**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents were permitted to remain at the facility and not discharged for one (1) out of twenty-eight (28) sampled residents, Resident #341. Interview with Resident #341's son, on 11/08/19 at 11:30 AM, revealed Resident #341 was confused and could not make decisions while he/she was in the long term care facility. The son stated Resident #341 thought he/she was in Florida and sometimes did not recognize him on the phone. He further stated the resident did not act like this in the past and he found out from the hospital physician the resident had delirium because of the anesthesia administered during surgery. He also stated he told the facility he did not want the resident to leave the facility; however the facility discharged the resident because he/she wanted to go to the hospital. Interview with the Acute Care Hospital Social Worker, at 10:30 AM on 12/09/19, revealed Resident #341 was transported back to the hospital emergency room on [DATE], where the resident had surgery a few days prior. He/she stated after re-admission Resident #341 exhibited behaviors of yelling at staff and impatience; however, did not threaten to harm him/herself or others. The Hospital Social Worker stated the resident had mental health issues and was confused as a result of the surgery. Further interview revealed he/she did not feel the long-term care facility staff provided enough and/or appropriate interventions to deal with the resident's behaviors prior to transferring the resident back to the hospital. He/she stated if you gave the resident attention, he/she would calm down and would not exhibit those behaviors. In addition, review of Resident #341's long term care record revealed there was no documented evidence the transfer/discharge to the acute care facility was necessary or the facility attempted to find an appropriate discharge setting to meet the resident's needs. The findings include: Review of the facility's admission Criteria Policy, last reviewed date 07/30/18, revealed the facility would admit residents who could adequately and safely be cared for and whose medical and psychological needs could be met. Review of the facility's policy titled, Transfer/Discharge Notice, last revised date 09/05/18, revealed residents would be transferred and discharged according to resident's medical and psychological needs. Transfer and discharge provisions significantly restrict a facility's ability to transfer or discharge a resident once that resident had been admitted to the facility. The facility may not transfer or discharge a resident once that resident had been admitted to the facility unless: the transfer or discharge was necessary to meet the resident's welfare and the resident's welfare cannot be met in the facility; the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility; the safety of the individuals in the facility was endangered; the health of individuals in the facility would otherwise be endangered; the resident had failed, after reasonable and appropriate notice, to pay for a stay at the facility; or the facility ceased to operate. To demonstrate that for any of the events listed above, the facility would document in the resident's medical record. Review of the facility's policy titled, Discharge without Physician Approval, last revised date 06/28/18, revealed that discharges against medical advice of the attending physician would require a signed statement from the resident or responsible party to release the facility from responsibility for discharge. The order for an approved discharge would be signed and dated by a physician and recorded in the resident's medical record. If the resident or responsible party insisted upon being discharged without the approval of the attending physician/nurse practitioner/physician assistant, the resident and/or responsible party would sign a Release of Responsibility for Discharge against Medical Advice form. Should either party refuse to sign the release, such refusal would be documented it the resident's medical record and witnessed by two staff members. The administrator and director of nursing would be notified of the resident/responsible party discharge without an order from the attending physician/nurse practitioner/physician assistant. The director of nursing or charge nurse would inform the resident and/or responsible party of the potential risks involved in the early discharge of the resident. A copy of the statement would be filed in the medical record. Review of the facility's Discharge Planning Process Policy, last revised 07/29/19, revealed the facility would ensure a discharge planning process was in place to address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involve the resident, if applicable, the resident representative, and the interdisciplinary team in developing the discharge plan. Further review revealed if the resident chooses to be discharged to a setting which does not appear to meet the post-discharge needs or appears unsafe, the situation would be treated as a refusal of care and the facility would discuss with the resident and representative the implications and risks of the discharge to the location and attempt to determine why the destination was chosen; provide more suitable options to meet the resident's needs; document if the resident refused the offered option of an appropriate discharge setting and determine if a referral to Adult Protective Services or other state entity was necessary; and if so the referral should be made at the time of discharge. Record review revealed Resident #341 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of Severe Myopathy Secondary to Critical Illness Polyneuropathy versus Acute inflammatory Demyelinating Polyneuropathy/Guillian-Barre, Acute Metabolic Encephalopathy, Sepsis with Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteremia, Acute Hypoxic Respiratory Failure with Pneumonia, Right Wound Infection Status Post Above-Knee Amputation, and Acute Kidney Injury Secondary to Acute Tubular Necrosis Secondary to Sepsis. Interview on 11/08/19 at 3:25 PM with the Administrator, revealed the surveyor requested a copy of Resident #341's baseline care plan; however, he/she stated copies of all of the requested documents had been provided to the survey team. Review of all documents provided revealed no baseline care plan for Resident #341. Review of the Hospital Discharge summary, dated [DATE], revealed Resident #341 presented to the hospital on [DATE] for an open wound to the left lower extremity below-knee that was complicated by cellulitis and a recent surgery with dehiscence. The resident underwent left above-knee amputation; however, the stay was complicated by development of septicemia with MRSA bacteria and acute kidney injury resulting in requiring hospital prolongation. The resident developed encephalopathy which was attributed to toxic metabolic dysfunction with delirium and hyperactivity. Review of the Patient Transfer Form, dated 04/05/19, revealed Resident #341 was assessed by the hospital nurse to be oriented times two (2) with disruptive behavior as well as confused and forgetful. Review of admission Nurse's Note, dated 04/05/19 at 8:40 PM, revealed the facility assessed the resident to be oriented person, place and time. Resident #341 had frequent complaints of pain to hip and legs, had verbal behaviors upon arriving to the facility such as calling out and yelling repeatedly. Continued review revealed the staff were unable to redirect for very long. Review of a Nurse's Note, dated 04/06/19 at 5:51 PM, revealed Resident #341 had been unpleasant that shift by yelling out often and disrupting other residents. Continued review revealed the resident would yell for assistance and lash out at staff if demands were not met immediately. Resident #341 yelled and cursed at the nurse, and the nurse's attempts to redirect the resident were not successful. Additional review revealed Resident #341 stated that he/she was going home. Review of a Nurse's Note, dated 04/07/19 at 3:27 PM, revealed Resident #341 was alert and oriented with confusion. In addition, the resident was very demanding with staff and yelled for hours on multiple occasions. Staff attempted to redirect the resident by offering drink, snack, toileting and conversation. Continued review revealed Resident #341 rested