Every finding on record at El Reposo Nursing Facility

Based on interviews, record reviews, the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, and the facility's investigative files, the facility failed to protect residents' right to be free from sexual perpetrated another other residents. On 02/24/2024, Certified Nursing Assistant (CNA) #8 entered Resident Identifier (RI) #40's room and saw RI #212 in the room leaned over RI #40 whose shirt was pulled up. RI #212's face near RI #40's breast. CNA #8 said it appeared that RI #212's mouth was on RI #40's breast. The residents were immediately separated, and redness was noted to RI #40's breast. It was determined the facility's noncompliance with one or more requirements of participation had cause, 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. On 07/03/2024 at 6:46 PM, the Administrator, the Director of Nursing/Director of Nursing Services, were provided the IJ template and notified of the findings at the immediate jeopardy level and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 600-Free from Abuse and Neglect. The IJ began on 02/24/2024 and conti ued until 03/01/2024 when the facility implemented corrective action to correct the identified deficient practice and prevent reoccurrence. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00047084. The survey team applied the reasonable person concept to determine scope and severity. Findings include: A review of the facility's policy titled, Compliance with reporting Allegations of Abuse/Neglect/Exploitation, with a revised date of 06/04/2021, revealed: . Compliance Guidelines: The facility must develop and operationalize policies and procedures for . protection of residents and for the prevention . The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. 4. Identification: The facility will identify events, occurrences, patterns and trends that may constitute: . b. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes . sexual abuse, physical abuse, . ii. Sexual Abuse is the non-consensual sexual contact of any type with a resident. iii. Physical Abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment. RI #40 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's Disease and Dementia. A Review of RI #40's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/2023, indicated RI #40's Brief Interview Mental Status (BIMS) was one of 15, which indicated the resident was severely cognitive impaired. RI #212 was admitted to the facility on [DATE] and had diagnoses that included Dementia. A Review of RI #212's Significant Change MDS with an ARD of 12/28/2024, indicated RI #212's BIMS was four of 15, which indicated the resident was severely cognitive impaired. The Alabama Department of Public Health Online Incident Reporting System Report dated 02/24/2024 at 3:02 PM, documented: . Narrative summary of incident: (RI #22) resident had (his/her) call light on and told (CNA #8), that (RI #212) had been in (RI #40)'s room for a long time with the door shut. Certified Nursing Assistant (CNA #8), . went across the hall as fast as she could and (RI #212) was leaned over (RI #40) and had (RI #40's) shirt pulled up with (his/her) mouth on (RI #40's) breast. (CNA #8) immediately yelled for (him/her) to stop . (CNA #10) and (CNA #8) immediately got (RI #212) out of the room. When (CNA #8) was walking down the hall with (RI #212), (He/she) stated, (He/She) was trying to get a good licking. (RI #40) looked scared. Abuse Coordinator informed. Both families, (Medical Director), (Administrator) and (Certified Registered Nurse Practitioner), with . Behavioral Health, and Ombudsman will be made aware . (local law enforcement) made aware. The undated facility's incident summary documented: . Allegation: On 02/24/2024, at approximately 2:00 PM, (CNA #8) opened (RI #40)'s door to find (RI #212) standing in front of (RI #40) who was sitting in (his/her) recliner. (RI #40)'s shirt was pulled up which exposed (his/her) breast. (RI #212) was bent over with (his/her) hands on the arms of (RI #40)'s recliner. CNA's view of scene was (RI #212)'s back side and (RI #40) facing her. From the view of CNA, it appeared that (RI #212) had (his/her) mouth on (RI #40)'s breast area. Immediate Action Taken: . (Licensed Practical Nurse (LPN) #6) performed skin assessment on (RI #40) and noted . a slightly small, reddened area on (his/her) right breast area. Conclusion of Investigation: After investigating the allegation, the abuse committee has concluded that (RI #212) was sexually inappropriate toward (RI #40) and therefore, sexual abuse was substantiated. The facility's investigative file included a handwritten and signed statement from CNA #8 that included: . (RI #212) was leaned over (RI #40) with (his/her) mouth on (RI #40's) breast . (RI #212) said he/she was trying to get a good licking. (RI #40) looked scared. On 07/03/2024 at 5:31 PM, RI #40 was observed in his/her room and an interview was attempted. RI #40 was non-interviewable. An interview was conducted with RI #22 on 07/03/2024 at 5:37 PM. RI #22 stated he/she pressed the call light to inform staff that RI #212 had went into RI #40's room. RI #22 stated he/she knew something was going on and knew RI #40 could not defend himself/herself. A telephone interview was conducted with CNA #8 on 07/03/2024 at 4:02 PM. CNA #8 stated she answered a call light from another resident who informed her that RI #212 had went into RI #40's room and closed the door. CNA #8 stated when she walked in the room, she saw RI #40 in the recliner and RI #212's hands were on RI #40's chair and RI #212 was leaned over RI #40 with his/her face close to RI #40's right breast. She stated she intervened and then removed RI #212 from room. CNA #8 stated RI #40 had his/her mouth open like he/she was in shock. She stated RI #212 stated he/she was trying to get a licking. CNA #8 stated a reasonable person in this situation would be scared. An interview was conducted with the Administrator on 07/03/2024 at 2:34 PM. The Administrator stated she was told that RI #212 was found in RI #40's room. RI #212 was bent over RI #40. RI #40's shirt was up. The Administrator stated RI #40 had a slight redness to the chest area like the skin had been touched. The Administrator stated the abuse committee concluded that RI #212 was sexually inappropriate with RI #40, therefore sexual abuse was substantiated. The Administrator stated RI #40 was not capable to give consent to sexual interactions and stated a reasonable person would feel fearful if this happened to him/her. A telephone interview was conducted with Registered Nurse (RN) #4 on 07/03/2024 at 3:08 PM. RN #4 stated CNA #8 told her what happened, and they escorted RI #212 out of the room and assessed RI #40. RN #4 stated RI #40 had a look of surprise on his/her face. RN #4 stated RI #40 had a reddened area on the top of the right breast. RN #4 stated a reasonable person would have been angry if this incident had happened to him/her. A telephone interview was conducted with RI #40's daughter. She stated that she was informed RI #212 came into RI #40's room and lifted RI #40's shirt and was thought to be kissing RI #40's breast, which startled RI #40. She stated RI #40 would have been frightened and scared if he/she did not have Dementia and was his/her normal self. ***************************************** The facility took immediate action following the incident that occurred on 02/24/2024 that included: CNA #8 immediately intervened and separated RI #212 and RI #40. RI #212 was placed on 1:1 until discharged to a Geri-psych facility on 02/28/2024. RI #40 was assessed for injury. A small, reddened area was noted on RI #40 's breast. The resident was assessed the following two days and no injury was noted. The abuse coordinator was notified, and incident reported to residents' family/sponsors, Medical Director, ADPH, ombudsman, and local law enforcement The facility investigated the incident and substantiated sexual abuse. On 02/27/2024 through 03/01/2024 all staff were educated on Abuse to include wandering residents and sexually inappropriate behaviors. On 02/29/2024 the QA Committee reviewed the incident. On 2/28/24, The facility began monitoring residents for signs of potential abuse by documenting each behavior exhibited and weekly subcommittee meetings to review all behaviors and interventions. Interventions were changed as needed. If something immediate arises, Administrator, Abuse coordinator, Medical Director is to be notified. ************************************** Upon review and verification of the information provided in the facility's corrective action plan, in-service/education records, Sub-Committee Meetings minutes and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 02/24/2024 to 03/01/2024, with on-going monitoring implemented; thus, immediate jeopardy past noncompliance was cited. **************************************

Based on observations, interviews and the facility's policy titled, Labeling and Dating Foods (Date Marking), the facility failed to ensure out of date food was discarded on 06/30/2024 during the initial kitchen observation. This had the potential to affect 57 of 57 residents receiving food from the kitchen. Findings include: A facility's policy titled, Labeling and Dating Foods (Date Marking), documented, . Procedure: . 2. Date marking for refrigerated storage food items . *Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines . 4. Prepared food or opened food items should be discarded when: *The food items does not have a specific manufactured expiration date and has been refrigerated for 7 days *The food items is leftover for more than 3 days *The food item is older than expiration date . On 06/30/2024 at 4:20 PM, an initial kitchen tour was conducted with the Dietary Manager (DM). An observation was made of a quart of buttermilk with a use by date of 06/29/2024, a Ziploc or re-sealable bag of bologna with a use by date of 06/29/2024, a Ziploc bag of Deli Turkey with a use by date of 06/27/2024 and a Ziploc bag of Deli Smoked Ham with a use by date of 06/29/2024 in the reach in cooler. During the initial kitchen tour conducted on 06/30/2024 at 4:20 PM, an interview was conducted with the DM. The DM stated the quart of buttermilk, Ziploc bags of bologna, Deli Turkey and Deli Smoked Ham, should have been discarded by the used by date on the label. The DM admitted these items should not have been in the cooler. The DM stated the concern of having these items in the cooler after the use by date was the items could be used when they were possibly unsafe.

