**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of an injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the facility policy titled ABUSE PREVENTION PROGRAM, dated 10/22/2022, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .Investigation .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .For any incident involving suspicion of abuse, neglect, or mistreatment, the Administrator or person appointed by the Administrator will gather facts prior to making a determination to conduct an abuse investigation .The final investigation report will be completed within the required timeframe allowed by Tennessee Department of Health .The final report shall include facts determined during the process of the investigation .The final investigation shall also include a conclusion of the investigation based on known facts . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Sepsis, Protein-Calorie Malnutrition, Dementia, Contracture (a condition of hardening and shortening of tendons, muscles or other tissues, leading to possibly rigidity of joints and deformity) of Right Knee, Contracture of Left Knee, Dysphagia,(swallowing difficulties) and Altered Mental Status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 2 which indicated Resident #1 was severely cognitively impaired. Resident #1 was dependent on staff to perform Activities of Daily Living (ADLs) and had impairment in bilateral upper and lower extremities. Review of the nursing progress notes revealed, .5/9/2025 .Pt [patient] confused at this time grabbing for things and speaking incoherently .5/15/2025 .Midline [a type of intravenous access inserted in a vein in the upper arm to provide fluids] placed .to right arm .5/17/2025 .Vitals wnl [within normal limits] Midline noted to Rt [right] Forearm, patent flushes easily .5/18/2025 .Midline to the RUE [right upper extremity]. Patent and free of infiltration .5/19/2025 .Midline to the RUE. Patent and free of infiltration .5/19/2025 .Writer was asked to assist the nursing aide with repositioning resident. Upon arrival to room, resident was observed hold aide tightly by the shirt. Resident was educated on the harm it would cause on himself. The resident then proceeded to snatch his arm from the aide .5/21/2025 . new order X-Ray to R [right] [NAME] [shoulder] d/t [due to] pain .Discontinue midline .5/22/2025 .Late entry for 5/22/25 [2025] .Per physician's order, midline removed at this time. Writer noticed edema to right extremity and that resident groaned and moaned out in pain when arm touched. Midline removed at this time with no issues, tip still intact .Writer noticed no visible bruising to extremity .5/22/2025 .Radiology results for right shoulder .There is no bone abnormality to suggest a displaced fracture. There is an anterior dislocation of the humerus .CONCLUSION: anterior dislocation. Order placed to send patient to hospital for evaluation . Review of the Physician/Practitioner Progress Notes revealed, .5/10/2025 Contractures present to multiple extremities. Normal range of motion. No tenderness .swelling .of both rt/lt [right/left] arms and hands .5/12/2025 .swelling .of both rt/lt arms and hands .5/15/2025 Swelling .both rt/lt [right/left] arms and hands .5/16/2025 .swelling of .both rt/lt arms and hands .5/19/2025 .swelling of .both rt/lt arms and hands .5/20/2025 .swelling of .both rt/lt arms and hands .5/21/2025 . swelling of .both rt/lt arms and hands .5/22/2025 .swelling of .both rt/lt arms and hands . Review of the facility investigation revealed the following: a. A handwritten statement by the Assistant Director of Nursing (ADON) for Certified Nursing Assistant (CNA) M dated 5/22/2025. b. A handwritten statement by the ADON for CNA N dated 5/23/2025. c. A typed timeline dated 5/21/22 (2025) through 5/22/2025. Review of the facility timeline provided by the Administrator dated 5/21/22 (2025) through 5/22/2025, revealed .CNA statements .Licensed Practical Nurse [LPN] Statements .Registered Nurse placing Midline [statement]: Reported to me that she did not require any assistance when placing his [Resident #1's] Midline .stated .usually document if .request assistance from staff or if the resident is combative usually document it and she did not have any issues with him .Conclusion: Based on the investigation, it was determined that the manipulation of the right extremity was dislocated during the placement of the midline . During a telephone interview on 6/24/2025 at 12:10 PM, the ADON was asked did Resident #1 have any swollen limbs, including bruises. The ADON stated, .on admission [Named LPN A] noted edema to his right arm .no bruising . The ADON was asked did the resident complain of pain. The ADON stated, .I pulled his midline out .he arm was really swollen .it was IV [intravenous therapy-a tube inserted in a vein to provide fluids into the bloodstream] .didn't look like it had infiltrated [when fluid administered through an IV line leaks out of the v in and into the surrounding tissue] right upper inside of his arm .when I raised his arm up to put on a pillow is when he made a facial grimace .the family requested the x-ray .told the Nurse Practitioner they thought his arm was dislocated . The ADON confirmed that the x-ray showed Resident #1 had a dislocated shoulder. The ADON was asked what happened to his shoulder. The ADON stated, .I'm going to be honest I don't know . The ADON confirmed she had talked to RN L who had placed Resident #1's midline. The ADON stated, .if they [residents] are combative or having a hard time with the resident, will ask for assistance with staff, but she said she didn't need it with him .he was a little fellow . the way his midline was placed, would have to turn his arm around she may had put her hand on his shoulder to get in place .I had to turn his arm up .the day I took his midline out was the first day I ever saw him . During a telephone interview on 6/24/2025 at 3:36 PM, RN L who had placed Resident #1's midline was asked if the surveyor could read her statement that she gave to the ADON on 5/22/2025. RN L said that she had not spoken to anyone from the facility since she left the facility after she put in Resident #1's midline. RN L stated, I remember him [referring to Resident #1] .midline right brachial [ major blood vessel of the upper arm] attempted one time . RN L said she didn't remember him (Resident #1) being in pain or screaming out. RN L was asked did she have to manipulate his right arm to put in the midline and when she left did, she have any concerns that she had dislocated his right shoulder. RN L stated, No, absolutely not . During a telephone interview on 6/25/025 at 12:25 PM, the Certified Occupational Therapist Assistant (COTA) confirmed he did some of Resident #1's therapy 4 or 5 times a week and that his arms were not contracted. The COTA stated, .tried to maintain what he had .range of motion for his upper extremities . During a telephone interview on 6/25/2025 at 2:21 PM, the Medical Director was asked what he thought happened to Resident #1's right shoulder. The Medical Director stated, .don't know what happened .he didn't fall .he was bed bound .it is possible he came to us with that injury . During a telephone interview on 6/25/2025 at 5:16 PM, LPN F stated, .I put in the order for the midline .I went on break and when I came back, it [referring to the midline placement] was done .I went and checked on him [Resident #1] he was baseline the same as when he got here . LPN F confirmed she didn't see any concerns with the midline placement. During an interview on 6/27/2025 at 1:13 PM, the ADON confirmed she did not complete a written statement. The ADON stated, .the day I removed his [Resident #1] midline was the first day I had ever laid eyes on the man . The ADON was informed that [Named RN L] who had placed Resident #1's midline stated that she never talked to anyone from the facility after she had left the facility. The ADON was asked how she had spoken to RN L, who placed Resident #1's midline, because the company RN L worked for stated they do not give out employee's telephone numbers. The ADON stated, .I don't know how they did it .somehow she was on the phone . During a telephone interview on 6/27/2025 at 2:50 PM, the