Every finding on record at Fort Walton Rehabilitation Center, LLC

Based on observations, interviews and record Review, the facility failed to provide maintenance services to maintain a clean, safe living environment for 2 of 4 bathrooms observed in Hallway 200. (rooms [ROOM NUMBERS]) The findings include: On 06/23/25 at approximately 8:45 AM, an environmental observation was made in room [ROOM NUMBER], where holes were noted in the wall adjacent to the television and scratches were noted behind the bed. (Photographic evidence obtained) On 06/23/25 at approximately 9:50 AM, an observation in room [ROOM NUMBER] revealed peeling paint and a hole in the bathroom wall near the sink, with visible plaster residue deposited on the sink surface. Additionally, the bathroom faucet exhibited a buildup of a greenish hard biofilm. (Photographic evidence obtained) On 06/25/25 at approximately 12:16 PM, an interview was conducted with the Maintenance Technician. He explained the current process for reporting and addressing maintenance concerns, noting that any staff member may submit a work order, which can be recorded in maintenance logbooks located at each nursing station and in the kitchen. The Maintenance Technician further explained that both he and the Maintenance Director conduct monthly inspections to proactively identify and address areas in need of repair. During the interview, he assessed the bathroom wall and faucet in room [ROOM NUMBER]'s bathroom. He acknowledged the crumbling wall and the greenish biofilm buildup on the faucet, stating that the accumulation appeared to have developed over an extended period. He concluded that the condition was not acceptable and in need of corrective action. On 06/26/25 at approximately 11:35 AM, an interview was conducted with the Maintenance Director. He reported that he is responsible for reviewing the facility's work order book daily and addressing repairs requests accordingly. He clarified that the maintenance department consists of only himself and one technician and that the facility is currently undergoing renovations. During the interview, he assessed the bathroom wall and sink faucet in room [ROOM NUMBER]'s bathroom. He acknowledged that the wall above the sink was in poor condition with the crumbling deposit around the sink and confirmed the presence of a greenish biofilm buildup on the faucet. He indicated awareness of the need to repair the wall and replace the faucet and recalled discussing the matter previously with the Administrator. He explained that the repair priorities are determined in consultation with the Administrator and emphasized that renovation efforts are ongoing but take time to complete in addition to the daily repairs. On 06/26/25 at approximately 11:45 AM, an interview was conducted with the Administrator and the Maintenance Director. She confirmed her understanding of the facility's maintenance request and repair process. During the interview, the Administrator personally assessed the bathroom in room [ROOM NUMBER]. She acknowledged the deteriorating condition of the wall, noting crumbling deposits, as well as the presence of the greenish biofilm buildup on the faucet. She added that repairs would be made if deemed necessary. She agreed that the condition of the bathroom did not reflect a home-like or safe environment and acknowledged that the area was not in good repair. A record review of the 200 Hall Work Orders was reviewed. No work order was placed for the wall condition crumbling or the bathroom faucet with bio built up in Rooms 204 or 206.

Based on observations, resident and staff interviews, and record reviews, the facility failed to ensure 1 of 26 residents reviewed medical record was clear and accurately documented in accordance with accepted professional standards and practices. (Resident # 413) The findings include: On 06/23/2025 at approximately 2:00 PM, Resident #413 was observed lying in bed with hard braces on the bilateral lower extremities which were noticeably swollen. The resident stated that she fell at home a week ago, had surgery, and was admitted to this facility. When asked if she has done any physical therapy, the resident answered yes, but it is hard with the braces on both legs. She stated she has pain and takes extra-strength Tylenol for it. She then began to say that she found out that she has Deep Vein Thrombosis (DVT) (a condition where a blood clot forms in a deep vein) in both legs and has to take Eliquis (an anticoagulant that helps prevent blood clots) for it. The resident stated she was admitted to the facility on [DATE]. Resident #413's record revealed that she does have diagnoses including DVT. The Orthopedic Surgery Report on 06/12/2025 documented that the resident had a ground level fall, fractured right and left lower femurs, had surgery to both legs with no complications. The plan included pain control, nonweightbearing to both lower extremities, maintain hinged braces, Physical Therapy/Occupational Therapy, DVT prophylaxis, and start on Lovenox (another anticoagulant that helps prevent blood clots) for known bilateral DVTs. The Orthopedic Progress Report on 06/15/2025 at 1:32 pm states to use the prophylaxis therapy Lovenox. But when her hemoglobin and hematocrit (H&H) stabilized post transfusion, they would switch to Eliquis therapy. On 06/19/2025 at 4:16 pm and 6/23/2025 at 10:45 am, the Nurse Practitioner (NP) wrote in the electronic record, History of DVTs was previously on eliquis but stopped taking- continue lovenox. However, in the Medication Administration Record, she appeared to be receiving Eliquis 5mg once every 12 hours, with no Lovenox is ordered. On 06/26/2025 at approximately 8:25 AM, an interview with nursing staff took place with Nurse K, Nurse C, and Unit Manager B. They stated that Resident #413 was monitored for pain every 8 hours. When asked to review the medication orders versus what the NP ordered, they acknowledged that she was taking Eliquis but the orders appeared to state that she should be continuing the Lovenox. On 06/26/25 at 11:20 AM, a telephone Interview with the NP was conducted. She stated that this resident had bilateral femur fractures and she should be on Lovenox. She stated that Eliquis should be started when the resident's Hemoglobin lab numbers are between 8.5 and 9, thereby indicating her condition was stable. A record review of her recent lab results on 06/14/2025 indicated a Hemoglobin level of 7.7; on 6/15/2025, she had a Hemoglobin level of 6.7; and on 6/20/2025 her Hemoglobin level was 7.7.

