Every finding on record at South Hampton Nursing & Rehabilitation Center

Based on interviews, record review, review of the facility's video surveillance footage, the facility's policies titled: Abuse Prevention Program-Abuse, Neglect, and Exploitation and Reporting Abuse to Facility Management and Other Agency's, the facility failed to ensure the facility's abuse policies were implemented to identify abuse, intervene to protect the resident from further potential abuse, and report the abuse or suspected abuse immediately after staff-to-resident abuse was perpetrated on 02/11/2023 by Licensed Practical Nurse (LPN) #21 against Resident #374. On 2/11/2023 Medication Technician (MT) #22 observed Resident #374 approach LPN #21 in the hallway and LPN #21 grab Resident #374's wrists. After witnessing LPN #21 grab Resident #374's wrist, she did not identify the incident as abuse or suspected abuse, did not intervene, and immediately report the incident. Video surveillance footage was reviewed revealed, after LPN #21 grabbed the resident's wrist, the LPN quickly stepped toward the resident causing him/her to fall forcefully to the floor. LPN #21 worked providing resident care until the end of her shift at 6:47 AM. This failure affected Resident #374; one of two sampled residents reviewed for abuse prevention. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation at a scope and severity of J. On 07/14/2023 at 10:51 AM, the Administrator (ADM) and Director of Nursing (DON) were provided a copy of the immediate jeopardy templates and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation, at F607-Develop/Implement Abuse/Neglect, etc. Policies. The immediate jeopardy began on 02/11/2023 and continued until 02/17/2023, when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited. Cross Reference F600. Findings included: Review of the facility policy titled, Abuse Prevention Program-Abuse, Neglect, and Exploitation reviewed/revised 11/18/2022, revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by . implementing written policies and procedures that prohibit and prevent abuse . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse . This includes staff to resident abuse . VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim . Review of the facility policy titled Reporting Abuse to Facility Management and Other Agency's with a revised date of 09/22/2019 revealed, Policy Statement It is the responsibility of our employees . to promptly report any incident or suspected incident of . resident abuse . to facility management . 1. Our facility does not condone abuse by anyone, including staff members . 2. Our Facility staff are trained to stay with the resident if Abuse is witness and/or suspected until relieved by the Supervisor . 6. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Services or designee . Review of an Admission Record revealed the facility admitted Resident #374 on 03/05/2021 with diagnoses that included Alzheimer's Disease and Anxiety Disorder. Review of a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2022, revealed Resident #374 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #374 did not exhibit any behavioral symptoms. Per the MDS, the resident required limited assistance for bed mobility, transfers, and walking in room. Review of the facility's investigation summary dated 02/17/2023 regarding the investigation of physical abuse perpetrated against Resident #374 on 02/11/2023. The investigation summary indicated the ADM's reviewed the security camera footage from 02/11/2023 at approximately 5:04 AM and documented the summary. The ADM summary indicated; Resident #374 approached LPN #21 at the nurses' station. Resident #374 appeared to point at something and LPN #21, using both of her hands, grabbed both resident's arms and stepped toward the resident, causing the resident to stumble backwards and fall to the floor. LPN #21 initially attempted to pull Resident #374 up by their hands, but the attempt was unsuccessful. Certified Nursing Assistant (CNA) #23 and MT #22 responded to help. CNA #23 and LPN #21 assisted Resident #374 back to the resident's room. The investigative summary indicated that when interviewed, MT #22 reported she had observed LPN #21 grab Resident #374's wrists and that it was her observation that Resident #374 was going to strike LPN #21. MT #22 reported she had not observed how Resident #374 fell . The investigation summary indicated the allegation of abuse against LPN #21 was verified. LPN #21's employment with the facility was terminated on 02/13/2023. Surveyor's review of the video footage of the incident revealed that Resident #374 approached LPN #21 who rolled in her chair to face resident in the hallway. LPN #21 stood up and grabbed resident's wrist and then quickly stepped toward the resident causing the resident to fall forcefully to the floor. Prior to falling to the floor, Resident #374 did not hit LPN #21 or appear to attempt to hit LPN #21. MT #22's undated typed statement revealed, I .worked the night shift . February 10th . [Resident #374] had presented agitated and aggressive toward [LPN #21] and me earlier in the shift. [Resident #374] told me at one point to get out of [his/her] house . [He/She] then told [LPN #21] to get out of [his/her] house. [LPN #21] argued with [Resident #374]; I encouraged [LPN #21] to walk away and not argue with [Resident #374]. I was sitting at the nurses station . when [Resident #374] came out of [his/her] room and walked over to [LPN #21]. I heard [Resident #374] telling [LPN #21] to get out of [his/her] house. I saw [Resident #374] raise [his/her] hand .I observed [LPN #21] grab [Resident #374] by both of [his/her] wrist .I did not see [Resident #374] fall . In a telephone interview on 07/10/2023 at 1:00 PM, Medication Technician (MT) #22 reported she did not recall much about the incident but said she saw LPN #21 grab Resident #374's hands she thought to keep the resident from hitting the nurse. MT #22 said she did not report the incident to anyone because she did not know that it was considered abuse. In a follow-up telephone interview on 07/28/2023 at 3:15 PM MT #22 reported she was sitting at the nurses' desk unknown distance from LPN #21 when the incident occurred. MT #22 said she saw LPN #21 grab the Resident #374 wrist or arm. MT #22 said did not recall her next actions, but recalled that she had another resident's medications in her hand. MT #22 said she should have called the administrator because grabbing a resident was abuse. MT #22 continued to say, when the incident occurred, she did not know that it was abuse, but now knew when LPN #21 grabbed Resident #374's wrist that it was abuse because she was restraining the resident. MT #22 said she did not know it was abuse at the time because the facility had not provided detailed training other than who to report it to and when. She said after the incident the facility provided additional training that included scenarios and it was clear that she should have reported what she saw. During interview on 07/10/2023 at 10:41 AM with CNA #23, she stated she remembered Resident #374 was having an incident, and was yelling at the LPN #21. CNA #23 thought the situation was over so she walked away and then LPN #21 asked her to help get Resident #374 up from the floor. CNA #23 reported, the resident's arm was bleeding. CNA #23 assisted the LPN to get the resident off the floor and then LPN #21 cleaned Resident #374's arm. CNA #23 reported she left the room while LPN #21 remained and was assessing Resident #374's vital signs. CNA #23 stated she did not report the incident because she did not know the resident was pushed. She stated after the in-service provided following the incident, she became aware that she should have report the incident. In an interview on 06/22/2023 at 11:11 AM, the DON reported any observed abuse should have been reported immediately to the ADM, who was the abuse coordinator. During a follow-up interview with the ADM on 07/10/2023 at 12:24 PM, the ADM confirmed LPN #21 had continued to provide care to residents following the incident. LPN #21 assessed Resident #374 following the incident and administered medications to other residents. This deficient practice was cited as a result of the investigation of complaint/report #AL00043339. ******************************************************************** A review of the facility's investigation file indicated once the facility became aware of the incident of abuse involving Resident #374, the following corrective actions were implemented: On 02/11/2023 at 11:30 AM, the ADM reported the incident to the state agency and local law enforcement and suspended LPN #21. On 02/11/2023 through 02/12/2023, the DON and RN weekend supervisor conducted body audits of Resident #374 and all non-interviewable residents and conducted interviews with all interviewable residents. On 02/13/2023 the facility completed a Root Cause Analysis and determined LPN #21 chose to act outside of her scope and training as a nurse to commit a criminal act against Resident #374. On 02/13/2023, the ADM terminated LPN #21's employment and notified the state board of the abuse incident. On 02/13/2023, the ADM provided in-service education for 100% of the facility staff on abuse identification, reporting, and protection. Employees not on duty were educated by phone. On 02/14/2023, an ad hoc (done as needed for a necessary purpose) Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss the abuse incident and formulate a performance improvement plan. The ADM, DON, Medical Director, Rehabilitation Director, Long Term Care (LTC) Unit Coordinator, Medical Records, QAPI nurse, Activity Director, Restorative Nurse, Dietary Manager, and MDS Coordinator attended the meeting. On 02/14/2023, the QAPI committee developed a Performance Improvement Plan (PIP) and the ADM and DON initiated audits to ensure staff would recognize and report any further abuse incidents appropriately. The audits included presenting staff with scenarios and interviewing them to determine if they correctly identified them as abuse, correctly identified the type of abuse, whether the scenarios should be reported, when they should be reported, and to whom. The audits were conducted weekly for four weeks, then monthly for three months. On 02/17/2023, the ADM submitted the final 5-day report to the state agency. Additionally, the facility has continued previously established practices: Daily morning meetings Monday through Friday, during which the ADM, DON, and other department heads review incident reports and nurses' notes. The review includes root cause analyses for any incidents and discussion of any incidents suspicious of abuse to determine if staff identified, immediately reported, and protected residents. Monthly Resident Council meetings are held, during which resident concerns are discussed. Daily walk-through rounds were already in progress and continued, after morning meetings, Monday through Friday, during which time department heads speak with residents about any issues or concerns they may have. On 07/13/2023, the survey team interviewed staff regarding attendance of an in-service on 02/13/2023 regarding abuse. All staff reported they had attended the in-service in February 2023 and were able to name the types of abuse and indicated they would first protect the resident and remove the resident from any abusive situation, then contact the ADM/Abuse Coordinator immediately. All staff had the ADM's telephone number and knew where to find the ADM's telephone number. Staff also had the types of abuse on a laminated card on the back of their name tags. On 07/14/2023 at 9:17 AM, the Activity Director (AD) was interviewed and indicated Resident Council meetings were held monthly and included discussions on resident rights. The AD reported giving a copy of resident rights to the residents quarterly. Residents and families were given a Resident Handbook on admission to the facility. The Resident Handbook included information related to abuse. ************************************************************ After review and verification of the facility's corrective actions, including the facility's investigation, initial and five-day reports submitted to the state agency, in-service education records, QAPI meeting records and plans, monitoring tools, and staff interviews, the survey team determined the facility implemented corrective actions on 02/17/2023 with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.

