Every finding on record at NHC Healthcare, Milan

Based on policy review, job description review, medical record review, observation, and interview, the facility failed to ensure the environment was free from accident hazards when hot water temperatures ranging from 120 degrees Fahrenheit (F) to 138 degrees F were found in 23 of 92 (Resident #2, #11, #13, #23, #27, #28, #33, #46, #58, #63, #65, #66, #71, #76, #77, #82, #84, #87, #88, #90, #95, #105 and #106) Residents' bathrooms. Eleven Residents who were physically and/or cognitively impaired (Residents #11, #27, #28, #33, #46, #63, #65, #66, #71, #77, and #95) resided in a room with elevated hot water temperatures and nine of the cognitively impaired residents were able to access the hot water in their rooms. The findings include: 1. Review of the undated facility policy titled, Water Quality Management Program, revealed .committed to providing a safe environment for our patients. Review of the undated TELS [(The Equipment Lifecycle System) - a platform used to promote a safer environment]: Test and Log the Hot Water Temperatures, revealed .For burn prevention.keep domestic water temperatures below 120 degrees Fahrenheit. 2. Review of the Administrator's job description dated 5/4/2016, revealed .The Administrator has complete administrative and managerial responsibilities within the health care center .Ability to interpret and implement regulations .Assures compliance with State and Federal Regulations . Review of the Maintenance Supervisor's job description dated 10/18/2024, revealed .Plans, directs and supervises maintenance program ( .plumbing, water .) .Inspects all equipment and systems regularly for proper functioning and safety .When an outside contractor performs service, it is to be supervised by this position .Regular inspection of .equipment for compliance with safety regulations . Review of the Maintenance Assistant's job description dated 11/11/2024, revealed .Inspects all equipment and systems regularly for proper functioning and safety . 3. Review of the (named supplier) Invoice dated 8/1/2025, revealed .ON HALL 400 THEY HAVE HOT WATER COMING OUT OF BOTH HOT AND COLD .Installed new check valve and expansion tank. Also calibrated mixing valve . 4. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Anxiety, and Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #2 was cognitively intact. Resident #2 was dependent on staff to perform Activities of Daily Living (ADLs). Observations in the Resident's bathroom dated 8/25/2025 at 10:25 AM, revealed the water temperature at Resident #2's sink was checked with a calibrated thermometer with a reading of 120 degrees F. 5. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Pressure Ulcer, Osteoarthritis, and Anxiety. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #11 was moderately cognitively impaired. Resident #11 was dependent on staff to perform ADLs. 6. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Failure to Thrive, Hypertensive Heart Disease, and Heart Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #28 was moderately cognitively impaired. Resident #28 was dependent on staff to perform ADLs. Observation in the Residents shared bathroom on 8/25/2025 at 9:06 AM, revealed Residents #11 and #28's sink water temperature was checked with a calibrated thermometer with a reading of 134 degrees F. 7. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Diabetes, Chronic Respiratory Failure, and Anemia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #13 was cognitively intact. Resident #13 was independent with ambulation. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Encephalopathy, and Hypertensive Chronic Kidney Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score 00 which indicated Resident #33 was severely cognitively impaired. Resident #33 required supervision assistance with ambulation. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE], with diagnoses including Dementia, Femur Fracture, Depression, Anxiety, and Malnutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #95 was moderately cognitively impaired. Resident #95 was independent with ADLs. Observation in Residents #13, #33 and #95's shared bathroom on 8/25/2025 at 9:34 AM, revealed the sink water temperature was checked with a calibrated thermometer with a reading of 120 degrees F. 8. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anxiety, Depression, and Hypertensive Chronic Kidney Disease. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #23 was severely cognitively impaired. Resident #23 was independent with the use of a wheelchair for mobility. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Depression, Anxiety, and Chronic Kidney Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS was not completed due to Resident #76's severe cognitive impairment. Resident #76 was independent with the use of a wheelchair for mobility. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including Hypertensive Heart Disease, Diabetes, Dementia, and Malnutrition. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #77 was moderately cognitively impaired and was independent with ambulation. Observation in the Residents shared bathroom on 8/25/2025 at 9:37 AM, revealed Resident #23, #76, and #77's sink water temperature was checked with a calibrated thermometer with a reading of 126 degrees F. 9. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Hypertension, Dementia, Hyperlipidemia, and Hypercalcemia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 7, which indicated Resident #27 was severely cognitively impaired. Resident #27 was independent with ADLs and the use of a wheelchair for mobility. Review of the medical record revealed, Resident #106 was admitted to the facility on [DATE] with diagnosis including Femur Fracture (break in the upper bone of the leg), Chronic kidney disease, Anxiety, and Hyperlipidemia. Review of the Functional Abilities assessment dated [DATE], revealed Resident #106 was dependent on staff to perform ADLs. Review of the Brief Interview for Mental Status dated 8/25/2025, revealed a BIMS score of 15, which indicated that Resident #106 was cognitively intact. Observation in the Residents shared bathroom on 8/25/2025 at 9:22 AM, revealed Resident #27 and #106's sink water temperature was checked with a calibrated thermometer with a reading of 120 degrees F. 10. Review of the medical record revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Depression, Anxiety, and Polyneuropathy. Review of quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #46 was severely cognitively impaired. Resident #46 was independent with the use of wheelchair for mobility. Observation in the Resident's bathroom on 8/25/2025 at 9:08 AM, revealed Resident #46's sink water temp was checked with a calibrated thermometer with a reading of 130 degrees F. 11. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #58 was cognitively intact. Resident #58 required supervision assistance with the use of the wheelchair for mobility. Observation in the resident's bathroom on 8/25/2025 at 9:42 AM, revealed Resident #58's sink water temperature was checked with a calibrated thermometer with a reading of 120 degrees F. 12. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Malnutrition, Dementia, and Polyneuropathy. Review of quarterly MDS assessment dated [DATE], revealed a BIMS score of 2, which indicated Resident #63 was severely cognitively impaired. Resident #63 required supervision assistance with the use of a wheelchair for mobility. Review of the medial record revealed Resident #88 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Depression, and Hypertensive Chronic Kidney Disease. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #88 was cognitively intact. Resident #88 was independent with mobility. Observation in Residents shared bathroom on 8/25/2025 at 9:15 AM, revealed Resident #63 and #88's sink water temperature was checked with a calibrated thermometer with a reading of 136 degrees F. 13. Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Failure to Thrive, Diabetes, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 4, which indicated Resident #65 was severely cognitively impaired. Resident #65 required maximum assistance with a wheelchair for mobility. Observation in the Resident's bathroom on 8/25/2025 at 9:11 AM, revealed Resident #65's sink water temperature was checked with a calibrated thermometer with a reading of 120 degrees F. 14. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Dementia, Respiratory Failure, Depression, Anxiety, and Polyneuropathy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated Resident #66 was moderately cognitively impaired. Resident #66 was independent with the use of a wheelchair for mobility. Observation in the Resident's bathroom on 8/25/2025 at 9:13 AM, revealed the Resident #66's sink water temperature was checked with a calibrated thermometer with a reading of 126 degrees F. 15. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Hypertension, Depression, and Urinary Tract Infection. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS was not completed due to Resident #71's severe cognitive impairment. Resident #71 was dependent on staff to perform ADLs. Observation in the Resident's bathroom on 8/25/2025 at 9:35 AM, revealed Resident #71's sink water temperature was checked with a calibrated thermometer with a reading of 132 degrees F. 16. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anxiety, Depression, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS was not completed due to Resident #82's severe cognitive impairment. Resident #82 was dependent on staff to assist with ADLs for mobility. Observation in the Resident's bathroom on 8/25/2025 at 9:10 AM, revealed Resident #82's sink water temperature was checked with a calibrated thermometer with a reading of 132 degrees F. 17. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE], with diagnoses including Dementia, Respiratory Failure, Malnutrition, and Cognitive Communication Deficit. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 4, which indicated Resident #84 was severely cognitively impaired. Resident #84 required moderate assistance of staff with wheelchair use for mobility. Observation in the Resident's bathroom on 8/25/2025 at 10:40 AM, revealed Resident #84's sink water temperature was checked with a calibrated thermometer with a reading of 120 degrees F. During an observation and interview in the Resident's room on 8/25/2025 at 11:00 AM, Resident #84's daughter confirmed that the water seemed to be hot. During an observation and interview in the Resident's room on 8/25/2025 at 11:30 AM, the Maintenance Supervisor checked Resident #84's water temperature at the bathroom sink, and the temperature was 119.2 degrees F. The Maintenance Supervisor stated, .Its probably going to be lower than it was because I have already turned the water down . 18. Review of the medical record revealed Resident #87 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Seizure, Vascular Dementia, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 2, which indicated Resident #87 was severely cognitively impaired. Resident #87 was dependent on staff to perform ADLs. Observation in the Resident's bathroom on 8/25/2025 at 9:03 AM, revealed Resident #87's sink water temperature was checked with calibrated thermometer with a reading of 138 degrees F. 19. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Pressure Ulcer, and Heart Failure. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #90 was cognitively intact. Resident #90 was dependent on staff to perform ADLs. Observation in the Resident's bathroom on 8/25/2025 at 9:39 AM, revealed Resident #90's sink water temperature was checked with a calibrated thermometer with a reading of 132 degrees F. 20. Review of the medical record revealed Resident #105 was admitted to the facility on [DATE], with diagnoses including Sepsis, Pressure ulcer, Chronic Obstructive Pulmonary Disease, Depression, Anxiety, and Chronic pain. Review of the Functional Abilities assessment dated [DATE], revealed Resident #105 was independent with transfers and mobility. Review of the BIMS Score assessment dated [DATE], revealed a BIMS of 15, which indicated Resident #105 was cognitively intact. Observation in the Resident's bathroom on 8/25/2025 at 10:15 AM, revealed Resident #105's sink water temperature was checked with a calibrated thermometer with a reading of 124 degrees F. 21. Observations in the Residents' bathrooms on 8/25/2025 beginning at 10:40 AM, revealed the following water temperatures were obtained when the Maintenance Supervisor checked the water temperatures with a calibrated digital thermometer: a. Resident #71's bathroom water temperature was 138 degrees F. b. Resident #87's bathroom water temperature was 140 degrees F. c. Resident #106's bathroom water temperature was 138 degrees F. d. Resident #88's bathroom water temperature was 136 degrees F. e. Resident #11 and #28's shared bathroom water temperature was 138 degrees F. f. Resident #82's bathroom water temperature was 137 degrees F. g. Resident #46's bathroom water temperature was 134 degrees F. h. Resident #66's bathroom water temperature was 135.2 degrees F. i. Resident #65's bathroom water temperature was 135.4 degrees F. j. Resident # 90's bathroom water temperature was 133.7 degrees F. During an observation and interview on 8/25/2025 at 10:51 AM, the Maintenance Supervisor confirmed the water heater on the 100 Hall was set at 140 degrees F due to being turned up a month ago due to staff complaints that the water was not getting warm enough. The 300 Hall water heater was set in the 130s, the thermometer for the water heater contained a thick dust build up, and the Maintenance Supervisor was unable to visualize the exact temperature setting of the water heater. The 400 Hall water heater was set at 140 degrees F. The Maintenance Supervisor stated, The water heater on the 400 Hall had parts replaced by a vendor last week and they must have set the water heater temperature too high. The Maintenance Supervisor confirmed that it should be set at 112-113 degrees (F). The Maintenance Supervisor confirmed that he did not turn the water heater temperature back down after it was turned up a month ago. The Maintenance Supervisor confirmed that he performed weekly water temperature checks in one random resident room per hall on Thursdays or Fridays. During an interview on 8/25/2025 at 11:43 AM, the Administrator confirmed that the Maintenance Supervisor informed him of hot water temperatures in resident rooms, but he was not informed of the temperatures. During an interview on 8/27/2025 at 4:10 PM, the Maintenance Supervisor confirmed about a month ago Resident #90's daughter complained that there was not any hot water in the resident's bathroom, and at that time the 300 Hall water heater was turned up. The Maintenance Supervisor confirmed the facility could not provide documentation regarding the dates the water heaters were turned up.

