Every finding on record at PruittHealth - Toomsboro

Based on observation, staff and resident interviews, record review, and policy review, the facility failed to provide adequate supervision and implement appropriate safety measures to ensure residents remain free from preventable accidents and hazards for three residents (Resident (R) 49, R60, and R52) reviewed for accidents of 34 sample residents. Actual harm was identified to have occurred on July 26, 2026, when one Certified Nurse Aide (CNA) transferred R49 using a mechanical lift unassisted, resulting in the bar of the lift striking R49's forehead, causing a head laceration which required skin glue and wound closure strips. Additionally, the facility failed to ensure measures to prevent elopement for one of one resident (R60) reviewed for elopement risk, and failed to ensure safe transport of one resident (R52) reviewed for transfers in a reclining chair. Findings include: Review of the facility's policy titled, Training on Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 01/11/2024, read, in part, .providers should have mandatory ongoing in-service training related to prevention of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property at least annually. Among the topics that might be covered are the following.Age specific and/or population specific training. One of the topics listed was rehabilitative and restorative care. Review of the undated reclining chair manufacturer assembly/instruction guide, provided by the facility, read, in part, .Operation of recliner with missing or broken footrest or recline mechanism guards may result in bodily injury. 1. Review of R49's Face Sheet located under the Resident tab of the electronic medical record (EMR) noted the resident was admitted on [DATE] with diagnoses of reduced mobility, unsteady on feet, type two diabetes with complications, and obesity. Review of R49's quarterly Minimum Data Set (MDS) located under the RAI [Resident Assessment Instrument] tab of the EMR with an Assessment Reference Date (ARD) of 07/09/2026 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R49 was cognitively intact and was dependent for transfers from bed to chair. Review of R49's Care Plan located under the RAI tab of the EMR, dated 07/27/2026, revealed the resident needed assistance with transfers and required three people to assist with the mechanical lift at all times. During an observation and interview on 07/27/2026 at 11:05 AM, R49 was observed with wound closure strips at the top of her forehead near her hairline. When asked what happened, R49 said she was getting in her wheelchair, wasn't positioned correctly, and the lift flipped up on two wheels and hit her in the head. R49 stated only one person was doing the transfer, and the other staff member had not made it to her room yet to help. R49 said they used glue at the hospital instead of stitches. Review of R49's Progress Notes located under the Progress Notes tab of the EMR, dated 07/26/26 at 11:00 AM, revealed Writer was called to resident's room. Writer immediately enters room and observes resident sitting upright in wheelchair with total lift pad under resident with straps placed in total lift. Total lift machine was turned slightly onto the left side. CNA [Certified Nursing Assistant] is behind resident holding the bar to total lift machine above resident's face. CNA states that the total lift machine fell to the left after resident was seated in the wheelchair. CNA also reports that the bar holding the total lift pad straps did hit resident on the top of the forehead at resident's hairline. Small laceration, approximately two inches in length, observed at resident's hairline in center of forehead. Blood observed coming from laceration. Writer and CNA lowered the bar with the remote and was able to remove straps and place total lift back level onto the floor. Writer cleaned laceration with normal saline and placed pressure dressing around laceration. Resident remains awake, alert, oriented times four. Pupils equal and reactive. Resident complains of pain, rates two out of 10 to forehead. Resident describes pain as pressure pain. Hand grips equal and strong. Vitals: blood pressure (BP) 183/77 P [pulse] 59 respirations (R) 16 temperature (T) 98.2 Oxygen saturation: 95% room air. Writer exits room to notify (Medical Director) MD. Registered Nurse (RN) supervisor and other staff in room with resident; 07/26/26 at 11:25 AM, MD notified and a new order to send R49 to the emergency room (ER) for evaluation and treatment due to laceration/ head trauma; 07/26/26 at 12:05 PM, R49 was transferred to the hospital by ambulance; 07/27/28 [SIC] at 12:48 AM, R49 returned to the facility by ambulance. Review of R49's hospital paperwork, provided by the facility and dated 07/26/2026, revealed the resident was transported to the emergency room by ambulance for an evaluation of a head laceration. The document noted, The patient states that she slipped out of a [name of mechanical lift] lift and struck her frontal scalp on the bar. Resident had [name of wound glue] and [name of wound closure strips] strips applied to her scalp. Review of Witness Statement, provided by the facility by Licensed Practical Nurse Charge Nurse (LPNCN) 2, dated 07/26/2026, noted On 07/26/2025 at 11: AM: Writer was called to resident's room. Writer immediately enters room and observes resident sitting upright in wheelchair with total lift pad under resident with straps placed in total lift. Total lift machine is turned slightly onto the left side. CNA is behind resident holding the bar to total lift machine above resident's face. CNA states that the total lift machine fell to the left after resident was seated in the wheelchair. CNA also reports that the bar holding the total lift pad straps did hit resident on the top of the forehead at resident's hairline. Small laceration, approximately two inches in length. observed at resident's hairline in center of forehead. Blood observed coming from laceration. Writer and CNA lowered the bar with the remote and was able to remove straps and place total lift back level onto the floor. Writer cleaned laceration with normal saline and placed a pressure dressing around laceration. Resident remains awake, alert, oriented time four. Pupils equal and reactive. Resident complains of pain, rates two out of 10 to forehead. Resident describes pain as pressure pain. Hand grips equal and strong. On 07/26/26 at 11:15AM: Writer notifies MD of resident's status and vitals. New order: Send to ER for evaluation and treatment; On 07/26/26 at 11:25 AM: 911 called. Emergency Medical Services (EMS) in route to facility; On 07/26/26 at 11:30 AM: Writer notifies resident's [Family Member (FM) 1] of resident's status and order to send to ER. Resident's [FM1] requests that resident be sent to hospital; On 07/26/26 at 11:45 AM: Writer called and gave report to RN at the hospital. On 07/26/26 at 12:05 PM: Resident Leave of Absence (LOA) to hospital via stretcher per ambulance times two EMS staff. Resident transferred to stretcher via mechanical total lift with assist from staff times two and EMS. Resident has remained awake, alert, oriented times four. Pressure dressing remains clean/dry/intact. Bleeding is controlled and not coming through the pressure dressing. Review of Witness Statement Form, provided by the facility, dated 07/26/2026 and written by CNA2 revealed CNA2 stated, I, [CNA2] was transferring [R49] from her bed to her wheelchair with the [name of mechanical lift] lift. While sitting [R49] in the wheelchair, the lift tilted, causing the lift to bump [R49's] forehead. I called for help. Review of R49's Witness Statement Form, dated 07/27/2026 and provided by the facility, noted R49's statement, She had me on the lift and it looks like the lift just went one sided. I didn't fall; I just went down in the chair. She was doing everything right. I was one sided in the chair and needed to shift to straighten up in the chair. Review of Statement provided by the facility, dated 07/27/2026 and written by the Director of Nursing (DON), revealed I returned a call to [LPNCN2] on 07/26/26 due to a missed call from her. [LPNCN2] informed me of the incident involving [R49] and [CNA2]. I then spoke with [CNA2] and asked her what happened. She then stated she was lowering [R49] into her wheelchair, when she got her in the wheelchair the lift tilted over and the lift bar made contact with [R49's] forehead. [CNA2] stated she called for help and held the bar off [R49's] head until help arrived [LPNCN2]. [CNA2] did agree that she did not have assistance with the transfer at the time of the occurrence. I directed [CNA2] to write a statement and then go home. [LPNCN2] obtained orders to refer [R49] to the ER for further evaluation. Review of R49's Lift Observation, provided by the facility and dated 07/27/2027 2026, revealed the resident was non-ambulatory, could not stand or pivot without assistance, bedfast and required total mechanical lift. Review of the undated Root Cause Analysis Tool: Five Whys form, provided by the facility, noted Root Cause(s): 1. CNA did not follow requirement for two people at all times when using mechanical lift. Review of Inservice Education Program Attendance Record Form- Skills Fair CNA [Certified Nurse Assistant] Mechanical lifts- Transfer bed-chair, chair- bed (2- person), provided by the facility dated 09/18/2025-09/19/2025, noted 3. Ask another co-worker for help with the transfer (must have two persons with mechanical lifts). The document revealed CNA2 signed and dated the document on 09/19/2025. Review of CNA2's Skill Competency Checklist Form: CNA Annual, provided by the facility and dated 09/19/2025, revealed the CNA completed the mechanical lift competency. Review of the facility's undated Annual Skills Fair 2025 CNA provided by the facility revealed CNA2 completed mechanical lifts/ bed-chair transfer/ chair-bed transfer. During an interview on 07/29/2026 at 1:57 PM, LPNCN2 stated, The lift used was the total lift. I walked in and the lift was turned to the left up on one side of the legs. The legs were open just enough to go around the wheelchair. The resident was seated in the wheelchair seat when aide yelled for me and was holding the lift bar away from the resident's face. I had to pick the remote up off the floor to break the tension. A male aide came in and helped get the pressure off. I saw a trickle of blood and cleaned and dressed it with pressure dressing. The aide was asked why she was in the room alone using the lift and she said she didn't know. During an interview on 07/29/2026 at 1:54 PM, the DON confirmed the CNA was transferring R49 by herself and the facility policy was two staff when using the mechanical lift for safety. Review of the facility's policy titled, Clinical Procedures: Transfers with Mechanical Lift with a copyright date of 2025, noted Pre-Procedure: Before caring for a person review your organization's policies and procedures.Procedure: At least two staff members are needed to operate a mechanical lift.To use the lift.One person moves the lift while the other person supports the individual's legs.One person lowers the individual slowly into the chair while the other person guides the individual into the chair for proper body alignment. 