Based on observation, interview, personnel record review, and the facility policy review, it was determined the facility failed to complete reference checks for three (3) of three (3) newly hired staff, State Registered Nurse Aides (SRNA) #2, #3, and #4. The findings include: Review of the facility's policy, Identification and Reporting of Suspected Abuse/Neglect, and Exploitation Situations, review date 05/10/19, revealed the purpose identified potential victims of abuse or neglect and complied with state and federal regulations. Each resident had the right to be free from mistreatment, abuse, neglect, and exploitation. The facility planned for the screening and training of employees, the protection of residents, and for the prevention, identification, investigation, and reporting of mistreatment, abuse, neglect, and exploitation. All potential employees were screened during pre-employment through a criminal background check and a reference check. Review of SRNA #2's personnel file revealed her date of hire (DOH) was 05/06/19, and no reference check was documented as completed prior to SRNA #2 beginning employment. Review of SRNA #3's personnel file revealed her DOH was 05/20/19, and the facility did not provide evidence in the file or documentation of a completed reference check prior to hire. Review of SRNA #4's personnel file revealed her DOH was 03/25/19, and the facility did not provide evidence in the file or document a completed reference check. Interview with the Human Resource Manager (HRM), on 07/02/19 at 12:28 PM, revealed there were no reference checks on any of the staff. He stated there was a time period when the facility completed reference checks; however, the facility no longer completed the reference checks for the new hires. Continued interview with the HRM, and the Coordinator of Recruitment and Retention, on 07/02/19 at 3:47 PM, revealed the facility policy selection process was to verify current and past employment, and verify employer dates of services. The HRM stated there were some staff changes and the reference checks were not obtained on some of the new hires. Interview with the Unit Manager, and the Director of Nursing (DON), on 07/02/19 at 7:50 PM, revealed the nursing facility staff did not complete any of the hiring process for the new hires. They stated the Human Resource Department completed all components of the hiring process.

Based on interview, record review, and facility policy review, it was determined the facility did not provide the Ombudsman with resident discharge notifications, or hospital transfer notifications for two (2) of two (2) residents, Resident #9 and #10. Resident #9 was discharged to the community without ombudsman's notification, and Resident #10 was hospitalized without the ombudsman's notification. The findings include: Attempted review of the facility policy related to Transfers, Discharges, and Notifications to Residents, Representatives, and the Ombudsman, revealed the facility did not have a policy pertaining to notifications. Review of Resident #9's clinical record revealed the facility admitted the resident, on 04/01/19 with a diagnosis of Community Acquired Pneumonia. However, the facility transferred the resident to the hospital for admission, on 04/12/19 with diagnoses including Chronic Hypoxic Respiratory failure with Invasive Fungal Aspergillosis, and Worsening Hypoxia. Review of Resident #10's clinical record revealed the facility admitted the resident, on 04/05/19 with a diagnosis of Debility Related to a Cardio-Respiratory Condition. Continued review revealed the facility discharged Resident #10 to the community on 04/19/19. Interview with the Social Services Director, on 07/02/19 at 7:46 PM, revealed she did not provide written notification to the ombudsman, the resident's representative, or the resident regarding the reasons for transfer/discharge. She stated she did not provide any information related to the transfer, therefore, she had no reason to document the discharge in the medical record. She stated the facility did not have a policy related to the resident discharge that directed staff to provide notifcation to the resident, the resident's representative, or the ombudsman. Interview with Unit Manager, on 07/02/19 at 7:50 PM, revealed the facility did not have a policy related to notification of the Ombudsman of transfers and discharges of residents in the facility. She stated the notification responsibility would belonog to the social services staff. The Unit Manager stated notification was not provided to the Ombudsman. Interview with the Administrator, on 07/02/19 at 8:22 PM, revealed he also carried the role of the Medical Director for the facility. He stated he was not aware if the facility reported the discharges and transfers to the Ombudsman.

