**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of policy titled, Hand Hygiene, the facility failed to ensure a licensed staff member sanitized her hands after administering medication to Resident Identifier (RI ) #63 and before entering the medication cart to retrieve additional medications. This deficient practice affected RI #63, one of seven residents observed during medication administration. Findings include: A review of the facility policy titled, Hand Hygiene, with an effective date of December 01, 2009, revealed the following: . PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aid in the prevention of the transmission of infections. II. Hand Sanitizer If hands are not visibly soiled, use an alcohol-based hand sanitizer for routinely decontaminating hands . RI #63 was admitted to the facility on [DATE], with a diagnosis of Depression. On 6/12/19 at 5:09 p.m., during medication administration, the surveyor observed Licensed Practical Nurse (LPN), Employer Identifier (EI) #3, take medications into RI #63's room and give him/her the medicine cup. RI #63 asked for a PRN (as needed) medication. RI #63 gave the medication cup back to EI #3 with the medication still in it. EI #3 returned to the medication cart and entered it to obtain the additional medication requested by RI #63 without sanitizing her hands. On 6/12/19 at 6:16 p.m., the surveyor conducted an interview with EI #3. The surveyor asked EI #3 why should hand sanitizer be used. EI #3 said for germs. The surveyor asked EI #3 when should hand sanitizer be used after giving medications. EI #3 said before going back into the medication cart. EI #3 said if hands were not sanitized, something (germs) could be spread from one person to another. On 6/13/19 at 10:51 a.m., the surveyor conducted an interview with EI #4, Registered Nurse (RN) Unit Manager and Infection Control Nurse. The surveyor asked what were the procedures for handwashing after giving a medication. EI #4 said wash hands prior to going into the room, depending on what medication was given and when coming out of the room. The surveyor asked EI #4 what were the procedures for handwashing when a nurse entered the resident's room with the medications, then left the room with the medications after a resident touched the medication cup, returned to the medication cart and opened it up to retrieve a medication. EI #4 said what she wished the nurse had done was allowed the resident to take the medications, then returned to the medication cart empty handed to retrieve the requested medication. EI #4 said the nurse was not to go back to the medication cart with something the resident touched and place it on the cart. The surveyor asked EI #4 when should hands have been sanitized. EI #4 said they should have been washed before going into the room, after leaving the room and before going into the medication cart. The surveyor asked EI #4 what were the concerns with this. EI #4 said if she touched anything in the medication cart, her hands were not clean and if the resident touched the cup, EI #3 should have sanitized her hands before entering the medication cart. The surveyor asked EI #4 would this be a way of spreading germs or an infection. EI #4 said it did have that potential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident Indentifer (RI) #30's care plan approach to keep the lift chair remote out of reach was implemented on 6/13/18. This affected one of 16 residents for whom care plans were reviewed. Findings include: RI #30 was readmitted to the facility on [DATE] with diagnoses of Dementia and Muscle Weakness. Review of a Resident Incident Report, dated 12/15/2017, indicated RI #30 was found on the floor in front of his/her lift chair. Review of RI #30's fall care plan, with a start date of 12/14/2016, revealed a new intervention was added to the care plan on 12/17/2017 to keep the lift chair remote out of the resident's reach to help prevent dumping him/herself onto the floor. Review of an undated document titled CERTIFIED NURSING ASSISTANT INFORMATION also revealed a care approach dated 12/17/2017 to keep the lift chair remote out of the resident's reach to help prevent dumping him/herself onto the floor. A second Resident Incident Report for RI #30, dated 06/13/2018, documented RI #30 was found on the floor in front of his/her lift chair. Departmental Notes included with the facility's fall investigation documented the following: . 