Based on observation, interview, record and policy review, it was determined the facility failed to ensure staff performed infection control practices to prevent cross contamination. Observations revealed staff did not perform hand hygiene before and after each medication pass, picked up medications from floor with bare hands, and toileted resident with gloved hands and proceeded to complete resident's medication pass, and did not wash hands or change gloves. Further observation revealed staff handled medications bare handed and proceeded to give the meds to a resident. In addition, staff did not reconcile narcotic medication before administering to a resident. The findings include: Review of the policy titled, Infection Prevention and Control Program, dated 11/10/17, revealed the facility periodically audited staff in regards to education provided. The staff would provide care using hand hygiene to prevent cross contamination and provide safe medication administration practice. Review of the policy titled, Infection Prevention and Control General Guidelines, dated 11/10/17, revealed care provided included the use of hand hygiene as the primary technique for infection prevention and control included between contact with residents, use of or assistance to the restroom, and any other activities which could spread infections. Review of the policy titled, Handwashing, undated, revealed infection prevention included hand hygiene as the primary method to prevent infections. The hand hygiene definition included the use of soap and water and an alcohol based hand gel. Further review revealed hand hygiene after toileting, physical contact with residents, and after glove removal. The policy revealed the expectations of staff included washing hands was from fifteen (15) to twenty (20) seconds with liquid soap and water. Review of the policy titled, Medication Administration-General Guidelines, revised 11/18, revealed safe administration of medications included proper hand hygiene for all steps of the medication process. Review of the Facility Assessment Tool, dated January 2020, revealed the facility provided competent staff for assignments to ensure compliance with infection control and medication administration. The facility failed to provide a policy on controlled medication administration upon multiple requests. Observation of medication pass, on 02/20/2020 at 8:16 AM, revealed Registered Nurse (RN) #1, prepared, delivered, completed medication administration to resident and return to medication cart to continue medication pass without hand hygiene with multiple observations. Continued observation revealed RN #1 retrieved the medications from the floor with bare hands, failed to perform hand hygiene, and proceeded to administer newly prepared medications to a resident. RN #1 wore the same pair of gloves to administer medications after assisting the resident with toileting. In addition, she failed to reconcile narcotics prior to the administration, sign, and document after administration. Further observation revealed the Director of Health Services (DHS) and RN #1 did not complete sanitization of medical equipment after each resident. Per surveyor observation and timing, RN #1 washed hands for five (5) seconds. Interview with Licensed Practical Nurse (LPN) #3, on 02/20/2020 at 2:07 PM, revealed proper hand hygiene during resident medication administration prevented cross infection. She stated medications handled with bare hands potentially could cause an infection to the residents. She stated and showed the sanitizer wipes used for equipment cleaning were located in the bottom drawer of the medication cart. She stated the facility provided education for hand hygiene and infection control with the orientation and online training. She stated the process for narcotic removal included comparing the order to the medication packet, comparing the medication count with the narcotic sheet, removing the medication from the packet, and signing out the medication on the narcotic sheet prior to administration. Interview with RN #1, on 02/21/2020 at 10:39 AM, revealed staff completed hand hygiene before and after each resident, and after staff removed gloves. RN #1 stated the facility expected the practice of sanitization of equipment before and after use on the residents. RN #1 stated the facility educated staff not to touch medications with bare hands. She stated poor infection control practices caused infections because of the high risk of the resident population and an infection could cause a setback with a decline in condition. RN #1 stated the facility provided education during orientation that included infection control and hand hygiene. She stated the process for removal of narcotics included a signature in the computer and on the narcotic sheet after administration of the medication. She stated staff prevented medication errors with the required two (2)-step documentation for narcotic removal. Interview with the Staff Development Coordinator (SDC), on 2/21/2020 at 09:02 AM, revealed a poor infection control practice included five (5) second hand washing and education of staff needed to focus on the proper disinfecting of hands. She stated staff should not pick up medications with their bare hands because of the possibility to spread an infection. The SDC stated staff were educated during orientation on hand hygiene and infection control. The SDC stated the facility expected staff to perform hand washing for twelve (12) to fifteen (15) seconds or the length of time it took to sing Happy Birthday. She stated in addition, the facility provided infection control education on the importance of disinfecting of equipment. Further interview revealed the facility had not completed audits of hand hygiene. The SDC expected nursing staff to remove narcotics using the five (5) rights, which directed staff to remove medication, count the number of tablets, and sign medication out on the narcotics sheet with the date and time. The Director of Health Services (DHS) was not available for interview, due to out of the facility. Interview with the Executive Director (ED), on 02/21/2020 at 12:17 PM, revealed staff did not report issues with infection control techniques with medication pass. He stated the facility lacked a cleaning schedule for essential nursing equipment. The ED stated the facility did not have Sani-gel stations for hallways or resident room because of corporate standards. He stated stations existed at the entrances of the building; however, staff knew all resident area contained sinks and it was not rocket science to wash hands. He stated he expected staff to wash hands effectively and as trained. He stated education to all staff covered infection control practice and the importance and expectaion that hand hygiene occurred frequently. He stated hand hygiene prevented the spread of infection in the facility.

