Ohio Living Breckenridge Village

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review and interview, the facility failed to conduct a safe resident transfer onto a transportation van to prevent a fall with injury for Resident #63. This affected one resident (#63) of three residents reviewed for falls. The facility census was 64. Actual harm occurred on 09/10/25 when Resident #63 fell forward out of his wheelchair onto the concrete ground while being transferred by staff onto a facility transportation van. This resulted in resident complaints of back pain and multiple skin tears and abrasions to the head, left elbow, and multiple fingers of each hand. The resident was transferred to the hospital and admitted with the presence of an acute re-bleed from a chronic subdural hematoma.Findings include:Review of the medical record for Resident #63 revealed an admission date of 07/16/24. Resident #63 had diagnoses including chronic lymphocytic leukemia of B-cell type, history of a traumatic subdural hemorrhage without loss of consciousness, spondylolysis of the cervical and lumbar region, and a subsequent encounter on 09/13/25 of a trace acute re-bleed of a subdural hemorrhage. Review of the John Hopkins Fall Risk Assessment Tool completed 02/10/25 revealed Reside t#63 was at low fall risk.Review of the care plans revealed Resident #63 had the potential for functional status deficit related to a recent hospital stay for traumatic subdural hemorrhage without loss of consciousness, subsequent encounter started 07/17/24. Interventions initiated on 07/17/24 included keep bed in lowest position with brakes locked, keep environment free from clutter, keep personal items and frequently used items within reach, keep call light in reach at all times, respond to call light promptly and provide toileting assistance every two to three hours and as needed.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The assessment revealed Resident #63 was dependent on staff for toileting, dressing, transfers, and locomotion in a manual wheelchair.Review of a nurse's note dated 09/10/25 at 2:15 P.M. revealed Resident #63 was sitting in a wheelchair being transported by a facility van to a dental appointment in the accompaniment of his daughter. As transportation staff tried to pull Resident #63 in the wheelchair up onto the van's ramp with the resident facing outward away from the van, Resident #63 fell forward out of the wheelchair onto the concrete. Skin tears and abrasions were noted on the back of the resident's head, left elbow, and multiple fingers on each hand. The resident complained of back pain. The note indicated all paperwork was sent with the Emergency Medical Technicians (EMT's).Review of a facility fall investigation dated 09/10/25 revealed Resident #63 experienced a fall with injury while being transported by facility transportation into a transport van via a wheelchair using the van's side entry inclined wheelchair ramp. The van driver was unable to push the resident in the wheelchair up the ramp facing toward the van, so the driver turned the resident around and attempted to pull the resident backward up onto the inclined wheelchair ramp from behind. When this action was taken, the resident fell forward out of the wheelchair onto the ground. The daughter yelled out audibly when the event occurred which alerted surrounding staff. Immediately nursing and therapy staff responded to the scene. Resident #63 was found on the ground lying on his left side in front of the facility with an empty wheelchair behind the resident. The wheelchair accessible van was present with the side door open, and the inclined ramp was down. Only the resident, Resident #63's daughter and the transportation driver were at the scene when first responders arrived. Immediate assessment of the resident resulted in Resident #63's complaints of back pain and first aid was provided to areas of skin impairment. Emergency Medical Services (EMS) quickly arrived on the scene and took over care. The resident was transferred onto a gurney by EMTs and taken to the hospital. The hospital completed multiple computerized tomography (CT) scans which confirmed Resident #63's history of a chronic subdural hematoma and the presence of an acute re-bleed.Additional review of the fall investigation dated 09/10/25 revealed staff witness statements, first-hand account by the Director of Nursing (DON) and verbal witness reports from the resident and his daughter were utilized for investigation and root cause analysis. Follow-up intervention and information included the van driver was immediately removed from the transport assignment. Statements were collected from witnesses. The van driver's past completed education was reviewed. Thereafter, the van driver and all other facility drivers were provided with new education on safe wheelchair transport. Upon Resident #63's return from the hospital, PT and OT were ordered for evaluation and treatment for safe transport. Therapy recommended to only use the bus for wheelchair transport needs and no longer use the wheelchair accessible van with the side ramp which was used during the incident.Review of the witness