2. Review of R60's undated Face Sheet located in the EMR under the Face Sheet tab showed a facility admission date of 03/30/2026 and a re-admission date of 07/20/2026 with medical diagnoses that included generalized anxiety disorder, dementia, and bipolar disorder. Review of R60's quarterly MDS with an ARD of 06/22/2026 and located in the resident's EMR under the MDS tab revealed R60 had a BIMS score of nine out of 15, which indicated the resident was moderately cognitively impaired. Review of R60's Elopement Risk Evaluation located in the EMR under the Observation tab, with an unknown date, revealed R60 had a score of 11, placing her at high risk for elopement. Review of R60's Progress Note, dated 07/11/2026 and located in the EMR under the Progress Notes tab, revealed Around about 2:10 PM, a call was received from the Social Services Director (SSD) are y'all aware that R60 is wheeling himself to the store.Writer immediately left and observed R60 sitting in his wheelchair with a pack of cigarettes and lighter. During an interview on 07/27/2026 at 10:54 AM, R60 stated, I left the facility without telling anyone and used my wheelchair to go to the store. I won't do it again. During an interview on 07/29/2026 at 4:20 PM, the DON stated, [R60] left the property to go to the store to get something and then return. Review of the camera footage revealed [R60] leaving the facility property from the front porch without informing staff. This was about 1:30 PM, we received a phone call about him and a staff member went down to the store to get him. The store is about one to two minutes away. [R60] has never had any exit-seeking behaviors. He was gone for about 20 minutes. During an interview on 07/30/2026 at 2:25 PM, the Administrator stated, I expect all of our residents to be safe. Those residents who may elope have their information kept in the Elopement Book; it has their picture and information in it. Our front door is secure, and a code or buzzer is needed to go in or out. Residents who are not a risk for elopement can go outside without supervision if they are at risk for elopement then they must be supervised. [R60] was allowed to go outside without supervision but since his incident his information and his picture are now in the elopement book, and he is required to be supervised when he goes outside. He never demonstrated exit seeking behaviors before the incident and has not exhibited any exit seeking behaviors since. During an interview on 07/30/2026 at 2:25 PM, the Administrator stated, We do not have a policy specifically for elopement. 3. Review of R52's Face Sheet, located under the Printable Face Sheet tab of the EMR, revealed R52 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Diagnoses included, but were not limited to, acute kidney failure, reduced mobility, abnormal posture, lack of coordination, unsteadiness on feet, and difficulty in walking. Review of R52's quarterly MDS located under the MDS tab of the EMR with an ARD of 06/11/2026, revealed a BIMS score of 14 out of 15 which was indicative of intact cognition. The MDS reflected R52 did not exhibit any behavioral symptoms during the 7-day look-back from the assessment date. The MDS reflected R52 required partial or moderate assist to move from a seated position to standing. Record review of R-52's Care Plan located under the Care Plan tab of the EMR, dated 10/17/25, revealed he exhibited impaired physical mobility. The most recent 'approach' reflected R52 was to use assistive devices as ordered. The Care Plan did not specifically address the use of a reclining chair. Record review of R-52's Occupational Therapy (OT) Evaluation and Plan of Therapy, provided by the facility and dated 07/07/2026, revealed he was to receive OT four times per week. One Goal was to safely propel a wheelchair. The Plan did not reflect use of a reclining chair. The Plan read, in part, .Pt [patient] presented coordination, strength, mobility and activity deficits which limits independence during self care ADLs [Activities of Daily Living] . The Plan reflected R52 was dependent on staff for transfers. The Mobility Function Score (range 0-12, with 12 being the highest function) reflected a score of '1.' The Assessment Summary section read, in part, . Patient presents with impairments in balance, dexterity, fine motor coordination, mobility, sensation, strength, attention. Observation and interview on 07/27/2026 at 10:15 AM revealed R52 was in a reclining chair, which was being pushed by an Occupational Therapy Assistant (OTA). Observation revealed the back of the reclining chair was reclined to approximately 45 degrees. The leg supports were not extended. R52 was holding both of his legs in an extended position. While the reclining chair was in a forward motion, R52's right leg dropped, causing his right foot to contact the floor. R52's shoe gripped the floor, causing his foot to roll awkwardly. R52 screamed loudly. OTA stopped propelling the reclining chair. Interview with OTA at that time revealed that she said R52 had been having pain in his right knee. She said R52 was holding his leg up but let it drop. She said she had brought R52 from his room, which was on the adjacent hall. OTA said when the resident was in the reclining chair in his room, she was unable to extend the leg supports .so I brought him like this. R52 did not complain of pain at that time. Continuous observation on 07/27/2026 at 10:18 AM revealed OTA instructed R52 to raise his legs up and began pushing the reclining chair. Out of concern for R 52's safety, the Surveyor asked OTA to stop. Licensed Practical Nurse/Unit Manager (LPN/UM) approached the reclining chair and lifted R52's legs while OTA adjusted the lever to extend the leg supports. Both staff confirmed the reclining chair was functioning correctly. During an interview on 07/27/2026 at 10:19 AM, LPN/UM said if R52 was complaining of leg pain, the leg support should have been extended. During an interview on 07/27/2026 at 10:58 AM, LPN/UM said His [R52] leg could have gone under and caused some issues with his foot. Observation and interview on 07/27/2026 at 12:55 PM revealed R52 was lying in his bed. He was awake and alert. He said sometimes the staff would extend the leg supports on the reclining chair, and sometimes they would not. R52 said, Today my legs folded under me, and it hurt. During an interview on 07/29/2026 at 09:15 AM, the DON said that if a resident was having pain, a nurse should assess the resident. The DON said the leg supports should be extended. At 9:26 AM, the DON said the facility did not have a policy regarding use of reclining chairs. At 9:31 AM, the DON said there had not been an in-service regarding the use of reclining chairs. During an interview on 07/29/2026 at 10:27 AM, the Therapy Outcomes Coordinator (TOC) said the OTA training program included positioning, which covered use of the reclining chairs. She said that, at times, it can be normal not to have leg support extended for R52. She said if a resident needed to put their foot down, they should say 'Stop.' TOC said OTA should have extended the leg support if R52 complained of pain. TOC said not extending the leg support could result in injury to the resident. Review of an in-service training, dated 07/27/2026 and provided by the facility, revealed therapy staff were to stop what they were doing if a resident complained of pain. OTA was included in the in-service. During an interview on 07/30/2026 at 12:30 PM, the TOC said the in-service included safe use of the reclining chair.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots and pans and to ensure they were clean prior to storage for one of one kitchen. This failure increased the risk of foodborne illness by allowing wet pots and pans to be stored before fully drying. This had the potential to affect 50 of the 54 residents receiving dietary services. Findings include:Review of the facility's policy titled, Pot/Pan Washing and Sanitation, dated 10/20/25, revealed Policy Statement: It is the policy of [Name] that equipment and utensils are cleaned and sanitized appropriately after use to maintain a clean and sanitary environment for food preparation to maintain a clean and sanitary environment to prepare patient/resident meals. Scope: This applies to all dietary partners employed by [Name]. Procedure: 1. A three compartment sink is used for manual washing, rinsing, and sanitizing (a four-compartment sink allows a compartment for pre-soaking) of utensils, pots, pans, and all other items to be hand-washed.Air dry pots and pans on the drain board. Never use a dish towel. Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area. Keep pots and pans area clean and free of clutter.During an observation and interview on 07/27/2026 at 8:50 AM, the Dietary Manager (DM) confirmed four pans, six inches by 18 inches by four inches; three pans, six inches by 12 inches by four inches; one pan, 18 inches by 24 inches by one inch; one pan six inches by six inches by six inches that had been cleaned and stacked for use, were still wet. The pans had been stacked while still wet and were not given adequate time to air-dry before stacking. The DM stated, They [pans] should have been air-dried before they were stacked, they were wet nested and that can lead to bacteria on the pans.During an observation and interview on 07/27/2026 at 8:56 AM, the DM confirmed a set of tongs that were hanging for use still had food residue stuck to one side. The DM stated, That's supposed to be clean, and it still has food on it.