Based on interviews, record review, facility document review, review of facility policy titled Abuse Prevention Program-Abuse, Neglect and Exploitation, and review of the facility's video surveillance footage, the facility failed to protect the resident's right to be free from physical abuse perpetrated by staff for one (Resident #374) of two residents sampled for abuse prohibition. Video Footage from 02/11/2023 revealed a nurse identified as Licensed Practical Nurse (LPN) #21 and a resident identified as Resident #374. LPN #21 was seated in a rolling chair with back to the hallway. Resident #374 was ambulating toward LPN #21 along the opposite wall. At approximately 5:04 AM, Resident #374 approached closer to LPN #21. The nurse said, go back to your room and then turned in the rolling chair toward Resident #374. The resident took a few steps towards LPN #21 and the LPN stood up. The resident held their right arm up and gestured with their right hand. The LPN #21 grabbed the resident's right arm and stepped with each foot toward the resident, causing the resident to stumble backwards and fall forcefully to the floor. The LPN let go of the resident as the resident fell . When the resident's buttocks and right arm landed on the floor, the LPN told the resident, There you go. On the floor. There you go. At this time, there were no observations of Resident #374 hitting LPN #21 or attempting to hit LPN #21. The video revealed immediately after the fall, LPN #21 reached toward Resident #374, and the resident swatted his/her hand at the LPN's arms several times before being pulled to a seated position by LPN #21. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation at a scope and severity of J. On 07/14/2023 at 10:51 AM, the Administrator (ADM) and Director of Nursing (DON) were provided a copy of the immediate jeopardy templates and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation, at F600-Free from Abuse and Neglect. The immediate jeopardy began on 02/11/2023 and continued until 02/17/2023, when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited. Cross Reference F607. Findings included: Review of a facility policy titled, Abuse Prevention Program-Abuse, Neglect and Exploitation reviewed/revised 11/18/2022, revealed, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The policy indicated, .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . Review of an Admission Record revealed the facility admitted Resident #374 on 03/05/2021 with diagnoses that included Alzheimer's Disease and Unsteadiness on Feet. Review of a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2022, revealed Resident #374 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated Resident #374 did not exhibit any behavioral symptoms. Per the MDS, the resident required limited assistance for bed mobility, transfers, and walking in room. The review of Resident #374's Progress Notes dated 02/11/2023 at 5:14 AM and documented by LPN #21, indicated Resident #374 came out of their room and became aggressive because the resident did not know where the resident's children were. According to the note, the resident approached a nurse, who was not identified in the note, in a violent manner. The note indicated the nurse grabbed the resident's hands to prevent the resident from hitting the nurse or causing further harm to the nurse. The note described that when the nurse grabbed the resident's arms, the resident was lowered to the floor for safety. The nurse and an unspecified number of certified nursing assistants assisted the resident off the floor. In a telephone interview on 06/22/2023 at 7:34 AM, Registered Nurse (RN) #20 reported she worked the day shift on 02/11/2023 after the incident in question occurred earlier that morning. RN #20 reported the night shift had not included the incident in the morning report, so she was not aware of the incident. The RN reported that from 8:30 AM to 9:00 AM, Resident #374 sat in a wheelchair near the nurses' station. During this time, RN #20 stated she observed a skin tear on the resident's right elbow, that was three centimeters in length. The RN reported the resident had dementia and their memory fluctuated. According to RN #20, the resident reported that the skin tear occurred when the resident was wrestling with the nurse. The RN then reviewed the resident's medical record and found the documentation describing the incident. RN #20 reported Resident #374 was never aggressive or combative. RN #20 reported she spoke with the resident's family/responsible party. Per RN #20, the resident's family reported to her that they had received a call from LPN #21 who said she had to force the resident to the ground. According to RN #20, this prompted her to notify the ADM. During an interview on 06/22/2023 at 11:26 AM, the ADM stated he received a call from RN #20 and was made aware of the concern involving Resident #374. Per the ADM, RN #20 informed him of the report from Resident #374's family, namely that they had received a call from LPN #21 noting that the resident had to be forced to the ground by the nurse. At that time, the ADM stated he suspended LPN #21, reported the incident to the state, contacted the police, and contacted the resident's family. The ADM noted he received a statement from LPN #21 via email. According to the ADM, LPN #21 alleged she defended herself by holding the resident's arms, and that was when the resident's fall occurred. The ADM reported that after viewing the camera footage, the facility terminated LPN #21's employment. Review of the facility's investigation summary dated 02/17/2023 regarding the investigation of allegation of physical abuse perpetrated against Resident #374 on 02/11/2023, indicated the ADM's review of security camera footage revealed, at approximately 5:04 AM, Resident #374 approached LPN #21 at the nurses' station. Resident #374 appeared to point at something and LPN #21, using both of her hands, grabbed both of the resident's arms and stepped toward the resident, causing the resident to stumble backwards and fall to the floor. LPN #21 initially attempted to pull Resident #374 up by their hands, but the attempt was unsuccessful. Certified Nursing Assistant (CNA) #23 and Medication Technician #22 responded to help. CNA #23 and LPN #21 assisted Resident #374 back to the resident's room. Further review of the facility's investigation summary, indicated when the ADM interviewed Medication Technician #22, Medication Technician #22 reported she had observed LPN #21 grab Resident #374's wrists and that it was her observation that Resident #374 was going to strike LPN #21. Medication Technician #22 reported she had not observed how Resident #374 fell . The investigation summary indicated the allegation of abuse against LPN #21 was verified. LPN #21's employment with the facility was terminated on 02/13/2023. A phone interview was conducted on 07/11/2023 at 6:40 AM with LPN #21. LPN #21 said the incident resulted in a skin tear to Resident #374's right elbow. During interview on 07/10/2023 at 10:41 AM with CNA #23, she stated she remembered Resident #374 was having an incident and was upset because the resident's family member was not home. CNA #23 stated the resident was yelling at the LPN #21. CNA #23 thought the situation was over and walked away and then the nurse called her to help get Resident #374 up from the floor. CNA #23 reported, the resident's arm was bleeding, she thought the skin tear was caused from hitting the ground. During an interview on 07/11/2023 at 8:31 AM the ADM stated LPN #21 should have tried to de-escalate the situation, ensured the resident's safety, and walked away. A review of LPN #21's Employee Termination Evaluation, dated 02/13/2023, indicated the facility terminated the employment of LPN #21 on 02/13/2023 due to verified physical abuse of a resident. This deficient practice was cited as a result of the investigation of complaint/report #AL00043339. *********************************************************************** A review of the facility's investigation file indicated once the facility became aware of the incident of abuse involving Resident #374, the following corrective actions were implemented: On 02/11/2023 at 11:30 AM, the ADM reported the incident to the state agency and local law enforcement and suspended LPN #21. On 02/11/2023 through 02/12/2023, the Director of Nursing (DON) and RN weekend supervisor conducted body audits of Resident #374 and all non-interviewable residents and conducted interviews with all interviewable residents. On 02/13/2023 the facility completed a Root Cause Analysis and determined LPN #21 chose to act outside of her scope and training as a nurse to commit a criminal act against Resident #374. On 02/13/2023, the ADM terminated LPN #21's employment and notified the state board of the abuse incident. On 02/13/2023, the ADM provided in-service education for 100% of the facility staff on abuse identification, reporting, and protection. Employees not on duty were educated by phone. On 02/14/2023, an ad hoc (done as needed for a necessary purpose) Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss the abuse incident and formulate a performance improvement plan. The ADM, DON, Medical Director, Rehabilitation Director, Long Term Care (LTC) Unit Coordinator, Medical Records, QAPI nurse, Activity Director, Restorative Nurse, Dietary Manager, and MDS Coordinator attended the meeting. On 02/14/2023, the QAPI committee developed a Performance Improvement Plan (PIP) and the ADM and DON initiated audits to ensure staff would recognize and report any further abuse incidents appropriately. The audits included presenting staff with scenarios and interviewing them to determine if they correctly identified them as abuse, correctly identified the type of abuse, whether the scenarios should be reported, when they should be reported, and to whom. The audits were conducted weekly for four weeks, then monthly for three months. On 02/17/2023, the ADM submitted the final 5-day report to the state agency. Additionally, the facility has continued previously established practices: Daily morning meetings Monday through Friday, during which the ADM, DON, and other department heads review incident reports and nurses' notes. The review includes root cause analyses for any incidents and discussion of any incidents suspicious of abuse to determine if staff identified, immediately reported, and protected residents. Monthly Resident Council meetings are held, during which resident concerns are discussed. Daily walk-through rounds were already in progress and continued, after morning meetings, Monday through Friday, during which time department heads speak with residents about any issues or concerns they may have. On 07/13/2023, the survey team interviewed staff regarding attendance of an in-service on 02/13/2023 regarding abuse. All staff reported they had attended the in-service in February 2023 and were able to name the types of abuse and indicated they would first protect the resident and remove the resident from any abusive situation, then contact the ADM/Abuse Coordinator immediately. All staff had the ADM's telephone number and knew where to find the ADM's telephone number. Staff also had the types of abuse on a laminated card on the back of their name tags. On 07/14/2023 at 9:17 AM, the Activity Director (AD) was interviewed and indicated Resident Council meetings were held monthly and included discussions on resident rights. The AD reported giving a copy of resident rights to the residents quarterly. Residents and families were given a Resident Handbook on admission to the facility. The Resident Handbook included information related to abuse. *********************************************************************** After review and verification of the facility's corrective actions, including the facility's investigation, initial and five-day reports submitted to the state agency, in-service education records, QAPI meeting records and plans, monitoring tools, and staff interviews, the survey team determined the facility implemented corrective actions on 02/17/2023 with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.