Based on interview, record review, and review of a facility policy tilted Voting Policy and a facility document titled current registered voters, the facility failed to ensure Resident Identifier (RI) #12 and RI #21 were given the opportunity to vote in the (MONTH) 5, (YEAR) State Wide Election. This affected 2 of 8 registered voters in the facility. Findings Include: A review of an undated policy titled Voting Policy documented: .It is the policy of .to encourage all residents to exercise the right to vote while residing in the facility .Procedure: .3. During election periods, the Social Services Director will obtain absentee ballots for the residents interested . A review of a facility document titled current registered voters documented RI #12 and RI #21 were registered voters. On 6/12/18 at 10:00 a.m., a resident council meeting was held. During the meeting, residents reported they did not vote in the last election. 1) RI # 12 was readmitted to the facility on [DATE]. A review of RI # 12's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/18 documented a Brief Interview of Mental Status Score (BIMS) of 15, which indicated RI # 12 was cognitively intact. On 6/12/18 at 4:13 p.m., an interview was conducted with RI # 12. RI # 12 stated he/she was not asked if he/she wanted to vote in the (MONTH) 5, (YEAR) State Wide Election. RI # 12 stated he/she would have voted in the election if he/she had been asked. 2) RI #21 was readmitted to the facility on [DATE] A review of RI #21's most recent Quarterly MDS with an ARD of 4/22/18 documented a BIMS of 13, which indicated RI #21 was cognitively intact. On 6/12/18 at 4:21 p.m. RI # 21 was asked if he/she was allowed to vote in the (MONTH) 5, (YEAR) State Wide Election, he/she responded no. He/she was asked if he/ she would have wanted to vote in the (MONTH) 5, (YEAR) election, and he/she responded yes. An interview was conducted with Employee Identifier (EI) # 2, Social Services Director on 6/12/18 at 3:25 p.m. EI #2 stated there were 8 registered voters in the facility. EI # 2 stated the registered voters did not vote in the (MONTH) 5, (YEAR) State Wide Election. EI # 2 was asked if the residents were asked if they wanted to vote in the election. EI # 2 responded no, because it is not an election we normally participate in. EI # 2 stated the last election the residents were able to participate in was the (MONTH) (YEAR) presidential election. EI # 2 further stated we normally only participate in the presidential election. EI # 2 was asked if the residents should be able to participate in an election other than the presidential election. EI # 2 stated, yes, if they showed an interest. EI #2 was asked if she should ask residents if they want to vote if they are registered voters. EI #2 stated yes, she probably should have asked.