in bed after staff provided incontinence care. Review of a Daily Skilled Nurse's Note, dated 04/08/19 at 11:55 PM, revealed Resident #341 was assessed to have long term memory problems, memory/recall problems, unable to recall staff names and faces; exhibited signs/symptoms of delirium, inattention and disorganized thinking; verbal behaviors; and mood problems, little interest/pleasure in doing things and trouble falling/staying asleep/sleeping too much. Continued review of the nurse comments/concerns revealed the resident screamed and yelled profanities; the nurse and certified nurse aide (CNA) offered water, and repositioned him in bed multiple times. Resident #341 fell asleep after pain medication was administered. Review of a Psychiatric Initial Evaluation, dated 04/09/19, revealed Resident #341 was assessed as having a Mini-Mental Status Examination (MMSE) score of twenty (20) indicating the resident had moderate cognitive impairment and poor insight and poor judgement. Continued review revealed the treatment plan was to increase Seroquel 25 milligrams (MG) every morning (QAM) and 100 mg every four (4) hours if needed (PRN) for anxiety disorder. Review of a Nurse's Note, dated 04/09/19 at 9:00 AM, revealed Resident #341 was very demanding and yelling out into the hallway constantly, even after his/her needs were met. Further review revealed that if staff could not meet his/her needs immediately, he/she would curse and yell at staff. Review of a Nurse's Note, dated 04/09/19 at 10:30 AM, revealed Resident #341 continued with demanding and verbal behaviors, cursed at staff and yelled into the hallway inappropriate comments about staff. Further review revealed he/she stated that the resident wanted to go home and go to the hospital and that they should not have brought him/her here. Review of the Activity's Director (AD) note, dated 04/09/19 at 11:48 AM, revealed Resident #341 was observed by the nurse's station yelling and demanding to go to hospital. Resident #341 agreed to watch a movie in the activities room then demanded to talk to the Social Services Director (SSD) so he/she could get an update on how to discharge to the hospital. The AD took the resident to the SSD's office as the resident requested. Review of the Social Services Director (SSD) note, dated 04/09/19 at 11:49 AM, revealed Resident #341 was brought to his/her office for one to one support because he/she would yell and curse at staff. Further review revealed Resident #341 demanded to go home and the SSD explained that his/her home was torn down and his/her son could not take care of him. The SSD tried to call son for two days in a row, with no return call. However, there was no documented evidence the Resident was offered other options other than return to the acute care hospital that could meet the resident's needs. Review of a Nurse's Note, dated 04/09/19 at 1:36 PM, revealed Resident #341 was out in the hallway and continued to yell all shift. Review of the SSD note, dated 04/09/19 at 1:10 PM, revealed Resident #341 continued to demand to go home or to the hospital. Review of a SSD note, dated 04/09/19 at 1:44 PM, revealed Resident #341 asked for pain medication from the nurse but it was not given due to not due at the time. The SSD offered interventions but unable to keep him focused on tasks and continued to stated he/she wants to go home or to the hospital. Review of a Nurse's Note, dated 04/09/19 at 2:37 PM, revealed Resident #341 stated that he/she wanted to go back to the hospital and demanded that staff send him there and he/she was being held there against his/her will. Continued review revealed the nurse informed the resident that it would be against medical advice to leave the facility. Resident #341 stated he/she understood what it means to sign out against medical advice and what the repercussions were to sign out against medical advice. Resident gave verbal consent to sign out against medical advice with the nurse and the Social Services Director, as witness. Review of a Nurse's Note, dated 04/09/19 at 4:15 PM, revealed Resident #341 would yell that he/she wanted to leave and go back to the hospital. Continued review revealed Resident #341 cursed and yelled at staff and could not be redirected. Review of a Nurse's Note, dated 04/09/19 at 6:36 PM, revealed Emergency Medical Services (EMS) arrived at the facility and Resident #341 yelled at EMS staff as they transported him/her on the stretcher. Resident #341's son called the facility and he was informed that his/her father gave verbal consent for leave against medical advice (AMA) so the resident was transported to the hospital. The nurse told the son of Resident #341 the he/she was discharged to the hospital because he/she continually yelled stating that he/she wanted to leave. Review of the Emergency Medical Services (EMS) Transfer Report, dated 04/09/19, revealed EMS dispatched and responded to a non-emergent call to the facility for patient needing transport to hospital per the patient's request. The patient and nursing home were advised there were closer appropriate facilities but the facility agreed to cover the expenses of the transport. Continued review revealed the patient was transported by ambulance due to confined to bed and unable to sit in an upright position due to extreme pain. The patient was moved from the ambulance to the emergency room (ER) via stretcher. Review of the Resident Transfer or Discharge Notice, dated 04/09/19, revealed Resident #341 was discharged to the hospital because the safety of individuals in the facility was endangered by the resident being here. In addition, there was no documented evidence of a signed Against Medical Advice (AMA) Form. Review of the Hospital Social Services Worker note, dated 04/16/19, revealed the facility admitted Resident #341 on 04/05/19 with known behaviors and care needs from the Emergency Medical Services (EMS) transport. The long term care facility informed the hospital social worker that the resident wanted to leave the facility and return to the hospital against medical advice. Continued review revealed the facility dropped off the resident on 04/09/19 in the hospital's emergency department with nowhere to go. However, the hospital was attempting to find placement at another nursing facility because the long term care facility refused to readmit the resident. Review of the long term care SSD's note on 04/10/19, revealed the acute care hospital social worker contacted him/her to ask how Resident #341 ended back at that hospital since it was not medically necessary. The social worker informed the SSD that the resident was dropped off at the hospital's emergency room by ambulance and he/she was trying to find placement for the resident. Interview with Social Services Director (SSD) on 11/08/19 at 10:16 AM, revealed Resident #341 was his/her own person and was not cognitively impaired. The SSD stated Resident #341 demanded that he/she wanted to leave and go to the hospital on [DATE]. The SSD stated the resident was offered television shows to watch, sensory activities to help with anxiety, and reassured his/her feelings but the interventions did not work. Further interview revealed the SSD did not provide more interventions because the resident wanted to go home. The SSD stated the facility had to send him/her back to the hospital because that was what the resident wanted. Further interview revealed that on 04/09/19 the SSD signed the discharge against medical advice form on behalf of the resident. However, the SSD did not offer more suitable discharge options to meet the resident's needs. Interview with the Resident #341's son, on 11/08/19 at 11:30 AM, revealed Resident #341 was confused and could not make decisions while he/she was in the facility. The son stated Resident #341 thought he was in Florida and sometimes did not recognize him on the phone. Further interview revealed the resident called him all hours of the night because he/she did not know what he/she was doing. He further stated that the resident did not act like this in the past and he found out from the hospital physician that the resident had delirium because of the anesthesia administered to him during surgery. He also stated that he told the facility that he did not want the resident to leave the facility but they stated the resident was leaving against medical advice. Post