Based on interviews, document review, facility policy review, and review of the facility's investigation file, the facility failed to ensure residents' funds were not misappropriated for 13 (Residents #15, #18, #34, #376, #377, and #425 - #432) of 13 residents reviewed for misappropriation of funds. The facility determined Business Office Manager (BOM) #3 misappropriated funds from 13 residents and $18,591.57 was refunded to the residents' trust accounts. Findings included: A review the facility policy titled, Abuse Prevention Program - Abuse, Neglect and Exploitation, with a revised date of [DATE], revealed, under .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The policy indicated, .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . A review of the facility's investigation documentation revealed an investigation summary letter, dated [DATE] and signed by the Administrator (ADM), that indicated an initial report for an allegation of misappropriation of property of resident funds had been submitted to the state survey agency on [DATE]. The report was related to an individual who had not been admitted to the facility (Resident #74), but whose family had made a deposit for room and board in anticipation of the resident's admission. The letter indicated an audit review of the resident trust fund account revealed Business Office Manager (BOM) #3 moved a portion of that money from the prospective resident's trust fund to the facility's petty cash account. The facility was unable to account for the funds from there. The letter indicated this was discovered during an unrelated investigation into BOM #3's actions related to the facility's accounts receivable (A/R). Upon discovery of the A/R discrepancies, BOM #3 was suspended, interviewed, and subsequently terminated. BOM #3 confirmed she manipulated the A/R to clean up the books. The investigation summary letter indicated that based on the facility investigation, the facility substantiated the allegation that misappropriation occurred, and appropriate corrective action was taken by the facility. The total dollar amount suspected to have been misappropriated or unaccounted for was redeposited into the aggregate trust account as of [DATE]. Review of a facility document signed by the ADM and dated [DATE], indicated a third-party audit of the resident trust fund account was conducted and identified the following resident accounts were misappropriated - Residents #15, #18, #34, #376, #377, and #425 - #432. On [DATE] at 3:25 PM, an interview was conducted with the ADM. The ADM stated Resident #74 died in the hospital before being admitted to the facility. The family had already paid for the resident to come to the facility, and the money was put in a trust in the resident's name. An interview with the [NAME] President (VP) of Operations on [DATE] at 1:53 PM revealed BOM #3 adjusted the resident accounts, and over a five-year period, BOM #3 embezzled (misappropriated) over $187,000 from the facility. The VP of Operations stated $18,591.57 was refunded to the residents' trust accounts. An interview with the ADM on [DATE] at 2:23 PM revealed the facility was unable to determine exactly how many residents were affected, but the ADM indicated the audit findings from the outsourced company indicated 13 residents were affected by the missing funds. During a telephone interview on [DATE] at 4:16 PM, the Regional Financial Specialist indicated she performed audits every 30 to 60 days and there had been no discrepancies with the resident trust accounts. This deficient practice was cited as a result of the investigation of complaint/report #AL00041754. ************************************************************* A review of the facility's Performance Improvement Plan (PIP) indicated the following measures were implemented to correct the identified deficient practice: -The facility self-identified inconsistencies with credit balances, and self-identified checks that were cashed to resident petty cash but were unaccounted for in the bookkeeping. - BOM #3 was terminated on [DATE]. -An in-house audit was initiated by the Corporate Accountant on [DATE]. -A police report was filed on [DATE]. The Social Services Director (SSD) was suspended pending investigation on [DATE]. -An audit was outsourced to a third-party accounting firm on [DATE]. -The Department of Public Health was notified of an allegation of misappropriation of residents' funds on [DATE]. -A police investigation was initiated by the local police department on [DATE]. -Staff were in-serviced regarding misappropriation of resident funds on [DATE]. -Accounting policies were revised and implemented with in-service training provided to the appropriate personnel on [DATE]. -Monitoring for compliance and effectiveness of the plan for six months and to continue monthly when petty cash was replenished. ******************************************************************************* After review and verification of the facility's corrective actions, including the facility's investigation, initial and five-day reports submitted to the state agency, in-service education records, PIP, monitoring tools, and staff interviews, the survey team determined the facility implemented corrective actions from [DATE] to [DATE] with ongoing monitoring implemented; thus, past noncompliance was cited.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to assess and use bed rail alternatives before installing and using bed rails for two (Resident #13 and Resident #64) of two residents reviewed for bed rails. Findings included: Review of a facility policy titled, Proper Use of Bed Rails, revised on 09/10/2022, revealed, Appropriate alternative approaches are attempted prior to installing or using bed rails. The policy also indicated, The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The policy further indicated, The facility will attempt to use appropriate alternatives prior to installing or using bed rails. Alternatives include, but are not limited to: a. Roll guards b. Foam bumpers c. Lowering the bed d. Concave mattresses. 1. Review of Resident #13's Admission Record indicated the facility admitted the resident on 01/11/2023 with diagnoses that included Alzheimer's disease and repeated falls. Review of Resident #13's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/26/2023, revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition. The MDS indicated Resident #13 required extensive assistance from staff with bed mobility, transfers, and toilet use. The MDS indicated bed rails were not used for restraints. Review of Resident #13's care plan revealed focus areas of impaired self-care and risk for falls, initiated on 01/12/2023. Interventions included the use of one-quarter bed rails for mobility aids as needed with verbal cues for rolling side to side. A review of a Bed Side-Rail Assessment V2, dated 01/26/2023, revealed Resident #13 had not expressed a desire to have side rails raised while in bed for their own safety or comfort. The assessment included instructions to list bed rail alternatives considered but not attempted and alternatives attempted but that failed to meet the resident's needs. Both items were left blank. A review of an Order Summary Report for active orders as of 06/22/2023 revealed an order, dated 01/11/2023, for Resident #13 to have one-quarter left and right upper bed rails for mobility and transfers. On 06/19/2023 at 11:33 AM, Resident #13 was observed lying in their bed with one-quarter bed rails attached to the bed. During an interview on 06/22/2023 at 2:07 PM, Licensed Practical Nurse (LPN) #9 said the facility conducted bed rail assessments to determine whether a resident should receive bed rails and the type of bed rails. During an interview on 06/22/2023 at 2:17 PM, the Assistant Director of Nursing (ADON) stated bed rail assessments were conducted quarterly and annually using an electronic questionnaire. The ADON stated the facility standard was to utilize only one-quarter bed rails. The ADON said if the items on the assessment referencing bed rail alternatives considered and attempted were left blank then the alternative assessments probably did not take place. The ADON added that Resident #13's last bed-rail assessment took place in 01/2023. The ADON said the facility did not consider bed rail alternatives for Resident #13 and that when they missed this step, the MDS Coordinator would conduct that part of the assessment. During an interview on 06/22/2023 at 2:36 PM, the MDS Coordinator stated that the MDS staff did not conduct bed rail assessments for residents. During an interview on 06/22/2023 at 2:46 PM, Certified Nursing Assistant (CNA) #7 stated resident bed rails were not used unless they were addressed in the resident's care plan. During an interview on 06/22/2023 at 3:13 PM, CNA #19 said that Resident #13 required assistance from two staff with transfers and bed mobility. CNA #19 stated that CNA #19 cared for Resident #13 according to Resident #13's care plan, MDS, and bed rail policy. CNA #19 added Resident #13 was able to hold themself up and used bed rails for support. CNA #19 stated that cushions were placed on the bed rails to prevent Resident #13 from hurting themself. 37935 2. Review of Resident #64's Admission Record indicated the facility admitted the resident on 03/06/2023 and readmitted the resident on 03/31/2023 with diagnoses that included Ileus (an inability of the intestine to contract normally, leading to a buildup of food material), Dementia, and Delusional Disorder. A review of Resident #64's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS indicated Resident #64 was independent with bed mobility and required limited assistance from staff with transfers. The MDS also indicated bed rails were not being used as restraints. A review of Resident #64's care plan revealed a focus area, initiated on 03/08/2023 and revised on 04/06/2023, that indicated Resident #64 had impaired self-care related to impaired balance and multiple medications. The interventions indicated the resident required the use of one-quarter bed rails as needed for a mobility aid. The interventions also noted Resident #64 was independent with bed mobility with the use of one-quarter bed rails for mobility aide as needed. The care plan included a focus area, initiated on 03/08/2023 and revised on 04/06/2023, that indicated the resident was at risk for falls. Interventions instructed staff to ensure one-quarter bed rails were up to aid with bed mobility as needed and as resident would allow. A review of an admission Bed Side-Rail Safety Assessment V2, dated 03/06/2023, revealed Resident #64 had not expressed a desire to have bed rails raised while in bed for their own safety or comfort. The assessment indicated Resident #64 used the side rails for positioning of [sic] support and that the bed rail helped the resident rise from a supine position to a sitting/standing position. The sections on the assessment that indicated to List side rail alternatives considered but not attempted because they were considered inappropriate for resident and to List any Side Rail alternatives attempted that failed to meet resident's needs were left blank. A review of an admission Bed Side-Rail Safety Assessment V2, dated 03/31/2023, revealed Resident #64 had expressed a desire to have bed rails raised while in bed for their own safety or comfort and indicated the resident used the rails for bed mobility. The assessment indicated Resident #64 used the bed rails for positioning of [sic] support and that the bed rail helped the resident rise from a supine position to a sitting/standing position. The sections on the assessment that indicated to List side rail alternatives considered but not attempted because they were considered inappropriate for resident and to List any Side Rail alternatives attempted that failed to meet resident's needs were left blank. A review of a quarterly Bed Side-Rail Safety Assessment V2, dated 06/05/2023, revealed Resident #64 had not expressed a desire to have bed rails raised while in bed for their own safety or comfort. The assessment indicated Resident #64 used the bed rails for positioning of [sic] support and that the bed rail helped the resident rise from a supine position to a sitting/standing position. The sections on the assessment that indicated to List side rail alternatives considered but not attempted because they were considered inappropriate for resident and to List any Side Rail alternatives attempted that failed to meet resident's needs were left blank. On 06/22/2023 at 3:00 PM, an interview was conducted with Resident #64. Resident #64 stated they used the bed rails to help turn themself over in bed and to help them get up out of the bed. Resident #64 told the facility it was okay for them to have the bed rails and Resident #64 wanted them on their bed. One-quarter rails were observed at the head of the resident's bed. On 06/22/2023 at 4:03 PM, an interview was conducted with the Director of Nursing (DON). The DON stated a bed rail assessment was done upon admission to determine who would benefit from bed rails. The DON stated she was aware alternatives should have been explored prior to the use of bedrails, and if alternatives were considered, they would be documented. On 06/22/2023 at 4:08 PM, a follow-up interview was conducted with the DON. The DON stated the section on the bed rail assessment addressing the alternatives considered or attempted was left blank for Resident #64, and she would have expected that to have been filled out. On 06/22/2023 at 4:13 PM, an interview was conducted with the Administrator (ADM). The ADM stated the section for the alternatives considered or attempted was left blank for Resident #64, and he would have expected that to have been filled out.

