stated it was her expectation that nurses be responsible for cleaning their own carts and keep the medications stored according to the route they are administered. She stated ADON F trusted the LVN's to monitor themselves and keep the carts clean, but the ADON'S would be responsible for monitoring to ensure the carts were kept clean on a regular basis from this point forward. <BR/>Record review of the facility policy titled Storage of Medications dated revised April 2007, revealed in part:<BR/>2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. <BR/>5. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from regular medications. <BR/>8. Drugs shall be stored in an orderly manner in cabinets, rooms, refrigerators, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility mixing medications of several residents. <BR/>The policy did not address medications of different routes being kept separate. <BR/>Review of the SDS (safety Data Sheet) for the drug destruction liquid provided by the DON revealed in part:<BR/>Trade Name: Rx destroyer <BR/>2. Hazardous Identification. - Classification of the substance or mixture: The product does not need classification according to OSHA Hicom Standard 29 CFR paragraph (d) of Sec1910.122(g) and GHS (Globally Harmonized System Revision 3) <BR/>NFPA Rating (National Fire Protection Association) scale (0 - 4). HMIS H<BR/>Health + 1<BR/>Fire+0<BR/>Reactivity = 0 <BR/>HMIS Rating (Hazardous Materials Identification) = 1 (low risk for health) <BR/>First aide skin contact: generally, the product does not irritate the skin, After eye contact: rinse open eyes for several minutes under running water.<BR/>If ingested and symptoms occur notify the physician. <BR/>The usual precautionary measures for handling chemicals should be used. No hand protection required.