Every finding on record at Mcalester Nursing & Rehab

Based on observation, record review, and interview, the facility failed to ensure the shower curtain was kept clean and ceiling tiles were in good repair for 1 (east hall shower room) of 2 shower rooms observed.The administrator identified 25 residents used the east hall shower room. Findings:On 05/19/26 at 12:39 p.m., the east hall shower room was observed to have a grey and white shower curtain hanging with spots of black discoloration (too numerous to count) and two ceiling tiles with brown rings and water damage.A Laundry and Bedding, Soiled policy, revised 11/2010, read in part, shower linen ie curtains .shall be laundered as needed.A Bathrooms_Showers policy, revised 02/2021, read in part, showers . are cleaned and disinfected daily, shower linen is to be laundered monthly or when residue is noticed in accordance with our established procedures. On 05/19/26 at 12:45 p.m., maintenance #1 stated the black discoloration on the shower curtain looked like mold or mildew.On 05/19/26 at 12:47 p.m., maintenance #1 pointed at the damaged ceiling tiles and stated, Those are water leaks, it's wet right here and right there. They stated, The roof has leaks I only know when we get rain like this.On 05/19/26 at 1:29 p.m., the housekeeping and laundry supervisor stated housekeeping was responsible to ensure the shower curtains were clean. They stated the policy was to wash them and if the stains did not come out, they were discarded and the facility purchased new ones. They stated housekeeping was to check shower rooms and linens daily and ensure they were clean.

Based on observation, record review, and interview, the facility failed to ensure a resident was free from sexual abuse for 1 (#2) of 4 sampled residents reviewed for abuse. The DON identified 43 residents resided in the facility.Findings:1. On 05/18/26 at 12:25 p.m., Resident #2 was observed sitting in a wheelchair in a common area. The resident was clean and dressed for the day. Resident #2 did not verbally respond when spoken to, just smiled. Resident #2 did not have any visible bruises or wounds noted. Staff approached Resident #2 and spoke in a calm pleasant manner. Resident #2 smiled at the staff and did not appear fearful.An undated admission report showed Resident #2 had diagnoses which included frontotemporal neurocognitive disorder, focal traumatic brain injury, cognitive social or emotional deficit, and speech and language deficit.A quarterly assessment for Resident #2, dated 02/24/26, showed the resident had a BIMS of 3 (which indicated they were severely impaired in cognition) and did not have behaviors. 2. An undated admission record showed Resident #1 had diagnoses which included chronic obstructive pulmonary disease, diabetes mellitus, acute respiratory failure, and major depressive disorder.A quarterly assessment for Resident #1, dated 04/09/26, showed the resident had a BIMS of 15 (which indicated they were cognitively intact for daily decision making) and did not have behaviors toward others.A facility video for 05/12/26 at 5:20 p.m. was reviewed on 05/19/26 at 1:35 p.m. The video showed Resident #1 position their motorized wheelchair beside Resident #2's wheelchair in the lobby area. The video showed Resident #1 placed their hand through the open space of the arm rest of Resident #2's wheelchair and touched Resident #2's right breast area. An OSDH initial incident report, dated 05/12/26, showed an allegation of abuse regarding Resident #2 and Resident #1. The report showed CNA #1 witnessed Resident #1 touch Resident #2 on the breast. The report showed the administrator, physician, resident's legal representative, adult protective services, and local law enforcement were notified.An OSDH final incident report, dated 05/12/26, showed residents who were alert and oriented were questioned regarding Resident #1 touching inappropriately or witnessed them touching others inappropriately. The report showed body audits were completed for residents who were not cognitively intact. The report showed no resident verbalized, witnessed, or signs of abuse were noted. The report showed Resident #1 was transported to a psychiatric facility on 05/13/26. The report showed the physician, family, adult protective services, and the local police department was notified of the incident. The report showed a staff in-service regarding abuse and an emergency quality assurance and performance improvement meeting was completed.A Police offense/incident report, dated 05/12/26 at 5:19 p.m., showed a report of sexual assault. The report showed the suspect as Resident #1 and the victim as Resident #2. Facility forms titled 1:1 Monitoring for Resident Safety, dated 05/12/26 at 5:20 p.m. through 05/13/26 at 12:15 p.m., showed Resident #1 was monitored every 15 minutes for behaviors. The forms did not identify behaviors for Resident #1.A form titled Emergency QAPI [quality assurance and performance improvement], dated 05/12/26, showed the problem as Resident #1 touched Resident #2 on the breast. The form showed Resident #1 was immediately monitored 1:1 and a body audit was completed for Resident #2. The form showed a physician order was obtained to send Resident #1 to a psychiatric unit. A nursing progress note for Resident #1, dated 05/13/26 at 12:35 p.m., showed Resident #1 was discharged to the hospital. Facility forms for skin monitoring, dated 05/13/26, were completed for cognitively impaired residents. Facility survey forms, dated 05/13/26 through 05/14/26, showed residents were surveyed regarding being inappropriately touched or witnessed inappropriate touching.A facility in-service sign in sheet, dated 05/14/26, showed the staff were in-serviced regarding abuse.On 05/18/26 at 2:47 p.m., the administrator stated Resident #1 was not anticipated to return to the facility. The administrator stated if Resident #1 did return to the facility they would be monitored 1:1 with a staff member.On 05/19/26 at 12:24 p.m., CNA #1 was interviewed regarding the incident on 05/12/26. CNA #1 stated they saw Resident #1 touch Resident #2's right breast area over their clothes. CNA #1 stated they removed Resident #1 from the area of Resident #2 and reported the incident immediately to the assistant director of nursing.On 05/19/26 at 1:41 p.m. the DON stated abuse education was on going and was mentioned twice a month with in-services. The DON stated the staff were reminded they only had two hours to report abuse and it was important to notify them immediately. The DON stated Resident #1 had never shown inappropriate sexual actions prior to the incident date.On 05/19/26, direct care staff was interviewed regarding abuse. The staff were able to state types of abuse and the facility policy regarding abuse and reporting abuse.

