Health inspection·March 16, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for 1 of 1 rooms (room [ROOM NUMBER]) reviewed for environment. The facility failed to ensure residents in room [ROOM NUMBER] were provided with a safe, clean, comfortable, and homelike environment during observations on 03/13/2023 and 03/14/2023. These failures could place residents at risk of not residing in a safe, clean, comfortable, and homelike environment. Findings Included: During observation on 03/14/2023 at 11:13am of #404, the room appeared decorated with personal items, but with various areas of scratched, chipped, and discolored/stained off-white, light brown areas to the walls. The areas of concern were as follows: 1. The wall area separating the bathroom from the resident living area had a crack approximately 2.5 feet long. Areas of wall were jagged and protruding out. 2. The wall area to the right side of the closet had an approximately a 0.5 foot area of scuffed, scratched, and chipped paint and drywall. 3. The shared resident bathroom had significant debris accumulation (dust, various food remnants, paint chips, crumpled up paper products, and dead insects) , linoleum stained with multiple areas of black and/or brown substances, and toilet had significant brown staining present in the toilet bowl. During observation on 03/15/2023 at 10:29am of room # 404, the room appeared decorated with personal items, but with various areas of scratched, chipped, and discolored/stained off-white, light brown areas to the walls. The areas of concern were as follows: 1. The wall area separating the bathroom from the resident living area had a crack approximately 2.5 feet long. Areas of wall were jagged and protruding out. 2. The wall area to the right side of the closet had an approximately a 0.5 foot area of scuffed, Page 1 of 10 675175 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0584 scratched, and chipped paint and drywall. Level of Harm - Minimal harm or potential for actual harm 3. The shared resident bathroom had significant debris accumulation (dust, various food remnants, paint chips, crumpled up paper products, and dead insects) , linoleum stained with multiple areas of black and/or brown substances, and toilet had significant brown staining present in the toilet bowl. Residents Affected - Few During interview on 03/14/2023 at 11:13am with residents who lived in room # 404, they stated housekeeping was doing a poor job and it was very frustrating. They stated the walls had been damaged for months. They stated they reported it to maintenance, but it had not been addressed yet. They stated the bathroom did not get cleaned properly and housekeeping only swept and mopped a small linear area in front of the entry door and then would leave. They stated her room needed a deep clean and did not recall the last time the room was cleaned properly. They stated they tried to clean but was unable. They stated the condition of her room made they sad as they were not able to clean the room due to mobility limitations. Additionally, residents stated that cockroaches came in through the cracks in the walls and pointed to the area of the wall referenced (1) above. They stated they were tired of living in a dirty and damaged room. The residents stated the room was also dirty and housekeeping did not do an adequate job cleaning. They stated they asked housekeeping to sweep the perimeter of her room in the past, but they had not done it. She stated there has been a dead cockroach under the head of her bed for a while. They stated it was difficult not to be able to clean the room due to having mobility limitations. During an observation and interview on 03/16/2023 at 9:52am HK A's cleaning service was observed for room # 404 from onset until completion. HK A was not observed sweeping or mopping perimeter. HK A was observed placing the yellow wet floor sign in room and exited the room. She stated she completed her service for the room and the staff were responsible for cleaning the room the last three days. When the debris in the room that remained after her service was brought to her attention, she stated I guess I did not see it. She stated that the residents allowed her to clean the room with no restrictions or limitations on what she can touch or move around to clean. HK A refused to [NAME] why it was important to clean resident rooms thoroughly or why she did not report the damage to the walls. During interview 03/16/2023 at 10:27am with the HK Supervisor she stated her expectations were for staff to clean each resident room daily. She stated she was new to the management position at the facility and was in the process of implementing new protocols and procedures; but did not have any completed cleaning logs or checklists to provide for review at the time of survey. She stated she expected for her staff to clean and move things around to clean if the resident allows it. She stated that some residents do not allow staff to