survey interview with the Acute Care Hospital Social Worker, at 10:30 AM on 12/09/19, revealed Resident #341 was transported to the emergency room of the hospital where the resident had a surgery in April 2019. He/she stated that Resident #341 exhibited behaviors of yelling at staff and impatience; however, he did not threaten to harm himself or others. He/she stated the resident had mental health issues but was confused as a result of the surgery. Further interview revealed he/she did not feel the facility staff provided enough and appropriate interventions to deal with the resident's behaviors. He/she stated if you gave the resident attention, he would calm down and would not exhibit those behaviors. Interview with Licensed Practical Nurse (LPN) #4, on 11/08/19 at 11:46 AM, revealed Resident #341 was upset and demanded to go home and to the hospital. He/she stated the resident was lucid and responded appropriately, and the resident was not confused during the time she provided his/her care. Further interview revealed he/she provided redirection, pain medication, referred to the psychiatrist, but the facility could not keep the resident there against his/her will. However, he/she did not explain to Resident #341 that the facility could find an appropriate discharge setting to meet the resident's needs rather than the hospital. Interview with the Director of Nursing (DON), on 11/08/19 at 10:34 AM, revealed the DON was sent a referral for Resident #341 on 04/03/19 and the hospital's nurse's notes revealed the resident was confused, anxious, and agitated at times. The hospital staff reported to the facility nursing staff that the resident had behaviors of yelling out, cursing, noncompliance, anxiety and agitation. He/she stated the resident had inappropriate behaviors upon admission and throughout his/her stay on 04/09/19; however, did not harm himself or others. Continued interview revealed that multiple interventions were put in place such as redirection, one on one activities, and pain management; however, none of the interventions were successful. Further interview revealed the staff could have done more for the resident's behaviors but he/she might have refused it. Interview with the Administrator on 11/08/19 at 3:25 PM, revealed the facility provided care for residents that had dementia and psychiatric diagnosis as listed in the facility assessment. Residents were admitted based on the acuity and diagnosis of the resident. The Administrator stated they could have met Resident #341's needs but he/she did not want to be there. She further stated that Resident #341 was oriented enough to make his/her own decisions. Further interview revealed she trusted her staff to make discharge/transfer decisions and they followed the discharge/transfer policies.

Based on observation, interview, record review and review of the facility policy it was determined the facility failed to ensure one (1) of one (1) refrigerated scheduled medication boxes were affixed to the medication refrigerator located on the East Hall. In addition, the facility failed to ensure the pharmacy emergency scheduled medication kit was secured within an affixed box or area in the medication refrigerator. The findings include: Review of policy titled Medication Ordering and Receiving From Pharmacy Provider/ Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 2007, revealed emergency medications and supplies were provided by the pharmacy in compliance with applicable state and federal regulations. The policy further revealed that Schedule II medications were a part of the emergency medication supply and must be double locked and shall be stored in a locked cabinet or locked drawer separate from the non-controlled medications. Review of policy titled Emergency Pharmacy Service and Emergency Kits (E-KITS) policy, dated 05/16, revealed the emergency kit, along with the list of contents posted on the outside of the kit, is maintained at a designated, locked area that was easily accessible in an emergency. Emergency medications were secured, checked periodically for integrity and dating, and stored in accordance with the State Board of Pharmacy and federal regulations. Schedule II medications in the emergency medication supply must be double locked and shall be stored in a locked cabinet or locked drawer separate from non-controlled medication. Observation of facility medication storage room, on 11/06/19 at 9:52, revealed a two-lock, metal storage box that contained resident-specific medication was not affixed to the medication refrigerator. The refrigerated, narcotic emergency kit (E-Kit) was located in the top, right corner of the refrigerator. The E-Kit was in a plastic, latched container that was sealed with two (2), plastic, zip cable ties and was not affixed to the medication refrigerator. Both narcotic boxes were stored in a refrigerator that contained non-narcotic medications. Observation of the medication refrigerator on, 11/07/19 at 9:49 AM, revealed the resident-specific, refrigerated narcotic storage box was affixed to the medication refrigerator with a long, thick chain. The refrigerated E-Kit remained unaffixed, in a plastic box sealed with two (2), plastic, zip cable ties. Interview with Licensed Practical Nurse (LPN) #1, on 11/07/19 at 9:49 AM, revealed the facility affixed the refrigerated narcotic box to the refrigerator yesterday with a chain. Review of the Pharmacy's monthly Med Station Review form, for November 2019, revealed the Emergency Medication Services' Controlled EDK storage was in compliance. Review list did not note what it considered in compliance. Interview with the Consultant Pharmacist #1, on 11/08/19 at 11:59 AM, revealed she checked the resident narcotic box to make sure it was affixed during her monthly visits and did not recall the resident narcotic storage box not being affixed to the medication refrigerator. Interview with LPN #1, on 11/06/19 at 12:15 PM, revealed only the medication nurses with keys to each medication cart can get into the medication room and then into the medication refrigerator. She stated the residents' refrigerated narcotics box contained two locks with two separate keys that were needed to open the box. Each nurse had one key and an extra key was hanging on a hook in the medication room, next to the medication refrigerator. Interview with LPN #1, on 11/07/19 at 9:49 AM, revealed she was unsure if there was a log to document the unaffixed, refrigerated narcotic E-Kit was checked to see if it was both there and sealed. She stated she did not sign off on anything during her shift and that maybe 3rd shift does it. She revealed that when she opened the medication refrigerator to remove resident medication, she did not check to see if the narcotic E-Kit was there and sealed. Interview with Registered Nurse (RN) #2, on 11/08/19 at 10:38 AM, revealed the narcotic boxes were not affixed in the refrigator and the boxes could be taken out of the medication room. She stated nursing was instructed yesterday to start documenting that the narcotic boxes were present, affixed and locked to ensure they did not get misplaced, removed from the refrigerator or diverted. She stated if the narcotics were diverted, misplaced or not available in event of emergency, it could impact patient safety and their lives. Interview with the Director of Nursing, on 10/07/19 at 11:33 AM, revealed the facility did not document the monitoring of the narcotic boxes or the E-Kit, nor did they check for their presence, or if the E-box was sealed. She stated she believed the narcotic box in the refrigerator had a chain, but she had to confirm that. She stated that she had asked pharmacy to provide a log sheet so the facility could begin documenting their auditing of the narcotic boxes. The DON revealed it was important to verify the presence of the narcotic storage boxes and acknowledge there was always a percentage of a chance that it could go missing. She stated that the resident would not be able to get the medication they need, if either of the narcotic boxes were missing. Interview with the Administrator, on 11/07/19 at 2:39 PM, revealed she was unaware of how the refrigerated narcotics were stored and would have to review the policy of narcotic storage. She stated you have to be a nurse to go into the medication room and knew that the narcotic E-Kit was in the medication room. She revealed that you have to have a physician's order to remove anything from the narcotic E-Kit and a nurse had to contact pharmacy to obtain an access code to be able to pull medication from E-Kit. She stated the access code just has to be written down and was more for paper work and was not needed to physically open the box. She revealed she did not know if there was an actual lock on the narcotic E-Kit and stated narcotics could go missing, if not properly stored. She denied any impact to the residents, if emergency narcotics were found unavailable because the facility would be able to order stat medications if something were found missing. The DON stated the nurses were busy 24-7 and were in and out of the medication room and would know if it the narcotic E-Kit was not there. She stated the facility would know immediately and be able to correct it timely. She was unaware of any documentation of nursing auditing the narcotic E-Kit. When this surveyor asked if there was a potential for staff to divert narcotics or if residents could be affected, the Administrator stated she did not feel comfortable answering that question until she spoke with her regional support.