Administrator confirmed he based his outcome that Resident #1's dislocated shoulder was caused by the RN (L) who had placed the midline on 5/15/2025, on the ADON's statement. The Administrator stated, .the way it was expressed .per the ADON, she said his [referring to Resident #1] arm would have to be pushed back . The Administrator acknowledged that he now wasn't sure how Resident #1 had dislocated his right shoulder. The Administrator stated, .there are other grounds or facts that he is swinging .swatting at staff while giving care and was admitted to us with swollen extremity, it very well could be during his behavior his dislocation could have been from that .family made the statement that it is dislocated [referring to Resident #1's right shoulder] they were sure .they could have done it themselves . The Administrator was asked if he should have done a thorough investigation on Resident #1's dislocated right shoulder. The Administrator stated, .I would have a clearer picture .I would say a more extensive investigation of the matter would have helped . The facility was unable to provide a written statement from the ADON, statements from nursing staff who provided care to Resident #1, or staff education following Resident #1's injury of unknown origin. The facility provided two statements only from CNA staff. The investigation included a statement from RN L documented by the ADON; however, RN L denied that she had spoken to anyone from the facility about the incident. RN L denied any concerns with the placement of the midline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 3 of 53 (room [ROOM NUMBER], #230, and #307) resident rooms observed. The findings include: 1. Review of the facility's undated policy titled, GENERAL CLEANING POLICIES AND PROCEDURES RESIDENT ROOM - CLEAN revealed .To provide a clean, attractive and safe environment for residents .Clean .toilet .Dust Mop the Resident Room and Bathroom Floors .Wet Mop the Resident Room and Bathroom Floors .Clean and Sanitize Toilets .Use a separate cloth and a disinfectant to wipe every surface area of the commode including the tank .Flush the toilet as the final step to insure all cleaner is removed from the toilet bowl water . 2. Observations in room [ROOM NUMBER] on 9/10/2023 at 10:16 AM and 12:57 PM, 9/11/2023 at 7:50 AM, and 9/12/2023 at 12:35 PM, revealed a floor fan with a heavy build-up of dust particles hanging on the front and back casing of the fan against the wall at the foot of the resident's bed. The fan was blowing on the resident. During an interview on 9/12/2023 at 2:47 PM, Unit Manager #2 was asked should the resident's fan be covered in dust particles. Unit Manager #2 stated, No . 3. Observation in the room [ROOM NUMBER] on 9/10/2023 at 10:21 AM, 11:02 AM, 12:20 PM, and 1:02 PM, revealed the bathroom floor was observed with a large amount of smeared brown stains on the bathroom floor and leading to the resident's bedside. During an interview on 9/10/2023 at 1:02 PM, the Housekeeping Director was asked if she could tell me what the brown stains were in the resident's room. The House Keeping Director stated, .BM [bowel movement] . The Housekeeping Director was asked how often the rooms are cleaned. The Housekeeping Director stated, .three times a day .we had one housekeeper here today .normally have three [housekeepers] .I came in at 10:00 AM to help out . 4. Observation in room [ROOM NUMBER] on 9/10/2023 at 10:50 AM, 12:25 PM, 4:07 PM, on 9/11/2023 at 7:56 AM and 5:14 PM, and on 9/12/2023 at 9:12 AM, revealed a strong odor at the doorway, inside the room, and in the bathroom of room [ROOM NUMBER]. During an observation and interview on 9/10/2023 at 10:50 AM, Licensed Practical Nurse (LPN) #4 was asked what the strong smell was. LPN #4 stated, .we can smell it out in the hallway .it smells like urine . LPN #4 entered the resident's bathroom and noted the toilet filled with urine. LPN #4 was asked should the resident's room and bathroom have a strong odor of urine. LPN #4 stated, .No .it could be in the mattress .not sure where the odor is coming from . During an interview on 9/12/2023 at 5:40 PM, the Administrator was asked should the residents' room and bathroom have a strong odor. The Administrator stated, .No . The Administrator was asked how often the residents rooms are cleaned. The Administrator stated, .we clean his room [ROOM NUMBER] times a day at 7:00 AM, 12:00 PM, and between 3:00 PM and 4:00 PM. The Administrator was asked should a resident's room have smeared brown stains on the floor of the bathroom and the room. The Administrator stated, .No .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, facility investigation, and interview, the facility failed to ensure residents' were free from abuse for 1 of 5 (Resident #67) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled, Abuse Prevention dated 1/19/2017, revealed .It is the policy of the facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. Abuse is the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including caretaker .Verbal Abuse .Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability . Neglect/Mistreatment .means failure to provide, or willful withholding of adequate medical care .personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident . 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Osteoarthritis, Depression, and Anxiety. Review of the admission MDS dated [DATE], revealed Resident #67 had a BIMS of 14, which indicated he was cognitively intact with no behaviors exhibited, and required extensive assistance of 1 to 2 staff members for most ADLs. Review of the Concern and Comment Report, dated 8/28/2023, revealed .Spouse reported cell phone has been broken .SW [Social Worker] f/u [follow up] with resident's spouse re: [regarding] Reimbursement of cell phone in person [symbol for and] on telephone call . [Director of Social Services signature] .8/31/2023 . During an interview conducted on 9/10/2023 at 11:16 AM, Resident #67 stated, .an employee came in here and snatched the phone out of my hand .because I call my wife all the time when I need something when they don't come answer my call light . During an interview conducted on 9/11/2023 at 11:35 AM, Resident #67's spouse was asked about the resident's cell phone. Resident #67's spouse confirmed that he told her that a CNA snatched the phone out of his hand, and it broke. Resident #67's spouse confirmed that she reported to the Director of Social Services that her husband had told her a CNA had snatched his phone from his hand and it had broken, and that the Director of Social Services told her the facility would replace the phone. During an interview on 9/11/2023 at 12:15 PM, the Director of Social Services was asked for a copy of the investigation into the incident where Resident #67's cell phone was broken when a CNA snatched it from his hands. The Director of Social Services confirmed she only had a Concern and Comment Report that she filled out. The Director of Social Services confirmed that Resident #67's spouse told her that a staff member broke it and when she asked the resident about the cell phone, he just said it was broken. The Director of Social Services stated, I got 2 different stories, so I didn't do anything further. During an interview on 9/11/2023 at 2:18 PM, the Director of Social Services confirmed that after Resident #67's wife reported that the resident's cell phone was broken she went to his room to ask him about the incident, but he was positive for Covid-19 and she did not enter the room to speak with the resident. The Director of Social Services confirmed that she asked the staff members who were at the Nursing Station about the incident, she could not remember the names or how many staff members were present, and the staff denied any knowledge of the cell phone being broken. The Director of Social Services confirmed she failed to obtain any written statements from staff regarding the broken cell phone. The Director of Social Services was asked did she report the incident to anyone. The Director of Social Services stated, I want to say [named Unit Manager #1] .I think I brought it up in clinical [meeting] .but we didn't know the true details until today . The Director