Based on observations, interviews, and review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, the facility failed to ensure: 1) a licensed nurse did not place Resident Identifier (RI) #53's medication on the over bed table, then into her pocket, prior to placing the medication back into the medication cart; and 2) a licensed nurse washed her hands prior to preparing RI #31's medications. These failures affected RI #s 31 and 53, two of five residents, and two of four nurses, observed during medication administration observations. Findings Include: 1) On 6/12/19 at 4:34 p.m., during medication administration observations, Employee Identifier (EI) #3, a Licensed Practical Nurse, removed medication (eye drops) from the medication cart, placed the medication on RI #53's overbed table, then stored the medication in her pocket while administering other medications. EI #3 then returned to the medication cart and placed the eye drops back inside. A phone interview was conducted on 6/13/19 at 11:42 a.m. with EI #3. EI #3 was asked, what should be done before laying medication and supplies on the resident's overbed table. EI #3 stated, Usually it's cleaned off and I put a paper towel there. EI #3 was asked, did you do that yesterday. EI #3 stated, No ma'am. EI #3 was asked, after administering RI #53's eye drops, what did she do with them. EI # 3 stated, I put them in my pocket, then returned them to the med (medication) cart. EI #3 said she was not supposed to store things in her pocket because it could become contaminated. 2) A review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, effective August 2018, revealed: . MEDICATION ADMINISTRATION-GENERAL GUIDELINES Procedures . A. Preparation . 2) Handwashing and Hand Sanitation : The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: * before beginning a medication pass * prior to handling any medication . On 6/13/19 at 8:23 a.m., EI #4, a Licensed Practical Nurse, left the medication cart and went into the medication room, touching the door handles to the medication room and refrigerator. She then returned to the medication cart and began preparing medications for RI #31 without washing her hands. An interview was conducted on 6/13/19 at 9:10 a.m. with EI #4. EI #4 was asked, before starting to prepare medications, what should be done. EI #4 stated, Wash my hands. EI #4 was asked what she should have done after returning from the medication room, before continuing to prepare RI #31's medications. EI #4 stated, Wash my hands. EI #4 was asked, what is the potential for harm. EI #4 stated, Cross Contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure an individualized care plan was developed to address Resident Identifier (RI) #12's use of side rails. This affected one of 16 sampled residents for whom care plans were reviewed. Findings include: RI #12 was admitted to the facility on [DATE] with diagnoses of Muscle Weakness, Unspecified Lack of Coordination, and Cognitive Communication Deficit. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #4, the Minimum Data Set/ Care Plan Coordinator, was interviewed on 6/07/18 at 4:18 PM. EI #4 said the purpose of a resident's care plans was to ensure you know everything the resident needs, including all care needs. She explained the approaches should reflect the personal choices, likes, dislikes, diagnoses, and care areas for each resident. EI #4 said all care plans should be patient centered. When asked if RI #12's care plans were individualized for the use of side rails, EI #4 said, no not for side rails.