Based on observation, interview, and the (YEAR) Food and Drug Administration (FDA) Food Code, the facility failed to ensure the food-contact surfaces of insulated 6-ounce bowls and insulated 8-ounce coffee cups used for resident meal service were clean. This had the potential to affect 64 of 64 residents receiving meal trays, 64 of 65 residents in the facility. Findings include: The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES . shall be kept free of . soil accumulations. 4-603.14 Wet Cleaning. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be effectively washed to remove or completely loosen soils by using the manual or mechanical means necessary such as the application of . acid, alkaline . cleaners . The (YEAR) FDA Food Code further included the following in Annex 3 - Public Health Reasons/Administrative Guidelines: Page 491 . Cleanability 4-202.11 Food-Contact Surfaces. The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned . Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. Page 504 . Equipment 4-501.11 Good Repair and Proper Adjustment. . a chemical sanitizer will not sanitize a dirty dish . Page 513 . 4-603.12 Precleaning. . Depending upon the condition of the surface to be cleaned, detergent alone may not be sufficient to loosen soil for cleaning. Heavily soiled surfaces may need to be presoaked . Objective 4-701.10 Food-Contact Surfaces and Utensils. Effective sanitization procedures destroy organisms of public health importance that may be present on . food equipment, or utensils after cleaning, or which have been introduced into the rinse solution. It is important that surfaces be clean before being sanitized to allow the sanitizer to achieve its maximum benefit. During the initial tour of kitchen on 9/3/2019 at 5:45 PM, the interior food-contact surfaces of 6-ounce insulated bowls and 8-ounce insulated coffee cups stored on a rack in the kitchen were checked. One of the five insulated coffee cups checked had a heavy residue inside the cup. Three of the five insulated bowls checked had heavy residue on the interior surface of the bowls. It was also observed that the dishwashing machine used chlorine as the sanitizing method. On 9/4/2019 at 10:24 AM, an observation was made of dishwashing following the resident breakfast service. Insulated bowls and insulated coffee cups were observed being placed upside down on trays located on a storage rack in kitchen. Employee Identifier (EI) #1, the Dietary Manager, was questioned about the items stored on the rack during an interview at 10:30 AM. When asked if the bowls and cups on the rack were ready for resident meal service, EI #1 said yes. Upon inspecting the interior food-contact surface of the 6-ounce insulated bowls with EI #1, 23 of the 36 bowls checked had residue inside. When asked if these bowls were clean; EI #1 said no, they were dirty. Upon inspecting the interior food-contact surface of the 8-ounce insulated coffee cups, three of the fourteen cups checked contained residue. EI #1 was asked what would be the concern with the cups and bowls containing residue. EI #1 said the residue would touch the clean food and it would be cross-contamination. On 9/4/2019 at 3:37 PM, EI #2, the Registered Dietitian, was interviewed. EI #2 confirmed that 64 of the 65 facility residents received meals from the kitchen. When asked about the insulated coffee cups and the insulated soup bowls observed with heavy residue inside on the food contact surfaces, EI #2 said it could be a mineral build-up. Upon being asked if the food-contact surfaces of these bowls and cups were clean, EI #2 said no.