Based on interview and facility policy it was determined the facility failed to reconcile controlled medications for one (1) of one (1) Automated Dispensing Cabinet (ADC) to ensure all controlled medications were accounted for as per facility policy. The findings include: Review of facility policy, Management of Controlled Substances and Medications at High Risk of Diversion, revised 09/08/18, revealed an ADC unit inventory count was to be conducted weekly by the Unit Manager and a witness. Observation, on 07/01/19 at 11:00 AM, revealed the facility utilized an ADC to store scheduled medications to be administered to residents. Registered Nurse #1 was observed removing a scheduled medication for a resident with no other staff to witness if the count of medication was correct. Interview with Registered Nurse (RN) #1, on 7/02/19 at 9:49 AM, revealed staff did not count controlled medications in the ADC. She stated the unit was told what the count was in the ADC unit. She stated the nurses counted the medications in the cart and placed the count into the ADC system when the unit requested a count. She stated the ADC unit received the information from all the nurses. She stated the facility did not routinely count the schedule medications because pharmacy staff counted monthly or when they came to refill stock, and a witness was not required with the removal of a schedule medication to ensure the count was correct upon access into the drawer. Interview with the Pharmacy Tech, on 7/02/19 at 4:17 PM, revealed Pharmacy staff counted the controlled medication drawer in the ADC unit monthly and when new stock was added. He stated only the drawer to which the added stock was counted at that time and not all the drawers that contained controlled medications. Interview with the Unit Manager (UM), on 07/02/19 at 12:22 PM, revealed scheduled medications were reconciled monthly. She stated the ADC unit ensured the scheduled medication count was correct at all times. She stated staff signed into the computer, the ADC unit asked what the count was for the scheduled medication and the input into the computer was provided by staff. She stated two staff were not required to be present for removal of a scheduled medication and the ADC unit relied on what the staff input was to the unit. She stated staff were not required to count between shifts. She further stated she completed scheduled reconciliation monthly on the ADC unit. She stated the facility relied on the honesty of the staff. The UM stated the reason for scheduled medication reconciliation was to ensure the count was correct and identify diversion quickly. Interview with the Director of Nursing, on 07/02/19 at 11:56 AM, revealed the UM counted the scheduled medications once a month. However, she stated the facility may change this to a weekly schedule. She stated the ADC unit relied on staff for the input of the count of scheduled medications each time the drawer's were accessed. She stated medication reconciliation was to ensure diversion was identified quickly. She further stated the facility relied on the nurses for accurate input. Interview with the Administrator, on 07/02/19 at 8:22 PM, revealed the pharmacy in the facility was to complete scheduled medication reconciliation. However, he claimed ignorance to the process, requirements and further stated he probably should.

Based on observation, interview and facility policy review it was determined the facility failed to ensure one (1) of one (1) medication refrigerators was secured and one (1) of two (2) medication carts was secured and supervised. Observations revealed the medication refrigerator key hung from the outer door lock and the refrigerator contained ten (10) vials of injectable Marinol (Tetrahydrocannabinol (THC) a man-made form of the active substance in marijuana) in a locked inner box. Interview with staff revealed the key was left in the door of the medication refrigerator at all times and numerous staff were able to access the medication room. In addition, staff left a medication cart unlocked and unsupervised in a resident's room at the resident's bedside. The findings include: Review of facility policy, Storage of Medications, reviewed 04/23/18, revealed staff ensured medications were secure at all times. The facility policy defined secured as a locked area, room or cabinet where access was restricted to authorized personnel and under constant visual surveillance and control. Review of Resident #60's clinical record revealed the facility admitted the resident on 07/01/19 with diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease and Anxiety. Review of Resident #61's clinical record revealed the facility admitted the resident on 06/25/19 with diagnoses including Cerebral Vascular Disease, Pneumonia, and Hypertension. Observation, on 06/02/19 at 9:32 AM, revealed Registered Nurse (RN) #1 brought a medication cart into the room of Resident #60 and Resident #61. The RN then left the room with the medication cart in the residents' room unsupervised, and unlocked wth a drawer opened and medications visible. RN #1 returned to the room at 9:36 AM and shut the drawer while she stood at the medication cart. Interview with RN #1, on 07/02/19 at 9: 40 AM, revealed she left the medication cart in the residents' room unattended by staff when she left to obtain a pill splitter. She stated staff were not to leave medication carts in a resident's room whether locked or unlocked. RN #1 stated staff were to supervise medication carts at all times and the medication cart was not supervised when she left the room. She further stated in a perfect world staff would never leave medication carts unlocked. She further stated residents were at risk for safety issues because the medications were accessible while she was out of the room. She stated she was to ensure medications were safe, secure and her responsibility at all times was to ensure residents were safe. Observation, on 07/01/19 at 4:02 