Every finding on record at Shannondale of Maryville Health Care Center

Based on facility policy review, facility documentation review, and interview, the facility failed to maintain a grievance log for the required period of 3 years.The findings include: Review of the facility's policy titled, Grievances, dated 7/1/2009, revealed .Grievance Log will be kept for a period of three (3) years. The log shall contain evidence of the resolution and grievances . Review of the facility's Concern log revealed the facility had record of grievances from July 2024 - August 2025. There was no log available for grievances prior to July 2024. During an interview on 9/3/2025 at 11:44 AM, the Administrator confirmed no grievance log was available in the facility prior to July 2024. The facility changed administration and ownership in June 2024. The Administrator confirmed the grievance log was to be kept and available for review in the facility for a period of 3 years. During an interview on 9/3/2025 at 11:48 AM, the Case Manager stated she was the current grievance official at the facility. The Case Manager had been the grievance official since the facility changed ownership in June 2024. The Case Manager stated she was unaware where the grievance log was prior to July 2024. The Case Manager confirmed there was no grievance log available prior to July 2024 and that grievance logs were to be kept for a period of 3 years. The Case Manager stated she had reached out to the former grievance official who no longer worked at the facility who was unaware where the grievance logs were located.

Based on facility policy review, facility reported state intake information, medical record review, and interview, the facility failed to ensure allegations of abuse were reported to the appropriate authorities for 2 Residents (Residents #3 and #8) of 5 resident abuse investigations reviewed.The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Misappropriation of Residents Property, revealed .All alleged abuse and all substantiated incidents will be reported to the Bureau of Quality Assurance of Health Care Facilities and any other agencies as required . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Diverticulitis of Large Intestine, Dysphagia, Repeated Falls, and Dementia. Review of Resident #3's undated comprehensive care plan revealed .potential for impaired thought processes r/t [related to] dementia .Impaired thought processes .r/t cognitive loss .No male caregivers . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Resident #3 had moderately impaired vision with corrective lenses and exhibited no behavioral symptoms. The resident required a wheelchair for mobility and substantial/maximal assistance for toileting hygiene, shower/bathe self and personal hygiene. Review of the state agency facility reported incident intake information revealed the facility reported an allegation of sexual abuse for Resident #3 on 4/16/2024 by the former Director of Nursing (DON). The alleged incident occurred on 4/16/2024 at 2:25 PM. It was noted .It was noted, .Reporting out of an abundance of caution .[Resident #3] .had a Nurse approach her and she [Resident #3] stated 'Do Not let your daughter go to the bathroom alone.' She continued with 'There is 2 men .and they fingered me to death and I fell for the trap'. The resident also told the nurse. 'It was 2 old men' .investigation initiated Medical provider notified. Daughter notified . Continued review revealed .[Resident #3] .Resident was in the dining room, in her geri-chair watching television. Resident motion for nurse to approach her. The resident told the nurse 'Do not let your daughter go to the bathroom alone'. Nurse asked why? Resident stated, 'There is two men down there and they fingered me to death, I fell for the trap'. Nurse tried to comfort resident and notified social services of the situation. Social service notified the Director of Nursing (DON) .Investigation was initiated. Tearful .Physician notified .Social Service was notified .Resident exam with not injury noted .Conclusion .Not verified .No visitors or unknown people in the area. Resident was in sight of staff at all times .DX of dementia and when exam by staff RN [Registered Nurse], there was no harm or injury noted .Corrective Action .Have asked for no male caregivers for resident . During an observation and interview on 9/2/2025 at 3:07 PM, Resident #3 was lying in bed watching television. Resident #3 stated she had been at the facility for 2 weeks and the year was 3021. Resident #3 denied anyone hurting her or touching her inappropriately at the facility and stated .I'm bigger than everybody . During an interview on 9/3/2025 at 2:40 PM, the DON stated she was not employed by the facility at the time of Resident #3's allegation and did not participate in the investigation. The DON stated there was no documentation available in the facility related to the investigation of Resident #3's allegation of sexual abuse. The DON confirmed the only information she had related to the allegation of sexual abuse for Resident #3 was from the 5 day follow up report she was able to pull out of the facility reported incident computer system. The DON confirmed there was no other documentation available related to the allegation. The DON confirmed investigation documentation was to include what notifications were made. The DON confirmed she was unaware if law enforcement and Adult Protective Services (APS) were notified of Resident #3's sexual abuse allegation and stated there was no notification to law enforcement, Adult Protective Services (APS) .that I have located . Notifications to law enforcement and APS were to be documented and included in the facility investigation documentation. During a telephone interview on 9/4/2025 at 10:28 AM, the former DON stated she did not recall the allegation of sexual abuse for Resident #3. The former DON stated she would have been responsible for abuse investigations, and it would have included notifications to the family, physician, state agency, Adult Protective Services (APS) and police. The former DON stated all investigations were left in her desk drawer when she left the facility. During an interview on 9/3/2025 at 4:45 PM, the DON stated she was unaware if the former administration had notified law enforcement or Adult Protective Services (APS) of Resident #3's sexual abuse allegation. The DON stated she called the local police department on 9/3/2025 and there was no police report related to Resident #3. The DON stated the facility had contacted APS on 9/3/2025 and left a message to determine if they had been notified of the allegation. The DON confirmed there was no documentation available at the facility to indicate law enforcement or APS had been notified of the allegation and confirmed both agencies should have been notified of the allegation and there should be evidence of the notification. During a telephone interview on 9/4/2025 at 1:11 PM, the local police department stated they were unable to locate a report for Resident #3. During a telephone interview on 9/4/2025 at 1:28 PM, the APS intake counselor stated she was unable to locate any reports related to Resident #3. During a telephone interview on 9/4/2025 at 1:47 PM, the APS Supervisor stated she had checked the state and county records and there had been no reports to APS regarding Resident #3. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depressive Disorder, Adjustment Disorder and Delusion Disorder. Medical record review of Resident #8's current comprehensive care plan dated 5/30/2022 revealed .Verbally abusive behavior .Converse with others without swearing or berating .is experiencing alteration in mood AEB (as evidence by) .c/o (complaint of) people coming into room and stealing . Each problem identified by the facility had appropriate pharmacological and non-pharmacological interventions implemented. Review of a Psychiatric Nurse's note for Resident #8 dated 7/13/2023, revealed the resident was seen for psychiatric evaluation for .irritability, dementia, frustration previous gpsych (geri-psychiatric) admits 071323 (7/13/2023) Administration requests consult r/t (related to) ongoing lability . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. The resident required assistance from 1 or more staff members for activities of daily living (ADL's). During an interview on 9/4/2025 at 3:16 PM, the Administrator and DON confirmed there was no investigation documentation for allegations of abuse reported to the state agency or APS for Residents #3 and #8. The Administrator and DON were unaware what the investigations for Residents #3 and #8 included because no documentation of the investigation was retained by the previous administration. The Administrator stated all allegations of abuse were to be reported to the state agency, law enforcement, and APS within 2 hours of allegation. The Administrator confirmed she was unaware if the allegations had been reported because no documentation was available from the previous administration.

