**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of a facility policy titled Specific Medication Administration Procedures Oral Inhalation Administration, the facility failed to ensure Resident Identifier (RI) #50 was assessed to self-administer nebulizer treatments prior to the nurse leaving RI # 50 unattended during the administration. This affected RI #50, one of two residents observed receiving a nebulizer treatment. Findings Include: Review of a facility policy titled Specific Medication Administration Procedures Oral Inhalation Administration, dated 06/15, revealed: . NEBULIZER- . L. Remain with the resident for the treatment unless the resident has been assessed and authorized to self administer. RI#50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Alzheimer's Disease, Dementia, and Need for Assistance for Personal Care. RI #50's November 2019 Physician's Orders included an order for a nebulizer treatment to be administered every 6 hours related to COPD. On 11/25/19 at 11:21 AM, the surveyor observed RI#50 in his/her bed with his/her nebulizer mask laying on top of the covers, still connected to the nebulizer machine. A large amount of mist could be observed coming from the mask. The surveyor observed a fluid substance in the reservoir of the mask. There was no nurse observed in RI #50's room at this time. However, review of RI #50's current records and care plans revealed no order, assessment, or care plan to self administer medications. On 11/25/19 at 6:50 PM the surveyor was informed by RI#50's family member that he/she had visited and also found the breathing treatment on without anyone in the room . On 11/26/19 at 2:04 PM the surveyor conducted an interview with Employee Identifier (EI) #1, Registered Nurse (RN) . The surveyor asked EI #1 if RI #50 had been assessed to self-administer his/her nebulizer treatments. EI#1 replied no . The surveyor asked EI#1 if she stayed with the resident during the nebulizer treatment. EI#1 replied no. EI #1 said, per facility policy, the nurse should stay with the resident for the entire administration. The surveyor asked EI#1 what the potential harm of not staying with a resident during a nebulizer treatment could be. EI#1 replied RI#50 could have had a reaction to the medication, such as increased pulse and result in cardiac complications or they may not receive the full administration of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, resident record review, and review of Resident Identifier (RI) #73's care plan for falls, the facility failed to ensure RI #73's care plan intervention was followed for use of a gait/transfer belt during transfer on 9/21/19. This affected one of 30 sampled residents for whom care plans were reviewed. Findings Include: RI #73 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Spinal Stenosis and Muscle Weakness. Review of RI #73's admission Minimum Data Set (MDS) with an assessment reference date of 7/4/19, revealed RI #73 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated RI #73 had intact cognition for daily decision making and required extensive assistance of one person physical assistance for transfers. Review of RI #73's care plan with a Focus area for At risk for falls related to: . Use of medication, right sided weakness ., with a revision date of 10/14/19, revealed an intervention, with an initiation and revision date of 7/10/19, for Gait belt with transfers. Review of RI #73's undated care card revealed, . Transfer belt x 1 team member . On 11/25/19 at 8:54 AM, RI #73 told the surveyor he/she had a fall in the shower room while standing to the bar from the chair and the girl (Certified Nursing Assistant/CNA) was not paying attention. Review of RI #73's Fall incident report dated 9/21/19 at 11:41 AM, revealed: . Resident lowered to the floor in the shower . stated that (he/she) was unable to transfer to his/her w/c (wheelchair) and the CNA lowered him/her to the floor . No injuries observed at time of incident. On 11/26/19 at 9:30 AM, Employee Identifier (EI) #8, CNA at the time of the incident, was asked what happened to RI #73 in the shower room on 9/21/19. EI #8 said, RI #73 was trying to stand to the bar on the wall, and when he/she stood and started going down, as EI #8 was holding RI #73's pants, the chair slid back. EI #8 was asked if it was a transfer. EI #8 said, yes, she was going to stand RI #73 up and pull up his/her pants, and then move the shower chair to position the wheelchair. EI #8 was asked where the gait belt was. EI #8 replied, she was not using a gait belt. On 11/26/19 at 10:09 AM, EI #9, a Registered Nurse at the time of the incident, was asked what she remembered about RI #73's fall on 9/21/19. EI #9 said, the CNA was standing to put RI #73 back into the wheelchair and RI #73 slipped and fell. EI #9 was asked if a gait belt should have been used with the transfer. EI #9 said, yes. When asked why the CNA was not using a gait belt, EI #9 said, she did not know why. On 11/26/19 at 11:04 AM, EI #10, the Director of Nursing was asked what should have been in place according to RI #73's care plan prior to RI #73's fall on 9/21/19. EI #10 said, a gait belt, as of 7/10/19. EI #10 was asked what should have been done differently. EI #10 said, the CNA should follow the care sheet. When asked why it was important for CNAs to follow the Care Sheet for interventions, EI #10 stated it was what they needed to do to keep falls from happening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #73 did not sustain a fall in the shower room on 9/21/19, as a result of Employee Identifier (EI) #8, Certified Nursing Assistant (CNA), transferring RI #73 from a shower chair to a wheel chair without using a gait/transfer belt as specified in RI #73's care plan. This affected RI #73, one of three sampled residents reviewed for falls. Findings include: RI #73 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Spinal Stenosis and Muscle Weakness. Review of RI #73's admission Minimum Data Set (MDS) with an assessment reference date of 7/4/19, revealed RI #73 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated RI #73 had intact cognition for daily decision making and required extensive physical assistance of one person for transfers, had upper and lower extremity limitations on one side, and was not able to stabilize for transfer without staff assistance. Review of RI #73's care plan with a Focus area for At risk for falls related to: . Use of medication, right sided weakness . with a revision date of 10/14/19, revealed an intervention, with an initiation and revision date of 7/10/19, for Gait belt with transfers. Review of RI #73's undated care card revealed . Transfer belt x 1 (times one) team member . On 11/25/19 at 8:54 AM, RI #73 told the surveyor he/she had a fall in the shower room while standing to the bar from the chair and the girl (Certified Nursing Assistant/CNA) was not paying attention. On 11/25/19 at 7:30 PM, review of RI #73's Fall incident report dated 9/21/19 at 11:41 AM, revealed: . Resident lowered to the floor in the shower . stated that (he/she) was unable to transfer to his/her w/c (wheelchair) and the CNA lowered him/her to the floor . No injuries observed at time of incident. On 11/26/19 at 9:30 AM Employee Identifier (EI) #8, a CNA, was asked what happened to RI #73 in the shower room on 9/21/19. EI #8 said, she was trying to stand RI #73 to the bar on the wall, and RI #73 stood and started going down as EI #8 was holding onto RI #73's pants and the chair slid back. EI #8 was asked if