Based on the Refrigerator Temperature Log review, observation, and interview the facility failed to ensure medications were properly stored when 1of 3 (South Wing) medication refrigerator temperature logs had no documentation for 13 out of 26 days. The findings include: 1. Review of the facility's Refrigerator Temperature Log, dated 8/2025, revealed .Proper medication refrigerator temperature range is between 36 [degrees] - (and) 46 [degrees] Fahrenheit. 2. Observation in the South Wing Medication Storage Room on 8/27/2025 at 9:36 AM, revealed the Refrigerator Temperature Log dated 8/2025, revealed there was no documentation for the refrigerator temperature on 8/3/2025-8/5/2025, 8/9/2025, 8/10/2025, 8/12/2025, 8/14/2025, 8/16/2025, 8/17/2025, 8/20/2025, and 8/22/2025-8/24/2025. 3. During an interview on 8/27/2025 at 3:50 PM, the Director of Nursing (DON) was asked how often the medication refrigerator temperatures should be checked and logged. The DON stated, Daily. The DON confirmed that staff would not be able to ensure refrigerated medications were being stored at the proper temperature with an incomplete temperature log.

Based on observations and interviews, the facility failed to ensure posted Daily Staffing information was accurate for dates 8/26/2025 and 8/27/2025. The findings include: Observations in the hallway at the North Wing nurse's station and the South Wing nurse's station on 8/26/2025 at 7:31 AM, 10:10 AM, and 1:22 PM, revealed the posted Daily Staffing information was dated 8/25/2025. Observations in the hallway at the North Wing nurse's station and the South Wing nurse's station on 8/27/2025 at 9:00 AM and 10:35 AM, revealed the Daily Staffing information was dated 8/26/2025. During an interview on 8/27/2025 at 10:37 AM, the Assistant Director of Nursing (ADON) confirmed that she was responsible for posting the Daily Staffing at the North Wing nurse's station and the South Wing nurse's station, and the Daily Staffing should be posted first thing in the morning. During an interview and observation at the North Wing nurses' station on 8/27/2025 at 10:46 AM, the ADON confirmed the Daily Staffing posted was dated 8/26/2025.

Based on policy review, resident trust account review, medical record review, and interview, the facility failed to refund the residents' funds within 30 days of death or discharge for 2 of 52 sampled residents (Resident #109 and #110) reviewed for trust fund account statements. The findings include: 1. Review of the facility policy titled, Patient Trust, dated 10/2010, revealed .The balance remaining for a patient's trust fund account should be refunded as soon as all transactions are fully accounted for after a patient is discharged or deceased .the funds should be refunded within 30 days of death or discharge. 2. Review of the medical record revealed Resident #109 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Pneumonia, Dysphagia, and Dementia. Review of the Nurse's Note dated [DATE], revealed .Death pronounced at this time . Review of Resident #109's Quarterly Trust Fund statement from [DATE] through [DATE], revealed an account balance of $3,843.98. 3. Review of the medical record revealed Resident #110 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Dysphagia, Acute Kidney Failure, and Dementia. Review of the Nurse's Note dated [DATE], revealed .pronounced at 5:15 PM . Review of Resident #110's Quarterly Trust Fund statement from [DATE] through [DATE], revealed an account balance of $562.51. During an interview on [DATE] at 8:25 AM, the Accounting Bookkeeper confirmed Resident #109 and #110's account balances with existing funds should have already been refunded.

Based on policy review, record review, observation, and interview, the facility failed to provide care and services for residents with a percutaneous enteral gastrostomy (PEG) tube (a tube inserted through the skin and into the stomach to administer medications and supplements) when staff failed to administer the ordered enteral feeding and failed to check the residual volume for 2 of 2 residents (Resident #4 and #97) reviewed for tube feedings. The findings include: 1. Review of the facility policy titled, Peg tube medication administration, dated 12/2019, revealed .Check to see if the exit of the tube [PEG tube] was marked upon initial insertion. If tube was not marked check gastric residual volume unless the patient is able to verbalize discomfort such as nausea/vomiting, bloating. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Aphasia, Dysphagia, Diabetes, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not performed due to Resident #4 was unable to be interviewed and was dependent on staff for all care. Resident #4 received enteral feeding (the administration of nutrients, or medication through a tube through the abdomen directly into the stomach). Review of the Physician's Orders dated 3/29/2025, revealed (Named diabetic enteral feeding) 1.2 Calorie (Cal) to infuse at 65 Milliliters per hour (ml/hr) for 22 hours per day for a total volume of 1430 ml per day. Observation on in Resident #4's room on 8/26/2025 at 8:00 AM, revealed a (named) enteral feeding 1.5 Cal infusing at 65 ml/hr through the feeding tube pump. During an interview on 8/26/2025 at 11:10 AM, RN B confirmed Resident #4 was not receiving the correct enteral feeding as ordered by the physician. 3. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE], with diagnoses including Anoxic Brain Damage, Dysphagia following Cerebral Infarction, Gastro-Esophageal Disease, and Gastrostomy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score was not completed due to Resident #97's severely impaired cognition. Resident #97 was dependent on staff for activities of daily living (ADL's) and received nutrition through an enteral feeding tube. Review of the Physician's Order dated 6/27/2025, revealed .acetaminophen tablet . 500mg [milligram] .1 tab [tablet] .gastric tube . Review of the Physician's Order dated 8/18/2025, revealed .baclofen tablet .10mg .1 tab .gastric tube . Observation in Resident #97's room on 8/26/2025 at 2:27 PM, revealed LPN A checked residual (amount of fluid left in the stomach through a feeding tube between enteral feeding sessions to assess feeding intolerance) by pulling 60 ml of residual gastric contents using an enteral syringe and replaced the contents back into the peg tube without verifying the total gastric residual volume. LPN A then continued with medication administration and reattached to peg feeding tubing with (named) 1.5 Cal infusing at 50 ml/hr with 40 ml/hr water flush via peg pump. Observation in Resident #97's room on 8/27/2025 at 12:37 PM, revealed Resident #97's peg tube exit site had no markings on it for placement verification. During an interview on 8/27/2025 at 2:12 PM, the Director of Nursing (DON) confirmed Resident #97 was unable to verbalize discomfort such as nausea/vomiting and bloating and that staff should verify the full gastric residual volume prior to medication administration. The DON confirmed that by not doing so could result in complications including aspiration or discomfort for the resident and there should be a Physician's Order related to parameters for the gastric residual volume for residents receiving PEG medications or feedings.

