Andersonville Tn Opco Llc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to notify a resident representative of a change in condition for 1 resident (Resident #16) of 6 residents reviewed. The findings include:Review of the facility policy titled, Notification of Changes, undated, revealed .This facility will notify the .resident/resident representative of changes in the resident's condition or status .A facility must immediately .notify .the resident representative(s) when there is .significant change in resident's physical condition .such as deterioration in health .Review of the facility policy titled, Nutrition Guidelines, undated, revealed .Monitoring/revision .interviewing the resident and/or representative to determine if their personal goals and preferences are being met .notify of significant changes in weight, intake .Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Protein-Calorie Malnutrition, and Adult Failure to Thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) assessment score of 03 which indicated the resident had severe cognitive impairment and weight loss. Review of a Dietician Progress Note for Resident #16 dated 8/2/2025, revealed .significant weight loss of 8.3% x 30 days and 11.7% x 90 days .BMI [Body Mass Index] is 17.3 underweight status . Continued review showed no documentation the resident's representative had been notified of the significant weight loss. Review of the Comprehensive Care Plan revised 8/8/2025, revealed Resident #16 .has unplanned/unexpected weight loss r/t [related to] poor food intake . During a telephone interview on 12/2/2025 at 2:56 PM, Resident #16's responsible party/conservator stated he was not notified of the resident's significant weight loss. During an interview on 12/2/2025 at 3:10 PM, the Director of Nursing (DON) confirmed there was no documentation Resident #16's responsible party/conservator had been notified of the resident's significant weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to revise a care plan to include a new fall intervention for 1 resident (Resident #16) of 3 care plans reviewed for falls. The findings include:Review of the facility policy titled, Comprehensive Care Plan, undated, revealed .facility will develop and implement a person-centered care plan for each resident, that includes measurable objectives and time frames to meet resident's medical, nursing, mental, and psychosocial needs .maintains a comprehensive care plan participate in the development of and reviewing and revising of the Comprehensive Care Plan .Review of the facility policy titled, Fall Prevention & Management Program guidelines, undated, revealed .when any resident experiences a fall, the facility will .Review the resident's care plan and update as indicated .Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Osteoporosis, and Adult Failure to Thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) assessment score of 03 which indicated the resident had severe cognitive impairment and had no falls since admission. Review of a facility fall incident report for Resident #16 dated 11/19/2025, revealed .Resident [#16] was going to the bathroom unassisted and slipped from W/C [wheelchair] on right hip . New Intervention .Non-Skid footwear and bowel training program . Review of the Comprehensive Care Plan dated 11/29/2025, revealed Resident #16 .at risk for falls related to weakness . Continued review showed no new intervention had been added after the fall on 11/19/2025. During an interview on 12/2/2025 at 1:15 PM, the MDS Coordinator confirmed the care plan had not been revised to include the new intervention after the fall on 11/19/2025. During an interview on 12/2/2025 at 2:27 PM, the Director of Nursing (DON) confirmed Resident #16's comprehensive care plan had not been revised to include nonskid footwear and a toileting program after a fall on 11/19/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and interviews, the facility failed to follow infection control practices on 2 of 4 hallways observed. The findings include: Review of the facility policy titled, Infection Control: Hand Hygiene revised 6/2023, revealed, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents .This applies to all staff working in all locations within the facility .Hand Hygiene .is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .Review of the facility policy titled, Isolation Precautions guidelines undated, revealed, .Droplet precautions .refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory .contact with respiratory secretions .Droplet Precautions .Healthcare personnel will wear a facemask for close contact with an infectious resident .if there is a risk of exposure .gloves and gown as well as goggles (or face shield) should be worn .During an observation and interview on 12/1/2025 at 11:10 AM, Certified Nursing Assistant (CNA) A and CNA B entered room [ROOM NUMBER]. Observation of signage on the outside of room [ROOM NUMBER]'s door revealed Droplet Precautions. Further observation revealed CNA A and CNA B did not don (apply) goggles or a face shield prior to entering the room. CNA A and CNA B stated the resident in 106 A was COVID positive and was on droplet precautions. CNA