Every finding on record at Fairhope Health & Rehab

Based on interviews, review of Personnel File for Employee Identifier (EI) #3,Certified Nursing Assistant (CNA) and a facility policy titled, Abuse, Neglect and Exploitation, the facility failed to report allegations of abuse received on 08/29/2022 and 08/31/2022, This affected two of eight allegations of abuse/mistreatment reviewed. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation with an effective date of 02/2020, documented, . VI. Online initial reporting of incidents to the state A: Report to State agency all alleged violations involving abuse, . immediately but no later than 2 hours after forming the suspicion or allegation .to the Alabama Department of Public Health . E. Completed investigation must be sent online by the fifth working day . Review of signed statement from EI #4, CNA dated 08/28/2022, documented, . In voicing my concern about the residents on the 500 hall. I was told by another employee that (EI #3) carries a spoon around to pop residents on the hand to make them listen . She's very ruff verbally/physically. Review of signed statement from EI #4 dated 08/31/2022, documented, I witnessed (EI#3) on 08/25/2022 give a resident a wine beverage . Review of a signed statement from EI #2, Director of Nursing (DON) dated 09/02/2022, documented In investigating an allegation put forth by (EI #4), dated for August 28th, 2022 and received by ED on August 29th, 2022 a second allegation was put forth by (EI #4) on August 31, 2022 and received by ED on August 31,2022 . Allegations were unsubstantiated . Review of a signed statement from EI # 1, Administrator dated 09/03/2022, documented, I received a written note from (EI #4) on August 28th that I received on August 29th and a note received on August 31st . Allegations were unsubstantiated . Review of incidents reported to the State agency in the last six months provided by the Administrator revealed no allegations were reported involving EI #3 for 08/29/2022 and 08/31/2022. On 09/28/2022 at 3:57 PM, an interview was conducted with EI #2, DON. She stated she became aware of allegations of abuse on 08/29/2022 and 08/31/2022 when EI #4, CNA wrote note to EI #1. She stated she and EI #1 began to investigate allegations after they received the first note and continued investigation after second note was received. EI #2, stated allegations were not substantiated because no one knew anything or had witnessed anything staff would consider wrong. EI #2 stated to her knowledge the allegations were not reported to State agency and admitted they should have been reported. EI #2, stated the allegations were not reported to state agency because she questioned the validity of them. On 09/28/2022 at 4:39 PM, an interview was conducted with EI #1, Administrator/Abuse Coordinator. She stated she became aware of the allegations of abuse on 08/29/2022 and 08/31/2022 when she received note from EI #4, CNA. EI #1 stated her duties as Abuse Coordinator was to report any allegation of abuse to State agency, investigate and report findings to state agency. She stated she began investigating allegations immediately and the allegations were not substantiated. EI #1, stated these allegations were not reported to State agency, however admitted the facility's policy is to report any allegation or suspicion of abuse within 2 hours. This deficiency was cited as a result of investigation AL 077.

Based on observation, interview, and review of the facility's Food, Leftover - Storage and Use policy, the facility failed to ensure food was properly stored in the walk-in refrigerator and walk-in freezer. This had the potential to affect 54 of 55 residents in the facility who ate food prepared in the kitchen. Findings include: The facility's Food, Leftover - Storage and Use policy and procedure, dated 07/2016, indicated, .Standard: Leftover foods should be stored under sanitary conditions .Process: Leftover foods should be covered, labeled and dated . Opened bulk items that require refrigeration once open may be stored up to thirty (30) days but not beyond 'best by' or expiration date then discarded . On 02/21/2022 at 9:18 AM, during the initial tour of the kitchen and food storage areas, with Employee Identifier (EI) #13, the Dietary Manager, present, the following was observed: - In the walk-in refrigerator, there was no date on the following open food: two packages of sliced ham, a package of salami, a plastic bag of boiled eggs, a package of tortillas, a plastic bag of cinnamon raisin bread, and a plastic bag of grated cheese. - In the walk-in freezer, a box of frozen vegetables was stored on the floor and there was no date on the following open foods: a package of frozen pancakes, a plastic container of lemon meringue pie, a plastic container of red velvet cake, and a plastic bag of hush puppies. A plastic bag of French toast was open to air and not dated. On 02/21/2022 at 9:28 AM, EI #13 stated food was not supposed to be stored on the floor. On 02/21/2022 at 9:32 AM, EI #13 was interviewed. She stated open food packages in the refrigerator and freezer should be closed and dated.

Based on record review, interview, review of the facility's Resident Assessment Instrument (RAI) policy, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure the quarterly Minimum Data Set (MDS) assessments for Resident Identifier (RI) #s 9, 27, 8, 19, 23, 18, 14, 21, and 24 were completed within required timeframes. This affected nine of 23 residents reviewed for timely completion and/or transmission of MDS assessments. Findings include: A review of the facility's Resident Assessment Instrument (RAI) policy and procedure, dated 09/2019, revealed, .Purpose: Residents are assessed, based on a comprehensive assessment process, in order to ensure they receive treatment and care in accordance with professional standards of practice, the comprehensive care plan and the resident's choices .b.) Quarterly assessments are due at least every 92 days . Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed the following: .Chapter 2: Assessments for the Resident Assessment Instrument (RAI) . Non-Comprehensive Assessments and Entry and Discharge Reporting . Assessment Management Requirements and Tips for Non-Comprehensive Assessments: .The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of previous OBRA assessment - Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment - + 92 calendar days) . On 02/23/2022 at 8:13 AM, Employee Identifier (EI) #3, the MDS Coordinator, was asked to provide information from the MDS program in her computer regarding the completion of quarterly MDS assessments for RI#s 9, 27, 8, 19, 23, 18, 14, 21, and 24: 1. A review of RI #9's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 12/17/2021, had not been completed. The most recent prior MDS assessment, a quarterly assessment, had an ARD of 09/17/2021. 2. A review of RI #27's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 01/15/022, had not been completed. The most recent prior MDS assessment, a quarterly assessment, had an ARD of 10/18/2021. 3. A review of RI #8's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 12/15/2021, had not been completed. The most recent prior MDS assessment, a significant change in condition assessment, had an ARD of 09/16/2021. 4. A review of RI #19's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 01/06/2022, had not been completed. The most recent prior MDS assessment, an annual assessment, had an ARD of 10/08/2021. 5. A review of RI #23's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 01/12/2022, had not been completed. The most recent prior MDS assessment, a quarterly assessment, had an ARD of 10/13/2021. 6. A review of RI #18's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 01/07/2022, had not been completed. The most recent prior MDS assessment, a quarterly assessment, had an ARD of 10/06/2021. 7. A review of RI #14's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 01/04/2022, had not been completed. The most recent prior MDS assessment, an admission assessment, had an ARD of 10/05/2021. 8. A review of RI #21's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 01/08/2022, had not been completed. The most recent prior MDS assessment, an annual assessment, had an ARD of 10/09/2021. 9. A review of RI #24's RAI list revealed a quarterly MDS assessment, with an Assessment Reference Date of 01/13/2022, had not been completed. The most recent prior MDS assessment, a quarterly assessment, had an ARD of 10/14/2021. On 02/24/2022 at 8:40 AM, EI #3, the Minimum Data Set Coordinator, stated the quarterly MDS assessments for RI #s 9, 27, 8, 19, 23, 18, 14, 21, and 24 had not been completed in a timely manner. On 02/24/2022 at 8:45 AM, EI #1, the Administrator was interviewed. She stated she expected MDS assessments to be completed timely according to the MDS calendar.