Based on observation, interview, record review and policy review it was determined the facility failed to provide a safe and sanitary environment to prevent the transmission of communicable diseases and infections. Observations revealed staff failed to clean/sanitize dried blood from a sit-to-stand lift between resident uses for one (1) of two (2) sit-to-stand lifts. The findings include: Review of the facility's Infection Prevention and Control General Guidelines, dated 05/22/18, revealed the campus shall provide training to staff and residents regarding infection prevention and control practices to prevent the spread of infection. Interview with the Director of Health Services (DHS), on 02/20/2020 at 1:55 PM, revealed the facility did not have a calendar cleaning schedule for lifts. Review of Full Body Lift/Sit-to-Stand Facility Inventory, dated 02/21/2020, revealed the facility provided one (1) full body lift and one (1) sit-to-stand lift for each, three-hundred (300) hall and five-hundred (500) hall. Review of the Certified Nurses Assistant (CNA) Cardex, revised 02/10/2020, revealed three (3) residents resided on 500 hall that required the sit-to-stand lift, Resident #5, Resident #9 and Resident #35. Observation revealed on 02/18/2020 at 11:17 AM, staff exited Resident #5's room pushing a sit-to-stand lift, labeled three (#3). The left shin guard was observed to have a dried dark red/brown substance. Interview with Resident #5, at 02/18/2020 at 11:39 AM, identified the dried dark red/brown substance as blood and he/she had seen it there before but stated it did not come from him/her. Observation on 02/18/2020 at 03:30 PM, revealed sit-to-stand lift #3 located down 500 hall continued to have a dried red/brown substance on the left shin guard. Interview with Certified Nursing Assistant (CNA) #2, on 02/20/2020 at 1:25 PM, revealed staff was to clean the lifts between each use; however, the facility did not have a cleaning schedule, and there was no department/staff member officially responsible for cleaning the lifts. CNA #2 revealed the facility had another resident that used the same sit-to-stand lift #3 and had multiple open sores that bleed a lot. CNA #2 stated the importance of cleaning the lifts between uses, was to prevent the transfer of germs between one resident to another. Interview with Licensed Practical Nurse #1, on 02/20/2020 at 01:34 PM, revealed if there is visible blood on the lift, disinfectant wipes can be used to sanitize the equipment. The interview also revealed that leaving blood on the lift and using it on other residents would be cross contamination and an infection control issue. She revealed she inspects the lifts while using them and cleans them if needed, but did not notice any blood on sit-to-stand lift #3. Interview with Licensed Practical Nurse (LPN) #2 on 02/20/2020 at 1:40 PM, revealed the importance of cleaning the lifts between resident uses was to help with infection prevention. LPN #2 voiced it was not okay to use a lift with dried blood present, on another resident, due to the risk of infection and the potential spread. Interview with the Director of Health Services (DHS), on 02/20/2020 at 2:03 PM, revealed she performed weekly facility walk through's to ensure equipment was clean. The DHS also revealed other department heads were assigned to Ambassador Rounds and were expected to do room checks of their assigned areas every day. The DHS stated it was important to keep the lifts clean to assist with infection prevention. She stated the lifts were supposed to be cleaned when visibly soiled with blood, stool, or any other visible dirt. Interview with the Executive Director (ED), on 02/21/2017 at 12:17 PM, revealed the facility did not have a cleaning schedule for equipment. The ED stated staff were trained on hand hygiene and infection control procedures. The ED stated he expected equipment to be cleaned after use.