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 staff members (Registered Nurse (RN) B) failed to wear personal protective equipment (PPE) and failed to perform hand hygiene during medication administration for 1 of 5 (Resident #11) sampled residents. The findings include: 1. Review of the undated facility policy titled, Hand Washing and Hand Sanitizer, revealed .Hand Hygiene is the primary means to prevent the spread of infection.Wash or sanitize hands after contact with patient .removal of gloves. Review of the facility policy titled, .Enhanced Barrier Precautions, dated 2/2025, revealed .Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms .that employs targeted gown and glove use during high contact activities .Providers and partners must wear gloves and a gown for the following.Device care or use .Indwelling Medical Devices.Central lines. 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Gastrostomy, Dysphagia, and Small Bowel Resection Status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for [NAME] Status (BIMS) score of 12, which indicated Resident #11 was moderately cognitively impaired, was dependent of staff for activities of daily living, and received Total Parenteral Nutrition (TPN) ( a method of delivering nutrients directly into the bloodstream). Review of the Care Plan dated 7/8/2025, revealed .ENHANCED BARRIER PRECAUTIONS: Presence of .central line.Use of gown and gloves during high-contact care activities. Review of the Physician Order dated 8/4/2025, revealed .Enhanced Barrier Precautions presence. Review of the Physician Order dated 8/9/2025, revealed an order for TPN intravenous infusion at 195 milliliters (ml) per hour for 11 hours than 105 ml per hour for one hour then take down. Observation during medication administration in Resident #11's room on 8/26/2025 at 11:02 AM, revealed Registered Nurse (RN) B failed to perform hand hygiene between glove changes when preparing TPN medications and did not wear a gown when cleaning and accessing Resident #11's central line (an indwelling device inserted into a large vein used to administer medication or fluids During an interview on 8/27/2025 at 10:11 AM, the Director of Nursing (DON) confirmed staff should wear gloves and a gown when accessing a central line of a resident in EBP and staff should perform hand hygiene between glove changes.

Based on record review, observation, and interview, the facility failed to maintain emergency supplies at bedside for 2 of 2 (Resident #4 and #97) sampled residents reviewed for tracheostomy care. The findings include: 1. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Tracheostomy, Chronic Respiratory failure, Chronic Obstructive Pulmonary Disease, Dysphagia, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not completed due to Resident #4 was unable to be interviewed. Resident #4 was dependent on staff for activities of daily living (ADLs) and received Tracheostomy care. Review of the Care Plan dated [DATE], revealed .He [Resident #4] will not exhibit s/s [signs and symptoms] of complications r/t [related to] presence of tracheostomy . Observations in Resident #4's on [DATE] at 10:25 AM and [DATE] at 8:05 AM, in Resident #4's room, revealed there was no manual resuscitation bag at the bedside for emergencies. During an interview on [DATE] at 11:30AM, Resident Nurse (RN) B confirmed that residents with a tracheostomy should have a manual resuscitation bag at bedside. 2. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Anoxic Brain Injury, and Tracheostomy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score was not completed and Resident # 97 had severely impaired cognition, was dependent on staff for ADLs, and was noted for oxygen therapy, suctioning, and tracheostomy care. Review of Resident #97's Care Plan with a revised date of [DATE], revealed .Presence of.trach [tracheostomy].Respiratory Function - at risk for compromise . Review of the Physician's Order dated [DATE], revealed .Tracheostomy care instructions.TRACH CARE DAILY.PATENT [patient] HAS A .TRACH WITH .INNER CANNULA. Review of Resident #97's Tennessee Physician Orders for Scope of Treatment (POST) form dated [DATE], revealed .CARDIOPULMONARY RESUSCITATION [CPR] .Full treatment. Observation in Resident #97's room on [DATE] at 8:40 AM, revealed there was not a manual resuscitation bag present at bedside. During an observation and interview in Resident #97's room on [DATE] at 1:21 PM, Respiratory Therapist (RT) C confirmed there was not a manual resuscitation bag in Resident #97's room. RT C stated, .We use the ones [manual resuscitation bag] on the crash carts that are at the nurses' station.

Based on policy review, job description review, record review, observations, and interview, the facility failed to ensure each resident's environment was safe when 1 of 64 resident rooms on the 100 Hall was a vacant and being renovated. The unlocked and unattended 100 Hall room contained hazardous chemicals and materials including paint, an uncovered bucket with a mixture of paint and water liquid used to clean paint rollers, caulking, nails, screws, and sheetrock mud, and was accessible by residents. The findings include: 1. Review of the undated facility policy titled NHC Storage of Hazardous Chemicals, revealed Hazardous chemicals are to be stored out of the reach of patients . 2. Review of the Administrator's job description signed and dated 12/8/2022, revealed .The Administrator has complete administrative and managerial responsibilities within the health care center .Ability to interpret and implement regulations (state and federal) .Promote safety awareness .Assures compliance with State and Federal Regulations and NHC Corporate and Center policies . Review of the Maintenance Supervisor's job description signed and dated 10/18/2024, revealed .The position organizes, directs and supervises the maintenance and repair program involving buildings and grounds. Also coordinates maintenance and repair activities with functions of other departments .When an outside contractor performs a service, it is to be supervised by this position .Responsible for the care and use of supplies and maintenance equipment used in performance of duties . Review of the Maintenance Assistant's job description signed and dated 11/11/2024, revealed .Responsible for the care and use of supplies and maintenance equipment used in performance of duties . 3. Random observation on 12/16/2024 at 10:25 AM, revealed an unlocked vacant room on the 100 Hall, being renovated, containing the following hazardous supplies and materials that were unsecure and unattended: a. 1 five-gallon bucket containing a white liquid substance and a paint roller that was open and without a lid. b. 3 closed boxes of nails on the wall storage unit counter. c. 1 opened plastic container of screws and nails, and 1 unopened plastic container of screws on the floor in front of the wall storage unit. d. 4 five gallon closed buckets of paint and one of the buckets had dried paint around the top rim of the bucket. e. 1 opened box of approximately 10 tubes of caulking near the entrance door. 4. Review of the facility's list of cognitively impaired residents assessed as having wandering behaviors revealed 4 of 8 (Residents #9, #10, #11, and #12) of the residents were mobile. a. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Diabetes, and Moderate Intellectual Disabilities. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) was not performed due to Resident #9 was severely cognitively impaired. Resident #9 was ambulatory and independent with bed mobility and transfers. b. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Malnutrition, Anxiety, and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated Resident #10 was cognitively intact. Resident #10 was ambulatory and independent with transfer and bed mobility. c. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Schizoaffective Disorders, and Moderate Intellectual Disabilities. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS was not conducted due to Resident #11 was severely cognitively impaired. Resident #11 was ambulatory with supervision and independent with the use of a wheelchair. Resident #11 was assessed for wandering behaviors. d. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Heart Failure, Anxiety, and Alzheimer's Disease. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 10 which indicated Resident #12 was moderately cognitively impaired. Resident #12 was ambulatory and was independent with bed mobility. Resident required staff supervision with transfers. Resident was assessed for wandering behaviors. 5. During an interview on 12/16/2024 at 2:14 PM, the Maintenance Assistant confirmed that the following items in the vacant room on the 100 Hall was paint, a bucket with a white mixture of paint and water liquid used to clean paint rollers, nails, screws, caulking, and sheetrock mud. The Maintenance Assistant confirmed that the paint and screws could be hazardous to residents. During an interview on 12/16/2024 at 5:31 PM, the Administrator was asked if hazardous materials or chemicals should be stored in an unlocked room that is accessible by residents. The Administrator stated, if they are hazardous, then no.