Based on staff interview and record review, the facility failed to ensure that the resident and/or Resident Representative (RR) received a written notice of transfer and a written bed hold notice that included all the required information for one of two residents (Resident (R) 1) reviewed for an initiated emergent transfer to the hospital of 34 sample residents. This failure had the potential to affect the resident and their RR by not having knowledge of where and why the resident was transferred and/or how to appeal the transfer, if desired, and by contributing to the possibility of denial of readmission and loss of the resident's home following a hospitalization.Findings include:Review of R1's discharge return anticipated Minimum Data Set (MDS) located under the RAI [Resident Assessment Instrument] tab in the electronic medical record (EMR) revealed an Assessment Reference Date (ARD) of 06/02/2026.Review of R1's Progress Notes (located under the Progress Notes tab of the EMR), dated 06/02/2026 at 6:52 PM, revealed the resident was transported to the emergency room (ER). Progress Note, dated 06/02/2026 at 6:07 PM, revealed the resident was admitted for diverticulitis and acute kidney injury (AKI). Progress Note, dated 06/05/2026 at 6:25 PM, confirmed the resident was readmitted back to the facility from the hospital.Review of R1's EMR revealed no documentation that R1 or the RR was provided with the transfer notice or bed hold policy for the hospital transfer, dated 06/02/2026.During an interview on 07/29/2026 at 11:35 AM, the Financial Counselor stated, The nurses normally send the notices with the resident to the hospital, and I mail them to the resident representative. I must've missed that one. She confirmed she should have sent the transfer and bed hold notices, and she confirmed the residents and/or representative must be notified in case they need to pay private pay for the room.