A and CNA B confirmed they failed to don goggles or a face shield prior to entering the room. During an observation and interview on 12/1/2025 at 12:30 PM, Restorative CNA C entered room [ROOM NUMBER]. Observation of signage on the outside of room [ROOM NUMBER]'s door revealed Droplet Precautions. Further observation revealed Restorative CNA C did not don gloves, gown, mask, and goggles. Restorative CNA C confirmed she failed to don gloves, gown, mask, and goggles prior to entering the room.During an observation on 12/1/2025 at 12:43 PM, CNA D entered room [ROOM NUMBER] and closed the door to the room. The CNA exited the room, failed to wash or sanitize the hands, retrieved a gait belt from the clean linen cart, and entered room [ROOM NUMBER]. CNA D closed the door to room [ROOM NUMBER], exited the room, and failed to wash or sanitize the hands. CNA D re-entered room [ROOM NUMBER], turned the call light off, exited the room, and failed to wash or sanitize the hands. During an interview on 12/1/2025 at 12:51 PM, CNA D stated when he was in room [ROOM NUMBER], he provided incontinence care to the resident in 200B. He also stated he exited room [ROOM NUMBER], failed to wash or sanitize his hands, and entered room [ROOM NUMBER]. Further interview revealed he transferred a resident in 207B from the wheelchair to the bed. The CNA stated he exited room [ROOM NUMBER], failed to wash or sanitize the hands, re-entered the room, turned off the call light, and exited the room without washing or sanitizing the hands. CNA D confirmed he failed to follow the facility's infection control policy when he failed to wash or sanitize the hands after he provided direct care to resident's in rooms 200B and 207B.During an interview on 12/3/2025 at 3:12 PM, the Director of Nursing confirmed CNA A, CNA B, and Restorative CNA C had not followed infection control practices when they failed to don goggles, face shield, gloves, mask, and gown prior to entering a Droplet precaution room (room [ROOM NUMBER]). Further interview confirmed CNA D failed to follow infection control practices when he failed to wash or sanitize the hands after he provided direct care to resident's in rooms 200B and 207B.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and interviews, the facility failed to maintain a safe, comfortable, and homelike environment for room [ROOM NUMBER] on the 100 hall and rooms [ROOM NUMBERS] on the 400 hall on 2 of 4 hallways observed for a homelike environment.
The findings include:
Review of the facility's policy titled, Resident Environmental Quality, undated revealed .It is the policy of this facility to be .maintained to provide a safe .comfortable environment for residents .Resident rooms must be designed and equipped for adequate .comfort, privacy of residents .Preventive maintenance schedules, for the maintenance of the building .should be followed to maintain a safe environment .All facility personnel are responsible for reporting broken, defective or malfunctioning .furnishings immediately upon identification of the issue .
During observations on 5/21/2024 at 10:18 AM, in room [ROOM NUMBER], revealed the vertical blinds covering the window were missing blind slats. There was a small opening visible to the outside at the right upper corner of the heating and cooling unit in the wall.
During observations on 5/21/2024 at 10:25 AM, in room [ROOM NUMBER], revealed a small opening visible to the outside at the left upper corner of the heating and cooling unit in the wall.
During observations on 5/21/2024 at 10:30 AM, in room [ROOM NUMBER], revealed a small opening visible to the outside at the left upper corner of the heating and cooling unit in the wall.
During an interview on 5/21/2024 at 10:50 AM, the Administrator, Director of Nursing (DON), and the Maintenance Director, confirmed there was a small opening visible to the outside at the left upper corner of the the heating and cooling unit in the wall in rooms [ROOM NUMBERS].
During an interview on 5/21/2024 at 10:55 AM, the Administrator, DON and Maintenance Director, confirmed there was a small opening visible to the outside at the right upper corner of the heating and cooling unit, confirmed the vertical blinds were missing blind slats in room [ROOM NUMBER], and confirmed the facility had failed to provide an optimal home like environment for the residents.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with undated, expired, open to air, and undated with use by date, in 1 of 2 refrigerators, and in 2 of 2 freezers and failed to maintain a sanitary kitchen with debris in 1 of 3 plastic storage bins, and unsanitary use of food temperature thermometers. The facility failed to maintain a sanitary kitchen with dietary staff not using appropriate hand hygiene, undated, unlabeled, undated with a use by date, and food items stored inappropriately under 1 of 1 steam tables and failed to maintain kitchen equipment in a sanitary manner. The facility failed to maintain a sanitary kitchen with the use of an unsanitary cup at 1 of 1 drink stations in the kitchen with debris in 1 of 2 plastic containers, and open to air food items on counters in the kitchen potentially affecting 59 of 61 residents.