Based on record review, interview, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were submitted to CMS within 14 days of the completion date of the assessments for Resident Identifier (RI) #s 17, 15, 27, 11, 2, 23, 22, 16, 21, and 24, 10 of 23 residents reviewed for timely completion and/or transmission of MDS assessments. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, revealed the following: .CHAPTER 5: SUBMISSION AND CORRECTION OF THE MDS ASSESSMENTS . 5.1 Transmitting MDS Data All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS ' Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system . 5.2 Timeliness Criteria . .Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date . All other MDS assessments must be submitted within 14 days of the MDS Completion Date . On 02/23/2022 at 8:13 AM, Employee Identifier (EI) #3, the MDS Coordinator, was asked to provide information from the MDS program in her computer regarding the transmission of MDS for the following residents: 1. A review of RI #17's RAI list revealed a significant change in status Minimum Data Set, with an Assessment Reference Date of 01/05/2022, was signed off as completed by the Registered Nurse (RN) on 01/14/2022. This assessment was not transmitted to CMS until 02/21/2022. 2. A review of RI #15's RAI list revealed a quarterly Minimum Data Set, with an Assessment Reference Date of 01/01/2022, was signed off as completed by the RN on 01/14/2022. This assessment was not transmitted to CMS until 02/21/2022. 3. A review of RI #27's RAI list revealed a quarterly Minimum Data Set, with an Assessment Reference Date of 10/18/2021, was signed off as completed by the RN 11/01/2021. This assessment was not transmitted to CMS until 11/26/2021. 4. A review of RI #11's RAI list revealed a discharge Minimum Data Set, with an Assessment Reference Date of 11/17/2021, was signed off as completed by the RN on 01/28/2022. This assessment was not transmitted to CMS until 02/21/2022. 5. A review of RI #2's RAI list revealed a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/10/2021,was signed off as completed by the RN on 09/24/2021. This assessment was not transmitted to CMS until 10/12/2021. 6. A review of RI #23's RAI list revealed a quarterly Minimum Data Set, with an Assessment Reference Date of 10/13/2021, was signed off as completed by the RN on 10/27/2021. This assessment was not transmitted to CMS until 11/26/2021. 7. A review of RI #22's RAI list revealed a quarterly Minimum Data Set, with an Assessment Reference Date of 01/11/2022, was signed off as completed by the RN on 01/25/2022. This assessment was not transmitted to CMS until 02/21/2022. 8. A review of RI #16's RAI list revealed a quarterly Minimum Data Set, with an Assessment Reference Date of 01/03/2022, was signed off as completed by the RN on 01/17/2022. This assessment was not transmitted to CMS until 02/21/2022. 9. A review of RI #21's RAI list revealed an annual Minimum Data Set, with an Assessment Reference Date of 10/09/2021, was signed off as completed by the RN on 10/23/2021. This assessment was not transmitted to CMS until 11/26/2021. 10. A review of RI #24's RAI list revealed a quarterly Minimum Data Set, with an Assessment Reference Date of 10/14/2021, was signed off as completed by the RN on 10/28/2021. This assessment was not transmitted to CMS until 11/26/2021. On 02/24/2022 at 8:40 AM, EI #3 stated the Minimum Data Sets for all ten residents listed above had not been transmitted timely. On 02/24/2022 at 8:45 AM, EI #1, the Administrator, was interviewed. She stated she expected Minimum Data Sets to be transmitted timely.

Based on record review, interview, and review of the facility's Psychoactive Drug Monitoring and Behavior Management Program policies, the facility failed to ensure Resident Identifier (RI) #45 and RI #22, who both received [CONDITION(S)] medications, were monitored for the specific targeted behaviors for which medications were ordered. Further, the facility failed to ensure RI #45 and RI #22 were monitored for side effects of their ordered [CONDITION(S)] medications. This deficient practice affected RI #s 45 and 22, two of five sampled residents reviewed for unnecessary medications. Findings include: A review of the facility's Psychoactive Drug Monitoring policy and procedure, dated 3/2011, revealed, .Residents who receive psychoactive/psychopharmacological medications are monitored. These are defined as any medication for managing behavior, stabilizing mood, or treating psychiatric disorders. Every effort is made to ensure that residents receiving these medications obtain maximum benefit with the minimum of unwanted side effects. Psychoactive drug monitoring guidelines include, but may not be limited to, anti-anxiety drugs, antidepressants, antipsychotics, and sedative/hypnotics . A review of the facility's Behavior Management Program, dated 03/2018, revealed, .Behavior monitoring may be done to determine behavior or an isolated event . 1. A review of Resident Identifier (RI) #45's Face Sheet, dated 02/21/2022, revealed RI #45 was admitted the to the facility on [DATE] and had diagnoses which included [CONDITION(S)] Disorder, [CONDITION(S)] Type; Generalized Anxiety Disorders; Other Recurrent Depressive Disorders; Other [CONDITION(S)] Disorders; and other Drug Induced Movement Disorders. Review of RI #45's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2021, revealed the resident had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident had exhibited verbal symptoms directed toward others and had rejected care on one-three days during the seven day assessment look-back period. Review of RI #45's comprehensive care plans, most recently reviewed/revised on 02/21/2022, indicated the resident's problems included behaviors. Approaches for the problem included to place the resident on a behavior monitoring plan if needed and to document noted behaviors. Another care plan problem was the potential for adverse effects related to the use of [CONDITION(S)] medications. Approaches to the problem included to evaluate the effectiveness and side effects of the medication for possible need to increase, decrease, or eliminate drug; observe during routine rounds for signs and symptoms of adverse side effects of the medication and if observed document changes and notify MD (medical doctor); observe resident for excessive sedation, tardive dyskinesia, malignant syndrome, akathisia, changes in facial and oral movements, involuntary rapid, objectively purposeless; irregular spontaneous extremity and trunk movements and notify the physician if observed. Another approach was to document those symptoms in the medical record. Review of RI #45's Physician's Orders, dated 02/2022, revealed the resident was to receive the following [CONDITION(S)] medications: - 02/03/2022 - [MEDICATION(S)] 25 milligrams (mg) one tablet by mouth every morning. This order specified to hold for sedation and to monitor for gait changes; however, the order did not specify the diagnosis for which it was prescribed or indicate any specific targeted behaviors. - 10/03/2021 - [MEDICATION(S)] 150 mg one tablet by mouth at bedtime for sleep - 01/19/2022 - [MEDICATION(S)] 125 mg one tablet by mouth at bedtime. The order did not specify the diagnosis for which it was prescribed or indicate any specific targeted behaviors. - 02/04/2022 - [MEDICATION(S)] 5 mg on tablet by mouth every afternoon for [CONDITION(S)] disorder, current episode depressed, moderate - 08/21/2021 - [MEDICATION(S)] 30 mg one capsule twice daily A review of RI #45's electronic health record (EHR), including the Medication Administration Records for 12/2021, 01/2022, and 02/2022, revealed that while there was general behavior monitoring for RI #45, there was no monitoring of any specific target behaviors related to his/her [CONDITION(S)] medication use. Further, there was no monitoring for side effects of the antipsychotic and antidepressant medications. The EHR did not contain an AIMS (Abnormal Involuntary Movement Scale), a tool used to measure involuntary movements known as tardive dyskinesia, for the resident. On 02/24/2022 at 10:05 AM, Employee Identifier (EI) #24, Licensed Practical Nurse (LPN), was interviewed. She stated RI #45 received [MEDICATION(S)] and [MEDICATION(S)] for paranoia tendencies, but said a new nurse would not know that. She stated the behavior list in the electronic MAR was generalized and not specific to the resident's target behaviors. The LPN stated the resident was not monitored for side effects of the [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] and further stated there was no place to document monitoring of side effects. 2. A review of Resident Identifier (RI) #22's Face Sheet, dated 02/21/2022, revealed RI #22 was admitted to the facility on [DATE] and had diagnoses which included Cognitive Communication Deficit; Unspecified Dementia with Behavioral Disturbance; Other Specified Anxiety Disorders; Dementia in Other Diseases Classified Elsewhere; and Other Recurrent Depressive Disorders. RI #22's care plan, dated 01/27/2020, indicated the resident had the potential for adverse effects related to the use of [CONDITION(S)] medications. Approaches to the problem included to evaluate effectiveness and side effects of medication for possible need to increase, decrease, or eliminate the drug; observed during routine rounds for signs and symptoms of adverse side effects of the medication and if observed document changes and notify the physician; observe resident for excessive sedation, tardive dyskinesia, malignant syndrome, akathisia, changes in facial and oral movements, involuntary rapid, objectively purposeless; irregular spontaneous extremity and trunk movements and notify the physician if observed. Another approach was to document those symptoms in the medical record. RI #22's care plan, dated 05/01/2020, indicated the resident had been exhibiting behaviors of being demanding of staff, picking at her ear recently, non-compliance with social distancing and being disruptive at times. Approaches to the problem included to place the resident on a behavior monitoring plan if needed and to document noted behaviors. RI #22's care plan, dated 12/13/2021, indicated the resident had been exhibiting impulsive behaviors, hitting her roommate, non-compliance with wearing a mask when out in the hallway. Approaches for the problem included to place the resident on a behavior monitoring plan if needed, notify MD of any significant changes in behaviors, and document noted behaviors. A review RI #22's most recent annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/11/2022, revealed the resident had a Brief Interview for Mental Status Score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident had exhibited verbal behavioral symptoms directed toward others and had exhibited other behavioral symptoms not directed toward others during one to three days during the seven day assessment look-back period. A review of the Physician's Orders, dated 02/2022, revealed the resident was to receive the following [CONDITION(S)] medications: - 01/05/2022 - [MEDICATION(S)] 25 milligrams (mg) (1/2 tab to equal 12.5mg) give one-half tablet by mouth daily at bedtime for dementia with behavioral disturbance. The order did not specify a targeted behavior for which the medication was prescribed. - 01/19/2022 - [MEDICATION(S)] 30mg one by mouth daily for depression A review of RI #22's electronic health record (EHR), including the electronic Medication Administration Records (eMAR) for 12/2021, 01/2022, and 02/2022, revealed that while there was general behavior monitoring for RI #45, there was no monitoring of any specific target behaviors related to his/her [CONDITION(S)] medication use. Further, there was no monitoring for side effects of the antipsychotic and antidepressant medications. The EHR did not contain an AIMS (Abnormal Involuntary Movement Scale), a tool used to measure involuntary movements known as tardive dyskinesia, for the resident. On 02/23/2022 at 2:03 PM, Employee Identifier (EI) #24, a Licensed Practical Nurse, was interviewed. She stated there was no monitoring for side effects of the antipsychotic and antidepressant medications. On 02/24/2022 at 9:50 AM, a follow-up interview was conducted with EI #24. She stated the behavior monitoring listed on the eMAR was a generalized list used for every resident, and not specific to any target behaviors. On 02/24/2022 at 5:06 PM, a telephone interview was conducted with the psychiatric Nurse Practitioner. She stated she expected the facility's nurses to monitor for the target behaviors for which an antipsychotic medication is administered. She further stated she expected the facility nurses to monitor residents who received antipsychotic and/or antidepressant medications for side effects of the medications.