the fall happened during a transfer. EI #8 said, yes, and once standing, and RI #73's pants were up, she was going to move the shower chair back and pull the wheelchair up. When asked exactly where she was in the process, EI #8 said she was behind RI #73 and the shower chair started sliding because the floor under the chair was wet from the shower. EI #8 was asked where the gait belt was. EI #8 said, she did not have a gait belt. On 11/26/19 at 10:09 AM, EI #9, a Registered Nurse, was asked what she remembered about RI #73's fall on 9/21/19. EI #9 said, the CNA was standing RI #73 to put RI #73 back in the wheelchair and RI #73 slipped and fell. When asked if a gait belt should have been used with transfer, EI #9 said, yes. When asked why the CNA was not using a gait belt for the transfer, EI #9 said, she did not know. On 11/26/19 at 11:04 AM, EI #10, the Director of Nursing was asked what should have been in place according to RI #73's care plan prior to the fall on 9/21/19. EI #10 said, a gait belt as of 7/10/19. EI #10 was asked why the CNA did not know to use a gait belt. EI #10 said, it was on RI #73's care plan, so it should have been on the care sheet at that time. When asked what should have been done differently, EI #10 stated, the CNA should follow the care sheet. EI #10 was asked why it was important for CNAs to follow the care sheet for interventions. EI #10 said, it has what they need to do to keep falls from happening. When asked how the use of the gait belt would have helped to prevent the fall, EI #10 said, it would help stabilize RI #73 during the transfer. EI #10 was asked what was the potential harm for RI #73 if the gait belt and interventions were not followed. EI #10 said, the resident could fall and suffer injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure there were not expired eye drops on the Two South medication cart on [DATE]. This was observed on one of three medication carts in the facility. Findings Include: On [DATE] at 5:16 PM, the surveyor observed the Two South medication cart. An expired bottle of Latanoprost eye drops, opened [DATE], was noted on the cart. Employee Identifier (EI) #1, Registered Nurse, was interviewed on [DATE] at 5:16 PM. EI#1 stated the Latanoprost eye drops were opened on [DATE]. EI#1 said these eye drops should have been discarded six weeks after opening, on [DATE]. EI#1 was asked what the potential complications/harm could be of having and using medications that have been opened for an extended period of time. EI#1 said it could result in bacteria in the body if the the cap or tip was contaminated or the eye drops may not be as effective.

Based on observation, interview, review of the Food and Drug Administration (FDA) 2017 Food Code and review of the facility policy titled Waste Control, the facility failed to ensure the area around the outside dumpsters was free from discarded medical equipment, lumber and other debris on 11/24/2019. This had the potential to affect all 153 residents in the facility. Findings Include: The 2017 FDA Food Code included the following: . 5-501.15 Outside Receptacles. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around . the unit. 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE . shall be maintained free of unnecessary items, as specified under . 6-501.114, Maintaining Premises, Unnecessary Items and Litter. The Premises shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as Equipment that is nonfunctional or no longer used; and (B) Liter . Review of a facility policy titled Waste Control, dated August 1, 2012, revealed: POLICY It is the policy of the facility to store garbage and trash in a sanitary manner until disposed of properly for infection control. During the Initial Tour of the facility's kitchen on 11/24/2019 at 10:55 AM, the dumpster area was toured with Employee Identifier (EI) #5, Dietary Manager (DM) and EI #2, Registered Dietitian (RD). There were three dumpsters observed. On the cement pad next to the dumpsters, was a wooden desk. On the grassy area next to the dumpsters, there were seven bedside commode frames. Two of the frames had the containers in them and were full of water. There was an unknown black plastic item that was full of water next to the bedside commodes. There was an old wheel chair frame and a radiator cover observed behind the dumpsters. There were pieces of lumber in a pile behind the dumpsters. EI #5, DM, was asked why all of these items were out by the dumpster. EI #5 replied, the maintenance supervisor was cleaning out the storage buildings on Friday. EI #2, RD, was asked what was the concern of having discarded items left out by the dumpster. EI #2 replied, unable to empty the dumpsters and animals and pests. On 11/26/19 at 11:10 AM an interview was conducted with EI #11, Maintenance Supervisor. EI #11 was asked what was the concern of equipment and debris building up near the dumpster area. EI #11 replied, mosquitos during the summer, bugs, and animals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and review of facility policies titled,Self-Administration of Medications and Oral Inhalation Administration, the facility failed to ensure licensed staff did not allow Resident Identifier (RI) #135 to self-administer his/her nebulizer treatment on 09/18/18. This affected RI #135, one of five residents observed during medication pass observations and one of three nurses. Findings Include: A review of a facility policy titled, Self-Administration of Medications, dated 06/15, documented: Policy .residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures A. If the resident desires to self-administer medications, an assessment is conducted . A review of a facility policy titled, Oral Inhalation Administration, dated 06/15, revealed: .NEBULIZER .L. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer . RI #135 was admitted to the facility on [DATE] with diagnoses including, Shortness of Breath and Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation. A review of RI #135's medical record including a document titled, Order Summary Report, included: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (Milligrams)/3 ML (Milliliters) 3ml inhale orally every 4 hours related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . A review of RI #135's care plans documented the following: .Focus Alteration in Respiratory Status Due to Chronic Obstructive Pulmonary Disease, risk for shortness of breath .Interventions Administer medications as ordered . On 09/18/18 at 3:50 p.m., the surveyor observed Employee Identifier (EI) #3, Registered Nurse (RN), administer medications to RI #135. The surveyor observed the physician's order did not include self-administration. EI #3 was observed to set up RI #135's nebulizer treatment and leave the room and return to the medication cart and give medications to another resident. The surveyor went to RI #135's doorway and observed the resident lay the nebulizer pipe on the bed, get clothes from the end of the bed and then went and hung the clothes in the closet at the opposite end of the room. RI #135 went back to bed, turned off the nebulizer machine and came out to the medication cart to talk to EI #3. After the conversation, EI #3 asked the resident to go and finish his/her breathing treatment and put the oxygen back on. The surveyor observed RI #135 from doorway. RI #135 turned on the nebulizer machine and sat on side of the bed twirling the oxygen tubing in the air. EI #3 walked to the room and RI #135 stated he/she was slinging water