An IJ was identified from 11/17/24 through 11/21/24. The deficient practice remained at isolated level of a potential for harm. On 11/21/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment and elopement seeking behaviors, and to educate staff on how to identify residents at risk for elopement. On 11/17/24, Resident #1 was reported missing from the facility and found one block away from a driver passing by. Resident #1 stepped off the curb and fell to their knees and was transported to the ER. This resulted in Resident #1 acquiring a closed head injury, laceration of the face requiring sutures, and an abrasion of the knee. On 11/21/24 at 2:45 p.m., the Oklahoma State Department of Health was notified and verified the existence of an IJ situation. On 11/21/24 at 2:51 p.m., the administrator and DON were notified of the IJ situation and the IJ template was provided. On 11/21/24 at 4:51 p.m., an acceptable plan of removal was approved by the Oklahoma State Department of Health. The plan of removal documented the total number of residents at risk for the same deficient practice was three. It documented the actions to remove the immediacy of the alleged deficient practice were the following: a. on 11/17/24, Resident #1 was placed on one on one supervision when they returned to the facility, b. on 11/18/24, a care plan meeting was scheduled with Resident #1's family to discuss a safer and more appropriate setting such as an Alzheimer unit and information was provided on facilities with locked units, c. after the care plan meeting, Resident #1's family made the decision to discharge the resident home on 11/18/24 to seek a locked unit, d. on 11/18/24, all residents were educated to not let other residents out of the doors without consulting a nurse, e. signage was placed on exits and entry doors informing visitors, staff, and residents to be aware and not allow residents to exit the facility, f. an elopement risk manual was implemented that contained all residents that were elopement risk, g. on 11/21/24 at 2:56 p.m., all 54 staff were inserviced in person and by phone on the location of the manual and to check it prior to starting their shift each day to determine who was at risk for elopement, and h. all residents deemed an elopement risk, assessments were updated and the form with the residents picture was placed in the manual. It documented action taken to prevent recurrence of the alleged deficient practice were the following: a. the administrator or DON will monitor 3-5 employees weekly for 30 days to ensure they are proficient in where to locate the elopement risk manual and monitoring would continue until all employees could voice proficiency, b. all new staff will be educated upon hire to the location of the elopement risk manual and sign acknowledgment, and c. any new resident identified with exit seeking behavior will have a new elopement risk assessment completed with care plan and the elopement identification form will be placed in the elopement risk manual. The IJ was lifted, effective 11/21/24 at 4:52 p.m., when all components of the plan of removal had been verified as completed. The deficient practice remained isolated with the potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment and elopement seeking behaviors and to educate staff on how to identify residents at risk for elopement for one (#1) of three sampled residents reviewed for elopement. The DON identified 46 residents resided in the facility and two residents were at risk for elopement. Findings: The facility's Elopements policy, revised 12/2007, read in part, staff shall promptly report and resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Resident #1 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder and dementia. Resident #1's Elopement Risk Evaluation, dated 11/13/24, did not document any wandering behaviors or exit seeking behaviors. Resident #1's Care Plan, revised 11/13/24, read in part, [name withheld] could be at risk for Elopement as [they] voices [they] want to go home. It documented the following interventions: a. clearly identify resident's room and bathroom, b. identify if there is a certain time of day wandering/ elopement attempts occur, c. provide care in a calm and reassuring manner, e. provide clear, simple instructions, and f. provide reorientation to surroundings, environment. The care plan did not document wandering, exit seeking behaviors, or visual checks. An Administration Note, dated 11/15/24 at 7:58 p.m., documented Resident #1 was upset, pacing the halls, cursing, and attempting to exit the doors. It documented Resident #1 was angry when redirected. A Behavior Note, dated 11/16/24 at 12:30 p.m., documented Resident #1 was carrying laundry hampers, pacing hallways, going door to door, and wanting to go home. It documented the resident was showing signs of agitation. An initial State Reportable Incident, dated 11/17/24, documented Resident #1 was reported missing to the administrator at 10:07 a.m. during a visual check. It was documented Resident #1 was found one block away by a driver passing by. It documented Resident #1 stepped off the curb and fell to their knees and was transported to the emergency room arriving at 10:08 a.m Resident #1's [Name withheld] ER, report, dated 11/17/24, documented Resident #1 was treated for a CHI (closed head injury), complex laceration of the face requiring non-dissolvable sutures, and an abrasion of the knee. Resident #1's discharge assessment, dated 11/18/24, documented the resident's cognition was significantly impaired. It documented the resident exhibited the behavior of wandering for 1-3 days. On 11/21/24 at 8:47 a.m., the DON stated Resident #1 was placed on Q15 minutes visual checks on 11/15/24 after elopement seeking behavior ,but they did not care plan the Q15 minute checks or reassess Resident #1 for elopement risk. The DON stated it was Friday night when they observed the resident with exit seeking behaviors when they were leaving for the day. On 11/21/24 at 9:52 a.m., CNA # 2 was asked how they identified which residents were at risk for elopement. CNA #2 stated there was a list of residents at risk for elopement at the nurses station. On 11/21/24 at 9:56 a.m., CNA #3 was asked how they identified which residents were at risk for elopement. CNA #3 stated there was a list of residents at risk for elopement at the nurses station. On 11/21/24 at 10:00 a.m., CNA #4 was asked how they identified which residents were at risk for elopement. CNA #4 stated some residents wore red bracelets and the care plan was used to identify residents at risk for elopement. There was no observation of a list of at risk residents for elopement and residents were not observed wearing red bracelets. On 11/21/24 at 1:08 p.m., the administrator was asked about the list of residents at risk for elopement and the red bracelets. The administrator stated there was not a process in place to identify residents at risk for elopement and there was not a list or red bracelets used to identify at risk residents for elopement. They stated they were unsure how the resident eloped from the facility.