Based on facility policy review, medical record review, facility reported state intake information, the facility failed to maintain evidence that an allegation of abuse was thoroughly investigated for 2 residents (Residents #3 and #8) of 5 resident abuse investigations reviewed. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Misappropriation of Residents Property, revealed .All unusual occurrences to residents are to be reported to the immediate supervisor and document on the accident/incident Report Record for follow-up, investigation and monitoring of events, occurrences and patterns which may constitute abuse or neglect .All alleged violations will be thoroughly investigated, and precautions will be taken to prevent further chance of abuse while the investigation is in process . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Diverticulitis of Large Intestine, Dysphagia, Repeated Falls, and Dementia. Review of Resident #3's undated comprehensive care plan revealed .potential for impaired thought processes r/t [related to] dementia .Impaired thought processes .r/t cognitive loss .No male caregivers . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 3 on the Brief Interview for Mental Status assessment which indicated the resident had severe cognitive impairment. Resident #3 had moderately impaired vision with corrective lenses and exhibited no behavioral symptoms. The resident required a wheelchair for mobility and substantial/maximal assistance for toileting hygiene, shower/bathe self and personal hygiene. Resident #3 was always incontinent of urine and bowel and received antidepressants, anticoagulants, and antibiotic medications during the 7 day look back period with indications noted. Review of the state agency facility reported incident intake information revealed the facility reported an allegation of sexual abuse for Resident #3 on 4/16/2024. It was noted, .Date of Occurrence: 4/16/2024 .Time: 2:25 pm .Patient .Age .89 .Sexual Abuse of Patient/Resident .Reporting out of an abundance of caution .[Resident #3] .had a Nurse approach her and she [Resident #3] stated 'Do Not let your daughter go to the bathroom alone.' She continued with 'There is 2 men .and they fingered me to death and I fell for the trap'. The resident also told the nurse. 'It was 2 old men' investigation initiated Medical provider notified. Daughter notified .Dx: [Diagnosis] unspecified Dementia, unspecified severity without Behaviors, other specified Anxiety disorders, Major Depressive disorder, HTN [Hypertension], constipation, unspecified Diverticulitis, UTI [Urinary Tract Infection], Fe [Iron] def [deficiency] anemia, nonrheumatic valve disorder, osteoporosis .Personal Hx [history] of TIA [Transient Ischemic Attack] .Bims [BIMS] 3 .Report Date: 4/16/2024 .Continued review revealed .[Resident #3] .Resident was in the dining room, in her geri-chair watching television. Resident motion for nurse to approach her. The resident told the nurse 'Do not let your daughter go to the bathroom alone'. Nurse asked why? Resident stated, 'There is two men down there and they fingered me to death, I fell for the trap'. Nurse tried to comfort resident and notified social services of the situation. Social service notified the Director of Nursing (DON) .Investigation was initiated. Tearful. assessment of the alleged victim with no medical treatment necessary. Physician notified .Social Service was notified .Resident exam with not injury noted. Remained in Dining Room in her Geri-Chair watching television. No witness to any incident .spoke with all staff working in the area .daughter .stated [Resident #3] had been raped by her uncle when she was between the ages of 6-8 .She didn't know any details. Daughter feels that her mom is just progressing in her dementia and that she is relieving things from her childhood. She requested that Psych [Psychitric] nurse practitioner see her. social worker arrange this as well as inform staff so we can comfort resident as needed .All staff reports that resident has been up in chair in the dining room .ate good lunch with no visitors this day .have been able to see her at all times. no distress was noted .Conclusion .Not verified .No visitors or unknown people in the area. Resident was in sight of staff at all times .DX of dementia and when exam by staff RN [Registered Nurse], there was no harm or injury noted .Corrective Action .Have asked for no male caregivers for resident . During an observation and interview on 9/2/2025 at 3:07 PM, Resident #3 was lying in bed watching television. Resident #3 stated she had been at the facility for 2 weeks and the year was 3021. Resident #3 denied anyone hurting her or touching her inappropriately at the facility and stated .I'm bigger than everybody . During an interview on 9/3/2025 at 11:53 AM, the Case Manager stated she had served as the Case Manager/social services since July 2024. The Case Manager did not participate in the investigation for Resident #3's abuse allegation, was unaware of the details, and unable to locate any social service documentation related to the allegation/investigation. Attempted telephone interview on 9/3/2025 at 3:21 PM with the Former Administrator that was in place at the time of the allegation. During an interview on 9/3/2025 at 2:40 PM, the DON stated she was not employed by the facility at the time of the allegation and did not participate in the investigation. The DON stated there was no documentation available in the facility related to Resident #3's allegation of sexual abuse. The DON confirmed the only information she had related to the allegation of sexual abuse for Resident #3 was from the 5 day follow up report she was able to pull out of the facility reported incident computer system. The DON confirmed there was no other documentation available related to the allegation. An abuse investigation was to include witness statements, physical assessments, notifications to physician, resident interviews and skin assessments to determine if any other residents were affected, and incident report. The DON was unable to determine what the allegation was, when it occurred, who the witnesses were, what steps were taken afterward to investigate and protect the resident, what assessments were performed, and what notifications were made. The DON confirmed there were no witness statements, social worker notes, incident report, resident physical assessment, resident interviews and skin assessments .that I have located . The DON stated there was no entry into Resident #3's medical record related to the allegation. The DON stated the facility had tried to reach out to the former administrator and DON regarding complaint investigations without success. During a telephone interview on 9/4/2025 at 10:28 AM, the former DON stated she did not recall the allegation of sexual abuse for Resident #3. The former DON stated she would have been responsible for abuse investigations, and it would have included notifications to the family, physician, state agency, Adult Protective Services (APS) and police, physical assessment of the resident, resident interview, other resident interviews and skin assessments, incident report, and witness statements for all potential witnesses. The former DON stated all investigations were left in her desk drawer when she left the facility. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depressive Disorder, Adjustment Disorder and Delusion Disorder. Medical record review of Resident #8's current comprehensive care plan dated 5/30/2022 revealed .Verbally abusive behavior .Converse with others without swearing or berating .is experiencing alteration in mood AEB (as evidence by) .c/o (complaint of) people coming into room and stealing . Each problem identified by the facility had appropriate pharmacological and non-pharmacological interventions implemented. Review of a Psychiatric Nurse's note for Resident #8 dated 7/13/2023, revealed the resident was seen for psychiatric evaluation for .irritability, dementia, frustration previous gpsych (geri-psychiatric) admits 071323 (7/13/2023) Administration requests consult r/t (related to) ongoing lability . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. The resident required assistance from 1 or more staff members for activities of daily living (ADL's). During an interview on 9/4/2025 at 3:16 PM, the Administrator and DON confirmed there was no investigation documentation for allegations of abuse reported to the state agency for Residents #3 and #8. The Administrator confirmed a thorough investigation was to be completed for all abuse allegations/state reportable incidents and should include resident interview related to the allegation, witness statements, other resident interviews/skin assessments, physical assessments, physician notification, family notification, and notifications to other agencies. The Administrator and DON were unaware what the investigations for Residents #3 and #8 included because no documentation of the investigation was retained by the previous administration. The Administrator confirmed abuse investigations were to be documented and retained in the facility. The Administrator confirmed they were unable to determine if a thorough investigation was completed because there was no investigation documentation available for Residents #3 and #8.

