Every finding on record at Dyer Nursing and Rehabilitation Center

Based on policy review, medical record review, and interview, the facility failed to ensure proper infection control practices for 1 of 3 (Resident #7) residents reviewed for Tuberculosis (TB) Two Step Mantoux Test Results. The facility had a census of 63. The findings include: 1. Review of the facility's policy titled, Infection Prevention and Control Program, dated 10/2018, revealed An infection prevention and control program .is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission, of communicable diseases and infections .Surveillance tools are used for recognizing the occurrence of infections .detecting outbreaks . Review of the facility's policy titled, Tuberculosis ., dated 8/2013, revealed .This facility shall screen all residents for tuberculosis infection . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Malignant Neoplasm, Infectious Gastroenteritis and Colitis, and Abdominal Pain. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #7 is cognitively intact. Review of the Medication Administration Record (MAR) dated October 2024, revealed Resident #7 received the 1st intradermal injection for Two Step Mantoux Test on 10/25/2024. The results are to be read on 10/27/2024 for results. Review of the MAR dated October 2024 revealed there was no documentation the Two Step Mantoux Test was read for a negative or positive result. During an interview on 12/18/2024 at 11:20 AM, with the Infection Control Nurse was asked if Resident #7's Two Step Mantoux TB skin test was completed. The Infection Control nurse confirmed that staff did not read the results of the Two Step Mantoux test. During an interview on 12/18/2024 at 12:00 PM, with the Director of Nurses (DON), the DON confirmed the staff did not read the Two Step Mantoux as they should have.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 2 of 5 medication storage areas (North Back Medication Cart and South Middle Hall Medication Cart) that were left unlocked and unattended, and when 1 of 1 nurses (Licensed Practical Nurse (LPN) #A) failed to ensure medications were not left unattended. The findings include: 1. Review of the facility's policy titled, Storage of Medications, dated ,d+[DATE], revealed .The facility shall store all drugs and biologicals in a safe, secure, and orderly .The facility shall not use discontinued, outdated, or deteriorated drugs .All such drugs shall be returned .or destroyed .Compartments (including, but not limited drawers, cabinets .carts .) containing drugs and biologicals shall be locked when not in use .carts .shall be not be left unattended if open . Review of the facility's policy titled, Insulin Administration, dated ,d+[DATE], revealed .To provide guidelines for the safe administration of insulin .If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening) .28 Day Exp. [Expiration] Date (after first use) Lantus, Novolog, Humalog 42 Day Exp. Date (after first use) . Review of the facility's policy titled, Insulin Storage, dated ,d+[DATE], revealed .Insulin vials .should be dated and initialed when opened .should be discarded after the expired date . Review of the facility's policy titled, Administering Medications, dated ,d+[DATE], revealed .During administration of medications, the medication cart is kept closed and locked when out of sight .No medications are kept on top of the cart . 2. Random observation on [DATE] at 8:46 AM, revealed on top of the 300 Hall North Back Medication Cart was the following unattended, opened, and expired insulin (medication for Hyperglycemia) vials: a. An opened vial of Resident #11's Levemir insulin with no open date or expired date. The Physician order dated [DATE], revealed Resident #11 had an order for Levemir .inject 50 unit subcutaneously at bedtime . b. An open vial of Resident #11's Insulin Aspart (Novolog), with an open date of [DATE] and expiration date of [DATE]. The Physician's Order dated [DATE] revealed Resident #11 had an order for Novolog .inject as per sliding scale . c. An opened vial of Resident #12's Humalog labeled with no open date or expired date. The Physician's Order dated [DATE], revealed Resident #12 had an order for Humalog .inject as per sliding scale . d. An opened vial of Resident #14's Humalog with no open date and no expired date. The Physician's order dated [DATE], revealed Resident #14 had an order for Humalog Injection Solution .inject as pr sliding scale . e. An opened vial of Resident #13' s Lantus, with an open date of [DATE] and an expired dated of [DATE]. Physician's Order dated [DATE], revealed Resident #13 had an order for Lantus .inject 28 units subcutaneously two times per day . During an interview on [DATE] at 8:51 AM, Licensed Practical Nurse (LPN) A confirmed the vials of insulin should not have been left unattended on the med cart and the expired insulin vials should have been discarded. 3. A random observation and interview in the South Hall on [DATE] at 8:55 AM, revealed the South Medication Cart was unlocked and unattended. LPN B was asked about the med cart. LNP B stated, .there has been issues with the cart's lock, it takes a few tries before it will lock .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure enteral feedings were labeled and dated for 1of 1 (Resident #55) sampled residents reviewed for enteral feeding. The findings include: 1. Review of the facility's policy titled, Enteral Tube Feedings, revised 1/2014, revealed .On the formula label document initials, date and time the formula was hung/administered . 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Dysphagia and Gastroparesis. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status score of 5, which indicated the resident was severely cognitively impaired and had a Percutaneous Endoscopic Gastrostomy (PEG) feeding. Observation in the resident's room on 6/12/2024 at 1:33 PM, revealed Resident #55's enteral feeding bag was not labeled with the resident's name, the date, time, and rate, and the nurse's initial. During an interview on 6/12/2024 at 1:35 PM, LPN #A confirmed Resident #55's enteral feeding was not labeled with the resident's name, date, time, rate, and the nurse's initial.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 1 of 1 Licensed Practical Nurse (LPN #A) failed to follow Enhanced Barrier Precautions in a resident's room while giving care. The findings include: 1. Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, revealed .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity .Examples of high contact .activities . include .device care or use .feeding tube .any skin opening requiring a dressing .indwelling medical devices . 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses of Dysphagia, Gastrostomy Status, and Gastroparesis. Review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status score of 5, which indicated the resident was severely cognitively impaired, and had a Percutaneous Endoscopic Gastrostomy (PEG) feeding. Review of the facility's list of residents on enhanced barrier precautions revealed Resident #55 was placed on enhanced barrier precautions on 4/1/2024. Observation in the resident's room on 6/12/2024 at 1:35 PM, revealed LPN #A failed to wear gown and gloves when disconnecting Resident 55's enteral feeding tube from the PEG tube. During an interview on 6/13/2024 at 9:14 AM, the Regional Clinical Corporate Nurse Regional Clinical Corporate Nurse confirmed staff should wear a gown and gloves when a resident's enteral feeding tube is disconnected from the PEG site tubing.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, Time Detail Reports, COVID-19 Daily Employee Screening Logs, and interview, the facility failed to follow CDC Infection Control guidelines to ensure all staff who enter facility completed the screening process for the prevention or spread COVID-19 when 30 of 108 staff members (Nurses Aide (NA) #1, #2, #3, #4, #5, #6, and #7, Certified Nurse Aide (CNA) #1, #2, #3, #4, #5, and #6, Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, #6, #7, #8, and #9, Registered Nurse (RN) #1, Dietary Staff #1, #2, and #3, Housekeeping Staff #2 and #3, and Physical Therapy (PT) Staff #1 and #3) failed to complete screenings for COVID-19 prior to working for 8 of 8 days (7/10/2021-7/17/2021) reviewed. The findings include: Review of the Centers for Disease Control and Prevention (CDC) website document titled, .Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 [Coronavirus Disease] Spread in Nursing Homes, updated 3/29/2021, revealed, .Establish a process to ensure HCP [Healthcare Personnel], (including .ancillary staff environmental services and dietary services) entering the facility are assessed for symptoms of COVID-19 .individual screening on arrival at the facility. Review of the Time Detail Reports and COVID-19 Daily Employee Screening Logs from 7/10/2021-7/17/2021 revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 7/10/2021- NA #1, CNA #1, #2, and #3, and LPN #1 and #2. b. 7/11/2021- NA #1 and #6, CNA #1 and #2, LPN #1, #2, and #3, and Dietary Staff #1. c. 7/12/2021- NA #7, LPN #4 and #5, Dietary Staff #2, and PT Staff #1. d. 7/13/2021- NA #1 and #2, CNA # 3,#4, and #6, LPN #3, #4, and #6, and Housekeeping Staff #2. e. 7/14/2021- NA #1, #2 and #3, CNA #4, LPN #3, #4, #5, and #7, RN #1, and Housekeeping Staff #3. f. 7/15/2021- NA #1, #2, #3 and #4, CNA #1, #3 and #4, LPN # 3, #4, and #8, and Housekeeping Staff #3. g. 7/16/2021- LPN # 4 and #9, PT Staff #3. h. 7/17/2021- NA #2 #3, and #5, CNA #2 and #5, LPN #1, #2, and #3, and Dietary Staff #3. During an interview on 7/29/2021 at 2:45 PM, the Director of Nursing (DON) confirmed all staff should be screened for COVID-19 upon entering the facility.