Based on record review, interview and review of a facility policy titled Abuse Investigations, the facility failed to ensure Employee Identifier (EI) #5, Licensed Practical Nurse (LPN) was suspended during an investigation into an allegation of misappropriation of Resident Identifier (RI) #8's property (medication). This deficient practice was identified during the review of 1 of 3 facility abuse investigative files. Findings Include: A review of a facility policy titled Abuse Investigations, with a review/ revised date of 5/10/17, documented the following: . 7. Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator. RI #8 was admitted to the facility on [DATE]. Review of the resident's medication included [MEDICATION NAME] HCI 50 milligram tablet every six hours for pain. A review of a facility file documented an allegation was made against EI #5 on 7/16/19. The allegation was EI #5 took RI #8's medication [MEDICATION NAME]. A review of a facility document titled Time Card Report for EI #5, indicated EI #5 worked on 7/17/19 and 7/18/19. An interview was conducted with EI #4, Registered Nurse (RN/ Director of Nursing (DON)/ Abuse Coordinator on 9/5/19 at 2:00 p.m. EI #4 was asked when she was made aware of the allegation that EI #5 took RI #8's medication. EI #4 stated three CNA's came to her on 7/16/19. EI #4 was asked did she consider this an allegation of abuse. EI #4 stated at the time she did not because it was the same ones who always complained about things and she could never get anything concrete. EI #4 was asked if taking someone's medication would be misappropriation of resident property. EI #4 stated, absolutely. EI #4 was asked when was the first day of the investigation. EI #4 stated, 7/17/19. EI #4 further stated the last day of the investigation was 7/19/19. EI #4 was asked if EI #5 worked on 7/17/19 and 7/18/19. EI #4 stated EI #5 worked 7/17/19 and 7/18/19. EI #4 was asked if EI #5 was suspended during the investigation. EI #4 stated no, she worked and performed her normal duties to include passing medication on 7/17/19 and 7/18/19. EI #4 was asked what was the potential harm to other residents. EI #4 said she (EI #5) could be doing the same thing to other residents. EI #4 was asked if the abuse policy was followed concerning suspending an employee during an investigation. EI #4 stated, no. An interview was conducted with EI #3, the Administrator, on 9/5/19 at 5:19 p.m. EI #3 was asked if EI #5 worked during the investigation into misappropriation of RI #8's property. EI #3 stated she worked on 7/17/19 and 7/18/19. EI #3 was asked if she should have been working during the investigation. EI #3 stated, no. EI #3 stated EI #5 was not suspended during the investigation. EI #3 was asked what the abuse policy stated about employees involved in an allegation. EI # 3 stated that the employee needed to be suspended. EI #3 stated the abuse policy was not followed. EI #3 was asked why should someone be suspended during an investigation. EI #3 stated to make sure the resident is not further abused. EI #3 further stated EI #5 worked and completed her normal duties to include giving medication.

Based on interview, record review and review of facility policies tilted Reporting Abuse to State Agencies and other Entities and Abuse Investigation, the facility failed to report an allegation of misappropriation of Resident Identifier (RI) #8's property to the State Agency within 24 hours. This deficient practice was identified during the review of 1 of 3 facility abuse investigative files. Findings Include: A review of a facility policy titled Reporting Abuse to State Agencies and other Entities with a review/ revised date of 11/21/16, documented the following: . All suspected violations, allegations and/or incidents of abuse will be immediately reported to appropriate state agencies . A review of a policy titled Abuse Investigations, with a review/revised date of 5/10/17, documented the following: Type of Allegation . Misappropriation of resident property . 24 hour reporting . A review of a facility file documented an allegation was made against Employee Identifier (EI) #5 on 7/16/19. The allegation alleged EI #5 took resident Identifier (RI) #8's medication [MEDICATION NAME]. An interview was conducted with EI #4, Registered Nurse (RN) / Director of Nursing (DON)/ Abuse Coordinator, on 9/5/19 at 2:00 p.m EI #4 was asked when she was made aware of the allegation that EI #5 took RI #8's medication. EI #4 stated three CNA's came to her on 7/16/19. EI #4 was asked why this was not considered an allegation of abuse. EI #4 stated because she knew there was a rift between the parties involved. EI #4 was asked if taking someone's medication would be considered misappropriation of resident property. EI #4 stated, absolutely. EI #4 was asked if the allegation was reported to the State Agency. EI #4 stated, no. EI #4 was asked if she completed an investigation, why the findings were not reported. EI #4 stated it never crossed her mind that it would be reportable. EI #4 was asked if this allegation should have been reported to the State Agency. EI #4 stated, yes. EI #4 was asked what their abuse policy stated regarding misappropriation of property. EI #4 stated it should have been reported within 24 hours. An interview was conducted with EI #3, the Administrator, on 9/5/19 at 5:19 p.m. EI #3 stated she received a copy of an email containing the allegation that EI #5 took RI #8's medication. EI #3 was asked if taking someone's medication would be misappropriation of resident property. EI #3 stated, yes. EI #3 was asked if this allegation was reported to the State Agency. EI #3 stated, no. EI #3 was asked if the allegation should have been reported to the State Agency. EI #3 stated, yes. EI #3 further stated the facility policy stated all allegations of misappropriation of resident property should be reported to the State Agency within 24 hours.

Based on observations, interviews, medical record review and a review of the facility's policy and procedure titled, Infection Prevention and Control Program, the facility failed to ensure licensed staff washed their hands after removing gloves, before applying clean gloves and before touching clean items. The facility also failed to ensure licensed staff used a paper towel to turn the water faucet off after washing their hands. This affected RI (Resident Identifier) #10 and RI #25, two of eight residents on two of three halls, and two of four nurses observed during the medication administration observation. Findings Include: A review of the facility's policy and procedure titled, Infection Prevention and Control Program, with a revised date of 5/23/17, revealed the following: .Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE (Personal Protection Equipment) removal . 1. RI #25 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/08/18 at 2:25 PM, EI #3, LPN, was observed during the medication administration of RI #25. EI #3 prepared RI #25's medication and entered the resident's room. EI #3 administered the medications, removed her gloves and washed her hands. EI #3 turned the water off with her wet bare hands. EI #3 obtained paper towels, dried her hands and exited the room. On 08/08/18 at 2:35 PM, during an interview with EI #3, the surveyor asked how should the water faucet be turned off. EI #3 stated, With paper towels. The surveyor asked was that what she had done. EI #3 stated, I don't remember. The surveyor informed EI #3 of the above observation related to turning off the faucet with her wet bare hands and EI #3 stated, I'll take your word for it. The surveyor asked what type of an issue would that be. EI #3 stated, Infection risk, and transferring of germs. 2. RI #10 was re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/08/18 at 4:10 PM, Employee Identifier (EI)# 1, Licensed Practical Nurse (LPN) was observed preparing medications for administration to RI #10. EI #1 dispensed [MEDICATION NAME] and obtained a glucometer for a finger stick blood sugar (FSBS) for RI #10. EI #1 cleaned the glucometer with a Sani wipe then applied gloves without washing or sanitizing his hands. EI#1 entered RI #10's room to obtain a FSBS, administer insulin and [MEDICATION NAME] (via GT {Gastrostomy Tube} ). EI #10 removed and applied gloves several times without washing his hands or using hand sanitizer before applying gloves or after gloves were removed. EI #10 touched keys, the medication cart, supplies and tube feeding with unclean hands. On 8/8/18 at 5:20 PM, during an interview with EI #1, the surveyor asked what should have been done every time after gloves were removed and before gloves were applied. EI #1 stated, hands washed. The surveyor asked was that what he had done every time. EI #1 stated, No ma'am. The surveyor asked what was the potential for harm. EI #1 stated, Contamination of the GT and feeding.

Based on interview, record review and a review of the facility's policy and procedure titled, Quality Assessment and Assurance (QAA), the facility failed to ensure the Medical Director attended all of the QA (Quality Assurance) quarterly meetings from (MONTH) (YEAR) to (MONTH) (YEAR). This affected two of four QA quarterly meetings. Findings Include: A review of the facility's policy and procedure titled, Quality Assessment and Assurance, with a revised date of 06/23/18, revealed the following: .1. the Committee will be made up of, at a minimum, the Director of Nursing, the Medical director or his or her designee .2 .The committee must: a. Meet at least quarterly .d .The facility will maintain a record of he (the) dates of all meetings and the names/titles of those attending each meeting . A review of the facility's Quality Assurance Meeting sign-in forms revealed the Medical Director attended two of the four quarterly meetings from (MONTH) (YEAR) to (MONTH) (YEAR). On 08/09/18 at 10:44 AM, during an interview with Employee Identifier (EI) #4, QAA and QAPI (Quality Assurance and Performance Improvement) Nurse, the surveyor asked when did the QA committee meet. EI #4 said they had a monthly QA meeting. A review of the facility's QA committee meeting sign-in sheets revealed the Medical Director attended two out of four quarterly meetings that were held in the last year. The surveyor asked EI #4 how often should the Medical Director attend the quarterly meetings. EI #4 stated, Quarterly. The surveyor asked from (MONTH) of (YEAR) until (MONTH) of (YEAR), how many meetings had the Medical Director attended. The surveyor provided the QA minutes and sign in sheets for EI #4 to review. After review, EI #4 stated, Two times since (MONTH) of (YEAR) until now. The surveyor asked what was the policy and procedure for the QA meeting regarding the Medical Director. EI #4 stated, He should attend once a quarter. The surveyor asked was policy and procedure followed. EI #4 stated, No.