statement written 09/10/25 from Transportation Driver #204 stated she tried to take Resident #63 and the silver bars on the back of the wheelchair were too low and stopped the chair from going up. She turned the resident around and tried to pull him up. The resident leaned forward and fell out of the chair. He landed on his side.Review of the witness statement written 09/10/25 by the DON revealed the DONresponded to the outside front entrance of the facility on 9/10/25 after hearing someone yelling outside He fell! Oh my God. He fell. Resident #63 was noted laying on the concrete slightly on his left side. An empty wheelchair was behind him. The leg rests were on the bench to the left ofthe scene. Oxygen was on via nasal canula and connected to concentrator on back of the wheelchair. Resident #63's daughter standing to the resident's right side. Transport van with a right-side entry ramp was open behind the resident. Transportation Driver #204 was present and holding a cell phone. Multiple first responders arrived at the same time including employees from therapy, campus security and the front offices of the facility. On initial assessment Resident #63 was alert and responsive. Skin tears with active bleeding noted to left elbow and fingers on both hands. The charge nurse was notified. First aid supplies and vital signs equipment was obtained. Resident #63 complained of back pain from 'laying on the concrete'. The resident denied neck pain. Range of motion (ROM) was within normal limits. A towel for padding was placed under the resident's lower back for comfort. First aid to the skin tears was initiated. EMS responded while vital signs were being taken charge by the nurse, and EMS took over the assessment and treatment. Resident #63 was alert and oriented to person, place, and time, answering EMS responders' questions to time and place correctly. Resident #63 was transferred to the gurney by EMS and was taken to the emergency room (ER) for evaluation and treatment. Transfer paperwork was gathered and provided to EMS by the unit manager. Resident #63 remained alert and conversive through the interaction. The resident's daughter remained at the scene after Resident #63 was placed into the EMS ambulance. One to one was provided with the resident's daughter to offer support and obtain details of what she witnessed. The resident's daughter stated she saw her dad fall out of the wheelchair while the transporter was attempting to roll him in his wheelchair up the wheelchair ramp into the van. The resident's daughter stated Transportation Driver #204 first attempted to load the wheelchair into the van by approaching straight on and pushing him forward but the leg rests and metal pieces on the wheelchair prevented entry. The daughter stated Transportation Driver #204 then removed the wheelchair leg rests to try again. Resident #63's daughter stated the transporter then attempted to pull the resident backwards up the ramp and that is when he fell forward out of the wheelchair and she yelled out for help.Review of the witness statement written 09/10/25 from Business Office Coordinator (BOM) #214 revealed she heard a woman's scream, looked out the windows of the office, which she could see the outside area of the front door. I saw a man falling out of a wheelchair onto the ground. It appeared that he was being transferred into a vehicle from our transportation department. I responded immediately to the outside area of the front door. As I passed Receptionist #212, I asked her to call security. When I went through front doors to the outside area of the entrance, the elderly man was lying on his left side, his daughter was on his left side. Transportation Driver #204 was standing at the head of the resident about a foot behind. PT #215 was assessing the resident, when the DON and Admissions Coordinator #216 came out to assist. The DON went back into the building to obtain a vital signs machine. Resident #63 was asked if he hit his head, and he replied I don't think so but did state his back hurt. There was noticeable blood on the resident's left elbow, and fingers of left hand. The resident was rolled over to his back where a clearer assessment of his arm and hand could be seen. He had a large skin tear that from his elbow to approximately three to four inches up his arm. His fingers also had abrasions. When the DON returned to the scene along with Licensed Practical Nurse (LPN) #206, the DON further assessment was completed. Security Supervisor #217 was also was on the scene. Activities Director #203 was present consoling the daughter.Review of the witness statement written 09/10/25 from Receptionist #212 revealed she did not witness the actual incident.Review of the witness statement written 09/12/25 by PT #215 revealed she did not witness the event. She ran outside when she heard his daughter screaming. When she arrived, he was on the ground. The wheelchair was upright and off to side. She supported his head and assisted him to roll slightly off of his left arm that he reported hurt to be lying on. Resident #63 reported his arm felt better after he was able to get it out from under himself. Someone else brought