Based on medical record review, interview and review of a facility policy titled Comprehensive Care Plans, the facility failed to ensure a care plan was developed for an anticoagulant medication for Resident Identifier (RI) #16 and RI #22. This affected RI #16 and RI #22, two of 15 sampled residents reviewed for care plans. Findings Include: The facility policy, Comprehensive Care Plans dated 11/01/2017 documented: . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that are identified in the resident's comprehensive assessment . 1) RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2018, revealed the resident had received an anticoagulant medication in the last seven days or since admission. A review of RI #16's current Physician order [REDACTED].[MEDICATION NAME] 5 milligram (mg) . and 7.5 mg . by mouth at bedtime . On 06/12/2018 at 04:30 p.m., the Surveyor reviewed the care plans for RI #16. No care plan for an anticoagulant medication was found. On 06/12/18 at 05:29 p.m., an interview was conducted with Employee Identifier (EI) #1, a Registered Nurse/MDS and Care Plan Coordinator. EI # 1 was asked if RI #16 was on an anticoagulant medication. EI #1 stated yes. EI # 1 was asked if RI #16 had a care plan for an anticoagulant medication prior to 06/12/2018. EI #1 stated no. EI #1 was asked if RI #16 should have a care plan for an anticoagulant medication. EI #1 stated yes, and explained the care plan is so staff can take care of the residents, and would know what side effects to observe for, such as bleeding and bruising. 2) RI #22 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI # 22's most recent Quarterly MDS with an ARD of 4/15/18 revealed the resident had received an anticoagulant medication in the last seven days or since admission. A review of RI #22's (MONTH) (YEAR) Physician order [REDACTED]. 150MG(Milligrams) capsule Dose: (1 capsule/150mg) by mouth twice a day . First Date: 10/27/2017 For: [MEDICAL CONDITIONS] . On 6/12/18 at 4:30 p.m., a review of RI # 22's medical chart revealed no care plan for anticoagulant use. An interview was conducted with Employee Identifier (EI) # 1, RN/MDS Coordinator on 06/12/18 at 5:29 p.m EI # 1 stated RI # 22 was on an anticoagulant medication. EI # 1 stated there was no care plan for anticoagulant medication prior to 6/12/18. EI #1 stated there should have been a care plan for the use of the anticoagulant medication. EI # 1 further stated a care plan is needed so staff who cares for the resident would know what side effects to observe for, such as bleeding or bruising.

Based on observation and interview, the facility failed to ensure a notice of the availability of the previous three years of survey results was posted for residents and/or visitors. This had the potential to affect all 59 of 59 residents residing in the facility and any visitors. Findings Include: On 6/11/18 at 4:49 p.m., the survey result note book was observed in the front lobby of the facility. The notebooks contained results from the (MONTH) (YEAR) recertification survey and life safety survey. There was no notice posting the availability of the previous three years of survey results. Employee Identifier (EI) # 2, Social Service Director, was interviewed on 6/12/18 at 3:25 p.m. EI # 2 stated the survey results were posted in the front lobby. When asked what survey results were contained in the book, EI # 2 stated the (YEAR) Recertification and (YEAR) Life Safety Code Survey. When asked if there were any signs notifying residents or visitors of the availability of the previous three years survey reports, EI # 2 said no. EI # 2 further stated the sign should be available to let visitors and residents know three years of survey results were available for review.

Based on observations and interview, the facility failed to ensure Room Locator (RL) #1 was free of cracked paint. This deficient practice affected one of 16 rooms located on the 200 hall, one of three halls in the facility. The facility further failed to ensure RL #1 through RL # 7 did not have visible nails in the base of toilets without covers. This deficient practice affected five of six rooms located on the 300 hall, which is one of three halls in the facility. Findings Include: On 04/18//2017 and on 04/20/2017, observations were made of the following: RL #1: Bed B with crack in wall under window seal; Bathroom had bolts sticking up on the base of the toilet and not covered. RL #2: Bathroom had bolts sticking up on the base of the toilet and not covered. RL #3: Bathroom had bolts sticking up on the base of the toilet and not covered. RL #4: Bathroom had bolts sticking up on the base of the toilet and not covered. RL #5: Bathroom had bolts sticking up on the base of the toilet and not covered. RL #6: Bathroom had bolts sticking up on the base of the toilet and not covered. RL #7: Bathroom had bolts sticking up on the base of the toilet and not covered. On 04/20/2017, at 9:28 AM, the surveyor was accompanied by the Maintenance Supervisor, Employee Identifier (EI) #2. EI #2 accompanied the surveyor to observe and be made aware of the identified RL concerns. During the observation with EI #2 at 9:31 AM, EI #2 was asked how long were the bolts sticking up at the base of the toilets. EI #2 said one inch. On 04/20/2017 at 9:46 AM, an interview was conducted with EI #2. EI #2 was asked should one inch long bolts be sticking up on the sides of toilet bases. EI #2 replied, No. EI #2 was asked why should bolts be shortened and covered. EI #2 said to keep injuries down and they could be a potential hazard. EI #2 was asked why walls should be free of cracks. EI #2 replied, Appearance is the major thing. EI #2 was asked what was the potential harm in having one inch long bolts sticking up on base of toilets in resident bathrooms. EI #2 said it could be a trip hazard and a potential for cuts.