of Social Services stated, She didn't say snatched. She said he said she broke it . The Director of Social Services was asked did Resident #67's spouse not tell you that a staff member had snatched it from him. The Director of Social Services stated, She said he reported to her that a staff member broke it. Today she said he said she [staff member] snatched it. The Director of Social Services confirmed that if a resident reported that a staff member destroyed their personal property the incident should be fully investigated, staff statements should be obtained, an incident report should be completed, and the Administrator should be notified. The Director of Social Services was asked did she feel like she completed a thorough investigation of the incident. The Director of Social Services stated, .It wasn't as thorough as it should have been .I guess I should have went farther with it .to get more details, I was just trying to not have the wife upset, satisfy her, and satisfy him. The Director of Social Services confirmed that she reported Resident #67's cell phone was broken to the Administrator, but she did not report that the resident's spouse stated a staff member had broken the phone. During an interview on 9/11/2023 at 2:47 PM, the Administrator was asked when she was made aware of Resident #67's broken cell phone. The Administrator stated, End of August .reported that his phone was broken, and the wife had asked for reimbursement . [I was] only told that the phone was broken, brought a reimbursement form to sign off on and that's the process we follow to get [give] to corporate . The Administrator was asked was she told at that time that the resident alleged a staff member had broken the phone. The Administrator stated, No, I was never told that, she [named the Director of Social Services] told me today [9/11/2023]. The Administrator confirmed that she started the investigation into the incident today when she was made aware that Resident #67 alleged a staff member had broken his cell phone. The Administrator was asked what should have been done when Resident #67's spouse reported to the Director of Social Services that his cell phone had been broken. The Administrator stated, It should be reported to me immediately as the Abuse Coordinator .it's up to us to investigate and find the truth in it . The Administrator was asked what the facility's process was when an allegation of abuse was reported to a staff member. The Administrator stated, Immediately start our investigation, normally send the [named the Director of Social Services] down with one other staff member to interview .I call the family .this is our process .also start staff interviews, pull timelines of when staff members work, see who worked .interview all interviewable residents .skin audits .report it to the State .complete an incident report .make sure medical director is aware, ombudsman, APS [Adult Protective Services] as well .police as well. Then all of the staff is pretty much a part .any confidential witness statements, any staff or residents in the areas The Administrator was asked did she agree that this incident should have been reported and investigated. The Administrator stated, Yes, I agree.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to timely report an allegation of abuse for 1 of 5 (Resident #67) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the policy titled, Abuse Prevention Program, dated 1/19/2017, revealed .It is the policy of this facility to prevent resident abuse .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident .Abuse Reporting .All personnel must promptly report any incident or suspected incident of resident abuse .Any alleged violations involving mistreatment, abuse .misappropriation of resident's property .MUST be reported to the Administrator and Director of Nursing .the person(s) observing an incident of resident abuse or suspecting resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator or to the individual in charge of the facility . 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Osteoarthritis, Depression, and Anxiety Disorder. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact with no behaviors exhibited, and required extensive assistance of 1 to 2 staff members for most activities of daily living (ADLs). Review of the Concern and Comment Report, dated 8/28/2023, revealed .Spouse reported cell phone has been broken .SW [Social Worker] f/u [follow up] with resident's spouse re: [regarding] Reimbursement of cell phone in person [symbol for and] on telephone call .[Director of Social Services signature] .8/31/2023 . During an interview on 9/10/2023 at 11:16 AM, Resident #67 alleged that a staff member had snatched his cell phone from his hand and broken it. During an interview on 9/11/2023 at 11:35 AM, Resident #67's spouse confirmed that he told her a Certified Nursing Assistant (CNA) snatched his cell phone from his hand and broke it. Resident #67's spouse confirmed that she reported the allegation to the Director of Social Services, who told her the facility would replace the phone. During an interview on 9/11/2023 at 12:15 PM, the Director of Social Services was asked for a copy of the investigation into the incident where Resident #67's cell phone had been broken. The Director of Social Services confirmed she only had a Concern and Comment Report that she filled out. The Director of Social Services confirmed that Resident #67's spouse told her that a staff member broke it and when she asked the resident what happened to his phone, he had just said it was broken. The Director of Social Services stated, I got 2 different stories, so I didn't do anything further. During an interview on 9/11/2023 at 2:18 PM, the Director of Social Services was asked about Resident #67's broken cell phone. The Director of Social Services stated, His wife actually called and told me a couple of days ago he reported his cell phone got broken .she said the young lady snatched it and broke it .that was the end of August .I went to the room .and asked [named Resident #67] can you tell you about your cell .he said it's broken, see it's broken, it's over there .I didn't dress out to go in .stuck my head in the door . The Director of Social Services confirmed Resident #67 was in isolation due to a Covid-19 diagnosis and she did not enter the room to complete a thorough interview. The Director of Social Services confirmed she did not obtain statements from staff. The Director of Social Services confirmed that she reported Resident #67's cell phone was broken to the Administrator, but she did not report that the resident's spouse stated a staff member had broken the phone. During an interview on 9/11/2023 at 2:47 PM, the Administrator was asked when she was made aware of Resident #67's broken cell phone. The Administrator stated, .End of August .reported that his phone was broken, and the wife had asked for reimbursement . [I was] only told that the phone was broken, brought a reimbursement form to sign off on . The Administrator was asked was she told at that time that the resident alleged a staff member had broken the phone. The Administrator stated, No, I was never told that, she told me today [named the Director of Social Services]. The Administrator was asked what should have been done when Resident #67's spouse reported to the Director of Social Services that his cell phone had been broken. The Administrator stated, It should be reported to me immediately as the Abuse Coordinator . The Administrator was asked what the facility's process was when an allegation of abuse was reported to a staff member. The Administrator stated, Immediately start our investigation, normally send the [named the Director of Social Services] down with one other staff member to interview .I call the family .also start staff interviews, pull timelines of when staff members work, see who worked .interview all interviewable residents .skin audits .report it to the State .complete an incident report .make sure medical director is aware, ombudsman, APS [Adult Protective Services] .police as well. Then all of the staff is pretty much a part .any confidential witness statements, any staff or residents in the areas . The Administrator was asked did she agree that this incident should have been reported and investigated. The Administrator stated, Yes, I agree.