touch their things, but she was not aware of any limitations for Resident #2 or Resident #5. She stated that if her housekeeping staff did not clean resident rooms thoroughly, it could affect the residents' quality of life. She also stated she expected her staff to report any maintenance issues immediately. She said she did not know why the damage to the wall had not been reported despite her staff going in and out of the room daily. During an interview on 03/16/2023 at 10:46am with the MT Supervisor he stated he was not aware of any maintenance issues in room [ROOM NUMBER]. He stated that he addressed maintenance concerns as they were brought to his attention. He stated that if resident walls were compromised, it could hurt somebody. During an interview on 03/16/2023 at 02:25 pm with the DON, she stated her expectations were for resident rooms to be cleaned daily. She stated she expected maintenance to ensure resident walls were 675175 Page 2 of 10 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few intact and the room kept in good condition. She stated that if resident rooms were not clean, it could be an infection control issue. She stated if resident walls were compromised, injury can occur. During an interview on 03/16/2023 at 03:40 pm with the Administrator, he stated his expectations were for resident rooms to be cleaned daily. He stated he also expected any staff members to report maintenance concerns so it could be promptly addressed. He stated if a resident's environment was not maintained, it could affect the quality of care for his residents. Record review of facility grievance log for 11/2022, 12/2022, 01/2023, 02/2023 revealed evidence of repeated housekeeping concerns related to cleanliness from other residents previously discharged from the facility. Review of facility policy, Policy/Procedure Section: Housekeeping, rev. 05/2007, stated Policy: It is the policy of this facility to provide a clean, comfortable, homelike, and sanitary living area . Procedures . 6. Dust mop floors . 10. Report any maintenance repairs needed. Review of facility policy, Resident Rights, rev. 10/04/2026, stated Safe Environment: You have the right to a safe, clean, comfortable and homelike environment . 675175 Page 3 of 10 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents' Care Plan was implemented for 1 of 8 residents (Resident #50) reviewed for Care Plans. The facility failed to ensure the care plan related to resident #50's Non-weight Bearing (NWB) status was implemented . This failure could place residents at risk for reinjury or further injury. Findings Included: Review of Resident #50's Face Sheet, dated 03/16/23, revealed she was a 68 -year-old female admitted on [DATE]. Relevant diagnoses included Displaced fracture of lateral malleolus of right fibula (right ankle fracture), Diabetes (high blood sugar), Pain, and difficulty walking. Review of Resident #50's MDS, dated [DATE] stated she was moderately cognitively intact with a BIMS score of 14. She required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. Record review of Resident #50's Comprehensive Care Plan, dated 02/03/2023 revealed the resident had a focus on her fractured right ankle and an intervention was to follow MD orders for non-weight bearing status Record review of Physician orders for Resident #50 dated 01/30/23 revealed Non-weight bearing of Right Ankle. Interview on 03/15/23 at 1:45 PM, Resident #50 said on the night of 03/09/23 or 03/10/23, she used the call button for assistance. She stated it took a long time for someone to respond. She stated when C.N.A. B (Certified Nurse Aide) entered her room to respond to the call light, she told her she needed a bed pan. She said the aide searched for the bed pan and did not find it. She said the aide then told she would go locate a bed pan for her and Resident #50 told the aide she could not wait that long, so the aide told her she would have to go to bathroom instead. Resident #50 said the aide prepared her for transfer and then told her to use the transfer board to slide to the wheelchair. The resident said she told the aide she was not supposed to let her feet touch the floor and she could not bear weight on her ankle. She stated the aide insisted she do it and told her she believed in her. She said the aide told her it would help strengthen her ankle. The resident said the more she protested, the more the aide encouraged her to do it herself. She stated she made it into her wheelchair and the aide wheeled her to the bathroom. The resident stated she could not get the wheelchair close enough to the toilet and asked the aide for help. She said the aide pushed her closer to the toilet and told her to go ahead, she could do it. She stated having to do it all without the aide's help made her cry because she was so scared that she would fall or reinjure her ankle. She stated she had to try hard to not bear weight or as little as possible on her right foot. She stated she