Every finding on record at Twin Oaks Convalescent Center

Based on observation, resident and staff interviews, record review, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to ensure one resident (R)(R59) out of 22 sampled residents' room had an adequate working air conditioner for a comfortable temperature for the resident. This failure had the potential to cause R59 to not be comfortable in her own room. Findings include: Review of the facility's policy titled, Safe and Homelike Environment, original date of 10/22 revealed Twin Oaks Convalescent Center will provide a safe, clean, comfortable and homelike environment . comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents . housekeeping and maintenance services will be provided to maintain a sanitary, orderly and comfortable environment . the facility will maintain comfortable and safe temperature levels . any environmental issues that were unresolved should be reported to the Administrator. Review of R59's Admission Record Face Sheet located in the electronic medical record (EMR), under the Profile tab revealed R59 was readmitted to the facility on [DATE] with diagnoses of hemiplegia, hemiparesis, cerebral infarction (stroke), atrial fibrillation, aphasia, dysphagia, and fibromyalgia. Review of R59's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 3/7/2025 revealed R59 had a Brief Interview of Mental Status (BIMS) completed and it indicated R59 was unable to complete due to moderately impaired cognitive skills. During an observation on 3/25/2025 at 2:25 pm, R59 revealed she was in her room and was lying in bed. She was sweating, and her hair looked damp. Observation further revealed that R59 shook her head yes when Family Member (FM)1 asked her if she was hot. FM1 revealed the air conditioner in R59's room had not worked properly for almost a year, and she had reported it to staff many times. FM1 further revealed that staff would come in and use the remote to turn the air conditioner on, and it would blow out cool air for a while, but then it would get hot again in the room. FM1 further revealed maintenance had looked at it before, but the air conditioning still would quit working after maintenance looked at it. During an observation on 3/26/2025 at 3:50 pm revealed R59 was sweating, and she stated she was hot. During an interview on 3/26/2025 at 4:00 pm with the Maintenance man revealed that if there was an issue with the air conditioning not working properly, there should be a ticket in the electronic reporting system, which indicated a work ticket had been established. The Maintenance man further revealed that the E Hall, where R59 resided, had been renovated, and all the rooms had one of two air conditioning systems in their rooms. He revealed each unit had a universal remote control that the nurses or certified nursing assistants (CNAs) could use to control the temperature. During an interview on 3/26/2025 at 4:15 pm, the Safety Coordinator revealed if an issue had been reported, it should be on their log of work tickets. Interview further revealed that after he checked the air from the unit, the temperature of R59's room was 80 degrees Fahrenheit (F). The unit in the resident's room did not have a digital readout, so you could not tell what the temperature was set on. The Safety Coordinator confirmed the air conditioner was not blowing out cool air and it should be. During an observation and interview on 3/26/2025 at 4:45 pm revealed Licensed Practical Nurse (LPN) 3 got the remote from the nurse's station that staff had access to and gave it to the Safety Coordinator and when he attempted to change the temperature the remote did not work on the unit in R59's room. Observation further revealed the Safety Coordinator had to go to the hospital maintenance office to get the remote needed for the unit in R59's room. Observation further revealed that when the Safety Coordinator used the correct remote, the air conditioner kicked on and was cycling to cool the room off. LPN3 revealed to her knowledge that the remote at the nurse's station was the only one they had available. LPN3 further revealed she had been in R59's room earlier and used that remote to adjust the temperature of the room, but she did not realize it did not work for R59's room. During an observation on 3/26/2025 at 4:30 pm, the Maintenance man and the Safety Coordinator revealed the temperature of the room was 70 degrees F after the correct remote was utilized to set it. During an interview on 3/26/2025 at 4:36 pm, with the Maintenance Supervisor revealed a work ticket had been done on 3/25/2025 by the other Maintenance man but the Safety Coordinator and the Maintenance man did not look in the right place yesterday, however he did not see any other work tickets but would get back with me if he did. The Maintenance Supervisor further revealed the average room temperature should be between 70 and 80 degrees F, but that depended on the resident's preference. During an interview on 3/26/2025 at 4:36 pm, the Maintenance Supervisor confirmed there definitely was a lack of training on work tickets and remotes that were used to control room temperatures. During an interview on 3/28/2025 at 10:57 am, the Director of Nursing (DON) revealed she expected the staff to check with the residents on whether the temperature of the room was comfortable, and if it was not comfortable, then interventions should be taken to make the room comfortable for the residents.