Based on medical record review, observation, and interview, the facility failed to assess 1 of 1 sampled resident (Resident #57) reviewed for self-administration of medication. The findings include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Self Administration of Medication form dated 7/10/2018, revealed, .Patient Name .[Resident #57] .Do you wish to administer your own medication .[x mark] .No . Observation in the resident's room on 7/29/2021 at 8:09 AM, revealed Resident #57 was sitting on the bedside holding a nebulizer mask up to her face receiving a nebulizer breathing treatment, unattended by nursing staff. During an interview on 7/29/2021 at 10:55 AM, Licensed Practical Nurse (LPN) #11 confirmed that Resident #57 had not been assessed to administer her own medication. LPN #11 confirmed residents should not be left unattended when receiving a nebulizer treatment.

Based on policy review, medical record review, observation, and interview, the facility failed to acknowledge a resident's self-determination of food choices when 2 of 20 staff members(Certified Nursing Assistant (CNA) #7 and Nurse Aide (NA) #4) failed to offer an alternative food item when a resident (Resident #12) voiced her dislike and smell of food. The finding include: Review of the facility's policy titled, Resident Rights Policy, revised 11/2016, revealed .(f) Self-determination. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice . Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan updated 5/14/2021, revealed .Nutritional status, at risk for decline .Allow resident to make informed decisions about dietary choices and respect resident's wishes .Evaluate refusal of meals .offer alternatives .Maintain a pleasant, odor free environment during meals . Observation in the resident's room on 7/26/2021 at 11:15 AM, revealed CNA #7 entered Resident #12's room and set up her meal tray on the over the bed table. Resident #12 stated, I don't like carrots . CNA #7 stated, .they are really sweet, I like them, don't you. Resident #12 stated, No. CNA #7 exited the room and began to remove another tray from the meal cart and failed to acknowledge Resident #12's dislike of the carrots and failed to offer an alternative food item. Observation in the resident's room on 7/27/2021 at 5:06 PM, revealed NA #4 entered Resident #12's room, sat the meal tray on the over the bed table, removed the lid. Resident #12 stated, That green stuff [Brussels sprouts] smells awful. NA #4 stated, Eat what you want it's ok. NA #4 then exited the room and returned to the meal cart. NA #4 failed to acknowledge Resident #12's dislike of the smell of the food and failed to offer an alternative. During an interview on 7/29/2021 at 8:30 AM, the Director of Nursing (DON) was asked what should a staff member do when a resident voices their dislike of the food on a their meal tray. The DON stated, They should ask if they would like something else to eat. The DON was asked should a resident have a choice of food if they voice a dislike. The DON stated, Yes.