transferred herself to the toilet and then the aide told her she was going to locate a bed pan. Resident #50 said once she was done toileting, she pressed the call button and the aide returned with a bedpan in hand. She stated CNA B watched and encouraged her to get back in the chair on her own. She stated after she returned to the chair, the aide pushed her to the bed, and she had to get back in bed on 675175 Page 4 of 10 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her own. She stated once she was back in the bed, the aide was standing at the foot of her bed and told her, See, I knew you could do it, as she lightly hit her ankle four times as she was fanning her hand against the resident's fractured ankle in a fanning motion. The resident said she asked the aide, So you're just going to beat me up now too? She said the aide then replied, I'm sorry while snickering. Resident #50 said she reported what happened to LVN E and he just looked at her and said he did not know why she (CNA B) would do that. She stated that she had not mentioned this to anyone else. During an interview on 03/16/22 at 2:06 PM, the Director of Rehabilitation stated therapy and nurses did assessments and as a team, they determined what was best for Resident #50, as it pertains to functional status. She stated if a resident was NWB, it would be determined by the person's upper body strength, strength of non-affected side, cognition all play a part in what she needs. She stated Resident #50 basically needed two-person assist. She stated the safest thing would be to go with caution and do two-person assist. She stated one-person assist for a NWB resident was not typical practice. She stated they train direct care staff on how to transfer residents. She said Resident #50 did not mention the incident with C.N.A. B to her. She said Resident #50's order is NWB for eight weeks. She said it had been six weeks, as of this week and there were two weeks remaining, before going back to Ortho. She stated the possible harm which could occur from not following the interventions put in place would be a displaced fracture, displaced screws, or an elemental fall. Interview on 03/16/23 at 3:05 PM, C.N.A. B stated she had been a CNA for over 22 years. She stated on 03/1023, Resident #50 used the call button to alert staff she needed assistance. She stated the resident stated she needed a bedpan, but they could not find it. She stated they decided to go to the bathroom. She stated the resident was in her right mind. She stated the resident could make her needs known. She stated when she entered the room, the resident told her what she needed. She stated she asked her if she wanted to use her bed pan or go to the bathroom. She stated the resident wanted to use the bed pan, however, she could not locate the bed pan, so the resident chose to go to the bathroom. She stated she pulled the resident's wheelchair up to the bed and she was going to help the resident, but the resident told her she could do it herself and told her to move the arm of the chair so she could get in it. She stated she did so and got the board, but the resident stated she could do it herself. She stated she helped the resident, but very little, because the resident said she could do it herself. She stated her back was hurting, so she allowed the resident to do as much as she could, since she said she could do it. She stated she helped the resident to the bathroom and the resident got on the toilet with very little help from her because, again, she stated she could do it. She stated the resident used the call button in the bathroom once she was done. She stated she came to assist her with getting back in bed and then she cleaned the resident up and cleaned the board. She stated while the resident was in the bathroom, she located a bed pan and brought it back with her. She stated this was the first time she had had to assist the resident with getting out of the bed. She stated she did not have any type of conversation with the resident which did not pertain to what she needed. She stated she never touched the resident at all. She stated she had access to the [NAME] system, which was how the aides look up how to care for the residents. She stated she did not look at the [NAME] prior to going to the resident's room. She stated she went to the room to see what the resident needed first. She stated she did not think to look to see if the resident required one or two-person assist, she just took the resident's word, when she told her she could do it herself, regarding transferring. She stated the possible harm which could have taken place, would have been that the resident could have fallen or her by her putting weight on the ankle, could have re-injured the ankle. Interview on 03/16/23 at 2:31 PM, LVN E stated Resident #50 had physician orders for NWB 675175 Page 5 of 10 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few because of her fractured left ankle and required assistance