Based on observation, resident and staff interviews, record review, and review of the facility policy titled, Enhanced Barrier Precautions, the facility failed to implement Enhanced Barrier Precautions (EBPs) for one resident (R) (R219) with bilateral diabetic ulcers and weeping lower leg skin tears out of four sampled residents. This failure had the potential to place R219 at risk of increased transmission of infection. Findings include: Review of the facility policy titled, Enhanced Barrier Precautions, dated 7/3/2024, revealed, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms .prompt recognition of need .All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions .All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions .The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .An order for enhanced barrier precautions will be obtained for residents with any of the following .wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, surgical wounds, and chronic venous stasis ulcers . 1. Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R219 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes, and gout. Review of the Order Summary located in the Orders tab of the EMR revealed the following wound orders: A. Cleanse Blisters to Bilateral lower legs with NS [normal saline], apply xeroform and cover with large Tegaderm with pad daily. Dated 3/22/2025. B. Cleanse Diabetic ulcers to the left foot, 2nd toe with wound cleanser, apply xeroform and cover with band aids daily. Dated 3/22/2025. C. Cleanse diabetic wound to bottom of Right and Left foot w/NS, pat dry, apply TAO [topical antibiotic ointment], cover with band aids daily. Dated 3/23/2025. D. Cleanse skin tears to the left upper and lower arm with wound cleanser, apply xeroform and cover with padded Tegaderm daily. Dated 3/22/2025. E. Cleanse the Diabetic Ulcer on the right foot 1st and 2nd Toes with wound cleanser, apply xeroform and cover with Band aids. Dated 3/22/2025. During an interview/observation on 3/26/2025 at 12:14 pm, R219 was sitting in her wheelchair. She was alert and communicative. Her bilateral legs were without bandages due to having had a shower. There were multiple wounds observed on her legs, and the skin tears were large and weeping clear fluid. R219 was asked if staff wore a protective gown when providing treatments to her legs. R219 stated, No, they don't. During an observation and interview on 3/26/2025 at 1:58 pm, the Treatment Nurse (TN) performed wound care to R219's lower legs. She was not observed to have worn a gown during the procedure. The TN was asked why she didn't have a gown on during the resident's wound care. She stated, I don't know why. The TN confirmed that she did not wear a gown when performing wound care and said she should have had the proper personal protective equipment (PPE) on due to the oozing wounds. During an interview on 3/26/2025 at 2:19 pm, the Infection Preventionist (IP) stated, I was not aware that the ulcers on her legs were diabetic ulcers. I thought they were skin tears. If they are diabetic ulcers, then definitely she should have had EBP precautions.