Based on staff interviews, record review, and review of the facility policy titled, Monitoring of Antipsychotics, the facility failed to ensure that psychotropic medications were not ordered as needed (PRN) beyond 14 days and failed to document the reason for the extension or the period during which the extended order should be in effect for one of six residents (R) (R#17) reviewed for unnecessary medications. This failure had the potential for residents to experience excessive use and duration of psychotropic medication. Findings include: A review of the facility policy, Monitoring of Antipsychotics, revised [DATE], revealed as needed (PRN) orders for antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. All PRN antipsychotic orders will be automatically stopped after 14 days. A review of the medical record for R#17 revealed a past medical history not inclusive of dementia without behavioral disturbances, and medical non-compliance. A review of the physician orders dated [DATE] revealed R#17 was prescribed lorazepam 2 Milligram (mg)/ Milliliter (mL), to give 0.5 mg via Intravenous (IV) once per day, as needed (PRN). A review of the Consultant Pharmacist Communication to Physician form, dated [DATE], revealed the following: RE: Resident has a PRN order for Lorazepam [Lorazepam INJ (injection) 2 mg/mL] According to the new CMS (Centers for Medicare and Medicaid) Mega rule (which goes into effect [DATE].2017). Residents are not to receive PRN orders for psychotropic drugs unless the drug is intended to treat a condition that is documented in the clinical record. PRN orders are limited to 14 days, unless the provider believes it is appropriate to extend the orders beyond 14 days and documents this in the clinical record. Please evaluate the current order: Resident is doing well on current order - May attach a 6 month stop date. MD Response: Neither box (I agree, or other) was checked. They physician/practitioner signed the order on [DATE]. Interview on [DATE] at 2:16 p.m. with the Director of Nursing (DON) confirmed R#17 had no end date for the as PRN order for Lorazepam. The DON explained the pharmacist was supposed to audit all medications and ensure end dates were within 14 days for all PRN psychotropic medications. The DON added that some residents had special orders to extend the medication end date. She further revealed R#17 had a special order for an extended period of six months written in [DATE], but the DON acknowledged the extension had expired in [DATE].

Based on observation, record review, and staff interview, the facility failed to sort laundry in a manner to protect employee clothing from potentially contaminated materials, and failed to remove gloves and perform hand hygiene after performing perineal care, and before performing other activity of daily living (ADL) tasks for one resident (R) (R#41). The facility census was 55 residents, and the sample size was 35. Findings include: 1. Review of the facility's Infection Control-Linen and Laundry Services policy revised 1/15/16 revealed: All soiled linen will be treated as potentially infectious. In the laundry, hand washing facilities and protective barriers (e.g., gown, gloves, and masks) should be made available to personnel who sort laundry. Laundry personnel should wash their hands and remove protective barriers before going into the clean linen area. Review of the facility's Infection Control Prevention and Control Activities issued April, 2012 revealed: Linen: Handle, transport, and process used linen soiled fluids, in a manner that prevents skin and mucous membrane exposure and contamination of clothing and that avoids transfer of microorganisms to other equipment, patients and environments. Gowns: Utilize a gown that is appropriate for the activity and amount of fluid likely to be encountered. On 11/6/18 at 10:44 a.m., Laundry employee DD was observed sorting soiled laundry from a large plastic bag lined barrel. Further observation revealed that she wore gloves but no gown to protect her clothing. Continued observation revealed that the inner aspects of her short-sleeved shirt rubbed against the plastic bag liner in the barrel as she reached inside to retrieve each individual bag of soiled laundry, and at one point her entire upper body was inside the barrel as she reached for the bags of laundry on the bottom of the barrel. During interview following this observation, Laundry employee DD verified that she forgot and did not wear a gown when sorting the soiled laundry, and that she always wore either a disposable or non-disposable gown to cover her clothing. During interview with the Laundry Supervisor on 11/8/18 at 2:10 p.m., she stated that any time an employee sorted the dirty laundry, they should wear gloves and either a disposable or non-disposable gown to cover their clothes. 2. Review of the facility's Hand Hygiene policy revised 5/12/17 revealed: Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings; after removing gloves; and after contact with inanimate objects in the patient's environment. Keep in mind that glove use doesn't eliminate the need for hand hygiene. Review of the facility's Infection Control Prevention and Control Activities issued April, 2012 revealed: Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wear gloves when handling fluids, secretions, excretions, and contaminated items. Put on clean gloves just before performing tasks. Change gloves between tasks and when in contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before handling items, surfaces or cleaning equipment soiled by blood, body fluids, or other observable body substances, and when dealing with items from known infectious conditions. On 11/6/18 at 8:58 a.m., Certified Nursing Assistant (CNA) AA was observed giving R#41 a bed bath, which included washing the resident's perineal, rectal and buttocks area. After this was done, CNA AA placed a clean fitted sheet under the resident on one side of the bed, without removing the gloves she used to do the resident's bath. R#41 was then observed to be turned to the opposite side, and CNA BB was observed to wash the resident's back and buttocks from that side, and then pulled the fitted sheet under the resident with the same pair of gloves used for cleaning the buttocks. Continued observations revealed that CNA AA wore the same pair of gloves worn during the bath and perineal care to apply a clean brief and apply lotion to R#41's legs, and right arm and hand. Further observation revealed that CNA BB applied lotion to R#41's chest, abdomen, and left arm and hand, and then put a clean gown on the resident and clean pillowcase on the pillow using the same gloves she used to wash the buttocks earlier. During interview with the Infection Control Licensed Practical Nurse (LPN) CC on 11/8/18 at 1:03 p.m., she stated that staff should always wash their hands before beginning care, and anytime they felt they contaminated their gloves. She stated during continued interview that staff should change their gloves after completing the bath and pericare, before doing something like putting clean sheets on the bed.

Based on observation, record review, and staff interview, the facility failed to perform perineal care in a manner to prevent a potential urinary tract infection [MEDICAL CONDITION] for one resident (R) (R#41). The sample size was 35 residents. Findings include: Review of the facility's Perineal Care for the Female Patient (2018) revealed: For using a washcloth: Using downward [MEDICAL CONDITION], clean the perineal area from front to the back of the perineum; use a clean section of the washcloth for each stroke. Properly clean the anal area, wiping from front to back, and then rinse and dry it. Review of R#41's care plan for alteration in bowel and bladder elimination, reviewed 10/17/18, revealed that the resident had limited mobility, history of a stroke with left [MEDICAL CONDITION], contractures, was on a daily diuretic, had a history of [REDACTED]. On 11/6/18 at 8:58 a.m., Certified Nursing Assistant (CNA) AA was observed performing a bed bath for R#41. After washing the resident's face and chest, the folds at the tops of both legs were washed with a washcloth, and then the same section of the washcloth was used to wipe multiple times down the center of the perineum. After this was done, CNA AA was observed to dry the perineal area with a towel, again using the same section of the towel for multiple [MEDICAL CONDITION] down the perineum. On 11/6/18 at 9:16 a.m., CNA BB was observed to enter the room to assist with R#41's ADL (activity of daily living) care, and she was observed to wipe the resident's buttocks and rectal area several times with a washcloth, wiping from the back over the rectal area toward the urethra, and then dried the area with a towel, wiping once from the back to the front. During interview with the Licensed Practical Nurse (LPN) Infection Control Nurse CC on 11/8/18 at 1:03 p.m., she stated that she would expect staff to use a different section of the washcloth to wipe each side of labia and down the middle of the perineum, and to always wipe from the front to the back. She stated during further interview that a different washcloth should be used to do pericare than was used to wash other areas of the body.