Based on policy review, facility services agreement, medical record review, and interviews, the facility failed to provide timely radiology services for 2 of 2 (Resident #1 and #2) sampled residents reviewed with radiology services. The findings include: 1. Review of the facility's policy Lab and X-Ray Services dated 2/2023, revealed .The center maintains agreements/contracts for clinical, laboratory and radiological services . Review of the facility's [Named company] Portable Services Agreement, dated 3/1/2019, revealed .On-Call Emergency Provider Services. Provider shall be available 24 hours a day, seven days a week for STAT requests. STAT [emergency] services is provided for critical situations requiring rapid results .Facility shall use its best efforts to limit STAT orders to urgent situations where the absence of such an order could reasonably be believed to place the patient's health in serious jeopardy or result in serious bodily impairment or dysfunction . Review of the facility's [Named company] Placing An Order, undated, revealed .Click on Orders in blue on the top right .Click on Priority and select [Normal=same day] or [Stat= 2-4 hours] . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Osteopenia, Osteomyelitis Vertebra, Sacral, and Left Hip, Stage 4 Pressure Ulcer Left Hip present on admission, Heart Failure, Osteoarthritis Left Hip, Cerebral Infarction with Left Sided Hemiplegia/paresis, Epilepsy, Gastrostomy Tube, Methicillin Resistant Staphylococcus Aureus of the wound, Severe Calorie Malnutrition and Vitamin D Deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 12, which indicated Resident #1 was moderately impaired cognitively for daily decision making. Review of Resident #1's progress note dated 8/29/2022 at 5:02 PM, revealed .pt [patient] was turned to right side and a pop was heard towards hip and upper left leg region. Pt reports of some increased pain. NP [Nurse Practitioner] immediately notified and STAT left knee, femur and lt [left] hip x-ray ordered . Review of [Named Radiology Services] Radiology Report dated 8/30/2022 at 9:17 AM, revealed .Conclusion: Acute fracture left hip .Report was provided to the facility at the time of the dictation . During an interview on 7/5/2023 at 3:16 PM, Registered Nurse (RN) Wound Care Nurse confirmed the 8/29/2022 5:02 PM progress note. He stated .I immediately notified [named Radiology Services] for a stat x-ray . During an interview on 7/5/2023 at 3:31 PM, Assistant Director of Nursing (ADON) was asked what the expectation for timeliness of a stat x-ray is. He stated .When an x-ray is ordered stat, they [named company Radiology Services] are to be onsite in 2-4 hours as stated on the company order form of what stat is . The ADON confirmed 16 hours from the length of time order sent to the radiology company and the radiology report time. He stated .Yes, that is to long . During an interview on 7/5/2023 at 4:55 PM, LPN #1 stated .We call the [named company Radiology Services] and log in to place order when a stat x-ray is ordered .we are at the mercy of the x-ray people when they come .we put the order in but them coming in two to four hours doesn't happen every time and many times they don't call and let us know they can't come stat . 3. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Osteopenia, Chronic Obstructive Pulmonary Disease, Heart Failure, History of Falling, Osteoarthritis, Dementia with Behaviors, Anxiety and Chronic Pain. Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 was assessed to have a BIMS score of 3, which indicated Resident #3 was severely impaired cognitively for daily decision making. Medical record review revealed Resident #2 fell on [DATE] at 7:06 PM and stat x-ray ordered. Review of Resident #2's Nurse's note dated 5/31/2022 at 2:14 AM, revealed .Patient has been complaining of left hip pain from fall this shift. Scheduled Tylenol given not effective. STAT x-ray ordered but company [now] states unable to obtain x-ray until the AM. NP ordered send to ER [emergency room ] for eval left hip . Review of Resident #2's Emergency Department Patient Summary dated 5/31/2022 at 3:28 AM, revealed .Arrival time 5/31/2022 3:28:31 .apparent ground level fall has a comminuted left hip fracture . During an interview on 7/5/2023 at 3:31 PM, the ADON confirmed Resident #2 waited over 7 hours from the length of time the x-ray order was sent to the radiology services until notification by the radiology services unable to come to the facility until the AM. He stated, .Yes, we notified them of the stat x-ray around 7 PM and it wasn't until after 2 AM we found out they were not going to be able to come to the facility until later on in the morning .we expect 2-4 hours for stat .

Based on review of the Partner Handbook and Social Work Services Manual, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 4 of 18 staff members (Certified Nursing Assistant (CNA) #1, #5, #6, and #7) failed to knock before entering a resident's room and did not use courtesy titles to address residents. The findings include: Review of the facility's undated handbook titled, [Named company] Partner Handbook, revealed .CARING IN A BETTER WAY DAY BY DAY .combines the best clinical care with the best customer satisfaction for patients .Respect your privacy, dignity . Review of the facility's Social Work Services Manual, revised 6/2006, revealed .The Guarantee of rights that depends on the actions of PARTNERS are requirements for personnel .The right to respect and dignity are requirements for the partners . Observation in Resident #44's room during dining on 6/28/21 at 11:41 AM, revealed CNA #1 stated, .she is a feeder, within hearing distance of the resident. Observation in Resident #100's room during dining on 6/28/2021 at 11:48 AM, revealed CNA #6 entered the resident's room without knocking on the door, set up the meal tray, exited the room, went to the meal cart in the hallway, returned to the resident's room and entered the room again, without knocking on the door prior to entering. Observation in Resident #104's room during dining on 6/28/21 at 12:09 PM, revealed CNA #6 entered the resident's room to set up her meal tray, without knocking on the door prior to entering. Observation in Resident #95's room during dining on 6/28/2021 at 5:43 PM, revealed CNA #5 entered the resident's room to set up her meal tray, without knocking on her door prior to entering. Observation in Resident #73's room during dining on 6/28/2021 at 5:45 PM, revealed CNA #5 entered the resident's room to set up her meal tray, without knocking on the door prior to entering. Observation in Resident #100's room during dining on 6/28/2021 at 5:50 PM, revealed CNA #5 entered the resident's room to set up her meal tray, without knocking on the door prior to entering. Observation in Resident #91's room during dining on 6/28/2021 at 5:55 PM, revealed CNA #5 entered the resident's room to set up her meal tray, without knocking on the door prior to entering. Observation outside of room [ROOM NUMBER] on 6/28/2021 at 11:51 AM, revealed CNA #7 referred to residents who were dependent diners as, our feeders, while speaking to another CNA, within hearing distance of Resident #86. Observation outside of room [ROOM NUMBER] on 6/28/2021 at 11:58 AM, revealed CNA #7 was speaking to CNA #8, and stated, .there's one feeder ., referring to a resident who was a dependent diner. She said this in a loud voice, within hearing distance of Resident #6. Observation in Resident #75's room on 6/28/2021 at 12:05 PM, revealed CNA #5 stated loudly, She's a feeder . within hearing distance of the resident. During an interview on 6/28/2021 at 12:52 PM, CNA #8 confirmed she heard CNA #7 refer to residents who were dependent diners as feeders and stated residents should not be referred to as feeders, because they are dependent diners. During an interview on 6/28/2021 at 12:55 PM, CNA #6 was asked if she knocked on the residents' doors prior to entering their rooms. CNA #6 stated, Probably not. During an interview on 6/30/2021 at 12:27 PM, the Director of Nursing (DON) confirmed staff should always knock on the resident's door or verbally announce their presence prior to entering the resident's room. The DON confirmed that residents should not be called feeders.