to use the toilet. He stated that this was also on her Care plan and staff is required to be familiar with the specific care for each resident. He stated CNA B should have been aware of this as well. He stated the possible harm to the resident due the aide allowing her to bear weight on her ankle would have been that she could have reinjured the ankle. Interview on 03/16/23 at 2:38 PM, the DON stated the incident involving Resident #50 and C.N.A. B had never happened since Resident #50 had been in the facility. She stated the therapy department determines the extent of assistance which a resident need for ADLs. She stated therapy did not give NWB orders. She stated only doctors order such a status. She stated she spoke to the C.N.A. B, and the aide stated the aide offered the resident a bed pan, so she would not have to keep getting back up. She stated the aide did not say anything about telling the resident to do it herself. She stated the aide told her she entered the room and assisted the resident with her transfer from bed to wheelchair and wheelchair to toilet. She stated the aide told her that she gave the resident time and privacy to use the toilet and told the resident to use the call button in the bathroom when she was finished. She stated she assisted the resident back to bed after cleaning her up. She acknowledged that this was also on her Care plan. The DON stated she expects all her staff to follow Care plans and physician orders. The DON stated the possible adverse effect of not properly assisting the resident would be reinjuring the fracture. The DON stated the following policy regarding Care plans was the only one they had. Interview with Administrator on 03/16/203 at 4:00 PM, revealed he was made aware of the concerns regarding Resident #50 and can B and from what he could gather, the CNA B was trying to encourage the resident to self-transfer. He was advised that he is aware that resident #50 had standing orders for non-weight bearing of the right ankle and it was also planned on her care plan. He advised all staff are expected to be knowledgeable of resident's care needs and using the appropriate resources. The Administrator advised the risk of not following residents' Care plans could result in the resident injuring her ankle again. Record review of facility policy, Comprehensive Person-Centered Care Planning, rev. Jan. 2022, revealed Policy It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 675175 Page 6 of 10 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #50) of 8 residents reviewed for accidents and hazards. The facility failed to ensure Resident #50 was provided with the appropriate level of assistance to support the resident during transfer to prevent her from bearing weight on her fractured ankle. This failure could place resident #50 at risk of re-injuring the ankle or falling and injuring. Findings Included: Review of Resident #50's Face Sheet, dated 03/16/23, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included Displaced fracture of lateral malleolus of right fibula (right ankle fracture), Diabetes (high blood sugar), Pain, and difficulty walking. Review of Resident #50's MDS, dated [DATE] stated she was cognitively intact with a BIMS score of 14. She required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene. Record review of Resident #50's Comprehensive Care Plan, dated 02/03/2023 revealed the resident had a fractured right ankle and an intervention was to follow MD orders for non-weight bearing status Record review of Physician orders for Resident #50 dated 01/30/23 revealed Non-weight bearing of Right Ankle. In an interview on 03/15/23 at 1:45 PM, Resident #50 said on the night of 03/09/23 or 03/10/23, she used the call button for assistance. She stated it took a long time for someone to respond. She stated when C.N.A. B (Certified Nurse Aide) entered her room to respond to the call light, she told her she needed a bed pan. She said the aide searched for the bed pan and did not find it. She said the aide then told she would go locate a bed pan for her and Resident #50 told the aide she could not wait that long, so the aide told her she would have to go to bathroom instead. Resident #50 said the aide prepared her for transfer and then told her to use the transfer board to slide to the wheelchair. The resident said she told the aide she was not supposed to let her feet touch the floor and she could not bear weight on her ankle. She stated the aide insisted she do it and told her she believed in her. She said the aide told her it would help strengthen her ankle. The resident said the more she protested, the more the aide encouraged her to do it herself. She stated she made it into her wheelchair and the aide wheeled her to the bathroom. The resident stated she could not get the wheelchair close enough to the toilet and asked the aide for help. She said the aide pushed her closer to the toilet and told her to go ahead, she could do it. She stated