**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Resident Identifier (RI) #14's medical record and the facility's policy titled NURSE CALL SYSTEM, the facility failed to ensure RI #14's call light was in reach. This deficient practice affected RI #14, one of 19 sampled residents. Findings include: The facility's policy, titled, NURSE CALL SYSTEM, last updated on 4/30/2013, revealed, . Policy: . Call light cords in the resident rooms will be located within the resident's reach . RI #14 was readmitted to the facility on [DATE]. On 4/20/2021 at 3:29 PM, RI #14 was observed in bed. The resident's call light was behind the bed frame handing down to the floor. The call light was not in RI #14's reach. On 4/21/2021 at 5:03 PM, RI #14 was observed in bed. The resident's call light was pinned to the back of the mattress. When asked where the call light was, RI #14 stated on the back somewhere. When asked if he/she could reach the call light, RI #14 said no. On 4/21/2021 at 5:14 PM, Employee Identifier (EI) #3, the Activity Coordinator was asked to observe RI #14's call light. EI #3 was asked, where was RI #14's call light. EI #3 replied, it was at the head of the resident's bed. When asked if RI #14 was able to reach the call light, EI #3 said no. EI #3 was asked, what the potential concern was of RI #14 not being able to reach the call light. EI #3 replied, that RI #14 would need help and not be able to reach the call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Resident Identifier (RI) #46's medical record and the facility's policy titled, Hand Washing Policy & Procedure, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) performed hand hygiene after she removed her gloves during medication administration. This deficient practice affected RI #46, one of four residents observed for medication administration. Findings include: The facility's policy titled, Hand Washing Policy and Procedure, last updated April 2020, documented, POLICY: Hand hygiene practices will promote resident safety and prevent infections. Every member of the facility must perform proper hand-washing techniques. HAND WASHING IS TO BE DONE AS INDICATED: . After . Taking off gloves . RI #46 was readmitted to the facility on [DATE] with a medical history to include a diagnosis of: Diabetes Mellitus. During medication administration observation on 4/21/2021 at 3:34 PM, EI #2, an LPN washed her hands and applied gloves. EI #2 wiped RI #46's finger with an alcohol prep and pricked the resident's finger to obtain a blood sugar. After obtaining RI #46's fingerstick blood sugar, EI #2 removed her gloves and put on a new pair without performing hand hygiene. EI #2 then wiped RI #46's stomach with an alcohol prep and administered Insulin to the resident. In an interview on 4/21/2021 at 4:09 PM, EI #2, a LPN was asked, what should be done after gloves are removed. EI #2 replied, throw them in the garbage and wash your hands. EI #2 was asked, did she perform hand hygiene after taking the gloves off and putting on a new pair of gloves. EI #2 replied, no. When asked why not, EI #2 replied, she was supposed to wash her hands, but she was nervous and forgot. EI #2 was asked, what the potential harm was in not performing hand hygiene between changing gloves. EI #2 replied, germs. During an interview on 4/22/2021 at 2:01 PM, EI #1, the Infection Control Nurse was asked, what should be done after gloves are removed. EI #1 replied wash your hands. EI #1 was asked, what the potential concern was of not performing hand hygiene after removing gloves. EI #1 replied, possible transmission of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and a facility policy titled, PLANNED MENUS, the facility failed to ensure RI ( Resident Identifier ) #69 received a mechanical soft diet with chopped meat, as ordered by the physician. This was observed on 6/26/19 during the supper meal and affected one of four residents whose meals were observed. Findings include: A review of a facility policy titled, PLANNED MENUS, with an update of 2/21/2003 revealed: POLICY: . It is our intent to assure that the resident maintains acceptable parameters of nutritional status, . taking into account the resident's clinical condition or other appropriate intervention, . Planned Menus . A Therapeutic Diet is offered when ordered by a physician as part of treatment for a disease or clinical condition, . or to provide food the resident is able to eat. RI #69 was admitted to the facility on [DATE] with diagnoses to include: Unspecified protein-calorie malnutrition and Alzheimer's disease. RI #69's June 2019 Physicians Orders documented: . 