Based on observation, record review, and staff interview, the facility failed to apply a right-hand splint to prevent further contracture for one resident (R) (R #5). The sample size was 35. Findings include: Review of the clinical record revealed R #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R#5 Brief Interview Mental Status (BIMS) score of 3 meaning impaired cognition with functional limitations in range of motion (ROM) on right side upper and lower extremities. Review of the monthly Restorative Nursing Flow Sheet dated 9/18/18 documented resident is on restorative program for passive ROM and splinting. Further reviewed documented that as of 9/26/18 that R #5 continues to participate in Restorative Nursing Program (RNP) for splint and is encouraged to wear splint but there are times when resident refuses to participate. Review of the Restorative Nursing Flow Sheet dated 8/10/18 documented R #5 will wear splints for a short period and off for meals. Review of the care plan for R #5 related to contractures that was initiated on 7/15/15, revised 6/5/18 identified resident is at risk of further contractures related to contractures right upper and lower extremity, ankle, elbow, and wrist with limited ROM. Intervention to be implemented included splint application as indicted. Review of the Restorative Nursing Flow Sheet dated 6/30/18 revealed no documentation of R #5 removal of splint to right hand/wrist or refusal of the application of the splint device, how long the splint was applied or informing the supervisor of R #5 refusal or removal of the splint device to the right hand/wrist. Observation on 11/05/18 at 9:14 a.m., 11/6/18 at 8:40 a.m., 11/7/18 at 9:00 a.m. and 11/8/18 at 8:30 a.m., revealed R #5 with no splint applied to right hand/wrist contracture. Interview conducted on11/8/18 at 9:00 a.m. with Restorative Certified Nursing Assistant, (RCNA) EE he stated resident has a rolled wash cloth for his right-hand contracture as a splint device to wear as tolerated but R #5 often takes splint device off. He continued to state that documentation is completed on the Restorative Nursing Flow Sheet of the time it takes doing ROM and applying the splint device to R #5's right hand/wrist. RCNA EE stated R #5 takes this device off and complains of pain and documentation is not done daily but monthly related to R #5's refusal or removal of the splint device. Interview on 11/8/18 at 10:00 a.m. with Director of Nursing, (DON) confirmed that R #5 has not had the splint device on right hand/wrist this week. The DON stated that her expectation is for the restorative staff to inform the nursing staff of resident's refusal, complain of pain or removal of the splint device and for documentation to be completed by the restorative staff and the nursing staff in resident's clinical record.

Based on observations, record review and staff interview, the facility failed to follow the care plan for one resident (R) #5 related to splint application to right hand/wrist. The sample size was 35 residents. Findings include: Record review for Resident (R) R #5 revealed he was admitted to facility 6/26/17 with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R#5 Brief Interview Mental Status (BIMS) score of 3 meaning impaired cognition with functional limitations in range of motion on right side upper and lower extremities. Review of the care plan for R #5 related to contractures that was initiated on 7/15/15, revised 6/5/18 identified resident is at risk of further contractures related to contractures right upper and lower extremity, ankle, elbow, and wrist with limited Range of Motion (ROM). Intervention to be implemented included splint application as indicted. Review of the Restorative Nursing Flow Sheet dated 6/30/18 revealed there was no documentation of R #5 removal of splint to right hand/wrist or refusal of the application of the splint device, or how long the splint device was applied. There was no documentation of the supervisor being informed of R #5 refusal or removal of the splint device to the right hand/wrist. Observations were completed on 11/05/18 at 9:14 a.m., 11/6/18 at 8:40 a.m., 11/7/18 at 9:00 a.m. and 11/8/18 at 8:30 a.m., revealed R #5 was observed with no splint applied to right hand/wrist contracture. An interview with Restorative Certified Nursing Assistant, (RCNA) EE conducted on11/8/18 at 9:00 a.m. revealed that R #5 has a rolled wash cloth to place in his right-hand contracture as a splint device to wear as tolerated but R #5 will take the splint device out of his right hand. He continued to state that documentation is completed on the Restorative Nursing Flow Sheet of the time it takes doing (ROM) and applying the splint device to R #5's right hand/wrist. RCNA EE stated that monthly documentation is completed related to R#5's refusal and removal of the splint device. Interview on 11/8/18 at 10:00 a.m. with Director of Nursing, (DON) confirmed that resident has not had the splint device on right hand/wrist this week. She confirmed that staff is not following the care plan related to placement of a splint device to prevent further contractures. Cross refer F688

Based on observation and staff interviews the facility failed to ensure that staff were free of signs and symptoms of communicable disease while serving food from the steamtable during lunch meal service and failed to assure that clean linens were stored in a sanitary manner. This practice has the potential to affect all residents. The facility census was 58. Findings include: 1. Observation on 11/21/17 at 3:19 p.m. of the Laundry Aide DD revealed that Laundry Aide DD who was sweeping lint out of the dryer. Lint and dust landed on clean linens that were uncovered in the barrel by the dryers. Observation on 11/22/17 at 12:20 p.m. of Laundry Aide AA who was sweeping lint from under dryers, with dust and lint getting on clean towels on the linen cart that was not covered. Interview on 11/22/17 at 12:21 p.m. with the Housekeeping Supervisor revealed that the linen cart should be covered when sweeping in the laundry room. Interview on 11/22/17 at 12:25 p.m. with Laundry Aide AA revealed that the linen cart should have been covered before sweeping but he/she forgot to close it 2. Observation on 11/21/17 at 12:04 p.m. of Dietary Aide (DA) CC checking steamtable temperatures, while checking the steamtable temperatures DA CC experienced clear thin nasal drainage from her nasal passages that dripped onto the steamtable surface where food was being served for the lunch meal. Dietary Aide CC was made aware of the clear thin nasal drainage drippings connection with the steamtable surface. Interview with the Dietary Manager (DM) on 11/21/17 at 12:05 p.m. revealed when dietary aides exhibit signs and symptoms of a communicable disease or viral infections they are not allowed to work in food service. At this time the DM was made aware of DA CC having nasal drainage drippings contacting the steamtable surface while checking steamtable food temperatures. Review of facility policy titled Infection Control- Dinning Services last revised and reviewed on 10/18/17 revealed Partners who have symptoms of communicable diseases or open infected wounds are not permitted to work in the kitchen.