Based on observation, interview and record review, the facility failed to provide accurate Minimum Data Set (MDS) Resident Assessments on 5 of 6 residents sampled. (Residents #1, #5, #68, #78 and #92) The findings include: Resident #5 Resident #5's electronic medical record revealed a significant change minimum data set (MDS) with an assessment reference date of 1/13/23 that indicated, in section A.1500, that the resident is not considered by the state level II PASARR (Preadmission Screening and Resident Review) process to have serious mental illness and/or intellectual disability or a related condition. The record revealed a PASARR level II summary dated 3/21/19 indicating a diagnosis of Schizoaffective Disorder, which meets the state definition of serious mental illness. The record also contained a level I PASARR dated 6/19/18 indicating a PASRR level II evaluation was not required. An interview was conducted with employee B (Registered Nurse) on 1/23/23 at 2:35 PM. She stated she coded the MDS based on the level I review completed on 6/19/18 indicating she did not require a level II screening. She stated she did not see the level II and would have coded the the MDS differently if she had. 35609 Resident #68 On 1/23/22, a record review was conducted for resident #68. The quarterly MDS assessment completed on 1/22/22 documented the resident had received anticoagulant medication for 7 days immediately prior to the assessment. A review of the active, discontinued and completed orders revealed the resident did not have orders and had not been administered anticoagulant medications but had an order for and received Clopidogrel Bisulfate Tablet, an antiplatelet medication. 42926 Resident #1 A record review for Resident #1 on 1/23/2023 at approximately 12:30 PM noted a diagnosis of Unspecified Intellectual Disabilities dated 12/23/2007 and Cerebral Palsy dated 11/8/2022. A record review for resident #1 performed on 1/23/2023 at approximately 12:45 PM noted a Request for Level II PASARR Evaluation and Determination dated 12/13/2010. The Level II Determination for Mental Retardation dated 1/27/2011 acknowledges that specialized services were not needed. A record review of the Minimum Data Set (MDS) dated [DATE] noted no documentation in Section A1500 that acknowledged a Level II PASARR was completed for a diagnosis of Mental Retardation/Developmental Delay (MR/DD). A record review of the Annual MDS Assessment for Resident #1 dated 3/3/2011 noted no documentation in section A1500 acknowledging a diagnosis of MR/DD and/or the completion of a Level II PASARR screen. A record review of the Annual MDS Assessment for Resident #1 dated 6/4/2022 noted in section A1500 documented that Resident #1 was not considered by the state Level II PASARR process to have a serious mental illness and/or intellectual disability or related condition. An interview on 1/23/2023 at approximately 2:35 PM with Staff B, RN MDS Coordinator, acknowledged that a Level II screening was in the medical record from 2010, and that the MDS in section A did not acknowledge a Diagnosis requiring a Level II screen, and that a Level II screen had been completed. Staff B, RN MDS Coordinator stated the individual who did the annual MDS Screen dated 6.4.2022 was no longer at the facility. Resident #92 A record review performed on 1/24/2023 at approximately 2:34 PM of current and discontinued medications for Resident #92 noted that Resident #92 had not been prescribed a medication considered to be an anticoagulant. Resident #92 was prescribed Plavix (Clopidogrel Bisulfate) 75 mg on 8/9/2022, which is considered an antiplatelet medication. A review of the quarterly MDS of Resident #92 dated 11/10/2022 noted in Section N that Resident #92 received an anticoagulant for 7 of 7 days of the lookback period. In an interview on 01/25/23 at approximately 9:26 AM, the MDS Coordinators Staff B (a Registered Nurse) and Staff C (a Licensed Practical Nurse) were asked what medications are coded in MDS as an anticoagulant. Staff C stated that anticoagulants include Eliquis and Coumadin. Staff C stated that Plavix and Aspirin are not to be considered anticoagulants. Staff B and C were asked to pull up the records for Resident #92 and Resident #68. It was noted that both residents were noted to have been coded for an anticoagulant for 7 of 7 days. A review of the medications noted that neither resident #92 nor Resident #68 were prescribed a medication considered to be an anticoagulant. Both residents were prescribed Plavix which is not an anticoagulant. Staff B stated she had made that error. She stated she is recently new to the process and is learning. 47306 Resident #78 The record review of resident #78 documented diagnoses of Alzheimer's disease and Depression. The Level I PASARR for resident #78 was inaccurate, as it did not identify any serious mental disease or related conditions. On 01/23/2023, at approximately 3:00 PM, an interview was conducted with the Director of Nursing (DON). The DON indicates it is her responsibility to do a final review of all PASARRs. The DON indicates she performs the final review to determine if a Level II PASARR is needed. The DON verbally agreed that a Level II PASARR should have been completed for resident #78. On 01/23/2023, a review of the PASARR policy was completed. The Preadmission Screening and Resident Review policy (revised 11/18/2017) defined the federal requirement to complete a PASARR review to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. The policy requires that 1) all applicants to a Medicaid-certified nursing center be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing center, or acute care setting); and 3) receive the services they need in those settings.