from the oxygen tubing. EI #3 again left the room and went back to the medication cart. The surveyor asked EI #3 if the resident was careplanned for self-administration of medication. EI #3 stated she did not know, but the resident did their own treatments at home and walked around and did things on his/her own. On 09/19/18 at 3:08 p.m., an interview was conducted with EI #4, RN/Clinical Educator. EI #4 was asked should a nurse leave a resident that has not been assessed to self administer medications while a nebulizer treatment was infusing. EI #4 answered no. They should stay with the resident to ensure they got the medication. On 09/19/18 at 3:15 p.m., an interview was conducted with EI #3, RN. EI #3 was asked had RI #135 been assessed to self-administer medications. EI #3 said, apparently no. EI #3 was asked did RI #135 have an order to self-administer his/her nebulizer treatment. EI #3 replied, no. EI #3 was asked what was the concern with not staying with a resident while a breathing treatment was infusing. EI #3 said, not receiving the treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a care plan was developed to address Resident Identifier (RI) #17's required assistance for bed mobility. This affected RI #17, one of thirty-three sampled residents whose care plans were reviewed. Findings include: RI #17 was admitted to the facility on [DATE]. Diagnoses included cerebrovascular disease and osteoarthritis. A review of RI #17's June 23, 2018 Minimum Data Set (MDS) assessment revealed the resident required extensive assistance with two person for bed mobility. A review of RI #17's care plans revealed there was no person centered care plan for the resident's extensive assistance with two person for bed mobility. 09/19/18 at 3:44 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse/MDS Coordinator. EI #2 was asked how much assistance did RI #17 require for bed mobility. She reported, extensive assistance of 2 persons. EI #2 was asked how had bed mobility been care-planned for RI #17. EI #2 replied, she did not see anything in the care plans, upon reviewing the care plans. She then commented that bed mobility assistance was in the care plans. EI #2 was asked how many assist persons. She replied, not specified. EI #2 was asked how could staff assure that appropriate assistance was being provided for the resident. She replied, I guess they would not know. EI #2 was asked why should the resident have an individualized care plan for bed mobility. She replied, so the staff would know how to take care of the resident. EI #2 was asked what was the facility policy related to developing a person-centered plan of care. She answered, to build them as appropriate. EI #2 was asked what was the concern for not developing a person-centered plan of care to address bed mobility. She replied, perhaps the resident may not get the care as appropriate. On 09/19/18 at 5:20 PM, and interview was conducted with EI #1, Director Of Nursing. EI #1 was asked how much assistance did RI #17 require for bed mobility. She replied, two person extensive assistance. EI #1 was asked how had bed mobility been care-planned for RI #17. Upon looking at the care plans, she reported, it said bed mobility, it did not say two person or extensive assist. EI #1 was asked how could staff assure that appropriate assistance was being provided for RI #17. EI #1 replied, it would need to be more detailed information on the care plan and care giver guide. EI #1 was asked why should the resident have an individualized care plan for bed mobility. She replied, because they (resident) may need assistance and it should be detailed. EI #1 was asked what was the facility policy related to developing a person-centered plan of care. The DON replied, follow the RAI (Resident Assessment Instrument) process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and review of facility policies titled, Administration Procedures For All Medications and Oral Inhalation Administration, the facility failed to ensure licensed staff observed administration of Resident Identifier (RI) #135's nebulizer treatment while it was infusing to ensure RI #135 received the benefits of the treatment. This affected RI #135, one of five residents observed during medication pass observations, and one of three nurses. Finding Include: A review of a facility policy titled, Administration Procedures For All Medications, dated 06/15, documented: .To administer medications in a safe and effective manner. A review of a facility policy titled, Oral Inhalation Administration, dated 06/15, revealed: .L. Remain with the resident for the treatment . RI #135 was admitted to the facility on [DATE] with diagnoses including, Shortness of Breath and Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation. A review of RI #135's medical record including a document titled, Order Summary Report, included: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (Milligrams)/3 ML (Milliliters) 3ml inhale orally every 4 hours related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . On 09/18/18 at 3:50 p.m., the surveyor observed Employee Identifier (EI) #3, Registered Nurse (RN), prepare medications for RI #135. EI #3 documented administration of the medications before entering the resident's room. EI #3 was observed to set up RI #135's nebulizer treatment and leave the room and return to the medication cart and give medications to another resident. Surveyor went to RI #135's doorway and observed resident lay nebulizer pipe on the bed, get clothes from the end of the bed and then went and hung clothes in closet at opposite end of the room. RI #135 went back to bed, turned off nebulizer machine and came out to medication cart to talk to EI #3. After the conversation, EI #3 asked resident to go finish his/her breathing treatment and put oxygen back on. Surveyor observed RI #135 from doorway. RI #135 turned on nebulizer machine and sat on side of bed twirling oxygen tubing in air. EI #3 walked to room and RI #135 stated he/she was slinging water from oxygen tubing. EI #3 again left room and went back to medication cart. On 09/19/18 at 3:15 p.m., an interview was conducted with EI #3, Registered Nurse (RN). EI #3 was asked when should she document administration of medication. EI #3 said after they have take the medication. EI #3 was asked when did she document RI #135's medication administration yesterday. EI #3 replied when removing it from the medication cart. EI #3 was asked should she have stayed with RI #135 while the nebulizer treatment was infusing. EI #3 said yes. EI #3 was asked what was the concern with not staying with a resident while a breathing treatment was infusing. EI #3 answered not receiving the treatment. EI #3 was asked what was the concern with documenting administration of medication before it was administered. EI #3 said that she could sign out medication that the resident might not take. On 09/19/18 at 3:18 p.m., an interview was conducted with EI #4, RN/Clinical Educator. EI #4 was asked when should a nurse document administration of medication. EI #4 said after the resident has taken the medication. EI #4 was asked should a nurse leave a resident while a nebulizer treatment was infusing. EI #4 said no, they should stay with the resident to ensure they get the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record reviews and review of facility policies titled, Administration Procedures For All Medications and Topical Medication Administration and a facility document titled, Hand Hygiene Care