Every finding on record at Joseph Eddie Ballard Western Kentucky Veterans Cen

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure two (2) of eight (8) sampled (Residents #77 and #88) and one not in the selected sample (Resident #59) were treated with respect and dignity. Observations revealed Certified Nurse Aide (CNA) #1 stood over Residents #77, #88 and #59 while assisting with feeding snacks in commons area. The findings include: Review of the facility policy, Quality of Life, Dignity dated 09/01/18 revealed, each resident will be cared for in the manner in which promotes and enhances quality of life, dignity, respect and individuality. Resident shall be treated with dignity and respect at all times. 1. Record review revealed the facility admitted Resident #59 on 10/30/13 with [DIAGNOSES REDACTED]. Review of the Annual Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #59's was unable to complete the Brief Interview of Mental Status (BIMS) due to severe cognitive impairment which indicated the resident was mot interviewable. Observation on 08/20/19 at 9:48 AM revealed CNA #1 was standing at Resident #59's side and was feeding the resident yogurt and pudding while the resident sat in wheelchair. Observation on 08/21/19 at 10:11 AM revealed CNA #1 was giving Resident #59 a snack of fruit juice. The CNA hovered over resident and did not sit beside resident or bend down to eye level. 2. Record review revealed the facility admitted Resident #77 on 04/02/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility did not attempt to complete the BIMS due to the resident being rarely/never understood. Observation on 08/21/19 at 10:11 AM revealed CNA #1 was assisting Resident #77 to drink a snack of fruit juice while standing at his/her side. 3. Record review revealed the facility admitted Resident #88 on 06/28/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #88 was unable to complete the Brief Interview of Mental Status (BIMS) due to severe cognitive impairment which indicated the resident was mot interviewable. Observation on 08/20/19 at 10:27 AM, revealed CNA #1 was standing at Resident #88's side while feeding him/her a snack. Interview with CNA #1 on 08/21/19 at 10:46 revealed, If we feed them, we are suppose to sit down beside them. She stated she did not think giving snacks was actually feeding the resident. Interview with the Unit Manager on 08/21/19 at 10:57 AM revealed she expected staff to sit at a resident's side to give snacks or feed resident. Interview with Director of Nursing (DON) on 08/21/19 at 12:58 PM revealed she expected all staff feeding residents to be at eye level when feeding or giving fluids.

Based on observation, interview and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles to include the expiration date when applicable. Observations of four (4) of seven (7) medication carts revealed two (2) vials of eye drops, one (1) insulin pen, and (1) bottle of [MEDICATION NAME] liquid not dated when opened. Additionally, observation of two (2) of four (4) medication storage rooms revealed (1) bottle of [MEDICATION NAME] R insulin was opened [DATE] and had gone past the twenty-eight (28) days of recommended use. The findings include: Review of the facility policy titled, Vials and [MEDICATION NAME] of Injectable Medications, not dated, revealed the date opened and the initials of the first person to use the vial were to be recorded on multidose vials on the vial label or an accessory label affixed for that purpose. Observation of four (4) of seven (7) medication carts on [DATE] at 9:55 AM, revealed one (1) insulin pen, two (2) bottles of eye drops and one (1) bottle of [MEDICATION NAME] liquid not dated when opened. Additional observation on [DATE] at 10:15 AM of two (2) of four (4) medication storage rooms, revealed one (1) vial of insulin opened on [DATE] and was in use past the twenty-eight (28) day use cycle (expired). Interviews on [DATE] with Licensed Practical Nurse (LPN) #1 at 10:08 AM , Registered Nurse (RN) #2 at 10:17 AM, and RN #1 at 10:55 AM revealed any multidose vial of medication should be dated when opened by whomever opened the medication initially. Interview with the Director of Nursing (DON), on [DATE] at 12:55 PM, revealed she expected multidose vials to be dated when opened by the nurse that opened the medication.

Based on observation, interview, record review and review of the facility policy, it was determined, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, related to the failure to ensure the kitchen can opener was clean, a box of powdered thickener was sealed and the scoop was not laying in the thickener, and a box of fish squares were sealed. Review of the Census and Condition, dated 05/22/18, revealed eighty-six (86) of eighty-eight (88) residents received their food from the kitchen. The findings include: Review of facility policy titled, Ice, last revised (MONTH) 2006, revealed ice buckets, other containers and scoops shall be kept cleaned and shall be stored and handled in a sanitary manner. Review of facility policy titled, Shelf Life and Date Marking last revised (MONTH) 2012, revealed single service articles used by the facility shall be stored in closed cartons or container that protect them from contamination. 1. Observation of the walk in freezer, on 5/22/18 at 11:06 AM, revealed a box of fish squares open to air and not sealed. 2. Observation of the dry storage room on 5/22/18 at 11:12 AM, revealed a box of thickener open to air with a styrofoam cup, that staff were using to scoop thickener with, laying in the thickener. 3. Review of the facility policy titled, Sanitation, last revised (MONTH) 2012, revealed the food service area shall be maintained in a clean and sanitary manner. Further review of this policy, revealed all kitchens, kitchen areas and dining areas shall be kept clean and all utensils, counters, shelves and equipment shall be kept clean. Observation on 05/22/18 at 11:19 AM, revealed the kitchen can opener had a visible build up of black/brown material on the cutting edge and area surrounding the cutting edge. Interview with the Food Service Manager on 05/23/18 at 11:00 AM, revealed she always expects the kitchen to be sanitary. She stated she expects the can openers to be cleaned after each use and they should not have any build up on them. She revealed any powdered material they use such as thickener, sugar or flour is to be sealed in a container when not in use and no scoop left in the product. She stated she expects all food to be in a sealed container of sorts and not open to air when being stored in the refrigerator, freezer or dry storage. Interview with the Assistant Administrator on 05/24/18 at 09:46 AM, revealed she expected food to be stored, distributed and served in a sanitary manner.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one (1) resident (Unsampled Resident #39) not in the selected sampled of eighteen (18) . Observation of a facility medication pass on 05/23/18 revealed a licensed staff crushed a Do Not Crush medication. The findings include: Review of facility policy titled, Medication Administration-General Guidelines, last revised 12/18/12, revealed medications are administered as prescribed in accordance with good nursing principles and practices. Further review of this policy revealed, if it is safe to do so, medications tablets may be crushed, but long acting or [MEDICATION NAME] coated dosage forms should generally not be crushed. Record review revealed the facility admitted Unsampled Resident #39 on 09/08/16 with [DIAGNOSES REDACTED]. Review of Unsampled Resident #39's Quarterly Minimum Data Set (MDS) assessment, dated 03/27/18, revealed the facility assessed this resident's cognition as moderately impaired with a Brief interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable. Review of Unsampled Resident #39's physician's orders [REDACTED]. Further review of these orders, revealed directions to Do Not Crush this medication. Review of Unsampled