Based on observation, interview, and review of the facility policy, it was determined the facility failed to serve food under sanitary conditions. Dietary Aide (DA)2 failed to perform hand hygiene after touching various items, and prior to serving food. In addition, DA2 failed to wear a finger cot over a wound to prevent possible contamination while handling food. The findings include: Review of the facility policy Food Preparation dated 09/2017, revealed all staff will practice proper handwashing techniques and glove use. Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. Observation on 06/17/2025 at 11:15 AM, revealed DA2 was obtaining temperatures (temping) of several items on the food line. DA2 who had a band-aid on one finger, was not wearing gloves. He then stepped away from the food line and walked over to a bucket and, using his bare hands, pulled out a wet cloth from the bucket. DA2 then walked back to the food line, and wiped down the shelf above the food he was temping. He then went back to the bucket, dropped the soiled cloth in the bucket, and returned to the food temping area. DA2 failed to perform hand hygiene after cleaning the area and touching the soiled rag with his bare hands. He then reached for the lid of one of the food items on the food line. After intervention by the survey team, the Dietary Manager instructed DA2 to wash his hands prior to handling the food. In interview on 06/17/2025 at 12:45 PM, the Dietary Manager stated staff need to follow guidelines and policy. She stated when staff steps away from the food and does other tasks, they should always wash their hands prior to returning to the food line. She further stated DA2 should have worn a finger cot on his finger when there was an injury, such as a cut, on the finger to ensure safe handling of the food. Interview with the District Manager of Food Services at 06/18/2025 at 10:52 AM revealed a finger cot should be used when there is an injury, such as a cut. She stated DA2 should have worn gloves when wiping down the shelf and should have washed his hands before he returned to the food line. She stated hand washing is important because cross contamination can occur. In interview on 06/18/2025 at 1:47 PM, DA2 confirmed he did not wash his hands when going back to the table, stating that he had a lot on his mind and was distracted. He further stated he should have worn gloves to wipe down the shelf. Interview with DA1 at 06/18/2025 at 10:54 AM revealed hand washing needed to be done whenever you leave the food service area. She stated this was important because of the potential for cross contamination. In interview on 06/18/2025 at 2:51 PM, the Administrator stated education for all staff was done yearly and as needed, regarding infection control. She stated she has high expectations for the dietary staff, and it is important to wash hands properly when preparing food to prevent illness and ensure the safety of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure reasonable accommodations for one (1) of seventy-four (74) sampled residents (Resident) #79, on two (2) occasions. Observations of Resident #79 during survey revealed the call light button out of reach of the resident. The findings include: The facility did not provide a policy for accommodation of residents' needs. Review of Resident #79's medical records revealed the facility admitted the resident on 10/27/2020 with diagnoses of Cerebral Palsy, Seizures, Intestinal Obstruction, History of Urinary Tract Infection (UTI), Malignant Neoplasm of colon, Aphasia, and Sepsis. Review of Resident #79's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident as absent of the spoken word and somewhat had the ability to understand others. A Brief Interview for Mental Status (BIMS) examination was not completed at this time; no BIMS was present in Resident #79's medical record. Continued review of the MDS revealed the facility determined the resident had poor decision-making skills, required cues and supervision from staff. Continued review of Resident #79's MDS dated [DATE], revealed the facility determined the resident was an extensive assist for bed mobility, to transfer, to dress, to toilet and for personal hygiene. This MDS also revealed the facility identified the resident as set up only to eat. Review of Resident #79's Comprehensive Care Plan, last revised on 09/15/2021, revealed the facility determined the resident at risk for falls and the call bell should be placed within easy reach of resident. This approach was initiated 11/06/2020 and was last edited on 02/13/2021. The care plan further revealed the resident was at high risk for impaired vision related to inability to participate in vision test, edited on 09/15/2021. The intervention listed to keep call light in reach at all times as an approach for this resident, initiated on 11/06/2020. Observation, on 09/12/2021 at 11:16 AM, revealed Resident #79 pointed to the closet and motioned for a drink. When the resident was asked to push the call light, he/she looked around to find the call light button and could not locate it. Continued observations revealed the call light button was attached to the top of resident's pillow, closest to the mattress side. Resident #79 attempted to reach the call light, but was unable as the call light button was out of reach. Observation, on 09/16/2021 at 1:12 PM, revealed Resident #79 in the bed, with the head of the bed in the up position as the resident ate lunch. Continued observation revealed the call light was attached to the bottom part of the mattress, out of the resident's reach. When asked where the call light button was located the resident made a motion with his/her hands as to imply I do not know. On 09/18/2021 at 4:25 PM, interview with Certified Nurse Aide (CNA) #8 revealed she worked at the facility for one (1) year and one (1) month and she provided care for Resident #79. She revealed Resident #79 used a regular call light. She stated it was important for this resident to be able to reach the call light as the resident had a colostomy bag and the resident requested staff when he/she needed assistance. CNA #8 further stated the resident only used gestures to communicate and it was important to observe the resident since that was his/her communication style. She further stated the purpose of the call light was to notify staff when the resident needed something. Interview, on 09/18/2021 at 4:45 PM, with Licensed Practical Nurse (LPN) # 6 revealed it was important for the resident to have the call light button within reach, in case the resident needed anything. LPN #6 stated Resident #79 could only communicate through hand gestures and was nonverbal. She further revealed if the call button was out of reach from the resident, staff might not respond quickly to meet the resident's needs. On 09/18/2021 at 4:45 PM, interview with the Director of Nursing (DON) revealed the call button should have been within reach of the resident. She reported it was important to have the call button within reach, so residents had immediate access to it. On 09/18/2021 at 4:30 PM, interview with the Administrator revealed the expectation for the call light buttons was they would be located on the bed or if the resident was in a wheelchair it would be close to the wheelchair. The Administrator stated the purpose of the call light button was to inform staff if the resident needed something.