**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) signage for enhanced barrier precautions (EBP), and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 19 sampled residents, Resident (R) 18, R41, R56, R68, and R73. R18, R41, R56, R68, and R73 all had active orders to be on EBP. However, observations on 04/01/2025 to 04/03/2025 revealed none of the residents had EBP signage posted on their room doors of what the infection control requirements were when entering and exiting their rooms, for the resident, staff, and visitors. The findings include: Review of the facility's policy titled, Infection Prevention and Control, Transmission Based Precautions, dated 08/01/2024, revealed descriptions for the indications and measures for contact, droplet, and airborne precautions but no description of enhanced barrier precautions. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), undated, revealed EBP were enacted to prevent the transmission of multi-drug resistant organisms. Per the policy, EBP employed targeted gown and glove use during high contact resident care activities. The policy stated the same gown and gloves should not be worn for the care of more than one person. Further review of the policy revealed an order for EBP would be obtained for residents with a wound or indwelling medical device. Review of the facility's signage utilized for EBP, undated and labeled as obtained from the CDC revealed: 1) everyone must clean their hands, including before entering and when leaving the room; and 2) providers and staff must also wear gloves and a gown for the following high-contact resident care activities, such as dressing; bathing/showering; transferring; changing linens; providing hygiene; changing briefs or assisting with toileting; device use or care with a central line, urinary catheter, feeding tube, and tracheostomy; or wound care for any skin opening that required a dressing. 1. Review of R18's admission Record revealed the facility admitted R18 on 12/17/2020 with diagnoses of cerebral vascular disease, chronic obstructive pulmonary disease (COPD), and morbid obesity. Review of R18's Clinical Orders, dated 03/24/2025 and entered by the Minimum Data Set (MDS) Nurse, revealed R18 had an active order for EBP related to a wound located on the left inner upper thigh. However, observation on 04/01/2025 at 10:00 AM and 04/02/2025 at 9:02 AM revealed no EBP signage was posted outside R18's room. 2. Review of R41's admission Record revealed the facility admitted R41 on 07/25/2022 with diagnoses of unspecified dementia, anorexia, and contractures. On 03/07/2025 a diagnosis of squamous cell carcinoma of the skin of the left upper limb was added. Review of R41's Clinical Orders, dated 02/17/2025 and entered by the MDS Nurse, revealed R18 had an active order for EBP related to a wound. Review of R41's Clinical Orders, dated 03/06/2025, revealed an order to apply oil emulsion gauze to the left arm biopsy site daily. Observation on 04/01/2025 at 10:06 AM revealed no EBP signage was posted outside R41's door, and on 04/02/2025 at 9:08 AM and 04/03/2025 at 8:54 AM signage for Contact Precautions was posted outside R41's room. However, during an interview on 04/03/2025 at 2:07 PM with the Infection Preventionist Nurse (IPN), she stated R41 did not have an order for Contact Precautions, she had an order for EBP because of a wound, and that was the signage that should have been posted outside her room. 3. Review of R56's admission Record revealed the facility admitted R56 on 08/16/2024 with diagnoses of adult failure to thrive and dysphagia (swallowing difficulties). Review of R56's Clinical Orders, dated 03/28/2025 and entered by the MDS Nurse, revealed R56 had an active order for EBP related to a wound located on his coccyx. However, observation on 04/01/2025 on 10:06 AM revealed no EBP signage was posted outside R56's room. 4. Review of R68's admission Record revealed the facility admitted R68 on 02/28/2025 with diagnoses of fracture of the left humerus, congestive heart failure, and a pressure ulcer to the right lower back. Review of R68's Clinical Orders, dated 03/11/2025 and entered by the MDS Nurse, revealed R68 had an active order for EBP related to a wound and an indwelling urinary catheter. However, observation on 04/01/2025 at 10:08 AM revealed no EBP signage was posted outside R68's room. 5. Review of R73's admission Record revealed the facility admitted R73 on 10/22/2024 with diagnoses of unspecified dementia, need for assistance with personal care, cognitive communication deficit, and neck fracture. Review of R73's Clinical Orders, dated 03/10/2025 and entered by the MDS Nurse, revealed R68 had an active order for EBP related to a wound on his sacrum (lower back). However, observation on 04/01/2025 at 10:10 AM revealed no EBP signage was posted outside R73's room. During an interview on 04/03/2025 at 3:30 PM with Certified Nurse Assistant (CNA) 4, she stated this was her second week working at the facility, and she relied on the signage posted outside the residents' rooms to guide her in what personal protective equipment (PPE) to wear into the residents' rooms to provide care. She stated if there was no signage outside the resident's room, she would not know what she needed to do and to wear to care for the resident, which could place all the residents at risk for infection. CNA4 stated the residents' precautions were not indicated on the [NAME] (the list of resident needs for care and assist generated by the nursing care plan), so she would only be aware of the need for PPE, like a gown or a mask, if it was posted outside the resident's room. During an interview on 04/03/2025 at 3:35 PM with CNA5, she stated she had worked at the facility since 01/2025, and she looked at signage outside the resident's room to guide her as to what PPE she required to provide resident care. CNA5 further stated she would use a gown or mask as the sign posted outside the resident's room instructed. She stated if there was no sign, she would always use gloves as needed and perform hand hygiene with either soap or hand sanitizer as needed. She stated the sign was important so staff and visitors would know what to do before entering the room to keep everyone safe and infection free. During an interview on 04/03/2025 at 3:40 PM with CNA6, she stated she had worked at the facility for two years and was also a Kentucky Medication Aide (KMA). She stated as a KMA she was able to see if a resident was on infection control precautions as she administered medications because it was visible on the resident's dashboard on the electronic medical record (EMR). She stated she would also observe the signage which should be posted outside the residents' rooms indicating what PPE was required to perform resident care. She stated this was important to prevent the spread of infection and in some cases, protect a resident from getting an infection. During an interview on 04/03/2025 at 3:45 PM with the Staff Development Coordinator (SDC), she stated infection control precaution signage should be posted outside a resident's room immediately after an order was received by the nurse to ensure staff and visitor compliance with the precautions. The SDC stated if there was no signage posted outside the resident's room, staff would not know what PPE to wear to provide care. She also stated the signage would instruct staff on PPE the resident needed to wear to exit the room and would instruct visitors on what PPE they needed to wear to enter the room. She stated if staff and visitors did not have the signage information, everyone could be at risk for infection and the spread of infection. During an interview on 04/03/2025 at 3:53 PM with the Physical Therapist (PT), she stated she had worked at the facility for 15 years. She stated if a resident was on infection control based precautions, and there was not a sign posted outside the resident's room indicating the resident was on precautions, staff and visitors would not know which PPE to wear into the room. She stated the therapy department would not be aware if a resident could leave their room for therapy or if the resident's condition required therapy be performed in the resident's room. She stated this was important to protect the resident, staff, and any visitors. During an interview on 04/03/2025 at 2:44 PM with the Minimum Data Set (MDS) Nurse, she stated she had been at the facility for six years and had been in the role of MDS Nurse for one year. The MDS Nurse stated if she received an order for a resident for infection control precautions, she would usually let the