The findings include:
Review of the facility policy titled, Food Preparation, dated 9/2017 revealed, .All staff will practice proper hand washing techniques and glove use .All food contact equipment, and food contact surfaces will be cleaned and sanitized after every use .
Review of the facility's policy titled, Food Storage Dry Goods, dated 9/2017 revealed, .All dry goods will be appropriately stored .
Review of the facility policy titled, Environment dated 9/2017 revealed, .All food preparation areas, food service areas .will be maintained in a clean and sanitary condition .
Review of the facility policy titled, Equipment, dated 9/2017 revealed All foodservice [food service] equipment will be clean .sanitary .All equipment will be routinely cleaned .
Review of the facility policy titled, Food Storage Cold Storage, dated 4/2018 revealed, .All foods will be stored wrapped or in covered containers, labeled and dated .
Review of the facility's guideline titled, Labeling and Dating, undated revealed, .Guidelines for Labeling and Dating .All food should be dated upon receipt before being stored .Food labels must include .The food item name .The date of preparation .removal from freezer .Use By dating Guidelines .The manufactures expiration date, when available, is the use by for unopened items .
Review of the facility's policy titled, Infection Control Overview Policy, undated revealed, .[Name of the Dietary Contracted Company] promotes the health and safety of all employees, as well as that of the clients we serve .Standard precautions for .dining service employees .Proper hand hygiene .
During an observation on 4/18/2022 at 9:40 AM, in the kitchen, of the reach in refrigerator with the Dietary Manager (DM) revealed:
- 1 whole peanut butter jelly sandwich undated and available for resident use.
- Two 1/2 peanut butter sandwiches undated and available for resident use.
- 1 pack of approximately 20 unopened pieces of salami with a use by date of 1/2022 (expired 3 months ago) available for resident use.
- 4 pieces of sliced turkey in a plastic bag undated and available for resident use.
- One 2.5-pound bag of shredded mild cheddar cheese open to air and available for resident use.
- 1.5-pound bag of shredded mozzarella cheese undated, unlabeled, and available for resident use.
- 1 whole cabbage lying on a shelf, not in a container, undated, unlabeled and available for resident use.
- 2.5-pound bag of shredded lettuce opened to air, dated 3/31/2022 (17 days old), and with no use by date.
During an interview on 4/18/2022 at 9:41 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with undated, expired, open to air, unlabeled, and undated with a use by date food items available for resident use in the reach in refrigerator.
During an observation on 4/18/2022 at 9:59 AM, of the kitchen, in the reach in freezer, located near the stove, with the DM revealed:
- Approximately 25 pounds of crinkle cut sliced carrots located in a box in a bag open to air and available for resident use.
- Approximately 1 pound of raw green beans located in a box in a bag open to air and available for resident use.
- Appropriately 15 pounds of whole kernel corn in a bag open to air and available for resident use.
- 1/2 pound of French fries in a bag undated, undated with no use by date, and available for resident use.
During an interview on 4/18/2022 at 10:00 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with open to air, undated, and undated with a use by date food items available for resident use in the reach in freezer.
During an observation on 4/18/2022 at 10:14 AM, of the kitchen and storage room, with the DM revealed:
- One plastic storage bin of packets of saltine crackers with powdered beige debris located in the bottom of the storage bin.
During an interview on 4/18/2022 at 10:14 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with beige powdered debris in the plastic storage bin. Continued interview revealed the DM stated the bin should have been emptied and cleaned.
During an observation on 4/18/2022 at 10:17 AM, of the kitchen, of the meat freezer located in the storage room, with the DM revealed:
- 8 hot dogs in a bag open to air, undated, unlabeled, and available for resident use.
- 49 precook Salisbury steak patties located in a box in a bag open to air, undated, unlabeled, undated with a use by date, and available for resident use.
- 69 uncooked frozen hamburger patties located in a box in a bag open to air, undated, unlabeled, undated with a use date and available for resident use.
During an interview on 4/18/2022 at 10:17 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with open to air, undated, unlabeled, and undated with a use by date food items available for resident use in the meat freezer.
During an observation on 4/18/2022 at 11:36 AM, of the kitchen, revealed the DM removed a vegetable quiche prepared for the residents in the facility's lunch from the stove and placed the quiche on the counter preparation station opposite the stove. The DM informed the Dietary [NAME] (DC) #1 to take the temperature of the quiche. DC #1 picked up the previously used thermometer lying on the steam table surrounded by used alcohol wipes and food debris. The DC #1 then placed the unsantizied thermometer in the center of the quiche. Further observation revealed the quiche was to be served to the residents for lunch on the tray line.