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, it was determined the facility failed to maintain an infection prevention and control program that ensured a safe, sanitary, and comfortable environment for the prevention of communicable diseases and infections. Observations during the survey revealed direct care staff, housekeeping staff, compassionate care staff, and one (1) resident did not consistently utilize masks and/or eye protection, as currently required when working in, or traveling through resident care areas. The findings include: Review of the facility's policy titled Infection Control, revised October 2018, revealed the facility's infection control policies and practices applied equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public. Review of the facility's policy titled, Novel Corona Virus (COVID-19), last revised 09/13/2021, revealed under subheading General Prevention Measures, during the pandemic, the facility required all direct care stakeholders to wear a surgical facemask while in the facility, in coordination with the Centers for Disease Control (CDC), State and Federal guidelines. Under the same subheading, eye protection (face shield or goggles) would be worn by stakeholders (in addition to masks) during an outbreak, until the facility went fourteen (14) days without a new resident or stakeholder positive case; and when county/community spread was Moderate to High (meaning positivity rates were greater than or equal to 5%.) Review of the facility's policy titled Novel Coronavirus (COVID-19), last revised 05/17/2021, under subheading Facility Education and Visitation, revealed the facility's residents and families/visitors were expected to adhere to a list of seven (7) core principles labeled by alpha letters (a through g.) Principle (c) revealed a face covering or mask should cover the mouth and the nose, and social distancing of at least six (6) feet between persons should be maintained, in accordance with CDC guidance. Principle (d) revealed the facility should have instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices. Review of the facility's policy, titled Handwashing/Hand Hygiene, revised August 2019, revealed hands should be sanitized with an alcohol-based hand rub containing at least 62% alcohol; or, alternatively washed with soap and water before and after entering isolation precaution settings. Review of Droplet Isolation Signage, at a resident's doorway, revealed everyone must clean hands when entering and leaving the room, wear a mask, and doctors and staff must wear a gown, gloves, and an eye cover if contact with secretions was likely. Review of Contact Isolation Signage at a resident's doorway, revealed to clean hands when entering and leaving the room. Doctors and Staff must put on a gown and gloves at the door. Both, aforementioned signs also indicated families and visitors must follow instructions from the information sheets. Record review revealed the Administrator provided documentation the facility had one (1) dietary staff person that tested positive for COVID-19 on 09/09/2021. Interview, on 09/15/2021 at 10:57 AM, with the Director of Nursing (DON)/Infection Preventionist (IP), revealed a dietary staff person tested positive for COVID-19 on 09/09/2021, and the staff person last worked on 09/08/2021. The DON/IP provided a copy of the staff member's Polymerase Chain Reaction (PCR) positive lab test dated 09/09/2021, which confirmed the individual was positive for COVID-19 on 09/09/2021. The IP said the county/community spread designation was currently classified as High. Observation, on 09/12/2021 at 12:13 PM, revealed Certified Nursing Assistant (CNA) #14 entered the room of Resident #82 to give the resident their breakfast tray. The resident was in droplet precautions and the CNA entered the room with only a mask and goggles - no gown or gloves. Additionally, continued observation revealed the CNA performed no hand hygiene. Observation on the [NAME] Unit, 300 Hallway, on 09/14/2021 at 3:50 PM, revealed Resident #312, who resided in room [ROOM NUMBER], was sitting in his/her bed talking with a visitor. Signage at the resident's door indicated the resident was under droplet isolation precautions. Resident #312's visitor identified herself as the Hospice Social Worker. The Hospice Social worker was wearing a mask, but she was not wearing eye protection (no goggles or faceshield). Review of Resident #312's clinical record revealed the facility originally admitted the resident on 05/12/2021 for a brief respite care stay. The resident had a diagnosis of Alzheimer's Dementia. Interview on 09/17/2021 at 7:57 PM with Resident #312's daughter, revealed Resident #312 was readmitted to the facility on [DATE] for an additional respite care stay. She stated hospice staff visited Resident #312 during his/her brief stays at the facility. Interview, on 09/20/2021 at 8:50 AM with the Hospice Social Worker, revealed the facility's staff had not instructed her to wear eye protection while in resident care areas. She said she was aware the facility had a recent COVID-19 positive case because the admissions' staff person told her. She said she did not observe any signage at the front entry directing her to wear eye protection. The Social Worker said she had goggles with her on 09/14/2021 when she visited Resident #312, but she had taken them off because it was hot in the resident's room. Observation, on 09/17/2021 at 8:15 AM, revealed Certified Nursing Assistant (CNA) #15 entered resident room [ROOM NUMBER] after putting on gloves, but no gown. Signage at the doorway to the resident's room revealed the resident was in droplet precautions and staff must wear mask, gown, gloves and eye protection. Interview with CNA #15, at the time of the observation, revealed she just did not think to put on a gown. Additionally, CNA #15 stated by not wearing the appropriate protection she could become sick or she could relay an infection to a resident, causing their illness or death. Observation, on 09/18/2021 at 1:45 PM, revealed a Hospice Registered Nurse (RN), completed the electronic COVID-19 screening process at the lobby before proceeding to the [NAME] Unit to visit a resident. The Hospice RN was wearing a mask, but she did not put on eye protection before walking down the hallway toward the [NAME] Unit nurses' station. Interview, on 09/18/2021 at 1:45 PM with the Hospice RN, revealed no one instructed her that she had to wear eye protection while in the facility. She stated she visited many long-term care facilities in the city, and each one seemed to have different PPE use rules. She said she had not noticed any signs directing her to put on eye protection. The RN said she had goggles in her backpack; she put her goggles on. Observation, on 09/18/2021 at 1:53 PM of the front lobby and staff/visitor screening area, revealed there were no instructions directing staff and visitors to use eye protection when in the facility. Observation, on 09/17/2021 at 6:36 AM on the Maroon Unit, revealed Certified Nursing Assistant (CNA) #8 walked from the 700 hallway toward the nurse's station. The CNA was wearing a facemask, but she was not wearing eye protection. The CNA then walked into the nurse's station. Interview, on 09/18/2021 at 10:59 AM with Registered Nurse (RN) #1, revealed all facility staff and visitors were required to wear a mask and eye protection regardless of where they were in the facility. She said the protective measures prevented possible spread of COVID-19. RN #1 said if a resident was under isolation precautions, then staff and visitors were required to wear a disposable gown, gloves, a mask, and eye protection in the resident's room. Once again, the nurse stated wearing the PPE in the resident isolation rooms, as directed by the sign at the resident's door, assisted with preventing the spread of the infection(s). She said the guidance applied to compassionate care personnel (hospice staff), too. Observation, on 09/18/2021 at 1:00 PM on the Maroon Unit, revealed the Medical Records Staff/Registered Nurse (RN) was sitting at the nurses' station. The Medical Records Staff/RN was wearing a surgical mask, but her nose was fully exposed. In addition, she not wearing a face shield or goggles. While talking with the Medical Records Staff/RN, she pushed her mask back up on her face several times because it kept slipping down below her nose. Interview with the Medical Records/RN, revealed she did not think she had to wear eye protection when sitting at the nurses' station, but added she thought they (meaning facility leaders) wanted staff to wear the goggles or a faceshield everywhere. The Medical Records RN also stated, I guess I should go get a mask that fits me better. Observation, on 09/18/2021 at 1:55 PM on the Maroon Unit, revealed CNA #8 wheeled Resident #79 to a space in the common area of the unit near the Turf Room (dining area). Resident #79 was not wearing a mask. The CNA walked over to some cabinets in the dining room, and returned in about two (2) minutes. She then went back to be with the resident, but did not bring a mask to place on the resident's face. Interview, on 09/18/2021 at 1:59 PM with CNA #8, revealed Resident #79 was supposed to wear a surgical mask when not in his/her room, and said, Oh my God, I forgot to get a mask for the resident. I will get one for (him/her) immediately. The CNA also stated that when not