Based on observation, interview, and review of policy, it was determined the facility failed to ensure scheduled medications were properly labeled and secured for one (1) of two (2) medication refrigerators. Doors to the outside of (2) of two (2) medication refrigerators did not contain a locking apparatus. In addition, secondary key sets to five (5) of five (5) medication carts, which included narcotic drawer lock access were kept in a drawer in the Director of Health Services (DHS) office. The Maintenance Director (MD) and the Administrators key ring contained a master key, which opened the door of the DHS manager's office. The findings included: Review of policy titled, Medication Storage in the Facility, revised November 2018, revealed only licensed staff were to have the ability to access medications. The staff were to ensure all medications remained locked. Further review revealed refrigerated controlled medications required an inner lock box and secured to the inner portion of the refrigerator. Review of Medication Storage and Carts Information List, dated 01/15/2020, revealed the facility provided five (5) medication carts and two (2) medication storage rooms for access to licensed staff to complete medication administration to residents The facility did not provide a policy for Medication Storage Room(s). The facility did not provide a policy for Medication Refrigerators. Review of Drug Enforcement Administration (DEA) Controlled Substance Secure Storage Guideline, undated, revealed all controlled substances required a double lock system with different key lock for all controlled substance. Refrigerated medications required an inner lock box. Observation, on 02/20/2020 at 9:47 AM, revealed the five-hundred 500-hall medication refrigerator was unlocked. Observation revealed the facility did not provide an outer locking device for the refrigerator. Further observation revealed the inside did not contain a separate locked box. The second shelf contained a clear box with unlabeled contents, which Director of Health Services (DHS) identified as the emergency medication box from the pharmacy. Observation revealed the DHS removed the box, identified two (2) vials of injectable Lorazepam (anti-anxiety drug) with two milligrams per milliliter (2mg/ml) and one (1) bottle of thirty (30) cubic centimeters (cc) of liquid Lorazepam. The box possessed two plastic pull ties to each end and a metal clasp with a metal key lock. The DHS removed the entire box from the refrigerator to reveal the box lacked an attachment to the inner area of the refrigerators. Interview with the DHS, on 02/20/2020 at 9:47 AM, revealed licensed staff and the Certified Medication Technicians (CMT) with an assigned cart all had a key to enter the 500 Hall medication room. She stated the Personal Care Center (PCC) staff also used the room for medication needs. The DHS stated the refrigerator did not contain a separate box secured to the refrigerator. She stated the facility met the requirement of a double lock with the locked door to the room and the lock on the clear box provided by the pharmacy. She further stated the three hundred (300) and four hundred (400) hall also contained a medication refrigerator. Further interview revealed someone easily could remove the locked medication box from the room unseen because the box was small and the refrigerator did not contain an outer lock. She stated residents who needed medications would wait to have replacements brought to the facility and might get into trouble. Interview with Licensed Practical Nurse (LPN) #3, on 02/20/2020 at 9:57 AM, revealed the clear box located in the 500 hall medication refrigerator required two nurses to sign out the medication from the box and sign off on the medication in the electronic record. However, she stated a box with a cord to the refrigerator never existed to the 500 refrigerator. Interview with LPN #4, on 02/20/2020 at 10:02 AM, revealed staff did not audit the box of medication in the refrigerator with day and night change of shift. She stated unless staff went to obtain medications from the box the facility would be unaware of any removed medications or of a missing box. Continued observation, on 02/20/2020 at 10:05 AM, revealed in the 300/400 medication room an unlocked medication refrigerator without an outer locking device or lock as identified by the DHS. The inside contained a black box with a lock and secured to the inside. The box was empty. Continued observation revealed the DHS opened the resident food refrigerator, which contained a second black box labeled 300/400 medication room as identified by the DHS. The black box had a metal cord in a plastic bag inside. Interview with the DHS, on 02/20/2020, revealed the medication refrigerator inner box housed only scheduled medications for residents. She stated the facility previously placed