Resident #39's Medication Administration Record [REDACTED]. Do Not Crush. Observation of Licensed Practical Nurse (LPN) #2 performing a Medication Pass on 05/23/18 at 9:03 AM, revealed LPN #2 crushed Unsampled Resident #39'[MEDICATION NAME] Release medication (used to to prevent [MEDICAL CONDITION]/chest pain). Interview with LPN #2 on 05/23/18 at 9:08 AM, revealed she was expected to not crush extended release medications that are Do Not Crush medications. She stated she normally does not crush Unsampled Resident #39'[MEDICATION NAME] release medication and was not sure why she did. Interview with Unit Manager #1 on 05/23/18 at 10:16 AM, revealed she expected all licensed staff and med techs to follow physician's orders [REDACTED]. Interview with Advanced Practice Registered Nurse (APRN) #1 on 05/23/18 at 9:27 AM, revealed she would expect the staff to ensure they are not crushing medications that are extended release. She stated by crushing extended release medications it could cause the medication's desired effect to not be what it was intended. She stated Unsampled Resident #39 has been stable, however based on the medication that was crushed and given to him/her they would need to monitor him/her and take blood pressure readings throughout the day. Interview with Director of Nursing (DON) on 05/23/18 at 10:08 AM, revealed she expected all staff who pass medications to follow the physicians orders. She stated she expected staff not to crush extended release medications or do not crush meds. She stated it is not acceptable for a nurse or med tech to crush Do Not Crush medications and she would expect them to know not to crush Extended Release Medications.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure appropriate and proper incontinent care was performed, related to glove changes and hand hygiene for one of eighteen (18) sampled residents (Resident #60#)and one unsampled resident (Unsampled Resident #69.) Observations revealed staff did not wash hands in between glove changes and after the handling of objects at the bedside. The findings included: Review of the facility's policy titled, Hand Washing/Hand Hygiene, dated 10/01/17, revealed the staff were to have washed their hands, or used an Alcohol Based Hand Rub, before performing any clean or aseptic procedure, after removing gloves and after or in-between contacts with objects such as equipment in the immediate vicinity of the resident. Review of the facility's infection control policy titled Your five moments for Hand Hygiene dated (MONTH) 2009, revealed the following: Clean your hands immediately after an exposure to body fluids(and after glove removal), after touching a patient and his or her immediate surroundings when leaving, after touching any object or furniture in the patient's immediate surroundings, and when leaving-even without touching the resident. 1. Record review revealed the facility admitted Unsampled Resident #69 on 01/29/14, with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 04/26/18, revealed the facility assessed the resident as severely cognitively impaired, always incontinent of bowel and bladder and totally dependent on staff for all care needs. Review of Unsampled Resident #69's Comprehensive Care Plan for incontinence, dated 10/07/15, revealed the resident required disposable briefs for containment and dignity; staff were to have checked the resident every two hours and as needed, and completed incontinent care. Observation of incontinent care for Unsampled Resident #69 with Certified Nurse Aides (CNAs) #1 and #2 on 05/23/18 at 10:00 AM, revealed CNA #1 failed to wash her hands or use sanitizer on hands after changing gloves and prior to applying another pair of gloves. Additionally, CNA #1 picked up the trash can at bedside and handed it to CNA #2 and failed to wash hands or re-glove and continued to complete cleaning the resident's buttocks. CNA #1 stated she probably should have used the alcohol cleaner between glove changes and after grabbing the trash can. Interview with the RN #2 on 05/24/18 at 2:30 PM, revealed she observed staff frequently and watched them completing incontinent care and ensured their competency. She stated the staff received in-services, at least every three months and she was sure the CNAs were trained on following the infection control and hand washing procedures. Interview with the Unit Manager, Registered Nurse (RN) #1 on 05/24/18 at 7:45 AM, revealed she would have expected the CNA's to have changed their gloves and washed hands or used the sanitizer, in between glove changes, as gloves are very porous and open to infectious processes. Interview with the Director of Nursing (DON) on 05/24/18 at 2:35 PM, revealed she would have expected the staff to have followed their training and stated the staff just had a training about the CDC guidelines. Review of the facility's policy titled, Dress Code/Standard of Appearance dated last revised 09/14/17, revealed all employees will maintain standards of personal hygiene, safety and infection control principles at all times while on duty. Further review of this policy revealed hair should be clean, well groomed and styled in a manner that does not interfere with resident care or the performance of duties and long hair should be tied back or worn up. 2. Record review revealed the facility admitted Resident #60 on 11/20/15 with [DIAGNOSES REDACTED]. Review of a Significant Change MDS assessment, dated 04/18/18 revealed the facility assessed Resident #60's cognition as severely impaired with a BIMS score of seven (7), indicating the resident is cognitively impaired. Review of this same MDS revealed section G110 for Activities of Daily Living showed the resident to be totally dependent on staff with two person assist for toileting, and Section H0400 for Bowel and Bladder revealed the resident has a urinary catheter and is always incontinent of stool. Review of Resident #60's Comprehensive Care Plan dated 10/04/17 revealed to check for incontinent episodes every two hours and as needed; and provide incontinent care after each incontinent episode. Observation of incontinent care for Resident #60 with CNA #3 and LPN #1 on 05/23/18 at 10:00 AM revealed LPN #1 cleansed Resident # 60 of stool, then proceeded to touch the call light, handles on closet door, items in closet, and the bath room door handle before taking gloves off and washing hands. Additionally, LPN #1's hair was long, below shoulder length, and her hair was observed hanging down and touching the pad on the bed and linens at times during care. Observation of incontinent care on 05/23/18 at 10:10 AM revealed the resident had another bowel movement and was cleansed of stool by CNA #3. CNA # 3 did not change gloves after doing incontinent care and touched the resident's blanket, sheet, clothing, and clean pillow case with the contaminated gloves. Interview with CNA #3 on 05/24/18 at 10:37 AM revealed she realized after the fact she should have changed gloves as it is an infection control issue to be touching the resident's clothing and items in the room with dirty gloves. She stated she and LPN # 1 had discussed that LPN # 1 (not available for interview) should have changed gloves as it is an infection control issue to be touching closet door handles, items in the closet, call light and bathroom door handle with dirty gloves. CNA #3 stated when she had mentioned this to LPN #1 yesterday, LPN #1 also realized she should have had her hair pulled back when doing resident care as her hair touched the bed pad. CNA #3 stated if hair is below shoulder length,it should be put up. Interview with the DON on 05/24/18 at 10:37 revealed she expected staff to change gloves and wash hands after doing incontinent care before touching other items such as the call light, linens, closet handles, items in the closet, bath room door handles, and clean pillow case. She stated she also expect the LPN to have her hair up out of the way and not touching the bed sheet or pad when doing care.