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, review of facility investigation, and interview, the facility failed to provide documentation for an investigation of an allegation of abuse and failed to ensure a thorough investigation was completed for 1 of 5 (Resident #67) sampled residents reviewed for an allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse Prevention, dated 1/19/2017, revealed, .It is the policy of the facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. The following Procedures shall be implemented when an employee .becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .All incidents will be documented, whether or not abuse occurred, was alleged or suspected .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .the Administrator or designee will investigate the allegation and obtain a copy of any documentation relative to the incident .the investigation team will follow the investigation procedures outlined in this policy. The Charge Nurse must complete an incident report and obtain a written, signed and dated statement from the person reporting the incident. A completed copy of the incident reported and written statements from the witnesses .will be provided to the Administrator. The final investigation report will be completed within the required timeframe allowed by the Tennessee Department of Health of the reported incident. The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts. The Administrator or person in charge of the facility will review the report. The Administrator or designee is then responsible for forwarding a final written report of the results of the investigation and any corrective action taken to the Department of Public Health .The findings of such investigation will be provided to the Administrator within 5 working days of occurrence of such incidents. The Administrator shall either rule out or substantiate the allegation of abuse. When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator or person in charge of the facility, will notify the following persons or agencies of such incident immediately .State Licensing and Certification Agency, Resident Representative, Attending Physician, Law Enforcement Officials .The investigator will submit a final report of the conclusion of the investigation in writing within 5 days of the incident. The final investigation report shall contain the following .Name, age, Diagnosis and mental status of the resident allegedly abused or neglected. The original allegation facts determined during the process of the investigation, review of the medical record and interview of witnesses .Conclusion of the investigation based on known facts .If the allegation is determined to be valid and the perpetrator is an employee, include on a separate sheet the employee's name, address, phone number, title, date of hire, copies of previous disciplinary actions and current status (still working, suspended or terminated) .Attach a summary of all interviews conducted, with names, addresses, phone numbers and willingness to testify of all witnesses .Upon receiving information concerning a report of abuse, the Administrator or Director of Nursing will request that a representative of the Social Services department monitor resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation .the Social Service representative will provide the Administrator and the Director of Nursing with a written report of his/her findings in the resident's medical record. The facility shall report to the state nurse aide registry or licensing authorities any substantiated abuse determined by the facility investigation . 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Osteoarthritis, Depression, and Anxiety. Review of the admission MDS dated [DATE], revealed Resident #67 had a BIMS of 14, which indicated he was cognitively intact with no behaviors exhibited, and required extensive assistance of 1 to 2 staff members for most ADLs. Review of the Concern and Comment Report, dated 8/28/2023, revealed Resident #67's wife reported to the Director of Social Services that Resident #67's cell phone was broken. During an interview on 9/10/2023 at 11:16 AM, Resident #67 reported that an employee snatched his cell phone out of his hand because he called his wife when his call light wasn't answered timely. During an interview on 9/11/2023 at 11:35 AM, Resident #67's spouse confirmed that he told her that a CNA snatched the phone out of his hand, and it broke. Resident #67's spouse confirmed that she reported the incident to the Director of Social Services. During an interview on 9/11/2023 at 12:15 PM, the Director of Social Services confirmed an investigation was not completed into the incident regarding Resident #67's broken cell phone. During an interview on 9/11/2023 at 2:18 PM, the Director of Social Services confirmed Resident #67's wife reported to her that his cell phone was broken by a staff member. The Director of Social Services confirmed that she did not complete a thorough resident interview, obtain staff witness statements, or complete a thorough investigation. During an interview on 9/11/2023 at 2:47 PM, the Administrator confirmed that she was not made aware that Resident #67's wife reported on 8/28/2023 that a staff member had snatched his cell phone from his hand and broken it. The Administrator confirmed that she was made aware of the incident on 9/11/2023 and an investigation was begun at that time. The Administrator confirmed the incident should have been investigated timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for an indwelling urinary catheter (a tube in the bladder that drains the urine) for 2 of 2 (Resident #22 and #41) sampled residents reviewed for indwelling catheters. The findings include: 1. Review of the facility's policy titled, Perineal / Incontinence Care, dated 1/1/2020, revealed .Perform hand hygiene .Put on gloves .Wash all soiled skin areas, washing from front to back, rinse and dry very well, especially between skin folds .Remove gloves .Wash hands . Review of the facility's undated policy titled, Indwelling Urinary Catheter Care, revealed .Wash hands and don gloves .Assist the resident to lie on back and expose perineal area .Soap one cloth at a time and wash genitalia using proper aseptic technique .In male resident, wash the penis first .Cleanse catheter area by washing urethral area first followed by cleansing proximal 1/3 of catheter. Change cloth as necessary .Rinse area with remaining cloth using clean surfaces with each wipe .Gently pat dry area with towel from anterior to posterior .Turn resident to the side and wash/rinse perianal area. Dry area .Remove gloves and wash hands . Review of the facility's undated policy titled, Hand Hygiene Guidelines, revealed .Apply generous amount of soap to hands and rub hands together vigorously for at least 20 seconds . 2. Review of the medical record revealed Resident #22 was admitted on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Major Depressive Disorder, and Neuromuscular Dysfunction of Bladder. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #22 had a Brief Interview for Metal Status (BIMS) score of 12, which indicated he was moderately cognitively impaired, and had an indwelling urinary catheter. Review of the Physician's Orders dated 8/1/2023, revealed .Catheter: Size 16fr [16 French] .Indwelling . Observation in the resident's room on 9/13/2023 at 9:48 AM, revealed Certified Nursing Assistant (CNA) #7 gathered her supplies, knocked on the door and entered Resident #22's room, placed the supplies on the over bed table, exited the room, donned her gown and mask, reentered the room, and went into the bathroom. CNA #7 filled the basin with warm water and placed the basin on the over bed table. CNA #7 donned her gloves, adjusted the bed with the remote, Resident #22 positioned himself onto his back. CNA #7 pulled back the blanket, removed the front side of the brief, applied a bath blanket, picked up the washcloth, submerged it in the water and applied soap. CNA #7 cleaned down the shaft of the penis, discarded the wash cloth, and with a clean wash cloth rinsed the penis. CNA #7 removed her gloves, donned new gloves, and failed to perform hand hygiene. CNA #7 wiped down the catheter tubing with a wet washcloth, removed her gloves, donned new gloves, and failed to perform hand hygiene. CNA #7 dried the catheter tubing with a dry washcloth, removed her gloves, donned new gloves, and failed to perform hand hygiene. Resident #22 rolled to his left side, CNA #7 grabbed a washcloth soaked with water, wiped from front to back, grabbed a dry washcloth, dried from front to back, positioned Resident #22 on his back, and applied a new brief. Resident #22's catheter tubing was not secured with a securement. 