Based on medical review, observation, and interview, the facility failed to follow Physician's Orders for the use of oxygen and failed to ensure oxygen supplies were labeled for 2 of 4 sampled residents (Resident #17 and #27) reviewed for respiratory care. The findings include: Review of the facility's 11-7 Shift job description for Nurses, documented, .On the 3rd and 18th of every month change out nebulizer .and 02 [Oxygen] tubing and date and initial all .Mondays .replace water bottles and date and initial them . Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 was assessed for the use of oxygen. Review of the Care Plan dated 5/25/2021, revealed .Oxygen binasal cannula [pronged tubing placed inside the nose] @ [symbol for at] 2L [Liters] / [per] min [minute] and titratin [keep regulated] to maintain spo2 [the amount of oxygen in the blood stream] > [symbol for greater than] 90% [symbol for percent] . Review of the Physician's Orders dated 7/23/2021, revealed .Order Date .5/19/2021 .Oxygen AT 2 LITERS BNC [By Nasal Cannula] AND TITRATE TO MAINTAIN SP O2 > 90% . Observation in the resident's room on 7/26/2021 at 9:20 AM and 2:15 PM, on 7/27/2021 at 8:05 AM and 4:30 PM, and on 7/28/2021 at 7:45 AM and 3:00 PM, revealed Resident #12 was in her room with no oxygen was being administered, and an oxygen humidifier bottle and the oxygen tubing was dated 6/8/2021. During an interview on 7/28/2021 at 5:18 PM, the Assistant Director of Nursing confirmed that the Physician's Orders should have been for the use of oxygen for Resident #17. During an interview on 7/29/2021 at 10:55 AM, Licensed Practical Nurse (LPN) #11 was shown Resident #17's oxygen humidifier bottle and was asked should the bottle have a date of 6/8/2021. LPN #11 stated, No. LPN #11 was shown Resident #17's oxygen tubing and was asked should the tubing have a date of 6/8/2021. LPN #11 stated, No, it should not, it should have been changed. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 7/9/2021, revealed, Problem .Respiratory/Pneumonia/[CONDITION(S)] .Approaches .O2/BNC as ordered . Review of the July Physician's order revealed, .02 BNC BETWEEN 2L AND 3L TO MAINTAIN 02 SAT GREATER THAN 92 . Observation in the resident's room on 7/26/2021 at 2:04 PM, revealed Resident #27 was sitting in a wheelchair, wearing oxygen at 2L/minute BNC with no date on the oxygen humidifier bottle. Observation in the resident's room on 7/28/2021 at 7:51 AM, revealed Resident #27 was lying in the bed, wearing oxygen at 2L/minute BNC with no date on the oxygen humidifier bottle. During interview on 7/28/2021 at 10:15 AM, LPN #10 was shown Resident #27's oxygen humidifier bottle and asked if she saw a date on the oxygen humidifier bottle. LPN #10 stated, No ma'am . LPN #10 was asked should there be a date on it. LPN #10 stated Yes, ma'am .

Based on Consumer Medicine Information review, policy review, observation, and interview, the facility failed to ensure medications were not stored past their expiration date and opened medications were properly labeled and dated in 2 of 8 medication storage areas (South Hall Medication Cart and North Hall Medication Cart). The findings include: Review of the facility's policy titled, Storage of Medications revised 5/2015, revealed .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . Review of the Consumer Medicine Information dated 4/4/2017, revealed [MEDICATION(S)] should be discarded 4 weeks after opening. Observation of the North Hall Medication Cart on 7/27/2021 at 8:50 AM, revealed 1 bottle of [MEDICATION(S)] [MEDICATION(S)] eye drops with an open date of 5/15/2021. During an interview on 7/27/2021 at 8:40 AM, Licensed Practical Nurse (LPN ) #11 confirmed the eyedrops were expired based on the open date. Observation of the South Hall Medication Cart on 7/27/2021 at 11:40 AM, revealed 1 bottle of Geri-[MEDICATION(S)], opened and undated. During an interview on 7/27/2021 at 11:40 AM, LPN #11 confirmed that the medication should have had an open date. During an interview on 7/28/2021 at 5:00 PM, the Director of Nursing (DON) was asked should there be expired medications on the medication cart. The DON stated, There should not.

Based on a letter of communication with families from the facility, electronic mail (e-mail), laboratory results, and interview, the facility failed to ensure timely notification of families of positive Coronavirus 19 (COVID-19) results for 4 of 4 sampled residents (Resident #1, #2, #3, and #4) reviewed. The facility had a census of 75 residents residing in the facility. The findings include: Review of a letter dated 7/8/2020, showed, .To: Responsible Parties/Families of residents at (Named Facility) From: Management .We will communicate the results of testing on the (Named Company) website . Review of the facility's weekly employee COVID-19 laboratory test results showed 2 new COVID-19 positive employee test results on 7/17/2020, and 2 new COVID positive employee test results on 7/24/2020. Review of an email dated 7/18/2020, showed .Sent: Saturday, July 18, 2020 11:03 AM .Can you (Corporate Accountant) update the information for (Named Facility)? We (facility) have two more positive staff tests . Review of an email dated 7/28/2020, documented, .Sent: Tuesday, July 28, 2020 12:45 PM .Please post the following to the web site for family notification: On July 24, 2020, we (facility) received positive COVID-19 tests on two employees . The (Named Company) website, viewed 7/30/2020, documented, Below you will find current information regarding COVID-19 for each facility. This information will be updated as new cases arise and weekly . During an interview conducted on 7/30/2020 at 2:12 PM, the Director of Nursing (DON), was asked how soon resident representatives of families are updated of positive COVID-19 residents or employees. The DON stated, .we sent out a letter that the website would be updated weekly .a lot of the results we get come in late on Friday night .Only corporate office (can update the site). No one here has access to do that .(named the Administrator) sends an email to corporate . During an interview conducted on 7/31/2020 at 11:02 AM, the (Named Company) Accountant confirmed that she updates the website with the information provided by the facility. The Accountant was unable to provide a history showing when changes were made to the site. The Accountant stated, There was one time (7/18/2020) that I didn't get the email until Monday because I was out of town . The Accountant confirmed that an email was sent on 7/18/2020 stating positive results had been received, but that she updated the website on 7/20/2020. The Accountant was asked when the website was updated with the current results showing positive cases as of 7/24/2020. The Accountant stated On the 28th (7/28/2020) .he (the facility Administrator) sent it to me on the 28th and I updated it that day .