Based on observation, interview, and record review, the facility failed to coordinate a Level II Preadmission Screening and Resident Review (PASARR) assessment for 1of 1 residents sampled. (Resident #97) The findings include: A review of the PASARR form for Resident #97 dated 9/26/2021 noted no diagnosis of Serious Mental Illness (SMI) or Intellectual Disability (ID), or a primary diagnosis of dementia. A medical record review for Resident #97 noted a diagnosis of Generalized Anxiety Disorder added on 11/1/2021. In addition, on 9/13/2022, Resident #97 was prescribed Buspar tablet 7.5 mg by mouth three times a day for anxiety. On 12/16/2022, Resident #97 was additionally prescribed Lorazepam tablet 0.5 mg two tablets at bedtime for anxiety. A medical record review of thirteen psychiatry evaluations from 11/29/2021 through 11/15/2022 documented a diagnosis of Major Depressive Disorder and Generalized Anxiety Disorder. A medical record review of the Annual Minimum Data Set (MDS) assessment dated [DATE] for resident #97 noted in Section A: Section 1500 that the resident is currently considered to not have a serious mental illness and/or intellectual disability or related condition. In an interview on 1/24/2023 at approximately 11:59 AM with the MDS Coordinators, Staff B (a Registered Nurse) and Staff C (a Licensed Practical Nurse) were asked what the process was if the resident has a SMI added after they are admitted . Staff C stated that, when the consultant provides a new diagnosis, the Director of Nursing (DON) will let them know to add this to the MDS. In an interview with the Administrator, Director of Nursing (DON), and the Regional Clinical Director on 1/24/23 at 12:03 PM, they were asked what the process was to get a Level II PASARR screening completed when a resident gets a new diagnosis of a serious mental illness. They expressed confusion over what needed to be referred for a Level II, what qualified as a serious mental illness, and whether or not the resident had dementia. They produced guidance from the Level II contractor who provides their training and guidance. A review of the memo noted documentation that the Level II evaluation may be terminated if the evaluator determines at any time during the evaluation that the individual: 1. Does not have an SMI or ID. 2. Has a primary diagnosis of dementia; or 3. Has a non-primary diagnosis of dementia without a primary diagnosis of SMI or ID. They acknowledge that Resident #97 did not have a primary diagnosis of dementia and had been later given a diagnosis of anxiety disorder. They were then asked who does the referral for a Level II PASARR screening if there is an updated diagnosis or change. The DON stated that it would be her. A review of the facility policy titled Pre-Admission Screening and Resident Review (PASARR) dated as 11/28/2017 states that Referral to the Stated Mental Health (SMH)/Intellectual Disability (ID) authority should be made as soon as the criteria indicative of a significant change are evident.

Based on observation, staff interviews, and policy review, the facility failed to ensure staff effectively disinfected shared blood glucose meters during 1 of 1 random observations of blood glucose sampling for resident #43. The findings include: An observation of Employee A (Licensed Practical Nurse) checking resident #43's blood sugar was conducted on 1/23/23 at 4:41 PM. Employee A obtained the blood glucose meter from the medication cart, then placed the machine on the bedside table in resident #43's room. She obtained the blood sample from resident #43 and applied it to the strip in the machine then laid the machine in resident #43's bed. Afterwards, Employee A picked up the machine and placed it back on the bedside table. Employee A then disposed of the blood sampling strip and placed the blood glucose meter on top of the medication cart with no barrier under the machine. Employee A then cleansed the blood glucose meter with an alcohol wipe. An interview was conducted with employee A on 1/23/23 at 4:48 PM. She stated she had training to clean the blood glucose meter with bleach wipes. She stated she had to check 5 resident blood sugars and it was sometimes more convenient to use alcohol wipes to clean the machine. She then confirmed she was supposed to clean the machine with bleach wipes between each resident and stated the supervisor told her she could use alcohol. An interview was conducted with the Director of Nursing (DON) on 1/23/23 at 4:53 PM. The DON stated the staff are to use bleach wipes to clean the blood glucose meter, not alcohol. Review of the undated facility policy regarding Guidelines for Cleaning and Disinfecting Blood Glucose Meter revealed the meter should be disinfected with a germicidal wipe before and after each use. The policy states, Disinfect the meter with a germicidal wipe, place the meter on a clean barrier, and allow to air dry for a full 3 minutes. The policy includes a photo of bleach germicidal wipes.