Based on record review, interview, review of the facility's Resident Assessment Instrument (RAI) policy, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure the comprehensive annual Minimum Data Set (MDS) assessments for Resident Identifier (RI) #5 and RI #7 were completed within required timeframes. This affected two of 23 residents reviewed for timely completion and/or transmission of MDS assessments. Findings include: A review of the facility's Resident Assessment Instrument (RAI) policy and procedure, dated 09/2019, revealed, .Purpose: Residents are assessed, based on a comprehensive assessment process, in order to ensure they receive treatment and care in accordance with professional standards of practice, the comprehensive care plan and the resident's choices .Process: . a.) The comprehensive assessment is completed.annually (at least every 365 days), as clinically necessary . Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual revealed the following: .Chapter 2: Assessments for the Resident Assessment Instrument (RAI) . 2.6 Required OBRA Assessments for the MDS . Comprehensive Assessments . Assessment Management Requirements and Tips for Comprehensive Assessments: .The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment. On 02/23/2022 at 8:13 AM, Employee Identifier (EI) #3, the MDS coordinator, was asked to provide information from the MDS program in her computer regarding the completion of annual MDS assessments for the RI #5 and RI #7.: 1. A review of RI #5's RAI list revealed an annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 12/10/2021, had not been completed. The most recent prior comprehensive MDS assessment, an annual assessment, had an ARD of 12/17/2020. 2. A review of RI #7's RAI list revealed an annual MDS assessment, with an Assessment Reference Date of 12/16/2021, had not been completed. The most recent prior comprehensive MDS, a significant change in condition assessment, had an ARD of 12/22/2020. On 02/24/2022 at 8:40 AM, EI #3 stated the comprehensive annual MDS assessments for RI #5 and RI #7 had not been completed in a timely manner. On 02/24/2022 at 8:45 AM, EI #1, the Administrator, was interviewed. She stated she expected MDS assessments to be completed timely according to the MDS calendar.

Based on observation, interviews, and review of the facility's procedure, titled, Infection Control during Med Pass, the facility failed to ensure a nurse wore gloves while administering insulin for Resident Identifier (RI) #196, one of one resident that was observed being administered insulin. Findings included: A review of the facility's procedure, titled, Infection Control during Med Pass, undated, presented as the policy for infection control, by Employee Identifier (EI) #3 on 02/22/2022 at 9:15 AM, revealed, .Wear gloves with any treatment/technique . Resident Identifier (RI) #196 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #196's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/22/2022 at 7:57 AM, during medication pass, EI #4, Licensed Practical Nurse (LPN), was observed not wearing gloves while administering [MEDICATION(S)] insulin 10 units subcutaneous injection to RI #196. On 02/22/2022 at 9:20 AM, El #4 was interviewed. El #4 stated she did not wear gloves and it was a mistake. On 02/22/2022 at 9:25 AM, EI #1, Administrator, was interviewed. EI #1 stated her expectation is that staff should wear gloves when administering insulin.

Based on observation, interviews and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to report to the State Agency in the required timeframe, an allegation of abuse and neglect, alleged by Resident Identifier (RI) #6 on 9/8/21 at 6:45 PM in the presence of Employee Identifier (EI) #1, Director of Nursing, (DON). RI #6 alleged the facility did not provide incontinent care for 10 hours, a week or so ago. A report was not made to the Stage Agency until 9/10/21. This affected Resident Identifier (RI) #6, one of sixty resident residing at the facility that could potentially be affected by the alleged occurrence. Findings include: A review of the facility policy titled, Abuse, Neglect, and Exploitation with an effective date of 2/2020, revealed, . The resident has the right to be free from . neglect, . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the depravation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect means failure of facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Process . VI. Online initial reporting of incidents to the State A. Report to State agency all alleged violations involving abuse, neglect, . immediately but no later than 2 hours after forming the Suspicion or allegation, . An observation was made on 9/8/21 at 6:45 PM of RI #6 with Employee Identifier (EI) #1, Director of Nursing, (DON). The observation was intended for the DON to observed the Activities of Daily Living (ADL) care for grooming the resident had not received. During this observation RI #6 said, I don't want to complain and they are doing the best that they can. But one day a week or so ago we (RI #6 and his/her roommate) went 10 hours without being changed. It was into the night before they changed us. The Director of Nursing was present and signed that she agreed with what the surveyor had documented. On 9/10/21 at 6:37 PM an interview was conducted with EI #1, DON. EI #1 was asked what concerns RI #6 had voiced on 9/8/21 at 6:45 PM that the surveyor witnessed. She answered, issues of facial hair, finger nails, not receiving care for about 10 hours. EI #1 was asked what actions she took after RI #6 reported going 10 hours without being checked and changed. She answered she instructed staff that night to give the resident a bath and take care of the concern the resident had. EI #1 was asked what actions should she have taken. She answered look further into it. EI #1 was asked if she had done that and she answered they were working on it. EI #1 was asked what the abuse policy indicated she was supposed to do when potential neglect had occurred. She answered, report. EI #1 was asked if she had reported it to the state and she answered no. EI #1 was asked what the concern of not reporting and investigating allegations of abuse was. She answered more residents could potentially be affected. Review of reports from the facility to the Alabama Department of Public Health Online Incident Reporting System revealed, RI #6's allegation was not reported to the State Agency until 9/10/21 at 6:10 PM, two days after the allegation was made by RI #6 in the presence of the surveyor and the DON.