Based on review of the Centers for Disease Control (CDC) and Prevention guidance, policy review, observation, and interview, the facility failed to food was served under sanitary conditions when 6 of 18 staff members (Certified Nursing Assistant (CNA) #1, #2, #3, #5, #6, and #7) failed to don appropriate personal protective equipment (PPE) when entering a contact isolation room, failed to perform hand hygiene after touching potentially contaminated objects before serving residents meals, used their bare hands to handle a resident's food, failed to perform hand hygiene before and after glove use, failed to perform hand hygiene between serving residents, and used long acrylic nails to open a carton of milk. The findings include: Review of the facility's specialized CNA training titled, 000 Training revised 2/11/2013, revealed .MEAL DELIVERY - DINING ROOM .HANDS SHOULD BE WASHED ANYTIME YOU COME IN CONTACT WITH PATIENT OR EQUIPMENT . Review of the facility's policy titled, .TRANSMISSION-BASED PROCEDURES .HANDWASHING, revised 10/1/2008, revealed .Wash hands before and after contact with each patient .before and after removal of gloves . Review of the facility's policy titled, .GLOVE TECHNIQUE (CLEAN), dated 5/2021, revealed .Gloves are used to prevent contamination of healthcare personnel [personnel's] hands when .having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route .or .handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces . Review of the CDC and Prevention guidance titled, .Guideline for Isolation Precautions ., dated 2007, revealed, .Contact precautions .Use of personal protective equipment .wear gloves whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient .Don gloves upon entry into the room .Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don gown upon entry into the room .Remove gown and observe hand hygiene before leaving the patient-care environment . Review of the medical record, revealed Resident #209 was admitted to the facility on [DATE] with diagnoses of Urinary Tract Infection and Extended Spectrum Beta-Lactamase (ESBL) (a drug resistant bacteria) in the Urine. Review of a Physician's Order dated 6/25/2021, revealed Resident #209 was placed in contact isolation. Review of a Skilled Nursing Note dated 6/28/2021, revealed, .Isolation continued r/t [related to] ESBL urine . Observation in the 200 Hall on 6/28/2021 beginning at 11:14 AM, revealed CNA #7 carried a lunch tray into Resident 209's isolation room and placed it on his overbed table that was beside his bed. CNA #7 failed to don gloves or a gown before she entered the isolation room. CNA #7 touched the foot of Resident 209's bed and adjusted the overbed table. CNA #7 did not perform hand hygiene and donned clean gloves. She then set up the lunch tray for Resident #209, unfolded the silverware from the napkin, and used the silverware to cut up the food. Observation in the 100 Hall on 6/28/2021 at 11:19 AM, revealed CNA #2 assisted a resident down the hallway in her wheelchair to the nursing station, touched her head, and failed to perform hand hygiene. CNA #2 removed a tray from the lunch tray cart and entered Resident #3's room. Resident #3 refused the tray, and CNA #2 placed the tray back onto the clean cart. She then entered Resident #3's room, removed a housecoat from the resident's drawer, donned gloves, and assisted the resident with her housecoat. CNA #2 removed her gloves, failed to perform hand hygiene, and went back to dining cart and continued to serve trays. Observation in the resident's room on 6/28/2021 beginning at 11:26 AM, revealed CNA #1 entered Resident #35's room, placed the lunch tray on the overbed table, and exited the room. CNA #1 failed to perform hand hygiene and pushed the tray cart down the 100 hall. CNA #1 then entered Resident #80's room, failed to perform hand hygiene, and set up the lunch tray, touching all the items on the tray. CNA #1 returned to the cart and obtained another lunch tray, took it into Resident #88's room, failed to perform hand hygiene, and set the lunch tray up, touching all the items on the lunch tray. Observation in the resident's room on 6/28/2021 at 11:32 AM, revealed CNA #1 entered Resident #45's room, placed the lunch tray on the overbed table, dropped her badge on the floor, and picked her badge up off the floor. CNA #1 failed to perform hand hygiene and set up the lunch tray, touching all of the items on the tray. Observation in the resident's room on 6/28/2021 at 11:34 AM, revealed CNA #1 entered Resident #10's room, placed the tray on the overbed table, and moved the resident's wheelchair to the side. CNA #1 failed to perform hand hygiene and set up the lunch tray, touching all the items on the tray. CNA #1 then obtained another lunch tray, took it into Resident #30's room, failed to perform hand hygiene, and set up the lunch tray, touching all the items on the tray. Observation in the 100 Hall on 6/28/2021 beginning at 11:41 AM, showed CNA #7 knocked on Resident #15's door, and set a lunch tray on the overbed table. CNA #7 touched the table, reached down and touched the bottom of the table, near the wheel to adjust the table. CNA #7 failed to perform hand hygiene, touched the water pitcher, and then began to set up the lunch tray. She touched the napkin and removed the silverware, touched the straw and placed it in the iced tea, and used the silverware to cut up the chicken. CNA #7 failed to perform hand hygiene and began to assist the roommate, Resident #10. She picked up Resident #10's spoon and gave her a bite of food. Observation in the resident's room on 6/28/2021 at 11:48 AM, revealed CNA #6 entered Resident #100's room and placed the meal tray on the overbed table, donned gloves, propelled the resident in her wheelchair to the overbed table using the handles, reached down and manually turned the left front wheel of the chair with her left, gloved hand, and continued to set up the resident's meal tray, without removing the gloves and performing hand hygiene. CNA #6 exited the resident's room wearing the same pair of gloves, went to the meal cart, retrieved artificial sweetener from a plastic tray on top of the cart, and returned to the resident's room still wearing the same pair of gloves. CNA #6 removed her left glove and stirred the artificial sweetener into the resident's tea with her left hand, without performing hand hygiene. CNA #6 removed her right glove, exited the resident's room, returned to the meal cart, and opened the door of the cart, without performing hand hygiene. Observation in the 100 Hall on 6/28/2021 at 11:53 AM, showed CNA #7 took a lunch tray in Resident #86's room and placed the tray on the overbed table. CNA #7 then touched Resident #86's gown, touched her blanket, attached the call light button to Resident #86's gown, and failed to perform hand hygiene. CNA #7 then began to set up the lunch tray. She opened the milk, unfolded the napkin and silverware, touched the tip of the straw, and used the silverware to cut up the chicken. Observation in the resident's room on 6/28/2021 at 12:00 PM, revealed CNA #6 entered Resident #99's room, placed the meal tray on his overbed table, raised the head of his bed, moved the overbed table to his bedside, donned gloves, set up the resident's meal tray, removed the lids from the cups and bowls, cut up the resident's meat, added artificial sweetener to his cup of tea, and stirred it with the straw, without performing hand hygiene before donning the gloves. Observation in the resident's room on 6/28/2021 at 12:09 PM, revealed CNA #6 entered Resident #104's room, donned gloves, retrieved house slippers from a drawer in the chest, placed the slippers on the resident's feet, retrieved the resident's walker from across the room and placed it in front of the resident. CNA #6 then set up the resident's meal tray, and cut up food, without performing hand hygiene after touching the potentially contaminated surfaces in the room. Observation in the resident's room on 6/28/2021 at 5:14 PM, revealed CNA #3 unwrapped Resident #10's sandwich with her bare hands, placed her hand on top of the sandwich and cut the sandwich in half. CNA #3 opened the resident's crackers with her bare hands and placed them on the side of the resident's plate. Observation in the resident's room on 6/28/21 at 5:26 PM, revealed CNA #3 placed Resident #86's supper tray on the overbed table, pulled the cord to turn on the light, positioned the resident in bed with the draw sheet with her bare hands, and then failed to perform hand hygiene. CNA #3 set up the supper tray, touching all the items on the tray. Observation in the resident's room on 6/28/2021 at 5:40 PM, revealed CNA #5 opened Resident #312's milk carton by placing her long, acrylic fingernail inside the carton to open the spout. During an interview on 6/30/2021 at 12:27 PM, the Director of Nursing (DON) was asked if staff should don PPE for contact isolation before entering contact isolation rooms during dining. She confirmed PPE should be worn before entering a contact isolation room at any time. The DON confirmed that after touching any equipment or surfaces in the resident's room, staff should always perform hand hygiene before they set up a resident's meal tray. The DON confirmed that staff should not touch the resident's food with their bare hands. The DON was asked how often staff should perform hand hygiene when passing trays. The DON stated, After each patient. The DON confirmed once a tray is taken into a resident's room it should not be placed back on the clean tray cart. The DON was asked if staff should touch the tip of the residents' straws. The DON stated, Not without hand sanitizing. She confirmed staff should not use their fingernails to open a resident's milk carton.

Based on medical record review, observation, and interview, the facility failed to ensure a resident's indwelling urinary catheter bag did not touch the floor for 1 of 2 sampled residents (Resident #13) reviewed with indwelling urinary catheters. The findings include: Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #13 had an indwelling urinary catheter. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in Resident #13's room on 6/28/2021 at 10:56 AM and 4:45 PM, revealed that the indwelling urinary catheter bag was lying on the floor. During an interview on 6/30/2021 at 12:34 PM, the Director of Nursing (DON) confirmed that the indwelling urinary catheter bag should not be in the floor.

Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 2 (Resident #84) abuse incidents reviewed. The findings include: The facility's Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy revised 12/11/17 documented, .INTERNAL INVESTIGATION POLICY .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident .The investigation is conducted immediately under the following circumstances .When it is identified that an alleged incident may have occurred .When there is a question as to whether to conduct an investigation, it is best to do so . Medical record review revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #84 on 7/29/19 at 9:05 AM, in her room, Resident #84 stated, .I was left wet all night. They (staff) didn't do anything. She (Certified Nursing Assistant (CNA)) said I shouldn't be lying about her. The next night they (staff) got on to her (CNA). The third night she (CNA) kissed me in the mouth and said she (CNA) loved me. Resident #84 was asked if she knew the CNA's name. Resident #84 stated, (Named CNA #1). She works midnights . Review of an untitled facility timeline presented by the Assistant Director of Nursing (ADON) on 7/29/19 regarding an incident with Resident #84 documented, .7/18/19 .(Named Resident #84) reported the CNA from 11p (pm)-7am shift had not change her (Resident #84) properly. Patient (Resident #84) states that at approximately 2-3 am she (Resident #84) put her call light on because she (Resident #84) was wet and needed to be changed. Patient (Resident #84) stated (Named CNA #1) answered her call light. Only changed her (Resident #84) under pad and brief but did not change her wet bottom sheet .7/22/19---I (ADON) received a call from (Named Resident #84's daughter) .She (Named Resident #84's daughter) stated that her mother (Resident #84) had told her (Named Resident #84's daughter) about the incident of being wet and stated that .when (Named CNA #1) made her first round on 11-7 shift that she (CNA #1) asked (Resident #84) why she (Resident #84) lied on her (Resident #84) and said she (CNA #1) did not change her (Resident #84) appropriately .I (ADON) spoke with (Named Resident #84) who did state all of the above documented that occurred. She (Resident #84) also reported, that (Named CNA #1) cared for her (Resident #84) last night .stated when she (CNA #1) came in to check her (Resident #84), she (CNA #1) leaned over and kissed her (Resident #84) on the lips and stated 'I (CNA #1) still love you (Resident # 84)'. (Named Resident #84) stated that made her feel uncomfortable .and 'I (Resident #84) don't know why this has happened .I (Resident #84) did not lie on her (CNA #1)' .7/23/19 .(Named CNA #1) states she did change (Named Resident #84) properly. When I (ADON) questioned about her (CNA #1) accusing (Named Resident #84) of lying, she (CNA #1) stated, 'Yes, I did ask her why she (Resident #84) lied on me (CNA #1)' .Also questioned (CNA #1) about the kissing (Named Resident #84) on the lips. (Named CNA #1) stated, 'I (CNA #1) would never kiss my patients on the lips, but I do hug and kiss them on the cheek every night I work . The ADON confirmed that she had written this timeline and signed the document. Interview with Resident #84 on 7/31/19 at 8:32 AM, in her room, Resident #84 was asked if CNA #1 often kissed her on the cheek. Resident #84 stated, She kissed me on the mouth. Resident #84 was asked again if CNA #1 sometimes kissed her on the cheek. Resident #84 stated, No. Interview with CNA #1 on 7/30/19 at 7:35 AM, in the Conference Room, CNA #1 was asked what happened with Resident #84. CNA #1 stated, I went in the room and asked the patient, I'm trying to think what I said .asked patient why she (Resident #84) said I didn't change her and .why she (Resident #84) said I didn't change the bottom sheet. CNA #1 was asked if she kissed Resident #84. CNA #1 stated, On the cheek. CNA #1 was asked if she asked Resident #84 if she lied on her. CNA #1 stated, I don't recollect. Interview with the ADON on 7/30/19 at 1:46 PM, in the Conference Room, the ADON was asked about the incident with CNA #1 and Resident #84. The ADON stated, (Named Resident #84) said she (CNA #1) leaned down and hugged her (Resident #84) and kissed her on the lips and she (Resident #84) did not feel comfortable with that .Tuesday morning I came in and talked to her (CNA #1) about her (CNA #1 stating Resident #84) lying on her. She (CNA #1) admitted that she had said that .I then talked about the kiss .(CNA #1) said she .hug them and kiss them (residents) on the cheek . The ADON was asked when she typed up the untitled timeline. The ADON stated, .I completed it yesterday when you asked for it . The ADON was asked if any other residents were asked about CNA #1. The ADON stated, I did not. The ADON was asked if any staff were questioned about CNA #1. The ADON stated, I did not question any staff. The ADON was asked if Resident #84 had ever accused staff falsely. The ADON stated, Not that I'm aware of . The ADON was asked according to their policy, what should be done when there is an allegation of neglect or abuse. The ADON stated, An investigation should be conducted immediately. Interview with the Director of Nursing (DON) on 7/30/19 at 2:59 PM, in the Conference Room, the DON was asked if an investigation had been done about the incidents with Resident #84. The DON confirmed there was no investigation.

Based on policy review, Infection Control Manual review, medical record review, observation, and interview, the facility failed to maintain infection control practices for 1 of 2 (Resident #60) sampled residents reviewed for urinary catheters and failed to provide effective [MEDICAL TREATMENT] communication for 1 of 2 (Resident #340) sampled residents reviewed for isolation. The findings include: 1. The facility's undated USE OF FOLEY CATHETER policy documented, .Follow the Physician order [REDACTED]. 2. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].Indwelling Catheter change every month due to [MEDICAL CONDITION] Bladder/[MEDICAL CONDITION] . 3. Observations in Resident #60's room on 7/29/19 at 8:12 AM, 1:41 PM, and 5:26 PM, revealed Resident #60 was lying in the bed and his indwelling, urinary catheter bag was lying on the floor. Interview with the Director of Nursing (DON) on 7/31/19 at 2:33 PM, the DON was asked should the urinary catheter bag be lying on the floor. The DON stated, No, Ma'am. 4. The facility's Infection Control manual with a revision date of 10/1/08 documented, .It is the right of every patient in the center to receive a standard of care which includes a safe environment which prevents the transmission of infectious disease .The goals of the Infection Control Program .decrease the risk of infection to patients, partners and visitors . The facility's Nursing Home/[MEDICAL TREATMENT] agreement documented .The nursing home will inform (named clinic) of all relevant medical .information . 5. Medical record review revealed Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Contact Precautions .RELATED [MEDICAL CONDITION] BLOOD AND WOUND .[MEDICAL TREATMENT] every Tuesday, Thursday .and Saturday . Interview with Licensed Practical Nurse (LPN) #1 on 7/30/19 at 3:24 PM, in the South Nurse's Station, LPN #1 was asked what type of communication goes with Resident #340 to [MEDICAL TREATMENT]. LPN #1 stated, We (staff) fill out a form called the [MEDICAL TREATMENT] Communication Worksheet. LPN #1 was asked did Resident #340 [MEDICAL CONDITION] which required contact isolation. LPN #1 stated, Yes. LPN #1 was asked if the information concerning [MEDICAL CONDITION] was included on the [MEDICAL TREATMENT] Communication Worksheet. LPN #1 stated No, but I guess it (MRSA information) should be . LPN #1 was asked if that information was given today in verbal report to [MEDICAL TREATMENT]. LPN #1 stated, No . Interview with the DON on 7/31/19 at 2:48 PM, in the Conference Room, the DON was asked if isolation status should be included on the [MEDICAL TREATMENT] Communication Form. The DON stated, Just because it (isolation status) is not on the form doesn't mean they ([MEDICAL TREATMENT] staff) don't know. The DON was asked how can isolation status be communicated and not overlooked. The DON stated, I will have to add it (isolation status) to this form. Interview with LPN #2 on 8/1/19 at 9:50 AM, in the Conference Room, LPN #2 was asked if she was over Infection Control. LPN #2 stated, Yes. LPN #2 was asked should the [MEDICAL TREATMENT] Communication Worksheet reflect that the patient is in Isolation. LPN #2 stated, Yes .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure fall prevention measures were followed for 2 of 4 (Resident #18 and 76) sampled residents reviewed for falls. The findings included: 1. The facility's undated GAIT BELTS policy documented, .Designated partner will use a gait belt during ambulation or movement of the patient who needs security and assistance .Objective .Provide increased security for the patient and staff .Prevent injury during movement of patient .Use the belt during walking to stabilize the patient .If patient begins to fall, use the gait belt to .Draw patient close to your body with the belt .Gently and slowly lower patient to the floor by allowing the patient to slide down your leg . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment, required extensive staff assistance with transfers, walking did not occur, and Resident #18 had 1 fall in the month prior to admission. The Post Falls Nursing assessment dated [DATE] documented, .Fall in room ambulating to bathroom . The Fall Scene Investigation Report dated 10/2/17 documented, .(Certified Nursing Technician (CNT) #4) (with) pt (patient) (and) lowered to floor .root cause of the fall .Became weak . The SCREENING FORM PAGE 2 documented, .S/P (status [REDACTED].Pt was ambulating to bathroom (with) CNT and went to floor. Was using rw (rolling walker) and CNT reports pt was trying to amb (ambulate) too quickly (and) did not slow (with) verbal cues .followed up personally (with) this CNT. Educated her on how use of gait belt could have given her more control (with) pt to both slow her down (and) slow fall . Review of a hospital history and physical dated 10/31/17 revealed a [DIAGNOSES REDACTED]. Observations of Resident #18 in her room on 12/11/17 at 9:23 AM, revealed her lying in bed with an aircast to the left ankle. Interview with CNT #5 on 12/13/17 at 11:10 AM, outside the dining room, CNT #5 was asked when staff should use gait belts. CNT #5 stated, When we are transferring residents . CNT #5 was asked if staff should use gait belts when assisting residents to ambulate to the bathroom. CNT #5 stated, Yes. Telephone interview with Licensed Practical Nurse (LPN) #2 on 12/13/17 at 2:04 PM, LPN #2 was asked if she knew if the CNT was using a gait belt when she was assisting Resident #18 to the bathroom at the time of her fall. LPN #2 stated, I'm not for sure . LPN #2 was asked whether the CNT should have been using a gait belt. LPN #2 stated, Yes, for sure. Interview with the Rehabilitation (Rehab) Director on 12/13/17 at 4:55 PM, in the therapy gym, the Rehab Director was asked if she knew whether or not the CNT was using a gait belt at the time of the fall. The Rehab Director confirmed the CNT was not using the gait belt at the time of Resident #18's fall. The Rehab Director confirmed the CNT should have been using the gait belt. 3. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS dated [DATE] documented a BIMS score of 14, which indicated no cognitive impairment, and required extensive assistance for transfers and ambulation. The care plan dated 10/6/17 documented Resident #76 had falls noted since admission, and fall prevention interventions included placing 2 fall mats at bedside when Resident #76 was in bed. Observations in Resident #76's room on 12/11/17 at 2:37 PM and 3:11 PM, and on 12/13/17 at 7:50 AM, revealed Resident #76 lying in her bed. There were no fall mats at the bedside. Interview with Licensed Practical Nurse (LPN) #1 on 12/13/17 at 7:55 AM, in Resident #76's room, LPN #1 confirmed there were no fall mats at the bedside for Resident #76. LPN #1 went to the nurses' station, reviewed the care plan, and confirmed there should be fall mats at the bedside.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure incontinence care was provided for 1 of 1 (Resident #67) sampled resident reviewed for activities of daily living (ADL) care. The findings included: 1. The facility's INCONTINENT CARE policy documented, .PURPOSE .Designated partners to giveincontinent (give incontinent) care for those patients incontinent of bowel and/or bladder .OBJECTIVE .Prevent Infections .Prevent Odors .Provide comfort to perineal area caused by irritation, infection, or incisions .Prevent skin irritation . 2. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 15, which indicated no cognitive impairment, required extensive assistance with toilet use and personal hygiene, and was frequently incontinent of bowel. Review of the care plan dated 10/20/17 revealed, Resident #67 required extensive to total assist with most ADLs and was frequently incontinent of bowel. Interventions included to check for incontinence every 2 hours and as needed and provide care. Observations in Resident #67's room on 12/11/17 at 12:06 PM, revealed Resident #67 lying in bed. Certified Nursing Technician (CNT) #1 delivered Resident #67's lunch tray to her. Resident #67 told CNT #1 she needed to be cleaned up, and CNT #1 stated, OK. I'll tell (Named CNT). CNT #1 then left the room and continued serving trays. Interview with Resident #67 on 12/11/17 at 12:52 PM, in her room, Resident #67 was asked whether staff had come to help her get cleaned up. Resident #67 stated, No . Resident #67 confirmed she had an episode of bowel incontinence. Observations in Resident #67's room on 12/11/17 at 1:00 PM, revealed Resident #67 lying in bed, with 2 staff members providing incontinence care. The brief was removed, revealing fecal incontinence. Interview with CNT #1 on 12/11/17 at 1:01 PM, on the 300 hall, CNT #1 was asked what they normally do if a resident needed incontinence care provided during a meal pass. CNT #1 stated, We usually go in and change them. CNT #1 was asked whether it was appropriate to leave a resident waiting for incontinence care after an episode of bowel incontinence during an entire meal. CNT #1 stated, No. Interview with the Director of Nursing (DON) on 12/12/17 at 3:56 PM, in the conference room, the DON was asked when she expected staff to provide incontinence care to residents. The DON stated, Every 2 hours and PRN. The DON was asked what she expected staff to do if someone needed incontinence care during a meal. The DON stated, They would provide incontinence care. The DON was asked if it was acceptable for a resident to wait through a whole meal after a request for care after an episode of bowel incontinence. The DON stated, No.

