Every finding on record at Camellia Health & Rehabilitation

Based on review of facility records, policies, incident reports, and staff interviews, it was determined that the facility failed to provide adequate bed mobility assistance to prevent an avoidable accident, specifically, a fall for Resident (R1), resulting in harm to one of three residents reviewed for falls. The facility census was 55.On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing, and Assistant Director of Nursing were informed of the Immediate Jeopardy for F760 on [DATE] at 3:13 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE].An Acceptable IJ Removal Plan was received on [DATE] related to Comprehensive Care Plans 483.21(b) and Accidents, 483.25(d).Based on observations, record reviews, interviews, and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. This was determined to be Past Noncompliance.Findings included:A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility on [DATE]. Her diagnosis included Alzheimer's disease with early onset, chronic pain, muscle weakness, contractures of the upper and lower body, lack of coordination, and blindness.A review of the written statement dated [DATE] from Certified Nursing Assistant (CNA) WW revealed that when the fall occurred, she was changing the linens after bathing R1, and further revealed that she performed care with one-person assistance. CNA WW was on the opposite side of the bed, pulling the sheets and pads out, and saw R1 roll off the bed.A review of the written statement dated [DATE] from Registered Nurse (RN) XX revealed that CNA WW called her to the room and she performed an assessment on R1. The assessment revealed that a laceration was noted on the top of the resident's head, and she was unable to obtain vital signs. Emergency Medical Services was called, and when they arrived at the facility, the resident was pronounced at approximately 10:10 pm.A review of Nursing Notes dated [DATE] at approximately 11:30 pm revealed that the family was notified of the resident's expiration by the facility's Director of Nursing (DON).The DON reported the incident to the State Survey Agency, number 202509545.An interview with DON on [DATE] at 10:20 am revealed that she had only had one fall with injury, and she had investigated this incident and turned it into the state. She produced the care plan for the resident, including interviews and phone calls that were made after the event. Statement from the caregiver present at the time of the fall. Statement from the RN who assessed the resident. Sign-in sheet for education titled Turning and Repositioning, transfers, mobility. ADL POC resident alerts. The surveyor requested the education given to staff to go with the sign-in sheet. There were 13 signatures on the sheet. DON typed up a statement on what she taught.During an interview with Physical Therapist (PT) DD on [DATE] at 1:30 pm revealed that the resident in question, R1, was contracted and could not move herself in bed. She revealed that her legs were so contracted that they could not even use a wedge or splint for her. She stated that she had her on her case load at one time on case load but has not treated her since [DATE].During an interview on [DATE] at 1:00 pm with Certified Medical Assistant (CMA) and Restorative Aide EE revealed that the CNA looked at the (Plan of Correction) POC for the resident to find out if they were one or two-person assist.During an interview on [DATE] at 1:15 pm with CNA, FF revealed that when caring for a resident that the staff who were new looked at the POC on the computer, and that a lot of the older staff knew the residents and what they required. He stated that even though they may need two people to transfer, they could only need one person to change and perform care if they are in bed.During an interview on [DATE] at 1:30 pm with R2 revealed that the staff uses a Hoyer lift when transferring her, and she stated that she always has 2 caregivers when performing peri-care.During an interview with staff on 2-person assistance and bed mobility on [DATE] at 3:00 pm, with questions on the education they had received in the past few weeks. The CNAs were questioned about Hoyer lifts and if the resident is contracted, how many staff should assist. (All in attendance answered 2-person assistance). Discussed turning and repositioning, and changing the bed with one or two people. They all agreed that the resident should be brought toward the caregiver and held by the caregiver when on their side, that is how they were taught. Discussed night shift staffing and schedules.In attendance: CNA VV; CNA RR; MA/CNA TT; CNA SS; and Scheduler/CNA UU.A review of the ADL POC, which is the computer system for CNA staff to identify care, revealed that the resident R1 was dependent and required 2-person assistance.A review of the Care Plan dated [DATE] revealed that R1 had contractures in her bilateral legs, knees, hips, elbows, and hands. Dependent on staff for all Activities of Daily Living (ADL) care.A review of Facility records revealed training was performed on making an occupied bed and bed bath for CNA WW dated [DATE].A review of the facility records revealed QAPI was dated [DATE] on a dependent patient, too close to the edge of the bed.A review of Facility records revealed that audits were performed on [DATE] for all residents for bed mobility accuracy and data in POC.A review of facility records revealed education was given to nursing staff dated [DATE] on turning and repositioning, transfers, and mobility. Resident's alerts in the POC.The facility implemented the following actions to remove the IJ:1. R1 is no longer at the facility.2. Investigation initiated on [DATE], and the associate providing care to R1 was removed from the schedule. The associate received education on [DATE] regarding adhering to the plan of care with repositioning patients and the support staff needed for ADL care by the DON. Validation of associate education and competency was completed on [DATE] by the DON.3. In-service education was initiated on [DATE] for all nursing staff and was completed on [DATE] regarding falls management, adhering to the plan of care with repositioning patients and the support staff needed. Education included how to access the level of care required on the POCs and turning and repositioning, bed mobility, plan of care, and residents' alerts. The facility's fall management program was reviewed. Education was provided by the Administrator, DON, ADON, and nurse managers. 10 of 10 RN, 8 of 8 LPN, 19 of 19 CNAs, 9 of 9 CMAs, 1 of 1 RAI coordinator have been in-service, which totals 100%. No nursing staff shall work until they have completed in-service education. Newly hired associates will be educated upon hire.4. Audit was completed on [DATE] by DON, ADON, and nurse managers on residents with falls for the past 30 days to ensure the plan of care is being followed. No revisions needed after review.5. 100% audit completed of residents' plan of care on [DATE] by DON, ADON, and nurse managers to ensure each resident had the appropriate level of assistance needed for bed mobility. All levels of assistance are noted to be accurate.6. The facility's plan of care and ADL plan of care policy were reviewed by the administrator and medical director on [DATE], with no changes required at this time.7. Audits of staff providing care by the residents' plan of care are being monitored weekly by DON, ADON, Nurse Managers, and charge nurses beginning [DATE] and will continue weekly for six weeks across all shifts to include the associate involved in providing direct care to R1.8. An ADHOC QAPI meeting led by the administrator was held on [DATE], and a performance improvement plan was developed and re-evaluated for F689. A root cause analysis was conducted, and no trends were identified; it was determined to be an isolated incident. CNA followed the plan of care. The interventions implemented included the PIP review, a review of the fall Program with no changes, and a process for adhering to the plan of care, which involved repositioning patients and the support staff needed. The Administrator, DON, Medical Director, Director of Regulatory and Quality Services, ADON, Resident Care Coordinator, Social Service Director, Activity Director, Healthcare Navigator, Human Resource Partner, Rehab Director, Schedule Coordinator, and Housekeeping supervisor were in attendance.9. All co. corrective actions were completed on [DATE]. The facility alleges that the IJ was removed on [DATE].The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:1. A review of the electronic medical record revealed that R1expired [DATE] at the facility.2. A review of timesheet punches and staffing sheets for [DATE] and [DATE], and [DATE] was completed and revealed that the employee who provided care to R1 was removed from the schedule on [DATE].Review of the education dated [DATE] attended by CNA WW given by DON on complete skills checkoff titled Making an occupied bed and unoccupied bed and giving a complete bed bath. Reviewed signatures that CNA WW received an Inservice dated [DATE] titled Turning and repositioning, transfers and mobility, ADL (Activities of Daily Living), and review of POC (Plan of Care).3. A review of the in-service sheets dated [DATE] presented by DON, signature page matched to staff with 47 signatures, which included 10 RN's, 8 LPNs, 19 CNAs, and nine of nine CMAs, and the RAI Coordinator was present.Interviews conducted on [DATE] with staff via in-persona and telephone revealed that staff received and retained education as noted in the facilities plan.4. Audit sheet dated [DATE] revealed all residents on the census sheet were reviewed for ADL/POC (Activities of Daily Living, Plan of Care) and level of care required, that the care plan reflected the correct level of care and the number of staff required. Reviewed that they had the resident's name and type of care needed (Individual, dependent 2 person, partial or substantial assistance, partial or moderate assistance, or touch assistance.5. A review of the audits revealed that 100% of residents' plan of care was reviewed on [DATE] by DON, ADON, and nurse managers.6. A review of the care plans and interviews with management revealed that the plan of care and ADL plan of care policy were reviewed by the administrator and medical director on [DATE], as verified by signatures.7. A reviewed weekly audits for Bed Mobility dated 9/15 through [DATE] with CNA WW signature on the audit sheets.8. A review of the Adhoc QAPI meeting revealed that a performance improvement plan was put in place on [DATE] and those in attendance for the meeting included signatures for the Administrator, DON, Social Services, Activities Director, Dietary Manager, Health Information Manager, Human Resources, Maintenance Director, Director of Rehab, Infection Preventionist, RAI/MDS Coordinator, Schedule Coordinator, Housekeeping Supervisor. The Medical Director was in attendance via phone on the list. It was verified by review of the sign-in sheet.9. After a review of the audits and interview, it was determined that all corrective actions were completed on [DATE]. The IJ was removed on [DATE].