in their rooms residents were supposed to wear a surgical mask to prevent the spread of germs. Record review revealed the facility admitted Resident #79 on 10/27/2020 with diagnoses of Cerebral Palsy, Unspecified Convulsions, Major Depressive Disorder, Generalized Anxiety, and Malignant Neoplasm of the Colon. Review of Resident #79's Quarterly Minimum Data Set (MDS) assessment, dated 07/09/2021, revealed the resident was non-verbal and not interviewable. Interview, on 09/18/2021 at 11:38 AM with Licensed Practical Nurse (LPN) #6, who worked on the Maroon Unit, revealed staff and visitors who were allowed in the facility, such as hospice staff, were to wear a mask and goggles or a face shield to prevent the possible spread of COVID-19. LPN #6 stated staff and visitors entering a droplet isolation area were to put on a disposable gown and gloves in addition to the mask and goggles they should already be wearing. LPN #6 stated before exiting an isolation area or room, individuals were to remove the PPE, dispose of it in the resident's room, and wash/sanitize their hands. Further interview revealed even if just delivering a meal tray, staff should put on a gown and gloves at the doorway, and discard the PPE and wash or sanitize their hands before exiting the room. She stated staff should sanitize their hands after delivering each meal tray. LPN #6 stated this was necessary to prevent the spread of contagious infections. She stated staff received infection control training by completing modules in the facility's computerized training program. Interview, on 09/18/2021 at 2:27 PM with the Director of Nursing/Infection Preventionist (DON/IP), revealed she monitored staff and visitors for compliance with PPE use during frequent walking rounds through all nursing units and other areas of the facility. The DON/IP said she, the Administrator, and the Staff Development Coordinator (SDC) ensured they reviewed the most current guidance on the prevention of COVID-19. The DON/IP revealed eye protection and surgical masks were required PPE for all staff and visitors while they were in resident care areas. The DON/IP said the only areas not considered resident care areas were closed-in storage rooms and the staff break room. The DON/IP said the nurses' stations and facility hallways were designated as resident care areas, and staff working in or moving through those areas must wear their masks and eye protection. The DON/IP said in order to wear the surgical mask properly, it must fully cover the resident's or staff member's mouth and nose. Additionally, the DON/IP stated eye protection could include goggles, a face shield, or eye wings added to personal eyewear. The DON/IP said housekeepers must also wear masks and eye protection whenever they were working in resident care areas. She said this was the facility's current practice as recommended by the Centers for Disease Control (CDC). She stated COVID-19 was an airborne infection. Continued interview with the DON/IP, on 09/18/2021 at 2:27 PM, revealed use of a disposable gown and gloves was not always necessary for staff when in a droplet isolation room, unless the staff person had to provide direct care, for example, taking the resident to the restroom. The DON/IP said she clarified that with the Corporate Infection Control Nurse. Regarding delivery of meal trays to resident rooms, the DON/IP, said the facility's policy directed staff to sanitize their hands before leaving each resident's room. She stated, however, after delivering the third meal tray, the staff must then wash their hands with soap and water. The DON/IP stated she was confident she had previously educated the hospice nurse on the use of a mask and eye protection while at the facility, but was she not sure she had provided the education to the Hospice Social Worker. Interview with the Administrator, on 09/18/2021 at 4:36 PM, revealed she was unaware of any issues regarding staff use of personal protective equipment in the facility. The Administrator stated the use of personal protective equipment prevented the spread of infection to those in the facility.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, and distribute food under sanitary conditions and in accordance with professional standards for food safety. Initial tour of the facility revealed opened and undated containers of salad dressing in the walk-in refrigerator. The findings include: Review of the facility's policy, Labeling and Dating Policy, dated 2017, revealed proper labeling and dating ensured all foods were stored, rotated, and utilized in a first in, first out manner. This helped minimize waste and ensured items past their due date were discarded. Tour of the kitchen with the Dietary Manager, on 09/12/2021 at 10:00 AM, revealed two (2) salad dressing containers that were opened, but were not dated in the walk-in refrigerator. Interview with the Dietary Manager (DM), on 09/12/2021 at 10:00 AM, revealed food and drinks needed to be labeled so that staff would know when they were first opened. She stated food and drinks should be labeled and dated with the date opened and when it expired. She stated if food or drinks were opened and not dated that it could make residents sick if those food items were used. Interview with the Director of Nursing (DON), on 09/18/2021 at 3:24 PM, revealed she would have to refer to the facility's policy about labeling and dating of food items. She stated if residents received food that was undated it could be expired and could cause nausea, vomiting, upset stomach, or nothing could happen. Interview with the Senior Administrator, on 09/18/2021 at 4:36 PM, revealed her expectation for storage of food was that it should be labeled and dated with the opened date and the date it expired. She stated this practice occurred to prevent staff from serving expired food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to accommodate residents' needs for one (1) of nineteen (19) sampled residents, Resident #221. Observation revealed the resident's urinal was not within reach of the resident while he/she was in bed. The findings include: Review of the facility's Resident Rights, dated 08/16/18, revealed residents were treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the clinical record revealed the facility admitted Resident #221 on 02/15/19, with diagnoses of Diabetes Type 2, Muscle Weakness, Local Infection of Subcutaneous Tissue, and Open Wound to the Left Foot. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance from two (2) staff for toileting. The resident was frequently incontinent of bowel and bladder. The facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15) and determined the resident was interviewable. Review of Resident #221's Care Plan, dated 02/28/19, revealed the resident had a self-care deficit with a goal for the resident to maintain Activities of Daily Living self-performance levels. In addition, the resident had an actual or potential for complications associated with urinary incontinence with an intervention for staff to encourage self-performance. Review of the [NAME] Unit Assignment Sheet, dated 03/8/19, revealed Resident #221 required two (2) staff and a mechanical lift for transfers, and the resident's right leg was amputated below the knee. The document noted the resident was on a bowel and bladder training program and staff checked the resident for incontinence and changed briefs as needed every two (2) hours. The Assignment Sheet did not contain information regarding use of a urinal to facilitate independence and increase urinary continence. Observations, on 03/06/19 at 8:45 AM, 03/07/19 at 10:08 AM and 12:32 PM, and 03/08/19 at 8:20 AM, of Resident #221's room revealed a urinal in a plastic bag, which was tied to the resident's bedside table drawer and out of reach of the resident. Interview with Resident #221, on 03/07/19 at 12:33 PM, revealed staff placed the urinal out of reach in a bag tied to the handle of the drawer on the bedside table. The resident stated when in bed, he/she had to use the call light to get staff to hand him/her the urinal, and by the time staff arrived in the room to assist, the resident was not able to wait and urinated on himself/herself. Observation, on 03/08/19 at 8:22 AM, revealed Certified Nursing Assistant (CNA) #4 entered Resident #221's room, assisted the resident with his/her cell phone, and exited the resident's room