Based on record review and interview, the facility failed to ensure Resident Assessments were accurately coded for two (#39 and #50) of 13 sampled residents reviewed for accurate assessments. The Administrator identified 43 residents resided in the facility. Findings: 1. Resident #39 had diagnoses which included hepatic encephalopathy, metabolic encephalopathy, and cirrhosis of the liver. Resident #39's physical therapy treatment notes documented they received services on 06/26/24, 06/27/24, and 07/01/24. A Quarterly Resident Assessment, dated 07/01/24, documented Resident #39 did not receive physical therapy services. On 07/30/24 at 3:22 p.m., MDS Coordinator #1 stated they would code a resident received therapy services in section O of the Resident Assessment. They stated therapy brought them a log to identify what residents had received therapy services. They stated no therapy services were coded on Resident #39's assessment. MDS Coordinator #1 reviewed Resident #39's physical therapy records and stated the 06/26, 06/27, and 07/01/24 physical therapy services should have been captured on the Resident Assessment. 2. Resident #50 had diagnoses which included chronic kidney disease stage four. A Physician Order, dated 05/17/24, documented admit to hospice with a diagnosis of renal failure stage four. Resident #50's Significant Change Resident Assessment, dated 05/29/24, documented no for the question Prognosis: life expectancy of less than [six] months. On 07/30/24 at 9:37 a.m., MDS Coordinator #1 stated to ensure Resident Assessments were accurate, they would complete an assessment on the resident, look at the chart, and tried their best to get the right answer. They stated they would mark yes on the question for prognosis life expectancy less than six months if the resident was on hospice and if the physician deemed it that way. MDS Coordinator #1 reviewed Resident #50's record and identified the start date for hospice services was 05/17/24. They stated I put no on the prognosis life expectancy less than six months. They stated it was not accurately coded.

Based on record review and interview, the facility failed to ensure a care plan was updated related to an unstageable pressure ulcer for one (#152) of 12 sampled residents reviewed for care plans. The Administrator identified 43 residents resided in the facility. Findings: Resident #152 had diagnosis which included unstageable pressure ulcer. A nursing note, dated 07/18/24, documented Resident #152 had readmitted to the facility with a 5.0 cm in length by 3.0 cm in width by 0.1 cm in depth moisture associated wound to their right buttock. A Physician's order, dated 07/26/24, documented, clarification order clean unstageable area on buttock with wound wash, pat dry, apply hydrogel and collagen. cover area with foam dressing every day and PRN x 14 days then re-evaluate. There was no documentation of Resident #152's unstageable pressure ulcer in the care plan. On 07/31/24 at 9:39 a.m., MDS Coordinator #1 stated they had not updated the care plan since Resident #152 had returned from the hospital.

Based on observation, record review, and interview, the facility failed to ensure accurate documentation of blood pressure for one (#6) of five sampled residents observed for medication pass. The administrator identified 43 residents resided in the facility. Findings: A Nursing Care Policies and Procedures, for blood pressures, revised 05/18/01, documented, A blood pressure measurement is taken to accurately determine the blood pressure to assist in diagnosis and to show progress and change in a resident's condition. Resident #6 admitted on [DATE], with diagnoses which included essential hypertension and tachycardia. A Physician's order, dated 06/08/24, documented metoprolol tartrate give 25 mg twice daily, hold if SBP is less than 110. On 07/31/24 at 10:08 a.m., LPN #1 obtained Resident #6's blood pressure with a wrist cuff. the blood pressure reading was 101/52 with a pulse of 101. On 07/31/24 at 10:09 a.m., LPN #1 stated, I always round up so it is 102/52. On 07/31/24 at 10:10 a.m., LPN #1 documented 102/52 on the MAR. On 07/31/24 at 10:33 a.m., LPN #1 stated the purpose of rounding up a blood pressure number was to have an even number. They stated it could affect the parameters. On 07/31/24 at 10:56 a.m., the DON stated the policy for complete and accurate recording of vitals signs was to record them at the time they were obtained. They stated the vital signs should be documented as read on the machine. They stated it was not okay to round up ever.

Based on observation, record review, and interview, the facility failed to ensure information on how to file a formal complaint with the State agency was visible to the residents. The Administrator identified 43 residents resided in the facility. Findings: On 07/30/24 at 10:05 a.m., a meeting with the Resident Council Group was held. They stated they had not been informed of their right and given information on how to formally complain to the State about the care they were receiving. On 07/30/24 at 10:39 a.m., the Long Term Care Facility Complaint Procedure form was observed on a brown board next to the dining room. Only the top part of the form was visible. A plastic sleeve that contained survey results was observed covering the bottom half of the form. There was no contact information, mailing address, e-mail address, or telephone number for filing a formal complaint to the State viewable. On 07/30/24 at 11:02 a.m., Social Services stated they went over resident rights and how to file a grievance during Resident Council meetings. They stated as far as with the State agency, they didn't have a certain form. They stated, if they had a problem, they could speak with Social Services. They stated they had never had a resident who wanted to file a report with the State. On 07/30/24 at 11:05 a.m., the Administrator and Social Services walked over to the brown board to observe the Long Term Care Facility Complaint Procedure form. The Administrator stated the forms got moved around. They stated the contact information was not viewable at that time because someone had covered it. They stated staff did not cover it.

Based on observation, record review, and interview, the facility failed to ensure residents had access to the most recent survey results conducted by State surveyors. The Administrator identified 43 residents resided in the facility. Findings: A complaint investigation was conducted at the facility on 12/11/23. On 07/30/24 at 10:05 a.m., a meeting with the Resident Council Group was held. They stated they did not know how to access the results of the State inspections. They stated the facility had not informed them. On 07/30/24 at 10:39 a.m., there were State survey results observed in a clear plastic sleeve on a brown board next to the dining room. There was no sign indicating these were the State survey results. The survey results located inside were dated 06/28/23. On 07/30/24 at 10:52 a.m., the survey results for the 12/11/23 complaint survey conducted at the facility were not observed in the clear plastic sleeve. On 07/30/24 at 10:57 a.m., Social Services stated survey results were usually posted up by one of the west doors. Social Services stated they honestly didn't share where to find the survey results with the residents. They stated they had just taken over social services and they did go over resident rights with the Resident Council Group. They stated in April 2024, the right to be fully informed, which included the right to the results of survey, was gone over with the Resident Council Group. On 07/30/24 at 11:05 a.m., Social Services and the Administrator walked over to the brown board to observe the survey results. On 07/30/24 at 11:07 a.m., the Administrator reviewed the contents of the clear plastic sleeve and stated it was the facility's last survey dated 06/28/24. They stated the 12/11/23 complaint survey should have been in there, but it wasn't.

Based on record review and interview, the facility failed to ensure a resident's code status was updated in the care plan for one (#38) of 12 sampled residents reviewed for code status. The Administrator identified 43 residents resided in the facility. Findings: A Care Plans, Comprehensive Person-Centered policy, revised December 2016, documented assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions changed and when a resident had been readmitted to the facility from a hospital stay. Resident #38 admitted on [DATE] with diagnoses which include myocardial infarction and atherosclerotic heart disease of the native coronary artery without angina pectoris. A Care Plan, dated 05/03/24, documented Resident #38 had chosen a full code and staff were to follow full code protocol. A Physician's order, dated 06/27/24, documented Resident #38's code status as DNR. Resident #38's chart had an orange sticker on the front and the side that documented DNR. A DNR form, in Resident #38's clinical record was signed by their guardian. On 07/31/24 at 2:01 p.m., MDS Coordinator #1 stated the resident's code status was DNR. They stated the care plan documented Resident #38 was a full code.