pillows to support the resident's head. Once his head was supported, she returned to my resident indoors and let the others present take over.Review of the witness statement written09/15/25 by Certified Occupational Therapy Assistant (COTA) #213 revealed she did not witness the fall but heard the screams from the therapy gym. Resident #63 was on the ground next to the ramp, on his left side, alert and bleeding from the left forearm. Therapist, PT #215, was holding his head off the ground. Other people were around or on their way. She went back to therapy gym and got a pillow, a large bolster and a towel and brought them back to Resident #63. She placed the pillow under his head, others rolled Resident #63 onto his back and she placed the bolster under knees and the towel under his bleeding arm. Many people/nurses are around tending to him, so she retreated back to the therapy gym.Review of the witness statement written 09/15/25 from Activities Director #203 heard a loud scream and crash and ran out but did not witness the actual incident.Review of the hospital records for Resident #63's hospital stay from 09/10/25 to 09/13/25 revealed an acute re-bleed of the right frontoparietal subdural hematoma and the bilateral chronic subdural hematoma appeared slightly smaller than the prior exam eleven months ago with no significant global mass effect. Range of motion (ROM) was intact, and the right shoulder x-ray was negative. There was a left elbow skin tear with other superficial injuries.Interview on 11/17/25 at 11:53 A.M. with Resident #63 revealed on 09/10/25 the facility used a different van than usual and a different person loaded him onto the van. The resident revealed usually the staff pushed him up the ramp face first, but at that time he was pulled up backwards and fell. The resident said he hit his head and scratched and bruised his arm, mostly the elbow. The fall also made his back hurt, so he was taken to the hospital.Interview on 11/17/25 at 2:21 P.M. with Activities Director #203 revealed she saw Resident #63's daughter upset when the bus driver pulled up. The resident's daughter told the driver they had been waiting for an hour. Activities Director #203 did not witness the incident.She was inside the facility when she heard a loud noise from outside. She then went outside and saw Resident #63 lying to the side of the ramp. The DON and another nurse came running out and assessed the resident. Interview on 11/17/25 at 2:45 P.M. with Transportation Driver #204 stated she tried to push Resident #63 up the ramp, but the footrests did not clear the top, so she turned him around and pulled him up backwards. She told the resident to lean back, but instead he leaned forward and rolled out of the wheelchair onto the ground beside the ramp.Interview on 11/17/25 at 3:44 P.M. with Licensed Practical Nurse (LPN) #206 revealed she was assigned to care for Resident #63 on that day (09/10/25). The resident had a dentist appointment, and his daughter was accompanying him. The resident went out to catch the transportation van, and that was the last time she saw him until the daughter came running up after the fall. LPN #206 went outside, and the resident was on the concrete. He was bleeding from his elbow and fingers. LPN #206 saw blood on Resident #63's head. The resident complained of pain on his bottom which he had landed on. The resident's daughter called EMS and they arrived quickly.Interview on 11/17/25 at 4:01 P.M. with the DON revealed on 09/10/25 she heard Resident #63's daughter yelling, He fell. He fell. The resident was lying on ground with the wheelchair behind him. Transportation Driver #204 was in front of the van calling someone. The DON assessed Resident #63 and found the resident was bleeding on his elbow, but not from his head. No open areas were seen on the resident's head. After more people responded, staff tried to bandage the resident's elbow. EMS arrived and took Resident #63 to the hospital. The resident's daughter and the driver reported the resident fell when he was pulled backwards up the ramp. Thereafter, Resident #63 was diagnosed with an area of acute rebleed from the CT scan, and skin injuries.Upon hire, all transportation driver complete training using a computer learning module entitled Lift and Securement Review.The deficient practice was corrected on 09/22/25 when the facility implemented the following corrective actions: -Transportation Driver #204 was immediately removed from the assignment by Transportation Supervisor #210 on 9/10/25 and suspended by Human Resources #207 on 09/12/25.-Beginning 09/11/25, the DON completed observational audits of safe wheelchair transport was completed by the transportation drivers and continued three times weekly for four weeks, and then weekly for three weeks.-On 09/12/25, the Administrator and Transportation Supervisor #210 reviewed additional education and action items. As a result, Transportation Driver #204 received education on safe wheelchair procedures on 9/12/25 by Transportation Supervisor #210 and was permanently removed from future healthcare center transports. All campus drivers were educated on safe wheelchair protocols by Transportation Supervisor #210 by 9/15/25. The results of this meeting and plans of correction were then reviewed with the facility Quality Committee on 9/16/25.