Based on observations, record review, resident and staff interviews, and review of the facility policy titled Pest Control, and the maintenance log, the facility failed to maintain an effective pest control program for the following seven of seven sampled rooms (A-11, A-9, A-10, A-6, A-16, A-20, A-21) on B-Hall, one of one guest bathroom, and in tone one one faciliy kitchen.Findings included: Findings include:Review of the policy titled, Pest Control, the guidelines: This center maintains an ongoing pest control program to promote a center free of insects and rodents,Review of the pest control maintenance log showed the facilities routine maintenance schedule dates: 7/16/2025, 7/22/2025, 8/5/2025, 8/19/2025, Observation on 9/10/2025 at 9:00 am in room A-9, revealed when the Oxygen Concentrator was moved from the wall roaches came from behind and inside the concentrator, to many to countObservation on 9/10/2025 at 9:10 am in room A-11, revealed there were more than 20 roaches seen when the nightstand drawer was pulled out.Observation on 9/10/2025 at 9:15am in room A-21, revealed there were roaches in the windowsill.Observation on 9/10/2025 at 10:15 am of the kitchen revealed there were roaches were seen in the room with the refrigerators. Observation on 9/10/2025 at 11:10 am of room B-12 revealed there were roaches on the wall and the floor.Observation on 9/10/2025 at 11:15 am of room B-21 revealed there were roaches on the wall and the floor.Observation on 9/10/2025 at 11:22 am of room B-14 revealed there were roaches on the wall and the floor. Interview on 9/10/2025 at 8:30am with the Maintenance Director revealed that the pest control comes monthly and if they have an issues they will come more often, but he has not called them to come to because that is the administrator's job to call.Interview on 9/10/2025 at 9:15am with the Administrator revealed that it is his job to call for pest control, but he has not called. Interview on 9/10/2025 at 10:15 am with the Dietary Kitchen Manager revealed that that do have a problem with roaches, the roaches are usually seen near the dish washer.Interview on 9/10/2025 at 11:10 am with resident in room B-12 stated there were bugs in her food at times. She also stated that she had to keep bug spray to kill the roaches.Interview on 9/10/2025 at 11:34 am with housekeeping aid QQ revealed that they have had issues with roaches for several months.Interview on 9/10/2025 at 4:20pm with the Pest Control Technician revealed that he has been coming to the facility to provide the pest control, but when he is there some of the places that he needs to spray they have the doors locked and he is not able to find anyone to open the door, or when he needs to spray a residents room the staff get upset because they have to move the resident out of the room. The technician also revealed that there is a leak in the kitchen, and they are not going to get ride of the roaches until they get the leak fixed.

Based on observations, staff interviews, record review, and review of the facility's policy titled, SKILLED NURSING SERVICES Equipment Management, the facility failed to maintain good repair of residents' wheelchair armrests and wheelchair backs for three (3) of four (4) residents, (Resident (R) (R8, R39, and R47), that were observed to be either missing, torn, or tattered in appearance. The findings include: A review of the facility's policy titled, SKILLED NURSING SERVICES Equipment Management with a Review Date of 12/27/2024, revealed the following: INTENT It is the Intent of this center to implement a plan of scheduled equipment checks for specific equipment to facilitate properly functioning equipment. GUIDELINE .Documentation should be maintained related: Problems/concern identified including date concern noted immediate action actions taken for resolution . A review of the facility's Logbook Documentation revealed the following: .Task Name: Conduct Wheelchair inspections .Marked done on-time by Maintenance Assistance/Floor Technician (MF/FT) on 1/22/2025, 1/22/2025, 3/24/2025. This document review revealed the following wheelchair areas were checked OK: Upholstery-Back, Seat, Armrest, Leg rest panel; Wheels-Tires, Spokes, Bearings, Handrails, Adjustment; Casters-Tires, Stem bearings, Wheel bearings; Adjustment - NA (not applicable); Locks-Wheel, Arm; Back - Reclining -NA; Foot Rest-Right side, Left side; Misc (Miscellaneous) - Hand grips, Tripping . sleeves, Foot bumpers, Tube end caps, Lubrication, Clean. [sic] 1. Record review of R8's Face Sheet revealed an initial admitted [DATE] and a Readmitted [DATE], which included the following diagnoses: difficulty in walking, hereditary and idiopathic neuropathy, and peripheral vascular disease. A review of R8's current Quarterly Minimum Data Set (MDS) assessment, dated 3/19/2025, revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. A review of R8's care plan revealed the following: .Care Area/Problem At risk for skin impairment . Related To: Dx (diagnosis) of PVD (peripheral vascular disease) .Vascular disease .Evidence By : He is at risk for impairment in skin integrity .Skin Breakdown: at risk for/actual .Related To : Age and fragile skin .Evidence By : He is at risk for skin tears and bruising . [sic] A review of the resident's Physical Functioning Instructions revealed the resident's special equipment was a wheelchair. 2. Record review of R39's Face Sheet revealed an admitted [DATE], which included the following diagnoses: difficulty in walking, and lack of coordination. A review of R39's current Quarterly Minimum Data Set (MDS) assessment, dated 1/29/2025, revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, which indicated the resident's cognition was intact. A review of R 39's care plan revealed the following: .Care Area/Problem . Evidence By : Skin breakdown: at risk for/actual . Related To : . impaired mobility Evidence by : He is at risk for s/s (signs and symptoms) of pressure ulcers .Care Area/Problem Skin, fragile .Related To : Age and medication use .Evidence By : He is at risk for skin tears and bruising . [sic] A review of the resident's Physical Functioning Instructions revealed the resident's special equipment was a wheelchair. 3. Record review of R47's Face Sheet revealed an admitted [DATE], which included the following diagnoses: radiculopathy, lumbar region and arthritis. A review of the facility's Resident's Consolidated Order for R47, included the following diagnoses: difficulty in walking and type 2 diabetes. A review of R47's Admission Minimum Data Set (MDS) assessment, dated 1/29/2025, revealed the resident's Brief Interview for Mental Status (BIMS) score was one (1), which indicated the resident's cognition was severely impaired. A review of R 47's care plan revealed the following: .Care Area/Problem Skin breakdown: at risk for/actual .Evidence By: .He is at risk for pressure ulcers . Skin, fragile .Related To: . Age and medication use .Evidence by: He is at risk skin tears and bruising . [sic] A review of the resident's Physical Functioning Instructions revealed the resident's special equipment was a wheelchair. On 4/22/2025 at 12:45 p.m., during the initial tour, the following was observed: R8's wheelchair right armrest and back cover was observed to have tattered and torn areas, the right side of the back cushion cover was not connected to the wheelchair and was missing a screw. On 4/22/2025 at 12:55 p.m., during the initial tour, the following were observed: two wheelchairs were positioned in the hallway near Room B16 and B18. There were no visible names on the wheelchairs. The chair adjacent to Room B18 was observed to have discolored tape on the metal arm and no armrest. The left armrest and back of the wheelchair were observed with tattered and torn areas. The wheelchair that was positioned between Room B18 and Room B16 was observed to have tattered and torn areas to the back cushion and to the right armrest. On 4/22/2025 at 1:00 p.m., during an interview, with the Licensed Practical Nurse (LPN) AA, the surveyor asked her to observe the wheelchairs that were positioned at Room B18 and between Room B16. After LPN AA observed both wheelchairs, the surveyor asked who used the wheelchair located adjacent to Room B18. LPN AA stated that she did not know. The surveyor asked what was on the right arm of the wheelchair. LPN AA stated it appeared to be Coban tape, rubbed the armrest, and stated the armrest was not smooth and was stained. LPN AA also stated that both sides of the back of the wheelchair cushions were tattered and torn, and that was a potential risk for skin tears. The surveyor requested LPN AA to observe the wheelchair positioned between Room B18 and Room B16. After LPN AA observed the wheelchair, she stated that the back of the wheelchair was tattered and torn, and that the right armrest needed to be replaced as that was also a potential risk for skin tears. The surveyor requested for LPN AA to observe R8's wheelchair, which was in R8's room After LPN AA observed R8's wheelchair, she stated that the back cushion on the right side was not connected to the chair, it was missing a screw, and the right armrest was tattered and torn. Also, LPN AA stated those areas on the wheelchair had potential for R8 to sustain skin tears. On 4/22/2025 at 1:15 p.m., during an interview, with the Director of Nursing (DON) and Corporate Nurse (CN) CC, the surveyor requested them to observe the wheelchairs located outside of Room B16 and B18. The surveyor asked who was responsible for checking wheelchairs for repairs and how often. The DON stated the wheelchairs were checked every time prior to residents' usage and if there were issues with the wheelchairs, the Certified Nursing Assistants (CNAs) would notify maintenance. After the DON and CN CC observed the wheelchairs, the surveyor asked about where the wheelchairs were kept when they were not being used. The DON stated the wheelchairs should be kept in the maintenance department. The DON pointed at the wheelchairs and stated that both wheelchairs were ready for use by the residents, because they were in the hallway outside of the residents' room. The DON stated the chairs were used by R39 and R47. After reviewing the wheelchairs again, the DON stated there was nothing wrong with the wheelchairs. CNA DD was observed in the hall and was asked to observe the wheelchairs. She stated the wheelchair positioned at Room B18 had tears on the back of the chair, and the wheelchair between Room B16 and B18 was torn on the back of the wheelchair and the right arm rest was torn. She further stated that both wheelchairs could cause skin tears to the residents. On 4/24/2025 at 10:00 a.m., during an interview, with the Maintenance Assist/Floor Technician (MA/FT), the surveyor provided copies of the facility's Logbook Documentation dated 1/22/2025, 2/5/2025 and 3/24/2025 to the MA/FT to review. The surveyor asked how often wheelchair inspections were done. The MA/FT stated the wheelchair inspections were done monthly and as needed, and all wheelchairs in the facility were inspected. The MA/FT stated with the inspection, the wheelchairs' backs, the seat, and the armrest pads were inspected. She also stated that basically the entire wheelchair was inspected. The surveyor informed the MA/FT of the observation regarding the wheelchairs located near Room B16 and Room B18, and that the wheelchairs had tattered and torn areas and missing parts. The MA/FT stated the documentation on all three documents for the wheelchair inspection was incorrect.