resident's nurse or the IPN know about it. She stated she had never placed signage outside the resident's room and was not sure how soon after an order was received the signage should be placed, but it would be whatever the policy stated. She further stated the signage being placed on the door was not important as long as staff knew what the orders were, that would be okay. She stated she felt since staff was pretty consistent at the facility, they knew the residents well and would remember what infection control precautions they were on. When asked how visitors would be made aware of the precautions, the MDS Nurse stated she was not sure but agreed staff and visitors knowing if a resident was on ordered infection control precautions was important for the safety of the resident, staff, and visitors to prevent the spread of infection. During continued interview on 04/03/2025 at 2:07 PM with the IPN, she stated she had become certified as an IPN in July 2024. She stated it was her expectation the nurse that entered an order for a resident for any transmission-based precautions (TBP) or EBP then placed signage outside the resident's door immediately. She stated the placement of infection precaution signage outside the resident's room was important for the resident, visitors, and staff to prevent the spread of infection. During an interview on 04/03/2025 at 2:07 PM with the Director of Nursing (DON), she stated she had worked at the facility in the role of DON for a little less than a month and had worked as a floor nurse prior to that. She stated it was also her expectation the nurse that entered an order for a resident for any TBP or EBP ensured signage was placed outside the resident's room immediately whether that nurse placed it or asked another nurse to do so. She stated signage on the door was important for the safety of the resident, visitors, and staff to prevent the spread of infection. The DON also stated R41 should have been on EBP for a biopsy site to her left upper arm. During an interview on 04/03/2025 at 4:30 PM with the Administrator, she stated she had been at the facility for twenty-two (22) years. The Administrator stated signage indicating what infection control precautions were ordered for a resident should be posted outside the resident's room, and that signage should posted as soon as possible after the order was received. She further stated her expectation was the nurse that received the order would be responsible for ensuring the signage was posted so all staff and visitors would comply with the infection precautions. The Administrator stated compliance with ordered infection control precautions for a resident was important to protect all residents, staff, and visitors.

Based on observation, interview, review of the United States Department of Agriculture (USDA) web page, review of the facility's signage, and review of the facility's procedure, the facility failed to prepare and serve food under sanitary conditions as determined by observations during the initial kitchen tour and return tours. Observation on 04/01/2025 and on 04/02/2025 revealed dome lids were stacked wet. Observation on 04/01/2025 of food temperatures for the lunch service revealed an inaccurate temperature for puree food, but it was placed on the tray line for service. Additionally, observation on 04/02/2025 revealed staff changed gloves and performed tasks without proper hand hygiene. The findings include: Review of the facility's procedure titled, Dishwashing Procedure, dated 12/15/2022, revealed to air-dry dishes and keep them in a clean area to avoid contamination. Review of the facility's sign posted in the kitchen Use Disposable Gloves Properly, not dated, revealed to wash hands before and after use of disposable gloves and to change gloves frequently and between tasks. Review of the United States Department of Agriculture (USDA) web page https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/food-thermometers#:~:text=The%20food%20thermometer%20should%20be,reached%20the%20safe%20internal%20temperature revealed using a food thermometer was the only reliable way to ensure foods had been cooked to a safe minimum internal temperature to destroy any harmful microorganisms that might be in the food. Per the web page, the temperature danger zone was 40 degrees Fahrenheit (F) to 140 degrees F. It also stated the safe practice was to place the thermometer into the thickest part of the food item or for thin foods through the side which reached the middle. Per the web page, always check each piece of food to ensure it had reached the safe internal temperature. In addition, size, quantity, and distribution of food when cooking caused the pieces of food to reach a safe internal temperature at different times. It did not state the food could have a cover, such as plastic, when taking the temperature. Observation on 04/01/2025 at 10:00 AM during the initial tour of the kitchen with the Food and Beverage Director (FBD), revealed dome lids for the resident plates were not aired dried. The inside of the dome had condensation with beads of water. Observation on 04/01/2025 at 11:50 PM of the lunch meal service revealed at 11:57 AM, the FBD was taking the temperature of the food on the steam table. She pushed the thermometer through the plastic wrap over the peas and carrots. In an interview with the Food and Beverage Director (FBD) on 04/01/2025 at 11:57 AM, she stated she on occasion inserted the thermometer through the plastic to take the temperature. She asked the State Survey Agency (SSA) Surveyor if she should not put the thermometer through the plastic wrap. Observation on 04/01/2025 at 12:00 PM of food temperatures on the steam table revealed the temperature of the puree chicken taken by the FBD was 168 degrees F. The SSA Surveyor asked for the FBD to retake the temperature. The puree chicken recheck temperature was 119 degrees F. So, the FBD asked the cook to reheat the puree chicken. Continued observation of the FBD on 04/01/2025 at 12:00 PM, revealed she asked [NAME] 1, Where are the french fries? The cook did not know the location of the french fries, and both left the tray line to find them in the walk-in freezer. Further observation of the FBD and [NAME] 1 revealed they removed their gloves and entered the walk-in freezer. However, they did not wash their hands after changing tasks and the glove change. Observation on 04/02/2025 at 8:19 AM and 11:51 AM revealed the dome lids and bottoms were left wet on the rail near the tray line. In an interview with the FBD on 04/02/2025 at 8:20 AM, she stated the dome lids and bottoms were air-dried on the rack in the dishroom, and then she stacked the dome lids and bottoms together. In an interview with [NAME] 1 on 04/03/2025 at 10:09 AM, she stated hand washing and glove use was important for controlling bacteria. She stated the french fries were not prepared for the tray line. She stated she felt rushed and had to hurry to have time to prepare all the food. She stated she dried the dishes with a towel or let them air dry for a moment before putting them away. In another interview with the FBD on 04/03/2025 at 1:54 PM, the FBD stated the process was to leave dishes in the rack to drain and air dry in the dish room, and the dome lids should be placed in the rack in single file to air dry. The FBD stated there was the potential for bacteria to grow and cause cross contamination if the dome lids were left wet. The FBD stated the proper method to take food temperatures was to swab the stick of the thermometer, check the temperature, and clean between each food. The FBD stated to ensure an accurate temperature, the food should be stirred, and double checked if needed. The FBD stated to prevent the potential of food borne illness, food should be served at the correct temperature. The FBD stated staff did not use gloves on the tray line with serving utensils, and gloves should be changed when staff interrupted tasks to prevent the potential for cross contamination. In an interview with the Registered Nurse (RN) Director of Nursing (DON) on 04/03/2025 at 3:37 PM, she stated she expected staff to take care of residents through safe food handling practices. In an interview with the Administrator on 04/03/2025 at 9:18 AM and 3:49 PM, she stated the concern with the dome lids stacked together wet was bacterial growth. She stated she expected staff to take accurate food temperatures to prevent the growth of bacteria. Also, she stated she expected staff to perform proper hand hygiene and to change gloves as directed to prevent the potential for cross contamination.