Based on family and staff interviews, resident record reviews, and transfer & discharge policy review, the facility failed to provide the resident and the resident's representative a written notice outlining the reason(s) for the transfer, the effective date of the transfer, the transfer location, the resident's appeal rights including instructions for submitting an appeal hearing request and the Office of the State Long-Term Care Ombudsman's contact information upon facility initiated hospital transfers for 4 of 4 sampled residents (Resident #63, #155, #106, and #92) and for 1 of 4 transfers which subsequently became a discharge when the facility refused to readmit (Resident #106). The findings include: Resident #63 A review of Resident #63's record revealed a transfer to the hospital on 6/24/21. The record revealed a documented phone call to the resident's representative on 6/24/21, but did not contain evidence that the representative was provided notification of the transfer and the reason for the transfer in writing. Resident #155 A review of Resident #155's record revealed a transfer to the hospital on 7/19/21. The record revealed a documented phone call to the resident's representative on 7/19/21, but did not contain evidence that the representative was provided notification of the transfer and the reason for the transfer in writing. Resident #92 A record review was conducted for Resident #92 which revealed the resident was admitted on [DATE] and transferred on 7/29/21 to the Emergency Department. Further review of the medical record revealed a Notice of Bed Hold dated 7/29/21, however, a copy of the written notice provided to the resident and representative containing the effective date and reason(s) for transfer including a statement of appeal rights and the Office of the State Long-Term Care Ombudsman's contact information could not be located. On 9/1/21 at 3:10 PM, a telephone interview was conducted with Resident #92's family member who confirmed that she never received a written notice of Resident #92's transfer from the facility Resident #106 A record review of the electronic medical record for Resident #106 revealed the resident was admitted to the facility on [DATE] and transferred out via Baker Act (involuntary commitment for psychiatric evaluation and treatment) on the same day. The facility physician signed the Certificate of Professional Initiating Involuntary Examination (form CF-MH 3052B) for Resident #106. Further review of Resident #106's record failed to reveal a copy of the written notice provided to the resident and family containing the effective date and reason(s) for transfer including a statement of appeal rights and the Office of the State Long-Term Care Ombudsman's contact information. On 8/27/21 at 2:30 PM, a telephone interview was conducted with Resident #106's spouse which revealed that his child has more information than he does as he has been dealing with a lot and doesn't get around too good these days. He then placed another family member on the phone. The family member stated that his mom apparently wrapped a cord around her neck, so she was sent to the hospital, and the facility refused to take her back. He confirmed that he was the one who received the call from the facility notifying him of his mother's hospital transfer. He also reported that the ambulance returned his mom back to the facility, but the facility refused to take her back, so the ambulance brought her back to the hospital and he was called to come pick her up. He confirmed that he called the facility to find out if they would accept her back and he was told that they could not take her back because she wrapped the cord around her neck. He confirmed that Resident #106 still requires 24-hour supervision but had not attempted to harm herself since she had been home. He stated that he believed she was just acting out to get attention. He stated that his family knows a nurse who has been trying to find his mother someplace else to go, but it has been really difficult to find a place. On 8/30/21 at 2:20 PM, an interview was conducted with the Administrator who revealed that the Social Services staff are responsible for issuing the Discharge/Transfer notices to residents and their families. She stated that the previous Director of Nursing (DON) had a letter that gave the Social Services Director (SSD) the authority to do this. She further stated that the Social Services staff just stopped issuing the discharge/transfer notices after the previous DON left, rather than request a letter from the new DON authorizing them to continue issuing the notices. She stated that she was unsure why this happened. On 8/31/21 at 11:00 AM, an interview was conducted with the Administrator who stated that she was unaware until today that Resident #106 was brought back to the facility and denied return. On 8/31/21 at 1:10 PM, an interview was conducted with the Administrator who stated that on 7/9/21, immediately after Resident #106's admission, the resident began making suicidal gestures and was transferred to the hospital via Baker Act. When asked if a transfer/discharge notice was sent to the resident, resident's family, and Ombudsman, she stated that no residents who have been discharged from the facility over the past 12 months or so have received the notices, because the Social Services Assistant did not complete the forms. On 8/31/21 at 10:30 AM, an interview was conducted with the Social Services Assistant. The Social Services Assistant stated that she and the Social Services Director are responsible for completing the transfer/discharge paperwork. She further stated that they would send the notice to the family and Ombudsman upon discharge and then file a copy in a book maintained by the Social Services Director. However, according to the Social Services Assistant, the last time this was done was back in 2020 before COVID (Coronavirus Disease 2019). She stated that when COVID hit, no one was being discharged from the facility, so they stopped filling out the forms. The Social Services Assistant added that when she filled out the form, she documented that the family was notified by phone, and for residents who did not have any family members to contact, she let the Social Services Director know that there was not any additional contact information in the chart, so the form was sent to the resident's home. When asked why no transfer/discharge notices have been sent out this year, she stated that the previous DON's name was on the form, and he delegated the form completion to Social Services staff. She stated when the previous DON left and a new DON arrived, the name on the form did not change, and she has not sent them out since. When asked about each of the residents sampled and whether they had been provided a transfer/discharge notice, she confirmed that none of the residents sampled received a notice. She indicated that they started doing the notices again a couple weeks ago. When asked why she did not start doing the forms again once the facility started to discharge residents, she stated that no one explained to her that this form was so important and had to be completed. A review of the facility policy titled Transfer & Discharge (SHCO .13 revised 5/23/17) revealed the following for unplanned hospital transfers: 4. The facility will complete the Resident Transfer Form and provide a copy of the form for the transfer and retain a copy of the transfer form for the clinical record. and 5. Notify the family or responsible party of the pending transfer, and the reasons for the move.

Based on staff and family interviews, resident record review, and facility policy and procedure review, the facility failed to permit a resident to return to the facility after being hospitalized for 1 of 4 residents sampled for facility initiated hospital transfers (Resident #106). The findings include: On 8/27/21 at 2:30 PM, a telephone interview was conducted with Resident #106's spouse which revealed that his child has more information than he does as he has been dealing with a lot and doesn't get around too good these days. He then placed another family member on the phone. The family member stated that his mom apparently wrapped a cord around her neck, so she was sent to the hospital, and the facility refused to take her back. He confirmed that he was the one who received the call from the facility notifying him of his mother's hospital transfer. He also reported that the ambulance returned his mom back to the facility, but the facility refused to take her back, so the ambulance brought her back to the hospital and he was called to come pick her up. He confirmed that he called the facility to find out if they would accept her back and he was told that they could not take her back because she wrapped the cord around her neck. He confirmed that Resident #106 still requires 24-hour supervision but had not attempted to harm herself since she had been home. He stated that he believed she was just acting out to get attention. He stated that his family knows a nurse who has been trying to find his mother someplace else to go, but it has been really difficult to find a place. A record review of Resident #106's electronic medical record revealed a Level I Preadmission Screening and Resident Review dated 7/8/21 which indicated the resident had no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #106's electronic medical record revealed the resident was admitted to the facility on [DATE] and sent out via Baker Act (involuntary commitment for psychiatric evaluation and treatment) on the same day. The facility physician signed the Certificate of Professional Initiating Involuntary Examination (form CF-MH 3052B) for Resident #106. A record review of the Hospital Psychiatry Consultation conducted on 7/10/21 at 4:05 AM by a Medical Doctor revealed that The tele psychiatrist feels that the patient does not meet criteria for involuntary admission. The patient was diagnosed with [CONDITION(S)] due to multiple medical factors including Urinary Tract Infection ([CONDITION(S)]) and possible head injury which occurred yesterday. Additionally, the patient was diagnosed with adjustment disorder. The patient is cleared from a psychiatric standpoint. The Baker act will be rescinded. A record review of an EMT (Emergency Medical Technician) report dated 7/10/21 at 3:06 PM revealed the EMTs picked Resident #106 up from the hospital for return to the facility. Further review of the report revealed that the EMTs attempted to deliver Resident #106 back to the facility, but staff advised they would not accept the resident back because she required one on one care. The report indicated Resident #106 was diagnosed with a [CONDITION(S)] at the hospital. Resident #106 was then transported back to the hospital. A record review of the hospital's Emergency Provider Report dated 7/10/21 at 4:33 PM revealed that Resident #106 was a 74 yo (year old) seen here twice in the last 48 hours and cleared psychiatry was discharged and sent back to her facility but the facility is refusing to accept the patient despite her being at her baseline. She was reportedly turned down at the door when EMS (Emergency Medical Services) brought her there. She is at her baseline on arrival back to the emergency department has no acute complaints. Further review of the report revealed a chief complaint of Dementia. According to the record, the discharge/care plan patient instructions included providing a Dementia Caregiver Guide and advising the son that he should try to get his (sic) mother into another nursing home facility on Monday. On 8/31/21 at 11:00 AM, an interview was conducted with the Administrator who stated that she was unaware until today that Resident #106 was brought back to the facility and denied return. On 8/31/21 at 1:10 PM, a follow-up interview was conducted with the Administrator who stated that she spoke to the Weekend Registered Nurse Supervisor regarding Resident #106. The Administrator stated that it was the Weekend Registered Nurse Supervisor who refused to accept the resident back into the facility and turned EMS away on 7/10/21. She stated that the Weekend Nurse Supervisor knew she (the Administrator) wanted an evaluation on Resident #106, so he told EMS the facility could not accept the resident back without a report and proper documentation to determine that she was stable enough to return. She further stated that this resident has been in the facility before and constantly begs her family to come home. The Administrator continued that during a previous admission, the family did not want her to return home, but she begged and begged them, and they relented and she was discharged home on that occasion. According to the Administrator, on 7/9/21 immediately after her admission, she began making suicidal gestures and was transferred to the hospital via Baker Act. A review of the facility's policy and procedure titled Permitting Residents to Return to Facility dated 11/28/17 revealed that, It is the policy of the facility to permit the resident to return to facility according to state and federal regulations. According to the policy, a resident who requires the services provided by the facility and is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services, will be permitted to return to the first available bed in a semi-private room.