Based on resident family and staff interviews, record review, and facility policy review, the facility failed to notify the responsible party of a resident's change in condition for one (1) of 20 sampled residents (Resident #5). Findings include: Review of a policy titled SKILLED NURSING SERVICES Changes in a Patient's Condition revised 12/27/24, indicated the following under Intent: It is the intent of the center to notify the patient, his/her attending physician and responsible party/patient representative of changes in the patient's condition and or status. Under Guideline: Nursing services is responsible for notifying the patient, his/her next-of-kin, or responsible party/patient representative, as each case may apply when: There is a significant change in the patient's physical, mental or emotional status. Review of the electronic medical record (EMR) revealed R#5 was admitted to the facility with diagnoses including, but not limited to blindness of left eye, dysphasia, gastrointestinal hemorrhage, severe protein calorie malnutrition and iron deficiency anemia. Review of R#5's significant change Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident was assessed to be dependent on staff for all activities of daily living (ADL). Review of the admitting Hospice note dated 1/23/25 indicated the resident's diagnosis to be Severe Protein Calorie Malnutrition. Review of the Physician Order for Life Sustaining Treatment (POLST) signed 12/16/24, (no time noted) for R#5 indicated a selection under CODE STATUS to ALLOW NATURAL DEATH-Do Not Attempt Resuscitation The documentation was signed by the resident designating her to be her own responsible party. Review of a Nursing Note dated 2/11/25 at 9:54 am indicated R#5 was lying in bed with eyes closed. Answer questions when asked but seems very weak. Noted with increased abdominal pulling. Sats at 89% at room air. Oxygen (O2) applied at two (2) liters. Sats increased to 96%. Resident has had poor appetite today with difficulty swallowing. Supervisor notified and will notify daughter. (sic) Review of a Physician Order dated 2/12/25, (no time indicated) Oxygen: Nasal Canula two (2) liter per minute nasally every eight (8) hours. DX (diagnosis): Shortness of Breath (SOB) Review of a Nursing Note dated 2/12/25 at 3:00 pm indicated R#5's daughter visited patient and requested patient be sent to the hospital due to O2 being low. Resident was sent to name of hospital. Patient is currently under the care of hospice. Hospice was called and notified of daughter's request and stated they would meet the daughter at the hospital to sign papers to revoke the hospice.(sic) Review of a Nursing Note dated 2/13/25 at 3:01 pm indicated patient's daughter called and notified us that the patient had passed away this morning at name of hospital. During an interview with R#5's daughter on 3/25/25 at 10:25 am, she stated she was very distressed over the facility not notifying her of the change in condition. In the past they have called me every time any change has occurred. During an interview on 3/25/25 at 11:39 am, Licensed Practical Nurse (LPN) B stated she had applied 2 liters per minute (LPM) of O2 to R#5 and informed the nursing supervisor who stated she would notify the physician and the family. During an interview with LPN Supervisor C on 3/25/25 at 11:56 am, she stated she had not called the family. During an interview on 3/25/25 at 12:35 pm, the Director of Nursing (DON) stated the family should have been notified.

Based on observation, staff interviews, record review, and review of the facility policy titled, 'Skilled Nursing Services-Elopement', the facility failed to provide supervision and monitoring to prevent the elopement of one resident (R1) of three resident reviewed for elopement resulting in R1 walking out of the facility into the parking lot and falling onto the ground. Findings include: Review of the facility policy titled, 'Skilled Nursing Services-Elopement' last reviewed 12/29/2023 revealed 'Definition: Elopement is defined when a patient leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or necessary supervision.' R1 was admitted to the facility with diagnoses including but not limited to nontraumatic intracerebral hemorrhage in hemisphere, subcortical, cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries, and anxiety disorder. Review of hospital discharge documentation dated 1/19/2024 revealed R1 had a history of falling and wandering away from home. On 1/24/2024 at 9:45 pm R1 was found outside of the facility sitting on the ground next to a dumpster by a Certified Nursing Assistant during her lunch break. R1 had bruising and bleeding on her nose. R1 was outside unsupervised for 30 minutes. Review of facility investigation revealed R1 walked out of the facility through the employee entrance that was not properly secured. Interview on 2/5/2024 at 10:10 am with Administrator revealed all external doors in facility require a code to enter and exit. Stated R1 was able to exit facility through the employee entrance/exit because the door did not properly close for some reason unknown to staff. Further revealed an audit was conducted on all doors the day following the incident and no other doors were found to have an issue. The door was closing properly when checked by the Corporate Maintenance Director. Observation of eight exit doors on 2/5/2024 at 11:15 am surveyor observed door on 'B' hall exit was able to be opened without putting in a code. Interview on 2/5/2024 at 1:05 pm with the Corporate Environment Director revealed all the doors were checked after resident was able to walk out of the door without putting in the door code. Stated the doors were found to be working properly at that time. Stated he is unsure why the door did not close properly the night of the incident and why the door on 'B' hall was able to be opened by surveyor without putting in the door code. Follow up interview on 2/5/2024 at 1:10 pm with Administrator revealed an outside company was coming to facility to check all of the doors to ensure they are working properly. R1 was discharged from facility on 1/29/2024 to another skilled nursing facility with a secure unit.