Audit, the facility failed to ensure a licensed staff: 1. washed her hands after obtaining RI #8's FSBS, did not place the glucometer used to obtain the resident's fingerstick blood sugar (FSBS) on top of the medication cart without a barrier before cleaning it, and removed her gloves and washed her hands after administering the resident's insulin injection before going back to the medication cart for medication, 2. The facility further failed to ensure a licensed staff washed her hands after eye drop administration for RI #61 and before administering RI #61's nasal spray, and 3. the same staff washed her hands after retrieving medication from the supply closet and before applying gloves to administer topical medication to RI #9, changed her gloves and washed her hands after applying Calamine Lotion to RI #9's right arm and before applying Calamine Lotion to the resident's left arm and washed her hands after removing gloves worn during administration of the lotion before leaving the room and putting the lotion in treatment cart. These deficient practices affected RI #8, RI #61 and RI #9, three of five residents observed during medication pass observation and two of three nurses. Findings Include: A review of a facility policy document titled, Hand Hygiene Care Audit, with no date, documented: .Hand Hygiene .3. Hand washing is done every time you remove gloves.Gloving .9. Washes hands every time gloves are removed. A review of a facility policy titled, Administration Procedures For All Medications, dated 06/15, recorded: Procedures . F. Cleanse hands using antimicrobial soap and water or facility-approved hand sanitizer before beginning a med pass, before handling medication, and before contact with resident. A review of a facility policy titled, Topical Medication Administration, dated 06/15, revealed: Procedures .N. If resident has multiple treatment sites, the cleanest site is treated first .and each site is treated as a separate dressing. 1.) RI #8 was readmitted to the facility on [DATE], with diagnoses including, Type 1 Diabetes Mellitus With Unspecified Complications. On 09/18/18 at 6:02 p.m., during medication pass observation, Employee Identifier (EI) #5, Licensed Practical Nurse (LPN) was observed to obtain RI #8's FSBS and removed her gloves and without washing her hands, placed the glucometer on top of the medication cart, without a barrier. She then administered RI #8's insulin injection and with the same soiled gloves on, went to the medication cart and opened it. EI #5 then cleaned the pen with an alcohol wipe, took the soiled gloves off and placed the pen in a bag and put it in the cart. EI #5 then documented the location of the injection and without washing her hands took out the resident's inhaler. On 09/19/18 at 3:04 p.m., an interview was conducted with EI #5, LPN. EI #5 was asked when should she wash her hands during medication administration. EI #5 said before and after. The surveyor asked EI #5 how many times should she gel her hands before washing them. EI #5 replied twice. EI #5 was asked should she have removed her gloves and washed her hands after obtaining RI #8's FSBS and after giving RI #8's insulin injection. EI #5 replied yes. EI #5 was asked did she remove her gloves and wash her hands after administering RI #8's insulin injection before going back to the cart to get RI #8's Symbicort. EI #5 stated no. EI #5 was asked did she wash her hands at any time during RI #8's medication administration. EI #5 said no. EI #5 was asked what was the concern with not washing her hands and changing gloves when indicated. EI #5 answered infection control. 2.) RI #61 was readmitted to the facility on [DATE]. 3.) RI #9 was admitted to the facility on [DATE]. On 09/19/18 at 7:51 a.m., during medication pass observation, EI #6, LPN, was observed to administer RI #61's eye drops. EI #5 removed her gloves and without washing her hands administered RI #61's Flonase. On 09/19/18 at 8:03 a.m. EI #6 was observed to administer medications for RI #9. EI #6 was observed leaving the hallway to retrieve Calamine Lotion from the supply closet. EI #6 returned to the nurse's station with the lotion and dated the bottle. EI #6 then entered to RI #9's room and applied gloves without washing her hands and began applying the lotion to RI #9's right arm. Without changing gloves and washing her hands, EI #6 was observed applying the lotion to RI #9's left arm. EI #6 then left the resident's room and went back to the nurse's station, removed her gloves and put the lotion into the treatment cart. On 09/19/18 at 2:24 p.m., an interview was conducted with EI #6, LPN. EI #6 was asked when should she wash her hands during medication administration. EI #6 said before she gets started, before she puts gloves on, after she takes gloves off and if she is giving their medications and she directly touched the resident. EI #6 was asked did she wash her hands after removing her gloves when she administered RI #61's eye drops and before she administered his/her Flonase. EI #6 replied, no she did not. She further stated she should have washed her hands after she took the gloves off before giving RI #61's Flonase. EI #6 was asked did she wash her hands before applying gloves after she got the Calamine Lotion from the supply room and before she applied the lotion to RI #9's arms. EI #6 said, no. EI #6 was asked did she change gloves and wash her hands after applying lotion to the resident's right arm before applying the lotion to his/her left arm. EI #6 replied, no. EI #6 was asked why did RI #9 get the Calamine Lotion. EI #6 said the order said for a rash the resident had little horn-like places on his/her arms. EI #6 was asked were any of the places open. EI #6 answered she did not see open areas but he scratches. On 09/19/18 at 3:18 p.m., an interview was conducted with EI #4, Registered Nurse (RN)/Clinical Educator/Infection Control Coordinator. EI #4 was asked when should nurses wash their hands during medication administration. EI #4 said before and after and if they came in contact with a resident. EI #4 was asked how many times could a nurse gel their hands during med pass, before washing them. EI #4 replied three, unless they came into contact with the resident or their belongings. EI #4 was asked should nurses wash their hands when removing their gloves after obtaining a FSBS or giving an injection. EI #4 said, yes. EI #4 was asked should they wash their hands after removing their gloves after administering eye drops and before administering a nasal spray. EI #4 stated, Yes. EI #4 was asked should they remove their gloves and wash their hands after applying a topical medication to one body part before applying medication to another body part. EI #4 said, yes, they have to wash their hands. EI #4 was asked should a nurse lay a glucometer on top of the medication cart without a barrier after obtaining a FSBS. EI #4 replied, no. EI #4 was asked should a nurse go back to the medication cart wearing the gloves worn while administering an injection and get medication from the cart. EI #4 said, no. EI #4 was asked what was the concern with not washing hands and changing gloves when indicated. EI #4 answered, the spreading of microorganisms from surfaces to other areas and infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a review of resident records, the facility failed to ensure Resident Identifier (RI) #25's healthcare information was not open to public view. This affected one of eight resident's medication carts observed during medication pass. Findings Include: RI #25 was re-admitted to the facility on [DATE] with diagnoses including Bipolar Disorder. On 9/13/2017 at 6:14 p.m., during medication pass administration, a medication cart was observed in the hallway adjacent to a resident's room. There was no nurse observed at the cart. The laptop on the cart was not locked and RI#25's medication information was viewable. Other staff was observed to walk past the medication cart. The medication cart nurse was identified as Employer Identifier (EI) #19, Licensed Practical Nurse/LPN. On 9/14/2017 at 1:35 p.m., a phone interview was conducted with EI #19. EI #19 was asked what did the facility's policy indicate regarding what should have been done when stepping away from the medication cart. EI #19 said, I should have locked the screen. EI #19 was asked did she leave the laptop open on the medication cart. EI #1 said yes she forgot. When asked what was the potential harm to a resident when resident information was left in view of the public or other residents. EI #19 said it was a privacy issue.