Based on observation, interview, and record review, the facility failed to implement dressing changes consistent with physician's orders and facility policy, for 1 of 1 resident sampled for a peripherally inserted central catheter (PICC) line. (#81) The findings include: On 2/12/20 at approximately 8:03 AM, an observation was made of resident #81 during which a PICC line was noted on the resident's upper left arm, covered with a transparent dressing dated 2/1/20. (Photographic evidence obtained) On 2/12/20 at approximately 8:05 AM, an interview was conducted with staff C, a Licensed Practical Nurse (LPN) during which she confirmed that the dressing was dated 2/1/20, indicating the date it was last changed. She further stated that it is the responsibility of the registered nurse (RN) to change the dressing on the PICC lines. On 2/12/20 at approximately 8:10 AM, an interview was conducted with staff B, a RN during which she stated the physician orders were to change the PICC line every week. A review of the resident's clinical record revealed a physician's order dated 2/4/20 to change the transparent dressing on the PICC line weekly, every Friday. A review of the resident's Treatment Administration Record (TAR) for February contained the physician's order to change the PICC line dressing in the left upper extremity every Friday and initials indicating the dressing had been changed on Friday, [DATE], by staff member C. On 2/12/20 at approximately 2:48 PM, a follow up interview was conducted with staff member C, an LPN, during which she stated that she had initialed the MAR indicated [REDACTED]. A review of the facility's Central Venous Catheter Dressing Change Policy revealed that transparent dressings over PICC lines should be changed at least weekly.

Based on observation, record review, staff interviews, and policy review the facility failed to store discontinued medications separately from the resident's current medication supply in accordance with the facility policy for 1 of 22 sampled residents. (resident #2) The findings include: Observation of resident #2 was conducted on [DATE] at 12:01 PM. The resident was in his room sitting on the bed. A white, oblong pill was observed to be on top of his refrigerator in his room. The resident stated the night nurse gave him the pill, but he did not know what it was, so he did not take the pill. Employee A (licensed practical nurse) observed the pill and stated it looked like an [MEDICATION NAME]. Employee A stated the pill should not be at bedside. On [DATE] at approximately 12:06 PM, employee A reviewed resident #2's record and stated he had an order for [REDACTED]. Employee A opened the medication cart and observed a card of [MEDICATION NAME] [AGE]0 mg for resident #2 was in the cart with his current medications. An interview was conducted with the Director of Nursing (DON) on [DATE] at 2:14 PM. The DON stated the evening nurse admitted she gave the resident the [MEDICATION NAME] because it was in the medication cart, he used to receive the medication routinely and it was not removed from the medication cart when discontinued. Review of the facility policy for Disposal/Destruction of Expired or Discontinued Medications (8.2 effective [DATE], revised [DATE]) revealed once an order to discontinue a medication is received, facility staff should remove this medication from the resident's medication supply. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.

Based on record review and interviews, the facility failed to maintain accurate and complete medical records for 1 of 1 residents (#[AGE]) sampled for catheter care. The findings include: On 2/10/20 a record review was conducted for resident #[AGE]. The resident was admitted to the facility on [DATE] with a Foley catheter. A review of the physician orders [REDACTED]. On 2/12/20 at approximately 12:28 PM, an interview with staff E, a Licensed Practical Nurse (LPN) who after review the residents medication administration record/treatment administration record (MAR/TAR), physician orders [REDACTED]. On 2/12/20 at approximately 2:00 PM, an interview was conducted with the Regional Nurse Consultant (RNC) who stated the nurse who took the order and/or the nurse who did the admission should have put the orders in the computer.