PM, revealed RN #3 walked up to the medication room refrigerator and was observed to open the door with a key protruding from the lock. RN #3 identified the key as the key to the unit refrigerator. RN #3 counted ten (10) vials of injectable Marinol in the locked compartment in the refrigerator. Interview with RN #3, on 07/01/19 at 4:02 PM, revealed the facility kept the key to the refrigerator in the door and was in the door the entire time the refrigerator was in the medication room. She stated the door to the room and inner lock was considered the double lock for scheduled medications. However, she stated numerous staff were able to access the room. Interview with the Unit Secretary, on 07/01/19 at 4:17 PM, revealed she was able to access the medication room at any time. She further stated the facility kept the key in the refrigerator door for the many years she worked at the facility and staff were not instructed to do otherwise. Interview with the Hospital Based Pharmacy Tech, on 07/01/19 at 4:17 PM, revealed the facility considered the door to the medication room one lock and the medication compartment in the refrigerator as the second lock therefore the door to the refrigerator did not need to be locked. He further stated if the door to the refrigerator was locked it would be a triple lock. Further observation, on 07/01/19 at 4:17 PM, revealed Certified Nursing Assistant (CNA) #1 entered the medication room after she accessed the door. The CNA obtained a product for resident care and left the room. Interview with CNA #1, on 07/01/19 at 4:17 PM, revealed the CNA was able to access the door to the medication room at any time. She stated the supplies for the resident were held in the medication room and most staff had access to the room for resident care needs. Continued interview with RN #3, on 07/01/19 at 4:30 PM, revealed when she opened the refrigerator in the medication room the key hung from the lock. She stated the medication refrigerator was unlocked so therefore the mediations in the secured inner compartment were not double locked. She stated the facility was responsible to ensure schedule medications were double locked to prevent diversion. She stated the facility educated staff on proper medication securement and double locks for schedule medications. Interview with the Facility Unit Based Educator, on 07/02/19 at 12:49 PM, revealed staff were educated on proper medication safety, supervision and securement. She stated staff were to keep medication carts locked and supervised at all times unless stored at the nurses station. However, the facility did not teach staff not to take medication carts into the resident room. She further stated staff put resident's safety at risk when medication carts were unlocked and left unsupervised in resident's room. She further stated as the Unit Based Educator she did not audit the facility for medication pass or medication safety. Interview with the Unit Manager, on 07/02/19 at 12:14 PM, revealed medication carts were not to be left in resident rooms when the nurse was not in the room. She stated the staff was to supervise the cart at all times to ensure the residents were safe, and this included locking the cart when they were not in eyesight. However, she stated staff commonly took medication carts into resident rooms with medication pass. She stated staff were educated by the unit educator on medication safety as well as yearly in the education program. She further stated she did not identify issues with unsupervised or unlocked carts. She continued and stated the facility counted the medication room door as the first lock which was why the key was left in the refrigerator side. She stated staff were to ensure the double lock system was present at all times in regard to scheduled medications. She stated the facility recognized the issue of the key left in the door at all times with the survey Interview with the Director of Nursing, on 07/02/19 at 12:14 PM, revealed carts were to be locked and supervised at all times. She stated she did not audit medication pass. She further stated the Unit Manager did not identify issues to her with unsupervised or unlocked medication carts. She stated the facility expected nurses to keep medications and residents safe. Interview with the Administrator, 07/02/19 at 8:33 PM, revealed as Administrator he did not have an issue with medication carts being brought into resident rooms. He stated facility placed two locks to the refrigerator scheduled medication area with the door as one lock and the compartment as the second. He further stated he was unaware of what items were held in the medication room and who would need access to the room. He further stated the facility knew changes were required after the survey process identified the medication refrigerator was unlocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review the facility failed to implement an effective infection control program with medication pass. Staff brought one (1) of two (2) medication carts into multiple resident rooms without sanitation in between residents. Staff were observed to handle medication with contaminated gloves while the medications were returned to a cup and re-administered the same medications to a resident and touched the medication when they handed the medication to the resident for consumption. In addition, staff failed to sanitize hands or don new gloves after they touched a multitude of surfaces and provided an injection a resident. The findings are: The facility did not provide a policy on infection control or medication administration in regards to medication carts at resident bed side. Review of the facility policy, Hand Hygiene (HH) revised [DATE], revealed hand hygiene was the most effective pressure to prevent transmission of infection. Staff were to complete HH after staff touched contaminated devices, patients' environments or handled bodily substances. Observation, on [DATE] 08:53 AM of medication Pass with