having to do it all without the aide's help made her cry because she was so scared that she would fall or reinjure her ankle. She stated she had to try hard to not bear weight or as little as possible on her right foot. She stated she transferred herself to the toilet and then the aide told her she was going to locate a bed pan. Resident #50 said once she was done toileting, she pressed the call button and the aide returned with a bedpan in hand. She stated CNA B watched and encouraged her to get back in the chair on her own. She stated after she returned to the chair, the aide pushed her to the bed, and she had to get back in bed 675175 Page 7 of 10 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on her own. She stated once she was back in the bed, the aide was standing at the foot of her bed and told her, See, I knew you could do it, as she lightly hit her ankle four times as she was fanning her hand against the resident's fractured ankle in a fanning motion. The resident said she asked the aide, So you're just going to beat me up now too? She said the aide then replied, I'm sorry while snickering. Resident #50 said she reported what happened to LVN E and he just looked at her and said he did not know why she (CNA B) would do that. She stated that she had not mentioned this to anyone else. During an interview on 03/16/22 at 2:06 PM, the Director of Rehabilitation stated therapy and nurses did assessments and as a team, they determined what was best for Resident #50, as it pertains to functional status. She stated if a resident was NWB, it would be determined by the person's upper body strength, strength of non-affected side, cognition all play a part in what she needs. She stated Resident #50 basically needed two-person assist. She stated the safest thing would be to go with caution and do two-person assist. She stated one-person assist for a NWB resident was not typical practice. She stated they train direct care staff on how to transfer residents. She said Resident #1 did not mention the incident with C.N.A. B to her. She said Resident #50's order is NWB for eight weeks. She said it had been six weeks, as of this week and there were two weeks remaining, before going back to Ortho. She stated the possible harm which could occur from not following the interventions put in place would be a displaced fracture, displaced screws, or an elemental fall. Interview on 03/16/23 at 3:05 PM, C.N.A. B stated she had been a CNA for over 22 years. She stated on 03/10/23, Resident #50 used the call button to alert staff she needed assistance. She stated the resident stated she needed a bedpan, but they could not find it. She stated they decided to go to the bathroom. She stated the resident was in her right mind. She stated the resident could make her needs known. She stated when she entered the room, the resident told her what she needed. She stated she asked her if she wanted to use her bedpan or go to the bathroom. She stated the resident wanted to use the bed pan, however, she could not locate the bed pan, so the resident chose to go to the bathroom. She stated she pulled the resident's wheelchair up to the bed and she was going to help the resident, but the resident told her she could do it herself and told her to move the arm of the chair so she could get in it. She stated she did so and got the board, but the resident stated she could do it herself. She stated she helped the resident, but very little, because the resident said she could do it herself. She stated her back was hurting, so she allowed the resident to do as much as she could, since she said she could do it. She stated she helped the resident to the bathroom and the resident got on the toilet with very little help from her because, again, she stated she could do it. She stated the resident used the call button in the bathroom once she was done. She stated she came to assist her with getting back in bed and then she cleaned the resident up and cleaned the board. She stated while the resident was in the bathroom, she located a bed pan and brought it back with her. She stated this was the first time she had had to assist the resident with getting out of the bed. She stated she did not have any type of conversation with the resident which did not pertain to what she needed. She stated she never touched the resident at all. She stated she had access to the [NAME] system, which was how the aides look up how to care for the residents. She stated she did not look at the [NAME] prior to going to the resident's room. She stated she went to the room to see what the resident needed first. She stated she did not think to look to see if the resident required one or two-person assist, she just took the resident's word, when she told her she could do it herself, regarding transferring. She stated the possible harm which could have taken place, would have been that the resident could have fallen or her by her putting weight on the ankle, could have re-injured