Based on observations, staff interview, record review and policy review, the facility failed to ensure residents were appropriately assessed prior to allowing residents to self-administer medications for 1 of 33 sampled residents (Resident #29). The findings include: An observation of Resident #29 was conducted on 4/1/19 at 12:46 PM. The resident was sitting on the side of her bed eating lunch. Four white pills were observed in a medication cup on her over bed table and 2 vials of [MEDICATION NAME] nebulizer inhalation medication were observed on the bedside table. No nurse or other staff was present. The resident stated she liked to take the pills with her meal as she does not like water. Further observation of Resident #29 was conducted on 4/2/19 at 4:52 PM. The resident was in her room talking with the activities staff and a green pill was observed in a medication cup on her over bed table. An interview was conducted with employee A (licensed practical nurse) on 4/2/19 at 5:06 PM. Employee A observed the green pill and stated it was an iron pill and the resident took it with her meal because it made her sick. The nurse confirmed she did not observe the resident take the medication before she left the room. Review of the resident's clinical record revealed the resident had no assessment for self-administration of medications. An interview was conducted with the Director of Nursing (DON) on 4/3/19 at 3:45 PM. The DON confirmed the resident had not been assessed to self- administer medications. Review of the facility policy for Self Administration of Medication (SHCRC .01B) revealed if a resident desired to participate in self-administration, the interdisciplinary team would assess the competence of the resident to participate, by completing a self-administration of medication assessment.

Based on observations, record review, staff interview and policy review, the facility failed to document the medical symptoms that required the use of a restraint and failed to demonstrate attempts of less restrictive interventions prior to the initiation of a restraint for 1 of 1 sampled residents with restraints. (resident #18) The findings include: Observations of resident #18 were conducted on 4/1/19 at 10:54 AM, 4/2/19 at 1:42 PM, 4/2/19 at 4:40 PM, 4/3/19 at 9:05 AM, 4/3/19 at 11:53 AM and 4/3/19 at 4:22 PM. During each observation the resident was in her wheel chair and had a soft waist belt in place. An interview was conducted with employee B (certified nursing assistant) on 4/1/19 at 10:54 AM. Employee B stated the resident was unable to remove the soft waist belt herself. An interview was conducted with employee C (certified nursing assistant) on 4/3/19 at 11:04 AM. Employee C confirmed the resident was able to stand, but could not remove the soft waist belt by herself. Review of the resident's clinical record revealed a physician's order dated 3/7/19 for a soft waist belt at all times in wheel chair. The record contained no documentation regarding why the soft waist belt was applied nor interventions attempted prior to applying the waist belt. An interview was conducted with the Director of Nursing (DON) on 4/3/19 at 3:38 PM. The DON stated on 3/7/19 the nursing staff reported the resident was standing, trying to ambulate and the nurses then applied the soft waist belt. He confirmed the record contained no documentation regarding the events that lead to the application of the soft waist belt or previous interventions that had been attempted. Review of the facility policy for physical restraints (SHCRC .08) revealed physical restraints would be used upon a physician's order, with written consent, and only when warranted by medical symptoms. Documentation in the progress notes should record the use of restraints and prior interventions attempted prior to the use of a restraint.

Based on observations, staff interview and policy review, the facility failed to properly store food at safe temperatures in 1 of 2 nourishment rooms (C hall). Findings included: On 4/3/2019 at approximately 9:20am, during an observation of the nourishment room on C hall, the refrigerator temperature was observed to be 46 degrees Fahrenheit. The refrigerator contained 3 milk cartons in the door of the refrigerator and 6 yogurt cartons on the refrigerator shelf. A temperature log for (MONTH) 2019 revealed 3 temperatures above 41 degrees Fahrenheit. A subsequent observation at 10:27am revealed the refrigerator temperature to be 46 degrees Fahrenheit. On 4/3/2019 at approximately 10:35AM, in an interview with staff E, a dietary technician, the refrigerator temperature was confirmed to be 46 degrees. There was also a second thermometer observed in the refrigerator door at that time and it read 56 degrees Fahrenheit. Staff E measured the temperature of the milk to be 54.7 degrees Fahrenheit, Staff E confirmed that the internal temperatures should not be that warm, and stated that 41 degrees or lower was an acceptable temperature. A review of the facility policy, Cold Food Storage Areas with a most recent review date of 8/23/2016 indicated the maximum acceptable refrigerator temperature to be 41 degrees Fahrenheit.

Based on observations, staff interviews and review of facility policy, the facility failed to maintain infection control procedures during observed incontinent care for 1 of 3 sampled residents (#14) and failed to maintain infection control procedures to prevent possible cross contamination and to prevent possible spread of infection during washing of mop heads and residents' laundry in the laundry department. The findings are: An observation of the laundry department was conducted on 04/04/19 beginning at approximately 9:20AM with laundry staff, sampled staff H, and the housekeeping/laundry manager, sampled staff I. Inspection revealed two washers present, the first washing machine was actively washing laundry. We reviewed how they determined what chemicals were used for what type of clothing or articles and there was a chart on the wall with specific instructions on what laundry was to be washed with what chemicals and dispensing of chemicals was computerized. Observation of the second washer revealed the machine door was open and there were visibly wet laundry items inside the machine. This wet laundry included a wet mop head along with resident white towels, resident bed linens, resident washable incontinent bed pads and resident gowns. Inspection also revealed a clean laundry cart in front of this washer that contained another wet mop head draped over the side of the cart and wet bed linens including resident bed sheets, resident towels, resident gowns and resident blue washable incontinent bed pads in the laundry cart. At that time, an interview was conducted with both sampled staff H and the housekeeping manager. Staff H stated she had washed two mop heads in this load of laundry with the residents' towels, bed linen, blue washable incontinent pads and resident gowns and was just in the process of removing the wet laundry from the machine into the laundry cart. The surveyor asked sampled staff H, in the presence of the housekeeping supervisor, what type of bag she removed the mop heads from and she stated they were in white plastic bags, not the red biohazard bags. The housekeeper manager informed sampled staff H all mop heads were to be washed at the end of the day, in a washing machine by themselves and separately from all other laundry, and those in red bags were to be washed separately from those that were not. The housekeeping/laundry manager instructed sampled staff H that all the linens in the washing machine and the laundry cart would have to be rewashed due to washing the mop heads with them and possible cross contamination. Discussion with the housekeeping/laundry manager revealed it was the facility's policy that mop heads were not to be washed with bed linens or resident's linens/clothing. Observation of incontinent care for resident #14 was conducted with employee D (certified nursing assistant) on 4/3/19 at 11:43 AM. Employee D was observed to clean bowel movement from the resident's buttocks with her gloved hands, then used the same gloved hands to place a clean disposable brief under the resident. The employee did not remove soiled gloves and perform hand hygiene between soiled and clean tasks during incontinent care. An interview was conducted with employee D on 4/3/19 at 11:58 AM. Employee D confirmed she used the same gloved hands used to clean bowel movement to place a clean brief under the resident and stated she normally conducted the task in this manner. Review of the resident's clinical record revealed a quarterly minimum data set assessment, with an assessment reference date of 1/12/19, indicating the resident was always incontinent of bowel and bladder. Review of the facility policy for hand washing/hygiene (SHCO .04) revealed hand hygiene was to be performed when moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing.