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframe to meet the residents' mental and psychosocial needs that are identified in the comprehensive assessment related to Dementia for one (1) of twenty-two (22) sampled residents (Resident #10). Resident #10's Comprehensive Care Plan was not developed and implemented related to the resident's symptom and rate of progression of dementia (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks) or related to meaningful activities to address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. The findings include: Review of the facility Care Plan Development and Communication Policy, revised 01/04/19, revealed care planning processes allow for the delivery of comprehensive, coordinated, quality care designed to meet the ongoing individualized needs of residents. The Care Plan should be developed to include measurable objectives and timetables to meet a residents medical, nursing, and mental and psychosocial well-being. Review of Resident #10's clinical record revealed the facility admitted the resident on 01/04/19 with diagnoses including Heart Failure, Type 2 Diabetes, Unspecified Dementia without Behavioral Disturbance, and Chronic Obstructive Pulmonary Disease. Review of Resident #10's admission Minimum Data Set (MDS) Assessment, dated 01/14/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a fifteen (15) out of fifteen (15) revealing the resident was cognitively intact. Review of Section I, titled Active Diagnoses, revealed the facility assessed Resident #10 as having an active diagnosis of Dementia. Review of the MDS, Section F, titled Preferences for Customary Routine and Activities, revealed it was very important to choose what clothes he/she wears, and to take care of his/her personal belongings. Also, it was somewhat important for him/her to keep up with the daily news, to listen to the music he/she likes, to participate in his/her favorite activities, to do things with groups of people, and to participate in religious services. Review of the Comprehensive Care Plan, initiated 01/15/17, revised 01/20/19, revealed Resident #10 experienced short term cognition and recall problems. The goal revealed the resident would continue to make needs known through next review. Interventions listed included: administer cognition medication as ordered; observe for changes in condition that could impact mental status; and provide with cues and reminders as needed. Further review of the Comprehensive Care Plan, initiated 08/24/17, revised 10/08/18, revealed the resident had alteration in communication related to decreased cognition due to diagnosis of Dementia. The goal revealed the resident's needs would be met through the next review. Interventions included: allowing ample amount of time to respond, and repeat if necessary; ask yes and no questions if possible; notify physician as needed; observe for non-verbal signs and symptoms of communication; obtain diagnostic testing as ordered; and Speech therapy to treat and evaluate as ordered. Additional review of the Comprehensive Care Plan, initiated 02/28/19, revealed the resident was at risk for activity participation deficit related to a decrease in health and physical ability; and enjoyed church services, talking on the phone, watching TV, outings with grandson and time with family. The goal revealed the resident would attend two (2) activities through the review date of 04/04/19. The interventions included: inviting the resident to scheduled activities and providing the resident with an activities calendar. However, there was no documented evidence the facility developed and implemented an individualized Care Plan with interventions to address the resident's symptom and rate of progression of dementia (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks). In addition, there was no documented evidence the Care Plan was developed and implemented to include individualized, purposeful and meaningful activities that addressed the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. Observation of Resident #10 on 01/29/19 at 10:15 AM, revealed he/she was lying in bed in with eyes closed, with no interaction from staff; observation on 01/29/19 at 2:05 PM, revealed the resident was seated at the side of the bed reading with no interaction from staff; observation on 01/30/19 at 10:30 PM, revealed the resident was lying in bed talking on his/her cellular phone; and observation on 01/31/19 at 11:00 AM, revealed the activity assistant entered the resident's room and placed and activity calendar for February 2019 on the resident's bed side table and then exited the room. Interview with the Activity Director, on 01/31/19 at 2:30 PM, revealed it was her duty to implement activities specific to residents diagnosed with Dementia. She acknowledged Resident #10's Activity Care Plan needed to be more specific and person centered with individualized interventions to be implemented to ensure the resident was socializing and taking part in activities of choice. Interview with the Interim Director of Nursing, on 01/31/19 at 4:00 PM, revealed it residents with dementia needed to receive more of staff's attention. She stated residents with Dementia usually needed more assistance from staff with Activities of Daily Living; however, Resident #10 was in the early stages of Dementia and was more independent, and his/her main issue was mental health. Additional interview revealed it was important for Resident #10 to receive person centered care through individualized approaches, and therefore the resident's Care Plan should have been developed and implemented with specific approaches related to the diagnosis of Dementia. Interview with the Administrator, on 01/31/19 at 5:15 PM, revealed it was important for the Comprehensive Care Plan to be developed and implemented with goals and interventions to receive appropriate treatment and services related to individualized dementia care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure a resident with an indwelling urinary catheter, receives the appropriate care and services to prevent urinary tract infections for one (1) of (1) sampled residents observed for catheter placement out of twenty two (22) sampled residents (Resident #18). Observation on 01/29/19, of indwelling urinary catheter care for Resident #18, revealed during the procedure the catheter became dislodged, and State Registered Nurse Assistant (SRNA) #2 attempted to re-insert the catheter. SRNA #2 was unsuccessful at re-inserting the catheter and went to get the nurse. Further observation revealed Licensed Practical Nurse (LPN) #2 failed to use sterile technique when inserting the indwelling urinary catheter for Resident #18, and also failed to to test the retention balloon prior to inserting the catheter. The findings include: 1. Review of the facility Policy titled, Indwelling Urinary Catheter- General Information dated 06/03/06, revealed urinary catheters were a common source of infection and should be used only with clinical rationale. The policy did not have procedure guidelines for insertion and maintenance of the catheter. Review of the facility Policy titled, Indwelling Urinary Catheter General Information with effective date 09/01/18, revealed guidelines for appropriate urinary catheter use, but not procedural guidelines for catheter insertion. Review of [NAME] and [NAME] Clinical Nursing Skills and Techniques, Chapter Thirty Three (33), Eighth Edition, used by the facility's nursing staff, revealed urinary catheters should be inserted using sterile procedure. Review of the Kentucky Board of Nursing Advisory Opinion (AOS) #15, revised 12/2018, revealed Registered Nurses could delegate urinary catheter care to unlicensed personnel; however, insertion of the catheters remained a function for licensed nursing staff. Review of Resident #18's clinical record revealed the facility admitted the resident on 08/16/17 with diagnoses to include Parkinson's Disease, Degenerative Disease of the Nervous System, Speech and Language Deficits following Cerebrovascular Disease, Urinary Retention, and Benign Prostate Hypertrophy. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/05/18, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having a Foley catheter in place for urinary retention and benign prostate hypertrophy, requiring care and maintenance of the catheter. Observation on 01/29/19 at 9:09 AM, of catheter care for Resident #18, revealed during provision of catheter care the indwelling urinary catheter dislodged with the retention balloon deflated. SRNA #2 attempted to reinsert the catheter without success and then went to find the nurse. Licensed Practical Nurse (LPN) #2 entered the resident's room with the indwelling urinary catheter in one package with an outer wrapping and a sterile inner wrapping along with another package containing all other supplies, again with an outer package wrapping with sterile supplies inside. LPN #2 then set up the sterile field, donned sterile gloves, and picked up the outer package of the indwelling urinary catheter and opened it to reach the inner sterile catheter packaging. LPN #2 did not take off the contaminated gloves and don another pair of sterile gloves during the procedure of inserting the indwelling urinary catheter. LPN #2 also did not test the retention balloon prior to inserting the catheter. Interview with SRNA #2, on 01/31/19 at 11:25 AM, revealed he was assigned to care for Resident #18 on 01/29/19, when the Foley catheter came out during catheter care. SRNA #2 stated he knew he should not have reinserted Resident #18's catheter when it dislodged, but this was his immediate reaction. Further interview revealed catheters should be placed per sterile procedure by a licensed nurse. Interview with LPN #2, on 01/31/19 at 1:17 PM, revealed indwelling urinary catheters should be inserted using sterile technique. She revealed she was aware the outer packaging of the catheter should not be touched once sterile gloves were donned in order to maintain the sterile field. She further revealed she normally inflated the catheter balloon prior to insertion to ensure it was operational, deflated the balloon, and then inserted the catheter. Further interview revealed when she inserted the new urinary catheter for Resident #18, she forgot to test inflate the balloon prior to insertion of the catheter, and she failed to use sterile technique. Interview on 01/31/19 at 1:58 PM, with the Unit Manager for the Magnolia Unit where Resident #18 resided, revealed SRNAs should never insert indwelling urinary catheters as this was not in their scope of practice. She revealed only licensed nurses were trained to insert indwelling catheters. She further revealed nursing staff should always maintain sterile technique during catheter insertions to minimize infection risks. Continued interview revealed nursing staff should not touch the outer packaging of a catheter with sterile gloves during the procedure, and if that were to occur, the nurse would need to doff the contaminated gloves, wash hands, and don sterile gloves again. Interview with the Director of Nursing (DON), on 01/31/19 at 4:14 PM, revealed only licensed nursing staff were to place indwelling urinary catheters, as per nursing practice guidelines. Per interview, SRNAs were not trained on catheter insertion and should never perform this procedure. The DON revealed sterile technique should be followed by nursing staff when inserting indwelling urinary catheters to help prevent infection. The DON stated licensed nurses should maintain sterile technique and not touch the outer packaging of a catheter after sterile gloves were applied. The DON further stated the nurse should have tested the urinary catheter balloon prior to insertion, deflated, and then inserted the catheter. Further interview revealed the nursing staff used [NAME] and [NAME] guidelines for clinical procedures. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed it was her expectation for the nursing staff to follow sterile procedures in accordance with accepted standards of practice and facility adopted guidelines in inserting indwelling urinary catheters. She revealed her expectation was consistent with good infection control practices. Continued interview revealed it was never acceptable for a nursing assistant (SRNA) to insert a urinary catheter because the skill was beyond the scope of practice.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who is diagnosed with Dementia receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (1) of twenty-two (22) sampled residents (Resident #10). The facility failed to ensure necessary care and services were person-centered and reflected the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, and choice for Resident #10, related to the resident's diagnosis of Dementia. The findings include: Review of Resident #10's medical record revealed the facility admitted the resident on 01/04/19 with the diagnoses including Heart Failure, Type 2 Diabetes, Unspecified Dementia without Behavioral Disturbance, and Chronic Obstructive Pulmonary Disease. Review of Resident #10's admission Minimum Data Set (MDS) Assessment, dated 01/14/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Review of Section I, titled Active Diagnoses, revealed the facility assessed the resident as having an active diagnosis of Dementia. Continued review of the MDS, Section F, titled Preferences for Customary Routine and Activities, revealed it was very important to choose what clothes he/she wears, and to take care of his/her personal belongings. It is somewhat important for him/her to keep up with the daily news, to listen to the music he/she likes, to participate in his/her favorite activities, to do things with groups of people, and to participate in religious services. Review of Resident #10's Comprehensive Care Plan, initiated 01/15/17, revised 01/20/19, revealed the resident experienced short term cognition and recall problems. The goal stated the resident would continue to make needs known through next review. Interventions were listed as: administer cognition medication as ordered; observe for changes in condition that could impact mental status; and provide with cues and reminders as needed. Continued review of the Comprehensive Care Plan, initiated 08/24/17, revised 10/08/18, revealed the resident had alteration in communication related to decreased cognition due to diagnosis of Dementia. The goal stated the resident's needs would be met through the next review. Interventions included: allow ample amount of time to respond, and repeat if necessary; ask yes and no questions if possible; notify physician as needed; observe for non-verbal signs and symptoms of communication; obtain diagnostic testing as ordered; and Speech therapy to treat and evaluate as ordered. Further review of the Comprehensive Care Plan, initiated 02/28/19, revealed the resident was at risk for activity participation deficit related to a decrease in health and physical ability. Per the Care plan, the resident enjoyed church services, talking on the phone, watching TV, outings with grandson and time with family. The goal stated the resident would attend two (2) activities through the review date of 04/04/19. The interventions included inviting the resident to scheduled activities and providing the resident with an activities calendar. However, there was no documented evidence the facility developed individualized Care Plan interventions related to the resident's symptom and rate of progression (e.g., providing verbal, behavioral, or environmental prompts to assist a resident with dementia in the completion of specific tasks) or related to meaningful activities to address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. Observation of Resident #10 on 01/29/19 at 10:15 AM, revealed he/she was lying in bed in with eyes closed, with no interaction from staff. Observation of Resident #10 on 01/29/19 at 2:05 PM, revealed the resident was seated at the side of the bed reading with no interaction from staff. Observation of Resident #10 on 01/30/19 at 10:30 PM, revealed the resident was lying in bed talking on his/her cellular phone. Observation on 01/31/19 at 11:00 AM revealed the activity assistant entered the