without moving the resident's urinal within reach of the resident who was in the bed. Interview, on 03/08/19 at 8:25 AM, with CNA #4 revealed staff should have placed the urinal in reach of the resident while he/she was in bed, by hanging the urinal on the side of a trashcan beside the resident's bed. The CNA stated the Assignment Sheet did not have any instructions related to the resident's urinal, but noted the resident was incontinent. The CNA stated if a resident's urinal was out of reach, it could cause the resident to be incontinent. In addition, the CNA stated she did not know staff had left the resident's urinal out of reach. Interview, on 03/08/19 at 8:55 AM, with Licensed Practical Nurse (LPN) #7 revealed staff should have kept the resident's urinal at the bedside within reach of the resident positioned in bed. The LPN observed Resident #221's room and bathroom and stated there was a urinal in a bag in the resident's bathroom and another in a bag tied to the bedside table. She stated urinals should be kept accessible for residents to use, and staff should encourage residents to use the urinal and then press the call light as soon as they were done using the urinal. According to the LPN, when a urinal was out of a resident's reach it put the resident at risk for a fall if the resident attempted to get to the urinal, and being out of reach could cause the resident to have an incontinent episode unnecessarily. Per interview, CNAs and nurses were responsible for ensuring urinals were in reach of the residents. Interview, on 03/08/19 at 11:20 AM, with Assistant Director of Nursing (ADON) #2, revealed she had managed the unit since 01/21/19 and had not addressed expectations for staff related to resident urinals. However, she stated urinals should be clean, in a bag, and stored in reach of the resident, as the resident preferred. She stated the purpose of urinal use was to allow the resident to empty his/her bladder independently. The ADON further stated the best practice was for staff to ensure the resident's urinal was in reach when the resident was in bed. She revealed waiting for help to access the urinal after using a call light increased the resident's risk of incontinence. Interview, on 03/08/19 at 3:51 PM, with the Director of Nursing (DON) revealed staff should keep Resident #221's urinal where he/she could access it at all times in case he/she could not wait for someone to respond to the call light. She further stated CNAs were trained to keep items such as urinals in reach of the residents. Interview, on 03/08/19 at 4:17 PM, with the Administrator revealed staff should keep urinals in reach of resident's who were able to use the urinal independently.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the care plan was implemented related to behavior management for one (1) of three (3) sampled residents, Resident #30. Staff did not implement behavioral interventions prior to administration of a psychotropic medication (Ativan). The findings include: Review of the facility's policy, Comprehensive Care Plans, revised 07/09/18, revealed a person-centered comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs would be developed for each resident. The policy stated care plan interventions would address the underlying source(s) of the problem area(s) and reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. Observation, on 03/06/19 at 11:31 AM, revealed Resident #30 sitting up in bed with his/her eyes closed. Review of the clinical record revealed the facility admitted Resident #30 on 06/04/18, with diagnoses to include Cerebral Infarction, Aphasia, Cognitive Communication Deficit, and Flaccid Hemiplegia affecting the right dominant side. Review of the resident's Care Plan for Alteration in Mood State revealed the goal was to reduce or eliminate verbalization of negative thoughts and reduce yelling out episodes. Interventions included offering chaplain services, 1:1 visits for socialization, and encouraging out of room interactions. Review Resident #30's Physician Order, dated 01/10/19, revealed Ativan 1 milligram (mg) via gastrostomy tube (G-tube) or by mouth twice a day as needed (PRN) for anxiety. Review of the Resident #30's Controlled Drug Records, for Ativan 1 mg, revealed fifteen (15) doses were signed out in January 2019, and thirty-two (32) doses were signed out in February 2019. Review of the Progress Notes for Resident #30 revealed there was no clinical rationale for twelve (12) of the Ativan doses signed out in January, or for thirty-one (31) of the doses in February. In addition, there was no documentation of non-pharmacological interventions attempted, per the care plan, prior to administration of the PRN Ativan. Interview, on 03/08/19 at 9:45 AM, with Licensed Practical Nurse (LPN) #2 revealed staff was responsible for implementing interventions to manage behaviors, including repositioning the resident, toileting, and offering food or music. Interview with LPN #1, on 03/08/19 at 11:13 AM, revealed PRN Ativan was not a primary intervention to manage a behavior(s) and stated non-pharmacological interventions should be attempted first, such as repositioning and reassuring the resident. Interview with the Director of Nursing (DON), on 03/08/19 at 6:42 PM, revealed Resident #30's care plan interventions were not implemented to ensure management of behaviors. Interview with the Administrator, on 03/08/19 at 8:27 PM, revealed he was not aware of any issues related to implementation of care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide showers and grooming to one (1) of nineteen (19) sampled residents, Resident #221. The findings include: The facility did not provide a policy for resident showers. Review of the facility's Resident Rights, dated 08/16/18, revealed residents were treated in a manner and in an environment that promoted maintenance or enhancement of quality of life. Review of the clinical record revealed the facility admitted Resident #221 on 02/15/19, with diagnoses of Diabetes Type 2, Muscle Weakness, Local Infection of Subcutaneous Tissue, and Open Wound to the Left Foot. Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident required extensive assistance from two (2) staff for personal hygiene and physical assistance of one (1) staff for bathing. The facility assessed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15). Review of the Resident #221's Care Plan, dated 02/28/19, revealed the resident had a Self-Care Deficit with interventions for staff to provide all activities of daily living care to ensure the resident's needs were met. Observation, on 03/7/19 at 12:31 PM, revealed Resident #221 was unshaven, with visible facial hair. Interview, on 03/07/19 at 12:32 PM, with Resident #221 revealed he/she preferred to be clean-shaven and staff had not assisted him/her to shave for several days. In addition, the resident stated staff had not provided showers as scheduled and staff did not always assist him/her with washing up in the mornings. Review of the [NAME] Unit Assignment Sheet, dated 03/08/19, revealed Resident #221 was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays on second shift. Review of Resident #221's Bathing Report revealed the facility provided a shower for the resident on 02/23/19 (Saturday) and the activity did not occur again until seven (7) days later on 03/02/19 (Saturday). Review of Resident #221's Progress Notes, dated 02/22/19 through 03/02/19, revealed no entries related to staff not providing showers to the resident due to the resident refusing the showers. Interview with and observation of Resident #221, on 03/08/19 at 8:20 AM, revealed the resident remained unshaven. The resident stated staff assisted him/her with a shower the previous evening; however, had not assisted with shaving and he/she agreed to have shaving delayed until today (03/08/19). Interview, on 03/08/19 at 8:25 AM, with Certified Nursing Assistant (CNA) #4 revealed staff had not told her in morning report that she needed to shave Resident #221. She stated her assignment included assisting Resident #221, but since it was not his/her shower day, and she had not received information about shaving him/her in report, she would have not known to offer assistance with shaving the resident. According to the CNA, shaving was part of the showering process and should have been included when staff gave the resident a shower, as it was part of personal