-On 09/13/25, Resident #63 was evaluated by therapy services upon return from the hospital for safe transportation which resulted in recommendation to only use the bus for future transports and not to use the van with a side entrance ramp.-By 09/15/25, safe wheelchair education was completed with all facility drivers by Transportation Supervisor #210 which included repeating the computer learning module entitled Lift and Securement Review and additional training titled Transportation Department Wheelchair Procedures which included:1) Must evaluate the wheelchair for proper size for transport vehicle.2) Must push wheelchair in from behind! At all times! Prevent from falling forward.3) If you feel you cannot accommodate safely, you must ask or call for help!4) Under no circumstances should a resident be facing forward on a slope without guidance!5) If process of transporting cannot be done in a safe manner, the driver has the right to refuse.6)The transporter needs to call the office for a final decision.-On 09/16/25, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the incident with the Interdisciplinary Team (IDT) and the Medical Director. The Administrator monitored compliance in a QAPI meeting monthly for three months and then on-going as needed.-On 09/17/25 and 10/02/25, Resident #63 had follow-up medical appointments.-On 09/22/25, a care conference and incident review was held with Resident #63's daughter and son-in-law with the DON, Administrator, and Executive Director.-Social services followed Resident #63 for psychosocial impact and offered support after returning from the hospital on [DATE]. -Resident #63's skin tear was followed by nursing staff and Wound Nurse #211 from Encore Wound Group weekly after return from the hospital on [DATE] and was healed on 10/09/25.-On 09/22/25 additional education was completed by Transportation Driver #204 using computer learning entitled Lift and Securement Review which was specific to the incident. Transportation driver #204 no longer transports facility residents. -Additional Driver education on Lift and Securement was then completed. Transportation Driver #204 was permanently removed from future transports for nursing home residents. Relias transcript of completed additional Relias training attached upon return from leave.-On 10/22/25, the Administrator reviewed results of the audits and investigation at the quarterly Quality Committee meeting.This deficiency represents non-compliance investigated under Complaint Number 2621195.

Based on observation, interview, record review, facility policy and staff training review, and review of the Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH, the facility failed to use a gown for required enhanced barrier precautions (EBP) while administering medications through a gastric tube for Resident #44, failed to clean a wrist blood pressure monitor between use on Resident's #44 and #52, and failed to maintain a clean wall-mounted fan while in use and directed toward clean linen in the laundry area. This affected two residents (#44 and #52) of 60 residents reviewed for infection control and had the potential to affect all 60 residents residing in the facility. The facility reported 13 residents (#17, #22, #25, #30, #32, #44, #48, #113, #120, #121, #125, #126 and #162) on EBP precautions.
Findings include:
1. Observation on 05/13/25 at 8:06 A.M. with Licensed Practical Nurse (LPN) #615 of medication administration for Resident #44 revealed LPN #615 prepared three medications for administration into a gastric tube while at the medication cart then entered Resident #44's room which had a sign posted on the door to observe EBP with gowns and gloves stored in a door rack for staff use. LPN #615 donned gloves but did not put on the required gown before engaging Resident #44 and administering the medications through the gastric tube. Once completed, LPN #615 removed the soiled gloves, performed hand hygiene and then left the resident's room. Interview at the time of the observation with LPN #615 confirmed not wearing the required gown for EBP.
Review of the medical record for Resident #44 revealed an admission date of 02/27/25 with diagnoses including encephalopathy, diabetes mellitus type two, hypertensive heart disease with heart failure and gastrostomy status. The admission Minimum Data Set (MDS) assessment completed on 03/06/25 indicated Resident #44 had moderate cognitive impairment, and the plan of care dated 02/28/25 specified a need for enteral feeding through a gastric tube.
Review of CMS QSO Memo 24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, revealed EBP are indicated for residents with indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism (MDRO). The effective date for implementation of EBP under the guidelines was 04/01/24.
Review of the facility policy, Enhanced Barrier Precautions, revised 09/14/23, revealed EBP required the use of gloves and a gown with residents who had an indwelling medical device during high-contact resident care.