Based on observations, interviews, resident record review, a Modified Duty Assignments list, and review of the facility policies titled, Hair and Scalp Care and Shaving, the facility failed to ensure Activities of Daily Living (ADL) care and grooming to include: nail care, facial hair, and hair washing, was provided for Resident Identifier (RI) #6 prior to 9/8/21, when the surveyor observed RI #6 in need of ADL care. This affected RI #6, one of six residents sampled for ADL care provision. Findings include: A review of the facility policy titled, Hair and Scalp Care (Bathing ADL) with an effective date of 4/2018, revealed, . PURPOSE: Regular shampooing of the resident's hair promotes an attractive appearance and helps to prevent problems with the scalp. A review of the facility policy titled, Shaving (ADL) with an effective date of 6/2018, revealed, . PURPOSE: Shaving improves the resident's appearance and feeling of well-being. STANDARD: Male and Female residents are shaved as needed. RI #6 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Plan of Care for RI #6 with a problem onset of 8/3/20 for needs extensive assistance with ADL care, revealed an approach as follows: . Assist as necessary with dressing and grooming . A review of a Modified Duty Assignments list for Employee Identifier (EI) #2, dated 5/11/21 revealed, . 11. Trim assigned resident nails and toenails. 15. Shave assigned men and women. A review of RI #6's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 8/2/21 revealed RI #6 had a Brief Interview for Mental Status score of 15 out of a possible 15. That score indicated RI #6 was cognitively intact for daily decision making skills. The assessment further indicated RI #6 was totally dependent on one person of the staff for personal hygiene and bathing. An observation was made on 9/8/21 at 6:45 PM of RI #6 with Employee Identifier (EI) #1, Director of Nursing, (DON). All 10 of RI #6's fingernails were approximately 1/2 to 3/4 inches long and six of 10 had stains (brownish spots) under the nails. RI #6 reported, I asked ones (aides) to cut my fingernails but they just don't have time and I don't want to complain. Large thick white flakes, at the hairline over the left center of the forehead, were observed. RI #6 stated, It could be they didn't get the soap out. We just get bed baths. Hairs under the right side of RI #6's chin, approximately 10-12, each approximately 3/4-1 inch long. RI #6 felt his/her chin and pulled some hairs from top to tip and said, They sure do need to be done. But the aides don't have time. After this observation/interview, EI #1 signed the observations documented by the surveyor in agreement of the accuracy of what was documented. On 9/10/21 at 4:01 PM an interview was conducted with EI #2, a Certified Nursing Assistant, (CNA). EI #2 was asked if she worked on the hall on which RI #6 resided on 9/8/21. She answered yes. EI #2 was asked what ADL care she was expected to provide while on light duty. She answered pass ice, pass trays, feed residents, make beds, shaving and nail care. EI #2 was asked what she could tell about RI #6's facial hair on 9/8/21. She did not describe RI #6's facial hair, only that she did not get a chance to get to RI #6. EI #2 was asked what RI #6's facial hair looked like on Monday. She answered it was not real bad, it just needed to be shaved. EI #2 was asked why she did not shave RI #6 on Monday. She answered she just got side tracked. She just did not go back. EI #2 was asked how long the hairs were under RI #6's chin. She answered a little long, close to an inch. When asked how long it would take for facial hair to grow that long, EI #2 said she did not know. EI #2 was asked how often RI #6 should be checked for the need to be shaved. She answered every time RI #6 got a bath. EI #2 was asked why her job duties included shaving men and women. She answered she did them all over the building, but the building was a lot. EI #2 was asked how RI #6's fingernails appeared on Monday and Wednesday. She answered she did not look. She could not get to everyone. The person bathing RI #6 should have. EI #2 was asked if she should have looked. She answered she should have but she did not. EI #2 was asked what was the concern of a resident's fingernails being 1/2-3/4 inches long and stained underneath when RI #6 preferred for them to be kept short and clean. She answered they need to be kept short and clean. On 9/10/21 at 5:18 PM an interview was conducted with EI #3, a CNA. EI #3 was asked who was supposed to shower RI #6 on Tuesday. She answered that she had the hall and RI #6 was her resident. EI #3 was asked what the Care Plan indicated as the assistance RI #6 needed with grooming. EI #3 answered brush their hair, clean and rinse their dentures, and brush them if they needed it on shower days. EI #3 was asked what Activities of Daily Living (ADL) care was she supposed to provide with baths. She answered to comb their hair, she does not do RI #6's nails, but she was supposed to. She added that EI #2 does it and if the nails were really long she would clip them down and clean them. EI #3 was asked what RI #6's fingernails looked like on Tuesday. She answered they were long and they did need to be cut down. EI #3 was asked why RI #6's fingernails looked like that. She answered nobody cut them down. EI #3 was asked how long it would take for RI #6's fingernails to grow to 1/2-3/4 inches long. She answered she was not certain, but a good while, say weeks. EI #3 was asked why they looked like that and she answered she did not know. EI #3 was asked why nail care was not provided to RI #6. She answered honestly she did not know. EI #3 was asked what RI #6's fingernails should look like. She answered kept clean and cut because RI #6 did not like them long. EI #3 was asked what RI #6's facial hair looked like on Tuesday. She answered she did not remember. She did not believe RI #6 needed to be shaved. EI #3 was asked why was RI #6's facial hair under their chin with 10-12 hairs that were approximately 3/4-1 inch long. She answered nobody shaved them. EI #3 was asked why was facial hair grooming not provided to RI #6. She answered she did not know. EI #3 was asked how RI #6's facial hair should appear. She answered should not have any, should be shaved. EI #3 was asked how long would it take for RI #6's facial hair to grow to 3/4-1 inch long. She answered she honestly did not know. EI #3 was asked would it be greater than 7 days. She answered yes, probably. EI #3 was asked what RI #6's scalp looked like on Tuesday. She answered it needed to be washed. It had flakes. EI #3 was asked why RI #6's hair had not been washed. She answered RI #6 was not wanting to get up and shower. EI #3 was asked what she was supposed to do when RI #6 refused. EI #3 said, let the nurse know. EI #3 was asked how RI #6's hair and scalp be kept. She answered kept brushed and clean. EI #3 was asked if she should have identified those grooming need and ensured the resident's grooming needs were met. She answered yes. EI #3 was asked what was the concern of the resident's grooming needs listed above not being performed for them. She answered they will get flakes in their hair, the nails will grow too long and their facial hair will too. On 9/10/21 at 6:06 PM an interview was conducted with EI #1, the DON. EI #1 was asked what ADL grooming care were aides to provide with baths. She answered they should provide nail care, hair care, moisturize, mouth care and shaving. EI #1 was asked what RI #6's fingernails looked like on 9/8/21. She answered aged, discolored and long. EI #1 was asked what should RI #6's nails look like. She answered neat, cleaned and trimmed. EI #1 was asked what RI #6's facial hair should look like. She answered if they wished not to have any facial hair, they should not have any facial hair. EI #1 was asked what should RI #6's hair and scalp look like. She answered clean.

Based on an interview, review of Non-Controlled Medication Destruction records, and review of a facility policy titled, Disposal of Medications, Non-Controlled Medication Destruction, the facility failed to ensure the (MONTH) 27, (YEAR) and (MONTH) 29, 2019 Medication destruction records contained two required signatures. This was noted on two of seven months of Non-controlled Medication Destruction records reviewed. Findings Include: Review of a facility policy titled, Disposal of Medications Non-Controlled Medication Destruction, dated 3/11, revealed: .Policy Discontinued medications, expired medications, and medications left in the facility after a resident has expired or has been permanently discharged are destroyed or disposed of per federal/state regulations. Procedures . 3. The registered nurse and/or pharmacist witnessing the destruction, or their preparation for environmental service pickup, ensures the following is entered on the Record of Medication Destruction form .: . J. Signature of witnesses, two witnesses required for non-controlled substances (for example a pharmacist in Alabama and a registered nurse) in the designated areas on the destruction form. Review of the Record of Medication Destruction for Non-Controlled Drugs, dated 6/27/18, revealed only one signature. Review of the CERTIFICATE OF INVENTORY AND DESTRUCTION (non-controlled medications), dated 3/29/19, also revealed only one signature. On 5/23/19 at 9:03 AM, an interview was conducted with Employee Identifier (EI) #7, the Director of Nursing Services. EI #7 was asked who was responsible for the signing of the Non-Controlled Drug destruction sheets. EI #7 said the Unit Manager and herself. EI #7 was asked when the sheets were signed, should there have been two signatures on the non-controlled sheets. EI #7 said yes, according to facility policy they should be signed by two people. EI #7 reviewed the (MONTH) 27, (YEAR) and (MONTH) 29, 2019 medication destruction records and agreed they only had one signature.

Based on observations, interviews, record review and a review of a policy titled, ADL {activities of daily living} Care, Documentation of Routine ., the facility failed to check RI (Resident Identifier) #4 for incontinence and change him/her for four hours and 16 minutes. RI #4 is unable to carry out ADLs for himself/herself. RI #4 was continuously observed on 5/16/18 from 8:25 AM till 12:41 PM and staff did not check him/her for incontinence or change him/her during that time. This affected one of two residents whose ADL assistance was observed. Findings Include: Review of a policy titled, ADL Care, Documentation of Routine . with an effective date of 2/18, revealed: . PR[NAME]ESS .Care provided per policy and residents individualized plan of care . RI#4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI#4's care plan dated 12/21/17 revealed: .Problem/Need .Resident needs total assist with all ADL's related to: being totally dependant (dependent) on staff, head injury.Approaches . Incontinence care promptly and apply barrier cream as needed . RI#4's care plan dated 12/21/17, revealed: .Problem Onset . Potential for skin breakdown related to incontinence, total dependence, decreased mobility .Approaches .Assist/encourage to turn and reposition every 2 hours and prn (as needed) . A continuous observation was made by the surveyor of RI #4 on 5/16/18 from 8:25 AM until 12:41 PM. RI #4 was in front of the nurses station in a geri chair. At 9:49 AM, the staff moved RI #4 to the activity area for a coffee social. RI #4 remained in the activity area until lunch was served. RI #4 was fed by the staff at 12:00 PM. RI #4 was not repositioned and the staff had not checked the adult brief RI #4 was wearing for wetness (urine) or if it was soiled. At 12:41 PM, the staff took RI #4 to his/her room and RI #4 was placed in his/her bed to be checked for incontinence and changed. An interview was conducted on 05/16/18 at 1:46 PM, with EI (Employee Identifier) #17, a CNA (Certified Nursing Assistant). EI #17 was asked who was assigned to RI #4 today, 5/16/18. EI #17 stated she was. EI #17 was asked what time was RI #4 placed in his/her geri chair. EI #17 replied, 8:30 AM and they went to the nursing station. EI #17 was asked how often should the resident be checked. EI #17 replied, he/she should be checked for repositioning and drying every two hours. EI #17 was asked why should the resident be checked. EI #17 replied, so the resident would not get any pressure sores. EI #17 was asked when was RI #4 checked this AM. EI #17 replied, she checked RI #4 in the hallway just before lunch at the nursing station. EI #17 was asked who took RI #4 to the dining room after she checked the resident. EI # 17 replied, I don't remember. EI #17 was asked where did she check RI #4. EI #17 replied/ in the hall. EI #17 was asked if she was supposed to provide privacy when checking RI #4. EI #17 replied, yes. EI #17 was asked what was the concern for not providing privacy for the resident. EI #17 replied, it makes the resident feel bad. EI #17 was asked when did the resident attend the coffee social. EI #17 replied, 10:00 AM. EI #17 was asked to explain how she checked RI #4 for wetness and/or being soiled and turned RI #4 while he/she was in the gerichair at the nursing station. EI #17 replied, RI #4 was a heavy wetter. EI #17 also replied, I touched the resident's leg. EI#17 said, she did not check to see if RI #4 was wet. EI #17 was asked how was a resident supposed to be checked for wetness and if they were soiled. EI#17 was asked to describe RI #4's brief to the surveyor. EI #17 replied, it was soiled with urine, really soiled a lot. EI #17 was asked did she agree she said the urine was one inch from the top in the front and four inches from the top in the back of the brief. EI # 17 replied,yes. EI #17 was asked what was the concern of RI #4 being left wet. EI#17 replied she/he was concerned RI #4 would get breakdown, red areas and UTI (urinary tract infections). EI #17 was asked what was the facility policy for checking and changing residents. EI#17 replied, check the resident in their room every two hours.

