**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of Resident Identifier (RI) #14's medical record, the facility's ABUSE POLICY and the investigation file, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) did not verbally abuse and neglect RI #14 on 3/17/2021. On 3/17/2021, EI #1, a CNA cursed and neglected to change the resident's wet incontinence brief when asked. This affected RI #14, one of four sampled residents reviewed for abuse/neglect. Findings include: The facility's ABUSE POLICY dated November 2016, documented, . It is the policy of <<Facility>> to insure that each resident is free from verbal . abuse, neglect . Definitions . Verbal abuse is the use of oral, written or gestured language that includes disparaging and derogatory terms to residents . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . RI #14 was readmitted to the facility on [DATE]. RI #14's Annual Minimum Data Set with an assessment reference date of 2/5/2021 indicated the resident was cognitively intact with a Brief Interview for Mental Status of 15. The resident was assessed as requiring extensive assistance with toilet use and always continent of bowel and bladder. On 3/18/2021, the facility reported an allegation of neglect to the State Agency involving RI #14 and EI #1, a CNA. According to the report, (RI #14) alleged (EI #1) would not change (his/her) in a timely manner when asked to be changed. Also reported (EI #1) was fussing at (him/her). According to the undated facility's investigation summary, On the night of 3-17-202 (2021), (RI #14), resident, reported to (EI #2), LPN (Licensed Practical Nurse), that (he/she) was upset with (EI #1), CNA. (RI #14) told (EI #2) that (EI #1) entered (his/her) room at approximately 3:15 a.m. fussing at (him/her) because (he/she) had wet (him/herself), turned the call light off and left (him/her) in a wet diaper. (RI #14) stated (EI #1) returned to the room at approximately 5:00 a.m. still fussing about the resident's wetting (him/herself) stating you know damn good and well I asked you at 2:00 a.m. did you have to go to the bathroom.Upon conclusion of the investigation I have determined through resident and witness interviews that the allegation of neglect . is substantiated. (EI #1) will be terminated from Englewood Healthcare. In an interview on 5/26/2021 at 9:12 AM, RI #14 stated at the time of the incident, he/she reported his/her concerns to the nurse on duty. RI #14 stated this was the first and only time a staff member had been rude to him/her. According to RI #14, the staff was fired and the Administrator and other staff were very fast in taking care of the issue and making him/her feel safe. RI #14 stated he/she has not had any other issues with any other staff. On 5/26/2021 at 12:37 PM, an unsuccessful attempt was made to contact EI #1, a CNA by way of the telephone; EI #1's telephone number was no longer is service. EI #1's EMPLOYEE CORRECTIVE ACTION REPORT indicated on 3/25/2021, EI #1's employment with the facility was terminated for Class A: Immediate Discharge #3 Resident Abuse . During an interview on 5/27/2021 at 11:35 AM, EI #2, a LPN stated when she entered RI #14's room (on 3/18/2021), RI #14 appeared to look as if he/she had been crying. EI #2 stated she asked RI #14 what was wrong; RI #14 reported what EI #1 said and done. EI #2 stated she immediately reported the allegation to the Registered Nurse Supervisor, who then informed the (Regional) Administrator. In an interview on 5/26/2021 at 2:45 PM, EI #3, the Regional Administrator stated the facility does not tolerate abuse or neglect towards the residents. He stated abuse/neglect is discussed frequently with the staff and the expectation of the facility was to ensure all residents are free from abuse of any kind. He stated when he completed the investigation into the allegation, he was hurt to know what RI #14 had endured. According to EI #3, the staff member, EI #1, was immediately suspended and once the investigation was completed, EI #1 was terminated. On 6/14/2021 at approximately 5:15 PM, the facility's Administrator returned a telephone call to the State Survey Agency regarding corrective actions taken as the result of the substantiated allegation of neglect involving RI #1 and EI #1. ************************* The following corrective actions were implemented: On 3/18/2021, the facility reported an allegation of neglect to the State Survey Agency. On 3/18/2021, the facility suspended EI #1, a CNA depending the results of the investigation. On 3/18/2021, the facility began an investigation into the allegation of neglect. From 3/18/2021 to 3/25/2021, the facility provided education to their staff related to Resident Rights and Abuse. On 3/25/2021, the facility terminated the employment of EI #1, a CNA. On 3/25/2021, the facility concluded their investigation and submitted their investigative summary to the State Survey Agency. ************************* After review of the facility's corrective actions, observations during the survey, interviews with residents and staff, and no further allegation of abuse and/or neglect, the facility implemented corrective actions from 3/18/2021 to 3/25/2021, thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL00041372.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, review of a facility policy titled, Diet Orders, and review of a facility form titled Mechanical Soft Diet, the facility failed to ensure Resident Identifier (RI) #40, received a mechanical soft diet as ordered by the physician. This affected one of three residents for whom meals were observed. Findings include: Review of a facility policy titled, Diet Orders, dated 2013, revealed: Policy: When there is a nutritional indication, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of the patient/resident to achieve outcomes/goals of care. These diets coincide with the therapeutic diets on the facility menus. Procedure: . 