Based on staff interview and a review of the facility's policy and procedure titled, Abuse Policy and a review of personnel files, the facility failed to ensure licensure verification, abuse registry and background checks were completed for new hires, Employee Identifier (EI) #7, Certified Nursing Assistant/CNA and EI #8, Registered Nurse/RN, prior to employment. This affected two of seven personnel files reviewed. Findings Include: A review of the facility's policy and procedure titled, Abuse Policy with an effective date of 02/2017 revealed the following: . POLICY STATEMENT It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident/patient property Screening . All applicants for employment shall . have the following screening checks conducted: . 2. Appropriate licensing board or registry check. 4. Criminal background check . A review of a GRIEVANCE INVESTIGATION FORM FOR THE UNION ONLY completed for EI #7, dated 07/26/17, revealed the following: .WHEN . July 26 2017 (EI #7) sent text message to staffing saying she quit. Than NCNS 9No Call No Show) for her next two shifts . WHY IS THIS A GRIEVANCE? . This is a request for review of the situation and request rehire . COMPANY CONTENDS Return (EI #7) back to work at the PRN (per resident need) classification . On 09/13/17 at 5:30 p.m., during a review of personnel files, revealed the following: 1. A review of EI #7's Job History revealed EI #7 was terminated 07/26/17 and rehired 08/09/2017. EI #7's, CNA, file did not have documentation for verification of the background check. 2. A review of EI #8's Job History revealed EI #8 was terminated 11/02/2016 and rehired 08/01/2017. EI #8's, RN, file did not have documentation for verification of licensure, background check and abuse registry check. On 09/13/17 at 6:35 p.m., during an interview with EI #9, RN/Clinical Educator, the surveyor asked where was the licensure, background check and abuse registry check for EI #8. EI #9 replied the only checks that were completed were the reference checks and that was the only check that had been done. The surveyor asked where was the background check for EI #7. EI #9 replied the facility did not complete a background check for EI #7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the resident's record, and review of a facility's statement on letterhead regarding call lights, the facility failed to ensure Resident Identifier (RI) #1's call light was in reach on two of three days of the survey. This affected one of 21 sampled residents whose call light was observed. Findings Include: A review of a facility's statement on facility's letterhead dated 9/14/2017, revealed the following: . We do not have a written policy for answering call lights, we follow the regulation. RI #1 was readmitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Chronic Pain, Chronic Obstructive Pulmonary Disease, and Heart Failure. RI #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 6/10/2017 revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated RI #1 had moderately impaired cognition. A review of RI #1's care plan for . physical functioning deficit . with a revision date of 6/21/2017 revealed an intervention for the following: . Call bell within reach Date Initiated: 08/26/2013 . On 9/13/2017 at 8:40 a.m., during the initial tour of the facility, RI #1's call light was observed behind the head of the bed, through the bed frame, and on the floor. On 9/13/2017 at 11:30 a.m., RI #1's call light cord remained under the head of the bed, through the bed frame, and on the floor. On 9/13/2017 at 12:05 p.m., RI #1's call light cord remained under the head of the bed, through the bed frame, and onto the floor. On 9/13/2017 at 12:15 p.m., RI #1, whose room was at the far end of the hall, yelled for help two times. The call light remained on the floor through the bed frame. On 9/13/2017 at 12:16 p.m., RI #1 yelled for help three more times. The call light remained on the floor through the bed frame. On 9/13/2017, RI #1 was observed by the surveyor from 2:30 p.m. until 6:45 p.m. During the four hours and 15 minutes the surveyor observed RI #1, the call light remained through the bed frame and on the floor. During that time CNAs (Certified Nursing Assistants) and nurses entered RI #1's room. Staff did not check RI #1's call light positioning. From 2:50 p.m. until 2:58 p.m., RI #1 yelled for help 18 times. Forty-seven minutes later, at 3:45 p.m. a CNA, who was passing ice checked on RI #1, however, she did not check the call light positioning for RI #1. On 9/14/2017 at 8:25 a.m., RI #1's call light remained on the floor, under the bed through the bed frame. On 9/14/2017 at 1:30 p.m., Employee Identifier (EI) #3, CNA, was asked if she had been assigned to RI #1 on 9/13/2017. EI #3 said yes. When asked how RI #1 let her know when assistance was needed, EI #3 said RI #1 would use the call light. When asked how often RI #1 used the call light, EI #3 replied RI #1 would use the call light about three times a day to request milk or report incontinence. EI #3 was asked why RI #1's call light was under the bed on 9/13/2017 and 9/14/2017. EI #3 said she did not know it was under the bed. When asked why RI #1 should have a call light within reach. EI #3 replied so RI #1 could call for help. EI #3 observed RI #1's call light with the surveyor. EI #3 was asked where was RI #1's call light. EI #3 said behind the bed. On 9/14/2017 at 1:40 p.m., EI #4, CNA, was asked if she was assigned to RI #1 on 9/14/2017 and she said yes. When asked why RI #1's call light was under the bed. EI #4 said she did not notice the call light was under the bed. EI #4 stated RI #1 was not normally on her list of residents. When asked why it was important for RI #1 to have a call light. EI #4 said so RI #1 could call for staff. When asked if RI #1 should have the call light in reach. EI #4 said yes. When asked if RI #1 knew how to use the call light. EI #4 replied yes. On 9/14/2017 at 1:45 p.m., RI #1 was asked to demonstrate the use of the call light. RI #1 pressed the call light, the staff responded and RI #1 made a request for water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of a facility's document titled, HOUSEKEEPING IN-SERVICE and staff interview, the facility failed to ensure Resident Identifier (RI) #15's bathroom was free of a foul odor on two of three days of the survey. This affected one of 21 sampled residents whose bathrooms were observed. Findings Include: A review of a facility's