Based on record review and staff interview, the facility failed to offer and failed to document the offering of the pneumococcal immunization vaccine to 1 of 5 sampled residents (#44). The findings are: Review of the electronic record for sampled resident #44 revealed the resident was admitted to the facility on [DATE]. There was documentation showing the resident had been offered and had refused the influenza vaccine; however, there was no documentation to show she had been offered or received a pneumoccocal vaccine. Interview and record review on 04/02/19 at approximately 02:21 PM with sampled staff F, a licensed practical nurse, revealed she was unable to provide documentation of the the pneumococcal vaccine being offered to the resident, but she stated she would check with medical records. A few minutes later, this surveyor observed sample staff G, a registered nurse, conversing on the telephone and requesting verbal consent from the resident's power of attorney (POA) for the administration of the vaccine. She provided him with the required education. An interview with sampled staff G, at approximately 2:30PM on 04/02/2019 revealed her statement she had called the resident's POA and requested the consent to administer the pneumococcal vaccine after she provided the required education. Sampled staff G stated the resident's son provided verbal consent for the administration of the the pneumococcal vaccine. Interview and record review again with sampled staff F on 04/02/19 at approximately 02:40 PM confirmed the resident had not been offered or administered the the pneumococcal vaccine prior to the surveyor's inquiry.

Based on observation, interview and policy review, facility staff failed to follow appropriate infection control standards of practice, by failing to clean the glucose monitoring device (glucometer) between use for 4 residents (#4, #5, #6, & #7) and for failing to follow appropriate hand hygiene during catheter care for 1 of 3 residents (#2). The findings included: On 1/14/2019 at approximately 11:20am, observation of blood glucose testing on residents was observed with staff B performing the blood glucose testing. Staff B was observed to perform hand hygiene and remove a glucometer from the drawer of a medication cart. No cleaning of the glucometer was observed prior to use on resident #4. Staff B returned to the medication cart, set the glucometer on top of the cart without cleaning. Staff B then prepared to perform glucose tests for residents # 5, #6, #7, and #8. Staff B pulled a Styrofoam tray from a drawer on the medication cart and prepared it by placing 4 gauze pads on the cart and opened and placed an alcohol swab on top of each gauze pad, placed 4 lancets and 4 glucose test strips on the tray. Staff B placed a test strip in the machine and placed it on the tray and then went to the room of resident #5 to perform blood glucose testing. Staff B did not wear gloves during the procedure and was not observed to perform hand hygiene before or after the procedure. Staff B returned to the medication cart, logged the blood glucose value on paper and in the computer, moved the medication cart to plug it in, then sanitized hands using hand sanitizer and placed another test strip in the machine. Staff B went to the room of resident #7 and performed blood glucose test without wearing gloves, returned to the medication cart to document the blood glucose test result and did not perform hand hygiene. Staff B went to the room of resident #6 and performed blood glucose test without wearing gloves, left room and used hand sanitizer for hand hygiene in the hallway while returning to the medication cart to document the result. Staff B went to the room of resident #8 to perform blood glucose test, but resident was not in room, so staff B returned to the medication cart. An interview took place with staff B on 1/14/2019 at approximately 12:13pm. Staff B was interviewed regarding training to perform blood glucose monitoring and stated training included being checked off on carts. When asked if anything needed to be done with the glucometer, staff B replied that calibrations were done at night. Staff B also acknowledged that gloves were not worn and should have been when performing blood glucose testing, but stated at least I gooped up. On 1/14/2019 at approximately 2:39pm, an observation of catheter care for resident #2, performed by staff A, was performed. Staff A did not perform hand hygiene prior to entering the resident's room to provide care, prior to donning gloves to perform removal of dressing around the insertion site, after removing gloves, before donning fresh gloves prior to cleaning the insertion site, after removing gloves or before donning gloves to place new dressing on the insertion site, after final glove removal, or after leaving the resident's room. Staff A was interviewed about glove use and hand hygiene following the procedure and admitted to not washing hands and verbalized her intent to go to the end of the hall and wash hands. On 1/15/2019 at approximately 1:55pm, an interview took place with the infection preventionist, staff C. Staff C stated glucometer training and audits started about a month ago and provided copies of the documentation used for training and audits. Staff C stated that she had been employed at the facility since (MONTH) (YEAR) and the position had been vacant approximately 6 months prior to her hire, so there was a lot of catching up to do. Staff C stated that Staff B was hired around the same time and wouldn't have had the training for the glucomter because staff C learned of the requirement for glucometer training and audits after the initial training period of staff B. The steps indicated on the instruction sheet for disinfecting the glucometer stated that the glucometer was to be disinfected before and after each use and included the following steps: Clean the glucometer with a germicidal wipe, place the glucose meter on a clean barrier (paper towel) and allow to air dry for a full 3 minutes, remove gloves, wash hands with soap and water, dry thoroughly. The policy for hand washing and hand hygiene, with a most recent revision date of 2/20/2018, was reviewed and contained the following instructions for hand hygiene related to blood glucose testing and dressing changes: Alcohol based hand rub may be used when soap and water is not indicated. According to the World Health Organization, hand hygiene is to be performed: Prior to caring for a resident, prior to performing a procedure such as blood glucose monitoring or catheter care, when moving from a contaminated body site to a clean body site (such as when changing a brief or wound dressing), after caring for a resident (including after removing gloves) and after contact with the resident environment.