Based on a facility policy titled Handwashing/HandHygiene/Infection Control, observations, and interviews the facility failed to ensure a Certified Nursing Assistance (CNA) Employee Identifier (EI) #4, washed her hands or used hand sanitizer while feeding Resident Identifier (RI) #10 and RI #11 supper on 6/27/17 and breakfast and lunch on 6/28/2017. This was observed on two of three days of the survey and affected 2 of 11 residents whose meals were observed. Findings include: A review of the facility policy titled, Handwashing/Hand Hygiene/ Infection Control with a revised date April 2012 documented .Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections When to Wash Hands . Before and after assisting a resident with meals . On 6/27/2017 at 5:30 p.m., the surveyor observed EI #4 feeding RI #10 and RI #11 with the same hand reaching back and forth between the residents without washing her hands or using sanitizer. On 6/28/2017 at 8:00 a.m., the surveyor observed EI #4 feeding and assisting RI #10's breakfast meal. EI #4 fed RI #10 using her spoon then turned to RI #11 on the opposite side and used RI #11's spoon without washing her hands or using hand gel. EI #4 was observed throughout the meal picking up RI #10's spoon and RI #11's spoon. The residents was also observed picking up his/her own forks during the meal. EI #4 was also observed wiping the spoons with the resident's napkin and wiping the resident's mouth with their bib during the meal then picking up the spoon to feed the resident. EI #4 was observed touching the top of the resident's glasses. On 6/28/2017 at 12:15 p.m., EI #4 was observed during the noon meal. EI #4 fed a bite of food to RI # 10 then reached over to cut RI #11's meat and fed RI #11 a bite of meat. EI #4 then reached back to give a drink of tea to RI #10 . EI #4 continued to go back and forth between the residents feeding RI #10 and RI #11 their meal without washing her hands. EI #4 was observed during the meal touching RI #10's roll and tearing it in half with her bare hands and picking up RI # 10's tea glass by placing her hand over the top of the glass without washing her hands. On 6/29/2017 at 10:30 a.m., the surveyor asked EI #4, what was the problem with feeding two residents at once. EI #4 answered, you usually only feed one at a time. The surveyor ask EI #4 when should you wash your hands when feeding two residents at once. EI #1 answered, before you start, if you stop and go back, when you are done, everytime you touch the spoon and before touching another residents spoon. The surveyor asked EI #4 what is the potential harm when feeding two residents at the same time. EI #4 answered, spreading germs or diseases. On 6/29/17 at 11:30 a.m., an interview was conducted with EI #6, Restorative Nurse, The surveyor ask if two residents should be fed by one Certified Nursing Assistant (CNA) at once during a meal. EI #6 stated yes, you do not touch the residents food or anything with your hands. On 6/29/17 at 12:00 p.m., an interview was conducted with EI #5, Infection Control Nurse. The surveyor ask EI #5 what is wrong with one CNA feeding two residents at once. EI #5 responded they are not supposed to feed two residents at once. The surveyor asked EI # 5 what are they supposed to do. EI #5 stated one CNA is supposed to feed one resident. The surveyor ask what is the potential harm when two residents are fed by one CNA during a meal at the same time. EI #5 stated, cross contamination and Infection Control.

Based on observation, medical record review and review of Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.14 October 2016, the facility failed to ensure the Minimum Data Set (MDS) for Resident Identifier (RI) #5's and RI #8's urinary continence was accurately coded and further failed to ensure RI # 6's MDS dated [DATE] reflected the use of antipsychotic medications. This deficient practice affected three of 13 sampled residents whose MDS'S were reviewed during the survey. Finding include: 1) RI # 8 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of a physician order [REDACTED].# 8 had a size 12 Fr. (french) indwelling foley catheter with an order date of 01/10/2017. During the initial tour on 06/27/2017 at 12:20 p.m., RI # 8 was observed with an indwelling catheter. A review of RI #8's most recent Quarterly MDS, with an Assessment Reference Date (ARD) of 04/10/2017 revealed: Section H0100, Bladder and Bowel coded an indwelling catheter. Section H0300, Urinary Continence was coded 1, indicating occasionally incontinent. A review of .CMS's RAI Version 3.0 Manual CH3:MDS items (H) H0300: Urinary Continence (cont.) . Coding Instructions . Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter . During an interview on 06/29/2017 at 10:30 a.m., Employee Identifier (EI) #1, MDS Coordinator, was asked if RI #8 had a catheter. The response was, Yes. EI # 1 was asked what is the harm of not coding the MDS correctly. EI # 1 responded it is what we send in. 2) RI #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Current medications include, [MEDICATION NAME] 100 Milligrams (MG), one tablet by mouth at bedtime. A review of RI #6's most recent Quarterly MDS, with an ARD of 06/05/2017, had Section N0410, Antipsychotic coded as 0, indicating no antipsychotic use. A review of .CMS's RAI Version 3.0 Manual CH 3: MDS items (N) N0410: Medication Received (cont.) . Coding Instructions . N0410A, Antipsychotic: Record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period . During an interview on 06/29/2017 at 10:30 a.m., Employee Identifier (EI) #1 was asked if RI #6's MDS with an ARD of 06/05/2017 should have been coded for antipsychotic medication. The response was, Yes. EI # 1 further stated it was missed and should have been 7 for 7 days. EI # 1 was asked if the MDS was correct. EI # 1 responded no. 3) RI (Resident Indentifer) #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a physician order [REDACTED].# 5 had a size 16 FR. indwelling foley catheter with an order date of 01/10/2017. A review of RI # 5's most recent Significant change in status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/20/2017 documented RI # 5 had an indwelling catheter. Section H0300 Urinary Continence coded RI # 5 as 1 occasionally incontinent. A review of .CMS's RAI Version 3.0 Manual CH3:MDS items (H) H0300: Urinary Continence (cont.) . Coding Instructions . Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter . An interview was conducted with EI (Employee Indentifer) # 1, Minimum Data Set Coordinator on 6/29/17 at 10:30 a.m. EI # 1 was asked if RI # 5 had a catheter. EI # 1 responded yes. EI # 1 was asked what is the harm of not coding the MDS correctly. EI # 1 responded it is what we send in.

Based on observation, interview and a review of facility documents titled Menu Substitutions, OptimaSolutions .Dietary Management System .Spring and Summer 2017 and Pureed Cake Chocolate (mix) the facility failed to ensure residents ordered a pureed diet received pureed chocolate cake for lunch on 6/28/17. This affected RI (Resident Indentifer) # 4, one of nine sampled residents and six of 69 residents receiving meals from the kitchen. Findings Include: A review of a facility document titled Menu Substitutions documented the following: .To provide a substitute when an uncontrolled situation has temporarily made the item unavailable . A review of a facility document titled OptimaSolutions .Dietary Management System .Spring and Summer 2017 documented the following: .Week 1 Wednesday .Puree .Lunch .4oz (ounce) P (pureed) cake . A review of a facility document titled Pureed Cake Chocolate (mix) documented the following: .Chocolate Cake .1. Prepare according to regular recipe. 2. measure desired # of servings into food processor. Blend until smooth. Add milk if product needs thinning. Add commercial thickener if product needs thickening . On 6/28/17 at 11:15 a.m., the Surveyor entered the kitchen to watch the lunch tray line. At 11:50 a.m. the Surveyor observed kitchen staff serving chocolate pudding to the residents who received a pureed diet. An interview was conducted with Employee Indentifer (EI) # 7, Dietary Manger on 6/28/17 at 11:55 a.m. EI # 7 was asked if staff prepared the pureed cake. EI # 7 responded we are doing pudding for the pureed because we were not sure if the cake could be pureed. RI # 4 was readmitted to the facility on [DATE] . A review of RI # 4's diet order documented: .Dietary .NAS (no added salt)/LCS (low concentrated sweets) diet PUREE texture .order date 12/13/2016 . On 6/28/17 at 12:45 p.m. RI # 4's lunch meal was observed. Chocolate pudding was observed on the tray. A second interview was conducted with EI # 7, Dietary Manager on 6/28/17 at 5:35 p.m. EI # 7 was asked if pureed cake was made for residents at lunch on 6/28/17. EI # 7 responded that chocolate pudding was served instead of the cake. EI # 7 was asked why the pureed cake was not made. EI # 7 stated because the cake was thick and we couldn't get it to the correct consistency. EI # 7 was asked if there was a recipe for the pureed cake. EI # 7 responded yes. EI # 7 was asked should the residents who received a pureed diet have received pureed cake. EI # 7 responded yes. EI # 7 was asked if the menu was followed for the pureed cake for lunch on 6/28/17. EI # 7 responded not for the cake. EI # 7 was asked should the menu have been followed for the pureed cake. EI # 7 responded yes.