During an interview on 04/18/2022 at 11:57 AM, the DM confirmed the facility failed to maintain a sanitary kitchen environment by using an unsanitary food thermometer to test the temperatures of food available for resident use.
During an observation on 4/18/2022 at 11:44 AM, in the kitchen, of dietary staff, performing food temperature checks during lunch preparation, revealed the Dietary Aid (DA) #1 donned clean gloves and walked around the kitchen area touching 3 kitchen surface preparation tables while wearing the same gloves. DA #1 then returned to the preparation table located near the steam table while wearing the same unsanitary gloves and retrieved a clean thermometer and placed the thermometer in a cup of water. DA #1 then used the thermometer to obtain food temperatures of one 8-ounce tea and one 8-ounce honey milk. Further observation revealed DA #1 then returned to the food preparation table located next to the steam table then clean the thermometer with alcohol prep pads, walked to the trash can, lifted the lid of the dirty trash and discarded the used alcohol pads while wearing the same unsanitary donned gloves. Continued observation revealed while wearing the same donned gloves the DA #1 obtained the food temperature of cut peaches in one individual desert bowl on the preparation table without removing the unsanitary gloves and without sanitizing her hands.
During an interview on 4/18/2022 at 11:49 AM, in the kitchen, DA #1 confirmed she did not remove her gloves, and did not sanitize her hands after touching the preparation tables and trash can lid.
During an interview on 4/18/2022 at 11:50 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with staff not performing appropriate hand hygiene while handling resident's foods and while performing food temperature checks on foods available for resident use during lunch. Continued interview revealed the DM stated, She should have washed her hands and changed her gloves.
During an observation on 4/19/2022 at 2:03 PM, in the kitchen, on a shelve under the steam table with the DM revealed:
- 1 hard plastic cereal bowl with a disposable lid which contained an orange-colored powdered substance undated, unlabeled, undated with a use by date, and available for resident use.
- 1 hard plastic cereal bowl with a cracked disposable lid labeled cheese and dated 4/11/2022 (8 days old). Continued observation revealed approximately 3 tablespoons of orange colored cheese with green mold scattered throughout the bowl which was available for resident use.
During an interview on 4/19/2022 at 2:09 PM, revealed the DM was unable to name the orange powdered substance located in 1 of the cereal bowls. Continued interview confirmed the cheese was not to be stored at room temperature and should be stored in the refrigerator to prevent spoiling and mold. Further interview confirmed the facility failed to maintain a sanitary kitchen with undated, unlabeled, undated with no use by date, and storage of food items at non appropriate food temperatures. Interview confirmed the food items were available for resident use and should have been discarded.
During an observation on 4/19/2022 at 2:11 PM, in the kitchen, of the microwave with the DM revealed:
- black and orange food debris inside of the microwave.
During an interview on 4/19/2022 at 2:14 PM, the DM confirmed the facility failed to maintain a sanitary kitchen with debris located in the microwave.
During an observation on 4/19/2022 at 2:18-2:29 PM, of the kitchen, of the resident drink station with the DM revealed:
- One 8-ounce white Styrofoam cup covered in dark brown colored debris with the word tea handwritten in a black marker on the cup over 20 times. Continued observation revealed the Styrofoam cup covered 1 of the 3 handles on the right side of the coffee/tea dispenser and touched the spout of the coffee/tea dispenser.
- On the metal shelf below the coffee/tea drink station was a clear 20-quart plastic container containing loose packets of tea. Continued observation revealed approximately 4 tablespoons of a loose dark brown powdered substance scattered throughout the container.
During an interview on 4/19/2022 at 2:31 PM, the DM confirmed the facility failed to maintain a sanitary kitchen with an unsanitary Styrofoam cup touching the spout and handle of the coffee/tea dispenser, and a container with loose dark brown powdered substance located in the bottom of a food container. The DM stated the container should have been cleaned and emptied when it was soiled.
During an observation on 4/19/2022 at 2:33 PM, of the kitchen, of the metal preparation table located next to the refrigerator, with the DM revealed 3 individual sugar cookies and 1 chocolate chip cookie in clear plastic bags open to air and available for resident use.
During an interview on 4/19/2022 at 2:35 PM, the DM confirmed the facility failed to maintain a sanitary kitchen with open to air food available for resident use. The DM stated the cookies should be in a tight fitting bag.