Based on observation, record review and interview the facility failed to ensure: 1. Two coffee thermos' stored in the pantry were free of a dust like substance. This was observed during the initial tour on 4/5/16; and 2. Staff serving meals in the dining room for supper on 4/5/16 did not wear the same gloves to serve multiple residents after touching non-food items. This affected 16 residents receiving supper meal in the dining rooms. Findings Include: A review of a facility policy dated 4/6/16, titled INFECTION CONTROL: CROSS-CONTAMINATION WITH GLOVES revealed .ASSESSMENT GUIDELINES: .TRANSFER OF POTENTIAL INFECTIOUS ORGANISMS FROM RESIDENT TO RESIDENT FROM TOUCHING RESIDENT, FOOD ITEMS, OR ANY OTHER SURFACE DURING MEAL TIME . 1. On 4/5/16 at 1:15 PM during the initial tour of the kitchen 2 coffee thermos' on the shelf in the pantry were noted with a dust like substance on them. Employee Identifier (EI) #3, Dietary Manager accompanying the surveyor was asked what was on the pots, she replied dust. On 4/6/16 at 4:40 PM during a later interview EI #3 was asked, what was the harm in the dust on the coffee thermos. EI #3 replied, they were considered dirty. 2. On 4/5/16 at 5:00 PM, the surveyor observed the dietary manager and other staff putting on gloves and serving the residents in the dining room. EI #3 was observed getting a tray and taking it to a resident sitting in the dining room, she would open the milk carton and then place straws in the cup and milk carton, then go back to the serving line to get another, while waiting EI #3 propped up placing her hand on the steam table glass then got another tray to serve, first putting on the resident's bib then opening the milk and placing a straw in the milk. Another staff was observed serving a resident's tray then propping up on another resident's wheelchair handle; then went to get another resident's tray to serve. This staff also opened the milk carton then opened straws placing one in the milk and one in the cup with the same gloves. On 4/6/16 at 4:40 PM an interview was conducted with EI #3, Dietary Manager. EI #3 was asked what was the protocol for serving trays. EI #3 replied, bring the tray to the dining table, do not use gloves unless you are to touch the food. EI #3 was asked if gloves should be worn to serve trays. EI #3 replied no, only if you were going to touch food. EI #3 asked if staff wore gloves when serving trays on 4/5/16; she replied yes. EI #3 was asked, what was the potential for harm in staff wearing gloves to serve multiple residents in the dining room, after touching trays, wheelchairs and bibs. EI #3 replied cross-contamination.

Based on observation, interview and record review the facility failed to ensure wound care technique was provided for Resident Identifier (RI) #5 in a manner to prevent the potential for infection; staff did not change gloves and wash hands after cleaning the wound before applying the ordered treatment. This affected one of two sampled residents observed for wound care. Findings Include: A review of facility policy titled WOUND CARE with a revised date 4/6/16 revealed PURPOSE: TO PROVIDE GUIDELINES FOR GOOD TECHNIQUE IN DOING WOUND CARE .9. CLEAN WOUND .11. REMOVE GLOVES AND PLACE IN BAG. 12. WASH HANDS AND APPLY CLEAN GLOVES 13. APPLY CLEAN DRESSING . On 4/6/16 at 9:50 AM an observation was made of Employee Identifier (EI) #1, Licensed Practical Nurse, performing wound care for RI #5. EI #1 washed hands applied gloves then removed soiled dressing, she then removed her gloves and washed her hands applied clean gloves then cleaned the wound with normal saline and 4 X 4 gauze, she then placed the Santyl, Calcium alginate and the outer covering with the same gloves she cleaned the wound with. On 4/6/16 at 10:20 AM an interview was conducted with EI #. EI #1 was asked, what was the protocol for cleaning a wound. EI #1 replied, take off the dirty dressing, then wash your hands put on new gloves clean the wound then change gloves again after washing hands. EI #1 was asked if she changed gloves after cleaning the wound. EI #1 replied no. EI #1 was asked, what was the potential for harm in not changing gloves. EI #1 replied the possibility of infection, in not changing gloves germs could get in the wound. On 4/6/16 at 4:20 PM an interview was conducted with EI #2 Registered Nurse, Infection Control. EI #2 was asked, when should gloves be changed during wound care. EI #2 replied between clean and dirty and anytime gloves become soiled, she went on to say gloves should be changed after cleaning the wound and before the treatment is placed. EI #2 was asked if it would be an acceptable practice for the nurse to clean the wound then with the same gloves place the ordered treatment. EI #2 replied no. EI #2 was asked, what was the potential for harm if staff used the same gloves to clean a wound then place the treatment. EI #2 replied what you cleaned off could be on the gloves then get into the wound.