document titled, HOUSEKEEPING IN-SERVICE with a date of 01/01/2000, documented: . PURPOSE: . To show Housekeeping employees the proper method to sanitize a . bathroom in a long-term care facility. RI #15 was admitted to the facility on [DATE] with diagnoses to include Gastro-esophageal Reflux Disease, Hypertension and Chronic Pain. A review of RI #15's Significant Change Minimum Data Set (MDS) assessment with an Assessment Reference Date of 06/12/2017 revealed RI #15's Brief Interview for Mental Status (BIMS) score of 12, indicating cognition intact. On 09/13/2017 at 7:50 a.m., an observation was made of RI #15's bathroom during the initial tour. The surveyor opened the bathroom door, entered and a strong foul urine odor was detected. RI #15 said to keep the bathroom door closed because it smells bad. On 09/13/2017 at 12:50 p.m., an observation was made of RI #15's bathroom. The surveyor detected a foul urine odor and paper was on the floor. RI#15 said, I have to keep that door closed or you can't stay in this bed. The surveyor asked who had he/she told regarding the odor. RI #15 said everybody knows and he/she stated he/she would not be able to stay in the room if the door to the bathroom was not closed. On 09/14/2017 at 3:15 p.m., an interview was done with Employee Identifier (EI) #10, Housekeeping Supervisor. EI #10 and the surveyor entered RI #15's room. EI #10 entered the bathroom and said the odor was urine that was in the tiles. EI #10 was asked was there a problem with there being an odor. EI #10 said yes because of the resident in the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, a review of [NAME] and Perry's FUNDAMENTALS OF NURSING, a review of the facility's Controlled Substance Accountability Sheet and a review of Resident Identifier (RI) #26's Behavior Care Plan, the facility failed to develop a care plan for RI #26's behavior of false accusations related to narcotic administration. This affected one of 23 residents whose care plans were reviewed. Findings Include: A review of [NAME] and Perry's FUNDAMENTALS OF NURSING NINTH EDITION with a Copyright of 2017, CHAPTER 26, page 365 documented: . Standardized Care Plans . standardized care plans or clinical practice guidelines (CPGs) . Each CPG facilitates safe and consistent care for an identified problem . They also improve continuity of care among professional nurses. When they are used, the nurse remains responsible for providing individualized care to each patient. A review of a facility's statement dated 09/14/2017 revealed the following: . We do not have a written policy for Care Planning, we follow the RAI (Resident Assessment Instrument) process. RI #26 was re-admitted to the facility on [DATE] with diagnoses to include Gastro-Esophageal Reflux Disease with Esophagitis, Chronic Pain and Heart Failure A review of RI #26's care plans did not reflect behaviors of false accusations regarding narcotic medications. A review of RI #26's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/19/2017 revealed RI #26 had a Brief Interview for Mental Status (BIMS) score of 13, indicating cognition intact. On 09/14/2017 at 8:34 a.m., during Medication Administration with Employee Identifier (EI) #16, Licensed Practical Nurse/LPN. EI #16 administered Norco 7.5 milligrams (mg) to RI #26. EI #16 signed the narcotic book and RI #26 initialed the narcotic after EI #16's signature. On 09/14/2017 at 10:20 a.m., an interview was conducted with EI #16. EI #16 was asked why was RI #26 signing the narcotic book. EI #16 said because RI #26 made false accusations about not receiving the narcotic on time. On 09/14/2017 at 11:25 a.m., an interview was conducted with EI #17, Administrator. EI #17 was asked was there a care plan for false accusations regarding RI #26's Norco. EI #17 said no there is no care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and RI #1's medical record review, the facility failed to ensure Resident Identifier (RI) #1's care plan intervention was followed to have the call light in reach. This affected one of 21 residents whose care plans were reviewed. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Pain, Chronic Obstructive Pulmonary Disease, and Heart Failure. RI #1's Significant Change MDS (Minimum Data Set) with an Assessment Reference Date of 6/10/2017 revealed a BIMS (Brief Interview for Mental Status) score of 9 which indicated RI #1 had moderately impaired cognition. A review of RI #1's care plan for . physical functioning deficit . with a revision date of 6/21/2017, revealed an intervention for the following: . Call bell within reach Date Initiated: 08/26/2013 . On 9/13/2017 at 8:40 a.m., 11:30 a.m., 12:05 p.m., 12:16 p.m., and from 2:30 p.m. until 6:45 p.m., RI #1's call light was observed out of reach, behind the bed, through the bed frame, and on the floor under the bed. On 9/14/2017 at 8:25 a.m., RI #1's call light was observed out of reach, behind the bed, through the bed frame, and on the floor under the bed. On 9/14/2017 at 1:30 p.m., Employee Identifier (EI) #3, Certified Nursing Assistant/CNA who was assigned to RI #1 on 9/13/2017 was asked, how RI #1 would let her know when assistance was needed. EI #3 said RI #1 would use the call light. When asked how often RI #1 used the call light. EI #3 replied RI #1 would use the call light about three times a day. EI #3 was asked why RI #1's call light was under the bed on 9/13/2017 and 9/14/2017. EI #3 said she did not know it was under the bed. When asked why RI #1 should have a call light, EI #3 replied so RI #1 could call for help. EI #3 observed RI #1's call light with the surveyor. EI #3 was asked where was RI #1's call light. EI #3 said behind the bed. On 9/14/2017 at 1:40 p.m,. EI #4 CNA, who was assigned to RI #1 on 9/14/2017, was asked if RI #1 knew how to use the call light. EI #4 said yes. When asked if RI #1 should have a call light in reach. EI #4 said yes. When asked why RI #1's call light was under the bed. EI #4 stated she had not noticed it being under the bed and she did not normally have RI #1 on her list of residents. On 9/14/2017 at 1:45 p.m., EI #3 placed RI #1's call light on the bed in reach. On 9/14/2017 at 3:40 p.m., EI #2, RN (Registered Nurse) Supervisor, was asked why RI #1 was care planned to have a call light in reach. EI #2 replied so RI #1 could ask for help. When asked why the care plan was not followed for the call light to be in reach. EI #2 said it should have been followed and it was an error. EI #2 was asked how often the call light should be checked to ensure it was in reach. EI #2 said every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and a review of a facility's document titled, Clean Dressing Change, the facility failed to ensure licensed staff cleaned Resident Identifier (RI) #12's wound from inner to outer. This affected one of two sampled residents observed during wound care observation. Findings Include: A review of a facility's document titled, Clean Dressing Change without a date, revealed the following: . 