Based on policy review, medical record review, and interview the facility failed to ensure residents were free from physical abuse when staff did not immediately report an allegation of abuse to the facility Administrator and the Administrator did not report the allegation to the State Survey Agency for 1 of 1 (Resident #53) allegations of abuse reviewed. The findings include: 1. The facility's Abuse Prevention Program policy revised 4/2013 documented, .Our residents have the right to be free from abuse .Timely and thorough investigations of all reports and allegations of abuse .Anyone who witnesses a suspicious situation of possible abuse is to immediately notify the supervisor, who will begin an investigation into the reported occurrence . The facility's Reporting Abuse to Facility Management policy revised 4/2017 documented, .responsibility of our employees .to promptly report any incident or suspected incident of neglect or resident abuse .to facility management .Any employees .must immediately report any suspected abuse or incidents of abuse to the Supervisor and/or Director of Nursing (DON) Services .7. Staff members .shall not knowingly .fail to report an incident of mistreatment or other offense .The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse .occur or are discovered after hours, the Administrator or Director of Nursing Services must be called at home or must be paged and informed of the incident .the incident must be immediately reported . 2. Medical record review revealed Resident # 53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/10/19 at 10:09 AM, the survey team requested that any incidents currently being investigated or any outstanding incidents that have not been reviewed by the State Agency, be provided. The facility did not provide any incidents for review. Interview with the Administrator on 2/10/19 at 3:25 PM, in the main lobby, the administrator was asked if he had any incidents currently under investigation or any incidents that need to be reviewed by the state agency. The Administrator stated, .no . Interview with Nurse Aide #1 on 2/11/19 at 2:43 PM, in the day room, Nurse Aide #1 stated, .on 2/4/19 in the evening, I saw Certified Nurse Assistant (CNA) #1 put her hand over (Resident #53's) mouth to make her swallow liquid medication. The Nurse Aide was asked if she report the incident, Nurse Aide #1 stated, .a few days later . Interview with the DON on 2/11/19 at 3:44 PM, outside the DON office, the DON was asked when she had been notified of the incident involving Resident #53. The DON stated, .on 2/8/19 between 2:00 PM and 3:30 PM . Interview with the Administrator on 2/11/19 at 4:07 PM, in the day room, the Administrator was asked about the allegation of abuse that involved Resident #53. The Administrator stated, .it happened Monday of last week .she (the Nurse Aid) reported it late Friday afternoon about 3-3:30 PM . The Administrator was asked if he reported the allegation to the state agency, the Administrator stated, .no .we have 5 days to report . Interview with the DON on 2/13/19 at 11:58 AM, in the north middle hall, the DON was asked, when staff should report an incident of abuse. The DON stated, .immediately .

Based on policy review, medical record review, review of the facility's investigation and interviews, the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 (Resident #53) abuse incidents reviewed. The findings include: 1. Review of the facility's Abuse Investigations policy undated documented, .All reports of resident abuse, neglect .shall be promptly and thoroughly investigated by facility management interview other residents to whom the accused employee provides care or services .notify the ombudsman that an abuse investigation is being conducted . The facility's Abuse Prevention Program policy revised 4/2013 documented, .Timely and thorough investigations of all reports and allegations of abuse . The facility's Reporting Abuse to Facility Management policy revised 4/2017 documented, .Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident . 2. Medical record review revealed Resident # 53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's investigation revealed 3 staff interviews. There was no assessment of Resident #53 or any other residents and there were no interviews completed with other residents under the care of the accused Certifed Nursing Assistant (CNA). Resident #53's physician was not notified and the Medical Director was not notified. Telephone interview with the Long Term Care Ombudsman on 2/11/19 at 3:09 PM, the Long Term Care Ombudsman had no reports of any concerns at that time. Interview with the Administrator on 2/11/19 at 4:07 PM, in the day room, the Administrator was asked about the allegation of abuse. The Administrator stated, .happened Monday of last week .she reported it late Friday afternoon about 3-3:30 PM . The Administrator was asked if he had reported the allegation to the State Agency. The Administrator stated, I have not reported it .we have 5 days to report .I just got this late Friday afternoon and haven't had time to investigate it much, I've got 5 days . The Administrator was asked if there had been an assessment done on Resident #53. The Administrator stated, .no .she can't tell us, she doesn't have the mentality to tell you anything .the Resident was not injured .there is no apparent injury to the resident . The Administrator was asked if the Medical Director or the resident's attending Physician had been notified of this incident. The Administrator stated, .I don't think so .

Based on medical record review, observation and interview, it was determined the facility failed to ensure oxygen (O2) filters were properly cleaned for 1 of 3 (Resident #3) sampled residents receiving O2. The findings included: Medical record review revealed Resident #3 was admitted [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].OXYGEN AT 2L (liter)/MIN (per minute) . Review of the 11 to 7 Shift job description for Nurses revealed, .Mondays .Clean O2 Filters, wipe canisters down . Observation on 11/6/17 at 7:13 AM and 8:03 AM in Resident #3's room revealed Resident #3 was receiving O2 at 2 liters a minute through her [MEDICAL CONDITION]. The filters on each side of the oxygen machine were covered in dust. During an interview with the Assistant Director of Nursing (ADON) on 11/6/17 at 8:09 AM in Resident #3's room the ADON was asked if there should be dust on the O2 machine-filters in use for Resident #3. The ADON stated, No ma'am .the 11 to 7 night shift are responsible for cleaning them .