Based on an observation, interviews, record review and a review of Kozier & Erb's FUNDAMENTALS OF NURSING Concepts, Process, and Practices, the facility failed to ensure RI (Resident Identifier) #4, a resident at risk of developing a pressure ulcer, received the necessary care of checking for incontinence and changing. This affected RI #4, one of two sampled residents at risk for pressure ulcer development. Findings Include: A review of Kozier&Erb's FUNDAMENTALS OF NURSING Concepts, Processes, and Practices, page 830 revealed: .Risk Factors Several factors contribute to the formation of pressure ulcers: . immobility, .fecal and urinary incontinence IMMOBILITY Immobility refers to a reduction in the amount and control of movement a person has. Normally people move when they experience discomfort due to pressure on an area of the body.any causes of decreased activity can hinder a person's ability to change positions independently and relieve the pressure, even if the person can perceive the pressure . A review of RI #4's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 4/9/18, revealed RI #4 was totally dependent on staff for all ADLs and required a one person assist for transfers. RI#4's care plan dated 12/21/17, revealed: .Problem Onset . Potential for skin breakdown related to incontinence, total dependence, decreased mobility .Approaches .Assist/encourage to turn and reposition every 2 hours and prn (as needed) . A continuous observation was made by the surveyor of RI #4 on 5/16/18 from 8:25 AM until 12:41 PM. RI #4 was in front of the nurses station in a geri chair. At 9:49 AM, the staff moved RI #4 to the activity area for a coffee social. RI #4 remained in the activity area until lunch was served. RI #4 was fed by the staff at 12:00 PM. RI #4 was not repositioned and the staff had not checked the adult brief RI #4 was wearing for wetness (urine) or if it was soiled. At 12:41 PM, the staff took RI #4 to his/her room and RI #4 was placed in his/her bed to be checked for incontinence and changed. An interview was conducted on 05/16/18 at 1:46 PM, with EI (Employee Identifier) #17, a CNA (Certified Nursing Assistant). EI #17 was asked who was assigned to RI #4 today, 5/16/18. EI #17 stated she was. EI #17 was asked what time was RI #4 placed in his/her geri chair. EI #17 replied, 8:30 AM and they went to the nursing station. EI #17 was asked how often should the resident be checked. EI #17 replied, he/she should be checked for repositioning and drying every two hours. EI #17 was asked why should the resident be checked. EI #17 replied, so the resident would not get any pressure sores. EI #17 was asked when was RI #4 checked this AM. EI #17 replied, she checked RI #4 in the hallway just before lunch at the nursing station. EI #17 was asked who took RI #4 to the dining room after she checked the resident. EI # 17 replied, I don't remember. EI #17 was asked where did she check RI #4. EI #17 replied/ in the hall. EI #17 was asked if she was supposed to provide privacy when checking RI #4. EI #17 replied, yes. EI #17 was asked what was the concern for not providing privacy for the resident. EI #17 replied, it makes the resident feel bad. EI #17 was asked when did the resident attend the coffee social. EI #17 replied, 10:00 AM. EI #17 was asked to explain how she checked RI #4 for wetness and/or being soiled and turned RI #4 while he/she was in the gerichair at the nursing station. EI #17 replied, RI #4 was a heavy wetter. EI #17 also replied, I touched the resident's leg. EI#17 said, she did not check to see if RI #4 was wet. EI #17 was asked how was a resident supposed to be checked for wetness and if they were soiled. EI#17 was asked to describe RI #4's brief to the surveyor. EI #17 replied, it was soiled with urine, really soiled a lot. EI #17 was asked did she agree she said the urine was one inch from the top in the front and four inches from the top in the back of the brief. EI # 17 replied,yes. EI #17 was asked what was the concern of RI #4 being left wet. EI#17 replied she/he was concerned RI #4 would get breakdown, red areas and UTI (urinary tract infections). EI #17 was asked what was the facility policy for checking and changing residents. EI#17 replied, check the resident in their room every two hours. On 5/17/18 at 5:52 AM, an interview was conducted with EI #16, a Registered Nurse (RN). EI #16 was asked who was assigned to RI #4 on 5/16/18. EI #16 replied EI #17. EI #16 was asked what time was RI #4 was placed in the geri chair. EI #16 replied, before breakfast, maybe around 7:00 AM. EI #16 was asked how often should RI #4 be checked. EI #16 replied, every two hours EI #16 was asked was if RI #4 was a heavy wetter. EI #16 replied, not all the time. EI #16 was asked why should RI #4 be checked. EI #16 replied, make sure they were dry. EI #16 was asked when did RI #4 go to the coffee social. EI #16 replied, 10:00 AM. EI #16 was asked what was the facility policy on how to check residents to see if they were wet or soiled. EI #16 replied, check every two hours and make sure they were clean and dry.

Based on observations, interviews, a review of The 2013 Food Code and reviews of facility policies titled, MANUAL WAREWASHING and EMPLOYEE WORK PRACTICES, the facility failed to ensure: 1) a male dietary staff member had a covering over facial hair under his bottom lip, 2) a blender blade was rinsed and air dried after being removed from the soap compartment sink and 3) hand washing signage was placed over the area of the hand washing sink located near the three compartment sink. This had the potential to affect 55 residents who received meals from the kitchen. Findings Include: 1) A facility policy titled, EMPLOYEE WORK PRACTICES with a revised date of 10/2008 revealed the following: . PROCEDURE: .ii. Wear a clean hat or other restraint (e.g.(example) hair net, hat, surgical cap and /or beard restraint) in the food production area . On 05/17/2017 at 11:20 a.m., Employee Identifier (EI) #10 Dietary Supervisor was standing over food writing down temperatures and was observed not wearing a hair restraint over his mustache or covering his lip. On 05/17/2017 at 2:45 p.m., an interview was conducted with EI #10. EI #10 was asked what did the facility policy say about wearing a covering with facial hair. EI #10 said wear a beard restraint. EI #10 was asked did he have facial hair. EI #10 said yes. EI #10 was asked should he have had on a beard restraint. EI #10 replied yes. EI #10 was asked what was the potential harm in not wearing a hair covering over facial hair while working in the kitchen standing over food. EI #10 stated, Could contaminate the food. 2) A facility policy titled, MANUAL WAREWASHING with a revised date of 11/2008 revealed the following: . PROCEDURE: . 3. Wash items in the first sink in a detergent solution . 4. Immerse or spray rinse items in the second sink . 5. Immerse items in the third sink in hot water or chemical sanitizing solution . 7. Air dry all items . On 05/17/2017 at 12:03 p.m., an observation was made of the dietary staff plating food on the tray line. EI #11, Dietary Cook asked EI #7, Dietary Cook to prepare more pureed Chicken Divan. EI #7 was observed trying to get the blender blade out of the hot water in the soap area of the three compartment sink. EI #7 was not able to retrieve the blender blade out of the hot soapy water sink. EI #11 came off of the food tray line, removed her gloves and retrieved the blender blade from the hot water in the soap sink of the three compartment sink. EI #11 began to move away from the sink when she was prompted by EI #10, Dietary Supervisor and EI #9, Dietary Manager, to put the blender blade in the rinse sink. EI #11 did not put the blender blade in the rinse sink, but instead dipped it in the sanitizer sink for approximately three to four seconds. EI #11 shook the blender blade and placed it in the blender. EI #11 did not air dry the blender blade. On 05/17/2017 at 3:00 p.m., an interview was conducted with EI #10 and EI #9. EI #10 was asked if EI #11 put the blender blade in the rinse sink. EI #10 said she did not put the blender blade in the rinse sink before putting it in the sanitizer sink. EI #9 was asked if EI #11 air dried the blender blade after removing it from the sanitizing sink. EI #9 said she should have washed the blade, put in the middle rinse and then sanitize to let it air dry. EI #9 was asked what was the potential harm in not rinsing the blender blade before putting it in the sanitizing sink. EI #9 stated, It wasn't clean. 3) A review of The 2013 Food Code by the United States (U. S.) Public Health Service and the Food and Drug Administration (FDA) revealed: . 6-301.14 Handwashing Signage. A sign or poster that notifies FOOD EMPLOYEES to wash their hands shall be provided at all HANDWASHING SINKS used by FOOD EMPLOYEES and shall be clearly visible to FOOD EMPLOYEES . On 05/16/2017 at 1:45 p.m., an observation was made of the hand washing sink area located to the right of the three compartment sink. There was no hand washing sign in the area. On 05/17/2017 at 9:22 a.m., an observation was made of the hand washing sink area located to the right of the three compartment sink. There was no hand washing sign in the area. On 05/18/2017 at 8:27 a.m., an observation was made of the hand washing sink area located to the right of the three compartment sink with the EI #9 Dietary Manager. There was no hand washing sign in the area. On 05/18/2017 at 8:36 a.m., an interview was conducted with EI #9. EI #9 was asked if there was a hand washing sign over the hand washing sink area next to the three compartment sink. EI #9 stated No, a sign use(d) to be. EI #9 was asked should there be a hand washing sign over the hand washing sink. EI #9 stated, If the Food Code says that it needs to be up. EI #9 and surveyor reviewed the regulation on Hand Washing Signage in The 2013 Food Code. EI #9 was asked if she agreed it was in the Food Code regulations. EI #9 stated, That's what it says, yes. EI #9 was asked what was the concern in not having the hand washing sign up. EI #9 replied, Not remind them how to do it.