2. Review of the medical record revealed R#8 was an [AGE] year-old female, admitted in 2016, Do Not Resuscitate (DNR) and Allow Natural Death (AND) code status, and Brief Interview of Mental Status (BIMS) score of 14. Review of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revealed care area/problem included: a. Pulmonary disease related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included use of oxygen at 2 LPM via nasal cannula as ordered, initiated on 10/2/18, reviewed and continue date of 3/22/21. b. Patient requires the use of oxygen at 2 L/M via N/C PRN r/t Dx of [CONDITION(S)] (2 liters per minute via nasal canula related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Intervention included administrator oxygen as ordered, with an onset date of 10/2/18, reviewed and continue date of 3/22/21. During an observation on 5/24/21 at 12:59 p.m. and 2:25 p.m. R#8 was in bed with oxygen (O2) running at three liters per minute (LPM) via nasal cannula (N/C). During an observation on 5/25/21 at 2:47 p.m. R#8 was in bed with O2 running at three LPM via N/C. During an observation on 5/26/21 at 2:16 p.m. R#8 was lying in bed with O2 running at three LPM via N/C. During an observation on 5/27/21 at 9:59 a.m. R#8 was lying supine in bed with O2 running at 3.5 LPM via N/C. An observation on 5/27/21 at 10:07 a.m. with the Charge Nurse/Licensed Practical Nurse (LPN) AA, confirmed the O2 concentration was running at 3.5 liters and it should be on 2 liters. LPN AA confirmed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross Refer F695 Based on observation, record review, resident and staff interviews the facility failed to develop and implement a care plan related to catheter care for one of two residents (R) (R#24) with an indwelling catheter; and for one of four resident (R#8) receiving oxygen therapy. Findings include: 1. Review of R# 24's electronic medical record revealed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan, with an onset date of 1/14/21, indicated to position drainage bag below the level of the bladder, onset 5/6/2020, reviewed and continue date 1/14/21. Observation on 5/26/21 at 10:26 a.m., of R#24 sitting in wheelchair on hall A revealed the resident's catheter bag tied to left arm of wheelchair and level with seat of wheelchair. Observation on 5/27/21 at 9:58 a.m., revealed R#24 was sitting in wheelchair in the common area on hall A with catheter in a privacy bag and tied to left arm of wheelchair and level with the seat of wheelchair. Interview on 5/27/21 at 10:17 a.m., with Licensed Practical Nurse (LPN) AA, revealed R#24 had the catheter for [CONDITION(S)] and incontinence. LPN AA confirmed that the catheter bag was attached to the left arm of the wheelchair and was not hanging below the level of the bladder. Cross refer F690

Based on record review and resident and staff interview, and review of the facility policy titled, Skilled Inpatient Services, Patients Plan of Care it was determined that the facility failed to invite one of 19 sampled Residents (R#1) to participate in care plan meetings. The findings include: A review of policy titled, Skilled Inpatient Services, Patients Plan of Care, documented: The center will provide the patient and/or patient's representative with advance notice of care planning conferences to enable patient/patient representative participation at a time the patient/patient representative is available to participate, in person or via phone call/video conferencing. Record review revealed R# 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#1's most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 5/7/21, coded R#1 as being cognitively intact to make decisions of daily living. During an interview with R#1 in is room on 5/24/21 at 10:47 a.m., R#1 stated that he had not been invited to attend a care plan meeting to discuss his plan of care since his admission on 2/5/21. R#1 stated that he had never had a conversation with any of the staff members regarding care plan meetings. R#1 is listed as his own responsible party (RP). A review of R#1's clinical record did not reveal any documented evidence that R#1 had been invited to any care plan meetings since his admission to the facility. On 5/26/21 at 9:20 a.m., an interview with Licensed Practical Nurse (LPN BB), the MDS coordinator. LPN BB was asked who was responsible for inviting residents to their care plan meetings in the facility. LPN BB stated that a list was provided to the Interdisciplinary Team (IDT) and then given to the Social Services Director (SSD) who sends the invitations out to the family members/responsible party listed on the resident's face sheet. When asked how the residents who were cognitively intact were invited to the care plan meetings, LPN BB stated that SSD hand delivers invitations to residents who are self-responsible. A reminder is also given to residents the day of scheduled care plan meeting with time. Interview on 5/26/21 at 9:25 a.m. LPN BB stated that R#1 was not scheduled on the care plan list and was not invited and that he got over-looked.

Based on observation, record review and staff interview the facility failed to ensure Resident (R)#24's Foley catheter bag was always kept below the level of the bladder to promote adequate drainage of urine. This affected one of two sampled residents observed with Foley catheters. Findings Include: Review of the electronic medical record for R#24 revealed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for R#24, with an onset date of 1/14/21, indicated to position drainage bag below the level of the bladder. Observation on 5/25/21 at 9:13 a.m., revealed R#24 was sitting in a wheelchair with the resident's catheter bag inside a privacy bag hanging from the side of the wheelchair, not hanging below the level of the bladder. Observation on 5/25/21 at 2:42 p.m., revealed R#24 sitting in wheelchair in hallway resident's catheter bag was inside of dignity bag at seat level. Observation on 5/26/21 at 10:26 a.m., revealed R #24 sitting in a wheelchair on hall A resident's catheter bag was tied to the left arm of the wheelchair and level with seat of wheelchair. Observation on 5/27/21 at 9:58 a.m., revealed R #24 sitting in wheelchair in the common area on hall A with the resident's catheter in a privacy bag tied to left arm of wheelchair and level with the seat of wheelchair. Interview on 5/27/21 at 10:17 a.m., with Licensed Practical Nurse (LPN) AA, revealed R#24 has the catheter for [CONDITION(S)] and incontinence. LPN AA confirmed that the catheter bag was attached to the left arm of the wheelchair and is not hanging below the level of the bladder and it should be to ensure proper drainage of urine and to prevent a urinary tract infection (UTI). LPN AA said she didn't have an answer to why the catheter had been attached to the left arm of the wheelchair and not below the level of the bladder since 5/24/21. LPN AA said the Certified Nursing Assistant (CNA) must have attached the catheter bag to the left arm of the wheelchair or R#24 tied it there, but the nurse should have checked it. LPN AA confirmed that R#24 had not had any UTI's (urinary tract infections) in the last 30 days.