Intakes: TN 801 Based on policy review, review of the facility's investigation of an abuse allegation, personnel file review, observation and interview, the facility staff failed to report allegations of abuse timely for 4 of 4 (Resident #1, 2, 3, and 4) sampled residents. The findings included: 1. The facility's Abuse Prevention Program policy documented, .Our residents have the right to be free from abuse, neglect .Our facility is committed to protecting our residents from abuse .abuse prevention program provides policies and procedures that govern, as a minimum .Anyone who witnesses a suspicious situation of possible abuse is to immediately notify the supervisor, who will begin an investigation into the reported occurrence . 2. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], and the quarterly MDS dated [DATE], documented Resident #1 was cognitively intact and required extensive to total staff assistance for activities of daily living (ADLs). The quarterly MDS (1/18/17) documented Resident #1 exhibited verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others for 1 to 3 days. The care plan dated 1/19/17 documented Resident #1 had a self-care deficit, and required assistance with all ADLs, including staff was to provide the resident with a touch call light and encourage the resident to use it to call for assistance as needed. The nurses' notes dated 2/26/17, 2/8/17, 2/6/17, 1/29/17, 1/15/17, 1/10/17, and 1/5/17 documented Resident #1's repetitive use of the call light. The facility's investigation of an allegation of abuse documented, .Complaint Investigation .Complaint received .February 22, 2017 .Incident date(s) .Various .On February 22, 2017, aide (Certified Nursing Assistant (CNA) #3) informed nurse management that she had found a drinking straw inserted into the call light socket in Resident #1's room. Later she said that (CNA #2) admitted disabling the call light with the straw . Observations in Resident #1's room on 3/15/17 at 10:45 AM, revealed Resident #1 to be alert and in bed, and her touch call button was within easy reach. Resident #1 was rubbing her chin, and complained her chin was sore. Resident #1 pressed her call button for assistance. When the nurse arrived to assist, Resident #1 changed her complaint from chin pain, to chest pain and heartburn pain. Interview with Licensed Practical Nurse (LPN) #1 on 3/15/17 at 1:01 PM, in the Dayroom, LPN #1 was asked about finding Resident #1's call light disabled with a drinking straw. LPN #1 stated, I don't have any way of knowing how it got there .I noticed it on the 11-7 shift around midnight . LPN #1 was asked whether she reported it to management. LPN #1 stated, I didn't. Telephone interview with CNA #3 on 3/16/17 at 11:56 AM, CNA #3 was asked whether she reported it when CNA #2 allegedly disabled Resident #1's call light with a drinking straw. CNA #2 stated, .I told her not to do it again . 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE], and the quarterly MDS dated [DATE], documented Resident #2 had moderate cognitive impairment and required staff assistance for all ADLS. The care plan dated 3/2/17 documented staff was to keep the call light easily accessible to Resident #2, and remind the resident to call for assistance as needed. The facility's investigation of an allegation of abuse documented, .Complaint Investigation .Complaint received .February 22, 2017 .Incident date(s) .Various .On February 22, 2017, aide (CNA #3) informed nurse management that aide (CNA #2) drew her hand back as if she were about to strike (Resident #2) .Aide (CNA #4) said that (CNA #1) had said that (CNA #2) Would pinch and slap (Resident #2) . Observations of Resident #2 on 3/15/17 at 10:40 AM, revealed the resident to be alert, seated in a wheelchair with a lap belt in place, and confused. Resident #2 was not interviewable due to confusion. Interview with CNA #4 on 3/15/17 at 10:16 AM, in the Dayroom, CNA #4 was asked whether she was aware of the abuse allegations against CNA #2. CNA #4 stated, Well, I didn't see or hear anything .I was staying late to help out .I asked (CNA #1) to help me get (Resident #2) out of bed, and (CNA #1) .said .(CNA #2) slaps (Resident #2) .(CNA #2) pinched her . CNA #4 was asked what she did when she was told about the alleged abuse. CNA #4 stated, .I was off the next day .Then the next day I came back to work I really didn't think about it until I saw (Resident #2) .and I went straight to the office . CNA admitted she did not report the allegation immediately when she was informed about the allegation. Interview with CNA #1 on 3/15/17 at 11:42 AM, in the Dayroom, CNA #1 was asked what happened regarding the allegation of abuse against CNA #2. CNA #1 stated, .It was me and (CNA #2) in the room with (Resident #2) .(Resident #2) started scratching at (CNA #2), and (CNA #2) pinched her arm .and slapped her leg twice .The second time was another day .that time she just slapped her leg twice . CNA #1 was asked what she did when she witnessed the alleged abuse. CNA #1 stated, I didn't know what to do. (CNA #2) been here 2 or 3 years, and I thought they're not going to believe me .Later I told someone else, and she reported it for me . CNA #1 stated she had been employed at the facility 3 months. CNA #1 confirmed she did not report the alleged abuse allegation immediately when it occurred. 4. Medical record review revealed Resident #3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]., [MEDICAL CONDITION], Anxiety, Pleural Effusion, Chest Pain, [MEDICAL CONDITION], and [DIAGNOSES REDACTED]. The admission MDS dated [DATE], and the quarterly MDS dated [DATE], documented Resident #3 had moderate cognitive impairment, no behaviors, and required staff assistance with ADLs. The care plan dated 1/5/17 documented Resident #3 had a self-care deficit, and required staff assistance with ADLs. The care plan documented staff was to ensure the call light was easily accessible at all times while Resident #3 was in bed. The facility's investigation of an allegation of abuse documented, .Complaint Investigation .Complaint received .February 22, 2017 .Incident date(s) .Various .On February 22, 2017, aide (CNA #3) informed nurse management that (Resident #3) told her that 'long legs' ((CNA #2)) told her that she could not go to the restroom and raised her hand as if to strike her .We interviewed (Resident #3) on February 27, 2017 regarding the allegations. She states that one night she asked long legs ((CNA #2)) to take her to the bathroom. She did not want to and told her that she would change her. I told her no, I wanted to go to the bathroom. She drew her hand back and I said 'Don't hit me.' She said 'I'm just having fun.' She got me to the bathroom and didn't help me at all. I even had to pin myself up (pull up/adjust own clothing). And she stood there and watched me . Observations in Resident #3's room on 3/15/17 at 2:40 PM, revealed Resident #3 to be alert, seated in a wheelchair in her room, and watching television. There was a personal chair alarm in place on the wheelchair. Resident #3 was able to answer screening questions, but repeatedly spoke of not liking that she had to live in the facility, and that she had lost all of her furniture. 4. Medical record review revealed Resident #4 was admitted to the facility on [DATE], and discharged home from the facility on 2/17/17. [DIAGNOSES REDACTED]. The admission MDS dated [DATE], and the discharge MDS dated [DATE], documented Resident #4 had moderate cognitive impairment, required limited staff assistance for ADLs, and had no behaviors. The care plan dated 1/17/17 documented staff was to keep the call light easily accessible to Resident #4, and remind her to call for assistance as needed. The facility's investigation of an allegation of abuse documented, .Complaint Investigation .Complaint received .February 22, 2017 .Incident date(s) .Various .(CNA #1) stated on February 22, 2017 .that on or about January 28, 2017 she witnessed (CNA #2) talked (talk) badly to (Resident #4), when she told her she couldn't wait for her to go home .When (Resident #4) said she never had to ask to be able to use the restroom, (CNA #2) (said) she had to ask because she ((CNA #2)) was the boss . The personnel file for CNA #1 documented, .PERSONNEL ACTION .3/3/17 .WARNING .Failed to report observed abuse timely .It is never acceptable to delay reporting abuse .(DON's signature) .(Administrator's signature .(CNA #1's signature) . The personnel file for CNA #2 documented, .SEPARATION NOTICE .Employed .7/06/15 .to .2/21/17 . circumstances of this separation .Mistreatment of [REDACTED]. The personnel file for CNA #3 documented, .PERSONNEL ACTION .3/3/17 .WARNING .Failed to report observed abuse timely .It is never acceptable to delay reporting abuse .(DON's signature) .(Administrator's signature .(CNA #3's signature) . Telephone interview with the Assistant Administrator on 3/16/17 at 5:35 PM, the Assistant Administrator was asked whether the staff should have reported the abuse allegation immediately. The Assistant Administrator stated, Yes .