Based on observation, interview, review of the facility policy, and review of Material Safety Data Sheets, it was determined the facility failed to ensure the residents' environment remained as free from accident hazards as is possible and each resident received adequate supervision to prevent accidents. Observation throughout the survey 04/11/17 through 04/13/17, revealed unlocked chemicals stored under the three (3) compartment sinks, in the satellite kitchens, on each of the three (3) separate units (Kennedy, Roosevelt and Reagan). There were supplies also stored on the hallways, in the unlocked supply closets, to include scalpels, staple remover kits, intravenous (IV) start kits, etcetera (etc.) Review of the facility's List of Wandering Residents, undated, revealed there were thirty-nine (39) wandering residents. The findings include: Review of the facility policy titled, Storage Areas, Environmental Services, dated 07/27/16, revealed cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products. Review of the facility's Material Safety Data Sheets (MSDS,) issued 01/05/14, for the dishwasher detergent, glass cleaner, bleach, oven cleaner, all purpose cleaner and sanitizers, revealed all these products were considered hazardous and could cause acute skin toxicity, corrosion and irritation and serious eye damage and irritation. 1. Observations of the noon meal service on the Kennedy and Roosevelt Units, on 04/12/17 at 12:30 PM and 12:45 PM respectively, revealed the dining room and kitchen service area was designed with an open floor plan and the steam table and kitchen area was visible from the resident's dining room. There were twelve (12) residents being served the noon meal. A half-door, approximately thirty-six (36) inches tall, was the only separation between the two (2) areas. The half-door was equipped with a combination lock, however, the door was left open during the meal process. Observations of the Kennedy Unit on 04/12/17 at 12:30 PM, revealed unlocked storage areas under the three compartment sinks and the storage room and four (4) gallons of dishwashing liquids, seven (7) gallons of a rinse-aid for the dishwashers and two (2) gallons of bleach. In the unlocked storage room, to the right of the dishwashers, there were two (2) cans of spray oven cleaner and one (1) spray can of an all-purpose cleaner, two (2) gallons of Citrus All Purpose Cleaner, a thirty-two (32) ounce bottle of sanitizer, and a gallon of degreaser. Observations of the Roosevelt Unit on 04/12/17 at 12:45 PM, revealed the half-door was also opened during the noon meal service and revealed four (4) gallons of dishwasher detergent, five (5) gallons of the rinse aide, one (1) gallon of bleach and one (1) gallon of de-limer under the three (3) compartment sink. Additionally, the same types of products were noted in the unlocked storage closet. Interview with Cook #1, on 04/13/17 at 3:30 PM, revealed she was not aware chemicals stored at the facility should have been behind locked doors and stated the half-door, in between the dining room and the kitchen stayed locked, unless it was meal time and stated the staff had to go back and forth so much during the meal, it was not possible to keep it locked. She denied any resident ever attempting to step over the half-door to gain access to the kitchen and stated she had climbed over the door, when in a hurry and stated it would not be too difficult. Interview with the Maintenance Supervisor on 04/13/17 at 3:30 PM, revealed the half-door to the kitchens, on all three (3) satellite units, had a combination lock in use, since the facility was built and he was never aware of a problem with any resident getting over the half-door. Review of the satellite kitchen's location from the nursing station and the inability to see that area from the nursing station, revealed this could be a hazard, especially at night, when there may not be extra staff on the hallways. Interview with the Administrator, on 04/13/17 at 3:40 PM, revealed there had been no reports of any resident getting into the chemicals stored in the kitchen or supply closets, yet she would have expected hazardous chemicals to have been behind locked doors and stated there was no specific policy for the storage of chemicals or sharps, outside of the Material Safety Data Sheets (MSDS.) She also stated any sharps or products hazardous to the residents should have been behind locked doors. 2. Observation during the environment tour on 04/13/17 at 3:00 PM, revealed the unlocked supply room on the Roosevelt Unit contained several boxes of nursing supplies, to include five (5) scalpels, three (3) staple remover kits, IV start packs, syringes, two (2) boxes of Desitin Ointment, several containers of normal saline, cold packs and dressings. Interview with Registered Nurse (RN)/ Unit Manager #1, on 04/13/17 at 3:45 PM, revealed she had been working at the facility over two (2) years and had never known the supply room doors to have been locked. Interview with the Director of Nursing (DON), on 04/13/17 at 5:40 PM, revealed she would have expected all sharp objects and medications to have been in locked areas. Interview with the Administrator, on 04/13/17 at 3:40 PM, revealed she would have expected the supply closets to have been locked.