Based on observation, record review, resident and staff interview, and review of the facility policy titled, Use of Oxygen Therapy the facility failed to follow the Physician's Order for one of four residents (R) (R#8) receiving oxygen therapy. Findings include: Review of the policy titled, Use of Oxygen Therapy copyrighted 2020, revealed the intent was to ensure patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. 1. Resident #8 was an [AGE] year-old female, admitted in 2016, Do Not Resuscitate (DNR) and Allow Natural Death (AND) code status, and Brief Interview of Mental Status (BIMS) score of 14. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed R#8 had a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 5/24/21 at 12:59 p.m. and 2:25 p.m. R#8 was in the bed with oxygen (O2) running at three liters per minute (LPM) via nasal cannula (N/C). During an observation on 5/25/21 at 2:47 p.m. R#8 was in bed with O2 running at three LPM via N/C. During an observation on 5/26/21 at 2:16 p.m. R#8 was lying in bed with O2 running at three LPM via N/C. During an observation on 5/27/21 at 9:59 a.m. R#8 was lying supine in bed with O2 running at 3.5 LPM via N/C. An interview and observation on 5/27/21 at 10:07 a.m. with the Charge Nurse/Licensed Practical Nurse (LPN) AA, inside R#8's room with the surveyor, LPN AA was asked to confirm the O2 concentration. LPN AA confirmed the O2 was running at 3.5 liters and it should be on 2 and confirmed the physician order in the computer was for O2 at 2 LPM via NC. Interview at that time, LPN AA confirmed R#8 was on oxygen therapy for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview ,and the facility policy titled, Housekeeping Services and Safety Management Services -Plant Maintenance, the facility failed to maintain a safe, clean, and comfortable environment for five of 21 resident's bathrooms (A-5, B-9, B-12,B-18, and B-22) halls and four of four shower rooms (Hall A and Hall B shower rooms). Findings include: The facility policy titled, Housekeeping Services (February 2019) stated (a). Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. It is the intent of this center to maintain a clean and sanitary center that is free from odor and other environmental factors that may affect the quality of life of our patients. Routine Cleaning of Horizontal Surfaces (a). In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. The facility policy titled Safety Management Services (February 2019) stated It is the intent of this center that areas of the building, grounds, and equipment be maintained and properly serviced. 2. The following functions should be performed by plant operations but are not limited to: (B) Maintaining the building in good repair and free from hazards. (I) Providing routinely scheduled maintenance service to areas Record review of a document titled, 10 Step Cleaning Process Facilitator's Guide revealed standardized cleaning service for the housekeeping depart. Policy titled, Housekeeping Services dated revised (MONTH) 2019 revealed steps and instructions for cleaning the bathroom areas using chemicals. Observation on 7/10/19 at 11:15 a.m. and 3:05 p.m. of Room A-5 revealed a strong urine odor. Observation on 7/9/19 at 1:45 pm and 3:13p.m., 7/10/19 at 11:15 a.m., and 3:15 pm. of Room B-9 bathroom revealed strong urine odor in the bathroom Observation on 7/10/10/19 at 11:16 a.m. and 3:16 p.m. of Room B-12 bathroom revealed rust at the bottom of the door frame and a dark colored substance coating the tiles Observation on 7/10/19 at 3:12 p.m. of the bathroom in room [ROOM NUMBER] located on B Hall revealed missing tile by the doorway seal and a hole in the wall Observation on 7/10/19 at 2:00 p.m. of the bathroom in room [ROOM NUMBER] revealed brown coating on the sink. Observation on 7/10/19 at 2:01 p.m. of the light fixture in room [ROOM NUMBER] revealed dark stains and dead bugs, a skeleton of a lizard in the light fixture, coating the light ceiling fixtures, dead bugs and small holes in the ceiling. On 7/11/19 at 2:40 a.m., an environment tour was made with the Administrator of the resident 's bathrooms, shower rooms, and resident rooms about the environment concerns. During rounds of Room B22, the Administrator confirmed a skeleton of a lizard was in the light fixture. Continued observation with the Administrator on 7/11/19 at 2:50 p.m. of Room B9 the Administrator confirmed that there was a very bad old urine smell in the bathroom, In the bathroom of Room A5, the Administrator confirmed a very strong old urine smell in the bathroom. During an interview on 7/12/19 at 12:45 p.m., the Maintenance Supervisor (MS) revealed deep cleaning areas are performed in the shower rooms, resident 's bathroom, and all the common areas. Deep cleaning consists of removing the trash, wiping the toilet and floor. The MS stated the Administrator made him aware of the condition of the shower room yesterday and that his last observation of the shower rooms had been a few months ago. The MS stated his expectations are for staff to provide a sterile cleaning in all resident areas and that once a housekeeping or maintenance problem is identified, the problem is logged into maintenance log book. An observation made on 7/09/19 at 11:55 a.m., 7/10/19 at 9:14 a.m. and on 7/11/19 at 9:15 a.m. of the B-Hall Spa Room Long Hall Shower Room revealed missing and loose tile in the shower stall floor, brown colored matter buildup in the corner of the shower room, spider webs and spider in corner near floor and loose cement type material on floor near the cabinet. An observation made on 7/09/19 at 11:55 a.m., 7/10/19 at 9:14 a.m. and on 7/11/19 at 9:15 a.m. of the B-Hall Spa Room Short Hall Shower Room revealed missing tiles in the shower stall, standing water on the floor under the tub, and brown and green colored buildup in corner of the room near the back by the air conditioner. An observation made on 7/19/19 at 11:38 a.m., 7/10/19 at 9:55 a.m. and 7/11/19 at 9:38 a.m. of the A-Hall Spa Room Long Hall Shower Room revealed peeling ceiling material, exposed wires in the ceiling, and black substance on the ceiling. An observation made on 7/19/19 at 11:38 a.m., 7/10/19 at 9:55 a.m. and 7/11/19 at 9:38 a.m. of the A-Hall Spa Room Short Hall Shower Room revealed the bath tub was not clean and had dirt and dust and black spots in the bottom of the tub, the tub drains into a hole in the floor, the hole was not covered, and the drain part was in the tub and had a black substance and hair matted to it. An interview on 7/12/19 at 10:27 a.m. with Housekeeper BB revealed she cleans the shower rooms and residents' bathrooms daily. She indicated she does not clean the bathtubs. Observation on 7/9/19 at 11:30 a.m., bathroom of room A5 on hall A revealed a strong urine odor. Observation on 7/10/19 at 9:35 a.m., of room A5 on hall A revealed a strong and prevalent urine odor. Observation in bathroom of room A5 on hall A on 7/11/19 at 9:05 a.m., revealed that the strong urine odor continued to be present.

Based on record review, resident interview and staff interviews, the facility failed to offer one of five residents (R X) the choice of going to the shower verses receiving a bed bath. Findings include: Review of the medical record For R X revealed that she was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for Section C: Cognitive Patterns revealed that she has a Brief Interview of Mental Status (BIMS) score of 15, indicated the resident is cognitively intact and able to make her own decisions. Continued review of Section F: Preferences for Customary Routine and Activities revealed when it comes to how important a shower, bed bath, or tub bath, resident's response was noted to be very important. During an interview with R X on 7/10/19 at 10:16 a.m., she stated that she has never been to the shower but would love to go. Continued interview revealed that the reason that she did not go to the shower was because she was in a specialized wheel chair that could not be brought to the shower room. She stated that she was never given the option of a shower, but just given bed baths. Interview with Certified Nursing Assistant (CNA), GG on 7/10/19 at 10:30 a.m., revealed that she never asks residents if they want a shower, but goes by what is displayed in her electronic Kardex for reference of care for each resident she is assigned.