11. Cleanse wound . working from the inside out . RI #12 was admitted to the facility on [DATE] with a diagnosis including Atherosclerosis of Coronary Artery Bypass Graft and Hypotension. A review of RI's #12 Wound Evaluation Form dated 09/13/17, documented RI #12's wound as being identified on 09/12/17 to left heel . A review of RI #12's Order Summary Report dated 09/13/17, revealed the following: . Medihoney Wound/Burn Dressing Gel (Wound Dressings) Apply to L (left) medial heel injury topically every day shift every 2 days (s) for pressure injury . On 09/14/17 at 9:25 a.m., the following was observed during wound care: Employee Identifier (EI) #11, Licensed Practical Nurse/LPN/Treatment Nurse and EI #12, Registered Nurse/RN, washed their hands and applied gloves.EI #12 measured the entire wound as 5 cm x 3.6 cm. EI #11 obtained wound cleanser and sprayed wound cleanser to the wound area. EI #11 then obtained a dry 4 x(by) 4 and wiped the wound starting at the 12 o'clock position down to the 3 o'clock position. EI #11 repeated the cleanser and the 4x4 and wiped the outer edges of the wound. EI #11 completed the wound care. On 09/14/17 at 9:40 a.m., during an interview with EI #11 and EI #12, the surveyor asked EI #11 what direction should a wound be wiped. EI #11 stated from inner to outer and that was what she had done. EI #11 also stated she did not measure the entire wound area, which was her fault. EI #11 stated the importance of correct measuring is to see the progression of the wound and ensure appropriate treatment is administered. The surveyor asked EI #12 how should a wound be wiped. EI #12 stated to start in the middle and go around in a circular motion, moving outward, until the entire wound is cleaned. EI #12 also stated that was not what EI #11 had done when cleaning the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident Identifier (RI) #1 received timely incontinent care on 9/13/2017. RI #1, identified by the facility as a resident incontinent of bowel and bladder, and with a history of Urinary Tract Infection, did not receive incontinent care and was not checked for incontinence for four hours. This affected one of 10 residents sampled for bowel and bladder. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 6/10/2017 revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated RI #1 had moderately impaired cognition; and RI #1 was frequently incontinent of bladder and always incontinent of bowel, and required total assistance with toilet use and extensive assistance with hygiene. On 9/13/2017 from 2:30 p.m. until 6:45 p.m., RI #1 was observed by the surveyor. During that time, RI #1 did not receive incontinent care and was not checked for incontinence. At 3:45 p.m., Employee Identifier (EI) #5, a Certified Nursing Assistant/CNA, removed a pillow from under RI #1's legs but did not lift the sheet to check RI #1 for incontinence. On 9/13/2017 at 6:30 p.m., EI #5 was asked who was responsible for RI #1. EI #5 said,she was. EI #5 was asked what kind of care RI #1 required. EI #5 replied she did not normally take care of RI #1 and from what she understood RI #1 was total care. When asked what care that would require from her. EI #5 stated, Pretty much everything, turn, dry . When asked when the last time RI #1 had been provided incontinent care. EI #5 said she was not sure because she was not wearing a watch. EI #5 said she came to work at 3:00 p.m. and RI #1 should have been checked for incontinence every two to three hours. When asked why it was important to check and change every two hours. EI #5 replied to keep RI #1 from getting skin breakdown. On 9/14/2017 at 3:45 p.m., EI #2, RN (Registered Nurse) Supervisor, was asked what care CNAs were to provide for residents who were incontinent. EI #2 said They should check every two hours and change if wet. When asked why RI #1 was not checked for four hours on 9/13/2017. EI #2 replied it had been a problem when staff were floaters. When asked what the importance was of residents being clean and dry and being checked every two hours. EI #2 said for cleanliness, comfort, and to prevent skin breakdown. On 9/15/2017 at 10:00 a.m., EI #2 said on 9/13/2017, RI #1 was wet and had to be changed when he was checked after the four hours without being checked.

Based on observation, a review of a facility's policy titled, Patient Safety during Treatment and staff interview, the facility failed to ensure the Hydrocollator was locked and secured. This had the potential to affect all residents utilizing therapy and four of 23 residents sampled for specialized rehabilitation. Findings Include: A review of a facility's policy titled, Patient Safety during Treatment with an effective date of 11/2016 documented: . Policy: . Therapy Services team members understand their responsibility to . ensure the safety of their patients. Procedure: . Hydrocollator should be locked at all time, or in an area that prevents/deters patient access. On 09/13/2017 at 8:40 a.m., an observation was made in the therapy room. The Hydrocollator was not locked and a wooden therapy staircase was positioned next to the Hydrocollator. On 09/14/2017 at 3:00 p.m., an interview was conducted with Employee Identifier (EI) #6, Director of Physical Therapy. EI #6 was asked why was the Hydrocollator not locked. EI #6 said on 09/11/2017, housekeeping was helping move to prepare for the storm and the lock came off. EI #6 was asked should the Hydrocollator be locked. EI #6 said because of the water being hot and it could burn a resident. EI #6 was asked who was responsible to ensure it remained locked. EI #6 said she was.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and a review of the facility's Philosophy and Policy on Nutrition, the facility failed to ensure Resident Identifier (RI) #2's preferences were honored. This affected one of 15 sampled residents whose meals/tray cards were observed. Findings Include: A review of the facility's policy titled, Philosophy and Policy on Nutrition with an effective date of 08/01/12, revealed the following: . PROCEDURE . 2. The resident will be served food according to his/her individual food preferences . he/she is entitled to his/her reasonable preferences . RI #2 was re-admitted to the facility on [DATE] with diagnoses including: Alzheimer's Disease, Other Specified Disorders of Arteries and Arterioles and Dehydration. A review of RI #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #2 had long and short term memory problems and was severely impaired in cognitive skills for daily decision making. The MDS also assessed RI #2 as requiring extensive assistance with eating. A review of RI #2's Order Summary Report dated 09/14/17, revealed the following: . Dietary . Regular diet Puree texture . Order Date 11/03/16 . A review of RI #2's care plan titled, At risk for alteration in nutrition r/t (related to) diet revealed the following: . Date Initiated: 05/13/2017 . Interventions . Diet as ordered. Honor food/beverage preferences . On 09/13/17 a review of RI #2's tray card revealed the following: Breakfast . Dislikes/Intolerances: Eggs; . Notes: OATMEAL PUR (PUREED) SAUSAGE AND GRAVY SLICE CHEESE ON TOP OF SAUSAGE AND GRAVY PUR BREAD . On 09/13/17 at 7:50 a.m., during the initial tour, the following was observed: RI #2's was awake and alert, up to bed, fed per staff, Employee Identifier (EI) #13, Certified Nursing Assistance/CNA, at bedside. RI #2's breakfast tray was observed to have pureed sausage/gravy, oatmeal, pureed bread, scrambled/pureed eggs and beverages. No cheese was observed on top of the pureed sausage/gravy. On 07/13/17 at 8:07 a.m., during an interview with EI #13, the surveyor asked where was the cheese that was supposed to be on top of the sausage/gravy. EI #13 stated the resident did not get it. EI #13 also stated RI #2's tray card had a dislike for eggs and the resident received eggs on the tray for breakfast. On 09/14/17 at 2:25 p.m., during an interview with EI #14, Dietary Manager/DM and EI #15, Registered Dietician/RD. The surveyor provided RI #2's tray