3. Review of the medical record revealed Resident #41 was admitted on [DATE], with diagnoses of Diabetes, Major Depression, Hypertension, and Retention of Urine. Review of the quarterly MDS dated [DATE], revealed Resident #41 had a BIMS score of 12, which indicated he was moderately cognitively impaired, and had a indwelling urinary catheter. Review of Physician's Orders dated 9/14/2023, revealed .Catheter .Indwelling 16 FR 10 cc [cubic centimeters] bulb .Obstructive Uropathy . Observation in the resident's room on 9/13/2023 at 11:05 AM, revealed CNA #4 knocked on the door and entered Resident #41's room, entered the bathroom, and washed her hands for only 10 seconds. CNA #4 gathered her supplies and placed them on the over bed table and exited the room to don her gown and mask. CNA #4 entered Resident #41's room, donned her gloves, entered the bathroom, and filled the basin with warm water. CNA #4 placed the basin on the over bed table, removed her gloves, entered the bathroom, and washed her hands for only 8 seconds. CNA #4 donned her gloves, opened the cabinet, and retrieved a brief, pulled the privacy curtain, turned back the blanket, adjusted Resident #41 in bed, removed the front side of the brief, submerged a washcloth in water and applied soap. CNA #4 pulled back the foreskin of the penis, cleaned around the tip of the penis. A large amount of dark stains were noted on the washcloth. CNA #4 proceeded to clean down the catheter tubing using the soiled washcloth. CNA #4 dried around the penis and the tubing with a clean washcloth, using the same gloved hands. CNA #4 rolled Resident #41 on his left side and the resident was noted with a moderate amount of bowel movement. CNA #4, with the same gloved hand, wiped Resident #41 with his brief from front to back, and failed to change her gloves and perform hand hygiene. CNA #4 used a wet, soapy washcloth and wiped Resident #41's perineum using a back and forth motion, then placed the washcloth in the trash bag. The washcloth was noted with a large amount of brown stains. CNA #4, with the same gloved hands, used a wet washcloth and wiped the perineum with a back and forth motion and placed the washcloth in a trash bag. CNA #4 retrieved bath towel and dried Resident #41's perineum with a back-and-forth motion; the bath towel was noted with a small amount of brown stain. CNA #4 applied Resident #41's brief, replaced his blanket, emptied the basin into the toilet, placed the basin on the sink, removed her gloves, removed her gown, and washed her hands for 10 seconds. CNA #4 failed to clean and dry the basin following catheter care. During an interview on 9/13/2023 at 11:25 AM, CNA #4 was asked should she wipe back and forth with the same washcloth during catheter and incontinent care. CNA #4 stated, .No . CNA #4 was asked should she have changed gloves and performed hand hygiene before starting catheter and incontinent care. CNA #4 stated, .Yes . CNA #4 was asked how long she should have washed her hands. CNA #4 stated, .30 seconds . CNA #4 was asked when she should have changed her gloves during indwelling catheter care and incontinent care. CNA #4 stated, .I'm not sure . Observation and interview in the resident's room on 9/13/2023 at 11:41 AM, CNA #4 entered Resident #22's room, pulled back his blanket and loosened his brief. CNA #4 was asked should the indwelling catheter be secured. CNA #4 stated, .Yes ma'am .to keep it from pulling . During an interview on 9/13/2023 at 1:07 PM, the Director of Nursing (DON) was asked to tell about the process for indwelling catheter care. The DON was asked when a resident has had a bowel movement how should staff clean the peri area. The DON stated, .wash their hands .don new gloves .clean from front to the back with each stroke using a different washcloth . The DON was asked should the staff member use the same washcloth in a back-and-forth motion to provide peri care to a resident who had a bowel movement. The DON stated, .No . clean with a different washcloth .if soiled they should change their gloves .wash their hands . The DON was asked how long the staff members should wash their hands. The DON stated, .for 20-30 seconds . The DON was asked should a resident's catheter be secured. The DON stated, .Yes . The DON was asked if the staff member change or remove their gloves should they perform hand hygiene. The DON stated .Yes .

Based on policy review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of infection were used when 2 of 4 (Licensed Practical Nurse (LPN) #3, and LPN #5) nurses failed to perform hand hygiene and clean equipment after use during medication administration. The findings include: 1. Review of the facility's undated policy titled, Hand Hygiene Guidelines revealed .The scope of this guideline includes all interdisciplinary members .and individuals that partake in the resident's plan of care .Handwashing items .soap and water .Paper towels .Waterless Alcohol Based Agent .When hands are visibly soiled, exposure to a spore forming organism has been suspected .before and after eating, and after using the restroom hands should be washed .Allow hands to completely dry prior to applying gloves or interacting with a resident . 2. Observation in the resident's room on 9/12/2023 at 4:59 PM, revealed LPN #5 performed hand hygiene, removed Resident #32's medications from the med cart, placed the medication in a plastic medication cup, transferred the medication to a plastic pouch, crushed the medication using the pill crusher, and returned the medication to the plastic medication cup. LPN #5 gathered supplies from the med cart, locked the med cart, and went to Resident #32's bedside. LPN #5 placed the supplies on a barrier on the over bed table, closed the blinds, and donned gloves. LPN #5 paused Resident #32's feeding pump, removed the tubing, and covered it with a plastic tip. LPN #5 removed a 60 ml syringe from the plastic bag hanging on the pole, removed a stethoscope from around her neck, and checked tube placement. LPN #5 positioned the ear piece and ear tubing of the stethoscope around her neck after checking placement. LPN #5 administered Resident #32's medication. LPN #5 went to the bathroom with the same gloved hands and rinsed the syringe with water, returned the syringe to the plastic bag, hung it on the pole, reattached tubing to the resident, and restarted the feeding pump. LPN #5 failed to remove her gloves and perform hand hygiene after touching contaminated objects in the resident's room. LPN #5 returned to her med cart and positioned her stethoscope around her neck. LPN #5 failed to clean her stethoscope after use. 3. Observation in the resident's room during medication administration on 9/13/2023 at 8:29 AM, revealed LPN #3 performed hand hygiene, prepared Resident #10's medication, locked her med cart, knocked on the resident's door, entered the resident's room, and administered the resident's medications. LPN #3 failed to perform hand hygiene prior to administering medication after touching contaminated objects on the medication care. LPN #3 donned gloves, removed the resident's nasal spray from a plastic bag, and handed it to the resident who self-administered (per self-administration plan) the nasal spray. 4. During an interview on 9/13/2023 at 1:07 PM, the Director of Nursing (DON) confirmed staff should perform hand hygiene before donning, after doffing gloves, and after touching contaminated objects in the resident's room. During an interview on 9/14/23 at 8:00 AM, the DON confirmed staff should clean the equipment before and after use.