Based on observation, interview and review of a facility policy titled Resident Environmental Quality, the facility failed to ensure RL (Room Locator) #1 and #2 were maintained free of chipping paint, unknown substance on the floor/wall and a commode with continuous running water. This was observed on 3 of 3 days of the survey and affected 2 rooms on 2 of 3 halls in the facility. A review of a facility policy titled Resident Environmental Quality with an implementation date of 1/1/16 documented the following: .General Guidelines: Preventive maintenance schedules, for the maintenance of the building and equipment should be followed . On 6-27-17 at 1:00 p.m., during the initial tour of the facility RL # 1 was observed with chipping paint on the wall and a brown stain above the bed. On 6-27-17 at 12:15 p.m., during the initial tour of the facility RL # 2 was observed with an unknown substance on the floor and water continuously running in the commode. On 6-28-17 at 12:00 p.m., RL # 2 was observed with an unknown substance on the floor and water continuously running in the commode. On 6-29-17 at 10:00 p.m., RL # 2 was observed with an unknown substance on the floor and water continuously running in the commode. An interview was conducted with Employee Identifier (EI) # 2, Housekeeping Supervisor on 6/29/17 at 10:20 a.m. EI # 2 was asked what the stain in RL # 2 looked like. EI # 2 responded feces. EI # 2 stated the bathrooms are cleaned daily. EI # 2 was asked if RL # 2 looked like it had been cleaned daily. EI # 2 responded no. EI # 2 was asked what is the potential harm of floors in the bathroom not being cleaned. EI # 2 responded viruses, diseases and infections. An interview was conducted with EI # 3, Maintenance Supervisor on 6/29/17 at 10:30 a.m. EI # 3 was asked what was the problem with chipping paint and a stained ceiling in RL # 1. EI # 3 responded environmental issue, maintaining the facility. EI # 3 was asked why the paint was chipping. EI # 3 responded usually the beds cause the paint to chip. EI # 3 further stated the stain on the ceiling was possibly from a spilled soda. EI # 3 was asked how he becomes aware of maintenance issues. EI # 3 responded when grand rounds are made monthly.

Based on observation, review of the 2013 Food Code and interviews, the facility failed to ensure a food delivery person did not enter the kitchen and go into the walk in cooler without a hair restraint. They further failed to ensure that a male staff member did not enter the kitchen without a beard restraint on. This deficient practice had the potential to affect 75 residents receiving meals from the kitchen. Findings Include: The 2013 Food Code documented, .Hair Restraints-2-402.11 Effectiveness: (A) . FOOD EMPLOYEES shall wear hair restraints such as . hair covering or net, beard restraints, .that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSIL, . On 08/23/16 at 3:00 p.m., the surveyor observed a food delivery person enter the kitchen and go into the walk in cooler with no hair restraint on. On 08/24/16 at 11:55 a.m., the surveyor observed a male staff member enter the kitchen area by a food preparation table with no facial/beard restraint on. On 08/24/16 at 12:00 p.m., an interview was conducted with EI (Employee Identifier) #1, the Dietary Manager. EI #1 was asked did the male staff member have on a beard restraint when he entered the kitchen. EI #1 said, she did not see one on his beard or face. EI #1 was asked what was the facility's policy regarding hair and beard restraints while in the kitchen. EI #1 replied if they have facial hair they should wear a beard covering. EI #1 was asked what was the potential harm if staff did not wear a hair/beard restraint while in the kitchen. EI #1 said there was potential of hair dropping into the food. On 08/24/16 at 12:30 p.m., an interview was conducted with EI #2, the Maintenance Director. EI #2 was asked if he had on a facial/beard restraint when he entered the kitchen. EI #2 said, No. EI #2 was asked what was the potential harm if staff did not wear a hair/beard restraint while in the kitchen. EI #2 said, Contamination; could get hair in the food.

Based on observations, record review and interview: 1. The facility failed to prevent potential time/temperature abuse on the tray line as evidenced by: a) Failed to assure foods were maintained at 135 degrees Fahrenheit (F) or above by monitoring/documenting the holding temperature of a potentially hazardous food (Chicken Alfredo) to prevent potential foodborne illness. b) Staff failed to assure digital thermometers, used for monitoring tray line temperatures, were accurately calibrated. (thermometers determined to be 10 degrees too high). 2. The facility failed to assure equipment (meal tray delivery carts) were cleaned/disinfected to destroy potential food borne organisms between use for soiled return trays and use for delivery of meal trays. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 74 residents receiving meal trays from dining services. Findings include: 1. The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: 3-501.16(A)(1) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD SHALL BE MAINTAINED: (A)(1) At 57 degrees C (Centigrade) (135 degrees F) or above . On 8/18/15 at 5:40 PM, the evening tray line meal service was observed. Staff were plating for the Dining Room area. Temperature monitoring/documentation had been documented for items on the tray line. a) A record review of the facility's Food Temperature Log for the week of 8/16-22/2015, revealed staff had documented the data in the both the Lunch column and the Dinner column for Tuesday, August 18, 2015. There was no data documented for the alternate Chicken Alfredo. Upon surveyor request, the CDM (Certified Dietary Manager) obtained the temperature of the Chicken Alfredo. b) The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: 4-502.11(B) Good Repair and Calibration. Food Temperature Measuring Devices shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. On 08/18/2015 during tray line observation, dietary staff failed to assure digital thermometers, used for monitoring tray line temperatures were accurately calibrated. The food temperatures documented on the log for the evening meal ranged from 170 to 185 degrees F. The CDM was requested to recheck the temperatures of the food in the presence of the surveyor using the facility thermometer. The surveyor requested the CDM to validate the thermometer calibration. The facility thermometer was determined to be miscalibrated and registered 10 degrees higher. An interview with the CDM, Employee Identifier (EI) #3 at 9:48 AM on 8/20/2015, revealed that staff used a digital thermometer to monitor food temperatures. The CDM validated the thermometer was not properly calibrated and that staff failed to monitor/document the tray line temperature for the Chicken Alfredo. EI #3 was asked why staff failed to document the temperature and she responded that the cook forgot. EI #3 indicated the potential negative outcome could be the potential for foodborne illness. 2. On 8/18/2015 at 2:45 PM, the AM Cook, EI #4 was observed cleaning the tray delivery carts. EI #4 was observed to not follow standard protocol as she sprayed the sanitizer prior to cleaning & rinsing the tray delivery carts. On 8/18/2015 at 2:45 PM, the CDM was asked to provide evidence that EI #4 had been trained on how to clean tray delivery carts. The CDM responded that EI #4 had not been trained on the cleaning of the tray delivery carts. The CDM said that EI #4 was working over to help her. During an interview at 9:40 AM on 8/20/2015, the CDM was asked to describe the facility policy related to proper cleaning/disinfecting tray delivery carts. The CDM said that one should wash with soap and water, rinse, then disinfect. EI #3 indicated that a failure to follow the established procedure could lead to bacterial contamination and potential food borne illness.

Based on observations, record review and interview: 1) The facility failed to assure food (ice cream) received frozen remained frozen during storage. (2013 Food Code 3-501.11). 2) The facility failed to assure canned goods with compromised seals were removed from the active inventory. 3) The facility failed to assure dinnerware (divided plates) were clean and in good condition. (2013 Food Code 4-601.11). The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect 70 residents receiving meal trays from dining services. Findings include: 1) The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "...Temperature and Time Control 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen..." On 08/03/2014 at 4:40 PM, the ice cream stored in a walk-in freezer was monitored. The surveyor took an individual cup, applied pressure and finger indention's were left. The surveyor verbalized to the Cook, EI (Employee Identifier) #1 that the ice cream was found soft as evidenced by finger indentations left on the individual cup. EI #1 responded, yes Ma'am (agreeing with the assessment). The outside thermometer of the walk-in freezer indicated +22 degrees Fahrenheit. The internal temperature of the stored Ice Cream was determined to be +19 degrees F. A record review of staff's monitoring/documention on the "Freezer Temperature Record" revealed EI #1 had documented -10 degrees. In response to questions related to recording Fahrenheit vs Celsius, EI #1 stated that he should have written +10 and not -10 degrees. A record review of the facility updated 09/2011 "Record of Refrigeration Temperatures Policy/Procedure" revealed item "...#3. The freezer must be clean and food must be frozen solid with no indication of thawing..." 2) The facility failed to assure canned goods with compromised seals were removed from the active inventory. On 9/03/2014 at 4:40 PM, during the initial tour of kitchen, dry storage review revealed stored canned goods (Butterscotch Pudding) with a compromised seal. During an interview on 9/05/2014 at 9:56 AM, with the Certified Dietary Manager (CDM) Employee Identifier (EI) #2, was asked: a. Who is responsible for dry storage - putting up stock? EI #2 responded that she had a designated assigned position. b. What are potential areas of concern with stock canned goods? EI #2 responded, potential [DIAGNOSES REDACTED] and some kind of disease. c. What is a potential hazard if cans with compromised seals are left in the active inventory? EI #2 responded, the potential that someone would use them. 3) The 2013 Food Code indicated: "...Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch... " On 9/04/2014 at 11:58 AM, while observing the trayline plating/distribution, two of two sectional plates were observed. A divided sectional plate was observed stored on a hot pellet with a bottom liner at the tray line. An examination of the plate revealed there was water and the plate had not been air dried. Further review of another divided plate indicated it was stained and chipped. On 9/05/2014 at 10:03 AM, the CDM, EI #2 was interviewed and asked 3 questions: a. What are some problems with maintaining divided plates clean and in good condition? EI #2 stated, food adheres to corners and is hard to get out, destaining removes clear coat which is a potential for bacterial growth. b. Do you use divided plates? EI #2 responded, yes I do. c. When did we find wet, stained, or chipped plates at the trayline or for use? EI #2 responded, at lunch on 9/04/(2014).