the ankle. During an interview on 03/16/23 at 2:17 PM, Resident #50 stated when she is moving around, 675175 Page 8 of 10 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0689 one person assists her. She stated when she is moving around in the shower, two-people assist her. Level of Harm - Minimal harm or potential for actual harm Interview on 03/16/23 at 2:31 PM, LVN E revealed he was aware Resident #50 had physician orders for Non-Weight Bearing (NWB) because of her fractured left ankle and required assistance to use the toilet. He advised that staff should all be aware of residents 'care plan to ensure thy are receiving the appropriate personalized care. He stated the possible harm to the resident due the aide having her to bear weight on her ankle could have resulted in her reinjuring the ankle. Residents Affected - Few Interview on 03/16/23 at 2:38 PM, the DON stated she was not aware of any incident involving Resident #50 and C.N.A. B had ever happened since Resident #50 had been in the facility until it was mentioned on 03/15/23. She stated the therapy department determined the extent of assistance which a resident need for ADLs. She stated therapy did not give NWB orders. She stated only physician ordered such a status. She stated she spoke to the C.N.A. B and the aide stated the aide offered the resident a bed pan, so she would not have to keep getting back up. She stated the aide did not say anything about telling the resident to do it herself. She stated the aide told her she entered the room and assisted the resident with her transfer from bed to wheelchair and wheelchair to toilet. She stated the aide told her that she gave the resident time and privacy to use the toilet and told the resident to use the call button in the bathroom when she was finished. She stated she assisted the resident back to bed after cleaning her up. The DON stated the possible adverse effect of not properly assisting the resident would be reinjuring the fracture. She stated she and the Administrator will investigate the incident further and place the employee on suspension until the investigation is complete. Interview with Administrator on 03/16/203 at 4:00 PM, revealed he was made aware of the concerns regarding Resident #50 and can on 03/15/23 and from what he could gather, CNA B was trying to encourage the resident to self-transfer. He was advised Resident #50 had standing orders for non-weight bearing of the right ankle and it was also planned on her care plan. He advised all staff are expected to be knowledgeable of resident's care needs and using the appropriate resources. The Administrator advised the risk of staff not following Resident #50 Physician Order's could result in the resident injuring her ankle again. 675175 Page 9 of 10 675175 03/16/2023 Park Manor of McKinney 1801 Pearson Ave McKinney, TX 75069

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure the Iced Tea Dispenser, located in the facility's only kitchen, had the cover placed on top after filing it with tea. This failure could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observation and interviews on 03/14/23 at 09:40 AM in the facility's only kitchen revealed an Iced Tea dispenser filled with tea, but it did not have a top and it was exposed to the air. The Dietary Manager stated [NAME] A made the tea. The Dietary Manager asked [NAME] A when the tea was made, and [NAME] A stated the tea was made around 7:00 AM. The Dietary Manager and [NAME] A stated the container was uncovered for over 2 hours. The Dietary Manager stated they had not served any tea to residents from this dispenser, and it will be thrown out. Interview with the Dietary Manager on 03/16/23 at 1:30 PM revealed she expected her staff to ensure the tea dispenser was covered once it had been filled. She stated [NAME] A was responsible for filling the Tea dispenser and she should have placed the top on it once it was filled. She stated the risk of not placing the cover on top of the tea dispenser was an infection control concern and residents could get sick. Interview with [NAME] A on 03/16/23 at 1:40 PM revealed she was the person that prepared the Tea and placed it in the Iced Tea Dispenser. She stated she had forgotten to place the top back onto the dispenser. She stated the risk to residents of the tea being exposed could result in the resident getting some type of bacteria illness. Interview with Administrator on 03/16/23 at 2:00 PM revealed he was made aware of the full Iced Tea Dispenser not having a top placed on it. He stated the expectation was for staff to ensure they are practicing sanitary conditions for residents throughout the facility and the risk to the residents could be that they contract an air-borne illness. Record Review of facility's policy and procedure for Sanitation in Dietary, dated October 2007, revealed It is the policy of this facility that food service area shall be maintained in a clean and sanitary manner. 675175 Page 10 of 10