Based on record review and staff interview, the facility failed to ensure that [MEDICAL CONDITION] medications including antianxiety and antidepressant medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for 2 of 26 residents (R) (#15 and #24) reviewed for unnecessary medications. The sample size was 26 residents. Findings include: Review of the Medication Regimen Review Policy (MRR) adopted on 10/2017 revealed PRN medications will be reviewed with each MRR to determine if continued need is appropriate. Review of the Gradual Dose Reduction Policy adopted on 10/2017 revealed [MEDICAL CONDITION] Drug is defined as any drug that affects brain activities associated with mental processes and behavior. [MEDICAL CONDITION] drugs include but are not limited to the following categories: antipsychotics, antidepressants, anxiety, and hypnotics. 1. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] documented R#15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED]. Take 1 tablet PO at bedtime PRN for [MEDICAL CONDITION] with an original order date of 8/27/18. Review of the Medication Administration Record's (MAR) for (MONTH) (YEAR) and (MONTH) (YEAR) revealed R#15 received the following medications [MEDICATION NAME] tablet 50 mg give 1 tablet PO every 24 hours PRN for [MEDICAL CONDITION] on 8/28/18, 8/31/18, 9/1/18, 9/2/18, 9/5/18, 9/6/18, 9/7/18, 9/11/18, 9/15/18, 9/16/18, 9/17/18. Review of a Physicians Progress Note dated 9/7/18 revealed R#15 has failed gradual dose reduction (GDR) on Trazadone, I have restarted it PRN. 2. Review of the MDS Quarterly assessment dated [DATE] documented R#24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED].#24 revealed an order for [REDACTED]. Review of the MAR's revealed R#24 received the following PRN medications: [REDACTED]. Review of a Physicians Progress Note dated 5/3/18 revealed R#24 receives [MEDICATION NAME] 0.25 mg every 12 hours PRN. I do not feel the need to schedule this medication. Review of a Pharmacy Recommendation dated 7/2/18 revealed R#24 has been taking [MEDICATION NAME] 0.25mg every 12 hours PRN. She has been doing well, I believe a GDR would cause more harm than benefits. Physician agreed on 7/16/18. During an interview on 9/19/18 at 9:35 a.m. the Licensed Practical Nurse (LPN) AA confirmed R#15's PRN medication was started on 8/27/18 and it remains an active PRN order. She further revealed she thought the pharmacy recommended it that way. During an interview on 9/19/18 at 9:55 a.m. the LPN BB revealed that R#15 was started back on Trazadone 50mg PRN at her request. An interview was conducted with the Consultant Pharmacist on 9/19/18 at 10:45 a.m. He stated that he makes recommendations as needed with his monthly visits. He further revealed R#15's Trazadone 50mg was an indefinite PRN order and automatic stop orders were used for medications like antibiotics. During an interview on 9/19/18 at 11:21a.m. the Director of Nursing (DON) confirmed that on 1/10/18 the doctor started the PRN medication [MEDICATION NAME] 0.25 mg PO every 12 hours for R#24. During an interview on 9/20/18 at 9:15 a.m. the DON revealed the facility does not have a [MEDICAL CONDITION] drug use policy and procedure.

Based on observation, interview and record review it was determined the facility failed to revise/update care plan interventions for one resident (R#49). The sample size was 38 sampled residents. Findings include: Review of the medical record for R#49 revealed that on 9/23/17 R#49 experienced a fall. According to the Annual Minimum Data Set ((MDS) dated [DATE] Section G revealed R#49 required extensive assistance for bed mobility and total dependence for transfers. R#49 noted with unsteady gait and it only stabilizes with staff assistance and required the use of a wheelchair for mobility. The resident was also coded for one fall with no major injury. Review of R49's care plan with a start dated of 10/06/17 I am at risk for falling and I have a history of falling. Fall interventions included low bed, chair alarm, medications as ordered, frequent bed checks, increased monitoring, call light in reach, fall prevention program prn, and clutter free environment. Observation on 10/25/17 at 8:12 a.m. of R#49 in room sitting in wheelchair with lap buddy in place. Observation on 10/26/17 at 11:19 am of R#49 sitting in wheelchair with lap buddy in place in activity room. Interview on 10/26/17 at 3:36 p.m. with MDS Registered Nurse (RN) DD who reported that she completed R#49's annual assessment and care plan but must have failed to add the lap buddy as an intervention.