Based on a review of the facility's May 2017 Activity Calendar, a facility document titled, ACTIVITY DIRECTOR , medical record review and interviews, the facility failed to ensure an ongoing program of group activities was available throughout each calendar day including weekends. This was evident by complaints voiced in Resident Group Interview. This affected seven of 14 residents present at the Resident Group meeting on 05/17/2017, including RI (Resident Identifier) #6, #16, #17 and #18, who participated in group activities. Findings Include: A review of a May 2017 Activity Calendar revealed the following: May 3 Wednesday 10:00 Coffee Social, 10:30 Table Games, 1:30 Pretty Nails; May 5 Friday 10:00 A Splash of Mexico, 2:00 Room Visits; May 6 Saturday 10:00 Coffee Social, 10:30 Bingo; May 7 Sunday 10:00 House of Prayer; May 8 Monday 10:00 Coffee Social, 10:15 Inspirational Quotes, 10:30 Poetry, 1:30 Art and Crafts; May 10 Wednesday 10:00 Coffee Social, 10:15 Wheel of Fortune, 1:30 Baking Cookies; May 13 Saturday 10:00 Coffee Social, 10:30 Bingo; May 14 Sunday 10:00 House of Prayer; May 17 Wednesday 10:00 Happy Hour, 1:30 Pizza in the Diner(for staff); May 19 Friday 10:00 Milk and Cookies, 12:30 Be There or Be Square; May 20 Saturday 10:00 Coffee Social, 10:30 Bingo; May 21 Sunday 10:00 House of Prayer; May 24 Wednesday 10:00 Coffee Social, 10:15 Monopoly Board Game, 2:00 Ice Cream Float Social; May 25 Thursday 9:30 Walmart Trip, 2:00 Frank Miller's Band; May 26 Friday 10:00 Coffee Social, 10:30 Blackjack, 1:30 Resident Birthday Party; May 27 Saturday 10:00 Coffee Social, 10:30 Bingo; May 28 Sunday 10:00 House of Prayer; May 30 Tuesday 9:30 Eastern Shore Presbyterian, 10:00 Coffee Social, 10:30 Exercise, 2:00 Men's Group; May 31 Wednesday 10:00 Coffee Social, 10:15 Penny Auction, 2:00 Women's Group. A review of a facility document titled, Activity Director with no date, revealed the following: .General Functions .Maintain a schedule of on-going activities which reflect various times convenient to resident . On May 17, 2017 at 3:00 p.m., a Resident Group Interview was conducted with 14 residents. Of the 14 residents, seven voiced they wanted more activities offered during the week and on weekends. Those seven residents included RI #6, #16, #17 and #18. Three residents voiced there had been an issue with one of the scheduled group activity for May 17, 2017 at 1:30 p.m., for the Pizza in the Diner. The residents stated the activity must have been for staff. Two residents stated they had complained about activities to the Activity Director. RI #6 was re-admitted to the facility on [DATE]. A review of RI #6's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/2017, revealed a Brief Interview for Mental Status (BIMS)score of 14, indicating RI #6 was cognitively intact. On 05/18/2017 at 11:10 a.m., an interview was conducted with RI #6. RI #6 was asked if group activities offered were ongoing and throughout the day and on weekends. RI #6 said no. RI #6 was asked if the number of activities offered throughout the week and weekend were enough. RI #6 said no. RI #6 was asked would he/she like more activities offered throughout the day and weekend. RI #6 said yes but staff never let him/her know of the activities and he/she did not know of the Pizza activity scheduled for yesterday (May 17, 2017). RI #6 was asked why he/she wanted more activities offered that were ongoing throughout the day and on weekends. RI #6 said to keep him/her from being bored because he/she gets real depressed especially about his/her mother. RI #16 was admitted to the facility on [DATE]. A review of RI #16's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 05/12/2017, revealed RI #16 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. On 05/18/2017 at 11:39 a.m., an interview was conducted with RI #16. RI #16 was asked if group activities offered were ongoing throughout the day and on weekends. RI #16 said no. RI #16 was asked if the number of activities offered throughout the week and weekend were enough. RI #16 said no. RI #16 was asked would he/she like more activities offered throughout the day and weekend. RI #16 said yes. RI #16 was asked why he/she wanted more activities offered that were ongoing throughout the day and on weekends. RI #16 said to get him/her out of the room. RI #16 was asked had he/she mentioned group activity concerns to the Activity Director. RI #16 said yes, he/she had mentioned this to the Activity Director. RI #17 was re-admitted to the facility on [DATE]. A review of RI #17's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 03/14/2017, revealed RI #17 had a Brief Interview for Mental Status score of 11, which indicated the resident was moderately impaired cognitively for daily decision making. On May 18, 2017 at 11:39 a.m., an interview was conducted with RI #17. RI #17 was asked if group activities offered were ongoing throughout the day and on weekends. RI #17 said they should be. RI #17 was asked if the number of activities offered throughout the week and weekend were enough. RI #17 said no they were not. RI #17 was asked would he/she like more activities offered throughout the day and weekend. RI #17 said yes. RI #17 was asked why he/she wanted more activities offered that were ongoing throughout the day and on weekends. RI #17 explained it helped to get his/her mind off of things. RI #17 was asked had he/she mentioned group activity concerns to the Activity Director. RI #17 explained he/she had mentioned it quite a few times but it did not help. RI #18 was re-admitted to the facility on [DATE]. A review of RI #18's most recent Annual Minimum Data Set with an Assessment Reference Date of 04/27/2017, revealed a Brief Interview for Mental Status score of 15, which indicated RI #18 was cognitively intact. On May 18, 2017 at 11:25 a.m., an interview was conducted with RI #18. RI #18 was asked if group activities offered were ongoing throughout the day and on weekends. RI #18 explained they did not have enough activities on the weekdays and especially on the weekend. RI #18 was asked if the number of activities offered throughout the week and weekend were enough. RI #18 said not for him/her. RI #18 was asked would he/she like more activities offered throughout the day and weekend. RI #18 said yes. RI #18 was asked why he/she wanted more activities offered that were ongoing throughout the day and on weekends. RI #18 explained he/she liked to get together with people and not be stuck in his/her room. On 05/18/2017 at 11:47 a.m., an interview was conducted with EI (Employee Identifier) # 4, Activity Director. EI #4 was asked who developed the times and activities to be offered on the May 2017 Group Activity Calendar. EI #4 said he did the calendar and when the consultant came, she reviewed it. EI #4 was asked when reviewing the Group Activity Calendar for May 2017, were activities offered that were ongoing throughout the day and on the weekend. EI #4 explained the Activity Department was only at the facility on the weekend for four hours but he felt the activities were ongoing. EI #4 was asked what he meant when he said group activities were ongoing throughout the day. EI #4 explained they offered more activities that were not on the calendar. EI #4 was asked was the activity listed on the group activity calendar for May 17, 2017 at 1:30 p.m., for residents. EI #4 said it was for staff. EI #4 was asked why was the staff activity listed on the resident activity calendar. EI #4 explained that was how he informed staff of what was planned for them and to also let residents know. EI #4 was asked was it the correct process to place staff events on the resident group activity calendar. EI #4 explained it was not the correct process. EI #4 was asked why should group activities be offered ongoing and throughout the day and on the weekends. EI #4 explained, so residents could have multiple activities geared towards their interest and needs. EI #4 was asked had any resident spoken to him about wanting more activities offered ongoing throughout the day and weekends. EI #4 said, not to his knowledge. EI #4 was asked why ongoing activities should be offered. EI #4 said so residents would not feel like they were in prison and to give them leisure time to be around other residents. EI #4 was asked what was the potential harm of not offering group activities on an ongoing basis throughout the weekend and weekday to residents. EI #4 explained residents could feel no since of worth.