Based on observation, record review, and interview, the facility failed to ensure medications were not left at a resident's bedside for one (#39) of 16 residents observed for bedside medications. The Administrator identified 43 residents resided in the facility. The DON identified no residents with orders to self-administer medications. Findings: A Medication Storage in the Facility policy, revised 08/14, read in part, .Medications and biologicals are stored safely, securely, and properly .Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications .permitted to access medications . Resident #39 had diagnoses which included hepatic encephalopathy, metabolic encephalopathy, and cirrhosis of the liver. Resident #39's July 2024 Physician Order's did not contain an order to self-administer medications. On 07/28/24 at 9:37 a.m., Resident #39 stated they noticed a white pill they hadn't been taking during medication pass. They stated the staff was going to go and see what the medication was. Resident #39 stated the staff reported it was oxxybutynin, but the resident didn't believe that pill was white. They stated staff had brought them the medication maybe 45 minutes ago. There was one white medicine cup with one white pill observed on the resident's bedside table. On 07/28/24 at 10:06 a.m., Resident #39 stated CMA #3 was who passed their medications today. There was also a container of Vicks vapo stick no mess observed next to the resident's bed. They stated they used it when they had Covid-19. They stated they had asked their family member to bring it to them. They stated they knew they were not supposed to do that. On 07/28/24 at 10:08 a.m., CMA #3 stated they would go into a resident's room, introduce themselves, give them their medication, and watch them take it, then give them water. They stated they always took the empty cup. They stated they did not have any residents who self-administered their medications. They stated Resident #39 likes to hold [their] bladder pill. They stated they were not sure the reason the Vicks was in the room. On 07/28/24 at 10:10 a.m., the DON stated there was paperwork to complete if a resident wanted to self-administer medications. They stated they did not believe there were any residents who could self-administer medications in the facility. The Administrator stated staff should be watching the residents take their medications. The DON stated staff should punch, initial, and give the medications.

Based on observation, record review, and interview, the facility failed to ensure meat products were thawed in a manner to prevent cross-contamination for one of two kitchen observations. The Administrator identified 43 residents resided in the facility. The DON identified one resident who received nothing by mouth. Findings: A Food Receiving and Storage policy, revised 10/17, read in part, Foods shall be received and stored in a manner that complies with safe food handling practices .Uncooked and raw animal products and fish will be stored separately in drip-proof containers . On 07/28/24 at 9:00 a.m., there was a grey container observed on the bottom shelf of the walk in cooler. There was one clear wrapped container of meat labeled ground beef that was dated 07/11/24. In the same container, there were two partially frozen hams with a use by date of 10/29/24. There was a red liquid substance noted at the bottom of the container the meats were stored in. On 07/28/24 at 9:10 a.m., the Dietary Manager stated the meats were supposed to be separated. They stated both items required cooking before eating. They stated the red liquid was blood. On 07/28/24 at 9:22 a.m., the Dietary Manager and [NAME] #2 discarded the above meat products into the outside trash can.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#1) of three residents sampled for abuse. Two staff members witnessed CNA #1 slap and curse Res #1 on 12/06/23 evening shift. The facility had put measures in place to correct the deficiency on 12/06/23. The administrator identified 45 residents who resided in the facility. Findings: Res #1 had diagnoses which included dementia with agitation and metabolic encephalopathy. A quarterly MDS assessment, dated 10/06/23, documented the resident was cognitively impaired, required supervision to touch assistance with transfers, and independent with a manual wheelchair. An incident report, dated 12/06/23, documented staff witnessed CNA #1 slap Res #1 twice to the head with open hand in the west hallway. A statement by CNA #1, dated 12/06/23, read in entirety, I went to [Res #2 name withheld] room [Res #1 name withheld] was in there [Res #2] was trying to hit [Res #1] with walker and I go to remove [Res #1] from the room and he hit me in the jaw as I was removing him he hit me again. I got him into the hallway he went to swing at me again I went to keep him from hitting me again I ended up slapping him in the back of the head when I swiped his arm away from my face. Record review revealed an abuse prevention inservice sign-in sheet with all staff signatures, dated 12/06/23, and inservice material which was included in the inservice. Staff interviews were conducted and staff voiced knowledge of the the inservice on the 12/06/23 and other staff voiced they had to be inserviced over abuse prevention before working their shift. Interviews with residents were conducted and there were no residents who had complaints related to abuse or being afraid of any staff members. On 12/11/23 at 10:45 a.m., during an interview, DA #1 stated on 12/06/23 around 6:00 p.m., DA #1 and Cook #1 were in the lobby. They heard yelling from the [NAME] Hall. DA #1 stated the nurse was asked if they would go down to see what was wrong. DA stated as they were walking down the hall, they saw CNA #1 push Res #1 in his w/c backwards from Res #2's room into the hall. They then saw the CNA go back into Res #2's room then came right back out. DA #1 stated they saw CNA #1 hit Res #1 with an opened hand to one side of the head and then hit the resident with the other open hand to the other side of the head. DA #1 stated they heard CNA #1 say at that time, You stupid son of a bitch I told you don't ever hit me in my face again. DA #1 stated CNA #1 then walked down the hall. DA#1 stated the resident at that time stated, They attacked me, call the cops. The DA stated they took the resident to the nurse station and reported what had happened to the nurse and Cook #1 went to report the incident to the ADON. The DA stated they did not observed any injuries to the resident. On 12/11/23 at 12:33 p.m., Cook #1 stated on 12/06/23 at approximately 6:00, Cook #1 and DA #1 were in the lobby and heard yelling. Cook #1 stated the nurse, who was busy at the medication cart, said that it sounded like Res #2 and would we go check to see what was wrong. The cook stated Cook #1 and DA #1 went down the [NAME] Hall saw CNA shove Res #1 in the w/c out of Res #2's room backwards. Cook #1 stated CNA #1 went back in Res #2's room and then came right back out and slapped the resident with an opened hand on the side of the resident's head and then slap the resident on the other side of the head. The cook stated they heard CNA #1 say, I told you to never hit me in my fucking face again you son of a bitch, then walk off down the hall. The cook stated the resident said, They attacked me call the police. Cook #1 stated they did not see any marking or redness on the resident and then took the resident to the nurse station. The cook stated she immediately went to tell the ADON. She stated the ADON called CNA #1 to the office and then CNA #1 left the building. On 12/11/23 at 12:59 p.m., the DON stated they received a call from the ADON at 6:05 p.m. related to the abuse incident and was at the facility in a matter of minutes. The DON stated the resident was assessed thoroughly, including neuro checks, and no injuries or markings were observed on the resident. The DON stated when she arrived the residents could not recall the incident. The DON stated they called the police, the physician, and the family. The DON stated they reported to OSDH, the nurse aide registry, and APS. The DON stated the CNA was terminated on 12/06/23. On 12/11/23 at 1:34 p.m., the administrator stated an inservice over abuse prevention was conducted on 12/06/23 with staff present, and other staff members were inserviced at the beginning of their shift. On 12/11/23 at 1:53 p.m., Res #1 was asked if he had been hit or abused by any one at the facility. He stated, No. The resident was asked if any one had cursed at him at the facility. He stated, No. The resident was unable to recall the incident. On 12/11/23 at 2:35 p.m., the resident's guardian stated they were notified of the incident. They stated the resident did not sustain any injuries and could not remember the incident. They stated the facility handled the situation well and had no complaints.