Based on observations and staff interviews the facility failed to ensure that the holding temperature for hot food was maintained at the appropriate temperature necessary to prevent potential forborne illnesses. This practice had the potential to affect 54 residents receiving an oral diet. The sample size was 21. Findings Include: Observation of the lunch meal on 11/21/17 at 12:00 p.m. revealed hot food temperatures were not maintained at the proper holding temperatures on the steam table. The following food items were held at improper temperatures: Regular Diets Alternate Choice: Chicken Noodle Soup, one hundred twenty-four degrees Fahrenheit (124°F); one resident was served the soup for consumption. Temperatures were obtained by the Dietary Aide CC using the facilities calibrated thermometer. The DA CC verified that the above food temperature was not appropriate and the dietary staff immediately removed the food item to be re-heated. Interview with the Dietary Manager on 11/21/17 at 12:04 p.m. revealed that all food temperatures should be maintained at proper holding temperatures on the steamtable to prevent food Borne illnesses. Review of the facility policy titled Food Temperatures last revision date 3/24/17; last Reviewed on 8/3/17 revealed All hot foods served from the steamtable must be held at or above one hundred thirty-five degrees Fahrenheit (135°F).

Based on observations, interviews, and record reviews, the facility failed to ensure that the temperature in the medication refrigerator was correct and that a tank of oxygen was stored safely. This had the potential to cause harm to all of the residents in the facility. Findings include: 1. Observation on 01/25/17 at 11:30 a.m. revealed the medication storage refrigerator to be at a temperature of fifty degrees farhenheit (F) and the freezer to be at 14 degrees farenheit . RN AA confirmed the temperatures. Inside the refrigerator were six TB vaccines, one hep B vaccines, three Pneumovax vaccines in clear bags, one Influenza vaccine, 1 Pneumovax vaccine in a brown bag, one Prevnar for a resident, one bag of procrit, and the emergency kit (Eki)t for refrigerated narcotics. The freezer did not contain any medications. Surveyor and RN AA decided to wait another 15 minutes before rechecking the temperature. Continued observation at 11:45 p.m and after closing the refrigerator for 15 minutes, revealed the temperature was now at 52 degrees F. RN AA revealed that although she didn't know what the correct temperature should be, she could tell it is not correct at 50 degrees and that the thermometer must not be working. Review of the temperature log sheet on the refrigerator revealed the refrigerator temperature was recorded at 38 degrees and the freezer temperature at 12 degrees F on the overnight shift. There were no temperature parameters written on the log. Interview with the Assistant Director of Nursing (ADON) on 01/25/2017 at 11:47 p.m. revealed that the night shift nurse usually checks the refrigerator temperature and documents it onto the log. The ADON further revealed that she expects the temperature log to be posted on the refrigerators with the proper parameters so staff will know what they are looking for. The ADON stated the parameters should be 36 degrees F to 42 degrees F. When staff check the temperature of the fridge, they are expected to report any discrepencies to miantenance for immediat repair. ADON agreed that the temperature shouldn't be 52 degrees F and that the thermometer must not be working. During an interview on 01/25/17 at 11:49 a.m., the Director of Maintenance (DOM) revealed the thermometer must not be working and that the temperature should be no more than 42 degrees. He further revealed that he was going ot replace both the freezer and the refrigerator thermometers immediately and replace them with new ones. Review of the facility's policy of Medication Storage in the Healthcae Centers revealed medications requiring refrigeration are stored at temperatures between thirty six degrees F and 46 degreed F and are kept in a refrigerator with a thermometer to allow temperature monitoring. Observation on 01/25/17 at 1:03 p.m. revealed the refrigerator temperature to be at 50 degrees. This was once again confirmed by Nurse who proceeded to switch the refrigerator dial, that was on the top middle portion of the fridge, from 3.5 to 4 to make it colder. 2. 01/25/2017 11:53 a.m. Observation of the Floor Stock Medication Storage room revealed a full tank of Oxygen (O2) to be directly on the bare floor on the left of oxygen the storage rack. The rack was holding 19 more filled oxygen tanks and had extra space on the left side that could hold at least eight more tanks. An empty overflow cart had six empty spaces in it and was on the left of the main storage rack. The empty O2 tanks were in the front of the main storage rack. During an interview, RN AA confirmed that the O2 tank found on the floor was full and revealed it should not have been on the floor and that someone must have not paid attention and left it there. RN AA further revealed that even when the oxygen delivery company brings extra O2 tanks, they know not to place any on the floor. Review of the facility's policy on Oxygen Safety and Storage in section Storage revealed that O2 tanks kept in storage rooms must be either chained to the wall or installed on a stable, wheeled dolly or floor stand.

Based on record review, resident interview, and staff interview, the facility failed to allow one (1) resident ("S") a choice with bathing, from a survey sample of twenty-two (22) residents. Findings include: Record review for Resident "S" revealed a Quarterly Minimum Data Set (MDS) assessment completed in January of 2014 which indicated, in Section G - Functional Status, that the resident was totally dependent on staff for bathing. Section C - Cognitive Patterns of this MDS documented that Resident "S" had a Brief Interview for Mental Status Summary Score of fifteen (15), indicating that the resident had no cognitive impairment. During an interview with Resident "S" conducted on 03/12/2014 at 9:30 a.m., the resident stated that staff usually provided bed baths, and that he/she was uncertain as to why he/she was not provided showers. During an interview with Certified Nursing Assistant (CNA) "AA" conducted on 03/13/2014 at 9:53 a.m., CNA "AA" stated that she did provide care for Resident "S", and that the resident required total assistance. CNA "AA" stated that she would ask Resident "S" if he/she wanted to go the shower, but acknowledged that the majority of the time, the resident was given a bed bath. CNA "AA" further stated that she was not sure why Resident "S" did not usually get a shower, but that if a resident refused to shower, the CNA would let the nurse know and document the refusal on the shower sheet, and the nurse would document the refusal in the Nurse's Notes. During an interview with Register Nurse (RN) "BB" conducted on 03/13/2014 at 11:22 a.m., RN "BB" stated she would expect for CNAs to give Resident "S" his/her preference in going to the shower. RN "BB" stated that if the resident refused a shower, she would expect CNAs to let the nurse know of the refusal and would expect the nurse to document the refusal. However, further review of Resident "S"'s clinical record, to include review of the Nurse's Notes, revealed no evidence to indicate that the resident had refused to have showers.