Based on facility policy review, observation, and interview the facility failed to maintain sanitary kitchen equipment in 1 of 1 kitchen observed. The findings include: Review of the facility policy titled, Cleaning & Sanitation dated 9/2/2020 showed, .The Director of Food and Nutrition Services will develop, implement, and monitor schedules for cleaning, sanitizing .To ensure the food service department is maintained .as well as a clean, sanitary, and safe environment .Food service employees are trained on how to properly use, clean and maintain all equipment .Cleaning schedules designate cleaning tasks for each position and are posted in an accessible area . During an observation on 7/5/2022 at 9:52 AM, with the Dietary Manager (DM) #1 showed the can opener mounted on a stainless steel food preparation table was found with dry brown food debris build up behind the can opener blade. The can opener was observed with dried brown food residue on the shaft of the can opener from liquid content as a can was opened by the blade. During an interview on 7/5/2022 at 10:12 AM, DM #1 confirmed the can opener was in unsanitary condition and was available for use to prepare food for the 30 residents in the facility. DM #1 stated the equipment cleaning schedule did not include the task of sanitizing the can opener. There was no documentation the can opener had been cleaned before it was used by the facility.

Based on facility policy review, medical record review and interview the facility failed to complete a discharge summary for 1 resident (#30) of 3 residents reviewed for transfer/discharge requirements. The findings include: Review of the facility policy titled, Discharge Policy, undated showed .Residents will be discharged with a plan of care .When a Resident is discharged documentation will include a brief summary of significant findings, and events of the residents stay in the nursing home, his condition on discharge and the recommendation and arrangements for future care .Discharge Summary will be completed when discharged .Discharge Instruction Sheet will be completed .a copy of these instructions will be given to the Resident and or family/significant other/designated Resident Representative . Medical record review showed Resident #30 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #30's Discharge Summary dated 5/4/2022 showed .discharged to assisted living . The Discharge Summary did not include a final summary of the resident's status at the time of discharge, a recapitulation (summary) of the resident's medications, or a post-discharge plan of care for Resident #30. During an interview on 7/7/2022 at 7:10 PM, Registered Nurse (RN) #1 confirmed a discharge summary is to be completed for all residents transferred from this facility. RN#1 stated Resident #30 was discharged on [DATE] and returned to the Assisted Living side of the facility. RN #1 stated she completed the discharge summary for Resident #30 but it did not include a discharge instruction sheet, a discharge plan of care, a summary of the resident's stay or a list of Resident #30's medications. During an interview on 7/7/2022 at 7:20 PM, the Social Services Director stated Resident #30 decided she wanted to return to the Assisted Living facility. The Social Services Director stated the facility did not have adequate time to complete the required discharge summary.