resident's room and placed and activity calendar for February 2019 on the resident's bed side table and then exited the room. Interview with the Activity Director, on 01/31/19 at 2:30 PM, revealed she was new to the facility, but it was her duty to implement activities specific to residents diagnosed with Dementia. Per interview, Resident #10's Activity Care Plan needed to be more specific and person centered with individualized interventions to be implemented to ensure the resident was socializing and taking part in activities of choice. Interview with the Interim Director of Nursing, on 01/31/19 at 4:00 PM, revealed it was her expectation residents with dementia receive more of staff's attention. Per interview, residents with Dementia usually needed more assistance from staff with Activities of Daily Living; however, Resident #10 was in the early stages of Dementia and was more independent, and his/her main issue was mental health. Further interview revealed it was important for Resident #10 to receive person centered care through individualized approaches, and therefore the resident's Care Plan should have reflected the resident's care needs related to Dementia. Interview with the Administrator, on 01/31/19 at 5:15 PM, revealed it was her expectation staff be aware of residents' cognitive impairments due to Dementia. Per interview, it was important for residents with Dementia to receive appropriate treatment and services to ensure the residents' individualized dementia care needs were met.

Based on interview and record review, it was determined the facility failed to ensure medical records are maintained that are complete and accurately documented, per accepted professional standards and practices for one (1) of twenty-two (22) sampled residents (Resident #10). Resident #10 was being seen by a Wound Consultant Company and also a separate Wound Clinic. However, there was no documented evidence the Physician's Orders/Treatment Plans from the Wound Consultant Company and the Wound Clinic were inputted into the Electronic Medical Record (EMR) as Physician's Orders in order for the recommended Treatments to be implemented. In addition, there were conflicting Physician's Orders for the resident's Right Medial Ankle wound from 01/24/19, until 01/31/19. These concerns were not discovered by the facility until State Agency Representative intervention. The findings include: Review of the facility Medical Records Policy, dated 01/01/07, revealed medical records are to be maintained in a complete, readily accessible, and systematically organized manner in accordance with federal and state regulations, facility policies, and accepted professional standards of practice. The medical record will contain complete and accurate documentation that clearly identifies the resident, justifies the diagnosis, conditions, and treatment and care approaches. Review of Resident #10's medical record revealed the facility admitted the resident on 01/04/19 with diagnoses including Heart Failure, Type 2 Diabetes, Unspecified Dementia without Behavioral Disturbance and Chronic Obstructive Pulmonary Disease, and Diabetic Foot Ulcers. Review of the Wound Consultant Physician's Orders dated 01/11/19, revealed orders for the Diabetic Wound of the Right Medial Ankle as follows: Apply Betadine, apply sterile ABD (abdominal) pad, and apply sterile gauze roll, once daily. In addition, Physician's Orders dated 01/11/19, revealed orders for the Diabetic Wound of the Left, Lateral Foot as follows: apply sterile ABD pad, apply Alginate calcium with silver, and apply sterile gauze roll once daily. Review of the Treatment Administration Record dated 01/11/19, revealed these orders were implemented starting 01/11/19. Review of the Hospital Wound Care Clinic Patient Care Instructions, dated 01/17/19, revealed Physician's Orders/Patient Instructions for the Right Medial Ankle Wound: wash the extremity with soap and water, cleanse wound with normal saline, apply Venelex to open wound, secure with Kerlix, tape and change dressing daily. However, record review revealed there was no documented evidence these Orders/Instructions were inputted into the Electronic Medical Record (EMR) as Physician's Orders. In addition, review of the TAR dated January 2019, revealed there was no documented evidence these orders were implemented. Review of the Wound Consultant Companies Wound Physician's Evaluation and Management Summary, dated 01/17/19, revealed a Treatment Plan for order changes as follows: Diabetic Wound of the Right Medial Ankle: sterile ADB pad, sterile gauze roll, Alginate calcium, apply once daily for thirty (30) days. Diabetic Wound of the Left, Lateral Foot: sterile ABD pad, sterile gauze roll, Betadine, apply once daily for thirty (30) days. However, record review revealed there was no documented evidence this Treatment Plan was inputted into the EMR as Physician's Orders. Review of the Hospital Wound Care Clinic Note, dated 01/24/19, revealed Physician's Orders for the Right Medial Ankle Wound: wash the extremity with soap and water, cleanse wound with Normal Saline, apply Venelex to open wound, secure with Kerlix, tape and change dressing twice a day. Record review of the January 2019 TAR, on 01/031/19, revealed Resident #10's Physician's Orders dated 01/11/19, were still being implemented as follows: Left Lateral Foot was still being treated with Alginate calcium with silver. Also, the Right Medial Ankle wound was still being dressed with Betadine. In addition, the MAR had an intervention dated 01/24/19 for Venelex Ointment, apply to Right Medial Ankle topically two (2) times a day for wound healing, clean with normal saline, apply Venelex, wrap with Kerlix and change every day. There was conflicting orders on the MAR starting 01/24/19 for treatment to the Right Medial Ankle. These discrepancies in Physician's Orders related to this resident's wounds were not discovered by staff until the Surveyor brought it to the Wound Nurse's attention on 01/31/19, when watching wound care for Resident #10. Interview with the Wound Care Nurse, on 01/31/19 at 10:35 AM, revealed Physician's Orders were not inputted correctly into Resident #10's Electronic Medical Record. She stated due to the resident visiting different wound clinics, it was hard to keep up with both clinics and their orders. She stated she had oversight over the wounds and should have identified Physician's Orders/treatment plans were not inputted into the EMR, and there were conflicting orders on the TAR for the resident's Right Medial Ankle wound. Interview with the Interim Director of Nursing, on 01/31/19 at 4:41 PM, revealed it was her expectation orders were inputted into the EMR timely and accurately. Further interview revealed it was important Physician's Orders be accurate for resident safety. Interview with the Administrator, on 01/31/19, revealed it was her expectation Physician's Orders were correctly inputted into the computer system in a timely manner. She stated it was important for Physician's Orders to be accurate to keep the residents safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility Policies, it was determined the facility failed to ensure proper sterile technique was used during indwelling urinary catheter placement for one (1) of (1) sampled residents observed for catheter placement out of twenty two (22) sampled residents (Resident #18). Observation of indwelling urinary catheter care for Resident #18, on 01/29/19, revealed during the procedure the catheter became dislodged, and the State Registered Nurse Assistant (SRNA) attempted to re-insert the catheter. The SRNA was unsuccessful at re-inserting the catheter and went to get the nurse. Further observation revealed the licensed nurse failed to use sterile technique when inserting the indwelling urinary catheter for Resident #18, and also failed to to test the retention balloon prior to inserting the catheter. In addition, the facility failed to review the Infection Control Plan and other infection control policies on an annual basis. The findings include: 1. Review of the facility Policy titled, Indwelling Urinary Catheter- General