Based on clinical record review, staff interviews and facility policy review, the facility failed to revise a Care Plan to accurately reflect a Physician Order for a diet change for 1 of 3 residents reviewed for diets (Resident #17), and failed to revise a Care Clan to accurately reflect the risks of utilizing high-risk medications for 1 of 5 residents reviewed for medications taken (Resident #26). The facility reported a census of 61 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment completed for Resident #17, dated 8/22/23 documented the resident severely cognitive impaired. A Telephone Order signed by the physician dated 8/24/23 documented a Physician Order for diet ground meat and mechanical soft. A review of Resident #17's Care Plan documented the resident received a pureed diet. 2. The MDS Assessment completed for Resident #26, dated 10/3/23 showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS documented Resident #26 received a diuretic medication given 7 of the 7 days during the look back period. A Telephone Order signed by the physician dated 8/08/23 documented a Physician Order for Lasix (diuretic) 20 milligrams (mg) give once daily. A review of the Resident's August, September and October 2023 Medication Administration Records (MARs) dated 10/25/23 documented Resident #26 received a Lasix 20 mg oral tablet daily from 8/09/23 - 10/25/23. A review of Resident #26's Care Plan lacked documentation related to the use of a diuretic and the risk factors for use. An interview on 10/25/23 at 3:48 p.m., Staff A, MDS Coordinator reported any medication that are high-risk and diet changes should be updated on the Care Plan within 7 to 14 days of occurrence. During an interview on 10/25/23 at 4:15 p.m., the Director of Nursing (DON) verbalized she was unsure of how soon the Care Plan should be updated with changes such as diets and high-risk medications. She reported she thought it might be within 7 days but will check. An interview with the DON on 10/25/23 at 4:30 p.m., reported the Care Plans should be updated right away if it is something like an intervention from an incident such as a fall and all other things can be updated within 14 days of any changes to the residents plan of care. A policy titled Care Plans, Comprehensive Person-Centered with a revised date of March 2022 documented assessments of residents are ongoing and Care Plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 10/25/23 at 12:01 PM, in the [NAME] Wing Kitchen, Staff B, Food Service Worker washed her hands and applied gloves. While wearing the gloves she moved from surface to surface touching the serving utensils, the refrigerator, and a ketchup bottle. With the same gloved hands, she picked up a piece of sliced cheese and put it on a hamburger. She proceeded to handle the sliced cheese with the gloves for six other hamburgers served. On 10/25/23 at 12:15 PM, Staff E, Certified Nurses Aide (CNA) entered the kitchen area during meal services not wearing a hairnet and put juice away in the refrigerator. An interview on 10/25/23 at 12:38 PM, Staff C, Dietary Manager verbalized he expected staff to put clean gloves on or use a utensil when handling sliced cheese. He verbalized no staff should go into the kitchen area during meal service unless they are wearing a hairnet. An interview on 10/25/23 at 12:38 PM, Staff D, Director of Dining Services reported the staff serving in the dining room are educated on proper serving techniques and he expected staff to wear clean gloves or use a utensil when handling sliced cheese. The policy titled Handling Serviceware and Utensils dated 6/2003, directed Dietary Staff don't touch the food contact surface with bare or soiled gloves. The policy titled Personal Hygiene dated 6/01/2002, revealed Dietary Staff to wear proper hair restraints. Based on observations, staff interviews and facility policy review, the facility failed to maintain proper food handling practices while serving food for 4 out of 5 meals observed and failed to restrain hair for 3 out of 5 meals observed. The facility reported a census of 61 residents. Findings Include: 1. On 10/23/23 the following observations made during a lunch meal service in the Lynch Dining Room (DR): a. At 12:16 PM Staff F, Food Service Worker served food while she wore a baseball styled hat while several inches of her braided hair hung over the front of both shoulders. Staff F used her gloved hands to to pick up plates from under the counter and with the same gloved hands picked up grilled cheese sandwiches from the pan and placed them on plates. Staff used the same gloved hands to use the scoops to serve the rest of the items. b. At 10/23/23 12:19 PM, Staff F, used the same gloved hand to pick up the grilled cheese sandwich from the tray placed it on a plate. c. At 12:22 PM, Staff F used her gloved right hand to pick up grilled cheese sandwiches, she used the same gloved hand to scoop the food then reached for another plate from under the counter. She used the gloved hand to pick up the grilled cheese sandwich and put it on the plate. Staff F moved out of the kitchen area, obtained plastic wrap to cover a tray. She went back in to the kitchen area with the same gloved hand she took a plate from under the counter and placed the sandwich on the plate and dished up the additional items with multiple scoops and gave the plate to nursing staff for delivery. 2. On 10/24/23 observed the following in the Lynch DR: a. At 8:24 AM, Staff F, served a resident who sat at the table toast as her hair hung in a braid over her right shoulder while she wore a baseball like hat. b. At 12:44 PM, Staff F wore a baseball like hat in the kitchen while several inches of her braided hair hung over her right shoulder. Staff F failed to wear a hairnet. 