Based on medical record review, observation, and interview, the facility failed to ensure care plan interventions were followed for provision of activities of daily living (ADLs)/incontinence care and fall prevention for 2 of 23 (Resident #67 and 76) sampled residents reviewed. The findings included: 1. Medical record review revealed Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 10/20/17 documented, .Requires extensive to total assist with most ADL's .frequently incontinent of bowel .APPROACHES .Check for incontinence q (every) 2 hrs (hours) and PRN (as needed), provide care . Observations in Resident #67's room on 12/11/17 at 12:06 PM, revealed Resident #67 lying in bed. Certified Nursing Technician (CNT) #1 delivered Resident #67's lunch tray to her. Resident #67 told CNT #1 she needed to be cleaned up, and CNT #1 stated, OK. I'll tell (Named CNT). CNT #1 then left the room and continued serving trays. Interview with Resident #67 on 12/11/17 at 12:52 PM, in her room, Resident #67 was asked whether staff had come to help her get cleaned up yet. Resident #67 stated, No . Resident #67 confirmed she had an episode of bowel incontinence. Observations in Resident #67's room on 12/11/17 at 1:00 PM, revealed Resident #67 was lying in bed, with 2 staff members providing incontinence care. The brief was removed, revealing fecal incontinence. Interview with CNT #1 on 12/11/17 at 1:01 PM, on the 300 hall, CNT #1 was asked what they normally do if a resident needed incontinence care provided during a meal pass. CNT #1 stated, We usually go in and change them. CNT #1 was asked whether it was appropriate to leave a resident waiting for incontinence care after an episode of bowel incontinence during an entire meal. CNT #1 stated, No. Interview with the Director of Nursing (DON) on 12/12/17 at 3:56 PM, in the conference room, the DON was asked when she expected staff to provide incontinence care to residents. The DON stated, Every 2 hours and PRN. The DON was asked what she expected staff to do if someone needed incontinence care during a meal. The DON stated, They would provide incontinence care. The DON was asked if it was acceptable for a resident to wait through a whole meal after a request for care after an episode of bowel incontinence. The DON stated, No. 2. Medical record review revealed Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 10/6/17 revealed Resident #76 had falls noted since admission, and fall prevention interventions included placing 2 fall mats at bedside when Resident #76 was in bed. Observations in Resident #76's room on 12/11/17 at 2:37 PM and 3:11 PM, and on 12/13/17 at 7:50 AM, revealed Resident #76 lying in her bed. There were no fall mats at the bedside. Interview with Licensed Practical Nurse (LPN) #1 on 12/13/17 at 7:55 AM, in Resident #76's room, LPN #1 confirmed there were no fall mats at the bedside for Resident #76. LPN #1 went to the nurses' station, reviewed the care plan, and confirmed there should be fall mats at the bedside.

Based on observation and interview, the facility failed to ensure nurse staffing information was posted in a prominent place easily visible to the public on 3 of 3 (11/7/16, 11/8/16, and 11/9/16) days of the survey. The findings included: Observations in the facility throughout the days of 11/7/16 and 11/8/16 revealed no visible postings of the nurse staffing information. Observations in the Assistant Director of Nursing (ADON) office on 11/9/16 at 12:30 PM, revealed the staff posting for 11/9/16 was pinned on a bulletin board. Interview with the Director of Nursing (DON) on 11/9/16 at 12:45 PM, the DON was asked where the staff posting was located. The DON stated, .It is on the door of the ADON's office .I don't know why it is on the bulletin board . The DON was asked if the staff posting was visible to the public. The DON stated, Not really.

Based on policy review, review of employee files, and interview, the facility failed to provide documentation that employees were free from communicable disease for 2 of 9 (Dietary Manager (DM) and Activities Director (AD) employee health records reviewed. The findings included: 1. The facility's Partner Health policy documented, .An annual health screen is completed, reviewed, and filed annually in the partner health record . 2. Review of the employee file for the DM revealed no documentation that the DM had a physical in 2016, or that a physician had reviewed the health record or found the DM to be free from communicable disease and infection. Review of the employee file for the AD revealed no documentation that the AD had a physical in 2016, nor that a physician had reviewed the health record or found the AD to be free from communicable disease and infection. Interview with the Director of Nursing (DON) on 11/9/16 at 12:24 PM, in the Day Room, the DON was asked if there was a recent physical or a physican's statement that the DM and the AD were free from communicable disease. The DON stated, .No, there is no signature on the health form that states the employees are free of communicable disease .