Based on facility policy review, time punch review, review of staff statements, and interviews the facility failed to maintain a sufficient number of dietary staff to safely and effectively carry out the function of the food and nutrition service for dining during breakfast for 60 of 62 residents.
The findings include:
Review of the facility policy titled, Professional Staffing, dated 9/2017 revealed, .The Dining Services department will employ sufficient staff with .skill sets to carry out the functions of food and nutrition services .
Review of the facility's Midnight Census Report dated 4/15/2022 revealed the facility had a total of 62 residents in the facility on 4/15/2022.
Review of the facility's 672 form dated 4/19/2022 revealed the facility had a total of 3 resident's receiving tube feedings (1 of the 3 resident's was on pleasure feedings).
During an interview with Dietary Aid (DA) #1 on 4/19/2022 at 2:55 PM, revealed on 4/15/2022 Dietary Manager (DM) #1 and the DA #2 were not in the facility on 4/15/2022.
Review of the Dietary Staff Time Sheet and interview on 4/20/2022 at 9:44 AM, the Director of Operations ((DO) (Director of the contracted company used for dietary service in the facility)) revealed DM #1 and DA #2 were scheduled to work in the kitchen on 4/15/2022. Continued interview revealed DM #1 and DA #2 did not come to the facility to prepare breakfast for the residents in the facility on 4/15/2022. The DO revealed the nursing home staff prepared breakfast for the residents in the facility on 4/15/2022. The Administrator notified the Dietary District Manager on the morning of 4/15/2022, the dietary staff had not arrived at the facility to prepare breakfast for the residents. Further interview revealed the Dietary District Manager arrived at the facility at 8:30 AM and worked at the facility until 8:45 PM on 4/15/2022. Continued interview confirmed DM #2 came from another facility and worked in the kitchen between 8:00 AM and 8:30 AM and worked until 8:00 PM on 4/15/2022, and DA #3 was called and worked in the facility from 10:00 AM-8:15 PM. The DO revealed the kitchen was fully staffed for lunch on 4/15/2022. The DO revealed the bacon, eggs, and oatmeal on 4/15/2022, prepared by the facility staff was a nutritious meal. Continued interview confirmed if one of the previous DM's prepared a meal at the facility on 4/15/2022, she would have overseen all aspects of the kitchen as an old DM. This would include cooking resident's food and following the diet orders as prescribed by the physician, and she would be aware of the process to puree and provide different textures of food for the residents safely and effectively. The Director of Operations stated, .Tickets [meal tickets] were fully available [on 4/15/2022] .tickets are printed the day before at 2:00 PM-5:00 PM and placed on the preparation table for dietary staff to use to determine meal and any therapeutic restrictions . The DO confirmed the facility failed to maintain a sufficient number of dietary staff to safely and effectively carry out the function of the food and nutrition services for dining during breakfast on 4/15/2022 until 8:30 AM.
Observation on 4/20/2022 at 10:33 AM, of the kitchen preparation table next to the steam table revealed resident meal tickets readily accessible to kitchen staff. Continued observation revealed the Production Count Form which shows the recipe number and the quantity of food required to feed the residents bacon, scrambled eggs, oatmeal (hot cereal), and toast was also located on the preparation table.
During an interview on 4/20/2022 at 12:19 PM, with the Resident Care Specialist/Restorative Aid (RCS/RA) and review of the RCS/RA's written statement dated 4/20/2022 revealed on 4/15/2022 at 6:50 AM, revealed she received a call from the Staff Coordinator/Health Care Coordinator (SC/HCC) requesting assistance with breakfast preparation for residents in the facility, and was informed dietary staff had not arrived at the facility. Further interview confirmed the RCS/RA arrived at the facility at 7:03 AM on 4/15/2022, and went directly to the kitchen and assisted the SC/HCC, Administrator, and the Activity Manager (AM) in preparing the residents' breakfast meal. The RCS/RA confirmed the meal tickets were utilized, and the SC/HCC ensured residents received the appropriate meal and fluids as ordered by the physician. Further interview revealed, .The dietary staff showed up a little after 8:00 AM [on 4/15/2022] .