3. Diets will be offered as ordered by the physician. Review of the facility document Mechanical Soft Diet, dated 2011, revealed: A Mechanical Soft or Dental Soft Diet is used for individuals who have difficulty chewing regular textured foods.Foods that are difficult to chew are chopped, ground, shredded and/or soft cooked to facilitate chewing and ease of swallowing. Mechanical Soft (Dental Soft) Diet . Foods Allowed . Protein Foods . Must be very tender, small pieces, shredded, chopped or ground, and well moistened with gravy or cream sauce . Foods to Avoid . dry/tough meats, whole pieces of meat . RI #40 was admitted to the facility on [DATE] with a diagnosis of Dysphagia, oropharyngeal phase. Review of RI #40's April 2019 Physician Orders revealed an order dated 8/22/18 for DIET: MECHANICAL SOFT. On 04/16/19 at 2:44 PM, RI #40 stated that the meat was too tough, and stated he/she has a hard time chewing meat. An observation was made of the resident's meal tray sitting on the over bed table. The resident had a whole piece of meat, mashed potatoes, and butterbeans. On 04/17/19 at 05:34 PM, the dinner tray for RI #40 was observed to have two hot dogs with cheese. The hot dogs were whole and not mechanically soft. The meal ticket on the tray had his/her diet as mechanically soft. The resident had not eaten any of the hotdogs. RI #40 said he/she could not eat that . On 04/18/19 at 07:49 AM, an observation was made of RI #40's breakfast tray; it was observed to have a piece of sausage on it, that was not mechanically soft. On 04/17/19 at 05:58 PM, an interview was conducted with Employee Identifier (EI) #3, Certified Nursing Assistant (CNA) . EI #3 was asked, what does the diet card say on RI #40's tray. EI #3 replied, mechanical soft. EI #3 was asked if RI #40 received a mechanically soft diet. EI #3 replied, no. EI #3 was asked, what kind of diet is it. EI #3 replied, solid. EI #3 was asked, what is the potential concern of serving a regular diet to someone who requires a mechanically soft diet. EI #3 replied, malnutrition. On 04/18/19 at 01:34 PM, an interview was conducted with EI #1, Dietary Manager. EI #1 was asked, what is the purpose of a diet for a resident. EI #1 replied, to make sure they get adequate nutrition, and you don't want anything to make them sick. EI #1 was asked, who is responsible for making sure a diet is followed. EI #1 replied, the kitchen staff and me. EI #1 was asked, how do dietary staff ensure a resident receives the correct diet. EI #1 replied, it is printed out on their tray card, and as soon as we get the diet changes we upgrade or down grade their diet. EI #1 was asked, what is a mechanical soft diet. EI #1 replied, being able to mash with a fork.

Based on observation, interviews, and review of a facility policy, titled, Hand Hygiene Policy and Procedure, the facility failed to ensure a licensed staff member did not perform a finger stick blood sugar (FSBS) on a resident and place his/her soiled gloved hand into a cup and bag containing clean items, and place them back on the medication cart. This affected one of four nurses observed during medication pass. Findings include: A facility policy titled, Hand Hygiene Policy and Procedure, revised 6/17, revealed, Purpose: Hand hygiene is recommended to reduce the transmissions of infection to residents,staff, and visitors in the health-care setting. Procedure: . 3. Perform hand hygiene after contact with blood, body fluids, mucous membranes, non-intact skin, . when handling invasive devices .and when otherwise indicated to avoid transfer of microorganisms to other residents or environment. On observation was made on 4/17/19 at 4:46 PM during medication pass with Employee Identifier (EI) #5, Licensed Practical Nurse (LPN). EI # 5 performed a FSBS on a resident, then reached her contaminated gloved hand into a cup filled with cotton balls and glucometer strips, and into a bag containing Sani-wipes. She then removed her gloves and washed her hands and placed the cup of items and the bag of Sani-wipes back into the medication cart. On 04/17/19 at 05:22 PM an interview was conducted with EI # 5, LPN. EI # 5 was asked, what should you do after performing a FSBS, before reaching your soiled gloved hand into a cup with cotton balls and glucometer strips, and before reaching your soiled gloved hand into a bag of Sani-wipes. EI #5 replied, wash hands. When asked if she put those items back into the medication cart, EI #5 replied, yes. EI #5 was asked, what is the potential concern for reaching your soiled gloved hand in a cup with cotton balls and glucometer strips and your soiled gloved hand in a bag of Sani-wipes. EI #5 replied, contamination. EI # 5 was asked, what is the potential concern for placing these items back on the medication cart. EI #5 replied, contamination. On 04/18/19 at 10:50 AM, an interview was conducted with EI #4, Infection Control. EI #4 was asked, what should a nurse do after performing a FSBS, before reaching her gloved hand into a cup with cotton balls and glucometer strips, and before reaching her gloved hand into a bag of Sani-wipes. EI #4 replied, she should have taken her gloves off and washed her hands. When asked what the potential concern was of not removing the gloves and washing her hands first, EI #4 replied, spread of infection, exposing someone else to a blood pathogen.