Based on review of facility documents titled, ACTIVITY DIRECTOR JOB DESCRIPTION, Employee Change Form, a review of an activity consultant contract and interviews, the facility failed to ensure the Activity Program was provided by a certified Activity Director within the timeframe of January 1, 2017 to April 19, 2017. This had the potential to affect all residents who attended activities, were assessed for activities and care planned for activities during this time frame. Findings Include: A review of a facility document titled, ACTIVITY DIRECTOR JOB DESCRIPTION with no date revealed the following: .CERTIFICATION, LICENSES, AND REGISTRATION Must be .currently licensed or registered by the State, or otherwise qualified by the State. A review of a facility form titled, Employee Change Form revealed EI (Employee Identifier) #4, had a job change to Activities Director with the effective date of change on 01/01/2017. EI #4 signed and dated the form on 01/03/2017. Review of an activity consultant contract, signed and dated 04/20/2017, revealed the following: . 6. The consultant agrees to provide consulting services to achieve the following scope of results for (Name of Facility) to be achieved when Activity Director Training completes required course. 1. Complete training of facility required documentation for State/Federal levels. 8. Independent Contractor: .shall be an independent contractor and not an employee . On 05/17/2017 at 11:38 a.m., a telephone interview was conducted with EI #12, Activity Consultant. EI #12 was asked what required documentation was being completed for State/Federal levels for EI #4's training and what training materials were being provided. EI #12 explained she was not doing anything for EI #4 to become certified and stated she was unsure if EI #4 was doing on-line training or courses. EI #12 was asked how often she came to the facility. EI #12 stated twice a month. EI #12 was asked who developed the activity care plans for each resident. EI #12 said EI #4. EI #12 was asked if she had reviewed care plans EI #4 developed to ensure the care plans were individualized for activities. EI #4 said she had gone over that with EI #4 but further explained EI #4 did them. EI #12 was asked who developed activity care plans for January, February and March 2017. EI #12 said she did not know. On 05/18/2017 at 9:07 a.m., an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked how long the current Activity Director EI #4, had been in the position. EI #2 said January 2017. EI #2 was asked who the current Activity Director was. EI #2 said EI #4. EI #2 was asked was EI #4 certified to be the Activity Director. EI #2 said no, not that she knew of and he did not have his certification. EI #2 was asked what certified Activity Director developed Group Activities and activity care plans that were individualized during January, February, March, and April 2017. EI #2 said EI #4. EI #2 was asked why EI #4 was not certified. EI #2 said she did not think he ever pursued it. On 05/18/2017 at 11:47 a.m., an interview was conducted with EI #4, Activity Director. EI #4 was asked if he had taken required courses to become certified. EI #4 said yes. EI #4 was asked where his evidence was. EI #4 said, to his knowledge, it would be through the consultant to become certified. On 05/18/2017 at 1:42 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked if EI #4 was certified. EI #1 said no. EI #1 was asked from January 2017 until April 20, 2017, who had been the certified Activity Director. EI #1 said EI #4. EI #1 was asked was it regulatory to have an Activity Director who was not certified, to develop activity care plans and group activities for residents until the contract with the activity consultant on April 20, 2017, had been signed. EI #1 said no. EI #1 was asked what was the potential harm of having an Activity Director who was not certified to develop individualized activity care plans and group activities for residents within the January 2017 through April 19, 2017 timeframe. EI #1 explained it could cause some of the residents to be bored and not have anything for them to do.

Based on observation and interview, the facility failed to ensure Room Locators (RL)#'s 1-17 were free of chipped paint, exposed bolts/screws at the commode bases, stained ceiling tiles, a hole in a dining room ceiling, a missing closet door and a hole at an exit door. This affected RL #1 through RL #17 on three of four halls in the facility. Findings Include: RL #1: Observations were made on 5/16/17 at 2:35 p.m. and 5/17/17 at 9:43 a.m. of the bathroom ceiling tiles with a brownish semi circle spot around the fan over the toilet and over the sink. RL #2: Observations were made on 05/16/17 at 2:40 p.m. and 5/17/17 at 9:38 a.m. of brownish spots on the ceiling over the bathroom door and over the sink. RL #3: An observation was made on 5/16/17 at 2:53 p.m. of the bathroom with screws/bolts sticking up approximately one and one half inches on both sides at the base of the commode. RL #4: Observations were made on 5/16/17 at 1:50 p.m. and 05/17/2017 at 8:30 a.m. of the bathroom with exposed commode screws on both sides at the base. RL #5: Observations made on 5/16/17 at 2:00 p.m. and 5/17/17 at 8:30 a.m. of the clothing cabinet missing the door on the right side and bathroom with exposed screws on both sides of the commode. RL #6: Observations were made on 5/16/17 at 2:05 p.m. and 5/17/17 at 8:30 a.m. of the bathroom with exposed screws on both sides of the commode. RL #7: An observation was made on 5/16/16 at 1:45 p.m. of the bathroom with screw at the base of the commode on the left side without a cover. RL #8: An observation was made on 5/16/17 at 1:55 p.m. of the bathroom with screws on both sides of the commode exposed. RL #9: An observation was made on 5/16/17 at 1:58 p.m. of the bathroom with exposed screws sticking up on both sides at the base of the commode. RL #10: An observation was made on 5/16/17 at 2:08 p.m. of the bathroom with exposed screws on both sides at the base of the commode. RL #11: An observation was made on 5/16/17 at 2:21 p.m. of the bathroom with exposed screws on both sides at the base of the commode. RL #12: An observation was made on 5/16/17 at 2:26 p.m. of the bathroom with exposed screws on both sides at the base of the commode. RL #13: An observation made 5/16/17 at 2:31 p.m. of the bathroom with exposed screws at base of commode on both sides, the toilet paper dispenser with missing right handle and also vent in the bathroom ceiling above the commode was detached from the ceiling hanging low. Side B air conditioning seal was detached exposing a gap to the outside. RL #14: An observation was made on 5/16/17 at 2:40 p.m. of Side B with a cracked light fixture; the bathroom with exposed screws at the base on both sides of the commode. RL #15: An observation was made on 5/16/17 at 2:43 p.m. of the Dining Room on the 500 Hall with a large area of plaster missing and brown stains on the ceiling tiles. RL # 16: An observation was made on 5/17/17 at 9:30 a.m. of the 300 Hall ceiling with a large brown stain; paint peeling at the doorway and dark spots on the ceiling next to the air vent near the nurses' station. RL #17: An observation was made on 5/17/17 at 9:30 a.m. of the 500 Hall with a hole at the bottom of the exit door located on the left side of the door. On 5/18/17 beginning at 7:51 a.m. and ending at 8:51 a.m, EI (Employee Identifier) #3, Maintenance Assistant, observed the above concerns along with the surveyor. On 5/18/17 at 9:26 a.m., an interview was conducted with EI #3. EI #3 was asked why screws and bolts at the base of the commodes should be covered. EI #3 replied to prevent skin tears. EI #3 was asked why light fixtures should be free of cracks. EI #3 replied there was a chance it could fall and strike a resident. EI #3 was asked what caused brown stains on the ceiling tiles and the plaster to have a large gaping hole in the dining room. EI #3 replied a leaking roof. EI #3 was asked why pipe insulation should be in good repair above the air conditioning units. EI #3 replied if it was not in good repair, the room would not get cool and insects could come through the gaps. EI #3 was asked why the exit door should be free of holes at the bottom of it. EI #3 replied insect infiltration. EI #3 was asked who was responsible for the upkeep and repair of equipment such as commodes and ceiling tiles. EI #3 replied maintenance. EI #3 was asked why should ceilings and door frames be free of peeling paint. EI #3 replied safety issues, the paint chips could fall on the resident or their food and they could eat it. EI #3 was asked if he was made aware of the environmental concerns and he replied yes. EI #3 was asked why he had not made the repairs. EI #3 was asked what was the potential harm with the bolts at the base of the commodes being exposed. EI #3 replied skin tears. EI #3 was asked what was the potential for harm in ceiling tiles having brown stains and peeling paint. EI #3 replied mildew. EI #3 was asked why the vent in the bathroom ceiling should be tightly fitted above the toilet. EI #3 replied if it was loose there was a chance it could fall on the resident.