Based on observation, interview, record review and review of Mosby's Standards of Practice, Seventh Edition, it was determined the facility failed to follow professional standards of quality for one (1) of twenty (20) sampled residents related to a suprapubic catheter (Resident #3). Observation on 04/12/17 revealed Licensed Practical Nurse (LPN) #1 failed to cleanse from the stoma site outward per professional standards of quality. The findings include: Review of Mosby's Standards of Practice, Seventh Edition, dated 2015 Pages 363-364 under section on giving catheter care, revealed staff should clean the catheter from the meatus (stoma) down the catheter about four inches, then clean downward away from the meatus (stoma{catheter insertion site) when washing and drying. Review of the facility policy revealed to use the same procedure for supra pubic catheter care as catheter care. Record review revealed the facility readmitted Resident #3 on 02/08/17 with [DIAGNOSES REDACTED]. Observation of Suprapubic Catheter care for Resident #3, on 04/12/17 at 1:45 PM, revealed LPN #1 cleansed around the supra pubic stoma (insertion site) in a circular motion with the wash cloth with soap and then rinsed with the other wash cloth; however, she then failed to follow professional standards of quality when she proceeded to take another clean wet wash cloth and cleaned around the insertion site with an outward motion toward groin then from groin back towards stoma site. Interview with LPN #1, on 04/12/17 at 1:45 PM, revealed she did it backwards. Interview with Unit Manager # 1 on 04/12/17 at 2:00 PM revealed it was not good nursing practice to clean the supra pubic catheter site from outward to inward and she would expect staff to follow proper procedures when providing catheter care. Interview with Director of Nursing (DON), on 04/13/17 at 2:28 PM, revealed she would expect staff to clean Supra pubic catheter site from inward to outward with soap and water, then rinse and dry.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide catheter care in a manner to prevent or reduce urinary tract infections for one (1) of twenty (20) sampled residents (Residents #3). Observation on 04/12/17, revealed Licensed Practical Nurse (LPN) #1 failed to clean the suprapubic catheter site in a spiral pattern beginning at the stoma site and working outward to prevent possible UTIs per facility policy. The findings include: Review of the facility policy in the Nursing Manual Catheter Section, dated February 2002, revealed the peri [MEDICATION NAME] area (catheter insertion site) should be cleaned with soap and water using a spiral pattern, beginning at the stoma site and working outward, then rinse and pat dry. Record review revealed the facility readmitted Resident #3 on 02/08/17 with [DIAGNOSES REDACTED]. Review of Physician's Progress Note, dated 02/09/17, revealed Resident # 3 was sent out to hospital on [DATE] due to a syncopal episode and was diagnosed with [REDACTED]. Review of a Physician's Progress Note, dated 03/24/17, revealed Resident #3 had a UTI. Review of the Comprehensive Care Plan for at risk for UTI'S, dated 01/31/17, revealed Resident #3 was at risk for UTIs related to suprapubic catheter. Further review revealed the resident has frequent UTI'S with goal of remaining free from signs/symptoms of UTI. Intervention were to wash, rinse and dry soiled areas, check every two (2) hours for incontinent of bowel, clean peri area well after each bowel movement in order to prevent bacteria in urinary tract. Observation of Suprapubic Catheter Care for Resident #3 by LPN #1, on 04/12/17 at 1:45 PM, revealed LPN #1 washed her hands, donned gloves, and wet several wash cloths at sink (one with soap and one without soap). LPN #1 then cleaned around the supra pubic stoma (insertion) site in a circular motion with the wash cloth with soap and then rinsed with the other wash cloth. LPN #1 was then observed to take another clean wet wash cloth and clean around the insertion site with an outward motion, washing outward toward the groin area and then back towards the stoma site. Interview with LPN #1, on 04/12/17 at 2:00 PM, revealed she stated I did it backwards, didn't I? Well, I already cleaned it this morning. Interview with Unit Manager for this unit, on 04/12/17 at 2:10 PM, revealed it would not be good nursing practice to clean from outward to inward when doing supra pubic catheter care due to potential for urinary tract infections. Interview with Director of Nursing (DON), on 04/12/17 at 2:28 PM, revealed she expected staff to follow facility policy and to clean supra pubic catheter site from inward to outward with soap and water and rinse in same manner in order to prevent urinary tract infections.

Based on interview, record review, review of the facility investigation and review of facility policy, it was determined the facility failed to thoroughly investigate an allegation of abuse for one (1) of one (1) sampled resident (Resident #1). On the morning of 07/18/16, Resident #1 alleged the night before a tall, red-haired man had gripped his/her arm too tightly during repositioning, which caused bruising. The facility failed to interview all staff who had contact on 07/17/16 with Resident #1 to determine if the abuse occurred. The findings included: Review of facility's Abuse Policy and Procedure, last revised June 2015, revealed the facility should interview staff members on all shifts who have had contact with the resident during the period of the alleged incident. Record review revealed the facility admitted Resident #1 on 08/20/12, with diagnoses, which included Difficulty in Walking, Muscle Weakness, Gait/Mobility Abnormality, Dementia without Behavioral Disturbances and [MEDICAL CONDITION]. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/20/16, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) Score of nine (9), which indicated the resident was interviewable. Review of facility's investigation, dated 07/18/16, revealed Resident #1 alleged a big, tall guy with curly hair had pulled him/her up by his/her arm last night. Further review of the investigation revealed the facility interviewed staff who worked 7AM-3PM and 3PM-11PM but no staff that worked 11Pm-7AM on 07/17/16. In addition, the facility had suspended Nurse Aide State Registered (NASR) #8 who worked the 3PM - 11PM shift on 07/17/16 even though she was a female and did not fit the description of the alleged perpetrator. Interview with Resident #1, on 08/08/16 at 8:48 AM, revealed a tall, red-haired man was helping him reposition in bed and during the repositioning the tall, red-haired man gripped his arm a little tight and it caused some discoloration the next day. He/she stated the tall, red-haired man did not mean to do this and he/she did not believe the tall, red-haired man was being mean. Interview with NASR #8, on 08/08/16 at 12:03 PM, revealed she worked second shift the night of 07/17/16 which was the night of the alleged allegation from Resident #1 and was unaware of any incident until the facility interviewed her in regards to the allegations. She stated she was suspended pending the investigation due to the facility felt she matched the description of the allegation. She stated she was confused as to why the facility did not interview NASR #1 due to he met the exact description of the allegation. Interviews on 08/08/16 with NASR #6 at 9:47 AM, and NASR #7 at 10:15 AM, revealed they were providing care to Resident #1 on 07/18/16 in the morning when Resident #1 alleged a tall red haired man gripped his/her arm to tightly while assisting him/her with positioning and it had left some bruised areas. NASR #6 and #7 stated NASR #6 immediately reported this to management and they though NASR #1 fit the exact description from Resident #1's allegations. Interview with NASR #1, on 08/08/16 at 2:29 PM, revealed he was a tall man with red hair and he did in fact work on Resident #1's unit the night Resident #1 alleged a tall red haired man gripped his arm to tightly during repositioning. He stated Resident #1 had never mentioned to him that he gripped Resident #1's arm too tightly and the facility had never interviewed him in regards to the allegations Resident #1 had voiced. NASR #1 stated he was very fond of Resident #1 and would never purposely hurt anyone and had since worked with Resident #1 without any concerns voiced from Resident #1. Interview with Director of Nursing (DON), on 08/08/16 at 2:10 PM, revealed she felt the facility had done a thorough investigation and came to an appropriate conclusion to unsubstantiate the allegation made by Resident #1. She stated in hindsight the facility could have and should have been more thorough in their investigation. Interview with Assistant Administrator, on 08/08/16 at 4:20 PM, revealed she led the investigation due to the Administrator was on vacation. She stated the facility did have an employee working at the facility that did meet the description Resident #1 gave and they failed to interview this staff member due to they did not thoroughly research who all worked during the time of the alleged abuse. She stated that in hindsight the facility should have done a more thorough investigation at the facility. Interview with facility Administrator, on 08/08/16 at 5:00 PM, revealed she did not believe a thorough investigation had been completed and would have expected a thorough investigation to be completed by the facility.