Based on policy review, observation, and interview, the facility failed to maintain and enhance resident's dignity and respect when 7 of 24 (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, LPN #2, Unit Manager #1, Unit Manager #2, Certified Nursing Assistant (CNA) #1, CNA #4, CNA #6) staff members failed to knock before entering resident rooms, when 1 of 24 (LPN #1) staff members stood to assist Resident #45 with meals, when 1 of 24 (CNA #4) staff members did not use proper courtesy titles, and when 1 of 4 (RN #1) nurses failed to provide privacy for 1 of 5 (Resident #46) residents observed during medication administration. The findings include: 1. Review of the facility's undated policy titled, Dignity, revealed .will not refer .as feeder .Staff will not stand to feed .Privacy .Staff will knock prior to entering a resident's room .Staff will provide privacy for residents .curtain must be pulled anytime .resident needs .privacy . Review of the facility's undated policy titled, Resident Rights, revealed .The facility must care for you in a manner and environment that enhances or promotes your quality of life . Review of the undated facility's undated policy titled, Insulin Pens, revealed .Administer the insulin affording privacy . 2. Observations during dining revealed the following: a. On 9/10/2023 at 12:54 PM, CNA #1 failed to knock or ask permission to enter Resident #40's room. b. On 9/10/2023 at 12:57 PM, LPN #2 failed to knock or ask permission to enter Resident #27's room. c. On 9/10/2023 at 1:01 PM, Unit Manager #2 failed to knock or ask permission to enter Resident #18's room. d. On 9/10/2023 1:05 PM, Unit Manager #1 failed to knock or ask permission to enter Resident #16's room. e. On 9/10/2023 at 1:13 PM, CNA #1 failed to knock or ask permission to enter Resident #64's room. f. On 9/10/2023 at 1:21 PM, LPN #1 stood at Resident #17's bedside while she assisted the resident with her lunch tray. Resident #17 was not at eye level with LPN #1. g. On 9/11/2023 at 7:44 AM, CNA #1 failed to knock or ask permission to enter Resident #71's room. h. On 9/11/2023 at 7:46 AM, CNA #4 entered Resident #8's room, placed the food tray on the over the bed table, lifted the lid off the tray, and stated, She is a feeder. i. On 9/11/2023 at 7:58 AM, CNA #6 did not knock or ask for permission to enter Resident #75's room. 3. Observation in the resident's room during medication administration on 9/12/2023 at 12:45 PM, revealed Registered Nurse (RN) #1 lifted Resident #45's gown, exposed her abdomen, and administered an insulin injection. RN #1 failed to close the door or the privacy curtain, and Resident #45 was visible to anyone walking in the hallway. During an interview on 9/13/2023 at 1:07 PM, the Director of Nursing (DON), confirmed that staff should not stand over residents when assisting with meals, staff should not refer to residents as feeders, staff should knock before entering a resident's room and staff should provide privacy when administering insulin in the abdomen by pulling the curtain.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 5 of 24 staff members Certified Nurse Assistant (CNA#1, #2, #3, #4, #6) failed to perform hand hygiene during meal services. The number of meal trays served on 9/10/2023 for lunch were 73. The number of meal trays served for breakfast on 9/11/2023 were 72. The findings include: 1. Review of the facility's policy titled, Meal Service, dated 9/5/2023 revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each residents nursing and personal care needs including meals service and assistance with eating .Staff providing direct care by passing meals/trays will wash their hands before serving the food .There is no bare hand contact with ready to eat foods . Review of the facility's undated policy titled, Hand Hygiene Guidelines, revealed .When hands are visibly soiled, exposure to a spore forming organism has been suspected .hands should be washed with a non-microbial or anti-microbial soap . Review of the facility's undated policy titled, Resident Rights, revealed .The facility must care for you in a manner and environment that enhances or promotes your quality of life . 2. Observation in the resident's room on 9/10/2023 at 12:54 PM, revealed CNA #1 entered Resident #5's room with her lunch tray, placed the tray on the over bed table, pulled the resident up in the bed, and then proceeded to set up the resident's tray. CNA #1 did not perform hand hygiene prior to setting up Resident #5's tray. 3. Observation in the resident's room on 9/10/2023 at 1:08 PM, revealed CNA #3 entered Resident #75's room with his lunch tray, placed the tray on the over bed table, donned gloves, pulled the privacy curtain, and moved the resident up in the bed. CNA #3 doffed her gloves, removed the sandwich from the plastic bag with her bare hands and the straw from the wrapper, and then performed hand hygiene. CNA #3 failed to perform hand hygiene prior to donning gloves and after doffing gloves and touched the resident's food with her bare hands. 4. Observation in the resident's room on 9/11/2023 at 7:28 AM, revealed CNA #4 entered Resident #281's room, placed the food tray on the over the bed table, picked up the bed remote and raised the head of bed, did not perform hand hygiene, opened the residents butter and spooned it in the oatmeal, opened packets of sugar and poured on the oatmeal, spread jelly on the toast, turned on the light, did not perform hand hygiene, went outside the resident's room and got the resident some coffee, returned to the room and opened packets of artificial sweetener and pour in the resident's coffee, removed the paper from a straw and placed the straw in the resident's drink. CNA #4 failed to perform hand hygiene while assisting Resident #281 with dining. 5. Observation in the resident's room on 9/11/2023 at 7:32 AM, revealed CNA #2 entered Resident #7's room with her breakfast tray, set the tray on the over bed table, returned to the 100 Hall, obtained a towel from the clean linen cart, and placed the towel on the resident's chest at her request. CNA #2 removed the meal tray lid, picked up the knife, cut the hard-boiled egg in half with her right hand while she held the egg in place with her bare left hand, picked up toast with her bare left hand and used the knife to spread jelly on the toast with her right hand. CNA #2 failed to perform hand hygiene and touched Resident #7's food with her bare hand. 6. Observation in the resident's room on 9/11/2023 beginning at 7:42 AM, revealed CNA #4 entered Resident #15's room, placed the food tray on the over bed table, put sugar and butter in the resident's oatmeal, picked up the resident's remote and readjusted the bed. CNA #4 pulled the resident's draw sheet from under him putting her right hand under his back and her left hand on his right shoulder to reposition the resident, moved the over bed table closer to Resident #15 and did not perform hand hygiene. CNA #4 returned to the meal cart, retrieved Resident #8's food tray, entered Resident #8's room, placed the food tray on the over bed table and lifted the lid off. CNA #4 picked up and placed a chair near the resident, sat down in the chair to assist Resident #8 with his meal. CNA #4 failed to perform hand hygiene during dining. 7. Observation in the resident's room on 9/11/2023 at 7:44 AM, revealed CNA #1 entered Resident #71's room with his breakfast tray. CNA #1 placed the tray on Resident #71's over bed table, removed the lid, moved the over bed table to the opposite side of the bed, added sugar to the resident's oatmeal, and placed a straw in his juice. CNA #1 touched Resident #71's toast with her left hand and spread jelly on the toast with her right hand using a fork. CNA #1 then held the other half of Resident #71's toast with her left hand and spread jelly on the toast using a fork. CNA #1 failed to perform hand hygiene and touched Resident #71's food with her bare hand. 8. Observation in the resident's room on 9/11/2023 at 7:58 AM, revealed CNA #1 entered Resident #25's room with his breakfast tray. CNA #1 placed the resident's tray on his over bed table, removed the lid from the tray, and added sugar to the resident's oatmeal and pepper to his eggs. CNA #1 picked up a slice of Resident #25's toast with her left land and used a fork to spread jelly on the toast with her right hand, and then returned it to his plate. CNA #1 picked up the second half of Resident #25's toast with her left hand and spread jelly on the toast with a fork using her right hand, and then returned it to his plate. CNA #1 picked up the third half of Resident #25's toast with her left hand and spread jelly on the toast with a fork using her right hand, and then returned it to his plate. CNA #1 failed to perform hand hygiene and touched Resident #25's food with her bare hand. 9. Observation in the resident's room on 9/11/2023 at 8:03 AM, revealed CNA #6 entered Resident #333's room, placed the resident food tray on the over bed table, used the resident fork to put a hole in his juice drink, placed the fork back on the food tray for the resident to use, removed the straw paper and placed the straw in the juice, lifted the resident's bed sheet and asked another staff member to assist her with repositioning the resident. CNA #6 donned gloves, assisted Resident #333 reposition himself in bed, removed her gloves, failed to perform hand hygiene, moved the resident's over bed table closer to him, and left the resident's bedside. 10. During an interview on 9/13/2023 at 1:07 PM, the Director of Nursing (DON) confirmed staff should wash their hands after touching contaminated items, after repositioning resident up in bed, and after removing their gloves. The DON confirmed the staff should not use their bare hands to pick up the resident's food, and staff should wash their hands after they assist a resident with repositioning in bed.