3/14/19/ . MECH (Mechanical) SOFT WITH CHOPPED MEATS . On 06/26/19 at 5:15 p.m.,Surveyor observed EI (Employee Identifier) #1, CNA (Certified Nursing Assistant) feeding RI #69 his/her supper meal. RI #69's supper meal included a hamburger pattie, bun, french fries and super potatoes. EI #1 was asked what diet was RI #69 prescribed. EI #1 said, Her/His ticket says mechanical soft and chopped meat. EI #1 was asked if RI #69's meat was chopped. EI #1 said, No, it is not chopped. EI #1 was asked could the resident chew the meat. EI #1 said, No because she/he does not have any teeth, she/he gum it. On 6/26/19 at 5:40 p.m. EI #2, RN (Registered Nurse) accompanied the surveyor to RI #69's room. EI #2 was asked, according to the resident's meal ticket what diet should he/she be prescribed. EI #2 said, Mechanical soft, chopped meat. EI #2 was asked what type of meat was on the resident's tray. EI #2 said, whole meat, regular diet. EI #2 was asked why RI #69 was served regular meat instead of chopped meat. She replied she did not know, she would have to ask the kitchen. EI #2 was asked what was the potential concern with RI #69 receiving a regular diet instead mechanically soft diet with chopped meat. EI #2 said, the resident could get choked. On 6/27/19 at 1:09 p.m. an interview was conducted with EI #3, DM (Dietary Manager). EI #3 was asked what diet was RI #69 prescribed. EI #2 said regular with super potatoes he thought , he would have to look it up. EI #3 was asked to review RI #69 meal ticket which documented resident was prescribed a mechanical soft with chopped meat. EI #3 was asked if that was a regular diet or mechanical diet. EI #3 said, Yes, it is a mechanical diet. EI #3 was asked what was the menu for the supper meal on 6/26/19. EI #3 said hamburger patty, lettuce, tomato, and french fries. EI #3 was asked if the resident's hamburger patty should have been chopped. EI #3 said, Yes, it should have been chopped. EI #3 was asked should resident diet orders be followed. EI #3 said, Yes, it all times. EI #3 was asked what was the potential concern with RI #69 not receiving his/her prescribed diet of Mechanical Soft with chopped meat. EI #3 said possible choking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review,and a review of the facility's policy titled, RESIDENT PRIVACY POLICY & (and) PROCEDURE, the facility failed to ensure a licensed nurse provided privacy while administering an injection to Resident Identifier (RI) #28. This affected one of five nurses observed during medication pass. Findings Include: A review of the facility's policy titled, RESIDENT PRIVACY POLICY & (and) PROCEDURE, updated 10/2011, revealed: . POLICY: It is the policy of this facility to care for residents in the manner and in an environment that maintains resident dignity and respect. PROCEDURE: . 4. Provide privacy by screening the resident. (The staff will examine and treat the resident in a manner that maintains the privacy of the resident's body) * Close all doors to the room (resident room door and bathroom door). RI #28 was re-admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. On 7/10/18 at 4:44 p.m., Employee Identifier (EI) #4, a Registered Nurse, did not shut the resident's room door, leaving him/her exposed as she gave an insulin injection into his/her abdomen. An interview was conducted on 7/1/18 at 4:30 p.m EI #4 was asked, what should be done before performing an invasive procedure/care to a resident. EI #4 stated, Explain what I am doing and then provide privacy. EI #4 was asked if she had done that. EI #4 stated, No. An interview was conducted on 7/11/18 at 5:15 p.m. with EI #5, the Infection Control Nurse. EI #5 was asked, what should be done before performing an invasive procedure/care to a resident. EI #5 replied, knock on the door, explain the procedure and provide privacy, close blinds and door, pull the curtain and have supplies.