Based on record review and interview, the facility failed to ensure resident MDS assessments were transmitted to CMS in the required time frame for three (#10, 24, and #37) of three residents sampled for MDS transmission. The Census and Conditions of Residents form, dated 06/28/23, documented a census of 43 residents. Findings: A CMS Submission Report, dated 06/27/23, documented an annual assessment for Res #10 with a target date of 04/16/23 was transmitted on 06/27/23, an annual assessment for Res #24 with a target date of 05/07/23 was transmitted on 06/27/23, and an annual assessment for Res #37 with a target date of 04/19/23 was transmitted on 06/27/23. On 06/27/23 at 3:30 p.m., the MDS coordinator reported the resident assessments were transmitted by the corporate office. The MDS coordinator reported the resident assessments for Res #10, #24, and #37 should have been transmitted within the 14 day required time frame.

Based on record review and interview, the facility failed to ensure insulin was held and blood sugars were obtained per physician's orders for one (#6) of one resident reviewed for diabetic care. The DON identified six residents with orders for insulin. Findings: Res #6 was admitted with diagnoses which included diabetes. A physician order, dated 01/14/22, documented to inject Novolog (Insulin to lower blood sugar) 10 U SQ TID at 0700, 1130 and 1630. Hold if FSBS below 110. A physician order, dated 11/08/22, documented to check FSBS AC (before meals) & HS (bedtime). The Finger Stick Blood Sugar and Injection log for April 2023 documented the following: On 04/01/23 at 4:00 p.m. - FSBS (blood sugar) was 90 and insulin was administered. On 04/09/23 at 4:00 p.m. - No FSBS reading was documented and insulin was administered. On 04/22/23 at 8:00 p.m. - No FSBS reading was documented On 04/23/23 at 4:00 p.m. & 8:00 p.m. - No FSBS reading was documented On 04/28/23 at 4:00 p.m. & 8:00 p.m. - No FSBS reading was documented On 04/29/23 at 6:00 a.m. - No FSBS reading was documented On 04/30/23 at 1100 - No FSBS reading was documented A physician order, dated 05/02/23, documented to perform FSBS AC & HS. A physician's order, dated 05/02/23, documented to inject Novolog 10 U SQ TID with meals. Hold if FSBS below 110. The Finger Stick Blood Sugar and Injection log for May 2023 documented the following: On 05/04/23 at 4:00 p.m. - FSBS was 86 and insulin was administered, On 05/05/23 at 4:00 p.m. - FSBS was 106 and insulin was administered, On 05/06/23 at 11:00 a.m. - FSBS was 93 and insulin was administered, On 05/08/23 at 8:00 a.m. - FSBS was 96 and insulin was administered, On 05/09/23 at 4:00 p.m. - FSBS was 71 and insulin was administered, On 05/10/23 at 4:00 p.m. - FSBS was 106 and insulin was administered, On 05/16/23 at 11:00 a.m. - FSBS was 92 and insulin was administered, On 05/18/23 at 11:00 a.m. - No FSBS reading was documented and insulin was administered, On 05/24/23 at 4:00 p.m. - No FSBS reading was documented and insulin was administered, and On 05/29/23 at 4:00 p.m. and 8:00 p.m. - No FSBS reading was documented. The Finger Stick Blood Sugar and Injection log for June 2023 documented the following: On 06/03/23 at 4:00 p.m. - No FSBS reading was documented and insulin was administered On 06/04/23 at 4:00 p.m. - FSBS was 71 and insulin was administered On 06/09/23 at 4:00 p.m. - FSBS was 109 and insulin administered On 06/18/23 at 11:00 a.m. - No FSBS reading was documented On 06/25/23 at 4:00 p.m. - FSBS was 100 and insulin was administered On 06/27/23 at 3:45 p.m., the DON reported the staff should not have administered insulin when Res #6's FSBS was below 110 and should have documented the blood sugar results.

Based on observation, record review, and interview, the facility failed to ensure oxygen tubing and humidifier bottles were labeled per physician orders for three (#13, 26 and #28) of three sampled residents reviewed for oxygen therapy. The DON identified six residents on oxygen therapy. Findings: 1. Res #13 had diagnoses which included COPD and pulmonary hypertension. A physician order, dated 05/25/23, documented to change O2 concentrator humidifier bottle weekly on Sunday 10-6 shift and PRN and date bottle. A physician order, dated 05/25/23, documented to change O2 tubing weekly on Sunday 10-6 shift and PRN if contaminated and date O2 tubing. On 06/26/23 at 9:00 a.m., Res #13's oxygen was in use with tubing and humidifier bottle not labeled or dated. On 06/27/23 at 8:45 a.m., Res #13's oxygen was in use with tubing and humidifier bottle not labeled or dated. 2. Res #26 had diagnoses which included chronic lung disease. A hospice order, dated 05/27/23, documented to provide oxygen 3L via NC continuously. On 06/27/23 at 8:37, Res #26 was observed with oxygen at 3L per NC, there was no label on the tubing or humidifier. 3. Res #28 had diagnoses which included chronic respiratory failure with hypoxia and hypercapnia. A physician order, dated 07/01/22, documented to change O2 tubing weekly on Sunday 10-6 shift and PRN if contaminated and date O2 tubing. A physician order, dated 07/01/22, documented to change O2 concentrator humidifier bottles weekly on Sunday 10-6 shift and PRN and date bottle. On 06/26/23 at 9:25 a.m., Res #28's oxygen was in use with tubing and humidifier bottle not labeled or dated. On 06/27/23 at 8:35 a.m., Res #28's oxygen was in use with tubing and humidifier bottle not labeled or dated. On 06/27/23 at 4:00 p.m., the DON reported the oxygen tubing and humidifier bottles were to be changed and labeled weekly per the physician orders.