hygiene. The CNA stated she made sure she completed resident showers assigned to her unless a resident refused. In addition, she would not know to pick up resident showers from a previous shift unless she was told in report because she was unable to look back at records to see if there were any missed showers. Interview, on 03/08/19 at 8:55 AM, with Licensed Practical Nurse (LPN) #7 revealed residents should receive showers three (3) days a week unless a resident refused. She stated if staff could not provide a scheduled shower to a resident, she asked the CNA to pass it on to the next shift in report. In addition, she stated shaving was part of the showering process and when a CNA provided a shower, the CNA should offer shaving as well. LPN #7 observed Resident #221 and stated the resident had several days beard growth. Interview, on 03/08/19 at 11:41 AM, with Assistant Director of Nursing (ADON) #2 revealed she saw Resident #221 earlier in the morning and noted the resident had up to a week's beard growth. She stated she expected staff to offer shaving to residents when they provided showers and should not delay the shaving to the next shift if the resident wanted to be shaved. The ADON reviewed the Bathing Report for Resident #221 and stated the record showed a gap in showers given. She stated staff should have provided Resident #221 a shower on 02/26/19 (Tuesday) and 02/28/19 (Thursday). She further stated staff should have noted the reason the resident missed the two (2) showers on the shower sheet. According to the ADON, if a resident had not received a scheduled shower, it should have been passed on to next shift or staff should have re-approached the resident later if he/she had refused. She stated she was not aware of a way for the nurses to look back to see if showers had been given. The ADON stated if staff did not provide residents their showers, it posed a risk of skin breakdown, or if the resident's skin was already compromised, the condition could become worse. She stated she was not aware of the facility doing any audits of resident showers. Interview, on 03/08/19 at 3:32 PM, with the Director of Nursing (DON) revealed the facility scheduled showers for residents three (3) times a week and staff was to assist residents with washing their face and peri-care daily and as needed. She stated if a resident refused a shower, the CNA should have documented the refusal and reported it to the nurse. In addition, any showers that the CNAs could not give should have been passed on to the next shift. She stated the risk for residents not having a shower for a week was compromised skin integrity. In addition, CNAs were to offer shaving when providing showers. She stated a resident that wanted to be clean-shaven and was not could result in altered self-image, as the resident might not like the way they looked. Interview, on 03/08/19 at 4:07 PM, with the Administrator revealed staff was to meet residents' needs, which included showers and shaving.

**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 ensure one (1) of three (3) sampled residents, Resident #30, was free from unnecessary psychotropic medication. Nursing staff did not monitor behaviors or implement non-pharmacological interventions prior to administration of a psychotropic medication (Ativan). The findings include: Review of the facility's Behavior Management Program Overview, not dated, revealed the purpose of the program was to identify and assess for disruptive behaviors in residents in order to develop interventions as appropriate. The policy revealed nursing staff should document each episode of the resident's behavior, precipitating factors, interventions, and outcomes of the interventions with noted side effects of psychoactive medications using the flow record in the Medication Administration Record (MAR). Further review revealed the Clinical Nurse Manager was responsible to ensure the licensed nurses completed the Behavior/Intervention Monthly Flow record correctly in the MAR. Observation, on 03/06/19 at 9:54 AM, revealed Resident #30 was in bed with his/her eyes closed. Review of the clinical record revealed the facility admitted Resident #30 on 06/04/18, with diagnoses of Cerebral Infarction, Aphasia, Cognitive Communication Deficit, and Flaccid Hemiplegia affecting the right dominant side. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of five (5) of fifteen (15) and determined he/she was not interviewable. Review of a Physician Order, dated 01/10/19, revealed Ativan 1 milligram (mg) via gastrostomy tube (G-tube) or by mouth twice a day as needed (PRN), for sixty (60) days for anxiety. Review of Resident #30's Controlled Drug Records, revealed fifteen (15) doses of Ativan 1 mg PRN were signed out in January 2019. Further review revealed thirty-two (32) doses of Ativan were signed out in February 2019. Review of Resident #30's MARs, dated January 2019 and February 2019, and the Progress Notes for Resident #30, revealed there was no clinical rationale for twelve (12) of the doses of Ativan signed out in January or thirty-one (31) of the doses signed out in February. In addition, there was no documentation indicating non-pharmacological interventions were attempted prior to administration of the PRN Ativan. Interview, on 03/08/19 at 9:45 AM, with Licensed Practical Nurse (LPN) #2 revealed the nurse was responsible for documenting the behaviors exhibited, non-pharmacological interventions attempted, and the effectiveness of the medication when a psychoactive medication was administered. She stated non-pharmacological interventions would include repositioning the resident, toileting, and offering food or music. LPN #2 stated it was important to document the behaviors, interventions, and effectiveness to effectively manage future behaviors. She further revealed it was important to follow-up with the resident after the medication was given to ensure it was effective and monitor for potential side effects. Interview with LPN #1, on 03/08/19 at 11:13 AM, revealed PRN Ativan was not a primary intervention to manage a behavior(s) and stated non-pharmacological interventions should be attempted first, such as repositioning and reassuring the resident. LPN #1 stated administration of PRN medication should be documented on the MAR, including follow up for effectiveness; however, she did not always document. She further revealed she did not always document the non-pharmacological interventions because she got busy. According to the LPN, a resident could potentially be prescribed a medication they did not need. Interview with the Social Services Director (SSD), on 03/08/19 at 7:57 PM, revealed the interdisciplinary team (IDT) monitored resident behaviors by reviewing progress notes during the morning meeting. He stated behavior monitoring would not be effective if behaviors and interventions were not documented in the clinical record. Interview with the Assistant Director of Nursing (ADON), on 03/08/19 at 4:13 PM, revealed she randomly audited clinical records and was not aware of any issues related to behavior monitoring or PRN psychoactive medication. According to the ADON, behaviors and interventions should be documented in the record to ensure a psychoactive medication was necessary. Interview with the Director of Nursing (DON), on 03/08/19 at 6:42 PM, revealed behavior monitoring would not be effective if all components were not included in the record. She further revealed the psychoactive performance improvement team reviewed clinical records for psychoactive medications and behavior monitoring; however, the team had not met since October 2018. Interview with the Consultant Pharmacist, on 03/08/19 at 4:46 PM, revealed resident specific behaviors should be documented in the clinical record in order to monitor for effectiveness of a psychoactive medication. The Pharmacist stated he audited MARs and psychoactive medication usage monthly and was not aware of any issues. Interview with the Administrator, on 03/08/19 at 8:27 PM, revealed he was not aware of any issues related to psychoactive medications or behavior monitoring. He stated the IDT reviewed clinical records to identify resident behaviors and implement appropriate interventions; however, it did not appear to be an effective system. According to the Administrator, the facility should have an understanding of the potential impact of medications on residents.