Based on observations, interview, medical record review, a review of a facility policy titled, Oxygen Administration, and a review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a physician's order was written for oxygen therapy use for Resident Identifier (RI) #4 and RI #9. This affected two of of three sampled residents observed for oxygen use. Findings Include: A facility policy titled, Oxygen Administration with a revised date of October 2010, documented the following: .Preparation 1. Verify that there is a physician's order for this procedure . A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, Copyright 2017, page 900, Chapter 41, Oxygenation revealed the following: . Oxygen Therapy . Routinely check the health care provider's orders to verify that the patient is receiving the prescribed oxygen concentration . 1) RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/2017, in Section O - Treatments, Procedures, and Programs, assessed RI #4 as being treated with oxygen therapy while being a resident in the facility. On 05/17/2017 at 8:03 a.m., RI #4 was observed sitting on the side of the bed with oxygen on infusing at two liters per nasal cannula. On 05/17/2017 at 8:40 a.m., RI #4's physician's orders were reviewed and there was no order for oxygen therapy use. On 05/18/2017 at 8:24 a.m. RI #4 was observed lying in the bed with head of bed elevated and oxygen on infusing at two liters per nasal cannula. 2) RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's 5 day MDS with an ARD of 5/18/2017, in Section O - Treatments, Procedures, and Programs, assessed RI #9 as being treated with oxygen therapy while being a resident in the facility. On 05/16/2017 at 4:50 p.m., RI #9 was observed resting in bed with oxygen on infusing at two liters per nasal cannula. On 05/17/2017 at 8:06 a.m., RI #9 was observed lying in bed with oxygen on infusing at two liters per nasal cannula. On 05/17/2017 at 8:45 a.m., RI #9's physician's orders were reviewed and there was no order for oxygen therapy use. On 05/17/2017 at 3:30 p.m., an interview was conducted with EI (Employee Identifier) #5, RN (Registered Nurse), Unit Manager. EI #5 was asked if there was a physician's order for oxygen therapy use on RI #4 and RI #9. EI #5 stated, No ma'am. EI #5 was asked why was there not a physician's order for oxygen therapy use on RI #4 and RI #9. EI #5 replied, Overlooked it. EI #5 was asked should there be a physician's order for oxygen therapy use on RI #4 and RI #9. EI #5 stated, Yes. EI #5 was asked what was the harm in not having an order for [REDACTED].#5 said if someone came along on another shift they would not know if the resident was on oxygen without an order.

Based on interviews, record review and review of a facility policy titled, Care Plans - Comprehensive, the facility failed to ensure a care plan was developed for the use of oxygen for Resident Identifier (RI) #4. This affected one of 14 sampled residents whose care plans was reviewed. Findings Include: A facility Policy titled ,Care Plans - Comprehensive with a revised date of October 2010, documented the following: .2. The comprehensive care plan is based on a thorough assessment that includes, . 3. Each resident's comprehensive care plan is designed to: .f. Identify the professional services that are responsible for each element of care: . RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #4's Admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 05/07/2017, in Section O - Treatments, Procedures, and Programs, assessed RI #4 as being treated with oxygen therapy while being a resident in the facility. On 5/18/2017 at 8:00 a.m., RI #4's care plan was reviewed and there was no care plan that addressed the use of oxygen. On 5/18/2017 at 9:17 a.m., an interview was conducted with Employee Identifier (EI) #8, Registered Nurse (RN) MDS Coordinator. EI #8 was asked if she was responsible for making sure pertinent areas of care was addressed on the residents care plan. EI #8 stated, Yes ma'am. EI #8 was asked if there was a care plan addressing RI #4's oxygen use. EI #8 stated, I don't see one. EI #8 was asked why there was not a care plan addressing RI #4's oxygen use. EI #8 said, I didn't see an order for [REDACTED].#8 said some people may not know what to do, such as checking the oxygen saturation and applying the oxygen as needed.

Based on reviews of a facility policy titled, Resident Food Preferences, a meal tray card, medical record review, observation and interview, the facility failed to ensure RI (Resident Identifier) #2 did not receive foods listed as dislikes. This was observed on 05/17/2017 during the lunch meal. This affected one of seven residents whose meals were observed. Findings Include: A review of a facility policy titled, Resident Food Preferences with a revised date of December 2008 revealed the following: Policy Interpretation and Implementation . 4. The resident's clinical record .or other appropriate locations .will document the resident's likes and dislikes . 6. The Food Services Department will offer a limited number of food substitutes for individuals who do not want to eat the primary meal . RI #2 was re-admitted to the facility on [DATE]. A review of RI #2's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2017, revealed RI #2 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident was moderately impaired cognitively for daily decision making. On 05/17/2017 at 12:12 p.m., an observation was made of RI #2's lunch meal which was chicken casserole and mixed vegetables. The chicken casserole was observed with broccoli and the mixed vegetables contained carrots. RI #2 did not eat the casserole or the mixed vegetables. A review of RI #2's meal tray card dated 05/17/2017, listed carrots and broccoli as RI #2's dislikes. When RI #2 did not eat the casserole or the mixed vegetables, RI #2 was not offered an alternate meal. On 05/18/2017 at 12:58 p.m., an interview was conducted with EI (Employee Identifier) 9, Dietary Manager. EI #9 was asked why residents should receive their food preferences. EI #9 explained if it says dislike, we should not give it at all. EI #9 was asked how dietary staff prevented residents from receiving foods listed as dislikes. EI #9 said by looking at the meal card. EI # 9 was asked what was the purpose of the meal tray card. EI #9 explained it was to indicate the resident food preference and diet. EI #9 was asked if the casserole served on 05/17/2017 for lunch had broccoli. EI #9 said yes it did. EI #9 was asked what types of vegetables were served with the 05/17/2017 lunch meal. EI #9 said Italian mixed vegetables. EI #9 was asked did the vegetables have carrots in it. EI #9 said it came with carrots. EI #9 was asked if a food was listed on the meal tray card as a dislike was it the resident's preference not to receive it. EI #9 said yes. EI #9 was asked why EI #9 received chicken casserole with broccoli and vegetables with carrots. EI #9 stated it was a mistake. EI #9 was asked should RI #2 have received the meal with his/her dislikes. EI #9 said no. EI #9 was asked what was the potential harm in serving RI #2 his/her dislikes. EI #9 explained he/she was not going to eat it.

Based on observations, interviews, medical record review and a review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed staff did not place oxygen tubing and cannula from the floor back into Resident Identifier (RI) #4's nostrils. This affected one of three residents observed for oxygen use. Findings Include: A review of Potter and Perry Fundamentals of Nursing, Ninth Edition, 2017, page 448, Chapter 29, Infection Prevention and Control revealed the following: Examples of Sites for and Causes of Health Care - Associated Infections . Respiratory Tract Contaminated respiratory therapy equipment . RI # 4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 05/07/2017, in Section O - Treatments, Procedures, and Programs, assessed RI #4 as being treated with oxygen therapy while being a resident in the facility. On 05/16/2017 at 2:50 p.m., during the initial tour, the surveyor observed Employee Identifier (EI) #5 Registered Nurse (RN) Unit Manager pick up RI #4's oxygen tubing and cannula off the floor and place the cannula back into RI #4's nostrils. The oxygen tubing was dated for 5/8/2017. On 05/16/2017 at 5:30 p.m., the surveyor observed RI #4's oxygen tubing and cannula dated 5/8/2017 not on resident, but wrapped around a side rail. On 05/17/2017 at 2:40 p.m., the surveyor observed RI #4's oxygen tubing dated 5/8/2017 lying on the floor. On 05/17/2017 at 3:26 p.m., an interview was conducted with EI #5. EI #5 was asked what she was trained to do when the resident's oxygen tubing and cannula was found on the floor. EI #5 stated, Should get new tubing and change it out. The surveyor shared the observation from 05/16/2017 at 2:50 p.m., where she picked the oxygen tubing off of the floor and placed the cannula back in RI #4's nostrils. EI #5 was asked if she picked the oxygen tubing and cannula off the floor and placed the cannula back in RI #4's nostrils. EI #5 stated, I should have taken it off and gone and got new tubing and put it on. EI #5 was asked what was the potential harm in placing the oxygen tubing and cannula that had been on the floor back into RI #4's nostrils. EI #5 replied, There are germs on the floor and we don't want to harm him/her with germs putting it in his/her nose. On 05/18/2017 at 1:05 p.m., an interview was conducted with EI #6, Licensed Practical Nurse (LPN) Infection Control. EI #6 was asked what should staff do when the resident's oxygen tubing and cannula was on the floor. EI #6 stated, Throw it away. EI #6 was asked if it should be placed back on the resident with cannula in nostrils. EI #6 stated, Absolutely not, it should be thrown away and a new one obtained. EI #6 was asked what was the potential harm in placing the oxygen tubing and cannula back in the residents nostrils. EI #6 replied a chance of causing an infection just from the bacteria on the floor and environmental surface.