Based on observation, interview, and a review of the facility's policy titled, Medication Storage, the facility failed to ensure that the locked medication box in the medication refrigerator was secured. This affected one of one of one medication refrigerator observed. Findings Include: A review of the facility's policy titled, Medication Storage, with an update of 1/2017, revealed: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. Narcotics and Controlled Substances: Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. On 7/11/18 at 2:37 p.m. the surveyor observed the locked box in the medication refrigerator in Medication Room One was not attached to the inside of the medication refrigerator. Stock supplies of Ativan were stored in the refrigerator locked box. An interview was conducted on 7/11/18 at 2:45 p.m. with Employee Identifier (EI) #6 ,a Registered Nurse/ the Director of Nursing. EI #6 was asked, besides being locked, what else should the locked box in the medication refrigerator be. EI #6 replied, attached. EI #6 was asked, what was the potential for harm. EI #6 replied, someone could get the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, a review of the facility's policy titled, HAND WASHING POLICY & (and) PROCEDURE, and a review of the facility's policy titled, Infection Control Policy and Procedures, the facility failed to ensure: 1) A licensed nurse washed her hands after taking gloves off, prior to putting on new gloves while administering medications. Further she did not wash her hands after returning to the medication cart to prepare medications for other residents or use a paper towel to turn off the water faucet. This licensed nurse also placed the glucometer and supplies directly on Resident Identifier (RI) #28's over bed table; and 2) a Certified Nursing Assistant (CNA) did not touch items in the resident's room, as well as clean items in the linen bag while providing incontinence care to RI #45. This had the potential to affect RI #28, one of ten residents observed during medication pass administration and RI #45, one of one sampled resident observed for incontinence care. Findings Include: A review of the facility's policy titled,Infection Control Policy and Procedures, with an update of 1/20/2016, revealed, GENERAL INFECTION CONTROL: Within the health-care setting, GENERALIZED INFECTION CONTROL PROCEDURES have been developed to minimize the risk of residents acquiring infection from contact with contaminated devices, objects, or surfaces or of transmission of an infectious agent from health-care workers to the residents. GENERAL INFECTION CONTROL: The following practices are considered to be the minimum standard. B. GLOVES will be worn for contact with any body substance . Wash your hands before applying gloves. A review of the facility's policy titled, HAND WASHING POLICY & PROCEDURE, with an update of 10/2017, revealed: POLICY: Hand hygiene practices will promote resident safety and prevent infections. PURPOSE: To prevent the spread of infection. HAND WASHING IS TO BE DONE AS INDICATED: Before: a) Direct resident care b) Before leaving any area and beginning work c) Before starting any procedure . After: g) Taking off gloves. HANDWASHING TECHNIQUE: 8. Turn off water with a towel (remember that germs are now on sink). 1) RI #28 was re-admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. On 7/10/18 at 4:03 p.m., Employee Identifier (EI) #5, a Registered Nurse, was observed putting on and removing gloves without washing her hands during medication pass administration. EI #5 was also observed returning to the medication cart after going into the medication room without washing her hands and then began preparing medications for the residents. EI #5 was observed laying the glucometer and other supplies directly on Resident Identifier (RI) #28's over bed table without using a barrier. EI #5 was also observed turning the water faucet off with her bare hands after washing her hands. An interview was conducted on 7/11/18 at 4:30 p.m. with EI #4. EI #4 was asked what should be done before putting gloves on and after taking gloves off. EI #4 stated, Wash your hands. EI #4 was asked if she had done that. EI #4 stated, No. EI #4 was asked what should be done before laying the glucometer and supplies on the resident's bedside table. EI #4 stated, Put a paper towel down or something. EI #4 was asked if she had done that. EI #4 stated, Not every time. EI #4 was asked, after going to the medication room and returning to the medication cart, what should be done before starting to prepare medications. EI #4 stated, I should have washed my hands. EI #4 was asked, in handwashing, how do you turn the water faucet off after washing your hands. EI #4 stated, With a paper towel. EI #4 was asked if she had done that. EI #4 stated, Not that I recall. An interview was conducted on 7/11/18 at 5:15 p.m. with EI #5, the Infection Control Nurse. EI #5 was asked, what should be done before putting gloves on and after taking gloves off. EI #5 replied, washing your hands. EI #5 was asked, what should be done before laying the glucometer and supplies on the resident's over bed table. EI #5 replied, placing a barrier. EI #5 was asked, in hand washing, how do you turn the faucet off after washing your hands. EI #5 replied, you get a paper towel to turn off the faucet. EI #5 was asked, after going elsewhere and returning to the medication cart, what should be done before starting to prepare medications for the residents. EI #5 replied, clean your hands. EI #5 was asked, what was the potential for harm. EI #5 replied, spreading bacteria. 2) EI #45 was re-admitted to the facility on [DATE] with a diagnosis of Hemiplegia following Cerebral Infarction affecting the Right Dominant Side. On 7/11/18 at 9:44 a.m. the surveyor observed EI #7, a Certified Nursing Assistant (CNA), touch the curtain and the bathroom door handle wearing the same gloves used to clean the buttocks of RI #45. EI #7 was also observed reaching into the clean linen bag wearing the same gloves use to clean RI #45's perineal area. An interview was conducted with EI #7 on 7/11/18 at 2:40 p.m. EI #7 was asked what should be done after cleaning the buttocks before touching the curtain or the door handle. EI #7 stated, Remove your gloves. EI #7 was asked if she had done that. EI #7 stated, No. EI #7 was asked, should you place a dirty, gloved hand into a bag of clean linen after cleaning the perineal area. EI #7 stated, No. EI #7 was asked if she had done that. EI #7 stated, Yes. EI #7 was asked what was the potential for harm. EI #7 stated, Contaminate it. An interview was conducted on 7/11/18 at 5:15 p.m. with EI #5, the Infection Control Nurse. EI #5 was asked, what should be done after cleaning the buttocks before touching the curtains and the door handle. EI #5 replied, take off gloves and wash hands. EI #5 was asked, should a dirty, gloved hand be placed in a bag of clean linen after cleaning the perineal area. EI #5 replied, no, of course not. EI #5 was asked what was the potential for harm. EI #5 replied, spreading bacteria.

Based on observations, interviews and review of the facility's policy titled, Food and Beverage Labeling Policy, the facility failed to ensure bags of food items in the walk in cooler and the chest freezer were labeled with an open and use by date after opening the bags. This had the potential to affect 52 of 52 residents receiving meals from dietary. Findings include: The facility's policy titled, Food and Beverage Labeling Policy, updated May 14, 2015, documented: . Procedure - . If It Is A . Opened Item It Will Have Two Dates - A . Open Date And Discard Date, which is the Use By Date (UBD) . EVERYTHING HAS TO HAVE . AN OPENED DATE AND A DISCARD / USE BY DATE! . On 07/09/18 at 5:30 PM, during the tour of the kitchen the following observations were made: 1) The two door stand up refrigerator was observed to have an open bag with 2 chicken patties in it. There was no open date or use by date label on the bag. 2) The chest freezer was observed with 3 bags of opened items with no opened date or use by date. The bags contained coffee cake pieces, 5 cornbread muffins and cheese biscuits. EI # 2, dietary staff said the labels probably fell off. No labels were observed in the freezer; and 3) The walk in cooler was observed with bags of mixed shredded cheese, a cheese block and pieces, parmesan cheese and shredded carrots without opened and use by dates. On 07/09/18 at 5:45 PM, Employee Identifier (EI) #3, Assistant Dietary Manager, was shown and asked about the opened bags that had no opened and use by date labels. EI #3 said the bags were supposed to have an open date label, all bags opened were suppose to have open date labels. EI#3 further reported perishable items were to be used within seven days of opening.