Based on observation, interview, and facility policy review, it was determined the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection for one (1) of nineteen (19) sampled residents, Resident #62. Observation of medication pass revealed Licensed Practical Nurse (LPN) #4 dropped a pill on the medication cart, used her bare fingers to pick up the pill, and put the pill into the medication cup, and administered the medication to Resident #62. In addition, the nurse failed to perform hand hygiene during medication administration. The findings include: Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2015, revealed all facility personnel was trained and regularly in-serviced on the importance of hand hygiene to prevent the transmission of healthcare-associated infections and followed the handwashing/hand hygiene procedures to help prevention and spread of infections to other personnel, residents, and visitors. The policy stated hand washing was required before and after handling medications, before and after direct contact with residents, and after contact with a resident's intact skin. The policy further stated the use of gloves did not replace hand washing/hand hygiene. The facility recognized the integration of glove use along with routine hand hygiene as the best practice for preventing healthcare-associated infections. Observation of medication pass, on 03/06/19 at 8:48 AM, revealed LPN #4 pushed Resident #62's Potassium pill from the bubble pack and it landed on the medication cart. The nurse used her bare fingers and put the Potassium pill in the medication cup, with the resident's other medications. She entered the resident's room, washed her hands in the resident's bathroom and grabbed a pair of gloves, touched the bathroom door handle, laid the gloves on the bed, and obtained the resident's blood pressure. She administered the oral medications, put on the gloves without performing hand hygiene after touching the door handle, used an alcohol pad to clean an area on the left side of the resident's stomach, and administered an injection of Victoza. She removed her gloves and left the room without performing hand hygiene. Interview with LPN #4, on 03/06/19 at 9:07 AM, revealed she probably should not have put the Potassium pill into the resident's medication cup because the medication could have been contaminated from germs on the medication cart, and her fingers. She further stated she was educated on how to handle a dropped medication and she was supposed to waste the pill and pop out another pill from the bubble pack. LPN #4 stated she should have washed her hands again after she touched the handle of the resident's bathroom because anything could be on the handle, like germs. She further stated she should have washed her hands again because she gave an injection (Victoza) and broke the resident's skin, which could cause infections. Interview with the Director of Nursing (DON), on 03/08/19 at 8:16 PM, revealed the medication cart was dirty and there was a potential for cross contamination when the pill landed on the cart and was put in the medication cup with bare hands. The DON stated nurses were to follow the infection control policy related to hand hygiene. Interview with the Administrator, on 03/08/19 at 9:17 PM, revealed staff should follow infection control for handwashing and he was not aware of any issues with infection control prior to today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to safeguard, control, and account for controlled medications for three (3) of nineteen (19) sampled residents, Resident #9, #33 and #36. Review of Controlled Drug Records and Medication Administration Records (MAR) revealed the residents' controlled medications were not maintained and accurately reconciled to ensure the residents received their medications. The findings include: Review of the facility's policy, Controlled Medication and Drug Diversion, reviewed [DATE], revealed medication included in the Drug Enforcement Administration (DEA) classified as controlled substances were subject to special handling, storage, disposal, and recordkeeping with the facility in accordance with federal, state and other applicable laws and regulations. A controlled medication accountability record was prepared when receiving or checking in a Schedule II, III, IV, or V medication and the following information was part of the report: name of resident; prescriber number; name, strength, and dosage form of medication; date received; quantity received; and name of the person receiving the medication supply. At shift change, or when keys were rendered, a physical inventory of all controlled medications was conducted by two (2) staff, either a licensed nurse, Certified Medication Technician, or per state regulation, and documented on the controlled substances accountability record. The facility kept a current controlled medication accountability record in the narcotic book and when it was completed, the record/s was submitted to the Director of Nursing (DON) and maintained on file at the facility. Review of the facility's policy, Medication Discrepancies, reviewed [DATE], revealed discrepancies were documented and reported to the resident's attending physician, DON, responsible party and the Performance Improvement Committee. In the event of a medication discrepancy, the facility took immediate action, as necessary, to protect the resident's safety and welfare and a medication discrepancy/error/incident report was completed and was included in the shift change report. Review of the facility's policy, Medication Administration General Guidelines, dated [DATE], revealed the individual who administered the medications dose, recorded the administration on the resident's MAR immediately following the medication being given The resident's MAR/Treatment Administration Record (TAR) was initialed by the person administering the medications in the space provided under the date, and on the line for that specific medication dose administration and times. Review of the facility's policy, Provider Pharmacy Requirements, dated [DATE], revealed the pharmacy assisted the facility, as necessary, in determining the appropriate acquisition, receipt, dispensing, and administration of all medications and biologicals to meet the medications needs of the residents and the facility. 1. Observation of Licensed Practical Nurse (LPN) #4, on [DATE] at 10:41 AM, revealed she was about to sign off on the Controlled Substance Accountability Count Record for the 500 Hall medication cart in the presence of the Surveyor. However, the nurse did not attempt to count the controlled medication in the double locked narcotic box prior to signing. Interview with LPN #4, on [DATE] at 10:42 AM, revealed she and another nurse had counted the controlled medication in the locked box earlier but she forgot to sign the Controlled Substance Accountability Count Record. She stated since she signed the Record later than when she counted the medication, the count could have been off, as a medication could have been taken out since the count was conducted. Interview with Registered Nurse (RN) #1, on [DATE] at 1:51 PM, revealed when she started her shift she counted controlled medications with the off going nurse and they signed the Controlled Substance Accountability Count sheet. She stated sometimes the previous nurse would forget to sign the Controlled Substance Accountability Count sheet, which happened occasionally. Interview with the DON, on [DATE] at 12:06 PM, revealed nurses signed off on the Controlled Substance Accountability Sheet Record when shift change occurred, or if a nurse split the shift with another nurse. 