Registered Nurse (RN) #1 revealed the medication cart was brought into the a resident's room and stationed at the residents bedside. The resident was observed to have placed all the medication tablets onto the over the bed table and proceeded to count the tablets. The resident was observed to have swallow difficulty with a large tablet, regurgitated, and RN #1 was observed to have assisted with a held napkin under the resident's chin and manipulated the napkin with her gloved hands full of stomach matter. RN #1 was observed to have scooped up the resident pills into the medication cup with the same gloved hands used to assist to clean and wipe the resident's mouth, chin and manipulation of the cloth with stomach contents. The resident's medication were placed into the medication cart. RN #1 was observed after completion of assist with a clothing change of the resident to have wash hands, put clean gloves onto hands, and pulled the cup out of the drawer and physically removed the medications with her fingers from the cup one by one and gave them physically to the resident. The resident was observed to have self-administered the medications which were in the cup which were handled with contaminated gloves. RN #1 continued with the same gloved hands to proceed to inject a medication into the resident abdomen without washed or replaced the gloves to her hands. Continued observation of RN #1 with observation of medication pass, on [DATE] at 9:17 AM, revealed RN #1 completed the medication pass with the first resident and proceeded to the next residents' room and took the medication cart into the residents room and parked the cart besides the resident's bed. The cart was not sanitized before the RN entered the next room. Interview with RN #1, on [DATE] at 9:30 AM, revealed RN #1 stated she pulled the medication carts into the room with medication pass so she was able to pass resident medications timely. RN restated on, [DATE] at 9:51 AM, she normally brought the medication cart into each resident room. Continued observation of medication pass, on [DATE] at 9:30 AM, revealed RN #1 washed her hands and donned clean gloves. RN #1 was observed to have handled the computer mouse, typed in information on the keyboard, pulled the curtain, moved resident table, call bell and handled bedding. RN #1 continued and prepared an injection for the resident and continued with the same gloved hands to clean the resident's skin, pinch the resident's skin and complete the injection with the same gloves. RN #1 continued medication pass observation, on [DATE] at 10:04 AM, revealed RN #1 removed the cart from a resident's room and proceeded into the next resident's room and brought the medication cart to the bedside and parked the cart. The medication cart was not sanitized before she entered the room with the cart. After completion of the medication pass, RN #1 brought the medication cart to the nurses station and parked the cart to the wall and left the cart. RN #1 was not observed to sanitize to sanitize the cart after contact with multiple resident rooms with medication pass. Interview with RN #1, on [DATE] at 3:11 PM, revealed staff were to properly wash their hands and don gloves when medication pass was ongoing to prevent cross contamination. She stated staff were not to take medication carts into resident rooms who were under isolation, and she did not routinely take the cart into resident rooms after 12:00 PM. However, in the AM she stated residents required a lot of medications at one time and to save time she brought the carts into each resident room. RN #1 stated she did not wipe down the medication carts after leaving each room because each resident were given single dose medication packets. In addition, she stated Certified Nursing Assistants (CNA) were to wipe the vital sign machine after every use and room. She continued and stated she touched a resident's medication with her gloved hands after she scooped up the medication previously with dirty gloves. She stated it was not typical for her to handle medications but the resident was very difficult at the time. RN #1 further stated she should not have handled the medication and was to pass medications to the resident with a spoon. She stated this was to prevent transfer of germs to the resident. RN #1 stated staff were to follow infection control practice to prevent the spread of germs at all times. She further stated she completed education for infection control, hand hygiene and medication pass for the facility; however, she used poor practices with hand hygiene, when she touched the medications. She stated poor infection control practices would cause residents to become ill. Interview with the Unit Manager (UM), on [DATE] at 11: 56 AM, revealed staff were to use a hand foam when entering or leaving resident rooms during medication pass. She stated staff were to wear gloves if medication was to be handled. She stated medication carts were not to be brought into resident rooms that was in isolation. However, it was common practice for staff to have medication carts into resident rooms and work from the bedside. However, she stated the aides were required to wipe down the vital machine cart so she thought this would be the same practice with medication carts to prevent cross contamination from one room to another. She further stated staff were not to touch multiple surfaces with medication pass. The UM stated the medications were to be readied, then hands re-cleaned and gloves donned to complete the medication pass or injection to prevent issues. The UM stated all staff were to maintain proper hand hygiene and use good infection control practices. She stated this was to prevent infections; and residents could become ill if not followed. Interview with the Director of Nursing, on [DATE] at 11:56 AM, revealed she was unsure if medication carts were brought into resident rooms. She stated the unit had not identified infection control issues with medication