Based on policy review, observation, and interview, the facility failed to deliver meal trays to residents in a timely manner resulting in late meals. This had the potential to affect the 73 of the 78 residents who had received a tray from the Kitchen. The findings included: Review of the facility's policy titled, Resident Dining Services dated 12/6/2016, revealed .The Food and Nutrition Services department will have a process in place to assure residents receive meals in a timely manner with appropriate assistance and supervision . Observation of the halls on 7/12/2021 revealed lunch meal trays were scheduled to be delivered on the 300 Hall at 12:45 PM, on the 400 Hall at 12:50 PM, on the 100 Hall at 1:00 PM, and on the 200 Hall at 1:15 PM. Observation on 7/12/2021 revealed the first meal was delivered on the 300 Hall to a resident at 1:38 PM. The meal was 53 minutes late. Observation on the 100 Hall revealed the first meal was delivered to a resident at 2:08 PM. The meal was 1 hour and 8 minutes late. The first meal tray was delivered on the 200 Hall at 2:28 PM. The meal was 1 hour and 13 minutes late. During an interview on 7/13/2021 at 8:05 AM, Resident #51 stated that she had failed to receive a breakfast tray Sunday (7/11/2021) morning and her first meal that day was at 12:15 PM. She also confirmed she didn't receive her supper tray until 8:15 PM. During an interview on 7/13/2021 at 9:03 AM, Resident #121 confirmed that on 7/11/2021 he did not receive a breakfast tray and his first meal that day was between 1:00 or 2:00 PM and stated, .didn't get supper till 8o'clock [8:00 PM] .ever since I've been here all the meals are late . During an interview on 7/14/2021 at 9:15 AM, Dietary Staff #3 confirmed she worked Sunday and stated, .the young man that was supposed to be here didn't show up .he was new .no one stays .I was by myself .I didn't understand the tickets, they were a mess .breakfast trays are supposed to go out 7:00-7:30 [AM] . Dietary Staff #3 was asked if the breakfast trays were served. Dietary Staff #3 stated, .I didn't serve them breakfast .it didn't make any sense to serve them breakfast it was lunch time, I gave them a little extra . Dietary Staff #3 was asked if the Kitchen had been short staffed. Dietary #3 stated, Yes . Dietary Staff #3 was asked why meals were being on Styrofoam. Dietary Staff #3 stated, Because we are short staffed . Dietary Staff #3 was asked why were the lunch trays late being delivered. Dietary Staff #3 stated, .don't get out on time .we don't have that many people . During an interview on 7/14/2021 at 1:48 PM, Dietary Staff #1 was asked if the residents' meals have been late. Dietary Staff #1 stated, .they are always late .get breakfast at 9:00 or 10 o'clock [10:00 AM] .lunch at 2:00 or 3 o'clock [3:00 PM] . During an interview on 7/14/2021 at 2:02 PM, Dietary Staff #2 was asked what had happened on Sunday (7/11/2021). Dietary Staff #2 stated, .received a text .asked if I could come in and help Sunday morning .new guy didn't show up and [Named Dietary Staff #3] was working by herself .I think I made it here at 1 to 1:15 [PM] .serving lunch by the time I got here . During an interview on 7/14/2021 at 2:26 PM, Dietary Staff #4 was asked if she worked Sunday (7/11/2021). Dietary Staff #4 stated, .I was called to come in because [Named Dietary Manger] called and said [Named Previous Dietary Staff] didn't come in .breakfast was still on the steamer .hadn't been served .did have everything ready .when I got here I worked .long story short breakfast did not get served .I didn't even know how to read the tickets .she decided to go serve lunch .her lunch was done she just needed to move breakfast so lunch wouldn't get cold .she was the only one here .said she had asked the CNA [Certified Nursing Assistant]s and they said no .we did roll out lunch about 12 [PM] . Dietary Staff #4 was asked why were meals being served in Styrofoam. Dietary #4 stated, Because they are short staffed no one wants to be here at 10 o'clock at night washing dishes . During an interview on 7/14/2021 at 2:26 PM, the Dietary Manager (DM) was asked what happened Sunday (7/11/2021) in the Kitchen. The DM stated, .I received a phone call from [Dietary Staff #3] told me that the guy didn't show up .I then called [Named Dietary Staff #2] .to see if she could go ahead and come in .I then called [Dietary Staff #3] didn't have anybody to bring in if she could get someone .to pass the trays she said she had the whole meal fixed .breakfast supposed to go out between 7:00 - 7:30 [AM] .not feeding them is not option . The DM was asked if the residents received breakfast on Sunday. The DM stated, according to what I was told, no . The DM was asked why lunch was so late Monday (7/12/2021). The DM stated,We were down a dietary aide so I had to come in and cover his shift .just me and Dietary #3 in the Kitchen .I didn't realize it was that late .there is only so much one person can do. The DM confirmed the trays were late and stated, .the responsibility, it's all mine .I'm supposed to be here 24/7 .I've been dietary aide .cook .and management .on repeated basis .nearly everyday . During an interview on 7/14/2021 at 3:46 PM, the Registered Dietician (RD) was asked who was responsible for the Kitchen. The RD stated, The Dietary Manager . The RD was asked if the kitchen was short staffed. The RD stated, It has been this last month .they have had a tremendous turn over . The RD was asked if she was aware the residents didn't receive breakfast on Sunday (7/11/2021). The RD stated. I heard about it Monday .they said they served an early lunch . The RD was asked if an early lunch would take the place of breakfast. The RD confirmed she was at the facility Monday and was asked if she was aware the Kitchen was short staffed on Monday. The RD stated, No .but one day she [Named the DM] worked as an aide .worked as a cook .it might have been Monday .it's hard to keep up with them .so the Administrator asked me to come in Tuesday and make sure that the meals got out on time. The RD confirmed the meals had been late and stated, Yes .for the last month .I'm telling you the truth .they have been late .not everyday .but 50 percent The RD was asked if she offered to help the staff when they are short. The RD stated,No .I'm on limited hours here .I don't work the tray line .I don't actually go back there and work with them .I do oversight .I see the trays are late and try to figure out what was going on .we are short staffed .and need people that know what is going on .