Based on observation, record review, and interview, the facility failed to ensure a care plan was developed for one (#13) of one resident sampled with a skin condition and one (#26) of one sampled resident with oxygen therapy. The DON identified one resident who had psoriasis (a skin condition) and six residents with oxygen therapy. Findings: 1. A physician order, dated 05/30/23, documented betamethasone (a steroid cream) 0.05% apply topically to affected areas twice daily as needed for psoriasis. A physician order, dated 05/30/23, documented Stelara (immunosuppressant drug) 90mg/ml inject one ml SQ every 12 weeks. On 06/26/23 at 12:45 p.m., Res #13 was observed to have large red areas on their torso, both arms, and legs. Res #13 was scratching and picking at the red areas. Res #13 reported they had psoriasis and stated, it has flared up and is bad. There was no care plan for Res #13's psoriasis. On 06/28/23 at 9:15 a.m., the MDS coordinator reported Res #13's psoriasis had been care planned and Res #13's skin had improved so the care plan was resolved. The MDS Coordinator also reported they should have care planned the psoriasis when it flared up again and new medications were started. 2. Res #26 was admitted with diagnoses which included chronic lung disease. A hospice order, dated 05/27/23 documented oxygen 3 L via nc continously. An annual assessment, dated 06/19/23, did not contain documentation of oxygen therapy for Res #26. There was no care plan for Res #26's oxygen therapy. On 06/26/23 at 9:00 a.m., Res #26 and family member reported Res #26 utilized oxygen while sleeping. On 06/27/23 at 8:47 a.m., Res #26 was observed with oxygen at three liters per minute via nasal cannula. On 06/27/23 at 8:48 a.m., a family member reported the staff had placed the oxygen on Res #26 following a shower. On 06/26/23, at 2:30 p.m., the MDS coordinator reported a significant change had been completed for the resident's admission to hospice and the care plan was in progress. The MDS coordinator also reported the oxygen therapy should have been included in the care plan.

Based on observation, interview, and record review, it was determined the facility failed to conduct COVID-19 testing in a manner consistent with current Centers for Disease Control (CDC) guidance for one (#7) of one employee test observed. The assistant director of nursing (ADON) failed to don the appropriate personal protective equipment (PPE) prior to testing the staff member. The administrator identified a census of 42 residents and 57 staff members. The CDC guidance titled Performing Broad-Based Testing for [DIAGNOSES REDACTED]-CoV-2 in Congregate Settings, updated June 27, 2020, documented the following: Gown, N95 equivalent or higher-level respirator (or facemask if a respirator is not available), gloves, and eye protection are needed for staff collecting specimens or working within 6 feet of the person being tested . Findings: The facility policy on COVID-19 testing documented the staff collecting the sample would don PPE which would include an N95 or higher level respirator (or face mask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. On 11/30/20 at 11:48 AM, the ADON was observed performing rapid [MEDICATION NAME] testing on staff member #7. She was observed wearing a surgical mask and her personal glasses. The ADON was not observed to wear eye protection or a gown during specimen collection. The ADON reported she did not wear full PPE while testing staff members for COVID-19. On 11/30/20 at 12:05 PM, the administrator confirmed, according to the facility policy, staff members who collect COVID-19 test samples should don full PPE .

Based on observation, interview, and record review, it was determined the facility failed to assess and monitor a resident after returning from [MEDICAL TREATMENT] for one (#41) of one resident reviewed for [MEDICAL TREATMENT] services. The director of nursing (DON) identified two residents who received [MEDICAL TREATMENT] services. Findings: Resident #41 had [DIAGNOSES REDACTED]. An annual assessment, dated 08/18/19, documented the resident was cognitively intact, required assistance with activities of daily living, and received [MEDICAL TREATMENT] services. The care plan, last reviewed on 08/18/19, documented the resident received [MEDICAL TREATMENT] services for a [DIAGNOSES REDACTED]. The care plan documented to monitor for signs and symptoms of infection, [MEDICAL CONDITION], redness, drainage, fever, and pain at the fistula site. The care plan documented vital signs were to be checked before and after returning from [MEDICAL TREATMENT]. On 09/16/19 at 10:25 AM, the resident was observed seated in her wheelchair outside in the front of facility. During an interview related to [MEDICAL TREATMENT] services, the resident stated she attended [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays. The resident's fistula access site was observed on her left upper arm. The resident stated the nurses did not always check her site and obtain blood pressures when she returned from [MEDICAL TREATMENT]. On 09/17/19 at 10:15 AM, licensed practical nurse (LPN) #2 stated a communication form was sent with residents who attend [MEDICAL TREATMENT] services. She stated vital signs should be taken before the resident goes to [MEDICAL TREATMENT] and when they return. She was asked where the assessments were documented for the resident's return from [MEDICAL TREATMENT]. The LPN stated they were included in the nurse notes. The resident's medical record was reviewed and did not contain assessments of the resident's condition after her return from [MEDICAL TREATMENT]. On 09/17/19 at 5:00 PM, the DON stated the nurses should have documented their assessment of the resident's access site and vitals signs on return from [MEDICAL TREATMENT].