Based on observation, record review and interview the facility failed to ensure staff did not feed Resident Identifier (RI)# 's 11 and 12 at the same time and touch non-food items and then food items with the same gloves. This was observed on 4/6/16 during the breakfast meal, and affected two of two sampled residents requiring assistance with meals. Findings Include: A review of facility policy titled CROSS-CONTAMINATION WITH GLOVES with an effective date of 4/6/16 revealed .5. IF FEEDING MORE THAN ONE RESIDENT, CARE MUST BE TAKEN TO PREVENT CROSS-CONTAMINATION BY SANITIZING HANDS AND PROPER USE OF GLOVES . RI #11 was admitted to the facility 3/11/14 with a [DIAGNOSES REDACTED]. RI #12 was readmitted to the facility 6/27/14 with a [DIAGNOSES REDACTED]. On 4/6/16 at 7:45 AM, Employee Identifier (EI) #4, Certified Nursing Assistant, was observed feeding RI# 11 and 12 the breakfast meal. EI #4 was observed with gloves on feeding RI #11 and picking up the bib to wipe RI #11's mouth, EI #4 then turns to RI #12 picking up the cup and touching the straw to aid RI #12 to drink water. EI #4 removed her gloves to get RI #12 another cup of water, she then put on clean gloves and placed a straw in RI #12's cup then turned back to assist RI #11 by spooning food into his/her mouth. EI #4 then turns back to RI #12 picking up the spoon to offer more food and then picks up RI #12's cup touching the straw to offer more water. EI #4 then turns back to RI #11 to offer more food. EI #4 then picks up the milk cup and touches the straw to give RI #11 more milk. On 4/6/16 at 10:20 AM an interview was conducted with EI #4. EI #4 was asked, what was the feeding protocol. EI #4 replied she was not sure, they just feed. EI #4 was asked, what was the protocol for using gloves during feeding. EI #4 replied, use gloves only when going to touch food. EI #4 was asked when feeding two residents at the same time should you touch the bib of one then turn to the other and handle the cup and straw then turn back to the first resident and touch the cup and straw with those same gloves. EI #4 replied no. EI #4 was asked, what was the potential for harm in touching items of both residents with the same gloves. EI #4 stated, I could transfer germs . On 4/6/16 at 4:20 PM an interview was conducted with EI #2, Registered Nurse, Infection Control. EI #2 was asked if staff should feed two residents at the same time, she replied not if going to cross contaminate. EI #2 was asked, should gloves be worn during feeding residents. EI #2 replied if they were to be touching their food. EI #2 was asked, what was the potential for harm in a staff person feeding two residents at the same time. EI#2 replied cross contamination.