Based on interview, review of the facility investigation and review of the facility Abuse policy and procedure, it was determined the facility failed to follow facility policy related to investigating an abuse allegation for one (1) of one (1) sampled resident (Resident #1). Resident #1 alleged a tall, red-haired man had gripped his/her arm too tightly during repositioning which caused bruising on the night of 07/17/16; however, the facility failed to interview staff from all shifts that had contact with the resident per the facility policy. The findings include: Review of facility's Abuse Policy and Procedure, revised June 2015, revealed the facility is to interview staff members on all shifts who have had contact with the resident during the period of the alleged incident. Record review revealed the facility admitted Resident #1 on 08/20/12, with diagnoses, which included Difficulty in Walking, Muscle Weakness, Gait/Mobility Abnormality, Dementia without Behavioral Disturbances and [MEDICAL CONDITION]. Review of facility's investigation, dated 07/18/16, and interview with Resident #1 on 08/08/16 at 8:48 AM, revealed a big, tall guy with curly hair had pulled Resident #1 up by his/her arm during the night on 07/17/16. Further review of the investigation revealed the facility had not interviewed any staff that had worked the 11PM - 7AM shift on 07/17/16. Further review of the facility investigation revealed the facility had suspended Nurse Aide State Registered (NASR) #8 who had worked the 3PM -11PM shift on 07/17/16 even though she did not match the resident's description of the alleged perpetrator. However, interview with NASR #1, on 08/08/16 at 2:29 PM, revealed he was a tall man with red hair and he did in fact work on Resident #1's unit the night (07/17/16) Resident #1 alleged a tall red haired man gripped his arm to tightly during repositioning. He stated no one had interviewed him related to the allegation but he would never knowingly cause harm to the resident. Interview with Assistant Administrator, on 08/08/16 at 4:20 PM, revealed she led the investigation due to the Administrator was on vacation. She stated in hindsight they should have done a more thorough investigation at the facility and should have interviewed staff on all shifts that had provided care to the resident on 07/17/16 per facility policy. She also stated the facility did have an employee working at the facility that did match the description Resident #1 gave and they failed to interview this staff member. Interview with facility Administrator, on 08/08/16 at 5:00 PM, revealed she did not believe a thorough investigation had been completed and she felt the facility did not follow their policy and procedure related to abuse investigation.

Based on observation, interview, review of the dishwasher temperature log, review of the dishwasher manufacturer's guidelines, and review of the facility's policy and procedure, it was determined the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Observations revealed the dishwasher rinse temperature was not at the manufacturer's guidelines. Additional observation revealed kitchen staff failed to wash their hands after picking up trash off the floor. Review of the facility's Census and Condition, dated 03/15/16, revealed sixty-three (63) of sixty-four (64) residents received their meals from the kitchen. The findings include: 1. Review of the manufacture's guidelines for the dishwasher, not dated, revealed the machine was designed to clean and sanitize dishes with hot water at 160 degrees Fahrenheit (F) for washing and 180 degrees F (minimum) for the final rinse. Review of the Dishwasher Temperature Log, on 03/23/16 at 1:35 PM, revealed there was no documented evidence the dishwasher rinse temperature had been checked for breakfast on 03/23/16, but there was a documented temperature for lunch. The temperature documented was 176 degrees F for the rinse cycle. Further review of the Dishwasher Temperatures for the month of March 2016 revealed rinse temperatures below 180 degrees F on 03/03/16 and 03/21/16 at breakfast; and, on 03/02/16 and 03/21/16 at lunch. The Temperature Log stated the dishwasher rinse temperature should be above 180 degrees F per manufacture's guidelines and staff should report to the Certified Dietary Manager (CDM) or Registered Dietician (RD) when temperatures were not within the stated range. Observations of the dishwasher, on 03/23/16 at 1:35 PM and 2:13 PM, revealed the dishwasher rinse temperature was 176 degrees F. Interview with Food Service Worker #7, on 03/23/16 at 2:13 PM, revealed he documented the rinse temperature of 176 degrees F at lunch on 03/23/16. Interview (Post Survey), on 04/01/16 at 2:45 PM, with Food Service Worker #7, revealed he was not aware of what the temperature for the rinse cycle be should be to be acceptable. He stated he had not been inserviced nor had he read the Temperature Log which stated he was supposed to report the low temperature to a supervisor. Interview with the Dietary Manager, on 03/23/16 at 2:15 PM, revealed the person pulling dishes was responsible for documenting the dishwasher wash and rinse temperatures on the temperature log. She stated the person responsible for documenting on this day for breakfast and lunch was Food Service Worker # 7. She stated that Food Service Worker # 7 had only received three (3) days of orientation due to limited amount of staff and if it was another employee they would have reported the temperatures, but since he was new he probably was not aware that needed to report the low temperatures. The Dietary Manager stated she and the Assistant Dietary Manager ensured the logs were completed by checking the log on the next day. She stated she was not aware of the low temperatures and she expected the person recording the temperatures to alert her or the Assistant if the temperatures were not correct. Interview (Post Survey) with the Dietary Manager, on 04/01/16 at 3:15 PM, revealed she was not sure why she did not catch the other rinse temperatures on 03/02/16, 03/03/16, and 03/21/16, as they were below the manufacture's guidelines of 180 degrees F. She stated if the dishes were not rinsed at the temperature per manufacture's guidelines there was a potential risk for infection control. Interview with the Administrator, on 03/24/16 at 3:07 PM, revealed she would expect abnormal dishwasher temperatures to be reported to the supervisor. She stated if dishes were not properly sanitized, there could be a risk for infection. 2. Review of the facility's Food Services policy and procedure titled, Plastic Glove Use/Bare Hand Contact, revealed hands should be washed before donning gloves and after removing gloves. Observation, on 03/23/16 at 12:00 PM, revealed Food Service Worker #7 was on his way to prepare liquids when he threw a piece of paper towards the garbage can, but the paper fell on the floor. He then picked up the paper with his bare hands and threw it in the garbage can. The Worker then donned gloves without washing his hands and proceeded to prepare the liquids. Interview (Post Survey) with Food Service Worker #7, on 04/01/16 at 2:45 PM, revealed he was not aware of the handwashing policy that required handwashing prior to donning gloves if hands become contaminated. Interview with the Dietary Manager, on 03/23/16 at 12:50 PM, revealed the facility's policy is to wash your hands after picking objects up off the floor and before returning to food preparation. Interview with the Administrator, on 03/23/16 at 3:07 PM, revealed she expected staff to wash hands before donning gloves.