During an interview on 4/20/2022 at 12:41 PM, with the AM and review of the AM's written statement dated 4/19/2022, confirmed the dietary staff did not arrive at the facility to provide breakfast for the resident's on 4/15/2022. Further interview confirmed the RCS/RA requested the AM to assist her in preparing breakfast for the residents. Further interview confirmed the staff utilized the resident meal tickets in the kitchen and followed the physician diet orders to provide breakfast to the residents. The AM stated, .We followed the Doctor's orders for the resident meals and ensured resident received the textured food, the right amount, the right plate whether they needed a plate guard, or built-up silverware, a divide plate, or the plate with the edges . The AM confirmed the SC/HCC had been the previoius DM, and she prepared and checked the meal trays for accuracy prior to the trays leaving the kitchen.
During an interview on 4/20/2022 at 12:53 PM, with the SC/HCC (the previous DM) and review of her written statement dated 4/20/2022 revealed she arrived at the facility at 6:30 AM on 4/15/2022, and was informed by nursing staff dietary had not arrived at the facility. Further interview revealed she notified the Administrator the dietary staff had not arrived at the facility and was instructed to start preparing the residents' breakfast. The SC/HCC retrieved the emergency keys out of the medication room and went to the kitchen and prepared breakfast for the residents. The SC/HCC stated she worked as the DM at the facility for 9 months and she was knowledgable of how to ensure the residents received the correct diets as ordered by the phyician, and the trays were checked for accuracy. The SC/HCC revealed the dietary staff arrived around 7:40 AM-8:00 AM (4/15/2022). The SC/HCC stated, .When they [dietary staff] came in we had a little food left to be served and eggs to be fixed so the dietary staff finished up .the Manager [DM] quit that morning and the other staff she had to help her called in . The SC/HCC confirmed the facility failed to have a sufficient number of dietary staff to safely carry out the food and nutrition services for dining on 4/15/2022.
During an interview on 4/20/2022 at 1:17 PM, the Administrator and review of the Administrator's written statement dated 4/19/2022, revealed she received a telephone call from the SC/HCC on 4/15/2022, and was notified the dietary staff had not arrived at the facility to provide breakfast for the residents. Further interview confirmed the Administrator instructed the SC/HCC, the previous DM in the facility, to start preparing breakfast. The Administrator also stated she notified the Dietary District Manager the dietary staff had not arrived to the facility to prepare breakfast for the residents. The Administrator confirmed the facility failed to maintain a sufficient number of dietary staff to safely and effectively carry out the function of the food and nutrition service for residents dining at breakfast on 4/15/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, observation and interview the facility failed to maintain infection control practices for 1 resident (#52) of 3 residents observed for wound care.
The findings include:
Review of the facility policy Clean Dressing Change revised 12/09, revealed .Put on gloves .Remove soiled dressing, place in bag for disposal .Remove/dispose of gloves, wash hands, don clean gloves .Clean wound as ordered .Remove/dispose of gloves, wash hands, don clean gloves .Apply dressing and secure .Remove gloves .Wash hands .
Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Rheumatoid Arthritis, Lupus and Chronic Pain.
Medical record review of the Physicians Orders revealed the following:
5/16/19 - Collagenase Powder (medication to treat wound) Apply .every day shift for wound care clean daily with iodine x 3 rinse with (normal saline) x 3 pat dry, apply collagen granules (medication to treat wound) to base of wound bed with (a wound dressing) cover with waterproof silicone dressing.
5/31/19 - Santyl Ointment (medication to debride wound) Apply to areas of slough (dead tissue) .topically every day shift.
Observation of Resident #52's wound care on 6/5/19 at 10:15 AM, with the Wound Care Nurse (WCN) in the resident's room, revealed the WCN removed the soiled dressing from the resident's coccyx; removed and discarded the gloves; donned new gloves and did not wash the hands. Continued observation revealed the WCN disinfected the wound with iodine, removed the gloves, donned new gloves and did not wash the hands. Further observation revealed the WCN rinsed the wound with a 4 x 4 dressing soaked with normal saline, dried the wound, discarded the gloves and donned new gloves without washing the hands. Continued observation revealed the WCN applied Santyl ointment to the wound, discarded the gloves, donned new gloves and did not wash the hands. Further observation revealed the WCN applied the collagen granules to the wound, discarded the gloves, donned new gloves and did not wash the hands. Continued observation revealed the WCN completed the treatment and applied the dressing.
Interview with the Wound Care Nurse on 6/5/19 at 10:25 AM, in Resident #52's room, confirmed she failed to wash her hands after glove removal during wound care.
Interview with the Director of Nursing on 6/5/19 at 1:37 PM, in the conference room, confirmed during the observation of Resident #52's wound care, the facility's policy for infection control was not maintained when hands were not washed after glove removal.