Based on facility policy review, medical record review, and interview the facility failed to complete falls risk assessments for 1 residents (#38) of 3 residents reviewed for accidents of 13 sampled residents. The findings include: Review of the facility policy, Fall Management Policy and Procedure, revised 6/2018, revealed .Fall Risk Assessments are to be completed with the MDS (Minimum Data Set) quarterly, annually .by the MDS nurse .Residents who score 15 or above on the Fall Risk Assessment will be identified as a high fall risk . Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed a Fall Risk Assessment had been completed on 9/1/18 with score of 24 (a score of 15 or higher indicated a resident was at risk for falls). Continued review revealed no further fall risk assessments had been completed on 5/9/19 and 8/6/19. Medical record review of the Annual Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired and never or rarely understood. Continued review revealed the resident required total assistance for bed mobility, transfer, toileting and hygiene. Medical record review of the facility falls investigation dated 2/21/19 revealed Resident #38 had a fall on 2/21/19 and sustained a laceration to the forehead with a new intervention implemented of a personal safety alarm (PSA) to the chair. Medical record review of the facility falls investigation dated 3/31/19 revealed Resident #38 had a fall without injury on 3/31/19 with a new intervention implemented of pool noodles to the mattress. Medical record review of the facility falls investigation dated 5/9/19 revealed Resident #38 had a fall on 5/9/19 and sustained an abrasion to the forehead with a new intervention implemented of a PSA to the bed. Interview with the Director of Nursing on 8/21/19 at 3:30 PM, in the conference room, confirmed residents falls risk was assessed by completing a fall risk assessment form. Continued interview confirmed fall risk assessments are to be completed by the MDS nurse on admission and quarterly. Further interview confirmed the facility failed to complete fall risk assessments timely for Resident #38 and failed to follow their facility policy.

Based on review of the facility Inservice Proper Dish Washing and Sanitizing documentation, review of the facility dish washer temperature log, and interview, the facility failed to maintain the dish machine to ensure proper sanitation of dishes for 1 of 1 high temperature dish machines, potentially affecting all residents in the facility. The findings include: Review of the facility Inservice Proper Dish Washing and Sanitizing, dated 8/9/18 revealed .very important that the dish machine is functioning properly at all times .sanitizing temp should be 180 (degrees) . Observation and interview with the Dietary Manager on 9/24/18 at 8:45 AM, in the kitchen revealed the following dates breakfast, lunch, and dinner dish machine temperatures had been below 180 degrees: 7/29/18 - 7/30/18, 8/9/18 - 8/18/18, 9/1/18, 9/3/18 - 9/4/18, and 9/9/18-9/16/18. Interview with the Dietary Manager confirmed facility policy was to maintain the dish machine rinse temperature at 180 degrees or higher. Further interview confirmed he was not aware of the lower than required temperatures that occurred in 6/2018, 8/2018, and 9/2018. Further interview confirmed the facility failed to maintain the dish machine to ensure proper sanitation of dishes.

Based on medical record review and interview the facility failed to implement a care plan for 1 resident (#1) of 5 residents reviewed for fluid management of 22 sampled residents. The findings include: Medical record review revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the care plan revised 8/21/18 revealed .Resident is on a regular no added salt diet .2000 ml (milliliters) fluid restriction .2 plus [MEDICAL CONDITION] .Fluid Shifts .Will maintain adequate nutrition as evidenced by stable weight .7/6/18 .weights Mon, Weds, Fri . Review of the weights for Resident #1 dated 7/6/18-9/24/18 revealed 5 of 35 weights were not documented. Interview with the Director of Nursing on 9/26/18 at 4:00 PM, in the conference room confirmed the facility failed follow the care plan to weigh the resident every Monday, Wednesday and Friday.

Based on medical record review and interview the facility failed to follow a Physicians order to obtain weights for 1 resident (#1) of 3 residents reviewed for fluid management of 22 sampled residents. The findings include: Medical record review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physicians Order dated 7/6/18 revealed .Obtain wt (weight) 3 times a wk (week) on M,W,F (Monday, Wednesday, Friday). Medical record review of a Dietician note dated 8/17/18 revealed .wt continues trending up with sign (significant) wt (weight) gain 8.5% x 90 days. Wt gain likely r/t (related to) fluid shifts w (with) /[MEDICAL CONDITION] . Medical record review of the weights for Resident #1 dated 7/6/18-9/24/18 revealed 5 of 35 weights were not documented. Interview with the Director of Nursing on 9/26/18 at 4:00 PM, in the conference room confirmed the facility failed to weigh the resident 3 times per week as ordered by the Physician.

Based on facility policy review, observation and interview the facility failed to ensure an accurate reconciled account for controlled medications for 1 of 3 medications carts observed. The findings include: Review of the facility policy, Narcotic Count, undated, revealed .2 .To assure controlled drugs are handled, stored, and disposed of properly .3 .To assure proper record keeping for controlled drugs .Procedure .5 .After the supply is counted and justified, each nurse must record and date and his/her signature verifying that the count is correct .6 .Discrepancies found at any time, change of shift or other, are to be immediately reported to the director of Nursing Service. Medical record review revealed Resident #34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation and interview on 9/26/18 at 5:00 PM, with Licensed Practical Nurse (LPN) #1 in the 1st skilled medication room, revealed the narcotic log for Resident #34's [MEDICATION NAME] (medication to treat anxiety) 0.25 milligram (mg) was incorrect. Continued observation revealed the narcotic log for 9/25/18 at 9:00 PM showed (3) [MEDICATION NAME] 0.25 mg remained. Further observation revealed (2) [MEDICATION NAME] 0.25 mg tablets were available. Interview with LPN #1 confirmed she does not know why the count is wrong. Interview with the Director of Nursing on 9/26/18 at 6:30 PM, in the conference room confirmed the narcotic count for Resident #34's [MEDICATION NAME] 0.25 mg was incorrect and 1 tablet was missing. Further interview confirmed the facility failed to ensure an accurate reconciled account for a controlled medication.

Based on observation, review of facility policy, and interview, the facility failed to provide sanitary storage of food preparation and serving equipment. The findings included: Observation of the dietary department, with the dietary manager on May 7, 2013, at 10:19 a.m., revealed a trash can containing dirty towels and mop heads stored next to a shelving unit with twelve clean ready to use water pitchers and four racks of clean ready to use drinking glasses. Continued observation revealed a rolling trash container stored next to a wire shelving unit containing twelve clean ready to use cooking pots and pans. Review of facility policy titled, "Dietary Policies and Procedures" (no date), revealed "...storage and handling of cleaned equipment and utensils...shall be handled in such a manner as to be protected from contamination...protected from splash, dust, and other contamination..." Interview with the dietary manager on May 7, 2013, at 10:19 a.m., confirmed dirty items were stored next to clean items without any separation and the dirty items "need to be out of there."