Based on observation, interview, and record review the facility failed to ensure that licensed staff maintained the privacy of RI (Resident Identifier) #12's MAR (Medication Administration Record) during medication pass on 4/23/14. This affected one of three residents observed during medication pass. Findings included: A review of the facility's policy and procedure "Confidentiality of Information" with a revised date of December 2006 revealed "...Policy Statement Our facility shall treat all resident information confidentially...Policy Interpretation and Implementation 1. The facility will safeguard all resident records, whether medical...or social in nature, to protect the confidentiality of the information..." RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/2/2014 revealed that RI #12 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated that RI #12 was cognitively intact for daily decision making. On 4/23/2014 at 8:10 AM, EI (Employee Identifier) #2, LPN (Licensed Practical Nurse) was observed during medication pass preparing medications for RI #12. EI #2 walked away from the medication cart to obtain a medication, leaving the medication cart unattended and information on the MAR uncovered and exposed to residents and staff in the hallway. While the cart was unattended and information was exposed one resident sat in front of the cart in her wheelchair while two staff members passed by the cart. EI #2 returned to the medication cart to finish preparing the medication for RI #12. EI #2 entered RI #12's room at 8:20AM leaving the medication cart unattended and information on the MAR uncovered and exposed to residents and staff in hallway. One resident stood in the hallway beside the cart with RI #12's information exposed. On 4/23/2014 at 2:10 PM an interview was conducted with EI #2. EI #2 was asked what was the facilities policy and procedure on covering the MAR indicated [REDACTED]. EI #2 was asked why did you not cover the MAR indicated [REDACTED]. EI #2 stated she was probably distracted with everyone walking by. EI #2 was asked what is the potential for harm in leaving the MAR indicated [REDACTED]. EI #2 stated, "Privacy". On 4/23/2014 at 10:40 AM an interview was conducted with EI #4, DON (Director of Nursing). EI #4 was asked what was the facility's policy and procedure for confidentiality of records. EI #4 stated to always maintain security of records. EI #4 was asked should the MAR be left unattended and uncovered. EI #4 stated, "no". EI #4 was asked what is the harm if they are left unattended and uncovered. EI #4 stated, "privacy issue and HIPPA (Health Insurance Portability and Protection Act) issue."

Based on observation, interview, and record review the facility failed to maintain RI (Resident Identifier) #9's O2 (oxygen) concentrator filter free of an accumulation of dust. This was observed on three of three days of the survey. The facility further failed to ensure RI #6's O2 concentrator had a filter. This was observed on three of three days of the survey. This affected 2 of 3 residents receiving O2 therapy. Findings included: A review of the facility policy and procedure "USE OF OXYGEN" dated 2007 revealed "PURPOSE: To promote resident safety in administering oxygen. POLICY: ...IX. Routine equipment inspection and maintenance should be performed based on manufacturer's recommendations..." A review of the "Operator's Manual...Oxygen Concentrators Standard...", provided by the facility, revealed on page 29, "...Routine Maintenance...1. Remove each filter and clean at least once a week depending on environmental conditions..." 1.) RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/16/2014 revealed that RI #9 had severely impaired daily decision making ability. On 4/22/2014 at 2:15 PM during the initial tour, an observation was made of RI #9 receiving O2 at 2 L/M (liters per minute) by concentrator. RI #9's concentrator filter was observed with an accumulation of a gray substance. On 4/22/2014 at 4:35 PM an observation was made of RI #9 receiving O2 at 2 L/M by concentrator. RI #9's concentrator filter was observed with an accumulation of a gray substance. On 4/23/2014 at 9:00 AM an observation was made of RI #9 receiving O2 at 2 L/M by concentrator. RI #9's concentrator filter was observed with an accumulation of a gray substance. On 4/24/2014 at 9:45 AM an observation was made of RI #9 receiving O2 at 2 L/M by concentrator. RI #9's concentrator filter was observed with an accumulation of a gray substance. On 4/24/2014 at 10:05 AM an interview was conducted with EI (Employee Identifier) #1, LPN (Licensed Practical Nurse). EI #1 was asked who was responsible for cleaning O2 concentrators and filters. EI #1 stated that the night shift was responsible. EI #1 was asked how often were the filters changed or cleaned. EI #1 stated "Every two weeks." EI #1 was asked to describe what she saw on RI #9's O2 filter. EI #1 stated there was dust on the filter. EI #1 was asked how long it would take for that amount of dust to accumulate on the filter. EI #1 stated that it would take about two weeks. EI #1 was asked what would be the harm in dust accumulation on an O2 concentrator filter. EI #1 stated that it may cause the concentrator to overheat. 