Based on policy review, resident rights, observation and interview, the facility failed to promote care that ensured the preservation of the residents' dignity and quality of life for 6 of 37 (Residents #6, 20, 33, 53, 57, and 114) sampled residents included in the stage 2 review. The findings included: 1. The facility's Resident Rights Guidelines for All Nursing Procedures policy documented, .General Guidelines .Knock and gain permission before entering the resident's room . 2. The facility's Residents Rights policy revised 11/2016 documented, .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life .The resident has a right to be treated with respect and dignity, including: (1) the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience . 3. Observations during initial tour beginning on 2/13/17 at 6:30 AM, revealed signs posted outside each resident room that documented, PLEASE KNOCK BEFORE ENTERING. Observations in the dining room on 2/13/17 at 7:08 AM, revealed Residents #20, 53, and 114 were brought to the main dining room in their wheelchairs. Each of them had a lab buddy in place. They were placed at the table and Nursing Assistants (NA) #2 and #3 and Licensed Practical Nurse (LPN) #3 sat next to them and assisted with the meal, but did not remove the lap buddy for the 3 residents during that meal. Observations in Resident #57's room on 2/13/17 at 7:17 AM, revealed CNA #8 entered the resident's room with a meal tray without knocking or gaining permission to enter. Observations in the dining room on 2/14/17 at 7:55 AM, revealed Resident #20, 53 and 114 were seated at their table eating breakfast with lap buddys secured on each resident. Observations in Resident #33's room on 2/14/17 at 11:33 AM, revealed CNA #5 entered the resident's room with a meal tray without knocking or gaining permission to enter. Interview with the Director of Nursing on 2/14/17 at in the Day Room, the DON was asked what she expected staff to do before entering a resident room. The DON stated, Knock. 4. The facility's Resident Rights policy documented, .The nursing home shall establish and implement written policies and procedures setting forth the rights of residents for the protection and preservation of dignity, individuality .the following rights .To be free from chemical and physical restraints except as medically necessary . 5. The facility's Physical Restraint Application policy documented, .Physical restraints are defined .as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .The resident must be physically and cognitively able to self-release devices .If a resident cannot mentally and physically self-release, then the device is considered a restraint . 6. The facility's Use of Restraints policy documented, .Examples of devices that are/may be considered physical restraints may include .lap cushions and trays that the resident cannot remove .Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions .that may improve the symptoms .Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative .Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination .Care plans fro residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptoms(s) .Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use . 7. Observations in the dining room on 2/13/17 beginning at 7:08 AM, revealed Resident #20, 47, and 53 were served and assisted with breakfast while the lap buddy was in place in their wheelchairs. The lap buddies were not removed during the meal. 8. Observation on the North Hall on 2/14/17 at 10:15 AM, revealed Resident #6 was sitting in a wheelchair in the hall, and the Administrator walked by. Resident #6 said, Stop .Stop. Resident #2 then asked surveyor, Did he (Administrator) stop? The Administrator stopped further down the North Hall and said to surveyor, What did she say? The surveyor told the Administrator, She (Resident #6) said, 'Stop'. The Administrator said, I'm sure she did, and he kept walking. The Administrator did not respond to Resident #6. Interview with CNA #2 and CNA #4 on 2/14/17 at 7:55 AM, in the dining room, CNA #2 and CNA #4 confirmed lap buddies remained in place during meals. Interview with the Assistant Administrator on 2/14/17 at 10:10 AM, she stated, We do not remove the lap buddys during meals because they are not a restraint . Interview with the Minimum Data Set (MDS) Coordinator #1 on 2/14/17, she was asked if the care plan reflected releasing the lap buddy during meals. She stated, No . MDS coordinator #1 was asked which residents were coded to have a restraint. She stated, Only (Named Residents #53, 114 and 20) are coded for positioning devices .I think we used to care plan the lap buddy to be released during meals but we don't do that anymore. Interview with the Assistant Administrator in the MDS office on 2/14/17 at 2:46 PM, the Assistant Administrator was asked why the lap buddy was not removed during meals. The Assistant Administrator stated, .no guarantee the resident would not lean forward .