Based on observations, resident interviews and staff interviews, it was determined that the facility failed to ensure that a homelike environment was provided for thirty-seven (37) residents during two (2) of two (2) meal services in two (2) out of two (2) dining rooms (small dining room and large dining room). The census was seventy-seven (77) residents. Findings include: 1. Observation of the lunch meal service in the small dining room on 1/3/17 beginning at 12:17 p.m. revealed that the staff served a total of fourteen (14) residents their food and drinks on serving trays. Twelve (12) of the fourteen (14) residents were receiving assistance feeding by nursing staff and two (2) residents ate independently. Continued observation revealed that staff failed to promote a homelike dining experience for the residents by leaving the items and drinks on the serving tray instead of removing them and placing them on the dining table in front of the residents. Further observation at the end of the meal service revealed that all of the residents in the small dining room had their food items and drinks left on the tray when served. Observation of the large dining room on 1/3/17 beginning at 12:30 p.m. revealed that staff removed the food items and drinks from the trays and placed them on the table in front of the residents who ate independently. 2. Observation of the dinner meal service in the small dining room on 1/4/17 beginning at 5:20 p.m. revealed that staff served sixteen (16) residents their food and drinks on serving trays. Twelve (12) of the sixteen (16) residents were receiving assistance feeding by nursing staff and four (4) residents ate independently. Continued observation revealed that staff failed to promote a homelike dining experience for the residents by leaving the food items and drinks on the serving tray instead of removing them and placing them on the dining table in front of the residents. Further observation at the end of the meal service revealed that all of the residents in the dining room had their food items and drinks left on the tray when served. 3. Observation of the dinner meal service in the large dining room on 1/4/17 beginning at 5:20 p.m. revealed that staff served the residents their food and drinks on serving trays. Twenty-one (21) residents ate independently in the large dining room. Continued observation revealed that staff failed to promote a homelike dining experience for the residents by leaving the food items and drinks on the serving tray instead of removing them and placing them on the dining table in front of the residents. Further observation at the end of the meal service revealed that all of the residents in the dining room had their food items and drinks left on the tray when served. Interview with the Administrator on 1/5/17 at 2:58 p.m., revealed that she she did not work in the dining rooms during meal times and was unaware that food items and drinks were left on the trays during the meal. Each morning and at lunch we go through the resident ' s dining room (we must pass through the resident ' s dining room to gain access to the employee ' s cafeteria. As we pass through we always talk with the staff and the residents. Interview with the Director of Nursing (DON) on 1/5/17 at 3:05 p.m. revealed that she did not work in the dining rooms during meal times and was unaware that food items and drinks were left on the trays during the meal. Interview with the Quality Assurance (QA) Coordinator on 1/5/17 at 3:09 p.m. revealed that food items and drinks were left on the trays during the meal service for residents who ate in the small dining room because they required assistance with feeding from staff. Continued interview revealed that residents who ate in the large dining room were served buffet style. Further interview revealed that she was unaware that food items and drinks were left on trays in the large dining room during the dinner meal. Continued interview revealed that she was unable to say how long meals have been served on trays without removing the food items and drinks.