Information dated 06/03/06, revealed urinary catheters were a common source of infection and should be used only with clinical rationale. The policy did not have procedure guidelines for insertion and maintenance of the catheter. Review of the facility Policy titled, Indwelling Urinary Catheter General Information with effective date 09/01/18, revealed guidelines for appropriate urinary catheter use, but not procedural guidelines for catheter insertion. Review of [NAME] and [NAME] Clinical Nursing Skills and Techniques, Chapter Thirty Three (33), Eighth Edition, used by the facility's nursing staff, revealed urinary catheters should be inserted using sterile procedure. Review of the Kentucky Board of Nursing Advisory Opinion (AOS) #15, revised 12/2018, revealed Registered Nurses could delegate urinary catheter care to unlicensed personnel; however, insertion of the catheters remained a function for licensed nursing staff. Review of Resident #18's medical record revealed the facility admitted the resident on 08/16/17 with diagnoses to include Parkinson's Disease, Degenerative Disease of the Nervous System, Speech and Language Deficits following Cerebrovascular Disease, Urinary Retention, and Benign Prostate Hypertrophy. Observation of catheter care for Resident #18, on 01/29/19 at 9:09 AM, revealed during provision of catheter care the indwelling urinary catheter dislodged with the retention balloon deflated. SRNA #2 attempted to reinsert the catheter without success and then went to get the nurse. Licensed Practical Nurse (LPN) #2 entered the resident's room with the indwelling urinary catheter in one package with an outer wrapping and a sterile inner wrapping along with another package containing all other supplies, again having an outer package wrapping with sterile supplies inside. LPN #2 set up the sterile field, donned sterile gloves, and then picked up the outer package of the indwelling urinary catheter and opened it to reach the inner sterile catheter packaging. She did not take off the contaminated gloves and don another pair of sterile gloves during the procedure of inserting the indwelling urinary catheter. LPN #2 also failed to test the retention balloon prior to inserting the catheter. Interview with SRNA #2 on 01/31/19 at 11:25 AM, revealed he was educated about indwelling urinary care during orientation. He stated he was assigned to care for Resident #18 on 01/29/19, when the Foley catheter came out during catheter care. He further stated he had never had a catheter fall out during catheter care. SRNA #2 stated he knew he should not have reinserted Resident #18's catheter when it dislodged, but this was his immediate reaction. Continued interview revealed catheters should be placed per sterile procedure by a licensed nurse. Interview with LPN #2, on 01/31/19 at 1:17 PM, revealed urinary catheters should be inserted using sterile technique. She stated she was aware the outer packaging of the catheter should not be touched once sterile gloves were donned in order to maintain the sterile field. She further stated she normally inflated the catheter balloon prior to insertion to ensure it was operational, deflated the balloon, and then inserted the catheter. Continued interview revealed when she inserted the new urinary catheter for Resident #18, she forgot to test inflate the balloon prior to insertion of the catheter, and she failed to use sterile technique. Interview on 01/31/19 at 1:58 PM, with the Unit Manager for Magnolia Unit where Resident #18 resided, revealed SRNAs should never insert indwelling urinary catheters because it was not in their scope of practice. She stated only licensed nurses were trained to insert indwelling catheters. She further stated nursing staff should always maintain sterile technique during catheter insertions to minimize infection risks. The Unit Manager stated nursing staff should not touch the outer packaging of a catheter with sterile gloves during the procedure, and if that were to occur, the nurse would need to doff the contaminated gloves, wash hands, and don sterile gloves again. Interview with the Director of Nursing (DON), on 01/31/19 at 4:14 PM, revealed only licensed nursing staff were to place indwelling urinary catheters, as was consistent with nursing practice guidelines. Per interview, SRNAs were not trained on catheter insertion and should never perform the procedure. The DON stated sterile technique should be followed by nursing staff when inserting indwelling urinary catheters to help prevent infection. Per interview, licensed nurses should maintain sterile technique and not touch the outer packaging of a catheter after sterile gloves were applied. She further stated the nurse should have tested the urinary catheter balloon prior to insertion, deflated, and then inserted the catheter. Continued interview revealed the nursing staff used [NAME] and [NAME] guidelines for clinical procedures. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed it was her expectation for the nursing staff to follow sterile procedures in accordance with accepted practice and facility adopted guidelines in inserting indwelling urinary catheters. She stated her expectation was consistent with good infection control practices. She further stated it was never acceptable for a nursing assistant (SRNA) to insert a urinary catheter because the skill was beyond the scope of practice. 2. Review of the facility Policy titled, Infection Prevention and Control Program Overview, with a prior revision date of 10/15/14 and an effective date of 10/01/17, revealed the facility had not updated the policy on an annual basis. Review of the facility Policy titled Influenza with revision date of 02/15/11, revealed no current review date. The policy sponsor was clinical/infection control. Review of the facility Policy titled, Pneumonia with revision date 02/15/11, revealed no current review date. The policy sponsor was clinical/infection control. Interview with the facility Infection Control Practitioner, on 01/31/19 at 3:27 PM, revealed she had assumed the infection control role in December 2018. She stated the Infection Prevention and Control Program Overview policy had not been reviewed or updated in 2018. She further stated she was unable to produce an infection control policy with a current date. Interview with the Director of Nursing (DON), on 01/31/19 at 4:14 PM, revealed the Infection Control Plan and Policies should be reviewed at least annually. She stated she was new in her role and was unable to produce current infection control policies. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed she was aware of the requirement to review infection control policies and plans on an annual basis. She stated she thought that was done, but could not locate or produce any evidence to support her assertion.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals. Observation on 01/29/19, revealed the temperature of the Magnolia Unit medication refrigerator was out of range. In addition, observation on 01/30/19, revealed loose pills which were not packaged or labeled in three (3) of six (6) medication carts. The findings include: Review of the facility Policy titled, Medication Management Guidelines, dated 09/01/18, revealed no guidelines for checking medication carts for unlabeled medications nor for ensuring medication refrigerator temperatures were in range. 1. Observation on 01/29/19 at 10:52 AM, of the Magnolia Unit Medication Room, , revealed the medication refrigerator temperature gauge was out of range. The temperature was in the red out of range area at forty two (42) degrees. Interview with Licensed Practical Nurse (LPN) #9, on 01/29/19 at 10:52 AM, revealed night shift normally checked refrigerator temperatures. She stated she did not normally address any issues related to the refrigerator temperatures because she did not work night shift. Interview with the Unit Manager for the Magnolia Unit, on 01/31/19 at 1:58 PM, revealed it was her expectation for night shift nursing staff to check medication refrigerator temperatures each night and record the readings in a log book. Per interview, if nursing staff recognized the temperature was out of range, she expected staff to move the medications to a regulated refrigerator and notify Maintenance of the malfunctioning refrigerator. She stated it was important to maintain correct temperatures to preserve the medications. 