Based on policy review, medical record review, observation and interview, the facility failed to ensure the comprehensive care plan was revised to reflect the current status for restraint use, an indwelling urinary catheter, and sleeping preferences for 3 of 17 (Residents #47, 61, and 110) sampled residents reviewed of the 37 residents included in the stage 2 review. The findings included: 1. The facility's Use of Restraint policy documented, .Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use . 2. The facility's Care Plan Policy documented, .Care plans should be reviewed, and revised as often as necessary in order to reflect the resident's current status . 3. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/13/16, revealed Resident #47 did not have a trunk restraint. The care plan dated 12/14/16 documented .Apply lap buddy when up in wheelchair for positioning or upper body due to forward leaning when propelling in wheelchair. There was no documentation that the lap buddy was used as a restraint Observations were conducted of Resident #47 on 2/13/17 at 7:05 AM and 9:30 AM, and on 2/14/17 at 7:35 AM and 7:50 AM, Resident #47 was observed utilizing a lap buddy while in her wheelchair. Interview with the Restorative Nurse on 2/14/17 at 1:35 PM, the Restorative Nurse confirmed that the current care plan does not reflect restraint use or that the resident needs to be released every 2 hours. 2. Medical record review revealed Resident #61 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, and the presence of an indwelling urinary catheter. The physician's orders [REDACTED].Order Date .10/28/16 .FOLEY CATHETER . The care plan dated 1/9/17 documented, .incontinent of bowel and bladder at times, check with resident prn (as needed) for toileting needs . The care plan did not address the indwelling urinary catheter. Observations in Resident #61's room on 2/13/17 at 1:59 PM, and 2/14/17 at 10:17 AM, revealed a foley catheter draining to a bedside bag contained in a dignity bag hanging on the bedside. Interview with the Director of Nursing (DON) in the Day Room on 2/14/17 at 4:18 PM, the DON was asked whether she expected the presence of an indwelling urinary catheter to be included and addressed on the care plan. The DON stated, Yes. 3. Medical record review revealed Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], and the annual MDS dated [DATE], documented Resident #110 had no cognitive impairment and required staff assistance for all activities of daily living (ADLs). The care plan dated 12/16/16 documented, .Self Care Deficit .Approaches .Assistance to turn and reposition resident prn while in bed and prn while in chair .See inside .closet door for current mode of transfer and assistance needed for ADLs .Keep bed linens free from moisture, wrinkles, and crumbs daily mattress intact for pressure reduction .Side rails down .Keep bed in lowest position, locked .Prefers to go to bed around 9 pm . There was no documentation that Resident #110 prefers to sleep in the recliner. The Assigned Tasks List located inside Resident #110's closet door documented, .Siderails down . There was no documentation that Resident #110 prefers to sleep in the recliner. Observations of Resident #110 in his room on 2/13/17 at 8:39 AM, 10:08 AM, 12:26 PM, and 1:51 PM; and on 2/14/17 at 10:06 AM and 1:44 PM, revealed Resident #110 was sitting in the bedside recliner. Interview with Resident #110 in his room on 2/13/17 at 10:04 AM, Resident #110 stated he slept in the recliner instead of the bed. Interview with LPN #1 on 2/13/17 at 10:38 AM, in the South Hall, LPN #1 was asked whether side rails were used for Resident #110. LPN #1 stated, No. Actually, he sleeps in his recliner . Interview with LPN #1 on 2/14/17 at 1:46 PM, at the South Hall Nurses' Desk, LPN #1 was asked how the Certified Nursing Assistants (CNAs) know what to do for each resident, and whether there was a CNA care plan for the residents. LPN #1 stated, .They have the ADL sheets. They are hanging in the residents' closets. Interview with CNA #7 on the South Hall on 2/14/17 at 1:55 PM, CNA #7 was asked how she knows what care to provide for the residents. CNA #7 stated, .read their careplan .in the closet door Interview with the DON in the Day Room on 2/14/17 at 4:18 PM, the DON was asked whether Resident #110's preference to sleep in the recliner instead of the bed should be on the care plan. The DON stated, It would be good.