Review of the facility staff training completed on 05/13/25 revealed the use of a gown and gloves for high-contact resident care activities was indicated for residents with indwelling medical devices.
2. Observation on 05/13/25 at 8:06 A.M. with LPN #615 of medication administration for Resident #44 revealed LPN #615 obtained a blood pressure reading using a wrist monitor prior to medication preparation then placed the monitor on top of the medication cart without cleaning it after use. LPN #615 then prepared Resident #44's medications, administered them as ordered and then moved the medication cart to where Resident #52 was located. LPN #615 picked up the soiled blood pressure monitor and used it to obtain Resident #52's blood pressure prior to preparing the resident's medications. Once completed, LPN #615 returned to the medication cart and set the soiled blood pressure monitor on top of the medication cart without cleaning it after use. Interview at the time of the observation with LPN #615 verified the wrist blood pressure monitor was not cleaned after use between Resident's #44 and #52.
Review of the medical record for Resident #44 revealed an admission date of 02/27/25 with diagnoses including encephalopathy, diabetes mellitus type two, hypertensive heart disease with heart failure and gastrostomy status.
Review of the medical record for Resident #52 revealed an admission date of 02/24/25 with diagnoses including chronic kidney disease, palliative care, dementia, atrial fibrillation and congestive heart failure.
Review of facility staff training completed on 05/13/25, entitled Infection Control Review - Shared Medical Devices, revealed cleaning and disinfecting shared medical devices between residents are crucial for preventing the spread of infections, reducing healthcare-associated infections, and protecting residents' safety.
3. Observation on 05/14/25 at 11:19 A.M. with Housekeeping Supervisor (HS) #610 of the laundry room revealed in the clean laundry area there were two unknown laundry workers actively folding linen out of a large mostly filled clean linen cart. In proximity was a large wall mounted fan blowing air toward the two laundry workers and the clean linen. The fan had visible dirt buildup with accumulated dirt seen flapping from the air flow out of the fan toward the clean linen. Interview at the time of the observation with HS #610 confirmed the wall mounted fan being used in the clean laundry area was visibly dirty and blowing toward the clean linen.

Based on record review and staff interview, the facility failed to ensure the most recent state survey results were readily available for public review. This had the potential to affect all 90 residents residing in the facility.
Findings included:
Review of the facility folder titled Ohio Department of Health Survey Results located in the main lobby in clear view revealed the last survey in the folder and available to be reviewed by the public was the annual survey conducted on 06/27/19.
The Ohio Department of Health conducted a complaint survey at the facility on 01/04/22 resulting in a certification deficiency and licensure violation being issued to the facility:
Interview with the Administrator on 06/28/22 at 9:53 A.M. confirmed the last survey in the book was 06/27/19 for public review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #3: Record review of Resident #23 revealed she was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease, cognitive communication deficit, restlessness and agitation, and acute psychosis. She had an active order for 25 milligrams of Seroquel (an antipsychotic) to be given twice per day as needed (PRN) for behaviors including hitting, scratching, and screaming. The order was dated 12/02/21. A psychiatric service visit dated 05/26/22 noted her PRN seroquel order was to be continued. The surveyor could not find evidence the PRN seroquel was specifically reviewed and renewed every 14 days.
Record review of Resident #23's medication administration record revealed she received the PRN seroquel twice in April 2022 on 04/11/22 and 04/15/22, and no times in May or June 2022 as of the time of the record review.
Review of a pharmacy record review for Resident #23 dated 01/28/22 revealed the pharmacy recommendation that the PRN Seroquel order be made to only last 14 days, and to be renewed every 14 days. The provider checked 'disagree' on the response list at the bottom and wrote to continue the medication as-ordered.
Review of the facility's psychotropic medication policy dated 03/01/21 revealed antipsychotic medications were limited to 14 days and could not be renewed unless the physician evaluated the resident for appropriateness for another 14 days.
The surveyor confirmed the above findings with the Director of Nursing on 06/29/22 at 10:25 A.M.
2. Review of the medical chart for Resident #3 revealed an admission date of 03/15/22. Diagnoses include but not limited to vascular dementia without behavioral disturbance, torticollis, and brachial plexus disorders. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/22/22, revealed Resident #3 had severely impaired cognition and required extensive assistance with two staff for activities of daily living except eating required supervision with set up only.