6/13/2018 . RESIDENT WAS FOUND LYING ON THE FLOOR IN FRONT OF (his/her) RECLINER. REMOTE TO RECLINER IN CHAIR. Employee Identifier (EI) #1, Certified Nursing Assistant (CNA) was interviewed on 07/03/2018 at 8:41 AM. EI #1 recalled finding RI #30 on the floor in his/her room in June 2018. EI #1 said RI #30 had been in his/her recliner, but when she found RI #30, he/she was on the floor in front of the recliner with the remote control (to the lift chair) in his/her hand playing with it. According to EI #1, the recliner was tilted up and the resident slid out of it. When asked how CNAs know what care to provide to residents, such as keeping the chair remote out of the resident's reach, EI #1 said they have guides (CERTIFIED NURSING ASSISTANT INFORMATION) taped inside each resident's closet. When asked how long CNAs had been required to keep the remote away from RI #30 when in the recliner, EI #1 said she did not know the exact time frame, but pretty much since the resident had the recliner. EI #1 said that was already in place prior to the 6/2018 fall. EI #1 said it was important to follow the care guides for the safety of the residents. On 07/03/18 at 9:32 AM, EI #2, the Care Plan Coordinator was interviewed. When asked when the intervention to keep the lift chair remote out of resident's reach added to the care plan for RI #30, EI #2 stated 12/17/17. She stated the approach was added to the care plan after the resident sustained a fall. EI #2 explained staff should keep the remote out of the resident's reach. On 07/03/18 at 9:49 AM, EI #3, Registered Nurse (RN) Unit Manger, said she had updated RI #30's care plan after the 12/2017 fall to include an approach to keep the lift chair remote out of the resident's reach. EI #3 said RI #30 was forgetful and liked to play with the remote, and in reviewing the fall, it was determined the cause of the fall in December 2017 was that he/she lifted the chair too high and fell out of it. After reviewing the information for the 6/2018 fall, EI #3 said the fall occurred because RI # 30 raised the chair up with the remote and slid out of it. Based on information provided to EI #3, she determined the resident had the lift chair remote in his/her hand at the time he/she was found on the floor. EI #3 said if the CNA had reviewed the guide in the closet, she would have known to keep the remote out of the resident's reach, but that was not done. When asked why it was important for staff to follow the care plan/care guide, EI #3 said to make sure they know what they are doing; it is an instruction sheet for providing care to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #30 did not sustain an avoidable fall on 6/13/18 when staff placed his/her lift chair remote in reach. This affected one of four residents reviewed for falls. Findings include: RI #30 was readmitted to the facility on [DATE] with diagnoses of Dementia and Muscle Weakness. Review of a Resident Incident Report, dated 12/15/2017, indicated RI #30 was found on the floor in front of his/her lift chair. Departmental Notes included with the facility's fall investigation documented the following: . 12/15/2017 . RESIDENT IN FLOOR IN FRONT OF RECLINER ON (his/her) BACK WITH ELECTRIC CHAIR IN THE RAISED POSITION . Review of RI #30's fall care plan, with a start date of 12/14/2016, revealed a new intervention was added to the care plan on 12/17/2017 to keep the lift chair remote out of the resident's reach to help prevent dumping him/herself onto the floor. Review of an undated document titled CERTIFIED NURSING ASSISTANT INFORMATION also revealed a care approach dated 12/17/2017 to keep the lift chair remote out of the resident's reach to help prevent dumping him/herself onto the floor. A second Resident Incident Report for RI #30, dated 06/13/2018, documented RI #30 was found on the floor in front of his/her lift chair. Departmental Notes included with the facility's fall investigation documented the following: . 6/13/2018 . RESIDENT WAS FOUND LYING ON THE FLOOR IN FRONT OF (his/her) RECLINER. REMOTE TO RECLINER IN CHAIR. Employee Identifier (EI) #1, Certified Nursing Assistant (CNA) was interviewed on 07/03/2018 at 8:41 AM. EI #1 recalled finding RI #30 on the floor in his/her room in June 2018. EI #1 said RI #30 had been in his/her recliner, but when she found RI #30, he/she was on the floor in front of the recliner with the remote control (to the lift chair) in his/her hand playing with it. According to EI #1, the recliner was tilted up and the resident slid out of it. When asked how CNAs know what care to provide to residents, such as keeping the chair remote out of the resident's reach, EI #1 said they have guides (CERTIFIED NURSING ASSISTANT INFORMATION) taped