scheduled medications in the box with the refrigerator door unlocked because a lock never existed. She stated the door to the room was the first lock and the secured inner box a second. She stated the 300 and 400 assigned nurse key rings held the key for access to the inner box. However, all nurses assigned to a cart in the facility were able to open the door to the room. Observation, on 02/20/2020 at 10:41 AM, revealed the DHS kept the key to the narcotic disposal box in the upper left drawer of her desk. Further observations revealed multiple key rings with numerous keys. The labels on the rings included one hundred (100) hall, 300 hall, 400 hall, 500 hall, and PCC as identified by the DHS. Further observation revealed programmable access cards for the facility medication electronic cart used for emergency medication needs, which included narcotics. Interview with the DHS, on 02/20/2020 at 10:41 AM, revealed she stated all key rings were secondary keys for the medication carts, inner lock for narcotic drawers, and medication rooms. She stated the 300 key ring included the key to the refrigerated scheduled medication box. She stated the key rings were in the desk when she accepted the DHS position. She stated she did not make other arrangements to further secure the extra key rings. She stated she was unsure if the Maintenance Director (MD) carried a master key to the doors of the facility. She further stated the key to the drawer, which held the secondary key rings, might not be the only key available and she would have to ask. She stated when she found the keys were in the drawer, she initially was concerned. However, she found it this way, and she did not report concern to anyone. Interview with the MD, at 02/20/2020 at 12:12 PM, revealed his key ring contained a master key to all doors in the facility with except of the medication rooms. Interview with Registered Nurse (RN) #1, on 02/21/2020, at 10:39 AM, revealed numerous staff carried keys with the medication room key. She stated the maintenance department key ring contained a master key to all doors in the facility. She stated locks to the medication refrigerator's outer doors never existed. She further stated in the past the facility admitted a resident with liquid Lorazepam, which she knew required refrigeration. She stated the 300/400 refrigerator locked box contained a lock, but the facility did not have a key to the lock so the staff kept the liquid Lorazepam in the cart narcotic drawer. She further stated the resident who required the Lorazepam remained agitated throughout the admission. She stated the facility educated on securement of medications when hired and nursing administrative staff reminded floor staff to keep carts locked Interview with the Staff Development Coordinator (SDC), on 02/21/2020 at 09:03 AM, revealed medication carts securement included one set of keys per cart and staff keys kept keys physically on the person assigned to the cart. She stated the DHS room contained extra keys for the medication carts. Therefore, she stated two sets of keys were available in the building. She stated she completed walking audit observations and locked medication carts when found opened with verbal reminding to keep medications secured. She stated she did not complete a formal audit of carts, medication rooms or provided recent in services on medication securement. She stated the DHS provided the education to staff for medications. The DHS was not available for further interview on 02/21/2020. Interview with the Executive Director (ED), on 02/21/2020 at 12:17 PM, revealed each medication room door contained a combination lock for access into the room. He stated he was not aware the medication refrigerators were without an outside lock and an inside locked box. He stated he met with the pharmacist consultant monthly without mention of medication storage concerns. He further stated the nursing department did not report or recognized the lack of securement of medications in the refrigerators. The ED stated he expected the consultants and licensed staff to bring issues to his attention. He stated he was unaware of multiple sets of keys to medication carts and narcotic drawers in the building, never less in the DHS's office. The ED stated a nurse recently lost a set of keys. He stated his key ring contained a master key to all doors except the medications rooms. He stated the responsibility of proper securement of medications and key access included all licensed staff and management. The ED stated staff were not always trustworthy and he expected extra keys to be kept in a safe location and all medication secured at all times. He further stated the observations was like if he left his key and access badge in his room with the door open and left for the rest of the day. It gave opportunities for issues for resident and for the facility.