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy it was determined the facility failed to ensure food was stored in accordance with professional standards for food service safety. On 11/05/19, during initial tour, one (1) of four (4) refrigerator's temperatures were not within a safe range for food storage, the cooler temperature was fifty-eight (58) degrees Fahrenheit. The findings include: Review of the facility Census and Condition, dated 11/05/19, reveal forty-four (44) of out forty-four (44) residents received meals from the kitchen. Review of the facility policy, titled Record of Refrigeration Temperature, revised 08/08/19, revealed the refrigerator must be clean and temperature must be 41 degree Fahrenheit or less. Per the Food Code, a one (1)-two (2) degree variance are allow for accuracy. Review of the facility policy, tilted Food Storage, revised 09/14/18, revealed all frozen egg entrees and processed egg products should be stored according to manufacturer's instructions. These products are pasteurized. Thaw in refrigerator at 41 degrees Fahrenheit or less for eight (8) to ten (10) hours. Refrigerated items should be safe as long as power was out no more than four hours. Keep doors closed as much as possible. Discard any perishable foods such as meat, poultry, fish, eggs, and leftover have been greater than 41 degrees Fahrenheit for two (2) hours or more. On 11/05/2019 at 9:54 AM, the Director of Dietary (DOD) provided a tour of the kitchen, which included the food prep area, dry storage, and refrigerated storage. Observation revealed the walk-in cooler temperature was fifty-eight (58) degrees Fahrenheit. Continued observation of the kitchen, revealed one (1) and half (½) cases of liquid egg products, two (2) sleeves of American cheese, two (2) cream cheese, two (2) shredded lettuce, two (2) packages lunch meat/sliced ham. In addition one (1) bag shredded cheese, three-quarter case of sour cream packets, one (1) pimento cheese, one (1) margarine, and three (3) boxes pound cake. Second observation of the kitchen, on 11/06/19 at 3:05 PM, revealed the walk-in refrigerator cooler temperature was being worked on by the vendor. Review of the facility, titled Record of the Refrigeration Temperatures, on 11/06/19 at 11:30AM, revealed the walk-in cooler temperature reached 42 degrees at 7:20 AM. Review of the vendor report on 11/06/19 at 3:30 PM, revealed the vendor had been called to the facility on [DATE] at 11:20 AM. The vendor report stated the refrigerant on the cylinder was low, there was a leak on the thermal expansion value and the vendor tightened fitting pressure tested system. The vendor also vacuum and changed the refrigeration system and replaced the low-pressure switch. Further observation on 11/06/19 at 3:05 PM, revealed the walk-in cooler continued to store one (1) and half (½) cases of liquid egg products. Interview with Dietary Aide (DA) #1, on 11/05/19 at 10:35 AM, revealed she checked the facility refrigerators around 6:00 AM and recorded temperatures on the log. DA #1 states the temperatures were checked once daily and walk-in cooler temperature was 40 degrees Fahrenheit on 11/05/19. She stated she had not realize the walk-in cooler was above a safe temperature or was at 58 degrees Fahrenheit) until the DOD brought it to the dietary staff's attention on 11/05/19 around 11:00 AM. DA #1 stated once she pulled all her ingredients for breakfast from the walk-in cooler and placed in the prep cooler, she did not go back into the walk-in cooler unless she forgot something or it was lunch time. Further, interview with the Dietary Aide #1, revealed she witnessed the Dietitian and the Director of Dietary throwing away food which was not holding the correct temperature. She reported she was unsure what foods where kept and what was thrown away. The DA #1 state she did not use the food in the walk-in cooler. She stated if the food from the walk-in cooler was served by mistake, residents could become sick. Interview with Dietitian, on 11/05/19 at 2:11 PM, revealed she had only been employed with the facility for about a month. She stated she did not monitor the temperatures of the refrigerators or complete audits. Interview with Dietary Aide (DA) #2, on 11/07/19 at 8:52 AM, revealed the walk-in cooler temperature was at 50 degrees on 11/05/19, so the Director of Dietary (DOD) was contacted around 8:00 AM. She stated the DOD and Dietitian had checked temperatures on the food in the walk-in cooler and threw out some foods. She revealed none of the food was used for resident's consumption; however, she could not guarantee this. DA stated she anticipated another kitchen staff would stop anyone from using the foods from the walk-in cooler. She stated it was important to have correct temperatures for the walk-in cooler to prevent food-borne illness to the residents. Interview with Director of Dietary (DOD) on 11/06/19 at 3:05 PM, revealed she was not aware the walk-in cooler was not holding the correct temperature until the walk through. She stated she did not complete formal audits with documentation expect for the temperature logs, however, she expected her staff to let her know when there were issues with any of the kitchen equipment. Continued interview revealed, the DOD stated she did not know how the liquid egg products re-appeared in the walk-in cooler because she had thrown them away yesterday. She revealed consuming spoiled liquid egg products could cause illness to resident, which could result in hospitalization and emotional distress. Interview with Administrator on 11/08/19 at 4:29 PM, revealed she was not aware of the recent concerns of the high temperature in the walk-in cooler. The Administrator stated the Director of Dietary notified the maintenance department to repair any issues concerning the kitchen equipment. Continued interview with the Administrator, revealed while the repairs were being conducted, the DOD would contact her and they would determine the next action in the process. The Administrator stated she would have to look at policy to find out what foods would need to be removed from the walk-in cooler for resident safety. Furthermore, the Administrator reported her responsibility as an Administrator was to provide a safe environment and provide care to resident's needs.