Review of the physician's orders for June 2022 revealed Resident #3 was ordered 1.0 milligrams (mg) of lorazepam on 03/16/22 for muscle spasm as needed (PRN) with a maximum dose of three tablets with no stop date.
Interview on 06/30/22 at 8:07 A.M. with Registered Nurse (RN) #538 verified that there was no stop date for lorazepam PRN.
Review of the facility policy titled, Psychotropic Medications, with a revised date of 03/01/21, revealed PRN orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she will document their rationale in the resident's medical record and indicate the duration for the PRN order.
Based on record reviews and interviews the facility failed to ensure as needed medication orders for psychotropic drugs were limited to 14 days. This affected three (Residents #3, #23, and #34) of six residents reviewed for unnecessary medication. The census at the time of the survey was 90 residents.
Findings include:
1.Record review for Resident #34 revealed the resident was readmitted to the facility on [DATE]. Pertinent diagnoses for the resident included unspecified dementia, other dissociative and conversion disorders, cognitive communication deficit, chronic pain, anxiety disorder, and major depressive disorder. The brief interview for mental status (BIMS) from MDS dated [DATE] revealed the resident had a score of five indicating severe cognitive impairment.
Review of physician orders for Resident #34 revealed on 03/09/22 the physician had ordered the antipsychotic medication Seroquel one 50 milligram (mg) tablet by mouth every six hours as needed (PRN) for unspecified dementia with behavioral disturbance with no end date.
The medication administration record (MAR) for Resident #34 was reviewed for the month of June 2022 and had documented administrations of the PRN antipsychotic medication Seroquel as followed: one administration on 06/04/22, one administration on 06/05/22, one administration on 06/10/22, one administration on 06/20/22, one administration on 06/24/22, and one administration on 06/28/22.
The facility failed to provide evidence the physician had reviewed the continued and frequent use of the PRN psychotic medication for Resident #34. No evidence was presented to confirm the 14 day re-assessment and reorder interval was completed. These findings were verified during interview with the Director of Nursing on 06/29/22 at 10:21 A.M.
Review of the facility policy titled, Psychotropic Medications, with a revised date of 03/01/21, revealed PRN orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she will document their rationale in the resident's medical record and indicate the duration for the PRN order.

2. Observation of the Courtyard dining room during the lunch meal on 06/24/19 at 11:45 A.M. revealed State Tested Nursing Aide (STNA) #201 used her bare hands to place lettuce and tomato on Resident #52's sandwich, and then held the sandwich in place to cut it in half. STNA #201 then repeated these actions for Resident #91's food.
Interview with STNA #201 on 06/24/19 at 11:51 A.M. confirmed the above observations.
Review of the facility's bare hand contact with food policy dated 2013 revealed single-use gloves were to be worn by staff when handling food directly, and bare handed contact with food was prohibited to staff.
Based on observation, interview, and record review, the facility failed to ensure facial hair was covered and utensils and gloves were used when plating and serving foods. This had the potential to affect 45 residents who received meals served in the second floor dining room, as well as Residents #52 and #91. The facility census was 93 residents.
Findings include:
1. Observation on 06/24/19 at 12:30 P.M. of lunch service in the second floor dining room revealed Dietary Aide (DA) #150 setting up the food on the steam table. DA #150 had a full beard without a hair restraint.
On 06/24/19 at 12:30 P.M. with the Director of Dining Services (DDS) #160 confirmed DA #150 had a long beard and wasn't wearing a hair restraint to cover it.
Observation on 06/24/19 at 12:30 P.M. of the start of meal service revealed DA #150 used gloved hands to plate quiche. DA #150 held the serving utensil in one hand and with the other hand directly touched the quiche to help slide it from the serving utensil and then position it on the plate. Using the same gloves with visible particles of quiche on them, DA #150 also handled lettuce and tomato, and assembled and plated sandwiches.
On 06/24/19 at 12:57 P.M. DA #150 confirmed he used his gloved hands to directly handle and serve quiche, lettuce and tomatoes and sandwiches. DA #150 verified he should have used serving utensils.
Review of the facility policy titled Employee Sanitary Practices dated 2013 revealed all employees shall wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food and use utensils to handle food.