2. Review of Resident #9's MARs, dated [DATE] and February 2019, revealed an order for Ativan 0.5 milligram (mg), give half a tablet daily for anxiety. Review of Resident #9's Controlled Drug Record revealed the Ativan was signed out by LPN #3 on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. However, further review of the MAR revealed the no evidence the medication was administered to the resident on those dates. Continued review of Resident #9's MAR revealed an order for Ultram 50 mg, give every six (6) hours as needed for pain. Review of the Controlled Drug Records revealed Ultram was signed out by LPN #3 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. However, the MARs revealed no evidence the medication was administered to the resident on those dates. In addition, according to the MAR, LPN #3 administered Ultram on [DATE]; however, did not sign out the Ultram on the Controlled Drug Record. 3. Review of Resident #33's MARs, dated [DATE] and February 2019, revealed an order for Hydrocodone 5-325 mg every six (6) hours as needed. Review of the Controlled Drug Records, revealed Hydrocodone was signed out by LPN #3 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. However, review of the MARs revealed no evidence the medication was administered to the resident on those dates. 4. Review of Resident #36's MARs, dated [DATE] and February 2019, revealed an order for Ultram 50 mg, give half a tablet as needed for pain. Review of the Controlled Drug Records revealed Ultram was signed out by LPN #3 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. However, review of the MARs revealed none of the doses was administered to the resident. Interview with LPN #3, on [DATE] at 5:15 PM via telephone, revealed she was to sign medications out on the Controlled Drug Record and chart in the computer (MAR). However, the nurse stated she did not chart the medication 100% of the time in the computer. She revealed she had signed out controlled medications; however, she had not signed them as administered on the MAR. According to the LPN, Resident #9, #33, and #36 got their pills every night. She could not recall if she had been educated on the policy for medication administration and she had not received training on medication administration. The LPN further stated she had never seen anyone audit the medication cart and Assistant Director of Nursing (ADON) #1 had sometimes waited for over a month to remove discontinued controlled medications from the cart. Interview with LPN #1, on [DATE] at 11:25 AM, revealed she was trained on administering as needed medications and stated she should probably document the controlled substances were administered when she gave them to a resident, but she had a bad habit about not doing so. However, she stated it was good practice to document the right time of giving the medication because she could be pulled away and forget to sign the MAR. Interview with ADON #1, on [DATE] at 10:16 AM, revealed controlled medications were to be signed out on the Controlled Drug Record when they were pulled from the bubble pack, then after they were administered, the MAR was signed. She stated she had audited controlled medications and done so by looking at the Controlled Drug Records and the medication left in the bubble packs, and she removed narcotics from the mediation cart when a resident expired. However, she had no specific audit tool she used. Interview with RN #1, on [DATE] at 1:51 PM, revealed she reordered controlled medication when there were only about two (2) to three (3) days left in a bubble pack. However, when she called the pharmacy to reorder Resident #9's Ativan, the pharmacist said the resident's Ativan should last at least another three (3) days and could not be refilled. She checked the order for the frequency and it was correct and when she checked the Controlled Drug Record and MAR, she realized there were missing signatures on the MAR, she notified ADON #1, and an investigation began. However, the RN stated she had not seen any supervisor audit the medication carts for accuracy. RN #1 stated she had been trained on counting controlled substances in orientation. Continued interview with LPN #1, on [DATE] at 11:45 AM, revealed she probably had not documented all the time at night when she administered controlled medication. She stated because she was too busy might be why there were omissions on the MAR. She was not aware if medication carts or controlled medications were monitored by the ADON or the DON. Interview with the Pharmacy Consultant, on [DATE] at 4:25 PM via telephone, revealed he was not aware Resident #9 needed an early refill for controlled medications. He stated he performed routine monthly audits at the facility and had not noticed any discrepancies. He stated he audited controlled medication by comparing the Controlled Drug Record with the MAR and he had not found any discrepancies. He would pick one random medication on a couple of medication carts and after completed his audit, he compiled a report. According to the Pharmacy Consultant, the signature on the Controlled Drug Record just meant the medication was taken out of the bubble pack and did not verify it had been administered. If a controlled medication was signed out on the Controlled Drug Record, but not on the MAR, there was a possibility of diversion and he would make sure nursing staff checked the Controlled Drug Record and the MAR on a daily basis and recommended frequent, in-depth auditing. Interview with the DON, on [DATE] at 10:22 AM and [DATE] at 6:42 PM, revealed RN #1 informed her the pharmacy was not able to refill Resident #9's Ativan because there should have been several doses left. However, when the RN inspected the bubble pack it contained only three (3) doses of the eight (8) to nine (9) doses expected to be in the bubble pack. The DON started an investigation, reported to all state and local authorities, and suspended LPN #3, who was suspected of drug diversion. ADON #1 interviewed Resident #9, #33 and #36 and other residents, and no one voiced any concerns related to pain or anxiety during the interviews. During the audit, she noticed a trend of discrepancies in documentation on the Controlled Drug Records and the MARs. She discussed the findings with the Administrator and the resident's medications were replaced at facility cost. The DON stated ADON #1 and #2 and herself was responsible to ensure residents received the medications as ordered. Interview with the Administrator, on [DATE] at 8:28 PM, revealed the facility determined LPN #3 had signed out medications she had not documented on the MAR and he terminated the nurse for not following basic nursing standards.