Based on medical record review, review of facility documents, observation, and interview, the facility failed to ensure interventions to prevent skin tears were implemented for one resident (#1) of six residents reviewed. The findings included: Resident #1 (named resident) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident had short and long term memory deficits; severely impaired cognitive skills; was short tempered and easily annoyed; experienced [MEDICAL CONDITION]; wandered about the unit in a manual wheelchair; required extensive assistance with bed mobility, transfers, dressing and hygiene; had experienced 3 or more falls without injury while at the facility; and did not have any areas of skin breakdown. Medical record review of the Care Plan, dated April 5, 2011, and last updated November 20, 2011, revealed the resident had been identified as being at risk for skin breakdown with approaches to include dermasleeves tubes (1/4 inch foam protectors providing full coverage) on bilateral upper and lower extremities while out of bed. Review of facility documents related to investigations of incidents revealed the following: 1.) October 16, 2011, at 6:00 a.m., - resident observed by CNA to have left arm between side-rails and mattress and was noted with a skin tear (ST) to the left extremity (ext). The cause was not observed. A plan was implemented to initiate dermasleeves (1/4 inch foam tubes to cover the entire area of the upper and lower extremities) while in bed; 2.) November 6, 2011, at 8:00 p.m. - CNA observed a 1cm ST on the resident's left lower ext when getting the resident out of bed and notified the nurse. The cause was not observed. A plan was instituted to have resident wear dermasleeves when in bed as well as when out of bed; 3.) December 11, 2011, at 6:30 a.m. - while getting the resident up the CNA noted the resident lying against the left side-rail of the bed. The CNA notified the nurse to check the resident when it was observed the resident had bruising to the left eye and a ST to the left arm - dermasleeves present. A plan was initiated to pad the resident's side-rails; 4.) December 15, 2011, at 8:30 p.m. - CNA was putting the resident to bed and while transferring the resident from the wheelchair the resident cried out. The CNA noted the resident reach for the right leg and the CNA noted a large laceration to the outer calf of the left leg - dermasleeves present. The nurse was notified and the resident was sent to the hospital for sutures. A plan was initiated a plan to pad the flange (peg to attach calf rests) on the wheelchair leg. Observation of the resident in the resident's room with LPN#3 and CNA's #3 and #4 on December 19, 2011, at 3:20 p.m., revealed the following after removal dermasleeves on bilateral upper and lower ext: left lower extremity (ext) with 2 ? inch "L" shaped closed wound; bilateral (both) lower ext with 2 inch by 2 inch dark purple bruising; right posterior (back) calf with a 1 inch "L" shaped skin tear (ST); right lower ext with a 10 inch by 10 inch dark purple bruise containing a 3 ? inch ST; left upper ext with a 3 inch by 4 inch dark purple bruise containing a ? inch ST; right upper posterior ext with a 1 ? inch by 1 ? inch dark purple bruise; right antecubital (bend in elbow) area with a 2 inch "C" shaped dark purple bruise; and no bruising on the back. Continued observation revealed the wheelchair the resident was currently utilizing had no padding on the calf rest attachment peg and the side-rails of the bed were not padded. Interview on December 19, 2011, at 3:20 p.m., in the resident's room with CNA #3, who was present on December 15, 2011, confirmed the resident's wheelchair calf rest pegs were to be padded and confirmed the wheelchair which was present in the resident's room did not have calf rest pegs and padding applied. Continued interview confirmed the side-rails of the bed were not padded. Interview by phone with the Director of Nursing on January 17, 2012, at 8:50 a.m., confirmed the resident's care plan for the side-rails to be padded and the wheelchair calf rest flange had not been padded. C/O #

Based on medical record review, review of facility documents, observation, and interview, the facility failed to ensure interventions were implemented to prevent injury for one resident (#1) of six residents reviewed. The findings included: Resident #1 (named resident) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident had short and long term memory deficits; severely impaired cognitive skills; was short tempered and easily annoyed; experienced delusions; wandered about the unit in a manual wheelchair; required extensive assistance with bed mobility, transfers, dressing and hygiene; had experienced 3 or more falls without injury while at the facility; and did not have any areas of skin breakdown. Medical record review of the Care Plan, dated April 5, 2011, and last updated November 20, 2011, revealed the resident had been identified as being at risk for skin breakdown/skin tears with approaches to include dermasleeves tubes (1/4 inch foam protectors providing full coverage) on bilateral upper and lower extremities while out of bed. Review of facility documents related to investigations of incidents revealed the following: 1.) October 16, 2011, at 6:00 a.m., - resident observed by CNA to have left arm between side-rails and mattress and was noted with a skin tear (ST) to the left extremity (ext). The cause was not observed. A plan was implemented to initiate dermasleeves (1/4 inch foam tubes to cover the entire area of the upper and lower extremities) while in bed; 2.) November 6, 2011, at 8:00 p.m. - CNA observed a 1cm ST on the resident's left lower ext when getting the resident out of bed and notified the nurse. The cause was not observed. A plan was instituted to have resident wear dermasleeves when in bed as well as when out of bed; 3.) December 11, 2011, at 6:30 a.m. - while getting the resident up the CNA observed the resident lying against the left side-rail of the bed. The CNA notified the nurse to check the resident when it was noted the resident had bruising to the left eye and a ST to the left arm - dermasleeves present. A plan was initiated to pad the resident's side-rails; 4.) December 15, 2011, at 8:30 p.m. - CNA was putting the resident to bed and while transferring the resident from the wheelchair the resident cried out. The CNA observed the resident reach for the right leg and the CNA noted a large laceration to the outer calf of the left leg - dermasleeves present. The nurse was notified and the resident was sent to the hospital for sutures. A plan was implemented to pad the flange (peg to attach calf rests) on the wheelchair leg. Observation of the resident in the resident's room with LPN#3 and CNA ' s #3 and #4 on December 19, 2011, at 3:20 p.m., revealed the following after removal dermasleeves on bilateral upper and lower ext: left lower extremity (ext) with 2 ? inch "L" shaped closed wound; bilateral (both) lower ext with 2 inch by 2 inch dark purple bruising; right posterior (back) calf with a 1 inch "L" shaped skin tear (ST); right lower ext with a 10 inch by 10 inch dark purple bruise containing a 3 ? inch ST; left upper ext with a 3 inch by 4 inch dark purple bruise containing a ? inch ST; right upper posterior ext with a 1 ? inch by 1 ? inch dark purple bruise; right antecubital (bend in elbow) area with a 2 inch "C" shaped dark purple bruise; and no bruising on the back. Continued observation revealed the wheelchair the resident was currently utilizing had no padding on the calf rest attachment peg and the side-rails of the bed were not padded. Interview on December 19, 2011, at 3:20 p.m., in the resident's room with CNA #3, who was present on December 15, 2011, confirmed the resident's wheelchair calf rest pegs were to be padded or the resident was to use a different wheelchair which was present in the resident's room which did not have calf rest pegs. Continued interview revealed the side-rails of the bed were to be padded. Continued interview confirmed neither a different wheelchair or padding on the wheelchair were in use. Continued interview confirmed the side-rails were not padded. Interview by phone with the Director of Nursing on January 17, 2012, at 8:50 a.m., confirmed the resident's side-rails had not been padded and the wheelchair calf rest flange had not been padded. C/O #