Based on interview, record review and facility policy review, it was determined the facility failed to report allegations of abuse immediately and conduct interviews with other residents who received care from the alleged perpetrators for two (2) of four (4) sampled residents (Resident #1 and Resident #2) related to allegations of abuse. The findings include: Review of the facility's policy titled, Reporting Abuse to Facility Management, dated February 2002, revealed it was the responsibility of each employee to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown origin to the administrator or his/her designee. Review of the facility's policy titled Investigating Allegations of Physical Abuse, dated February 2002, revealed all reported incidents of physical abuse should be promptly and thoroughly investigated and when an investigation of physical abuse was conducted there should be a full body examination paying particular attention to the areas of the resident's complaint. Review of the facility's policy titled, Prevention of Abuse, Neglect, and Misappropriation, dated 03/01/2010, revealed alleged violations of suspected abuse should be immediately reported to the Administrator or designee and any person having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report. The facility should have evidence that all alleged violations are investigated thoroughly. Review of the facility's policy titled Abuse Investigation Protocol, last revised 05/13/15, revealed all reports of resident abuse, neglect, injuries of an unknown source, resident -to-resident abuse and resident-to-staff abuse should be promptly and thoroughly investigated by facility management. The individual conducting the investigation at a minimum should interview other residents to whom the accused employee provides care or service to determine if there are any complaints about the employee. 1. Record review revealed the facility admitted Resident #1 on 03/13/15, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 04/01/15, revealed the facility assessed that Resident #1 needed extensive assistance with activities of daily living. The facility assessed Resident #1 to not be interviewable due to his/her cognitive status. Review of an Incident Report and Investigation, dated 05/08/15, revealed Patient Aide (PA) #1 had reported to the Director of Nursing (DON) she observed Nurse Aide State Registered (NASR) #1 slap Resident #1 on his/her leg on 05/07/15. Further review of the investigation revealed no documented evidence the facility interviewed interviewable residents (Brief Interview of Mental Status {BIMS} score of eight {8} or above), who received care from NASR #1 to determine if there was any evidence of abuse. Interview with PA #1, on 06/02/15 at 1:58 PM, revealed she did not report her observation of NASR #1 slap Resident #1's leg during incontinent care at the time of the incident on 05/07/15, she stated she reported it the next day to the Director of Nursing (DON). PA #1 stated she was educated on the reporting of abuse prior to providing patient care. Further interview with PA #1 revealed she did not report the incident immediately because it was her first day at work and she was uncomfortable. Interview with the DON, on 06/03/15 at 9:57 AM, revealed she expected staff to report any suspicions of abuse immediately. The DON stated PA #1 reported the alleged abuse to her on 05/08/15. Interview with the Administrator, on 06/02/15 at 4:00 PM and 5:00 PM, revealed abuse allegations should be reported immediately and PA #1 had not reported the allegation of abuse till 05/08/15, a day after the incident on 05/07/15. 2. Record review revealed the facility admitted Resident #2 on 12/16/09 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 03/21/15, revealed the facility assessed Resident #2's cognition as cognitively intact with a Brief Interview of Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. In addition, the resident needed extensive assistance with activities of daily living. Review of the Incident Report and Investigation, dated 04/30/15 at 4:05 PM, revealed Resident #2 had informed his/her Guardian that NASR #2 had grabbed his/her arm when attempting to retrieve tobacco from his/her pocket. Further interview revealed the Guardian reported to the Social Worker at approximately 4:00 PM. Further review of the investigation revealed there was no documented evidence the facility interviewed interviewable residents (BIMS score of eight {8} or above) who received care from NASR #2. Interview with Resident #2's Guardian, on 06/03/15 at 8:33 AM, revealed she had reported the allegation of abuse on 04/30/15 between 8:30 AM-9:00 AM to staff at the nursing station. The Guardian stated she spoke to the Advance Registered Nurse Practitioner (ARNP) at the desk about the allegation. Continued interview revealed the Guardian stated she had consulted with her supervisor and reported the allegation to the facility again at approximately 3:50 PM on 04/30/15 and had informed Adult Protective Services of the allegation. Interview with Office Support Assistant (OSA) #1, on 06/02/15 at 1:20 PM, revealed Resident #2's Guardian came to the nursing station on 04/30/15 around 10:00-10:30 AM, and reported Resident #2 had accused NASR #2 of grabbing his/her wrist. OSA #1 stated she did not report the incident because she thought someone else had reported it. Interview with the ARNP, on 06/02/15 at 3:52 PM, revealed Resident #2's Guardian came to the nursing station on the morning of 04/30/15 and reported an allegation involving NASR #2 and Resident #2. The ARNP stated she did not report the incident. However, she stated all allegations should be reported immediately to the supervisor. Interview with the Unit Manager, on 06/02/15 at 5:57 PM, revealed she was at the nursing station when Resident #2's Guardian reported NASR #2 grabbed Resident #2's arm but she did not look at it as an allegation of abuse and she did not report it. Interview with the Social Service Worker (SSW), on 06/02/15 at 1:33 PM, revealed Resident #2's Guardian had notified her of the allegation of abuse on 04/30/15 around 4:00 PM via telephone. The SSW stated she immediately informed the Assistant Administrator of the allegation. Interview with Licensed Practical Nurse (LPN) #2, on 06/02/15 at 6:00 PM, revealed other than Resident #1 and Resident #2, there were no additional interviews conducted related to the abuse allegations. Further review with the Unit Manager, on 06/02/15 at 5:57 PM, revealed in order to ensure the safety of residents during an allegation of abuse, interviewable residents should be interviewed. UM #1 further stated she did not know what the facility's policy said. Further interview with the DON, on 06/03/15 at 9:57 AM, revealed there were no additional interviews with alert and oriented residents during the investigation of either of the allegations of abuse involving Resident #1 or Resident #2. Interview with the Assistant Administrator, on 06/03/15 at 1:47 PM, revealed he did not see interviews done on the other residents during the investigations involving Resident #1 and Resident #2. Interview with the Administrator, on 06/02/15 at 4:00 PM and 5:00 PM; and, on 06/03/15 at 2:30 PM, revealed she did not know of the allegation of abuse involving Resident #2 until it was reported to her on 04/30/15 after 4:00 PM when the Guardian of Resident #2 called the facility and notified them again of the incident. The Administrator stated she should have been told of the allegation involving Resident #2 when the Guardian had reported it that morning at the nursing desk. Further interview with the Administrator, on 06/02/15 at 4:00 PM and 5:00 PM, and on 06/03/15 at 2:30 PM, revealed they did not do interviews with any other residents during the investigations involving Resident #1 and Resident #2, and that probably would have been best practice. The Administrator stated she did feel the investigations were thorough and they did follow their policy.