Based on interview, record review and facility policy review it was determined the facility failed to maintain an accurate clinical record related to medication administration for four (4) of nineteen (19) sampled residents, Residents #9, #30, #33, and #36. The findings include: Review of the facility's policy, Medication Administration, dated September 2018, revealed the individual who administered the medication dose should record the administration on the resident's Medication Administration Record (MAR) immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medication. When as needed (PRN) medications were administered, the following documentation should be provided: the date and time of administration, dose, route of administration (if other than oral), and if applicable, the injection site; complaints or symptoms for which the medication was given; results achieved from giving the dose and the time results were noted; and signature or initials of the person recording administration and signature or initials of the person recording the effects. The resident should be observed for medication actions/reactions and recorded in the nurse's notes as appropriate. Any noted adverse consequence should be reported to the prescriber and/or attending physician. 1. Review of the clinical record for Resident #30 revealed a Physician Order, dated 01/10/19, for Ativan 1 milligram (mg) via gastrostomy tube (G-tube) or by mouth twice a day as needed (PRN) for anxiety. Review of the Resident #30's Controlled Drug Records for Ativan 1 mg revealed fifteen (15) doses were signed out in January 2019. Further review revealed thirty-two (32) doses of Ativan were signed out in February 2019. Review of Resident #30's MAR, dated January 2019, revealed eight (8) of the fifteen (15) doses of PRN Ativan signed out in January were administered; however, there was no documentation for the remaining seven (7) doses that were signed out. Review of the MAR, dated February 2019, revealed ten (10) of the thirty-one (31) doses signed out were administered; however, there was no documentation of administration for the remaining twenty-two (22) doses that were signed out. 2. Review the MAR for Resident #9, for January and February 2019, revealed an order for Ativan 0.5 mg, give half a tablet daily for anxiety. Review of the Controlled Drug Record revealed staff signed out the Ativan on 01/31/19, 02/02/19, 02/03/19, 02/14/19, 02/16/19, and 02/17/19. However, there was no documentation on the MAR that the medication was administered to the resident on those dates. Further review of the MAR for Resident #9 for January and February 2019, revealed an order for Ultram 50 mg, give every six (6) hours as needed for pain. Review of the Controlled Drug Record revealed staff signed out the Ultram on 01/11/19, 01/14/19, 01/20/19, 01/21/19, 01/25/19, 01/31/19, 02/03/19, 02/14/19, 02/16/19, and 02/17/19. However, there was no documentation on the MAR that the medication was administered to the resident on those dates. 3. Review of the MAR for Resident #33, for January and February 2019, revealed an order for Hydrocodone 5-325 mg every six (6) hours as needed. Review of the Controlled Drug Records revealed staff signed out the Ultram on 01/14/19, 01/17/19, 01/20/19, 01/25/19, 01/27/19, 02/02/19, 02/03/19, 02/14/19, 02/16/19, and 02/17/19. However, there was no documentation on the MAR that the medication was administered to the resident on those dates. 4. Review of the MAR for Resident #36, for January and February 2019, revealed an order for Ultram 50 mg, give half a tablet as needed for pain. Review of the Controlled Drug Records revealed staff signed out the Ultram on 01/11/19, 01/14/19, 01/17/19, 01/20/19, 01/25/19, 01/27/19, 01/28/19, 01/31/19, 02/02/19, 02/03/19, 02/14/19, and 02/17/19. However, there was no documentation on the MAR that the medication was administered to the resident on those dates. Interview, on 03/07/19 at 5:15 PM, with Licensed Practical Nurse (LPN) #3 via telephone revealed staff was to sign out controlled medication in the Controlled Drug Record and the sign them as administered on the MAR. However, documenting administration of the medication in the computer on the MAR was not her first priority, and she did not chart the medications 100% of the time on the MAR. Further interview revealed LPN #3 had access to the computer and was able to chart on the MAR, except for times when the computer system went down for updates. Interview with LPN #2, on 03/08/19 at 3:22 PM, revealed PRN medication should be documented on the Controlled Drug Record and on the MAR; however she did not always document on the MAR. According to LPN #2, there was potential for a medication error if an administration was not documented on the MAR. Interview with LPN #1, on 03/08/19 at 11:13 AM, revealed administration of PRN medication should be documented on the MAR, including follow up for effectiveness; however, she did not always document. The LPN further revealed she signed out controlled medications after she administered them, but should probably sign them out as soon as the narcotic was removed from the pack to prevent potential discrepancies in the count. She stated there was a risk of a medication error if an administration was not documented on the MAR. Interview with the Assistant Director of Nursing (ADON), on 03/08/19 at 4:13 PM, revealed she audited random MARs and was not aware of any issues. She stated it was important to document administration and follow up of PRN medications to ensure the medication was effective. She further revealed there was a potential for diversion of controlled medication if the medication was not signed out on both the MAR and Controlled Drug Record. Interview with the Consultant Pharmacist, on 03/08/19 at 4:46 PM, revealed he spot checked random MARs and Controlled Drug Records monthly and was not aware of any issues related to discrepancies in documentation. According to the Pharmacist, there could be potential diversion of controlled medication if narcotics were signed out on the Controlled Drug Record and not documented on the MAR. Interview, on 03/08/19 at 8:28 PM and 8:51 PM, with the Administrator revealed leadership had identified documentation issues. He was concerned about the gaps in documentation and expected nurses to document according to the policy.

Based on observation, interviews, and policy review, it was determined the facility failed to ensure food was heated and held on the steamtable at safe temperature levels, which created the risk for foodborne illness. Observation of food temperatures revealed the ground beef temperature was 130 degrees F. In addition, during food temperature testing, the Dietary Manager failed to wash her hands prior to the testing process. The findings include: Review of the facility's policy, Food Temperatures, revised 01/04/19, revealed foods should be served at proper temperatures to insure food safety and palatability. Acceptable serving temperatures for meat was => 140 degrees F; however, the preferable temperature range was 140-165 degree F. Further review revealed the Food and Drug Administration Food Code allowed 135 degrees as the minimum hot holding temperature. The policy stipulated reheating food for hot holding had to reach 165 degrees F and had to hold this temperature for 15 seconds. Reheating of food by dietary staff was done within a two (2) hour period. Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2015, revealed all facility personnel was trained and regularly in-serviced on the importance of hand hygiene to prevent the transmission of healthcare-associated infections and followed the handwashing/hand hygiene procedures to help prevention and spread of infections to other personnel, residents and visitors. The policy stated the use of gloves did not replace handwashing/hand hygiene. The facility recognized the integration of glove use along with routine hand hygiene as the best practice for preventing healthcare-associated infections. Observation of the main dining room steamtable, on 03/05/19 at 12:10 PM, revealed the Dietary Manager conducted food temperature testing without performing hand hygiene prior to testing. The ground beef temperature was 123 degrees F and the Manager took the ground beef to the kitchen to reheat. She returned at 12:20 PM with the reheated container of ground beef and retested the temperature, which resulted 130 degrees F, which was below the safe holding temperature for meat. After completion of this task, she stood at the door and briefly chatted with the Nurse Consultant. While doing so, she pulled her pants up and touched her stomach, and proceeded to grab resident meal tickets and organized them, and put them on the top of the steam table where the Dietary Assistant picked them up. Interview, on 03/08/19 at 8:05 AM, with the Dietary Manager revealed the ground beef holding temperature should have been 140 degrees F to keep residents from getting sick, because they were more vulnerable. She stated handwashing was important because germs could possibly transfer through anything she touched and could potentially affect a resident's wellbeing. She stated she thought she washed her hands prior to taking food temperatures and did not realize she had touched her body. The Dietary Manager further stated she had been trained handwashing was the most important thing to do. Interview, on 03/08/19 at 9:17 PM, with the Administrator revealed staff was to follow infection control practices for handwashing and other associated issues with infection control. He stated he was not aware of any issues with infection control prior to today and was not aware of infection control practices during the survey.