Based on observation, staff interview, and medical record review the facility failed to ensure that staff sanitized their hands between serving residents' meal trays on two (2) of five (5) halls, and in two (2) of two (2) dining rooms during three (3) dining observations with seventy-nine (79) of eighty (80) residents receiving oral alimentation. Findings include: 1. During dining observation on 03/30/15 at 12:05 p.m. a Certified Nursing Assistant (CNA) delivered a meal tray to a resident in the restorative dining room. The CNA donned gloves and touched multiple inanimate objects including wheelchairs and tables and did not remove gloves and don a new pair of gloves or sanitize hands before serving trays and handling food during set-up of trays. The CNA was never observed to change gloves during delivery or set-up of trays in the Dining Room. Multiple CNA's in the Dining Room were noted to have donned gloves, delivering trays and setting up multiple resident trays without changing gloves or sanitizing hands between residents. . 2. During dining observation on 03/30/15 at 12:54 p.m. on A-hall during lunch revealed that CNAs donned gloves, touched the meal cart and resident table prior to delivering and setting-up resident tray without ever changing gloves and washing or sanitizing hands. 3. During dining observation on 03/30/15 at 1:00 p.m. on A-hall revealed that a CNA donned gloves, repositioned a resident in bed, removed gloves, re-donned the same gloves and did not wash or sanitize their hands before setting up the resident tray and touching the resident's bread. 4. During dining observation in the large dining room on 03/31/15 at 12:20 p.m. revealed that a CNA donned gloves and was observed touching resident wheelchairs then delivering and setting-up trays without washing or sanitizing hand or changing gloves. Observation in the large dining room on 03/31/15 at 12:28 p.m. revealed that a CNA donned gloves, touched a resident on her arm, never removed gloves, washed or sanitized hands then proceeded to deliver and set-up the resident's tray including touching resident's bread. Further observation in the large dining room on 03/31/15 at 12:35 p.m. revealed that a staff member delivering the trays wore one pair of gloves through the entire meal. The staff touched other residents, furniture, clothing, and then returned to the food cart to get another tray for the next resident. Observation of meal tray delivery on E Hall on 03/31/15 at 12:50 p.m. revealed that staff did not change gloves between the delivery of the residents trays. A Review of Policy and Procedure for dining revealed that wearing gloves does not replace the need for handwashing and that hands are to be washed or sanitized before and after coming in contact with a resident, or any time the hands are potentially soiled by any contaminated object. During interview with CNA "AA" on 04/02/2015 at 12:17 p.m. it was confirmed that for infection control purposes CNAs were to don hairnets when trays were served. Interview further confirmed that if a CNA touched any inanimate object or resident that they are to remove the gloves they had on and wash hands with soap and water and put on a new pair of gloves. Interviews on 4/02/15 at 12:20 p.m. with CNAs "BB" and "CC" confirmed the infection control procedure revealed by CNA "A." On 3/31/15 at 12:05 p.m. observations in main dining room of certified nursing assistants and supply assistant removing trays and setting them up for residents revealed that all were done without changing gloves in between touching resident, touching resident meal trays and items on trays, resident's clothing, or food items on trays of a different resident. Observations during meal time of certified nursing assistants going in and out of the kitchen door wearing the same gloves, touching the door frames in the main dining room and the dining room where residents were being assisted to be fed. At 12:07 p.m. observed "DD" wearing gloves she/he went from table to table assisting different residents with putting on clothing protectors and then with the same gloves on, started repositioning residents in their wheelchairs, touching the handles of the wheelchairs, touching the residents clothing and going to and from different residents. "DD" stated that he was not a certified nursing assistant (CNA), she/he just helped pass out supplies. I asked her/him what training she/he had in infection control and she/he said they had not had any training. She/he then removed her/his gloves and went out of the dining room. At 12:18 p.m. observation of CNA "EE" revealed that they put on purple gloves scratched his/her nose, repositioned a resident in a wheelchair, was then was observed touching the chairs of other residents and touching multiple residents' clothing in the main dining room, he/she then went to the food cart and removed the food trays and began setting up trays for the residents in the main dining room. At 12:23 p.m. interview with CNA "EE" revealed that they get educated every couple of months on Infection Control Procedures. CNA "EE" stated that hand washing was the most important and that it needed to be done between touching surfaces and touching residents. "EE" then said what was most important was that they didn't cross contaminate. The CNA verified that what he/she was doing was certainly breaking infection control.