Based on interview, record review and facility policy review it was determined the facility staff failed to implement the facility's policy on reporting alleged abuse allegations immediately and failed to conduct interviews with other residents who received care from the alleged perpetrator for two (2) of four (4) sampled residents (Resident #1 and Resident #2), per facility policy. The findings include: Review of facility policy titled, Reporting Abuse to Facility Management, dated February 2002, revealed it was the responsibility of each employee to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown origin to the administrator or his/her designee. Review of the facility's policy titled, Investigating Allegations of Physical Abuse, dated February 2002, revealed all reported incidents of physical abuse should be promptly. Review of facility's policy titled, Prevention of Abuse, Neglect, and Misappropriation, dated 03/01/2010, revealed alleged violations of suspected abuse should be immediately reported to the Administrator or designee immediately and any person having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report. The facility should have evidence that all alleged violations are investigated thoroughly. Review of facility policy titled Abuse Investigation Protocol, last revised 05/13/15, revealed all reports of resident abuse, neglect, injuries of an unknown source, resident -to-resident abuse and resident-to-staff abuse should be promptly and thoroughly investigated by facility management. The individual conducting the investigation at a minimum should interview other residents to whom the accused employee provides care or service to determine if there are any complaints about the employee. 1. Record review revealed the facility admitted Resident #1 on 03/13/15 with [DIAGNOSES REDACTED]. Review of an Incident Report and Investigation, dated 05/08/15, and interviews with Patient Aide (PA) #1, on 06/02/15 at 1:58 PM; the Director of Nursing (DON) on 06/03/15 at 1:58 PM; the Unit Manager, on 06/02/15 at 5:57 PM; the Assistant DON, on 06/03/15 at 12:55 PM; and, the Assistant Administrator, on 06/03/15 at 1:47 PM, revealed PA #1 had reported to the Director of Nursing (DON) she observed Nurse Aide State Registered (NASR) #1 slap Resident #1 on the leg on 05/07/15 around 10:00 AM. However, the incident occurred on 05/07/15, but the PA failed to report the incident immediately per facility policy; the allegation was not reported until 05/08/15 (the next day). In addition, the facility failed to conduct a complete investigation with interviews with interviewable residents who were assessed to have a Brief Interview of Mental Status (BIMS) score of eight {8} or above to determine if there was any evidence of abuse per the facility's policy. 2. Record review revealed the facility admitted Resident #2 on 12/16/09 with [DIAGNOSES REDACTED]. Review of the Incident Report and Investigation, dated 04/30/15 at 4:05 PM, and interviews with Resident #2's Guardian, on 06/03/15 at 8:33 AM; Office Support Assistant (OSA) #1, on 06/02/15 at 1:20 PM; the Advance Registered Nurse Practitioner, on 06/02/15 at 3:52 PM; the Social Service Worker (SSW), on 06/02/15 at 1:33 PM; Licensed Practical Nurse (LPN) #2, on 06/02/15 at 6:00 PM; the Unit Manager, on 06/02/15 at 5:57 PM; the Assistant DON, on 06/03/15 at 12:55 PM; and, the Assistant Administrator, on 06/03/15 at 1:47 PM revealed Resident #2 had informed his/her Guardian that Nurse Aide State Registered (NASR) #2 had grabbed his/her arm when attempting to retrieve tobacco from his/her pocket. The staff at the nursing station failed to report the allegation to the Administrator, as required per the facility's policy. The Guardian called and reported the incident again to the Social Worker at approximately 4:00 PM and the incident was reported to Administration at that time. In addition, the facility failed to conduct a complete investigation of the allegation to include interviews with interviewable residents (BIMS score of eight {8} or above) to determine if there was any evidence of abuse per the facility's policy. Interview with the DON, on 06/03/15 at 9:57 AM, revealed staff should have reported the allegations of abuse immediately per facility policy. The DON stated there were no additional interviews conducted with alert and oriented residents during the investigation of either of the allegations of abuse involving Resident #1 or Resident #2 to ensure a complete investigation was conducted per facility policy. Interview with the Administrator, on 06/02/15 at 4:00 PM and 5:00 PM; and, on 06/03/15 at 2:30 PM, revealed staff should have reported the allegations of abuse immediately. The Administrator stated they did not do any interviews with other residents during the investigations involving Resident #1 and Resident #2, and that probably would have been best practice.