Based on observation, interview and record reviews, the facility failed to ensure Resident Identifier (RI) #1's head of the bed remained in an elevated position at all times while the enteral (tube) feeding was continuously infusing. This affected RI #1, one of one sampled residents fed via a feeding tube. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change in Status Minimum Data Set with an assessment reference date of 08/01/13, assessed RI #1 as being moderately impaired in cognitive skills for daily decision making. RI #1 was assessed as requiring extensive assistance with eating. According to this MDS, RI #1 has a feeding tube. RI #1's August 2013 physician's orders [REDACTED]. During an observation of incontinent care on 08/29/13 at 10:00 AM, Employee Identifier (EI) #6, a Certified Nursing Assistant, lowered RI #1's head of the bed to a flat position, while the resident's tube feeding pump was on and infusing at 55 cc/hr. During an interview on 08/29/13 at 5:50 PM, EI #6, a CNA, was asked should she have lowered the head of RI #1's bed while the resident's tube feeding was infusing. EI #6 said no and explained the tube feeding should be put on hold. When asked why, EI #6 said to keep the resident from potentially aspirating. EI #6 explained that she had asked a nurse to turn RI #1's tube feeding off but forgot to check to see if the tube feeing was off before she lowered the head of the bed. Chapter 44, Page 1018 and 1019 of "Fundamentals of Nursing Eighth Edition" with a copyright date of 2013, documented " ... Enteral Tube Feeding ... A serious complication associated with enteral feedings is aspiration ... Some of the common conditions that increase the risk of aspiration include ... lying flat ... ."

Based on record review and interviews, Employee Identifier (EI) #3, the Director of Social Service failed to ensure appropriate discharge planning, to include Durable Medical Equipment (DME), was made for Resident Identifier (RI) #11 prior to discharge from the facility. This affected RI #11, one of three residents sampled for discharge planning. Findings include: RI #11 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #11 was discharged from the facility on 03/20/13. RI #11's "Discharge Summary" dated 03/20/13 10:45 AM, indicated special instructions to flush the Foley catheter with 60 cubic centimeters (cc) of sterile water twice a day and as needed and change the Foley catheter every month and as needed. According to this document, the equipment needed included: a nebulizer, Foley catheter supplies, a wheelchair, oxygen concentrator with nasal cannula and a kangaroo pump (for tube feeding). This document further indicated RI #11 to have continuous oxygen at three liters per minute and Glucerna (tube feeding formula) 1.5 at 50cc for 23 hours via kangaroo pump and flush with 150cc of water every four hours. RI #11's physician order [REDACTED]." During an interview on 08/28/13 at 4:40 PM, EI #3, the Director of Social Service acknowledged that she was responsible for arranging discharge services for RI #11. EI #3 stated she usually would get the nurse to write an order for [REDACTED]. When asked if she followed up on RI #11's needed equipment, EI #3 said no. When asked why not, EI #3 stated she was informed that the home health agency was going to get the equipment. A telephone interview was conducted with the local Home Health Agency Nursing Supervisor (NS) on 08/29/13 at 8:36 AM. The NS acknowledged she was aware of RI #11's discharge referral information. The NS explained that RI #11 had been a patient of the company before but this discharge from the nursing home was different because RI #11 was now had a tube feeding, required a nebulizer and had a Foley catheter. The NS stated she called the nursing home back after a referral was received and spoke with EI #3 to ask EI #3 who would be the infusion company for RI #11's tube feeding. According to the NS, EI #3 told her that home health needed to set that up. The NS stated at that time she informed EI #3 that all those arrangements should be taken care of prior to RI #11 leaving the nursing home. According to the NS, EI #3 again informed her that the facility was not responsible for arranging those services, that would be the responsibility of the home health agency. A telephone interview was conducted on 08/29/13 at 12:30 PM with the Admissions Nurse (AN) for the local Home Health Agency. The AN acknowledged she visited RI #11 at home on 03/20/13 at 11:30 AM. The AN stated when she arrived at RI #11's home, the resident only had a walker and a portable oxygen tank. When asked who was responsible for making sure RI #11 had all the needed medical equipment and supplies when the resident was discharged from the nursing home, the AN said the nursing home that discharged RI #11. When asked who arranged for RI #11's durable medical equipment, the AN stated the home health agency had to call the doctor to get prescriptions for all the items RI #11 needed. When asked what adverse effect did all this have on RI #11, the AN explained comfort was the biggest thing because there was no hospital bed, there was a delay in RI #11's breathing treatment because there was no nebulizer. The AN further explained it could have been a big deal had the oxygen run out of the portable tank the resident had. The AN stated RI #11 never received an oxygen concentrator because the resident did not qualify. The AN stated the nursing home sent someone home on oxygen that didn't qualify for an oxygen concentrator. According to the AN, the facility should have faxed prescriptions for all the DME RI #11 would need so that the equipment would have been there when RI #11 was discharged from the nursing home. This deficiency was written as a result of the investigation of complaint/report number AL 679.

Based on observations, interview and record reviews, the facility failed to ensure Resident Identifier (RI) #5 and RI #13's catheter was in a privacy bag. This affected RI #5 and RI #13, two of three sampled residents reviewed for indwelling urinary catheters. Findings include: The facility's policy titled "Quality of Life-Dignity" with a revised date of October 2009, documented " ... 11. ... Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered ... ." 1) Resident Identifier (RI) #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 07/11/2013, identified RI #5 as having an indwelling catheter. During the initial tour on 08/27/13 beginning at 1:30 PM, with Employee Identifier (EI) #1, a Licensed Practical Nurse, RI #5's catheter was observed not in a privacy bag. In an interview on 08/27/13 at 5:00 PM, EI #1 was asked if RI #5's catheter was in a privacy bag during the initial tour. EI #1 said RI #5's catheter was not in a privacy bag. When asked what is the problem with RI #5's catheter not being in a privacy bag, EI #1 stated if the resident cared it might embarrass him or make him feel uncomfortable. 2) Resident Identifier (RI) #13 was admitted to the facility 07/03/13 with a [DIAGNOSES REDACTED]. The Minimum Data Set with an assessment reference date of 06/25/13, indicated RI #13 had an indwelling catheter. During the initial tour with Employee Identifier (EI) #1, a Licensed Practical Nurse, on 08/27/13 at 2:00 PM, RI #13's catheter was observed hanging on the side of the bed not in a privacy bag. In an interview on 08/27/13 at 5:00 PM, EI #1 was asked if RI #13's catheter was in a privacy bag during the initial tour. EI #1 said no. When asked what is the problem with RI #13's catheter not being in a privacy bag, EI #1 stated if the resident cared it might embarrass him or make him feel uncomfortable.

Based on observation, interview and record reviews, the facility failed to ensure Resident Identifier (RI) #5's catheter bag and tubing was not touching the floor. This affected RI #5, one of three sampled residents reviewed for indwelling urinary catheters. Findings include: The facility's policy titled "Catheter Care, Urinary" with a revised date of October 2010 documented " ... Infection Control ... 2. ... b. Be sure the catheter tubing and drainage bag are kept off the floor ... ." Resident Identifier (RI) #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an assessment reference date of 07/11/2013, identified RI #5 as having an indwelling catheter. During the initial tour on 08/27/13 beginning at 1:30 PM, with Employee Identifier (EI) #1, a Licensed Practical Nurse, RI #5's catheter bag and tubing was observed touching the floor. In an interview on 08/27/13 at 5:00 PM, EI #1 acknowledged RI #5's catheter bag and tubing was observed touching the floor. When asked what is the problem with RI #5's catheter bag and tubing touching the floor, EI #1 stated it could leak and urine could get on the floor; it could be an infection control issue.