2. Observation on 01/30/19 at 10:00 AM, revealed the Medication Cart for Hall B, on the Rehabilitation to Home Unit, contained eight (8) loose pills in the medication drawers. The pills were not packaged or labeled and were scattered in the drawers. Interview with Licensed Practical Nurse (LPN) #10 on 01/30/19 at 10:00 AM, revealed the medication cart for Hall B on the Rehabilitation Unit had eight (8) loose, unlabeled pills in the medication drawers. She stated the unlabeled pills should not be left in the cart, and should have been discarded for safety reasons. 3. In addition, observation on 01/30/19 at 10:15 AM, revealed the Medication Cart for Hall A, on the Rehabilitation to Home Unit , contained two (2) loose pills which were not packaged or labeled in the cart drawers. Interview with LPN #11, on 01/30/19 at 10:15 AM, revealed the medication cart for Hall A, on the Rehabilitation to Home Unit, had two (2) unlabeled, loose pills in the drawers. She stated the pills should have been discarded because they were unidentified medications. 4. Furthermore, observation on 01/30/19 at 11:34 AM, revealed the Medication Cart for the 210 Magnolia Hall had three (3) loose pills which were not packaged or labeled in the cart drawers. Interview with LPN #7, on 01/31/19 at 1:17 PM, revealed the medication cart for the 210 Hall on the Magnolia Unit, had three (3) loose unlabeled pills in the drawers. Per interview, these unidentified pills should have been discarded as they were not safe for administration. Further interview with the Unit Manager for Magnolia Unit, on 01/31/19 at 1:58 PM, revealed loose, unlabeled medications were not to be in the Medication Cart, and staff were to discard such medications. Interview with the Director of Nursing (DON), on 01/30/19 at 10:25 AM, and on 01/31/19 at 4:30 PM, revealed medication carts should not have loose, unlabeled medications present in the drawers as these medications were not safe to administer and should be discarded. Further interview revealed the night shift nursing staff was to check medication refrigerator temperatures and record results on a temperature log. Per interview, if medication refrigerator temperatures were out of range, this should be immediately reported to the Unit Managers for resolution. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed it was her expectation for nursing staff to check medication refrigerator temperatures, and report out of temperatures to the DON. Per interview, medication refrigerator temperatures should be maintained at appropriate temperatures to maintain the integrity of the medications. The Administrator further stated she would not expect to find loose, unlabeled medications in the medication carts. She stated loose pills should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy, it was determined the facility failed to maintain patient care equipment in a safe operating condition. The facility failed to ensure glucometer control solutions were dated when opened as directed by Manufacturer's Recommendations. Observation on [DATE], of the Magnolia Unit Medication Room, revealed a MediSense Glucose and Ketone Control Solution box containing two (2) glucometer testing solutions which had been opened and were not marked with the open date. In addition, observation on [DATE], of the Rehabilitation to Home Unit Medication Room, revealed a MediSense Glucose and Ketone Control Solution box containing two (2) glucometer testing solutions which had been opened and were not marked with the open date. The findings include: Review of the facility Policy titled, Blood Glucose Calibration/Quality Control Testing dated [DATE], revealed the policy's purpose was to set forth the procedures to be followed to test the accuracy of the blood glucose monitoring devices. Policy guidelines included testing when test results were questionable and use of a calibrator packaged with the box of test strips to be used. No guidelines in accordance with manufacturer's recommendations were included relative to dating the glucose control testing solutions (MediSense Glucose and Ketone Control Solutions) when opened. Review of the package insert for MediSense Glucose and Ketone Control Solutions, published by [NAME] and dated Rev. A 10/2017, revealed the solution was stable for ninety (90) days after opening. Further recommendations for product usage revealed the open date of the solution should be written on the vial at the time it is first opened. The recommendations stated the vials should be discarded ninety (90) days from the open date on the vial or on the expiration date, whichever occurred first. 1. Observation on [DATE] at 11:11 AM, of the Magnolia Unit Medication Room, revealed a MediSense Glucose and Ketone Control Solution box with two (2) glucometer testing solutions which had been opened and were not marked with the open date. 2. Observation on [DATE] at 10:00 AM, of the Rehabilitation to Home Unit Medication Room, revealed a MediSense Glucose and Ketone Control Solution box with two (2) glucometer testing solutions which had been opened and were not marked with the open date. Interview with Licensed Practical Nurse (LPN) #7, on [DATE] at 1:17 PM, revealed night shift performed the glucometer control testing . She stated she generally did not work nights and thus, did not usually perform the testing. LPN #7 further stated new control solution vials should have the open date marked on the vial. Interview with LPN #3, on [DATE] at 1:37 PM, revealed although she usually did not work night shift, she knew how to perform glucometer checks using the MediSense control solutions. She stated it was very important to date the vials when new testing solution was opened. She stated control testing was important to ensure accurate glucometer readings. Interview with the Unit Manager for Magnolia Unit, on [DATE] at 1:58 PM, revealed night shift performed glucometer testing each night and recorded readings in a log book. She stated when new testing solution was opened, the open date of the vial should be written on the vial itself. She stated accuracy of the glucometer readings was dependent on using testing solution that was not expired. She further stated the glucometer readings were the determinant in administering accurate sliding scale insulin doses. Interview with Registered Nurse (RN) #1, on [DATE] at 7:40 AM, revealed she worked night shift and performed glucometer testing at night. She stated when she opened a new box of MediSense Glucose and Ketone Control solution vials, she dated the box. She further stated she should date the vials and not the box in case the vials were separated from the box. Interview with the Director of Nursing (DON), on [DATE] at 11:11 AM, and on [DATE] at 4:14 PM, revealed the MediSense Glucose and Ketone Control Solution vials should be dated when opened. Further interview revealed she expected the MediSense Glucose and Ketone Control solution vials to be dated both on the vials and on the box. She stated glucometer testing helped ensure accurate blood glucose readings which determined sliding scale insulin dosing. She stated using expired testing solution could compromise the integrity of the glucometer results and impact resident safety negatively. Continued interview revealed following manufacturer's recommendations was an important component to ensure correct glucometer results. Interview with the Administrator, on [DATE] at 5:02 PM, revealed she expected nursing to manage glucometer control testing. She stated the DON should manage the process and ensure staff were following facility policy. The Administrator stated the control solution vials should be dated when opened. Further interview revealed glucose testing solution should not be expired to ensure the accuracy of glucometer readings, which in turn determined sliding scale insulin dosing.

