Based on observations, interviews, record review, and review of a facility policy titled, CONTROLLED MEDICATIONS, the facility failed to ensure licensed nurses implemented the facility's system of accounting for narcotic medications when Resident Identifier (RI) #s 53, 70, and 8's narcotics were removed from the medication carts for administration. This affected three of 13 residents whose narcotic medication counts were verified and was observed on two of seven total medication carts in the facility. Findings Include: A review of a facility policy CONTROLLED MEDICATIONS, with an effective date of 7/1/09, revealed: . CONTROLLED MEDICATIONS . Policy . Medications included in the . classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility . D. When a controlled medication is administered, the licensed nurse . immediately enters . on the accountability record . On 1/08/2020 at 9:52 a.m., the surveyor and Employee Identifier (EI) #2, Registered Nurse (RN), checked narcotic counts on the A2 Cart 2 (medication cart). RI #70's Tramadol medication card contained 53 tablets; however, the INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD for Tramadol to be given twice a day indicated there should have been 54. The last tablet signed out was dated 1/7 at 9:00 PM. RI #8's Lyrica medication card contained no capsules; however the INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD for Lyrica to be given every twelve hours indicated there should have been one. The last capsule signed out was dated 1/7 at 9:00 PM. On 1/08/2020 at 10:03 a.m., the surveyor and EI #2 checked narcotic counts on the A2 Cart 1. RI #53's Norco medication card contained 36 tablets; however, the INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD for Norco to be given three times a day indicated there should have been 37. The last tablet signed out was dated 1/7 at 9:00 PM. RI #53's Ativan medication count was also off by one. The medication card contained 56, but the INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD for Ativan to be given every twelve hours indicated there should have been 57. On 1/08/2020 at 12:14 p.m., RI #70 confirmed he/she had received Tramadol earlier that morning. On 1/08/2020 at 12:17 p.m., RI #8 confirmed receiving his/her Lyrica earlier that morning. On 1/08/2020 at 12:22 p.m., RI #53 confirmed receiving his/her morning medications. On 01/08/20 at 10:08 a.m., the surveyor conducted an interview with EI #2, RN. EI #2 was asked if she gave RI #70, 8, and 53 his/her medications. EI #2 stated yes. EI #2 was asked to describe the process for administering narcotic medications. EI #2 stated when you pop the medications out of the medication card, they should be signed off on the narcotic log sheet. EI #2 was then asked after she pulled the narcotic medications for RI #70, 8, and 53 earlier that morning, if she signed the narcotic log sheets before administering the medications to the residents. EI #2 stated no. EI #2 said she had not followed the the facility's policy for when a dose of controlled narcotics was removed. EI #2 was asked what is the potential concern of not having a corrected narcotic control count in the narcotic log records. EI #2 stated someone could have taken the medication. On 01/08/20 at 05:33 p.m., the surveyor conducted an interview with EI #4, RN/DON (Director of Nursing). EI #4 was asked what the facility policy stated regarding removing a controlled substance from a medication cart. EI #4 stated when a controlled medication is administered, the nurse administering the medication immediately signs the narcotic log accountability record when the medication is pulled. The surveyor asked EI #4 if EI #2 followed the facility's policy on removing a controlled substance from the medication carts on 01/08/2020. EI #4 stated no, she did not sign the narcotic accountability log after pulling narcotic medication from medication cart.

Based on observations, interview, review of facility policies titled, Refrigerators and Freezers, Food Receiving and Storage, and review of the 2017 U.S. (United States) Public Health Service Food Code, the facility failed to ensure: 1. open food items were labeled with a use by date or preparation date prior to storage in the walk-in cooler; and 2. flour and meal were labeled and dated. These failures had the potential to affect all residents who received meals from the kitchen. Findings Include: The facility policy titled, Refrigerators and Freezers, with a last revised date of 12/2008, included, . This facility will ensure . Use by dates will be completed with expiration dates on all prepared food in refrigerators . A review of the 2017 U.S. Public Health Service Food Code revealed: . 3-5 LIMITATION OF GROWTH OF ORGANISMS OF PUBLIC HEALTH CONCERN . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (B) . FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES . The facility policy titled, Food Receiving and Storage, with a last revised date of 12/2008, included, . Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date) . On 1/06/2020 at 12:47 p.m., the surveyor and Employee Identifier (EI) #1, Dietary Manager (DM), observed four large prepared salads on a glass plate consisting of spring salad mix, cheese and tomatoes covered with clear plastic wrap, not labeled with a preparation date or use by date in the walk- in cooler. On 1/08/2020 at 11:03 a.m., the surveyor and EI #1 observed the flour and meal container bin not labeled and not dated with a use by date. On 1/08/2020 at 5:00 p.m., an interview was conducted with EI #1, the DM. EI #1 was asked if the four salads with spring mix lettuce, cheese and tomatoes were labeled with a preparation date and use by date. EI #1 stated no they were not dated. EI #1 was then asked if the salads should be dated with a preparation date and a use by date. EI #1 stated yes the salads should have been dated. EI #1 was asked what was the potential harm in having salads in the refrigerator not labeled with a use by date. EI #1 stated that it could have made the patients sick if given to a resident, as well as have Listeria and Salmonella. EI #1 was then asked should the flour and meal be labeled and dated. EI #1 stated yes. EI #1 was asked why should the flour be labeled and dated. EI #1 stated it could be outdated and we don't know when it came. EI #1 was asked what is the potential harm in the flour and meal not being labeled and dated. EI#1 stated the resident could get sick. EI #1 was then asked what was their policy on dating refrigerated items. EI # 1 stated the item should be dated with the date it goes into the refrigerator and with the discard date. EI# 1 was asked what is their policy on dating the flour and meal. EI #1 stated it should be dated when you open it and put it in the container.