Based on staff interviews and record reviews, it was determined that the facility failed to ensure timely responses to and prompt implementation of pharmacist recommendations agreed to by the residents' attending physicians for two residents (#74 and # 86) and to follow the physician's orders [REDACTED].#86) from a total sample of 34 residents. Findings include: During an interview on 4/5/12 at 8:50 a.m., licensed nurse "BB" stated that she was responsible for the pharmacy recommendations. She explained that the Director of Nursing ( DON ) gave the consultant pharmacist's drug regime review recommendations to the Health Information Secretary, who was responsible for taking them to the physician for their signed responses. Then the secretary brought them to her to put on the chart and to change the orders if needed. She stated that the process usually took a few days but, sometimes the physician did not sign or comment so, the recommendations had to be sent back to the physician. She said she usually wrote on the recommendation form what had happened. Licensed nurse "BB" returned at 9:00 a.m. to explain that if a resident was on [MEDICAL TREATMENT] then, the recommendations were also sent to the physician at the [MEDICAL TREATMENT] center for review and signature. However, the facility failed to ensure timely physician responses and prompt implementation of orders for residents #74, and #86. 1. Resident #74 had [DIAGNOSES REDACTED]. The pharmacist recommended that the facility staff change the times that [MEDICATION NAME] was administered and allow at least two hours between administering it and [MEDICATION NAME]. The consultant pharmacist noted that the concomitant use of [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) was not recommended and recommended that [MEDICATION NAME] be discontinued. The attending physician signed the drug regime review on 2/10/2012 to indicate agreement with the recommendations but, facility staff failed to note those changes to the physician's orders [REDACTED]. 2. The consultant pharmacist recommended on 1/30/12 that resident #86's physician increase the resident's dose of [MEDICAL CONDITION] from 75 micrograms(mcg) to 88 mcg and then monitor the resident's [MEDICAL CONDITION] Stimulating Hormone (TSH) every month for 6 months. Although the resident's attending physician signed that he/she accepted those recommendations on 2/3/12, the facility did not implement those changes until 2/29/11 (26 days later). There was a note on the pharmacist's recommendation form that the recommendation had been sent to the [MEDICAL TREATMENT] physician and were accepted on 2/29/11. According to documentation on the the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. b. Resident #86 had a [DIAGNOSES REDACTED]. blood pressure was greater than 150 or his/her diastolic blood pressure was more than 110. However a review of nursing staff's documentation on the Medication Administration Records (MAR) for January, February and March 2012 revealed that the resident's blood pressure had not been obtained timely to determine if the parameters had been met to administer [MEDICATION NAME] to the resident. According to the nursing staff's documentation on the January MAR, the resident's blood pressure had only been taken weekly, 1/7/12, 1/14/12, 1/21/12 and 1/28/12. Although instructions on the February 2012 MAR indicated [REDACTED]. to 7 a.m. shift. Nursing staff recorded having taken the resident's blood pressure each shift on the March 2012 MAR but, did not give [MEDICATION NAME] to the resident when his/her systolic blood pressure was recorded above 150 on 3/1, 3/16 and 3/20/12.

Based on observation, interview with resident and staff, and record review, it was determined that the facility failed to plan and implement interventions to address the prevention of petecia, bruises and skin tears for one resident ("A") in a total sample of 34 residents. Findings include: Resident "A" had [DIAGNOSES REDACTED]. The resident's 1/19/12 care plan, as well as the reviews of it on 1/25/12 and 3/19/12, identified that he/she had petechaie, bruises and skin tears which were to be monitored daily and the skin tears treated. However, it was observed that the staff failed to consistently provide care to attempt to prevent the re-occurrence of skin tears and bruises. The resident was observed on 4/3/12 at 10:39 a.m. sitting in his/her wheelchair in the activity room. His/Her left arm was positioned between the left side panel of the wheelchair and his/her body. The resident had a blue colored bruise and a small dressing on his/her left elbow. The resident was observed to have been wearing a short sleeved shirt to an activity on 4/3/12 at 2:00 p.m. The resident was sitting in his/her wheelchair and his/her left arm was resting between his/her body and side of wheelchair. There was not any padding on the arm of his/her wheelchair or a device to prevent his/her left arm from being wedged in the wheelchair. In an interview on 4/3/12 at 3:30 p.m., the resident said that his/her left elbow was not much better and then lifted his/her left arm with his/her right arm to show his/her elbow. His/Her left arm had been positioned between his/her body and the left inside of the wheelchair. The resident said that he/she thought the bruise and skin tear had been caused by him/her having pinched it on the side of the wheelchair. During an interview on 4/5/12 at 9:45 p.m., licensed charge nurse "AA" said that she had not noticed that the resident was leaning. "AA" said the resident usually rested his/her left arm on the arm rest. "AA" said that she assisted the resident to reposition his/her arm onto the arm rest, if she saw that it had dropped to between the side panel of the wheelchair and the resident's body. The resident was observed sitting in his/her wheelchair in the activity room on 4/5/12 at 9:50 a.m. He/She was wearing a short sleeve shirt and his/her arm was propped between his/her body and the left side panel of the wheelchair. When the resident lifted his/her left arm up with his/her right hand, his/her left forearm and elbow scrapped the side of the wheelchair and tugged the dressing on his/her left elbow. The blue discoloration on the resident's bruised left elbow appeared to have been fading. There were not any devices in place to prevent the resident's arm from being positioned between the wheelchair and the resident's body.