Based on observations, record review, resident and staff interviews the facility failed to follow the care plans for four of 15 residents (R#20, R#29, R#45, R#6) reviewed for Activities of Daily Living care plans. Findings include: 1. Record review revealed that Resident #20 (R#20) was admitted with [DIAGNOSES REDACTED]. Her Activities of Daily Living (ADL) abilities as noted in her most recent Minimum Data Set (MDS), was coded under Section G - Functional Status, G0120 Bathing for needing supervision and over sight help. Review of R#20's the individual comprehensive care plans for R#20 documented that she was independent with ADL's but required more assistance with bathing. During a review of the bath schedule provided by the Don revealed the following ADL information for R#20: out of 31 baths/shower opportunities, R#20 was provided only 3 bath/showers from (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30. During an interview with the Director of Nursing (DON) on (MONTH) 12, 2019 at 12:04 p.m., revealed that she expects the staff to follow the resident's care plan related to ADL care and according to their preferences. She also stated that refusals should be noted on the care plan. The DON stated that information about nail care, shaving, etc., were all lumped together under the ADL Care Plan. During an interview with the Administrator on 7/12/19 at 12:15 p.m., he stated that his expectations are that the care plans are followed by the staff to meet the resident's needs. He stated this would fall under the Director of Nursing's (DON) responsibility. He stated that if he had been made aware that the care plans were not being followed by the staff he would have corrected the problem. 2. Resident #29 (R#29) has [DIAGNOSES REDACTED]. Review of the most current quarterly Minimum Data Set (MDS) for R#29 dated 5/8/19 revealed section G-Functional Status-Bathing resident is Total Dependent requiring one person assist. Review of the Comprehensive Care Plans for R#29 revealed the following: Resident has limited Range of Motion (ROM0 to his left hand, right arm and hand. He requires the use of a splint to his right hand. He has a contracture to his right hand and is at risk for further contracture formation and decline in current contracture. Assist with ADL's as needed Resident is dependent with ADL's due to muscle weakness, [MEDICAL CONDITION] and tremors. Resident will not have complications due to ADL's during the review period. Medicated shampoo as ordered with hair washes. Provide assistance with self-care as needed. Observations made on 7/09/19 at 11:00 a.m. and observation and interview on 7/10/19 at 3:05 p.m. of R#29's revealed untrimmed, long, jagged finger nails with brown matter under the nails. R#29 stated he doesn't like his fingernails to be long and would not mind having them cleaned and trimmed. He stated he had a shower this morning (7/9/19), but that they did not offer to trim his nails. During a review of the bath schedule provided by the Don revealed the following ADL information for R#29: out of 30 baths/shower opportunities, R#29 was provided only 17 bath/showers from (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30. Further review revealed that there was not any evidence of any documentation that indicated that nail care had been provided for R#29. During an interview with the Director of Nursing (DON) on 7/10/19 at 11:56 a.m., she agreed that the number of baths/showers for R#29 were inadequate. She stated there is no documentation to indicate if those baths/showers were offered to the resident. She stated that she expected the CNA's to give all resident's their bath/showers according to the individual resident's bath/shower schedule. She stated that R#29's bath/shower schedule is set for every Tuesday, Thursday and Saturday on the evening shift and nail care should be completed during ADL care. An interview on 7/12/19 at 10:02 a.m. with CNA AA revealed that R#29 is total care and needs two persons assist with Activities of Daily Living (ADL)'s. He does not refuse his showers or nail care. An interview on 7/12/19 at 10:06 a.m. with the Director of Nursing (DON) revealed she would expect the residents to get their showers as scheduled and nails trimmed on their shower days or as needed. 3. Resident #45 (R#45) has [DIAGNOSES REDACTED]. Review of the most current quarterly Minimum Data Set (MDS) for R#45 dated 5/29/19 revealed section G-Functional Status-Bathing resident needs supervision. Review of R#45's Comprehensive Care Plans revealed the following: ADL deficit: Resident will continue to assist with ADL's as able during the review period. He is independent with most ADL's He requires more assist with bathing Observations made on 7/09/19 at 11:00 a.m., 7/10/19 at 3:01 p.m. and 7/11/19 at 12:56 p.m. of R#45 revealed the residents finger nails were long, untrimmed, jagged, with brown matter under the nails. During a review of the bath schedule provided by the Don revealed the following ADL information for R#45: out of 30 baths/shower opportunities, R#45 was provided only 14 bath/showers from (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30. Further review revealed that there was not any evidence of any documentation that indicated that nail care had been provided for R#45. During an interview with the DON on 7/10/19 at 11:56 a.m., she agreed that the number of baths/showers for R#45 were inadequate. She stated there is no documentation to indicate if those baths/showers were offered to the resident. An interview on 7/11/19 at 12:56 p.m. Interview with R#45 revealed the resident washes himself every day in the bathroom. He indicated his nails do need to be trimmed. An interview held on 7/12/19 at 10:06 a.m. with the DON revealed she would expect the residents to get their showers as scheduled and nails trimmed on their shower days or as needed. Cross Refer F677 4. Record review revealed that R#6 was admitted with [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADL) abilities as noted in his most recent Minimum Data Set (MDS), was coded under Section G - Functional Status, G0120 Bathing for total dependence requiring one-person physical assist. During a review of the bath schedule provided by the Don revealed the following ADL information for R#6: out of 31 baths/shower opportunities, R#6 was provided only nine bath/showers from (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30. During an interview with R#6 on (MONTH) 10, 2019 at 2:05 p.m. he stated that he has not received a bath or shower in seven days. He stated that he is supposed to get a bath every other day but that doesn't happen. He stated he went seven days without a bath. He stated the last time he received a bed bath was last Thursday. Further interview with R#6 revealed that he has had only two showers since (MONTH) of last year which is his preference. He stated he would not mind a shower if they don't hurt his hip. During an interview with Resident Care Coordinator CC on 7/10/19 at 3:00p.m., she stated that R#6's bath/shower schedule is set for every Monday, Wednesday and Friday. During an interview with the Director of Nursing (DON) on (MONTH) 12, 2019 at 12:04 p.m., she stated that she expects the staff to follow the resident's care plan related to ADL care and according to their preferences. She also stated that refusals should be documented on the care plan. The DON stated that information about nail care, shaving, etc., were all lumped together under the ADL Care Plan.

Based on record review, and resident and staff interviews the facility failed to offer baths/showers for four of 15 residents (R#20, R#29, R#45, R#6) reviewed for baths/showers. Findings include: 1. Resident #20 (R#20), admitted on [DATE] with [DIAGNOSES REDACTED]. Her Activities of Daily Living (ADL) abilities as noted in her most recent Minimum Data Set (MDS), was coded under Section G - Functional Status, G0120 Bathing for needing supervision and over sight help. During a review of the bath schedule provided by the Director of Nursing (DON) revealed the following ADL information for R#20: out of 31 baths/shower opportunities, R#20 was provided only 3 bath/showers from (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30. During an interview with R#20 on (MONTH) 9, 2019 at 2:05 p.m. she stated that she never gets a bath or shower offered to her. She stated that she usually just cleans up in her sink because they won't come and assist her in the shower room. During an interview with the Director of Nursing (DON) on 7/10/19 at 11:56 a.m., she agreed that the number of offerings of baths/showers for R#20 were inadequate. She stated there is no documentation to indicate if those baths/showers were offered to the resident of if she refused. She stated that she expected the certified nursing assistants (CNA's) to give all resident's their bath/showers according to the individual resident's bath/shower schedule. She stated that R#20's bath/shower schedule is set for every Tuesday, Thursday and Saturday. During an interview with the Administrator on 7/12/19 at 7:59 a.m., he stated he did not know why residents weren't getting showers. During the first part of (MONTH) 2019 the staffing ratio was 2.68% and residents were still not getting showers. He stated he was aware that some showers were not being given but he had no idea that it was to such a great extent until this interview. He stated he thought the DON was taking care of this situation. He also stated residents mentioned they were not getting showers and he was told by the nursing staff that the residents had refused. The Administrator stated monitoring of this task would fall under the DON's job description. He stated that his expectations are that a resident can have a bath every day if they wanted one, but at least two times a week. He stated he was surprised that there was no policy for ADL care or care and services for this facility. 2. Resident #29 (R#29) had [DIAGNOSES REDACTED]. Review of R#29's most current quarterly Minimum Data Set ((MDS) dated [DATE] revealed section G-Functional Status-Bathing resident is Total Dependent with one person assist. Review of R#29's Comprehensive Care Plans revealed the following: Resident has limited Range of Motion (ROM) to his left hand, right arm and hand. He requires the use of a splint to his right hand. He has a contracture to his right hand and is at risk for further contracture formation and decline in current contracture. Assist with ADL's as needed. Resident is dependent with ADL's due to muscle weakness, [MEDICAL CONDITION] and tremors. Resident will not have complications due to ADL's during the review period. Medicated shampoo as ordered with hair washes. Provide assistance with self-care as needed. Observations made on 7/09/19 at 11:00 a.m. and 7/10/19 at 3:05 p.m. of R#29's revealed untrimmed, long, jagged finger nails with brown matter under the nails. Resident indicated he doesn't like them long and would not mind having them cleaned and trimmed. He stated he had a shower this morning (7/9/19), but they did not offer to trim his nails. During a review of the of the ADL information for R#29 revealed a total of 17 bath/showers were provided during the time-frame of (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30 possible opportunities. There was no indication that nail care was provided. This bath schedule was provided by the DON. A break-down of this information is as follows: During a review of the bath schedule provided by the Don revealed the following ADL information for R#29: out of 30 baths/shower opportunities, R#29 was provided only 17 bath/showers from (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30. Further review revealed that there was not any evidence of any documentation that indicated that nail care had been provided for R#29. During an interview with the Director of Nursing (DON) on 7/10/19 at 11:56 a.m., she agreed that the number of baths/showers for R#29 were inadequate. She stated there is no documentation to indicate if those baths/showers were offered to the resident. She stated that she expected the CNA's to give all resident's their bath/showers according to the individual resident's bath/shower schedule. She stated that R#29's bath/shower schedule is set for every Tuesday, Thursday and Saturday on the evening shift and nail care should be completed during ADL care. An interview held on 7/12/19 at 10:02 a.m. CNA #AA revealed the resident is total care and needs two persons assist with Activities of Daily Living (ADL)'s. He does not refuse his showers or nail care. An interview held on 7/12/19 at 10:06 a.m. with the Director of Nursing (DON) revealed she would expect the residents to get their showers as scheduled and nails trimmed on their shower days or as needed. 3. Resident #45 (R#45) has a [DIAGNOSES REDACTED]. Review of R#45's most current quarterly Minimum Data Set ((MDS) dated [DATE] revealed section G-Functional Status-Bathing resident needs supervision. Review of R#45's Comprehensive Care Plans revealed the following: ADL deficit: Resident will continue to assist with ADL's as able during the review period. He is independent with most ADL's He requires more assist with bathing Observations made on 7/09/19 at 11:00 a.m., 7/10/19 at 3:01 p.m. and 7/11/19 at 12:56 p.m. of R#45 revealed the residents finger nails were long, untrimmed, jagged, with brown matter under the nails. During a review of the bath schedule provided by the Don revealed the following ADL information for R#45: out of 30 baths/shower opportunities, R#45 was provided only 14 bath/showers from (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30. Further review revealed that there was not any evidence of any documentation that indicated that nail care had been provided for R#45. During an interview with the DON on 7/10/19 at 11:56 a.m., she agreed that the number of baths/showers for R#45 were inadequate. She stated there is no documentation to indicate if those baths/showers were offered to the resident. She stated that she expected the CNA's to give all resident's their bath/showers according to the individual resident's bath/shower schedule. She stated that R#45's bath/shower schedule is set for every Tuesday, Thursday and Saturday. Nail care should be completed during ADL care. An interview held on 7/11/19 at 12:56 p.m. Interview with R#45 revealed the resident washes himself every day in the bathroom. He indicated his nails do need to be trimmed. An interview held on 7/12/19 at 10:06 a.m. with the DON revealed she would expect the residents to get their showers as scheduled and nails trimmed on their shower days or as needed. There was no policy for ADL care or care and services for this facility. 4. Record review revealed that R#6 was admitted with [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADL) abilities as noted in his most recent Minimum Data Set (MDS), was coded under Section G - Functional Status, G0120 Bathing for total dependence requiring one-person physical assist. During a review of the bath schedule provided by the DON revealed the following ADL information for R#6: out of 31 baths/shower opportunities, R#6 was provided only nine bath/showers from (MONTH) 1, 2019 through (MONTH) 10, 2019 with 30. During an interview with R#6 on (MONTH) 10, 2019 at 2:05 p.m. he stated that he has not received a bath or shower in seven days. He stated that he is supposed to get a bath every other day but that doesn't happen. He stated he went seven days without a bath. He stated the last time he received a bed bath was last Thursday. Further interview with R#6 revealed that he has had only two showers since (MONTH) of last year which is his preference. He stated he would not mind a shower if they don't hurt his hip. During an interview with Resident Care Coordinator CC on 7/10/19 at 3:00p.m., she stated that R#6's bath/shower schedule is set for every Monday, Wednesday and Friday. During an interview with the Director of Nursing (DON) on (MONTH) 12, 2019 at 12:04 p.m., she stated that she expects the staff to follow the resident's care plan related to ADL care and according to their preferences. She also stated that refusals should be documented on the care plan. The DON stated that information about nail care, shaving, etc., were all lumped together under the ADL Care Plan.

Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of 19 of 36 rooms on two of two halls. The facility census was 63 residents and the sample size was 26 residents. Findings include: Observation on 5/16/17 at 3:27 p.m. in room A22 revealed a large gap between the end of the privacy curtain and the wall. Environmental tour with Maintenance Supervisor and Housekeeping Supervisor on 5/18/17 from 11:51 a.m. to 1:10 p.m. Observations revealed resident privacy curtains had a width space/gap of 80 inches or less, which did not ensure full visual privacy coverage during patient care, including rooms A5, A6, A7, A8, A9, A11, A13, A15, A17, A18, A19, A20, A21, A22, A23, A24, B10, B16, and B17. There was an 80 inch space/gap from end of privacy curtain for Bed A and the wall in room A22. Interview on 5/18/17 at 11:58 a.m. with the Housekeeping Supervisor revealed that he was not aware of the short privacy curtains. Interview on 5/18/17 at 12:50 p.m. with the Maintenance Supervisor who reported that management staff complete Zone defense rounding. It was further revealed that management staff are assigned to specific rooms in which they are to inspect to assure that there are no concerns in the room. Interview on 5/18/17 at 12:59 p.m. with the Assistant Director of Nursing (ADON) who confirmed that she does have a room assignment with Zone Defense rounding but she does not look at privacy curtains as that is a task that is the responsibility of housekeeping. ADON reported that she follows the layout of the form and she has not noticed any short privacy curtains. Interview on 5/18/17 at 2:02 p.m. with Certified Nursing Aide (CNA) AA, CNA, reported that the privacy curtains are pulled during care but she has not paid attention to whether or not the curtains touch from one wall to the next. Interview on 5/18/17 at 2:55 p.m. with the Administrator provided documentation titled Discrimination of Patients. The Administrator reported that the facility does not have a policy related to privacy curtains and the closest thing to a policy that the facility has states that a closed door or drawn curtain shields patient from passersby. The Administrator reported that the Zone defense department heads are assigned to an area/residents and check to assure that identified equipment is in order. The Director of Nursing (DON) reported that it has not been identified that gaps being a problem with privacy curtains, however, they had identified that some curtains were too short for residents in low beds and curtains were ordered accordingly.

Based on observation and staff interview, the facility failed to ensure expired medications were properly disposed in a timely manner for one (1) of two (2) medication room refrigerators. Findings Include: Observation on 7/30/15 at 9:33 a.m. in the medication room refrigerator on Hall B revealed the six (6) unopened single dose vials of 20 mcg/ml of Hepatitis B vaccine with an expiration date of 6/28/15. During an interview on 7/30/15 at 9:40 a.m. with the unit supervisor for B hall, he/she confirmed the vaccine was expired. He/she stated the vaccine is offered and administered to all residents and employees who desire one at various times.

Based on observation, interview and health record review the facility failed to follow the Plan of Care regarding diabetic monitoring of fingerstick blood sugars (FSBS) for two (2) of four (4) residents with diabetes sampled (#1 and #3). Findings include: Health record review for Resident #1 indicated a [DIAGNOSES REDACTED]. The FSBS were not recorded though the results were elevated and requires sliding scale insulin every night in February. Review of the Plan of Care for Resident #1 dated 2/14/12 indicated a plan for diabetes, risk for hypo/[MEDICAL CONDITION]. The interventions included observing for signs and symptoms of hyper/[DIAGNOSES REDACTED] and FSBS as ordered. Additionally, health record review for Resident #3 indicated a [DIAGNOSES REDACTED]. Review of the Plan of Care for Resident #3 dated 9/22/2010 indicated plan for [DIAGNOSES REDACTED]. The interventions included to observe blood sugars as needed and notify MD as needed.

Based on observation, interview and health record review the facility failed to follow the physician's orders for fingerstick blood sugars (FSBS) for two (2) of four (4) residents with diabetes sampled (#1 and #3). Findings include: Review of the Patient Information Summary for Resident #1 indicated [DIAGNOSES REDACTED]. An interview and observation of the medications for Resident #1 was conducted with the administrator and the medication nurse " AA " on 2/15/14 at 12:55 PM. The medication nurse explained that Resident #1 ' s Fingerstick Blood Sugars (FSBS)checks were done on the 7 PM to 7 AM shift not the day shift. Review of the Physician Orders for the month of February 2014 for Resident #1 indicated that FSBS were to be done at 6 AM and 9 PM daily and to use the sliding scale for insulin coverage. Review of the Medication Administration Record (MAR) for Resident #1 for the month of February 2014 indicated that FSBS were scheduled twice a day at 6:00 AM and at 9:00 PM. Review of the results of the FSBS that were recorded on the MAR indicated that Resident #1 ' s blood sugars had been elevated every night at 9 PM and required sliding scale insulin coverage each night that it was checked. Nurse " AA " admitted that she was on duty on 2/11/2014 at 9 PM and failed to check the Resident ' s blood sugar. Review of the Medication Administration Record for Resident #1 also indicated that the blood sugar check was omitted at 9 PM on 2/12/14. Medication nurse " AA " said that he/she was not on duty that night but acknowledged the blood sugar was not checked. Review of the Plan of Care for Resident #1 dated 2/14/12 indicated a plan for diabetes, risk for hypo/[MEDICAL CONDITION]. The interventions included observing for signs and symptoms of hyper/[DIAGNOSES REDACTED] and FSBS as ordered. Review of the Physician's Order Sheet for February 2014 for Resident #3 indicated [DIAGNOSES REDACTED]. Review of the Physician ' s Orders for February 2014 for Resident #3 indicated that FSBS were to be performed twice daily at 6:00 AM and 4:00 PM with sliding scale insulin coverage. Review of the MAR for Resident #3 indicated that the FSBS was elevated each recorded reading at the 4:00 PM check and required sliding scale insulin coverage. Review of the MAR for Resident # 3 indicated that the nurse failed to record the FSBS on 2/11/14 and 2/12/14. During the same interview on 2/15/14 at 12:55 PM Nurse " AA " stated that he/she knew that the FSBS was done on 2/12/14 at 6 AM but he/she forgot to record the results on the MAR. Nurse "AA" acknowledged that there was no evidence that Resident #3 had a FSBS or sliding scale insulin coverage on 2/11/14 or 2/12/14. Review of the Plan of Care for Resident #3 dated 9/22/2010 indicated plan for [DIAGNOSES REDACTED]. The interventions included to observe blood sugars as needed and notify MD as needed.