Based on observation and interview, the facility failed to ensure nutritional adequacy for the mechanically altered diet (puree) for eight of forty-four residents. The findings included: Observation on August 31, 2011, at 11:30 a.m., revealed dietary staff (DS #1) preparing to puree the pork chops. Continued observation revealed DS #1 removed the bone from the pork chop and cut the pork chop into chunks. Continued observation revealed DS #1 poured the pork chop pieces into the processor and activated the blades to cut/puree the meat. Observation revealed DS #1 added apples via tongs from a gallon can into the meat. Observation revealed DS #1 poured the remaining apples and the juice into the processor. Observation revealed the DS #1 took the lid off the processor; obtained water from the faucet; and poured the water into the processing meat. Interview in the prep area with DS #1 on August 31, 2011, at 11:56 a.m., revealed no recipe was followed to obtain the altered diet, but the goal was to "obtain the consistency of baby food." Interview revealed the apples, apple juice and water were not measured when used in preparing the mechanically altered diet. Interview with the DS #1 in the dietary department on August 31, 2011, at 11:58 a.m., confirmed no recipe was followed when preparing the pureed diets and the nutritional adequacy of the altered diets could not be assured. .

Based on observation, review of facility policy, and interview, the facility failed to maintain food temperatures; failed to store food in a sanitary manner; failed to follow hand hygiene protocol during food preparation and service; and failed to ensure the hair was restrained. The findings included: Observation on August 30, 2011, at 12:00 p.m., revealed the Certified Dietary Manager (CDM) attempted to calibrate a thermometer (a process to assure accuracy) using the three thermometers in the dietary department. Observation revealed the CDM was not able to obtain the desired 32 degrees Fahrenheit. (The thermometers read 38-40 degrees.) Continued observation revealed the CDM obtained a temperature of 60 degrees of an individual bowl of cottage cheese. Continued observation revealed the CDM obtained a second serving of cottage cheese and obtained a temperature of 50 degrees. Interview in the dietary department with the CDM on August 30, 2011, at 12:30 p.m., verified the 'danger zone' for cold foods is above 41 degrees; and confirmed the facility failed to maintain the proper food temperature of the cottage cheese. Observation in the dietary department on August 31, 2011, at 12:00 p.m., revealed meal trays for one of three resident areas had already been sent out for lunch delivery. Continued observation revealed the CDM successfully calibrated the thermometer to the desired temperature of 31 degrees; and proceeded to obtain food temperatures from the steam table. Observation revealed the CDM obtained a temperature of 124 degrees for the pork chops. Interview in the dietary department with the CDM on August 31, 2011, at 12:20 p.m., verified the 'danger zone' for hot foods is below 135-140 degrees; and confirmed the facility failed to maintain the proper food temperature of the pork chops. Observation of the dry goods storage room on August 30, 2011, at 9:20 a.m., revealed three stacks of food in cardboard boxes on the floor. Observation revealed the stacked items included fruits, vegetables, and condiments. Observation of the walk-in freezer on August 31, 2011, at 12:15 p.m., revealed in the walk-in freezer was a one pound plastic bag of broccoli lying on the floor beside an overflowing shelf of vegetables. Continued observation revealed one unopened cardboard box of ice cream and one opened box of garlic bread lying on the floor. Interview with the CDM on August 30, 2011, at 9:28 a.m., and on August 31, 2011, at 12:22 p.m., confirmed the facility failed to store the food in a sanitary manner. Observation on August 30, 2011, at 12:00 p.m., revealed the CDM obtaining temperatures of the food on the tray line. Continued observation revealed the CDM dropped an alcohol pad onto the floor; picked it up; and obtained the temperature of the cottage cheese without changing gloves or washing the hands. Observation on August 31, 2011, at 12:15 p.m., revealed the staff member serving food from the steam table onto the plates was wearing gloves. Continued observation revealed the staff (dietary staff DS #1) left the tray line and went into the walk-in refrigerator (which required opening the highly used door), obtained an item, and removed the gloves. Observation revealed the DS #1 donned a pair of gloves without washing the hands. Observation on August 31, 2011, at 11:50 a.m., revealed DS #1 preparing to puree the pork chops. Continued observation revealed DS #1 poured the pork chop pieces into the processor and activated the processor. Observation revealed DS #1 with both hands picked up the gallon can of apples and poured the remaining apples and juice into the processor. Observation revealed DS #1, without removing the gloves or washing the hands, then reached into the pureed meat and removed some of the meat, and rolled it between the thumb and finger to determine the consistency. Interview with the CDM on August 31, 2011, at 12:32 p.m., confirmed the facility failed to use proper hand hygiene. Observation on August 30, 2011, at 12:00 p.m., revealed the CDM ambulating from the Dietary Manager's office and not wearing a hair restraint. Continued observation revealed the CDM ambulated from the Manager's office between the food prep counter and the food prep cart. Review of the facility policy (un-numbered) titled Dietary Policy, revealed, "Hair nets, covering all of the hair, will be worm by all dietary personnel at all times." Interview with the CDM on August 30, 2011, at 12:01 p.m., confirmed the facility failed to ensure a hair restraint was used in the dietary department.