Based on interview, record review and facility policy review, it was determined the facility failed to provide care in accordance with one (1) of four (4) sampled residents' (Resident #1) care plans. The Nurse Aides State Registered failed to implement Resident #1's care plan to apply a warm blanket during an episode of agitation, combativeness, and rejection of care, and leave and reapproach the resident in fifteen (15) minute intervals. The findings include: Review of the facility's policy titled, Care Plans, last revised 05/06/15, revealed the comprehensive care plan should include measurable objectives to meet the individual resident's medical, nursing, mental and psychological needs; incorporate problem areas and risk factors; reflect treatment goals, and recognize standards of practice for problem areas and conditions; and when goals are not achieved the care plan should be updated with new goals and objectives. Record review revealed the facility admitted Resident #1 on 03/13/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 04/01/15, revealed the facility determined Resident #1 needed extensive assistance with activities of daily living and was unable to be interviewed due to cognitive status. Review of Resident #1's Comprehensive Care Plan, last revised 05/01/15, revealed the resident was on [MEDICAL CONDITION] medications. The resident had behaviors of hitting, cursing, yelling out, kicking staff, swinging arms towards staff, periods of rejection of care in staff attempts to provide personal care with interventions for staff to attempt to redirect the resident's thoughts to a pleasant topic such as family and music; to apply a warm blanket during periods of agitation, combativeness, and rejection of care; and, if the resident refuses or rejects care to reapproach in fifteen (15) minutes times three (3). Interview with Patient Aide (PA) #1, on 06/02/15 at 1:58 PM, revealed while providing incontinent care, Resident #1 was trying to kick staff during care and NASR #1 slapped Resident #1's leg with the back of her hand telling him/her to stop. Interview with NASR #1, on 06/03/15 at 11:10 AM; and, on 06/04/15 at 5:08 PM, revealed Resident #1 was told not to kick, or hit during incontinent care, and they were not aware of what the interventions on the care plan were when the resident became combative during care. NASR#1 revealed she should be aware of the care plan interventions in order to provide the appropriate care for that resident. Further interview (Post Survey) with NASR #1, on 06/17/15 at 1:18 PM, revealed there were NASR care plans in a binder on the unit and she had access to the binder at all times. NASR #1 stated they have to chart in the binder and she looks at the binder at the end of the shift when she charts. She stated that was the only opportunity she had to look at the book because she hits the floor running when she arrives at work every day. Interview with NASR #4, on 06/04/15 at 3:38 PM, revealed she provided care to Resident #1 with NASR #1. She stated she was not aware of what the care plan interventions were related to Resident #1's behaviors during care, she just knew the resident was combative. Interview (Post Survey) with the Director of Nursing (DON), on 06/17/15 at 1:33 PM, revealed she expected the staff to read the NASR care plans daily prior to going to the floor to care for the residents to see if there had been any changes in addition to receiving report. The DON stated there were interventions on Resident #1's care plan that addressed what to do if the resident became combative with care and she expected them to follow the care plan.

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services for a Percutaneous Endoscopic Gastrostostomy (PEG) tube (feeding tube) for one (1) of four sampled (4) residents (Resident #1). Observation revealed Resident #1's PEG tubing and connector was on the floor and the staff failed to change the feeding and tubing prior to reconnecting the tubing. The findings include: Interview with the Administrator, on 06/03/15 at 4:10 PM, revealed there was no policy related to infection control with PE[DEVICE]s (feeding tube). Record review revealed the facility admitted Resident #1 on 03/13/15 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 04/01/15, revealed the facility determined Resident #1 needed extensive assistance with activities of daily living and was unable to be interviewed due to his/her cognitive status. Observation of Resident #1, on 06/01/15 at 3:45 PM, revealed the PEG tube and connector were in a small puddle of [MEDICATION NAME] 1.5 (tube feeding), on the floor in the television room and was not connected to the resident's abdominal tubing. Further observation at 3:46 PM, revealed Licensed Practical Nurse (LPN) #1 picked up the PEG tube and connector from the floor and placed it over the feeding pump. LPN #1 then obtained an alcohol pad and wiped the PE[DEVICE] connector and the abdominal connector and reconnected the tube. Interview with LPN #1, on 06/01/15 at 3:48 PM, revealed she had used her nursing judgment to clean the tubing connector. She further stated the facility had not provided her any inservicing about how to do it. Interview with the Unit Manager, on 06/01/15 at 4:04 PM, revealed she did not expect alcohol pads to be utilized to clean the connections to the tube feeding. UM #1 stated the bottle of [MEDICATION NAME] 1.5 and the connecting tubing should have been thrown away and replaced because of the risk of infection and contamination. She stated the tubing should not be used once it had touched the floor. Interview with Registered Nurse (RN) #1 (Charge Nurse for whole facility), on 06/01/15 at 4:10 PM, revealed she expected staff to change the tubing and bottle of feeding if the tubing was found on the floor. RN #1 stated she would not expect a nurse to use alcohol pads to wipe the connecting ends and reconnect them because they would not know how long it had been on the floor. RN #1 further stated she was not aware of any inservicing on infection control for peg tubes. Interview with the Infection Control Nurse (ICN) #1, on 06/01/15 at 4:25 PM, revealed the staff would need to change the tubing and feeding if they found it disconnected and on the floor. She stated there was the potential to introduce contaminants to the system anytime there was a break in the system. Interview with Staff Development Coordinator (SDC), on 06/02/15 at 3:06 PM, revealed she expected the tubing and the bottle of nutrition supplement to be changed if it was on the floor for an undetermined amount of time. The SDC stated if there was a puddle on the floor the whole thing needed to be changed because it had been there a while, and using alcohol to clean the connectors and reattach them may not introduce bacteria but she would not want to take the chance. Interview with Assistant Director of Nursing (ADON), on 06/03/15 at 12:55 PM, revealed she did not expect staff to utilize alcohol pads to wipe the connecting ends of the tubing and reconnect them back together after they had touched the floor, because anything that touched the floor was considered contaminated. Interview with the Director of Nursing (DON), on 06/03/15 at 9:57 AM, revealed if tubing was found on the floor she would not expect alcohol swabs to be used to wipe the connecters and reconnect them; she would expect the tubing to be changed. Interview on 06/03/15 at 1:47 PM with Assistant Administrator (AA) revealed he would expect the tubing to be replaced if it had been found on the floor. Further interview revealed the best practice would not be to clean the connections with an alcohol pad and reconnect them because there could be bacteria.