inside each resident's closet. When asked how long CNAs have been required to keep the remote away from RI #30 when in the recliner, EI #1 said she did not know the exact time frame, but pretty much since the resident had the recliner. EI #1 said that was already in place prior to the 6/2018 fall. EI #1 said it was important to follow the care guides for the safety of the residents. On 07/03/18 at 9:49 AM, EI #3, Registered Nurse (RN) Unit Manger, said she had updated RI #30's care plan after the 12/2017 fall to include an approach to keep the lift chair remote out of the resident's reach. EI #3 said RI #30 was forgetful and liked to play with the remote, and in reviewing the fall, it was determined the cause of the fall in December 2017 was that he/she lifted the chair too high and fell out of it. After reviewing the information for the 6/2018 fall, EI #3 said the fall occurred because RI # 30 raised the chair up with the remote and slid out of it. Based on information provided to EI #3, she determined the resident had the lift chair remote in his/her hand at the time he/she was found on the floor. EI #3 said if the CNA had reviewed the guide in the closet, she would have known to keep the remote out of the resident's reach, but that was not done. When asked if this fall could have been avoided, EI #3 said yes, it could have been avoided by staff reading the sheet that was provided to to them and providing the care the resident required. When asked why it was important for staff to follow the care plan/care guide, EI #3 said to make sure they know what they are doing; it is an instruction sheet for providing care to the resident.

Based on observations, interview, and review of the facility's policy titled Food Preparation Guidelines, the facility failed to ensure: 1) packaged lettuce was not stored past the manufacturers best by date; and 2) milk was not held at room temperature throughout meal service, resulting in a temperature exceeding 41 degrees F at the time it was served to residents. This had the potential to affect all 99 of 99 residents receiving meals in the facility. Findings include: 1) On 7/01/18 at 8:24 AM, an opened bag of lettuce stamped with a manufacturer's date of: Best if Used By 06/27/18 was observed in the walk-in cooler. Some of the lettuce leaves appeared wilted with a slight brown discoloration. A second unopened bag with the same date was also observed in the cooler. During an interview with Employee Identifier (EI) #4, the Dietary Manager (DM), on 07/03/2018 at 7:46 AM, EI #4 was asked what the facility's policy was in regard's to the manufacturer's best by dates. EI #4 said staff should be going by those dates and once exceeded discard them. EI #4 said the staff member that finds an item that exceeds the best by date would be responsible for discarding it. When asked what potential harm could occur if lettuce was stored past the best by date on the packaging, EI #4 said it would not taste good, look good, and could make some of the residents sick. 2) Review of the facility's policy titled Food Preparation Guideline, effective 08/15/2009, revealed the following: . PROCESS: . g. Food should be protected from contamination, while being stored, prepared and served to residents. To prevent growth of pathogenic organisms: . 1. Refrigerated at or below 41 (degrees) F (Fahrenheit) . On 07/02/2018 at 11:02 AM, it was noted cartons of milk were out on trays (at room temperature) without any ice during meal service. At 11:40 AM, a carton of milk on the counter measured 50 degrees F at the time of service. The DM verified the temperature of the milk, but continued to allow the dietary staff to serve it. Staff began plating the last cart at 11:50 AM and the last resident was served at 11:52 AM. At that time, EI #4 checked the milk temperature again, which measured 58 degrees F. During an interview with Employee Identifier (EI) #4, the Dietary Manager (DM), on 07/03/2018 at 7:46 AM, EI #4 said milk should be at a temperature of 41 degrees F or below at the time of meal service. When questioned about the milk sitting on the counter-top throughout meal service at room temperature, that measured 58 degrees while serving the last residents, EI #4 said drinking bad milk might make someone sick if it were to sour. EI #4 also said she would probably not want to drink milk at that temperature. When asked why they keep the milk out at room temperature throughout the meal service, EI #4 said they normally only pull out a tray at a time and put the milks over bags of ice, but they failed to do that.