Based on observation, review of the facility's Infection Control book, and interview, the facility failed to ensure staff practiced proper infection control practices during medication administration for two (#3, one random observation) of fifteen residents reviewed and failed to maintain an effective infection control program to help prevent the transmission of infection. The findings included: Resident #3 was admitted to the facility from the hospital August 16, 2011, with [DIAGNOSES REDACTED]. Interview with the resident at 9:35 a.m., on August 30, 2011, revealed, "I thought I was going home yesterday and they sprang this on me (indicating intravenous fluids infusing)...said I needed it for my kidneys." Observation, at the time of the interview, revealed 100 milliliters remained in the liter of intravenous (IV) fluids being infused and the IV tubing leading to the resident's venipuncture site was resting on the floor for approximately 12-16 inches. Observation at 11:35 a.m., on August 30, 2011, revealed the resident currently had a full liter of IV fluid infusing and the IV tubing continued to rest on the floor. Interview with licensed practical nurse (LPN) #3 on August 30, 2011, at 11:45 a.m., at the Unit 2 nursing station, verified the IV tubing had continued to rest on the floor after LPN #3 had began an infusion of a second liter of IV fluids and LPN #3 stated, "I went to the room and removed the tubing from the floor." Observation of LPN #4 during the administration of medications on August 31, 2011, at 9:00 a.m., revealed an [MEDICATION NAME] coated aspirin tablet (81 mg) did not go into the medication cup when the individual package was opened, instead landing atop the medication cart. Observation continued and LPN #4 retrieved the aspirin tablet with bare hands, placed into the medication cup, and proceeded to administer to the resident. Interview with LPN #4 on September 1, 2011, at 8:45 a.m., verified the observed practice did not maintain aseptic technique and revealed, "...these medications are expensive and I usually go ahead and give them if they land on top the medication cart..." Interview with the Director of Nursing during the entrance conference on August 30, 2011, at 8:50 a.m., revealed Registered Nurse (RN #1) was designated as the Infection Prevention Nurse. Interview in the conference room with RN #1 on September 1, 2011, at 1:50 p.m., revealed RN #1 had been delegated the task of immunizations for the facility. Continued interview revealed RN #1 stated, "...had never been told I was in charge of the infection control program...I was told my responsibility was to compile the monthly report and keep up with the rate of infection in the infection control book." Review of the infection control book revealed a Nosocomial Infection Summary for each month. The summary included a list of the types of infection (urinary, respiratory, wound, etc.) and included the unit where the infection occurred. The summary included the calculation of the current infection rate and the comparison to the previous month's infection rate. (Review of the infection control book revealed the infection rate for May was 7.5%; for June was 7.5%, and for July was 9%). Continued interview included the question, "Tell me the estimated percent of time the facility allows you to perform surveillance or education regarding infection concerns?" Interview revealed RN #1 responded, "None, I would love to have more time to do it if I am responsible for infection control." Interview revealed RN #1 stated, "...I have learned by my boot straps." Interview confirmed RN #1 had not received any formal training regarding developing and assuring an effective infection control program. Continued interview revealed RN #1 did not perform hand hygiene staff surveillance or perform education regarding infection practices and updates, "...other than on my shift (3-11 house Supervisor)." Interview continued and RN #1 stated, "I had to go to the Director of Nursing after you started asking me questions yesterday and ask 'Am I the Infection Control Nurse?'" Interview with the Director of Nursing in the Director's office on September 1, 2011, at 4:20 p.m., revealed, RN #1 "has only been here since December (9 months) and I did not want to give ...too much at once and overwhelm ...Did not want to scare ...off." Continued interview confirmed the facility failed to ensure an effective infection control program.

Based on medical record review, observation, facility, and interview, the facility failed to assess bladder function for one (#1) after an indwelling catheter was removed; and failed to provide services to restore or improve normal bladder function for one (#9) of fifteen residents reviewed. The findings included: Resident #1 was admitted to the facility June 8, 2011, with [DIAGNOSES REDACTED]. Medical record review revealed the resident had lived in an assisted living facility for the previous seven years and had been hospitalized prior to admission. Medical record review revealed the resident had an indwelling catheter from admission, due to a pressure sore in the sacral area, until discontinued on June 20, 2011. Record review of the facility's Urinary Continence Assessment revealed it was completed the day of admission. Review of the medical record revealed no reassessment after the indwelling catheter was removed. Medical record review of the resident's plan of care revealed, "Problem Onset: 6/28/2011 - Frequent episodes of urinary incontinence related to loss of bladder muscle tone...Approaches * Complete assessment to determine potential for bladder training..." Observation of the resident on August 30, 2011, at 9:00 a.m., and 11:35 a.m., revealed the resident sitting in a wheelchair in the dining room. Observation of resident on August 31, 2011, at 8:30 a.m., and 11:35 a.m., revealed resident sitting in a wheelchair in the dining room. Observation continued and the resident was wheeled to their room by licensed practical nurse (LPN) #3 and cooperated with having a blood sample obtained for a blood glucose check. Interview with the resident on September 1, 2011, at 9:30 a.m., revealed the resident did not initiated conversation, but offered agreement and brief responses to simple questions about their life-long vocation as a teacher. Interview with the director of nurses (DON) on September 1, 2011, at 8:45 a.m., in the DON's office, confirmed the resident had not received the benefit of a "complete assessment to determine potential for bladder retraining" as planned for by the interdisciplinary team on June 28, 2011. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on September 1, 2011, at 1:30 p.m., revealed resident #9 in the wheel chair in the day room sitting at the table interacting with other residents. Medical record review of the admitting Bladder assessment dated [DATE], revealed the resident was frequently incontinent, can walk or transfer to the bathroom with assistance, is sometimes mentally aware of toileting needs, and did not have any predisposing disease or condition for incontinence. Continued review revealed the resident scored a '6' which resulted in 'scheduled toilet plan (time voiding).' Review of Part 2 of the Bladder Assessment revealed the resident's scheduled toileting plan was 'Upon rising, before and after meals, and at bedtime.' Interview with LPN #2 at the nurses' station on September 1, 2011, at 9:25 a.m., revealed resident was a 'check and change' (for incontinence) and was "most times incontinent." Review of the Bladder assessment dated [DATE], (8 months after admission) revealed resident was 'incontinent all or most of the time.' Interview with Certified Nursing Assistant #3 at the nurses' station on September 1, 2011, at 1:45 p.m., revealed the resident "used to be continent (of urine) more often." Medical record review revealed no documentation of any service or program the facility had provided to restore or improve the resident's bladder function. Interview with the Director of Nursing in the conference room on September 1, 2011, at 2:05 p.m., confirmed the facility did not provide a service more than a scheduled toileting plan to promote/restore bladder function.