Based on observation, record review, resident interview, and staff interview, the facility failed to provide oral/dental care for one (1) resident ("S") from a survey sample of twenty-two (22) residents. Findings include: Record review for Resident "S" revealed a Quarterly Minimum Data (MDS) which was completed in January of 2014 which indicated in Section G - Functional Status that the resident required the extensive assistance of staff with personal hygiene, including oral/dental care. Section C - Cognitive Patterns of this MDS documented that the resident had a Brief Interview for Mental Status Summary Score of fifteen (15), thus indicating no cognitive impairment. Review of the Nutritional Screening and Assessment Form dated 10/18/2013 for Resident "S" revealed that the resident wore upper and lower partial dentures. During an interview with Resident "S" conducted on 03/10/2014 at 2:40 p.m., the resident stated that when family visited, the family would brush his/her teeth and dentures. However, Resident "S" further stated that staff did not provide assistance with cleaning and brushing his/her teeth and dentures, and that when he/she asked staff for assistance, staff would hand him/her the toothbrush. During observations of Resident "S" conducted on 03/10/2014 at 2:40 p.m. and on 03/12/2014 at 9:30 a.m., the resident's lower, center teeth appeared to be dingy and darkened. Resident "S" was also observed to have upper dentures in place. During an interview with Certified Nursing Assistant (CNA) "AA" conducted on 03/13/2014 at 9:53 a.m., when asked about brushing Resident "S"'s teeth, CNA "AA" stated that she would at times swab the resident's mouth, but further stated that she did not think the resident wore dentures. During an interview with Register Nurse (RN) "BB" conducted on 03/13/2014 at 11:22 a.m., RN "BB" confirmed that Resident "S" did have dentures, and that she would expect the CNAs to remove the resident's dentures at night, soak them in a denture cup with tablets, and rinse them after meals.

Based on record review, resident interview, and staff interview, the facility failed to provide dental care to one (1) resident ("S"), in accordance with the resident's Care Plan, from the survey sample of twenty-two (22) residents. Findings include: Record review for Resident "S" revealed a Quarterly Minimum Data Set assessment completed in January of 2014 which documented in Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status Summary Score of fifteen (15), indicating no cognitive impairment. Review of Resident "S"'s Care Plan revealed a 10/25/2013 entry which identified that the resident had the potential for alteration in Activities of Daily Living (ADL) function related reasons which included, but were not limited to, [MEDICAL CONDITION] with left sided weakness, tremors of the bilateral upper extremities, and arthritis. Approaches to address Resident "S"'s ADL deficits included for staff staff to provide daily oral care. However, during an interview with Resident "S" conducted on 03/10/2014 at 2:40 p.m., the resident stated that staff had not provided him/her with assistance in cleaning his/her teeth and dentures, and that when asked, staff would only hand him/her a toothbrush. During an interview with Register Nurse (RN) "BB" conducted on 03/13/2014 at 11:22 a.m., RN "BB" that she expected certified nursing assistants to removed Resident "S"'s dentures at night and soak them, and also to rinse the dentures after meals. Cross refer to F312 for more information regarding Resident "S".

Based on observation, record review, and staff interview, the facility failed to store raw meats below other foods in the cooler; failed to wash hands after touching a contaminated surface; failed to use the 4-compartment sink in a manner to ensure sanitization of items washed; failed to clean dusty vents in food service areas; failed to store a scoop in a manner to prevent contamination of food contents; and failed to store personal items off of food preparation equipment. There were fifty-two (52) residents who consumed an oral diet. Findings include: 1. Observation during initial tour of the kitchen on 06/11/12 beginning at 11:13 a.m. revealed a sheet pan of raw sliced sausage on top of two cases of individual cartons of milk in the walk-in cooler. Observation on 06/13/12 at 11:00 a.m. revealed a sheet pan of raw bacon on top of two crates full of milk cartons. Interview on 06/13/12 at 11:15 a.m. with the Dietary Manager (DM) revealed that meat needed to be stored on the bottom shelf of the cooler and not on top of the milk. 2. Observation during the initial tour of the kitchen on 06/11/12 beginning at 11:13 a.m. revealed the lid to the trash can by the handwashing sink did not open when the foot pedal was pressed. Kitchen employee "BB" lifted the lid to a large barrel-type trash can with her hands so that a paper towel could be thrown away and immediately began washing dishes in the 4-compartment sink without first washing her hands. Continued observation revealed kitchen employee "CC" lifted the lid to the trash can, used the inside of the trash can to knock food debris off a large utensil and then started washing dishes without washing her hands. Interview on 06/13/12 at 1:10 p.m. with the DM revealed that anytime the kitchen staff touched any unclean surface, they should immediately wash their hands. 3. Observation on 06/13/12 at 10:29 a.m. revealed kitchen employee "DD" preparing pureed broccoli and pork in a food processor. After completing the puree process, the food processor parts were washed in the 4 compartment sink. The employee dipped the washed parts in the sanitizing compartment and immediately pull them out. Continued observation revealed kitchen employee "DD" washing pots in the 4-compartment sink. Again, the employee just dipped the items in the sanitizing compartment, pulling them out immediately. "DD" confirmed that she immediately removed items from the sanitizing compartment and that she had never been told how long to leave items submerged. Interview on 06/13/12 at 10:40 a.m. with the DM verified that the EcoLab Manual Pot and Pan Wash Procedure sign above the sink noted to submerge items in the sanitizer sink for one (1) minute. Review of the the facility's Pot/Pan Washing and Sanitation policy revealed that items needed to be immersed for 30 to 60 seconds in the quaternary solution. 4. Observation on 06/13/12 at 10:45 a.m. revealed two of four ceiling vents in the kitchen, one over the emergency food supply, and one in front of the steam table, had an accumulation of thick dust. Interview on 06/13/12 at 10:45 a.m with the Maintenance Director confirmed the above findings and revealed that he last cleaned the vents about three months ago and that they were due to be cleaned again. 5. Observation on 06/13/12 at 11:00 a.m. revealed a Styrofoam cup lying sideways on top of the thickener used for preparing pureed foods. Interview on 6/13/12 at 11:00 a.m. with the DM, verified that the staff used their hands to remove the Styrofoam cup from the container of thickener, and then put the used cup back inside. 6. Observation on 06/13/12 at 11:05 a.m. revealed a small plastic bag on top of a metal tray that was used to catch food prepared with a circular slicer. This was confirmed by the DM, who stated the bag contained a birthday card purchased by one of the kitchen employees.