Based on policy review, observation and interview, the facility failed to ensure medications were stored properly and safely as evidenced by expired medication, opened and undated multi-dose vials of medication, and medications stored with chemicals in 2 of 8 (South Medication Room and North Treatment Cart) medication storage areas. The findings included: 1. The facility's INSULIN STORAGE policy documented, .Insulin vials that are currently in use should be dated and initialed when opened .Vials should be discarded after the expired date . 2. The facility's Storage of Medications policy documented, .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and the directions for use, and shall be stored separately from regular medications . 3. Observations in the South Medication Room refrigerator on [DATE] at 9:52 AM, revealed an opened vial of Levemir insulin without an opened date, and an opened vial of Novolog insulin with an expiration date of [DATE]. Interview with LPN #5 in the South Medication Room on [DATE] at 9:56 AM, LPN #5 was asked whether the opened vial of Levemir insulin should have been labeled with the date it was opened. LPN #5 confirmed there was no opened date, and that it should have been dated when opened. LPN #5 was asked whether the expired vial of Novolog should still be in the medication refrigerator. LPN #5 stated, No. It should be out, too. Interview with the Director of Nursing (DON) on the North Hall on [DATE] at 10:43 AM, the DON was asked whether it was acceptable for opened and undated insulins and expired insulins to be stored in the medication refrigerator. The DON stated, No. 4. Observations in the North Hall Treatment Cart on [DATE] at 10:35 AM, revealed a canister of germicidal wipes stored in the same compartment in the cart as 2 bottles of skin repair topical lotion and a box of iodine swabsticks. Interview with the Assistant Administrator on [DATE] at 10:42 AM, in the North Hall, the Assistant Administrator was asked whether the germicidal wipes should be stored in the same compartment as the skin repair topical lotion and the iodine swabsticks. The Assistant Administrator stated, No.

Based on policy review, observation, and interview, the facility failed to maintain an effective infection control program when they failed to clean and disinfect reusable items after performing wound care on 1 of 1 (Resident #135) sampled residents observed for wound care. The findings included: 1. The facility's Cleaning and Disinfection of Resident-Care Items and Equipment Policy revised 04/2013 policy documented .1. d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . 2. Observation of wound care for Resident #135 in Resident's #135's room on 2/13/17 at 8:58 AM, revealed Licensed Practical Nurse (LPN) #5 and the Wound Care Nurse positioned Resident #135 on his side. During the positioning the Wound site Management System (a measurement tool) slipped to the floor from the bed. LPN #5 picked it up and placed it back on the bedding. While preparing the (Named Dressing) to fit the wound, LPN #5 removed scissors from the pocket of the Wound Care Nurse to cut the (Named Dressing) to fit the wound, place the scissors on the bedding and later returned the scissors to the pocket of the Wound Care Nurse. After finishing the wound care LPN #5 used the measuring tool to do the weekly wound measurement assessment. Interview on 2/13/17 at 10:09 AM, the Wound Care Nurse and LPN #5 confirmed the scissors should had been disinfected before returning it to her pocket and LPN #5 confirmed the wound measuring tool should had been discarded and not used. LPN #5 stated, I should have gotten a new one.

Based on policy review, license renewal list, working schedule, and interview, the facility failed to ensure 1 of 52 (Licensed Practical Nurse (LPN #1) licensed staff had a current license. The findings included: 1. Review of the facility's Licensure, Certification, and Registration of Personnel policy documented, .A copy of the current license, certification, or registration number must be filed in the employee's personnel record .A copy of re-certifications (e.g. (for example) annual, bi-annual etc., as applicable) must be presented to the Human Resources Director/designee upon receipt of such re-certifications and prior to the expiration of current licensure, certification, and/or registration . 2. Review of the facility's License Renewal list revealed LPN #1's license expired on [DATE]. Review of the [DATE] schedule documented the following days were worked by LPN #1: a. 2nd, 3rd, 4th, 5th , 6th, 9th, 10th, 11th, 12th, 13th, 16th, 17th, 18th, 19th 20th, 23rd, 24th, 25th, 26th, 27th, 30th and 31st. Review of the February 2017 schedule documented the following days were worked by LPN #1: a. 1st, 2nd, 3rd, 6th, 7th, 8th, 9th, 10th and 13th. 3. Interview with the Administrator on [DATE] at 2:50 PM, in the North Hall Day Room, the Administrator stated, .ya'll showed us something we didn't know .she was working today. We pulled her off the floor she said she never got a letter or anything . The Administrator was asked if the nurse had been working (with the expired license). The Administrator stated, .yes .

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by open food items with no open date, staff not wearing hair restraints, pans and mixer with dried food particles and splatters, and wetnesting of trays, pans, and dishware. The facility had a census of 94, with 90 of those residents receiving a meal tray from the kitchen. The findings included: 1. The facility's Food Receiving and Storage policy documented, .All foods stored in the refrigerator will be covered, labeled and dated (use by date or open date) . Observations in the kitchen freezer on 11/22/15 at 9:05 AM, revealed the following: a. An opened bag of pulled chicken with no open date. b. An opened bag frozen bread sticks with no open date. c. An opened bag diced onions with no open date. Interview with Dietary Staff (DS) #1 on 11/22/15 at 9:06 AM, in the kitchen, DS #1 confirmed that food should be dated after it is opened. 2. Review of the facility's Food Preparation and Service policy documented, .staff . shall wear hair restraints . so that hair does not contact food . Observations in the kitchen on 11/22/15 at 9:12 AM, revealed Facility Staff #1 in kitchen without a hair restraint. Interview with the Certified Dietary Manager (CDM) on 11/22/15 at 9:13 AM, in the kitchen, the CDM was asked if it was acceptable to work in the kitchen without a hair restraint. The CDM stated, No. 3. Review of the facility's Sanitization policy documented, .All utensils, counters, shelves and equipment shall be kept clean . All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils . Observations in the kitchen on 11/22/15 at 9:16 AM, revealed the following: a. Food particles on baking pans and pan lids. b. Food splatters on a mixer. c. Wetnesting of trays, plates, plate covers and deep dish pans. Interview with the CDM on 11/22/15 at 9:42 AM, in the kitchen, the CDM confirmed the presence of food particles on the baking pans and lids and food splatter on the mixer. the CDM was asked if it was acceptable to stack wet dishes. The CDM stated, No.