Based on observations, interviews with resident and staff, and record review, it was determined that the facility had failed to revise the care plan for one resident ("A") with facility identified problems of petechiae, bruising and skin tears from a total sample of 34 residents. Findings include: Resident "A" had [DIAGNOSES REDACTED]. The resident was observed on 4/3/12 at 10:39 a.m., sitting in a wheelchair with his/her left arm dropped down between the left side panel of the wheelchair and the resident's body. The resident had a blue colored bruise on his/her left elbow and a wound dressing on the back of his/her elbow. The resident's care plan dated 1/19/12, which was reviewed on 1/25/12 and 3/19/12 included that the resident had petecia, bruises and skin tears. However, there were not any interventions to prevent the re-occurrence of more bruises or skin tears. See F 323 for additional information regarding resident "A".

Based on observation, record review, and staff interview, it was determined that the facility failed to store ice in a sanitary manner and failed to prevent the potential for cross-contamination in the use of snap-lids on trash receptacles at the handwashing sinks in the kitchen. Findings include: 1. During an observation of the kitchen with the Dietary Manager on 7/07/10 at 11:10 a.m., there was a black substance on the plastic shield inside the ice machine. According to the facility's ice machine cleaning log and an interview with the Dietary Manager at that time, the ice machine was cleaned once a month. Staff had most recently been cleaned it on 6/13/10. During an interview on 7/08/10 at 11:50 a.m., the Dietary Manager stated that the ice machine needed to be cleaned twice a month because of the high humidity. 2. During an observation of the kitchen with the Dietary Manager on 7/07/10 at 11:10 a.m., there were three handwashing sinks without foot pedal operated trash receptacles. The trash receptacles in the kitchen were industrial barrel garbage cans with snap-on lids. Therefore, when the kitchen staff washed their hands, they contaminated their hands when they opened the garbage can's snap on lid to dispose of their soiled paper towels. During an interview on 7/08/10 at 11:50 a.m., the Dietary Manager confirmed that the kitchen staff were unable to dispose of their soiled paper towels without touching the 'dirty' lid of the garbage can.

Based on observations and record review, it was determined that the facility failed to ensure that one resident (#5) of three residents with gastrostomy tubes received the appropriate treatment to prevent complications from a total sample of 16 residents. Findings include: Resident #5 had [DIAGNOSES REDACTED]. The resident had a care plan to address his/her gastrostomy tube feedings which included an intervention since 2/22/10 for licensed nursing staff to keep the head of the resident's bed elevated at all times except during the provision of activities of daily living care. The resident had a physician's orders [REDACTED]. However, it was observed prior to administration of medication and a water flush on 7/08/10 at 11:15 a.m., that the head of the resident's bed was not elevated. L licensed nurse "LL" failed to elevate the head of the resident's bed from the flat position before he/she administered the medication and water flush. The head of the the resident's bed was not elevated during the water flush or administration of medication. Upon completion of that administration of medication and the water flush, licensed nurse "LL" did not elevate the head of the bed .

Based on observation and record review, it was determined that the facility failed to implement the plan of care to keep the head of the bed elevated for one resident (#5) from a sample of three residents with gastrostomy tubes in a total sample of 16 residents. Findings include: Resident #5 had a care plan for requiring gastrostomy tube feedings because of [DIAGNOSES REDACTED]. There was a care plan intervention since 2/22/10 for nursing staff to keep the head of the resident's bed elevated at all times except during activities-of-daily living (ADL) care. \However, on 7/08/10 at 11:15 a.m., it was observed that staff had not elevated the head of the bed. During that observation, licensed nurse "LL" administered medication and a water flush to the resident through the gastrostomy tube. It was observed that upon completion of that medication administration and water flush, licensed nurse "LL" did not elevate the head of the resident's bed. See F322 for additional information regarding resident #5.