Based on policy review, observation and interview, it was determined the facility failed to ensure food was protected from physical contaminates and other sources of contamination as evidence by kitchen doors observed propped open and 18 of 18 unauthorized persons (Administrator, Director of Nursing (DON), Business Office Manager (BOM), Certified Nursing Assistant (CNA #1, 2, 3, 4, 5, 6, 7, 8 and 9, Maintenance Director, Physical Therapy Assistant #1, Housekeeper #1, 2 and 3 and family member #1) entered the kitchen without a hair net. The facility had a resident census of 92 with 5 residents currently under isolation precautions. One (1) of 15 staff members (CNA #3) failed to ensure practices were performed to prevent the potential spread of infection when CNA #3 adjusted Resident #65's underpad, removed a pillow between the resident's legs, set up the meal tray and assisted Resident #65 to eat without performing hand hygiene. The findings included: 1. Review of facility's "Safety & (and) Sanitation Best Practice Guidelines" policy documented, "...3. Hair Restraints... (a) Dietary partners shall wear hair restraints such as hats, hair coverings, or nets... that covers body hair, that are designed and worn to effectively keep their hair from contacting expose food; clean equipment, utensils, and linens... 5. Persons unnecessary to the food establishment operation are not allowed in the food preparation, food storage, or warewashing areas..." 2. Observations on 8/11/14 beginning at 7:25 AM through 8:15 AM revealed the following: Three (3) doors allowed entrance into the kitchen from the main dining room. The door on the far left entered the dietary office/kitchen hallway. This hallway contained the dietary office, the walk in refrigerator and freezer, dietary storage cabinet, the dish drying rack, an opening into the dish room, the dietary bathroom, and an entrance directly into the kitchen adjacent to the dish machine. The door to this hallway was observed propped open. The following staff members were observed to enter the kitchen during the breakfast meal on 8/11/14. None of these staff members wore hair coverings. a. 7:28 AM - the administrator entered the kitchen. b. 7:43 AM - the BOM entered the kitchen. c. 7:45 AM - the DON entered the kitchen. d. 7:58 AM - the administrator re-entered the kitchen. Observations on 8/11/14 from 7:25 AM through 8:15 AM revealed, the door on the far right of the main dining room entered directly into the kitchen. Just inside there was a drink/ice bar to the right. The tray line/steam table was in front of and ran to the left of this entrance. There was a walk space across the front of the tray line/steam table that ended in front of and to the right of the middle door that entered the kitchen from the main dining room. At both corners of the tray line/steam table were signs that documented "Dietary partners only beyond this point". The door entering the kitchen on the far right side was observed propped open. Both doors were observed to be open throughout the breakfast service. The following staff members were observed to enter the kitchen through the far right door at the drink bar/tray line during the breakfast meal on 8/11/14. None of these staff members wore hair coverings. a. 7:25 AM - CNA #1 got a plate of food. b. 7:30 AM - CNA #2 got a plate of food. CNA #2's hair was long dreadlocks and was uncovered. c. 7:35 AM - CNA #3 got a bowl of cereal. CNA #3's hair was long dreadlocks and was uncovered. d. 7:38 AM - CNA #1 re-entered the kitchen to get coffee. e. 7:38 AM - CNA #2 re-entered the kitchen to ask a dietary staff member a question and left. f. 7:40 AM - BOM and CNA #1 entered the kitchen and fixed coffee. The Maintenance Director entered the kitchen and spoke with a dietary staff member and left. g. 7:44 AM - CNA #3 entered kitchen and fixed coffee at the drink bar. h. 7:45 AM - CNA #4 entered kitchen and left. i. 7:50 AM - CNA #5 entered kitchen and got coffee. j. 7:52 AM - PTA #1 entered the kitchen and got bowl of cereal. k. 7:58 AM - CNA #4 entered the kitchen. l. 8:00 AM - Housekeeper #1 entered the kitchen and got a cup of coffee and CNA #6 entered the kitchen and spoke with a dietary staff member. m. 8:10 AM - CNA #4 entered the kitchen and got a glass of ice. n. 8:12 AM - CNA #2, CNA #3, and CNA #7 all re-entered the kitchen. 3. Observations on 8/12/14 at 8:00 AM through 8:40 AM revealed the far left door entering the dietary office / kitchen hallway was propped open. Observations on 8/12/14 from 8:00 AM through 8:15 AM revealed the far right door entering the kitchen was propped open while dietary staff were serving the breakfast meal. The following staff were observed to enter the kitchen during the breakfast meal. None of these staff members wore hair coverings. a. 8:00 AM - CNA #8 entered the kitchen. b. 8:15 AM - CNA #9 entered kitchen and got a bowl of cereal. A dietary staff member was observed to close the far right kitchen door at 8:15 AM. Observations on 8/12/14 the following staff members entered the kitchen through the center door that was closed. None of these staff members wore a hair covering. a. 8:20 AM - CNA #3 entered the kitchen. b. 8:23 AM - Housekeeper #2 entered the kitchen and got a glass of tea. c. 8:25 AM - Housekeeper #3 and CNA #1 entered the kitchen. Observations on 8/12/14 at 12:50 PM, revealed the far left and far right kitchen doors were propped open, while dietary staff were serving the noon meal. Observations on 8/12/14 from 4:25 PM through 5:20 PM, revealed the far left and far right kitchen doors were propped open, while dietary staff were serving the supper meal. Observations on 8/12/14 from 4:25 PM through 5:20 PM, revealed an unauthorized person (family member #1) entered the kitchen through the open far right door multiple times talking to staff and moving the filled meal carts to the hall area outside the main dining room. Family member #1 did not wear any hair covering while in the kitchen during the supper meal service. 4. Observations on 8/13/14 at 7:30 AM through 7:45 AM, revealed the far left and far right kitchen doors were propped open while dietary staff were serving the breakfast meals. The BOM was entered the kitchen to get a cup of coffee through the far right kitchen door. The BOM did not wear a hair covering during this breakfast meal service. Observations on 8/13/14 at 11:15 AM and at 12:30 PM, revealed the far left and the far right kitchen doors were propped open while dietary staff were serving the noon meal. 5. During an interview at the south nurses' station on 8/11/14 at 10:55 AM, CNA #2 was asked about the resident meal service. CNA #2 stated, "No one eats in the dining rooms at breakfast. We sanitize our hands, get the tray, knock on the door, and set the tray up. If there is something missing or the resident requests something different we go to the kitchen to get it. If it is coffee we go to the drink bar and fix it for the resident. If it is a food or juice we ask the dietary staff and they will hand it to us." During an interview at the south nurses' station on 8/11/14 at 2:00 PM, CNA #7 was asked the about the meal service process. CNA #7 stated, "We sanitize hands, get tray, knock on door, take tray to the room and set tray up for the residents. If they (residents) ask for alternates or something else we go to the kitchen and get it." CNA #7 was asked about the process for getting things from the kitchen. CNA #7 stated, "If the resident wants a drink like coffee we go in and fix that ourselves from the drink line. If it is a juice or food we ask the dietary staff and they will give it to us." CNA #7 was asked what the process was for staff entering the kitchen. CNA #7 stated, "We sanitize our hands and go in." During an interview in the conference room on 8/13/14 at 8:40 AM, the head cook was asked to explain the signs posted at the corners of tray line. The head cook stated, "That is to let staff and visitors know they are not go past those signs. Past those signs they have to wear hair nets but only dietary staff are past those signs." The head cook was asked about entering the kitchen. The head cook stated, "Staff and visitors can come into the front area. They do not have to wear hairnets, they can get drinks. The doors are open to allow staff and visitors to come in to fix their drinks." During an interview in the conference room on 8/13/14 at 9:00 AM, the DON was asked about staff in the kitchen. The DON stated, "Staff and visitors can go into the front area of the kitchen. They cannot go past the tray line. They can go in and get drinks. We don't have to wear hairnets in the area we can go in." The DON confirmed a resident census of 92 with 5 residents currently under isolation precautions. During an interview in the conference room on 8/13/14 at 12:45 PM, the Registered Dietician (RD) was asked what her expectations were regarding the kitchen doors. The RD stated, "The doors leading into the kitchen food serving area are suppose to be closed. The door leading into the dietary office hallway is sometimes closed and sometimes open." The RD was asked what her expectation were regarding hairnet use in the kitchen. The RD stated, "Anyone going beyond the tray line has to have either a hairnet on or a cap." The RD was asked what her expectations were regarding non dietary staff entering the kitchen. The RD stated, "Staff can go into the kitchen up to the tray line. There are signs at the ends of the tray line for dietary staff only past that point." The RD was asked if staff in these areas are required to have hairnets on. The RD stated, "No, as long as they don't go past the tray line." The RD was asked what her expectations were regarding family going into the kitchen. The RD stated, "It is the same, they cannot go past the tray line area. They do not have to have on hairnets in the front part of the kitchen at the tray line." The facility failed to ensure that food was protected from sources of physical contamination such as hair and from other sources of contamination. 6. Review of the facility's "Safety & Sanitation Best Practice Guidelines HANDWASHING" policy documented, "...OUTCOME: All partners handling food products or contacting equipment in food preparation should wash their hands... The basic practice of hand washing is the single most important action that can be taken to prevent the spread of disease... GUIDELINES: 1. Hands should be washed... after touching hair, face, or body... touching clothing... or after touching anything that might contaminate hands..." Observations in Resident #65's room on 8/11/14 at 7:42 AM, revealed CNA #3 repositioned Resident #65, adjusted the resident's underpad and removed a pillow between her legs, touching the resident's legs. CNA #3 continued to set up the meal tray, then started to assist Resident #65 to eat, without performing hand hygiene. During an interview in front of the conference room on 8/13/14 12:40 PM, the DON was asked what should staff do while passing meal trays or assisting a resident to eat after touching a resident or inanimate objects. The DON stated, "They (staff) should wash their hands."