2.) RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent quarterly MDS with a ARD of 2/12/2014 revealed that RI #6's BIMS (Brief Interview For Mental Status) score was a 14 which indicated RI #6 was cognitively intact for daily decision making. The MDS further revealed that RI #6 received O2 therapy. On 4/22/2014 at 2:35 PM, during the initial tour, an observation was made of RI #6 receiving O2 at 2 L/M by concentrator. RI #6's O2 concentrator filter was missing from the back of the concentrator. On 4/22/2014 at 4:35 PM an observation was made of RI #6 receiving 02 at 2 L/M by concentrator. RI #6's O2 concentrator filter was missing from the back of the concentrator. On 4/23/2014 at 9:00 AM an observation was made of RI #6 receiving O2 at 2 L/M by concentrator. RI #6's O2 concentrator filter was missing from the back of the concentrator. On 4/24/2014 at 9:50 AM an observation was made of RI #6 receiving O2 at 2 L/M by concentrator. RI #6's O2 concentrator filter was missing from the back of the concentrator. On 4/24/2014 at 10:15 AM an interview was conducted with EI #5, LPN. EI #5 was asked who was responsible for monitoring O2 concentrators and filters. EI #5 stated that the charge nurses on the night shift were responsible. EI #5 was asked what should have been on the back of the concentrator. EI #5 stated that there should have been a filter. EI #5 was asked why was there not a filter. EI #5 stated that there is supposed to be a filter. EI #5 was asked what was the potential harm in having no filter on the concentrator. EI #5 stated there is a potential for infection, air needs to be filtered. On 4/24/2014 at 10:30 AM an interview was conducted with EI #4, DON (Director of Nursing). EI #4 was asked who is responsible for monitoring and maintaining O2 concentrators and filters. EI #4 stated maintenance and nurses are responsible. EI #4 was asked should there have been a filter on RI #6 O2 concentrator. EI #4 stated, "Yes". EI #4 was asked what was the potential for harm if there was no filter. EI #4 stated, "Not filtering air, infection." .

Based on observation, interview, and record review the facility failed to ensure licensed staff washed their hands during wound care in a manner to prevent cross contamination. This affected one of one observation of wound care. Findings included: A review of the facility policy and procedure "HAND HYGIENE" dated 2007 revealed "PURPOSE: To decrease the risk of transmission of infection by appropriate hand hygiene. POLICY: Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections..." A review of the facility policy and procedure "WOUND CARE" with an effective date of 3/31/2014 revealed "...PURPOSE: To provide guidelines for good technique in doing wound care...PROCEDURE: ...8. Wash hands. Put on gloves. 9. Clean the wound...11. Remove gloves...12. Put on clean gloves..." RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most recent significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/13/2014 revealed that RI #4's BIMS (Brief Interview for Mental Status) score was a 6 which indicated that RI #4 was severely cognitively impaired for daily decision making. On 4/23/2014 at 9:35 AM, EI #2, LPN (Licensed Practical Nurse) was observed providing wound care to RI #4. EI #2 put on a pair of gloves and cleaned RI #4's open abdominal wound and then dressed and taped the wound while holding the roll of tape in her gloved hand, without washing her hands or changing gloves. EI #2 then placed the roll of tape on the supply barrier. Then while wearing the same gloves EI #2 pulled up and fastened RI #4's brief, pulled up her pants and pulled down her shirt. EI #2 then removed her gloves and pulled up the covers for RI #4. EI #2 then washed her hands. On 4/23/2014 at 2:10 PM an interview was conducted with EI #2. EI #2 was asked what was the facilities policy and procedure for handwashing during wound care. EI #2 stated that you should wash your hands after taking off the dirty dressing and after cleaning the wound. EI #2 was asked why did you not wash your hands before wound care. EI #2 stated that she had probably washed her hands before going into the room. EI #2 was asked why did you not wash your hands after you cleaned the wound. EI #2 stated that she washed her hands and put on clean gloves after she removed the dressing. EI #2 was asked if she should have washed her hands after she cleaned the wound before applying the clean dressing. EI #2 stated yes. EI #2 was asked what was the potential harm in not washing hands before wound care and after cleaning the wound. EI #2 stated it could cause infection. On 4/24/2014 at 10:45 AM an interview was conducted with EI #4, DON (Director of Nursing). EI #4 was asked what is the facilty's policy and procedures on handwashing. EI #4 stated to always handwash before any procedure . EI #4 was asked when should you wash hands during wound care. EI #4 stated hands should be washed before and after wound care and after cleaning a wound. EI #4 was asked what is the potential for harm if hands are not washed. EI #4 stated infection.