3. On 10/25/23 the following observed during a lunch meal service a. At 12:04 PM, Staff G, Food Service Worker in the Lynch kitchen used her gloved right hand to grab the hamburger bun and place it on the plate, she used the same gloved hand for the tongs as she placed the tomato on the hamburger. b. At 12:05 PM, Staff G, used the right gloved hand to apply bacon, lettuce, tomato then took a hold of the tongs to dish other food onto the plate. Staff G went to the water dispenser filled a glass, she retrieved from the cupboard to the left of the water dispenser with her gloved hand. c. At 12:07 PM, She used her gloved right hand to pull a slice of cheese from package and put on bun. She grabbed onions from the dish with right gloved hand after she pulled a dish from under the counter and continued to handle scoops for the other meal items. d. At 12:10 PM, Staff G, took her right and left gloved hand, pulled apart the bun, sat it on a plate. She used her left gloved hand to add tomato, cheese, and reached below the serving counter to get another dish and continued to use scoops to serve other menu items. e. At 12:11 PM, Staff G, used her gloved hand to put tomato, lettuce and onions on the hamburger and used utensils to scoop the rest of the meal onto the plate. On 10/25/23 at 12:54 PM, Staff G reported the facility provided her training on glove usage. She stated she knew not to touch the food with her gloved hands. On 10/25/23 at 12:48 PM, Director of Dining Service's reported he expected the staff to use a glove to touch ready to eat food only if they were not touching anything else with that gloved hand. He stated he expected Dietary Staff to have hairnets in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews and policy review, the facility failed to ensure lorazepam concentrated liquid (anti-anxiety medication) also referred to as Ativan, a level 4 controlled drug that required refrigeration was secured in a separately locked, permanently affixed compartment while refrigerated for 4/5 residents with liquid lorazepam observed during shift count (Res. #5, #6, #7, and #8). Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence. The facility reported a census of 62 residents. Findings Include: 1. Review of a Physician's Telephone Order for Resident #5 documented an order dated as received on 4/4/23 for Ativan solution 2 milligrams (mg)/milliliter (ml), administer 0.25 ml (0.5 mg) sublingually every hour as needed for anxiety/restlessness. Review of a Controlled Drug Receipt/Record/Disposition Form for Resident #5 documented 30 ml of Lorazepam concentrate 2 mg/ml was dispensed on 4/4/23. The record further documented on 4/5/23 at 11:20 a.m. 29.75 ml remained. 2. Review of an Electronic Order for Resident #6 documented an order dated 12/7/22 for lorazepam solution 2 mg/ml, administer 0.25 3 times a day for anxiety/restlessness. Review of a Controlled Substance Shift Count and Usage Record for Resident #6 documented 30 ml of Lorazepam 0.25 ml (0.5 mg) was dispensed and on 4/5/23 after the a.m. dose 7.5 ml remained. An observation of the [NAME] Neighborhood Medication Cart on 4/5/23 at 12:20 p.m. Staff A, Registered Nurse (RN) revealed the Lorazepam liquid for Resident #5 and #6 were located in an unlocked medication refrigerator in the locked medication room adjacent to the Nurse's Station. Staff A stated the medication refrigerator, which also contained insulin and other medications should have been locked. Staff A produced a key and locked the medication refrigerator. 3. Review of an Electronic Order for Resident #7 documented an order dated 3/21/23 for Lorazepam (2 mg/ml) concentrate 0.5 ml sublingual every hour as needed for anxiety or nausea for 14 days. Review of a Controlled Drug Receipt/Record/Disposition Form for Resident #7 documented 30 ml of Lorazepam concentrate 2 mg/ml was received on 3/22/23 and on 4/5/23 29.5 ml remained. 4. Review of an Order Sheet for Resident #8 documented an order dated 3/31/23 for Lorazepam 2 mg/ml administer 1 mg by mouth 45 minutes to 1 hour prior to shower on shower days. Reviewed of a Controlled Drug Receipt/Record/Disposition form for Resident #8 documented 30 ml of Lorazepam concentrate 2 mg/ml was received on 3/31/23 and on 4/5/23 30 ml remained. An observation of the Lynch Neighborhood Medication Cart on 4/5/23 at 12:30 p.m. Staff B, RN revealed the Lorazepam liquid for Resident #6 and #7 were located in an unlocked medication refrigerator in the locked medication room adjacent to the Nurse's Station along with other medications. Staff B, RN stated the medication refrigerator should be locked but she was unable to locate the key. In an interview on 4/5/23 at 1:30 p.m., the Director of Nursing (DON) confirmed would expect the medication refrigerator to be behind the locked Medication Room door and would expect the medication refrigerator to be locked by the lock integrated into the door. Review of the facility's Controlled Substances Policy dated September 2022 and revised November 2022 noted the Policy Statement documented the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances. Under the Policy Interpretation and Implementation Section of the policy at Point #4 documented - Following Chapter 58.21, Scheduled II Medications remain double locked at all times except during administration and access is recorded, and Schedule III – IV controlled medications are locked and recorded.