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the care plan was implemented for one (1) of thirteen (13) sampled residents, Resident #45, related to diabetic foot care. The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/19/18, revealed the care plan focused on how the facility would assist residents to meet their goals. The care plan was designed to identify problems, reflect treatment goals, and to identify measureable outcomes. The care plan was an aide to prevent and or reduce decline in residents' status and promote optimal functioning. Review of Resident #45's clinical record revealed the facility re-admitted the resident on 10/21/16, with the diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, and Diabetes. Review of Physician Orders, dated 07/10/18 and 07/24/18, revealed Resident #45 was to have Diabetic Shoes. Review of the Care Plan for Resident #45, dated 02/24/17, revealed the resident was at risk for complications associated with Diabetes. Interventions included diabetic shoes when available, dated 08/28/18. Observation, on 09/11/18 at 10:41 AM, revealed Resident #45 wearing black, worn, leather type shoes to both feet. The shoes were stretched where the foot entered the shoe and visibly worn on the outside and under-sole of both shoes. Interview with Resident #45, on 09/11/18 at 10:41 AM, revealed the facility evaluated the resident's eligibility for diabetic shoes several months ago. The resident stated the shoes, which he/she currently wore, were regular sneakers. The resident further stated he/she did not know why the facility had not provided the diabetic shoes. Interview with the Social Services Director (SSD), on 09/13/18 at 3:55 PM, revealed she and the Director of Nursing (DON) identified diabetic residents who needed and were eligible for diabetic shoes and Resident #45 was identified as eligible. She stated the medical company notified her of the required documentation to get the shoes and the DON worked on obtaining the documentation. The SSD stated the facility was waiting for the physician to make facility rounds in order to obtain the required documents, and the physician made rounds once a month. She stated Resident #45 had not received diabetic shoes as of 09/13/18. Interview with the DON, on 09/13/18 at 4:55 PM, revealed in early July 2018, she and the SSD compiled a list of diabetic residents who would benefit from diabetic shoes and identified Resident #45 eligible for shoes. She stated when she attempted to order the shoes she was informed of documentation required by the medical company. She stated the facility was waiting on the medical provider to make monthly rounds to obtain required documentation and had not made progress in obtaining Resident #45's diabetic shoes. Continued record review revealed a Report of Consultation, dated 08/30/18, from the Podiatrist for Resident #45's wound care to the right toes. The Podiatrist recommendation/order was to clean the right foot ulcers with saline, dry well, apply a thin layer of Santyl cream, apply a saline moist gauze, and a dry dressing. Review of a Physician Order, dated 08/30/18, revealed staff was to cleanse the right foot ulceration with normal saline, pat dry, apply Santyl to the wound bed, cover with a moist gauze, secure with a dry dressing, and change daily. Review of the Care Plan, dated 08/28/18, revealed Resident #45 had diabetic ulcers to the right great toe, second toe, and ball of the foot, with interventions to provide treatments as ordered. Review of Resident #45's electronic Medication Administration Record (MAR), dated 09/01/18 to 09/30/18, revealed an order for Santyl Ointment, with a start date of 08/30/18, to cleanse ulceration on right foot with normal saline, apply thin layer to wound bases, wrap with Kerlix, daily. The order on the MAR did not contain the direction to cover with moist gauze as ordered. Observation, on 09/13/18 at 8:20 AM, revealed Registered Nurse (RN) #1 completed wound care to Resident #45's right foot. The RN removed the soiled dressing, cleaned the toe with normal saline, and patted the area dry. She placed Santyl to the wound bed followed by a dry dressing. RN #1 completed wound care to the other areas on the foot with the same procedure. The nurse did not place a moist saline dressing on top of the Santyl as ordered. Interview with RN #1, on 09/13/18 at 8:56 AM, revealed prior to completing wound care she reviewed the treatment orders on the MAR. She stated she washed Resident #45's wound, applied the medicated cream, and placed a dry dressing proceeded by another dry dressing to hold the smaller dressing in place. She stated she did not check the wound care order on the MAR against the original order in the paper chart. Continued interview with the DON, on 09/13/18 at 4:55 PM, revealed she was responsible to ensure all orders were correct on the electronic MAR. She stated physician orders treated resident conditions to keep them at their optimum level of health and an incorrect treatment could cause slow or no progress in wound healing. Interview with Certified Nursing Assistant (CNA) #1, on 09/13/18 at 2:30 PM, revealed the care plan included how to care for the residents. She stated if the residents had specialty shoes, they would be included on the care plan. She stated she reviewed care plans weekly for changes and either the nurses or the Assistant Director of Nursing (ADON) updated the care plans. Interview with Licensed Practical Nurse (LPN) #3, on 09/13/18 at 1:50 PM, revealed resident care plans gave staff a guide on how to properly care for residents and were to be followed as written. She stated she did not review care plans daily and was notified about changes to care plans during report. She further stated if staff did not follow resident care plans, the residents' conditions could worsen. Interview with LPN #4, on 09/13/18 at 2:40 PM, revealed care plans told a story as to how to care for the resident. She stated nurses and CNAs were to follow the resident care plan and if not, then harm could occur to the resident. Interview with the Minimum Data Set (MDS) Coordinator, on 09/13/18 3:00 PM, revealed all staff was responsible to follow resident care plans. She stated she placed new orders/treatments on care plans during the Interdisciplinary Team (IDT) meeting every morning. She stated when diabetic shoes were requested; the facility added 'as available' on the care plan until the shoes were acquired. She stated the facility was to acquire the shoes in a timely manner and if the shoes were not available, or if treatment orders were done incorrectly, the care plan was not followed and could result in a negative outcome. Interview with the ADON, on 09/13/18 at 4:20 PM, revealed the IDT reviewed orders every morning and the MDS Coordinator placed new orders on the resident care plans and staff was verbally informed of changes to the care plans. She stated care plans helped care for residents and were not followed if staff did not have specialty equipment available or did not complete treatments correctly, which could affect resident outcomes. She stated she did not audit care plan implementation. Further interview with the DON, on 09/13/18 at 4:55 PM, revealed staff was to start care plans when new orders were obtained and the IDT reviewed the plans to ensure they were complete, and added other essential needs to existing care plans. She stated the IDT reviewed the entire resident care plan during the MDS quarterly review of the resident. She further stated staff was to follow care plans and if not, the residents' conditions could decline. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed staff was to provide good customer service and quality care to the residents. He stated the nursing administration had not presented issues with staff not following care plans. He further stated nursing administration made daily rounds to observe resident care, which would include care plan implementation. He stated if staff was not implementing the care plan, the DON and ADON would address the issue immediately.