Based on observation, interview, and record review, it was determined the facility failed to ensure an infection prevention and control program was maintained in order to prevent the possible development and transmission of communicable disease and infections. The facility failed to ensure: a) hand hygiene was performed when assisting residents to eat. b) the glucometer was cleaned with an environmental protection agency (EPA) approved wipe. c) the scoop was not kept in the ice while serving. d) staff members received two step [MEDICATION NAME] skin tests. The director of nursing (DON) identified 50 residents who resided in the facility. Findings: 1. On 09/16/19 at 11:21 AM, CNA #1 was observed to assist a male resident with a drink and then assist another resident with a drink after touching the rim of the glass. Hand hygiene was not observed. On 09/16/19 at 11:27 AM, CNA #2 was observed to sit down by a resident, touch her own hair, and started assisting a resident to eat pancakes. Hand hygiene was not observed. On 09/18/19 at 11:37 AM, the ice scoop was observed to be laying in the ice chest on top of the ice. On 09/18/19 at 11:38 AM, observed CNA #3 was observed to take trash from the residents' table to a trash can, returned to the table, and assisted a resident to eat. Hand hygiene was not observed. On 09/18/19 at 11:45 AM, CNA #4 was observed assisting a resident to eat. A resident on the other side of the table knocked the condiments off the table. CNA #4 was observed to touch the resident's hand then pick up the condiments from the floor and place them back on the table. The CNA then touched her hair moving her bangs over and returned to assisting the resident to eat her meal. Hand hygiene was not observed. On 09/18/19 at 11:47 AM, the dietary manager (DM) was shown the ice chest with the scoop inside. The DM stated the scoop should not be stored in the ice. On 09/19/19 at 08:55 AM, the DON confirmed condiments dropped on the floor should have been thrown away and not placed back on the residents' table. 2. On 09/16/19 between 11:24 and 11:29 AM, certified nursing aide (CNA) #1 and licensed practical nurse (LPN) #3 were observed assisting three residents to eat their noon meal. The staff members were observe to feed the residents by giving a bite of food and/or drink to a resident, then turned to another resident and gave a bite of food and/or drink. The staff members were observe to wipe the residents' faces as needed and took turns feeding the residents. Hand hygiene was not observed throughout the observation. On 09/19/19 at 8:55 AM, the DON reported if the staff only touched the utensils and did not come into contact with any resident secretions, they could feed two residents without performing hand hygiene between. She stated if they wiped the residents' mouth or some of saliva got on the utensils, hand hygiene should have been performed. 3. On 09/17/19 at 10:35, licensed practical nurse (LPN) #2 was observed during obtaining a finger stick blood sugar (FSBS) tests for residents. She was observed to clean the glucometer with an alcohol wipe after a FSBS was obtained. At 09/17/19 at 10:38, LPN #2 was observed to gather supplies to enter the room of a second resident to obtain an FSBS. The LPN was asked to stop at that time and asked what she cleaned the glucometer with. She confirmed she cleaned the glucometer with an alcohol wipe. The LPN was asked if cleaning the glucometer with alcohol was the facility policy. She was observed to open the treatment book and consult a policy on file which documented the staff were to clean the glucometer with Super-Sani cloths or a bleach based wipe. On 09/17/19 at 10:52 AM, the DON confirmed the LPN should have cleaned the glucometer with Super-Sani cloths to disinfect it after use. 4. Five newly hired staff members employee records were reviewed. The five staff members had received one [MEDICATION NAME] (TB) skin test as part of the on-boarding process rather than the two step TB test. On 09/19/19 at 12:27 AM, the DON was interviewed regarding new hire TB test. She confirmed the facility gave one TB test on hire and annually there after. She stated she was unaware the two step TB test was still required.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident with an indwelling urinary catheter received services to prevent urinary tract infections for one (#6) of one resident reviewed for indwelling urinary catheters. The facility failed to ensure the staff maintained the catheter bag below the level of the resident's bladder. The director of nurses (DON) identified two residents who had indwelling urinary catheters. Findings: Resident #6 had [DIAGNOSES REDACTED]. A quarterly assessment, dated 06/14/19, documented the resident was severely impaired for daily decision making and required total assistance with toilet use and personal hygiene. The assessment documented the resident had an indwelling urinary catheter and had a urinary tract infection in the last 30 days. The care plan, updated 06/15/19, documented the resident had a potential for complications related to having an indwelling urinary catheter. The care plan documented to keep the closed drainage system's collection bag lower than the bladder level at all times. On 09/16/19 at 9:28 AM, the resident was lying in bed and the catheter bag was lying on bed beside the resident. The catheter bag drainage spout was open and the bag was not below the level of the resident's bladder to allow drainage to gravity. On 09/17/19 at 8:24 AM, the resident was lying in bed and the catheter bag was lying on bed beside the resident. The catheter bag was not below the level of the resident's bladder. On 09/18/19 at 9:30 AM, catheter care for the resident was performed by licensed practical nurse (LPN) #1 and certified nurse aide (CNA) #4. The catheter bag was lying on the bed at bladder level with cloudy urine in the tubing. The catheter bag was lifted above the resident's body three times during the cleaning process allowing the urine to back-flow in the tubing. On 09/18/19 at 10:23 AM, the director of nurses (DON) was interviewed and stated the catheter bag should always be below the level of the bladder.