Based on observations, interview and review of facility policies titled Food Storage and Hand Washing, the facility failed to ensure: 1. Three half pint cartons of milk were not expired in the refrigerator; and 2. Staff properly washed hands when changing tasks in the kitchen, including preparing a meal and throwing trash in the garbage can. These deficient practices had the potential to affect all residents receiving meals from the kitchen. Findings include: 1) Review of the facility policy titled Food Storage, sated 2013, revealed: .Procedure: .14. Refrigerated Food Storage: . f. All foods should be . labeled and dated. All foods will be checked to assure that foods . will be consumed by their safe use by dates . or discarded. On 4/16/19 at 2:15 PM, the Surveyor observed the facility's milk refrigerator contained a total of three fat free skim milk (half pint cartons) with an expiration date of 4/15/19. Employee Identifier (EI) #1, the Dietary Manager, was interviewed on 04/17/19 at 05:10 PM. EI #1 confirmed the presence of three expired milk cartons on 4/16/19. When asked what the potential harm was in having expired milk in the refrigerator, EI #1 replied, it can make somebody sick. 2) Review of the facility policy titled, Hand Washing, dated 2013, revealed: . Procedure: .1. When to Wash Hands: . * After handling soiled equipment or utensils. * During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. . *After engaging in other activities that contaminate the hands. On 4/17/19 at 10:41 AM, the surveyor observed EI #2, a Cook, use bare hands (no gloves) to roll soiled, used tin foil from the pan the cooked chicken was prepared on. EI #2 picked up the rolled tin foil, walked to the trash can, lifted the lid to the trash can, and threw the rolled up tin foil away. EI #2 then walked to the ice chest and picked up a scoop on top of the chest. EI #2 dipped ice out with the scoop and placed it onto exposed raw chicken in a pan. EI #2 did not wash hands or have gloves on. EI #2 then picked up a tray of bowls with lids covering them. EI #2 placed the tray on top of another tray of bowls that was labeled puree fruit. EI #2 also took a pan of rolls from the shelf below and placed them on the counter. EI #2 began placing wrapped rolls into another pan using bare hands (no gloves on), without washing hands. She again touched the garbage can lid to throw an item away, proceeded to take a dirty pan to the sink, and then entered the storage room. After leaving the storage room, EI #2 then walked to the stove and touched a pan on it. EI #2 still had not washed hands. She then walked to a metal rack and removed tongs, placed them in a pan, and stirred a pot of gravy. The surveyor interviewed EI #2 on 04/17/19 at 4:38 PM. When asked what the facility's policy was regarding hand washing while working in the kitchen, EI #2 replied, before putting on gloves, before and after dealing with food, when coming in and out of the kitchen, and when leaving the dishwashing room and restroom. The Surveyor asked, if you touch a soiled pan that chicken was cooked in should you wash your hands before you handle a pan of rolls that was being served for lunch. EI# 2 replied, yes. When asked what the potential harm was if a staff member touched the trash can and soiled items and then touched the food being served to the residents, EI #2 replied, bacteria. EI #1, the Dietary Manager, was interviewed on 4/17/19 at 5:13 PM. When asked what the policy was for handwashing for staff in the kitchen, EI #1 said staff were supposed to wash hands before putting gloves on. The Surveyor asked, should staff wash hands after touching the trash can lid in the kitchen and before touching ice scoop or rolls in bags being served to residents for lunch. EI# 1 replied, yes, due to cross contamination.