Based on observations, interviews and review of a facility policy titled, Gloving, the facility failed to ensure a licensed staff member wore gloves when administering a subcutaneous injection to Resident Identifier (RI) #7 on 6/06/2018. This affected one of three residents observed for subcutaneous injections during medication administration observations. Findings include: Review of a facility policy titled: Gloving, with an effective date of 8/2005 revealed: . I. Indications A. To reduce the possibility that personnel will become infected with microorganisms, to reduce the likelihood that personnel will transmit their own endogenous microbial flora to resident . II. A. All employees who come in direct contact with blood or body fluids are to wear gloves . B. Gloves should be worn for any procedure requiring aseptic technique. On 6/06/18 at 4:32 PM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), was observed administering a subcutaneous injection to RI #7. EI #6 did not wear any gloves for the administration of the injection. EI #6 was interviewed on 6/07/18 at 3:39 PM. When asked what the facility's policy indicated about when gloves should be worn, EI #6 was unsure; however, after reviewing the policy, EI #6 said gloves should be worn anytime a procedure requires aseptic technique. EI #6 said gloves should be worn when administering a subcutaneous injection to prevent cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure Resident Identifier (RI) #12 was assessed to determine the need for side rails and the risk of entrapment prior to utilizing two upper side rails. Further the facility failed to obtain informed consent prior to applying side rails for RI #12. This affected RI #12 one of one resident sampled for siderail use but had the potential to affect 28 of 64 total residents in the facility identified by staff as using side rails. Findings include: RI #12 was admitted to the facility on [DATE] with diagnoses of Muscle Weakness, Unspecified Lack of Coordination, and Cognitive Communication Deficit. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #3 also confirmed RI #12 was not able to use the side rails. When asked if she could provide evidence the resident was assessed to determine the risk of entrapment, EI #3 said she could provide a fall risk assessment, but it did not address entrapment, only confusion and falls. When asked if residents should be assessed to determine if side rails were appropriate for them, EI #3 said the facility only used one size of side rail, and it was not individualized for each resident's needs. EI #5, the Interim Director of Nursing, was asked to explain the facility's process for determining whether a resident requires the use of siderails on 6/07/18 3:52 PM . EI #5 said she came to the facility in mid March of 2018 and had determined the facility was not using an assessment tool for siderails. She also said she was working on a policy, but neither the policy or the assessment for siderails had been implemented yet. When asked how the size of siderail a resident requires should be determined, EI #5 said therapy should be involved in that decision, but that had not yet been implemented. During a follow-up interview with EI #5 on 6/07/18 at 4:55 PM, the Interim Director of Nursing said RI #12 should have two top siderails up, but did not know what size. EI #5 further stated RI #12 had not been assessed for the risk of entrapment; nor did the facility have informed consent for the use of the side rails. On 6/07/18 at 5:18 PM, EI #5 stated the facility did not currently have a policy addressing siderail use. She further said none of the 28 residents identified by the facility as utilizing siderails had informed consent for the use of their side rails.

Based on observation, interviews, and review of the facility policy titled . SUBJECT: Food and Supply Storage Procedures and review of the 2017 Food Code, the facility failed to ensure: 1.) a dented can of pineapple chunks was removed from stock rotation; 2.) Glucerna TF was not stored past the manufacturer's use by date; and 3.) raw chicken was not stored directly over coed/prepared pork tenderloins. These failures had the potential to affect all 60 residents receiving meals from the dietary department. Findings include: Review of the undated facility policy titled . SUBJECT: Food and Supply Storage Procedures revealed the following: . POLICY: Dry Storage * . Remove Dented Cans and place in dented can area for credit and discard. * Remove from storage any items for which the expiration date has expired. * . Store cooked meat above raw meat. On 6/06/18 at 8:38 AM a can of pineapple chunks was observed on a shelf in the dry storage area in rotation for use. The can had a large dent on the bottom, side of can. The dry storage area also had two cases of expired tube feeding formula (Glucerna 1.2 Cal). The cases had a manufacturer's use by date of 5/1/2018. On 6/06/18 at 8:49 AM a rack containing trays of cooked pork tenderloins and raw chicken was observed in the walk-in cooler. The rack had a plastic tray with cooked pork tenderloins, and on each of the three shelves above the cooked pork were sheet pan of raw chicken breasts with blood-colored juices on the pans. Employee Identifier (EI) #1, Dietary staff, confirmed the raw chicken was stored over top of the cooked pork and said raw items should not be stored over cooked items because it could cause contamination.- EI #2, the Dietitian, was interviewed on 6/07/18 at 8:29 AM. EI #2 said it was important to ensure canned food items did not have dents because of the possibility of the seal being compromised. EI #2 also stated items should be checked on an ongoing basis for use by dates. EI #2 said the Glucerna should not have been stored past the use by date because it exceeded the manufacturer's quality standard. when asked how cooked and raw meat should be stored, EI #2 said raw meat should always be stored on the bottom, with cooked meat above it due to the potential for contamination.