2. Review of the facility Policy titled, Sanitation and Infection Control Standards for Food and Dining, dated 09/01/18, revealed employees were trained on sanitation and cleaning procedures. Interview on 01/31/19 at 4:14 PM, with the Director of Nursing (DON), revealed the Nursing Department did not have a policy for cleaning the residents' nutritional refrigerators in the Medication Rooms. Observation on 01/29/19 at 10:52 AM, revealed the nutrition refrigerator in the Medication Room, located on the Magnolia Unit, had dried pudding running down the wall of the refrigerator to the bottom of the refrigerator, and the pudding had pooled in the corner of the bottom drawer. Interview with Licensed Practical Nurse (LPN) #9, on 01/29/19 at 10:52 AM, who also observed the nutrition refrigerator, revealed the residents' nutritional snacks and supplements were stored in the refrigerator, and the refrigerator should be kept clean. She agreed the refrigerator needed to be cleaned. Interview with LPN #2, on 01/31/19 at 7:30 AM, revealed night shift staff was responsible for cleaning the nutrition refrigerators each night. However, she stated staffing on night shift had been low, so there were times the refrigerator did not get cleaned. Interview on 01/31/19 at 1:58 PM, with the Unit Manager for the Magnolia Unit, revealed night shift was responsible for cleaning the nutrition refrigerators in the Medication Room nightly. She stated there was no policy or protocol to govern the cleaning; however, cleaning was important for infection control. Interview with the Director of Nursing (DON), on 01/31/19 at 4:14 PM, revealed it was her expectation for the nutrition refrigerators in the Medication Rooms to be kept clean as this was important for infection control. Interview with the Administrator, on 01/31/19 at 5:02 PM, revealed it was her expectation for nursing staff to maintain clean nutritional refrigerators for infection control purposes. Based on observation, interview and review of facility Policies, it was determined the facility failed to prepare and store food under sanitary conditions. Observation on 01/29/19, during initial kitchen tour, revealed there were no paper towels available at the kitchen sink. In addition, scoops were found lying in the food product, inside three (3) of the four (4) ingredient bins. Furthermore, observation on 01/29/19, revealed the nutrition refrigerator located in the Medication room on the Magnolia Unit was soiled. The findings include: 1. Review of the facility Policy titled Handwashing, dated 10/01/17, revealed instructions to turn the water off using a paper towel to prevent the hands from becoming contaminated. Review of the facility Policy titled Food Safety in Receiving and Storage, dated 09/01/18, revealed all food storage bins or containers should be maintained in clean condition and labeled with the contents. Scoops are not to be stored inside bins. Observation on 01/29/19 at 6:05 AM, upon initial tour of the kitchen, revealed there were no paper towels available at the hand sink in the pot and pan area. After washing hands, the State Agency Representative asked Dietary Aide #1 for paper towels and was told there was another hand sink in the kitchen. The State Agency Representative again requested paper towels and Dietary Aide #1 located the paper towels in dry storage and filled the paper towel holder. Continued observation during initial kitchen tour, revealed scoops were left inside three (3) of four (4) white storage bins containing sugar, rice and food thickener. Interview on 01/30/19 at 9:48 AM, with Dietary Aide #1 revealed she did not know the paper towel holder was out of paper towels. Continued interview revealed paper towels should always be available to access at the sinks in order for staff to dry their hands after hand washing. Further interview revealed scoops should be hung inside the storage bin lid and should not be left in the food product in order to prevent cross contamination. Interview on 01/30/19 at 8:05 AM, with the Dietary Supervisor, revealed all staff were responsible to fill the paper towel holder because staff were to use paper towels to dry wet hands after hand washing instead of using hand towels to prevent cross contamination. Further interview revealed the bin scoops were to be placed inside the scoop holder located inside the lid because if the scoops were left in the food product, the handle of the scoop could cause cross contamination. Interview on 01/30/19 at 3:05 PM, with the Registered Dietitian (RD), revealed paper towels should be accessible in the paper towel holder in order for staff to dry hands after handwashing for infection control purposes. Further interview revealed scoops should be placed in the scoop holder and should not be left inside the ingredients in the bins as this could cause cross contamination from the scoop to the food ingredients. Interview on 01/31/19 at 2:33 PM, with the Director of Nursing (DON), revealed it was important for staff to wash hands and to turn off the water faucets with paper towel and not by bare hand to prevent infection control concerns. Per interview, all Dietary staff were responsible for restocking the paper towel holder. Further interview, revealed scoops should be placed in the proper holder and not left in the ingredients in the bins in order to prevent cross contamination. Interview on 01/31/19 at 2:53 PM, with the Administrator, revealed after handwashing faucets were to be turned off with paper towels to prevent the spread of bacteria or germs, and paper towels should always be available at the kitchen sinks. He further stated scoops should not be left in the ingredients inside the kitchen bins, but should be properly stored in the scoop holders. Continued interview revealed it was his expectation for dietary staff to follow the facility policies regarding hand washing and the storage of scoops.