Based on observation, record review, family and staff interview, the facility failed to ensure that a decline did not occur for one (1) resident ("Q"), who had bilateral leg contractures, from a sample of twenty-seven (27) residents. Findings include: Interview on 06/11/12 at 1:34 p.m. with Licensed Practical Nurse (LPN) "GG" revealed that resident "Q" was admitted with bilateral knee contractures, was not receiving range of motion (ROM) and did not have a splint device. Interview on 06/12/12 at 4:00 p.m. with a family member of resident "Q" revealed that the resident had stiffness in his/her knees before they were admitted to the facility, but that it had gotten worse since they had been there. Continued interview revealed that the resident had not had any therapy services since admission. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as dependent for most activities of daily living and was assessed with [REDACTED]. Review of the Special Treatments and Programs section of all MDS assessments since admission revealed that the resident had not received Occupational Therapy (OT), Physical Therapy (PT), or Restorative Nursing Programs (RNP). Review of Physician's Progress Notes dated 12/06/11 and 06/08/12 revealed both legs had contractures. Observation and interview on 06/13/12 at 8:23 a.m. with the Treatment Nurse revealed that during care to an unstageable pressure ulcer to the left hip, the resident's knees and hips were noted to be bent towards his/her chest at a little greater than a 90 degree angle. The Treatment Nurse was able to straighten the legs to a little less than 90 degrees. The Treatment Nurse stated that the contractures made it difficult to position the resident to help prevent further skin breakdown. Interview on 06/13/12 at 2:39 p.m. with the Registered Nurse (RN) Clinical Competency Coordinator (CCC) stated that she and the Therapy Outcomes Coordinator reviewed all the residents to see if they would benefit from the restorative nursing program or if they needed to be referred to skilled rehab. She added that they also attended clinical meetings every Wednesday with an interdisciplinary group to see if there were any concerns related to declines in ROM or physical functioning, and that direct care givers and restorative aides could also refer residents if they noted a problem. The Therapy Outcomes Coordinator stated that PT was going to do a screen for resident "Q" after the Treatment Nurse requested a referral this week, and felt they would probably recommend some splint-type devices for his/her legs to prevent worsening of the contractures. RN-CCC and the Therapy Outcomes Coordinator did not know why the resident was not referred for therapy before now. On 06/13/12 at 3:50 p.m., the Treatment Nurse provided a Documentation of Wound Observation and Assessment Form dated 04/18/12, which noted that she had referred resident "Q" for a rehab screen for contractures on that date. At 4:12 p.m., the Therapy Outcomes Coordinator stated she just found a Interdisciplinary Referral to Rehab Screening form dated 04/17/12 in a PT folder in the therapy office; she did not know why the physical therapist did not screen the resident. Interview and observation on 06/14/12 at 10:30 a.m. with Certified Nursing Assistant (CNA) "AA" revealed that resident "Q"s knees were bent up, and it made it hard to turn him/her. The resident was noted in the bed with their knees bent so that the bottom of their feet were on the mattress. the resident attempted but was only able to straighten his/her legs approximately one inch.

Based on observation, record review, family and staff interview, the facility failed to develop a care plan that included measurable objectives and approaches related to contractures of both legs for one (1) resident ("Q") from a sample of twenty-seven (27) residents. Findings include: Review of the clinical record for resident "Q" revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], the quarterly MDS assessment dated [DATE] and the Significant Change MDS dated [DATE] revealed that the resident was assessed with [REDACTED]. Interview on 06/12/12 at 4:00 p.m. with a family member of resident "Q" revealed that the resident had stiffness in their knees prior to admission, but that it had gotten worse and the resident had not received any therapy services since admission. Interview on 06/13/12 at 8:23 a.m. with the Treatment Nurse revealed that the resident's contractures made it difficult to position the resident to help prevent skin breakdown. Observation on 06/14/12 at 10:30 a.m. revealed the resident lying in bed with their knees bent and feet resting on the mattress; he/she was able to extend their knees approximately one inch when asked. Review of Care plans developed on 04/09/12 for falls, pain, skin impairment, and self-care deficit risks revealed that each of these care plans mentioned that the resident had contractures of bilateral knees/legs; however, only the skin impairment care plan contained an approach to encourage ROM exercise during care. Interview on 06/14/12 at 9:29 a.m. with the Case Mix Director revealed that she combined the resident's contracture problem with the self-care deficit care plan, and that she didn't do a separate contracture care plan because the resident was on hospice. Continued interview revealed that she remembered somebody bringing up resident "Q"s contractures in a clinical meeting over a month ago and that a therapy referral was suggested but she did not develop a contractures care plan with the Significant Improvement MDS because she was waiting on therapy to tell them what they were going to do for the resident. Cross-refer to F 318.

Based on review of employee files and staff interview, the facility failed to ensure that annual [MEDICATION NAME] (TB) skin test were placed upon hire to the facility and read in a timely manner for three (3) of fourteen (14) employee files reviewed. Findings include: Review of the Employee Annual Physical Assessment Forms revealed that two (2) employees had TB skin tests placed but there was no evidence that either skin test had been read. Continued review revealed that Certified Nursing Assistant "FF" had an annual physical assessment completed on 5/3/12. Review of Employee Annual Physical Assessment Form dated 5/3/12 for Certified Nursing Assistant (CNA) "FF," hire date of 4/3/12, revealed that the was to bring a copy of TB skin test done prior to hire; however, there was no evidence that this information had been acquired by the facility in the employee file. Interview with the Director of Nursing (DON) on 6/14/12 at 9:50 a.m. revealed that she concurred that the TB skin tests were not read. Continued interview revealed that the TB testing information for CNA "FF" had been gotten by the facility. The DON acknowledged that all three (3) employees had been actively working with residents. Review of the facility [DIAGNOSES REDACTED] Control Plan Policy with revised date of 1/11 revealed that upon initial employment, unless the partner has documentation of a previous significant (positive) skin test or unless the partner has documentation of negative TB results in the last twelve (12) months of employment, a mantoux method [MEDICATION NAME] test must be performed. The results of the first TB test must be negative prior to partners seeing patients/residents. A trained healthcare worker must read the mantoux test forty-eight to seventy-two (48-72) hours after it is placed.