A deficiency was cited at the level of Immediate Jeopardy in regard to the facility's failure to ensure pasteurized eggs were used for frying over-easy eggs. The fried eggs did not reach an internal temperature of 145 degrees Fahrenheit. This had the potential to affect eleven residents (#5, 12 and #16 through #24) who were identified as receiving over-easy fried eggs. This deficient practice could also affect any resident who requested an over-easy egg. The facility had been using unpasteurized eggs since February 2012. On 09/19/12 at 7:07 a.m., the Oklahoma State Department of Health (OSDH) was notified. The IJ situation was verified. At 7:14 a.m., the ADM and DON were notified of the IJ situation. At 11:20 a.m., an acceptable plan of removal was presented to the survey team. The plan of removal was as follows: "September 19, 2012 All unpasteurized eggs have been removed from the facility and will be replaced with pasteurized eggs to be delivered on the next delivery date. Our food distributor has been called and the eggs that we will be receiving in the future will be pasteurized eggs. A meeting will be held with the resident's council to inform them that we will be unable to serve fried eggs until the next grocery delivery date. All dietary staff has been in-serviced to observe for the pasteurized stamp on the eggs to insure that they are using the correct eggs. All new dietary staff will be told in orientation to observe for the pasteurized stamp on the eggs and will be instructed not to use unpasteurized eggs and report immediately to dietary supervisor or administrator if any unpasteurized eggs exist in the kitchen. The dietary manager will monitor each delivery to insure that the proper eggs have been received. The IJ was removed effective 09/19/12 at 11:20 a.m. after the unpasteurized eggs had been removed and all dietary staff had been inserviced to use only pasteurized eggs, which had been ordered. The dietary staff were interviewed on the morning of 09/20/12. All the dietary staff answered questions appropriately concerning serving eggs to residents. The IJ was removed, but the deficient practice remained at no actual harm with potential for more than minimal harm, at a pattern. Based on record review, observation and staff interview, it was determined the facility failed to: a) Ensure pasteurized eggs were served to residents who received fried over-easy eggs. Residents #5, 12 and #16 through #24 were identified as receiving over-easy eggs. This had the potential to affect all eleven residents identified by the DM as receiving over-easy eggs. b) Ensure the unpasteurized fried eggs were heated to at least 145 degrees Fahrenheit before serving. Residents #5, 12 and #16 through #24 were identified as receiving over-easy eggs. Eleven residents were affected by the failed practice as identified by the DM as receiving over-easy eggs. c) Ensure the ice machine used to provide ice for the residents' liquids was kept clean. Nine sampled residents were identified as receiving ice from the ice machine. This had the potential to affect 53 residents identified by the DON as using ice from the ice machine. d) Ensure bread was not handled with soiled hands when making sandwiches during one of two meals observed. This had the potential to affect 49 residents identified by the DM as receiving a diet as tolerated. The DM identified seven residents as receiving pureed diets. Findings: The facility dietary policy and procedure documented, "Fried eggs...Large quantities of eggs can be fried in a large frying pan or on a grill...This type of egg service should be discouraged d/t increased risk of Salmonella poisoning... Keep hands and fingers out of the food...In order to avoid contact with unpackaged foods, always use tongs, scoops..." 1. On 09/18/12 at 9:15 a.m., the dietary department was toured. In the walk-in refrigerator a shelf contained a stack of shelled eggs. The eggs were not in the original carton and did not have a pink stamp to identify them as being pasteurized. At 9:30 a.m., cook #1 was asked if the eggs in the walk-in refrigerator were pasteurized eggs. She reported she was not sure. The cook was asked how they used the eggs. She reported some were boiled and some were used for fried eggs. The cook reported as many as half the residents wanted their eggs fried. The cook was asked if she fried the eggs hard. The cook reported some of the residents wanted their eggs over-easy. The cook identified 11 residents (#5, 12 and #16 through #24) as having received an over-easy egg that morning (09/18/12) for breakfast. The cook was asked if she could check the invoice for the eggs to see if they were pasteurized. The cook obtained the invoice, dated 09/13/12. The invoice documented large shell eggs had been delivered. The eggs were not identified as being pasteurized. At 11:35 a.m., the DM reported the eggs were not pasteurized. The DM reported they had changed vendors in February of this year and the new vendor did not know they were supposed to use pasteurized eggs. The DM was asked if they had been using the unpasteurized eggs since February. She reported they had. She reported they had not noticed they were not pasteurized. The medical records for the eleven residents identified as having received the over-easy unpasteurized egg were reviewed. The following was found: Resident #5 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #12 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #16 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #17 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #18 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #19 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #20 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #21 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #22 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #23 was [AGE] years old and had [DIAGNOSES REDACTED]. Resident #24 was [AGE] years of age and had [DIAGNOSES REDACTED]. The above residents' ages an/or [DIAGNOSES REDACTED]. On 09/19/12 at 6:30 a.m., the morning food service was observed. Cook #1 was preparing a hall cart to be sent out. The cook was observed to crack six eggs and place them in a skillet to be fried. The eggs were turned over once and then removed from the skillet. The yolks were observed to be soft. The cook was asked to take the temperature of one of the eggs as soon as it was removed from the skillet. The temperature of the center of the egg yolk registered 139.9 degrees Fahrenheit. The cook then fried five more eggs, turning them over once in the skillet and then removing them. The yolks were observed to be soft when removed from the skillet. The cook was observed to place a fried egg on a plate for resident #16. The plate was then placed on the cart to be sent out on the hall. The cook then placed a fried egg on a plate for resident #18 and placed the plate on the cart to be sent out on the hall. The cook was stopped before the cart was sent out to the hall. The cook was informed the over-easy eggs could not be served to the residents because they were not pasteurized and had not reached 145 degrees Fahrenheit. The cook was informed the unpasteurized eggs cooked over-easy placed the residents at risk for food borne illness. At 7:14 a.m., the ADM was informed the unpasteurized eggs were being fried over-easy. The ADM reported they had switched food service vendors last February and they had not noticed the eggs were not pasteurized. The ADM reported they would not use the remaining eggs and would ensure only pasteurized eggs would be used. 2. On 09/18/12 at 1:30 p.m., the ice machine was observed open while ice was being removed by a dietary staff member. The back splash inside the ice machine was observed to have a build-up of a blackish/brown substance. An area with a soft, mushy, yellow substance was also found on the white plastic area on the back splash. The area had a pink substance present. The dietary staff member, who was removing the ice from the machine, was asked who was responsible for cleaning the ice machine. She reported the maintenance man was responsible for cleaning the ice machine. At 1:40 p.m., the maintenance man was interviewed regarding the ice machine. The maintenance man was asked when he had last cleaned the ice machine. He reported he had started to work in July and he had never cleaned the ice machine. The corporate manager was present at that time and reported he would get the ice machine cleaned out. 3. The menu for the evening meal on 09/18/12, documented the residents were to receive chicken salad sandwiches and vegetable soup. On 09/18/12 at 5:30 p.m., the dietary staff were observed serving the residents who were attending the family dining service. Dietary aide #1 was observed moving about in the dining room and assisting residents. The dietary aide was observed to pick up two slices of bread without first washing her hands and make a sandwich for a resident. The dietary aide was observed to make another sandwich using her bare hands, without first washing her hands. On 09/19/12 at 11:50 a.m., the dietary aide was interviewed regarding touching the bread for the sandwiches with her bare hands. The dietary aide reported she had recognized her mistake. She reported she should have used tongs to pick up the bread. On 09/20/12 at 2:00 p.m., the DM was interviewed regarding the sanitary issues in the dietary department. The DM reported the problem with the eggs had been corrected and the ice machine was cleaned out. She reported the dietary aide should not have handled the bread with her bare hands and reported tongs should have been used.