Based on observations and staff interview, it was determined that the facility failed to ensure that one resident's (#54) non-pressure related skin changes were communicated to the licensed nursing staff for evaluation in a total sample of 30 residents. Findings include: Resident #54 had [DIAGNOSES REDACTED]. It was observed on 8/27/12 at 12:30 p.m. that resident #54 had redness in the fold of the skin on the left side of his/her neck. A review of the resident's medical record revealed [REDACTED]. Nursing staff completed resident #54's readmission assessment on 8/24/12 but, they did not identify any redness on the resident's neck at that time. The staff developed a 8/24/12 care plan for the resident which included an intervention for nursing staff to do routine skin assessments. The occupational therapist evaluated the resident on 8/27/12 and completed his/her "Plan of Treatment for Outpatient Rehabilitation" form. The occupational therapist noted that the resident had complained about having neck pain and that there was some redness on his/her neck. However, there was no evidence that the occupational therapist had reported that information to the nursing staff. It was observed with certified nursing assistant (CNA)"FF" and the licensed treatment nurse, "EE" on 8/30/12 at 11:10 a.m., that there was a reddened area under the fold of the skin on the left side of the resident's neck. At that time, CNA "FF" and licensed nurse "EE" denied having previously been aware of the redness. During an Interview on 8/30/12 at 11:20 a.m., the Director of Nursing stated that the resident was scheduled to be bathed on Tuesday and Thursday by the 3-11 shift . However, the DON had not been able to determine if the resident had been bathed on 8/28/12 (Tuesday). The DON stated that when the treatment nurse had completed the resident's readmission assessment, there had not been any redness on his neck. The DON said that resident #54 has had a history of [REDACTED]. The DON said that she had seen the occupational therapist's 8/27/12 note but had not reported the redness identified on left side of the resident's neck to anyone.

Based on record review and staff interview, it was determined that the facility failed to provide restorative nursing services in a timely manner for two residents (#40 and #54) to maintain their range of motion, bed mobility and/or ambulation abilities in a total sample of 30 residents. Findings include: 1. Resident # 40 had [DIAGNOSES REDACTED]. The 7/4/12 nurses note documented that the resident was found sitting on the floor and told nursing staff that he/she had slid out of the bed. The resident was referred to skilled physical therapy (PT)and occupational therapy (OT) services because of weakness. The resident received skilled occupational therapy services from 7/6/12 to 8/8/12, and was then discharged to a functional program. The 8/8/12 OT Functional Program included instructions from the occupational therapist that restorative nursing should provide range of motion exercises for the resident's upper extremities at least six days a week beginning on 8/9/12. The form was signed by two facility caregivers. However, a review of the August Restorative Program Flow Sheet revealed no evidence that restorative nursing staff had begun providing range of motion exercises until five days later on 8/14/12. The resident received skilled physical therapy services from 7/6/12 until 8/1/12 and was then discharged to a functional program. The 8/1/12 PT Functional Program form had instructions from the physical therapist for restorative nursing staff to ambulate the resident with a rolling walker and for the resident to attend group exercises for the lower extremities for six days a week, beginning on 8/02/12. The form was signed by two facility staff caregivers. However, a review of the August Restorative Program Flow Sheet revealed no evidence that staff ambulated the resident with a rolling walker or took him/her to ambulation and group exercise services until five days later on 8/7/12. During an interview on 8/29/12 at 2:30 p.m., licensed nurse "DD" stated that the facility only had one restorative certified nursing assistant (RCNA) and she just could not do it all. The licensed nurse stated that she did not know that resident #40 was supposed to be started in the functional program until she went to the facility's utilization review meeting. 2. Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's medical record, the resident received skilled physical therapy (PT) services from 3/5/12 to 3/30/12, then he/she was discharged to a functional program for active range of motion exercises and bed mobility. There was an Occupational Therapy(OT) discharge note that the resident had been provided skilled occupational therapy services from 3/5/12 to 3/22/12 and then was discharged to a functional program for range of motion exercises for his/her upper extremities. Both the 3/30/12 physical therapist and 3/23/12 occupational services functional program instruction sheets were signed by facility caregivers. However, during an interview on 8/29/12 at 2:30 p.m., licensed nurse, "DD" stated that the resident had not been provided restorative nursing services because she had not been given the instructions for them to start.

Based on observation, record review and resident and staff interview, it was determined that the facility failed to ensure that one resident ("X") with a hand contracture was provided services to prevent a further increase in the contracture from a sample of 30 residents. Findings include: Res "X" was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident received occupational therapy (OT) services from 6/5/12-8/2/12 for limitations in his/her upper extremities. According to the 8/2/12 Functional Program form, the restorative nursing program was supposed to provide the resident active range of motion exercises for his/her bilateral upper extremities using a two (2) pound dumbell at least six times a week and the application of an air soft resting hand splint on his/her left hand for four hours every day. The resident's Functional Program was supposed to start on 8/3/12. The Functional Program form had been signed by restorative aide "CC" to indicate that she/he had received training. On 8/27/12 at 2:54 p.m., licensed nursing staff "BB" stated that the resident had a contracture of his/her left arm. He/She said that resident "X" did not wear any splint devices or receive range of motion services. It was observed on 8/28/12 at 8:57 a.m., that the resident had a contracture of his/her left hand and fingers. However, the resident was not wearing a splint. During an interview on 8/29/12 at 8:40 a.m., restorative aide "CC" stated that she/he did not provide restorative services for the resident and that the resident did not wear a splint device. On 8/29/12 at 9:30 a.m., the resident did not have a splint device on his/her left hand. At that time, resident "X" said that he/she used to wear a splint on his/her left hand, but that staff had not applied it in approximately three weeks. Resident "X" stated that he/she did not know why staff no longer applied the splint. During an observation on 8/29/12 at 11:00 a.m., the resident was sitting in his/her wheelchair in the dining room participating in group exercises with other residents and staff. The resident was observed to do some limited exercises with his/her left arm. However, staff had not provided resident "X" with a dumbbell to lift during the exercises. The resident did not have on a splint. In an interview on 8/29/12 at 12:30 p.m. and 2:10 p.m., the resident did not have a splint device on his/her left hand. In interviews on 8/29/12 at 2:10 p.m., the resident stated that he/she only participated in the group exercises once or twice a week, but not daily. On 8/29/12 at 4:45 p.m. and on 8/30/12 at 8:45 a.m., 10:00 a.m. and 11:30 a.m., the resident did not have a splint device on his/her left hand. During an interview on 8/30/12 at 9:30 a.m., the physical therapist (PT) stated that the resident was discharged to restorative nursing services on 8/2/12. The physical therapist stated that she would expect restorative nursing services to be initiated the next day. On 8/30/12 at 11:30 a.m. the restorative nurse "DD" stated that she/he was not aware that the resident had been placed on a restorative program. "DD" stated that she did not know that the Functional Program form had been placed in the resident's chart nor had she been told by the therapist that the resident was being placed on restorative services. "DD" stated that the therapist was suppose to instruct "DD" and the restorative aide about the resident's functional program and then both of them were supposed to sign the Functional Program form. "DD" stated that she/he inputs the resident's Functional Program in the computer so that she could monitor the resident's progress. Although Restorative CNA "CC" had signed the form rather than both of them, the restorative nurse denied being aware of the functional program. The facility failed to ensure restorative nursing staff was providing services to resident "X according to the instructions from the skilled therapist.