card for review and asked EI #14 what were RI #2's dislikes. EI #14 stated eggs. The surveyor asked why did the resident get eggs on the breakfast tray. EI #14 replied she did not know. The surveyor asked what happen with the cheese on top of the sausage gravy. EI #14 stated she did not know what happen. The surveyor asked what was the importance of ensuring RI #2 received what was listed on the tray card and honoring the resident's dislikes. EI #14 replied the resident dislikes eggs. EI #15 replied it is the resident's preference and to ensure caloric needs are met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of a facility's document titled, Principles of infection control in long-term care facilities, and staff interviews, the facility failed to ensure a Licensed nurse did not stack medication cups, one on top of the other, and carry medications to Resident Identifier (RI) #26. This affected one of seven nurses and one of eight residents observed during medication administration. The facility further failed to ensure Certified Nursing Assistants/CNAs performed hand hygiene after removing gloves during performance of incontinent care. This affected affected two of three incontinent cares observed. Findings Include: A facility's document titled Principles of infection control in long-term care facilities, dated October 2014, revealed: Standard Precautions Standard precautions are the recommended practice for the care of all . residents receiving care within our centers. When properly followed and adhered to, they reduce the risk of transmission of infectious agents . 1. RI #26 was readmitted to the facility on [DATE] with diagnosis of Heart Failure. On 9/14/2017 at 8:34 a.m., medication administration was observed with Employee Identifier (EI) #16, Licensed Practical Nurse/LPN. A medication cup was retrieved and placed on top of the medication cart. Medications were placed inside the cup. A second medication cup was retrieved and placed on top of the medication cart and a narcotic medication was placed into the cup. EI #16 picked up the medication cups and placed the cup with the narcotic inside the cup with the other medications to be carried into RI #26 and administered the medication On 9/14/2017 at 2:00 p.m., an interview was conducted with EI #16. EI #16 was asked, should medication cups be placed one inside the other to carry medication into a resident's room. EI #16 said no. When asked why she placed the medication cup containing the Norco inside the cup with other medication. EI #16 said she was not aware that she did that. When asked was was the potential harm to a resident when medication cups contain medications and were stacked on top of the other. EI #16 said could cause contamination. A facility's document titled, Principles of infection control in long-term care facilities, dated October 2014 revealed: Standard Precautions Standard precautions are the recommended practice for the care of all . residents receiving care within our centers. When properly followed and adhered to, they reduce the risk of transmission of infectious agents . 1. Hand Hygiene before and after patient/resident contact--including after gloves are removed . RI #8 was readmitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease/ Stage 4. RI #8's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/2017 assessed RI #8 as requiring extensive assistance with one person physical assist for toilet use and personal hygiene. On 9/13/2017 at 4:46 p.m., incontinent care was observed on RI #8. EI #5, CNA, and EI #20, CNA. Upon entering the room EI #5 and EI #20 washed their hands prior to beginning the incontinent care. EI #5 performed the incontinent care using disposable periwipes and EI #20 assisted. Perineal care was completed and EI #5 removed her soiled gloves and donned clean gloves without washing or sanitizing her hands. RI #8 was turned and bowel movement was observed. EI #5 cleaned RI #8's buttock area, removed the soiled brief and removed her soiled gloves. EI #5 donned clean gloves without washing or sanitizing her hands. EI #5 placed a clean brief on the resident and secured the brief. On 9/14/2017 at 2:03 p.m., an interview was conducted with EI #20/CNA. EI #20 was asked what did the facility's policy indicate about when hands should be washed or sanitized during incontinent care. EI #20 said before care after touching dirty, before going to clean, and after care is done. EI #20 was asked should she have washed or sanitized her hands when changing her gloves when performing incontinent care. EI #20 said yes every time gloves are removed. When asked what was the potential harm to residents when hands were not washed or sanitized after gloves were changed during incontinent care. EI #20 said infection. On 9/14/2017 at 3:10 p.m., an interview was conducted with EI #5, CNA. EI #5 was asked what did the facility's policy indicate about when hands should be washed or sanitized during incontinent care. EI #5 said anytime gloves were taken off. EI #5 was asked when did she wash her hands during the incontinent care with RI #8. EI #5 said before and after. EI #5 was asked when should she have washed or sanitized her hands when changing her gloves during the provision of incontinent care. EI #5 said she did not think about it. When asked what was the potential harm to residents when hands were not washed or sanitized after gloves were removed during incontinent care. EI #5 said infection. 2. RI #10 was readmitted to the facility on [DATE] with diagnoses of Schizophrenia, Cerebral Infarction and Unspecified Kidney Failure. RI #10's Quarterly MDS with an ARD of 6/25/2017 revealed RI #10 required extensive assistance with personal hygiene and was always incontinent of urine. On 9/13/2017 at 5:22 p.m., an observation of incontinent care was made for RI #10. EI #5, CNA, and EI #20, CNA entered RI #10's room. EI #5 and EI #20 washed their hands and donned gloves. RI #10's brief was observed soiled with urine. Pericare was completed by EI #5 using periwipes and a clean brief was placed under RI #10. EI #5 removed her soiled gloves and donned clean gloves without washing or sanitizing her hands. EI #20 removed the soiled brief and straighten the clean brief. EI #20 removed her gloves and fastened the clean brief without washing or sanitizing her hands. On 9/14/2017 at 1:55 p.m., an interview was conducted with EI #20. EI #20 was asked how was she trained to perform hand hygiene during incontinent care. EI #20 said when changing a resident, when dirty is touched and when gloves are changed, hand sanitizer should have been used. EI #20 was asked why was it important to wash hands after removing gloves. EI #20 said so the resident would not get sick. When asked what did she touched before she took her gloves off. EI #20 said the soiled brief. On 9/14/2017 at 3:10 p.m., an interview was conducted with EI #5, CNA. EI #5 was asked what did the facility's policy indicate about when hands should be washed or sanitized during incontinent care. EI #5 said anytime gloves were taken off. EI #5 was asked when did she wash her hands during the incontinent care of RI #10. EI #5 said before and after. EI #5 was asked when should she have washed or sanitized her hands when changing her gloves during the provision of incontinent care for RI #10. EI #5 said she did not think about it. When asked what was the potential harm to residents when hands were not washed or sanitized after gloves were changed during incontinent care. EI #4 said could cause infection.