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to follow the physician order for one (1) of thirteen (13) sampled residents, Resident #45, related to wound care for a diabetic foot ulcer. The findings include: Review of the facility's policy, Resident with Diabetes, dated 09/17/15, revealed medications were to be administered as ordered. Review of the facility's policy, Change of Condition, revealed the facility entered orders for treatments or medications into the Electronic Medical Record (EMR). Review of Resident #45's clinical record revealed the facility re-admitted the resident on 10/21/16, with multiple diagnoses, which included Diabetes. Review of a Report of Consultation, dated 08/30/18, revealed the Podiatrist ordered to clean the right foot ulcers with saline, dry well, apply a thin layer of Santyl, apply a saline moist gauze, and a dry dressing. Review of a Physician Order, dated 08/30/18, revealed staff was to cleanse the right foot ulceration with normal saline, pat dry, apply Santyl to the wound bed, cover with a moist gauze, secure with a dry dressing, and change daily. However, review of Resident #45's electronic Medication Administration Record (MAR), dated 09/01/18 to 09/30/18, revealed an order for Santyl Ointment, with a start date of 08/30/18, with directions to cleanse ulceration on right foot with normal saline, apply thin layer to wound bases, wrap with Kerlix, daily. The order on the MAR did not have the direction to cover with moist gauze, per the physician order. Observation of Resident #45's wound care, on 09/13/18 at 8:20 AM, revealed Registered Nurse (RN) #1 removed the soiled dressing from the right toe, cleaned the toe with normal saline, and patted the area dry. RN #1 placed the Santyl cream to the wound bed followed by a dry dressing. The RN completed other areas to the foot with the same procedure. The nurse did not place a moist saline gauze on top of the Santyl cream before applying the dry dressing, per the physician order. Interview with RN #1, on 09/13/18 at 8:56 AM, revealed prior to completing wound care she reviewed the treatment orders in the EMR and gathered the supplies needed to complete the treatment. She stated she washed Resident #45's wound, applied the medicated cream, and placed a dry dressing proceeded by another dry dressing to hold the smaller dressing in place. She stated the nurses' station had a reference book for current treatment orders; however, she did not review the book because she knew the resident's treatment had not changed, as she had completed the treatments frequently. She further stated she did not check the wound care order in the EMR to the original order in the paper chart because the Assistant Director of Nursing (ADON) and Director of Nursing (DON) did that in the morning meeting after the order was written to ensure it was transcribed correctly. Interview with the DON, on 09/13/18 at 1:00 PM, revealed the facility reviewed new orders during the morning meetings the day after orders were received. She stated the orders were checked for transcription accuracy and to ensure all elements of an order were completed. She stated nurses did not do chart checks in the facility. She stated she accompanied staff weekly for wound assessments, measurements, and condition of the wounds and did not review accuracy of treatment orders during the weekly wound audits. She stated the pharmacy changed the treatment order for Resident #45 in the EMR on 09/04/18, because the pharmacy said the length of the order would not fit on the medication label and therefore shortened the order. The DON stated staff did not identify the inaccurate order when the medicated cream box arrived or when reviewing the order in the EMR prior to treatment. She stated the nurses were not following the physician order because the order was incorrect in the EMR. Interview with Licensed Practical Nurse (LPN) #3, on 09/13/18 at 1:50 PM, revealed nurses transcribed orders into the EMR and the DON checked to ensure the orders were transcribed correctly the next day in the morning meeting. She stated it was important to complete treatments as ordered or the wound could worsen or be delayed in healing. She further stated she did not review the original written order against the treatment order in the EMR with weekly wound assessments. She stated the facility did not instruct nurses to review the accuracy of the orders, except with the monthly print out of orders signed by the ADON or DON, and physician. Interview with the Minimum Data Set (MDS) Coordinator, on 09/13/18 at 3:00 PM, revealed she attended the morning meetings and she, the DON, and other staff present reviewed orders entered into the EMR to ensure staff transcribed the orders as written. She stated staff and administration did not review treatment orders weekly to ensure the order remained correct in the EMR. The Coordinator stated orders were written to care for the resident's condition and if the orders were not followed as written, the nurses were not following the physician order. She stated the resident's condition could be impacted and could change. Interview with the ADON, on 09/13/18 at 4:20 PM, revealed orders were reviewed during the morning meeting the day after the orders were written. One staff read the order from the chart to another staff that verified the order was transcribed correctly in the EMR. She stated the facility did not review treatment orders weekly during weekly wound assessments to ensure accuracy of the order. She stated if staff did not complete the correct treatment order, then staff did not follow physician order. She further stated the resident could be affected by prolonged wound healing and poor outcome. Continued interview with the DON, on 09/13/18 at 4:55 PM, revealed she was responsible to ensure all orders were correct in the EMR. She stated the physician orders were written to treat resident conditions to keep them at their optimum level of health. She stated incorrect treatment could cause slow or no progress in wound healing. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed staff should provide good customer service and quality care to residents. He stated nursing administration had not identified issues with incorrect treatment orders. He further stated he expected staff to resolve issues that could affect the condition of a resident.

Based on observation, interview, record review, and review of the facility's guidelines, it was determined the facility failed to provide diabetic shoes per physician order for one (1) of thirteen (13) sampled residents, Resident #45. The findings include: The facility did not provide a policy on Diabetic Foot Care. Review of the facility's Resident with Diabetes Guideline Steps, dated 09/17/15, revealed to provide diet as ordered and monitor intake, administer medications and lab work as ordered, monitor for signs and symptoms for hypoglycemia and hyperglycemia, monitor skin for redness or circulatory problems, monitor and ensure position changes, and encourage activity and exercise attendance. Review of Resident #45's clinical record revealed the facility re-admitted the resident on 10/21/16, with multiple diagnoses, which included Diabetes. Review of Resident #45's Physician Orders, dated 07/10/18, revealed an order for Diabetic Shoes. Review of Physician Orders, dated 07/24/18, revealed an order for Diabetic Shoes related to Diabetes. Review of the Care Plan for Resident #45, dated 02/24/17, revealed the resident was at risk for complications associated with Diabetes. Interventions included diabetic shoes when available, dated 08/28/18. Review of a letter from the [NAME] Specialist, dated 08/15/18, revealed the facility was notified of the required documentation in order to obtain diabetic shoes for residents. Observation, on 09/11/18 at 10:41 AM, revealed Resident #45 had on worn black leather type shoes to both feet. The shoes were stretched where the foot entered the shoe and visibly worn on the outside and under-sole. Interview with Resident #45, on 09/11/18 at 10:41 AM, revealed the facility evaluated the resident's eligibility for diabetic shoes several months ago, but had not provided the shoes for him/her. The resident stated he/she walked on the outer edge of his/her feet and his/her shoes were regular sneakers and uncomfortable because they were old and worn. The resident further stated the facility did not inform him/her as to why the diabetic shoes were not provided. Interview with Licensed Practical Nurse (LPN) #3, on 09/13/18 at 1:50 PM, revealed diabetic shoes were ordered by Social Services, as staff nurses did not evaluate for the need of diabetic shoes. She stated the facility did not train or instruct staff to evaluate for the need of diabetic shoes; however, she evaluated diabetic residents for good health and skin condition of the feet. She stated she would notify the Director of Nursing (DON) or Social Services if the resident requested diabetic shoes or felt the resident needed shoes. She further stated she had not previously identified Resident #45 as needing shoes nor did the resident request to her the need for shoes. Interview with the Minimum Data Set (MDS) Coordinator, on 09/13/18 at 3:00 PM, revealed the provider ordered diabetic shoes, and the Social Service Director (SSD) and DON worked on obtaining the documentation to order the shoes. The MDS Coordinator stated the Interdisciplinary Team (IDT) ensured the order was taken off and placed into the electronic