pass. She further stated she did not audit staff's medication pass techniques. She further stated staff were not to handle medications at any time and were to ensure hand hygiene practices were followed at all times to prevent infection. Furthermore, the Director stated the facility did not have a policy on carts at the bedside and infection control practices. Interview with the Unit Based Educator, [DATE] at 12:49 PM, revealed medications which were not prescribed to a resident were not to enter another resident's room. She stated medications were not to be handled by the staff; and if they were handled the medications were to be disposed and the nurse was to restart, because it was an infection control issue. She stated she did not conduct audits or observe medication pass for the unit or facility. She further stated all staff had monthly in-service books to review and they were to review the material printed and sign to signify the material was read and understood. However, an audit of staff's knowledge was not completed routinely or randomly. Interview with the Chief Medical Officer/Administrator, on [DATE] at 8:22 PM, revealed the facility did not identify issues or concerns related to infection control practices. He stated the Quality Assurance meeting routinely discussed infection control and no identified issues were brought to the meeting. He stated as Administrator he did not have an issue with medication carts being brought into resident rooms unless the resident was in isolation. He stated all residents came from an acute unit in the hospital so the unit knew what the resident had so this was not an issue in regard to infection control. He further stated infection control with medication pass was not a focus of his; however, the facility practiced infection control techniques as a whole and was committed to be a shepherd of good practice. He stated once a month staff were sent out for shopper audits where management observe ten (10) opportunities to foam in and foam out and if it was observed a reward was given. He stated with medication pass staff were to do the best they could and perfection was not obtainable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to serve food under sanitary conditions. Housekeeping staff were observed cleaning on two (2) of two (2) hallways during meal service, including delivery and set-up. The findings include: Review of the contracted Environmental Agency's New Hire Training Associate Record, dated August, 2012, revealed Housekeeping Staff were not trained to discontinue cleaning during mealtimes. Review of the contracted Environmental Agency's Residential Room Cleaning Procedure, dated 10/01/16, revealed no directive concerning guidelines related to mealtime. Review of the facility's Nursing Facility Patient Tray policy, updated 09/18/17, revealed the procedures for assembling, passing and retrieving resident food trays. The policy did not address housekeeping during mealtimes. Review of the facility's Material Safety Data Sheet (MSDS), dated 09/15/15, revealed Stride Floral Neutral Cleaner (mop solution) was classified as a Category 2A hazard and if ingested could cause irritation to mouth, throat and stomach. Other symptoms included stomach pain and nausea. Observation, on 06/12/18 at 12:00 PM, revealed Housekeeper #2 using a stand-up motorized floor scrubber on Hallways A and B. He maneuvered the floor scrubber around the Catering Associates as they delivered trays. Observation, on 06/12/18 at 12:05 PM, revealed Catering Associate #1 walked around a housekeeping cart in room [ROOM NUMBER], on Hallway B, and delivered a lunch tray. Further observation revealed Housekeeper #1 mopped room [ROOM NUMBER] while Patient Care Associate (PCA) #1 situated the lunch tray for Resident #116. Observation, on 06/12/18 at 12:08 PM, revealed Housekeeper #2 maneuvered the motorized stand-up floor scrubber around the open lunch tray cart on Hallway A. Observation, on 06/12/18 at 12:09 PM, revealed PCA #2 interrupted Housekeeper #2 telling him, you can't clean while patients are eating. Interview with Housekeeper #1, on 06/12/18 at 12:13 PM, revealed she was called by the unit to mop the floor in room [ROOM NUMBER]. Housekeeper #1 stated the cleaning chemicals, dust and dust mites could end up in resident food when she cleaned an area during meal times, which could potentially hurt residents. Interview, on 06/12/18 at 12:16 PM, with Housekeeper #2 revealed he always scrubbed the floors of halls A and B during mealtimes and did not see a problem. Interview with PCA #2, on 06/13/18 at 1:33 PM, revealed she asked Housekeeper #2, to stop using the motorized floor scrubber around the open food cart. She stated chemicals, dust and trash could contaminate the resident's food and make them sicker. She further stated a previous employer educated her regarding this matter. Interview, on 06/13/18 at 10:40 AM, with the Director of Environmental Services revealed he worked for the facility on a contractual basis. He stated the Housekeepers received training when hired and annually regarding infection control and cleaning chemical usage. Housekeepers were instructed to follow a cleaning schedule and to discontinue cleaning only if a patient complained. Interview, on 06/13/18 at 3:05 PM, with the Nurse Manager revealed she supervised the care of the patients in the absence of the Director of Nursing. She stated she was not educated regarding discontinuing housekeeping services during meal times. However, she stated cleaning during meals could release chemical smells which could be bothersome to residents. She further stated dust could contaminate the food and if chemicals got in the food that could cause harm to the patient. Interview with the Chief Medical Officer, on 06/13/18 at 3:33 PM, revealed he was unaware of regulations regarding the performance of housekeeping duties during meal service but stated doing so potentially led to cross contamination and harm to residents.