Based on observation, medical record review, review of Material Safety Data Sheets, and interview, the facility failed to ensure the environment was free of hazardous products and chemicals for one (Skilled #3) of three resident care areas and for one (#5) of fifteen residents reviewed. The findings included: Observation of the Skilled #3 resident care area on August 30, 2011, at 9:10 a.m., revealed six residents sitting in the open dining room which shared an open area with the nurses' station. Continued observation of the nurses' station revealed a 10 ounce aerosol can of air freshener and one 12 ounce pump spray of wound cleanser. Interview at the nurses' station with Licensed Practical Nurse (LPN #2) on August 30, 2011, at 9:11 a.m., revealed "some of the residents on this unit are wanders and confused...one of them is sitting in the dining room", and confirmed the facility failed to ensure the environment was free from accident hazards. Observation of the room labeled Washer/Dryer room (next to resident #5's room) revealed the door was not locked. Observation revealed beyond the door was a room containing two dryers. Observation revealed a door leading from the dryer room lead to the laundry room containing two washing machines. Observation revealed an opened, ? full, 50 pound cardboard box of laundry detergent between the two washers. Observation revealed the box of laundry detergent was sitting on a crate about 12 inches from the floor. Review of the Material Safety Data Sheet for the laundry detergent revealed inhalation "may cause respiratory irritation"; ingestion "may be severely irritating to digestive system", and contact to eyes "is severely irritating." Observation of the room for resident #5 on August 30, 2011, at 9:40 a.m., revealed the resident sitting in the chair in the room. Observation and interview revealed the resident was verbally rambling and talking in a fragmented manner. Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed resident #5 had temporal impairment (not oriented to year, month, and day); was not able to perform a memory recall test; had disorganized/incoherent thinking present; and had the behavior of wandering. Continued observation of the bathroom for resident #5 revealed two 1 ounce bottles, one almost full and one ? full, of a liquid analgesic for the joints. Review of the label on the bottle revealed, "If swallowed get medical help or call Poison Control." Interview with the spouse of resident #5 on September 1, 2011, on the skilled #3 area, at 9:30 a.m., revealed the wandering behavior has "improved" but has continued. Interview with the Director of Nursing in the Director's office on August 31, 2011, at 10:10 a.m., confirmed the facility failed to ensure the environment was free of accident hazards. .

Based on contract review and interview the facility failed to ensure the registered dietician supervised the food preparation, service, and storage. The findings included: Review of the 'Contract for Dietetic Services' signed by the Administrator and the facility's registered dietician on June 3, 2003, revealed, "...III. Consultant Responsibilities - 1. Evaluates and monitors food service systems, making recommendations for a conformance level that will provide nutritionally adequate, acceptable quality food. 2. Plans, organizes, and conducts inservice educational programs for food service personnel...4. Recommends and monitors standards for sanitation, safety, and security in food service...10. Consults with the Administrator in the guidance and evaluation of job performance of the Dietary Manager..." Interview with the registered dietician (RD) by phone at 2:40 p.m., on September 1, 2011, revealed the following: 1) the RD was in the facility an average of five hours each week to perform medical record reviews and resident interviews; 2) the RD "used to monitor the standards for sanitation and safety, but no longer...just happened;" and 3) the RD did not conduct any education for the food service staff in the last year. Interview continued and the RD stated, "I have spent no substantial time in the kitchen over the last year." Interview in the kitchen with the cook on August 31, 2011, at 10:45 a.m., revealed the dietician "has not been in here at all to supervise or inspect us." Interview with the Administrator in the office area at 2:46 p.m., on September 1, 2011, confirmed the facility failed to ensure the dietician supervise/evaluate the dietary services of the facility. .

Based on observation and interview, the facility failed to ensure the proper disposal of garbage; and failed to maintain closed doors on the dumpster. The findings included: Observation of the dietary department on August 31, 2011, at 12:20 p.m., revealed two large folded boxes of cardboard on the floor in the hallway outside the dry goods storage area. Interview with Dietary Manager (CDM) on August 31, 2011, at 12:20 p.m., revealed, "They are emptied boxes to be taken out to the dumpster." Continued interview with the CDM confirmed the garbage should not be on the floor and the facility failed to ensure the proper disposal of garbage. Observation of the two dumpsters with the CDM on August 31, 2011, at 4:45 p.m., revealed dumpster #1 had the slide door completely open on one side; and dumpster #2 had the slide door completely open on both sides. Interview with the CDM on August 31, 2011, at 4:45 p.m., confirmed the facility failed to ensure the dumpsters were maintained in a secure manner. .