medical record in the morning meetings. After the initial review, she was not sure how the shoes were tracked to ensure the residents received them. She stated if the orders were not followed and completed, the resident's condition could worsen. She further stated she did not follow-up during quarterly MDS reviews to check if residents received requested devices. Interview with the SSD, on 09/13/18 at 3:55 PM, revealed residents were not physically evaluated for diabetic shoes; however, she and the DON compiled a list of diabetic residents and reviewed who were eligible or would benefit from diabetic shoes. She stated Resident #45 was identified as eligible and the DON obtained an order for the shoes. She stated the medical company notified her of the required documentation for submission and the DON worked on obtaining the documentation. She stated the facility was waiting for the physician to make facility rounds in order to obtain the required documents, and the physician made rounds once a month. She stated Resident #45 had not received diabetic shoes as of 09/13/18. Interview with the Assistant Director of Nursing (ADON), on 04/13/18 at 4:20 PM, revealed diabetic shoes were ordered through a pharmacy. The resident required a foot exam by the medical provider and a detailed progress note and then the facility submission occurred with the resident's insurance. The pharmacy would send out a technician who measured the resident's foot for a correct fit. She stated the DON called the physician for needed documentation, but he had not been to the facility. She stated she was involved in the evaluation for diabetic shoes but was not instructed to follow-up on or fax documentation to the provider's office requesting completion. She stated not following through with orders resulted in a delay in treatment. Interview with the DON, on 09/13/18 at 4:55 PM, revealed in early July 2018, she and the SSD compiled a list of diabetic residents who would benefit from diabetic shoes and identified Resident #45 eligible for shoes. She stated she called the provider and obtained an order on 07/10/18 for the shoes, and on 07/24/18, the Nurse Practitioner wrote a second order for diabetic shoes. She stated when she attempted to order the shoes she was informed of the documentation required by the medical company and she called the provider to request the required documents, but had not faxed the documentation or followed up. She stated the facility was waiting on the medical provider to make monthly rounds and had not made progress in obtaining Resident #45's diabetic shoes. She stated she did not document communication or progress related to the shoes. She further stated the facility had not followed the physician order for Resident #45. Attempted phone interviews with the physician were unsuccessful. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed he was to ensure residents received proper care and services to maintain their optimal level of health. He stated nursing administration had not notified him of difficulties in obtaining shoes for Resident #45.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility's maintenance log, it was determined the facility failed to maintain a hazard free environment for one (1) of thirteen (13) sampled residents, Resident #18. Observation revealed Resident #18's footboard was wobbly on the resident's bed. Interview revealed he/she used the footboard to steady his/her balance when standing and his/her hand slipped off when it became unstable and he/she almost fell. The findings include: The facility did not provide a Maintenance Repair policy. Review of Resident #18's clinical record revealed the facility admitted the resident on 12/14/17, with diagnoses of Huntington's Disease, Lack of Coordination, Unsteadiness on Feet, and Muscle Weakness. Review of Resident #18's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident required extensive assistance of one (1) staff with transfers. The facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) and determined the resident not interviewable. Review of Resident #18's Care Plan, dated 12/28/17, revealed the resident had an unsteady gait and fluctuated with the level of assistance due to disease. Observation, on 09/11/18 at 8:42 AM, 09/12/18 11:10 AM, and 09/13/18 at 11:00 AM, revealed Resident #18's footboard on the bed was wobbly. Interview with Resident #18, on 09/12/18 at 11:10 AM and 3:07 PM, revealed he/she reported the wobbly footboard to staff multiple times, but maintenance staff had not evaluated the footboard. The resident stated he/she used the footboard to steady himself/herself with transfers and while transferring, his/her hand slipped off and he/she almost fell. He/she further stated the loose footboard was disturbing when repositioning in the bed. Interview with Resident #18's Roommate, on 09/12/18 at 3:07 PM, whom the facility assessed with a BIMS score of fifteen (15) out of fifteen (15) on 07/26/18 and deemed interviewable, revealed Resident #18 reported to staff about the wobbly footboard. He/she stated staff said they would notify maintenance but maintenance staff had not evaluated or addressed the footboard. Interview with Certified Nursing Assistant (CNA) #1, on 09/13/18 at 2:30 PM, revealed staff placed maintenance needs in the maintenance log and any staff could place a repair need in the log. She stated she had not noted any issues with bed boards being loose, but a loose board could hurt a resident. Interview with Licensed Practical Nurse (LPN) #3, on 09/13/18 at 1:50 PM, revealed maintenance staff was notified of repairs by staff writing the issue in the maintenance log. She stated maintenance staff reviewed the log twice a day, initialed, and marked through when it was completed. The LPN stated nursing staff was not required to evaluate bed equipment for resident safety; however, residents often used their beds for balance assistance with transfers. She stated a resident could get hurt if the bed frame was not intact. Interview with the Maintenance Director, on 09/12/18 on 3:45 PM, revealed the facility relied on the electronic system for routine maintenance. He stated the system prompted maintenance to check resident beds once a month; however, the head and footboards of the bed were not included on the routine bed maintenance. He stated he had prior awareness of Resident #18's loose footboard, but could not fix it because it required the bed to be removed from the resident's room to complete. He stated the resident could get hurt with the wobbly footboard. Review of the electronic Maintenance Log revealed the system prompted maintenance staff to test bed controls, bed hand controllers, and bed cords for correct operation on a monthly bases. Review of the electronic Maintenance Log, for July 2018, August 2018, and September 2018, revealed there was not an entry to repair Resident #18's footboard. Interview with the Regional Plant Operation Director, on 09/13/18 at 3:39 PM, revealed the electronic system prompted the maintenance department to check resident beds monthly. He stated the Maintenance Director should have requested nursing staff move another bed into the room as soon as he became aware of the safety issue. He further stated any equipment, directly related to the residents, that needed repair was to be repaired or removed from service immediately. Interview with the Assistant Director of Nursing (ADON), on 09/13/18 at 4:20 PM, revealed all staff was to place repair needs in the maintenance log and the director checked the log twice a day. She stated staff had been educated on how to fill out the repair form, and safety education was included in orientation and yearly in-services to check beds, lights, call bells, toilets, and equipment used daily for the care of residents. She stated it was a resident safety issue if the footboard was loose. Interview with the Director of Nursing (DON), on 09/13/18 at 4:55 PM, revealed staff was to place repair needs in the maintenance log. She stated she was not aware of any current repair needs that might affect resident safety. The DON stated staff was educated on the proper way to report maintenance needs and a wobbly footboard could be a safety hazard. She further stated it was the facility's responsibility to keep residents safe. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed safety was everyone's concern. He stated the Maintenance Director was new and still learning. He stated he was not made aware of safety issues with residents' beds and he was responsible to ensure the facility followed regulations to provide proper care and services to the residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain an effective infection control program for two (2) of thirteen (13) sampled residents, Resident #4 and #45. Observation revealed staff failed to wash hands and remove Personal Protective Equipment (PPE) before leaving Resident #45's contact isolation room. Further observation revealed while providing wound care, staff removed contaminated supply stickers from the biohazard wastebasket and placed them on the dresser, then took them out of the isolation room to the nurses' station. In addition, Resident #4 was in isolation and observation revealed a biohazard waste receptacle was not available in the room. The findings include: Review of the facility's policy, Isolation-Categories of Transmission-Based Precautions, revised January 2012, revealed standard contact precautions were to be utilized for residents with known infections which could be transmitted by direct contact. Staff and visitors were to wear gloves and gowns when entering a room for contact precautions and wash their hands after removal of gown and gloves and immediately leave the room. Masks were to be removed by the elastic bands prior to leaving the room and hands were to be washed. Review of the facility's Guideline Steps to Donning and Removing Personal Protective Equipment (PPE), dated 06/01/15, revealed removed PPE articles were to be placed in a waste or linen receptacle and immediately perform hand hygiene after removing PPE. 1. Observation, on 09/11/18 at 9:10 AM, revealed a cart with PPE at the entry of Resident #4's room. A sign on the door said see nurse before entering the room. Resident #4 was under contact isolation precautions for what was described by the Director of Nursing (DON) as a stomach bug. Continued observation revealed there was no biohazard waste receptacle in the room for staff disposal of PPE before exiting the room. Interview, on 09/13/18 at 11:25 AM, with Certified Nursing Assistant (CNA) #2 revealed before leaving a contact isolation room, staff, and/or visitors must deposit the worn PPE in a biohazard waste hamper and she had not seen any isolation rooms without a red bag waste hamper. CNA #2 stated a red bag waste hamper should always be in the room when the resident was under isolation precautions. The CNA stated if a red bag waste hamper was not in a resident's room, staff should place the worn PPE in a regular disposable waste container bag because PPE must not be worn outside of the resident's room. Interview with CNA #1, on 09/13/18 2:30 PM, revealed staff should place PPE in yellow or red biohazard bins in resident rooms. She stated the bins were placed in the rooms when the resident started on isolation precautions and the CNAs changed out the bags once a day. Interview, on 09/13/18 at 2:22 PM, with Licensed Practical Nurse (LPN) #1 revealed when a resident was under isolation precautions, a hamper with a red bag liner should be in the resident's room for deposit of biohazardous waste such as used PPE. She stated the room should also have a hamper with a yellow bag for the resident's soiled laundry. After removing PPE, the LPN stated staff or visitors should dispose of it in the red lined hamper and not in the regular trash. LPN #1 stated disposal of PPE in the proper waste container minimized cross-contamination throughout the facility. Interview, on 09/13/18 2:52 PM, with the DON revealed the biohazard (red bag) waste hamper was not in Resident #4's room on the morning of 09/11/18, because staff had not yet retrieved a hamper from storage outside of the main building. She stated there was not much storage space in the main building so some supplies had to be stored elsewhere. The DON stated she monitored staff for proper process with use of and disposal of PPE, but she did not have written records of her monitoring. 2. Record review revealed Resident #45 was placed in contact isolation on 09/07/18, due to the resident's wound culture resulted in Methicillin-Resistant Staphylococcus Aureus (MRSA) and Vancomycin-Resistant Enterococcus (VRE) (contagious infections). Observation, on 09/11/18 at 10:06 AM, revealed the Chaplain was donned in PPE including a mask in Resident #45's room. The Chaplain removed his gown and gloves, left the isolation room with the mask on, and did not wash his hands. The Chaplain walked around the facility with the mask on physically touching countertops, side rails, and residents. Interview with the Chaplain, on 09/11/18 at 10:35 AM, revealed he was educated on isolation precautions and knew he was to remove all PPE and wash hands before leaving the room. He stated if the steps were not followed, he could spread germs to other residents, and they could get sick. Interview with LPN #3, on 09/13/18 at 1:50 PM, revealed staff was to remove all PPE and wash hands before leaving the room. She stated if PPE was not removed and hands not washed, staff could spread infection around the facility. She further stated residents could become sick if staff did not follow proper infection control practices. Observation of Resident #45's wound care, on 09/13/18 at 8:20 AM, revealed Registered Nurse (RN) #1 did not clean the bedside table prior to placing a barrier and sterile dressing supplies for the resident's foot on top of the table. LPN #1 assisted with wound care and retrieved discarded outer wound packaging from the red biohazard bag, which contained the soiled dressings. The LPN removed the charge stickers from the packaging and placed them on top of the resident's dresser. LPN #1 washed her hands, put on clean gloves, placed the removed stickers onto the gloved fingers, left the isolation room, and placed the stickers on the resident's charge paper at the nurses' station. Further observation revealed RN #1 did not date or time the resident's dressing. Interview with RN #1, on 09/13/18 at 8:56 AM, revealed all surfaces were to be cleaned prior to placing sterile wound supplies on top and she did not complete this step during wound care. She stated cross contamination could occur and the wound could worsen or be delayed in healing. She stated staff was not to remove articles from the red biohazard bag because once items were placed into the biohazard bag, they were considered contaminated. RN #1 stated items were not to be removed from an isolation room because that was a cross contamination issue and could cause residents to become ill. Interview with LPN #1, on 09/13/18 at 10:45 AM, revealed she assisted RN #1 during Resident #45's wound care and retrieved supply stickers from the biohazard bag and placed the stickers on the resident's dresser. She stated she left with the stickers and placed them on the resident's page in the charge book. LPN #1 stated the facility educated her annually on infection control and audited her infection control techniques. She did know how else to ensure the resident was charged for the supplies if the stickers were in the biohazard bag. Interview with the Assistant Director of Nursing (ADON), on 09/13/18 at 4:20 PM, revealed she assisted the staff educator and audited staff handwashing techniques and observed staff on the floor daily. She stated she completed one on one training when she identified errors in technique. She stated once items were thrown into the red disposable biohazard bag, the items were not to be removed. Interview with the DON, on 09/13/18 at 4:55 PM, revealed she audited staff on infection control with visual observations and completed immediate re-education when breaks in techniques were identified. She stated staff development and the ADON monitored staff compliance with infection control. She stated staff received education during orientation, annually, and as needed for proper infection control. She further stated staff was not to wear PPE out in the hallway and hands were to be washed before leaving the room. Interview with the Administrator, on 09/13/18 at 5:10 PM, revealed he was to ensure staff followed regulations to ensure residents received proper care. He stated staff had not reported identified issues with infection control.