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by undated food items, a dirty deep fryer, meat slicer, and mixer, inappropriate tray line serving temperatures, and 2 of 13 staff members (Certified Nursing Assistant (CNA) #1 and #2) failed to distribute and serve food in a sanitary manner during dining. This had the potential to affect the 73 of the 78 residents who had received a tray from the Kitchen. The findings include: Review of the facility's policy titled,Table Top Mixer, dated 3/26/2012, revealed .The mixer will be cleaned and sanitized after each use . Review of the facility's policy titled,Food Slicer, dated 3/26/2012, revealed .This machine must be thoroughly cleaned and sanitized after each use . Review of the facility's policy titled, Deep Fryer, dated 3/26/2012, revealed .The deep fryer will be cleaned as needed .to ensure food safety. To produce evenly cooked, perfectly browned fried products keep the oil in the deep fryer clean and clear . Observation in the resident's room on 7/12/2021 at 1:37 PM, revealed CNA #1 delivered a lunch tray to Resident #9, placed the tray on the bedside table, repositioned the resident, and adjusted the bed controls. CNA #1 picked up and opened a plastic bag containing Resident #9's sandwich and removed the sandwich with her bare hands. CNA #1 did not perform hand hygiene. Observation in the resident's room on 7/12/2021 at 1:43 PM, revealed CNA#1 delivered a lunch tray to Resident #38, placed the tray on the bedside table, touched wheelchair handles, and repositioned the bedside table, knocking off a roll of toilet paper and a bottle of lotion onto the floor. CNA #1 picked up the items off of the floor and continued to set up the resident's meal tray without performing hand hygiene. Observation in the resident's room on 7/12/2021 at 1:49 PM, revealed of CNA #1 delivered a lunch tray to Resident #167, placed the tray on the bedside table, touched the bed controls to elevate the head of the bed, then opened the Styrofoam food container, removed the lids from the cups, and handled the plastic eating utensils without performing hand hygiene. Observation in the resident's room on 7/12/2021 at 1:52 PM, revealed CNA #1 delivered a lunch tray to Resident #37, placed the tray on the bedside table, picked up and opened a plastic bag containing a peanut butter and jelly sandwich. CNA #1 then removed Resident #37's sandwich from the plastic bag with her bare hands without performing hand hygiene. Observation in the resident's room on 7/13/2021 at 8:11 AM, revealed CNA #1 delivered a breakfast tray to Resident #38, placed the tray on the bedside table and knocked a plastic knife off onto the floor. CNA #1 then picked up the knife, touched the bedside table, turned on the light switch, and assisted the resident to reposition in the bed. CNA #1 picked up Resident #38's toast bare handed, spread jelly, and placed the toast back onto resident's plate without performing hand hygiene. Observation in the resident's room on 7/13/2021 at 8:17 AM, revealed CNA #1 delivered a breakfast tray to Resident #55, placed the tray on the bedside table, picked up the bed controls, touched the bedside table to reposition the table across the bed. CNA #1 proceeded to open all food containers, picked up 3 pieces of toast, individually spreading butter and jelly on each piece and placed the toast back onto resident's plate without performing hand hygiene. Observation in the resident's room on 7/13/2021 at 8:21 AM, revealed CNA #1 delivered a breakfast tray to Resident #42, placed the tray on the bedside table, touched the bed controls and the bedside table, and removed all the lids on the tray and the food containers without performing hand hygiene. CNA #1 picked up Resident #42's toast bare handed, buttered toast, and placed it back on the resident's plate. Observation in the 100 hall on 7/13/2021 beginning at 8:26 AM, revealed CNA #2 removed a breakfast tray from the meal cart, delivered and set up breakfast trays to Resident #168's, #219's, #45's, #57's, #121's, #169's, and #118's rooms. CNA #2 then prepared a cup of coffee and delivered the coffee to Resident #57 and #121. CNA #2 then went to Resident #118's room and fed her breakfast. CNA #2 did not perform hand hygiene during this meal delivery. Observation in the resident's room on 7/13/2021 at 8:28 AM, revealed CNA #1 delivered a breakfast tray to Resident #167, CNA #1 peeled Resident #167's banana and removed the banana from the banana peel with her bare hands and placed it on the resident's plate without performing hand hygiene. Observation in the resident's room on 7/13/2021 at 8:31 AM, revealed CNA #1 delivered a breakfast tray to Resident #61, placed the tray on the bedside table, touched the resident, bed controls, blanket, pillow, and the bedside table. CNA #1 then touched Resident #61's bacon and toast with bare hands to straighten it on the plate. CNA #1 continued to set up the resident's meal tray without performing hand hygiene. During an interview on 7/13/2021 at 9:13 AM, CNA #2 was asked what should be done before serving each resident their meal tray and assisting to feed residents. CNA #2 stated, Wash my hands .I washed them when I first got here . During an interview on 7/14/2021 at 6:05 PM, the Director of Nursing (DON) was asked what would be expected of staff when passing meal trays to residents. The DON stated, I expect them to wash their hands first The DON was asked what should staff do when they leave a resident's room to get another resident tray. The DON confirmed staff should sanitize their hands before and after delivering a meal tray to residents and before serving a meal to a resident. Observation in the Kitchen on 7/13/2021 at 12:15 PM, revealed the following items stored in the freezer: a. 2 undated bags of corn nuggets b. 1 open and undated bag of potato tots Observation in the Kitchen on 7/13/2021 at 12:20 PM, revealed brown sediment floating in the dark grease with thick build up around the pan of the deep fryer. Observation in the Kitchen on 7/13/2021 at 12:22 PM, revealed dried food particles on the meat slicer. Observation in the Kitchen on 7/13/2021 at 12:24 PM, revealed a dried unknown substance on the mixer. Observation in the Kitchen on 7/13/2021 at 12:28 PM, revealed Dietary Staff #3 took temperatures on the serving line. The alternate meat was turkey and the holding temperature was 80 degrees Fahrenheit (F). The first meal cart had left the Kitchen. During an interview on 7/14/2021 at 2:58 PM, the Dietary Manager (DM) confirmed the two bags of corn nuggets and one bag of potato tots should have been dated or left in the box. The DM was asked about the build up on and the dark grease in the deep fryer. The DM stated, It needed to be cleaned . The DM was asked what the dried particles were on the meat slicer. The DM stated, .it was dried chipped meat . The DM was asked how often should the meat slicer be cleaned. The DM stated, After every use. The DM was asked what was the dry substance on the mixer. The DM stated, .I don't know what that was .I'm going to say it was dry pudding. The DM was asked what should the temperature of the turkey have been. The DM stated,165. The DM was asked should it had been served to the residents. The DM stated, Absolutely not .

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when dietary staff did not properly restrain hair and when food items were stored in the refrigerator and freezer uncovered, unlabeled, and undated. The facility had a census of 82 residents, with 80 of those residents receiving a tray from the kitchen. The findings include: The facility's .Dress Code policy dated 3/27/12 documented, .Food employees wear a hair covering which covers all hair completely. [NAME] guards must be used for employees with facial hair . The facility's .Cold Storage Areas policy dated 3/26/12 documented, .Date, label and properly secure all products removed from original containers . Observations in the kitchen on 6/17/19 beginning at 5:50 AM, revealed: a. Dietary Staff #1 was in the kitchen during breakfast preparation with no beard cover over his facial hair. b. Ice filled glasses stored in the freezer uncovered, unlabeled, and undated. c. Trays of pancakes, turkey sausage, and bacon uncovered, unlabeled, and undated in the refrigerator. d. Bags of carrots and corn were stored in the freezer, under the fan, opened to air. Observations on 6/17/19 at 7:53 AM and 8:06 AM, revealed Dietary Staff #1 coming out of the kitchen pushing a meal cart with his beard cover pulled down exposing, facial hair. Observations in the kitchen on 6/18/19 at 11:30 AM, revealed Dietary Staff #2 was serving lunch plates with no beard cover over his facial hair. Interview with the Dietary Manager on 6/19/19 at 7:50 AM, in the Conference Room, the Dietary Manager was asked if dietary employees with facial hair should wear a beard guard while in the kitchen. The Dietary Manager stated, Yes. The Dietary Manager was asked if food and ice should be stored in the refrigerator and freezer open, uncovered, and unlabeled. The Dietary Manager stated, No, ma'am .