Based on observation, interview and record review, the facility failed to ensure that 1 of 3 residents (#2) received care and treatment for [REDACTED]. Findings included: On 1/14/2019 at approximately 2:39pm, an observation of catheter care for resident #2, performed by staff A, was performed. Staff A did not perform hand hygiene prior to entering the resident's room to provide care, prior to donning gloves to perform removal of dressing around the insertion site, after removing gloves, before donning fresh gloves prior to cleaning the insertion site, after removing gloves or before donning gloves to place new dressing on the insertion site, after final glove removal, or after leaving the resident's room. Staff A was interviewed about glove use and hand hygiene following the procedure and admitted to not washing hands and verbalized her intent to go to the end of the hall and wash hands. During the dressing change, a light brown substance was removed from the catheter insertion site on the lower abdomen and a red, excoriated area was noted to extend from the insertion site laterally to the right approximately 2 inches; however, this area was not addressed by the nurse, nor mentioned in her documentation. Review of the progress note, dated 1/14/2019 at 2:32pm, by staff A stated resident A&O (alert and oriented) x 3 with periods of confusion; took all medications well; requested PRN (as needed) pain medication with good relief; suprapubic dressing changed and site cleaned. Currently relaxing in room with call bell in reach. An active physician's orders [REDACTED]. The resident's care plan indicated that resident #2 had a suprapubic catheter and listed interventions for the catheter as follows: encourage consumption of all fluids provided, ensure proper positioning of drainage tube at all times, keep drainage bag below waist level at all times, keep drainage bag covered at all times, change cover monthly and as needed, monitor labs as ordered, provide catheter care every shift with warm water and soap per protocol. On 1/16/2019 at 10:44am an interview was conducted with the facility's wound care nurse, who stated the nurses did the weekly skin checks and reported concerns to the wound care nurse. The wound care nurse confirmed that he had not been made aware of any concerns regarding the catheter site for resident #2. At approximately 10:50am, per surveyor request, staff D assessed the insertion site for the suprapubic catheter of resident #2. The site was covered with dry dressing with four pieces of tape and dated 1/16/2019. When the dressing was removed, red and light brown drainage was noted on the gauze with an excoriated area in the resident's skin folds, extending approximately one and a half to two inches laterally to the resident's right side. The wound care nurse stated he would have expected this to be brought to his attention and would recommend triple antibiotic ointment at the site for one week. The wound care nurse stated that he would get the order, get the supplies, and apply the dressing immediately. On 1/16/2019 at 11:12am, an interview took place with the infection preventionist, the wound care nurse, and the director of nursing. The wound care nurse shared the observation of resident #2's suprapubic catheter site. The infection preventionist and the wound care nurse said this was something they could follow-up on with education for the nurses regarding what to report related to wound care. The wound care nurse acknowledged that the condition of resident #2's catheter insertion site met the expected parameters to be passed on for further evaluation and treatment.

Based on interview and record review, the facility failed to respond to grievances and recommendations voiced by the resident council for 6 of the last 6 meetings held (November 2, (YEAR), (MONTH) 7, (YEAR), (MONTH) 4, (YEAR), (MONTH) 2, (YEAR), (MONTH) 1, (YEAR) and (MONTH) 5, (YEAR)). Findings included: A resident council meeting was held in the dining room of the facility on 4/11/18 at approximately 1:30 PM. In attendance were the resident council president along with 9 additional council members who regularly attend the monthly resident council meetings. During this meeting the council stated meetings were held on the first Thursday of every month and the facility activities director attended and took minutes. The council stated they have voiced several concerns related to the facility being short staffed and they were told that the facility was attempting to hire new staff. The council reported this was an ongoing issue that had been discussed during every meeting for approximately 6 months. A review of the resident council meeting minutes for the 6 months prior to the start of the survey found there to be documentation in the (MONTH) 7, (YEAR) meeting minutes that facility needs more nursing staff, and that the council was informed that the facility was hiring. There was no further documentation within the minutes of the councils related to staffing concerns. On 04/13/18 at 12:31 PM an interview was conducted with the activities director in which she stated that she took the minutes for the resident council meetings, which were conducted monthly. She stated that staffing concerns had been discussed in several meetings and the facility staff had told the council that staff were being hired. Upon review of the minutes, she stated that in the (MONTH) meeting the council discussed staffing concerns and they were told that staff was being hired; however, she was unable to find further discussion within any of the council meeting minutes. She stated that if one resident stated they had concerns with staffing, it would be touched on in the meeting, but not necessarily documented within the minutes. She stated, we have conservations about staffing and other concerns but a grievance report is not generated. She was asked if there were concerns brought up by the council that had resulted in changes within the facility and she stated she was not able to show evidence of any changes initiated by resident council. Review of the facility policy SHCO .05 Grievances dated as revised on 3/28/2017 stated, The resident council and/or family council are additional forums for voicing grievances. Grievances received from these councils will be acted upon in accordance with this procedure: When a resident, or anyone on their behalf, has a grievance, a staff member shall encourage and assist the resident, or person acting on the resident's behalf, to file a grievance with the facility using the Grievance Report. When a grievance is submitted orally, the facility employee accepting the grievance must document it on the Grievance Report.

Based on record review and family and staff interview, the facility failed to provide an appropriate transfer notice to the resident, resident's representative and State Ombudsman for 1 of 1 resident (#77). Findings include: Review of the medical record for resident #77 revealed the resident went to the hospital via ambulance for an acute change in his medical condition on 3/29/18 and was subsequently admitted to the hospital for treatment. On 4/11/18 at approximately 1:52 PM, a family member of resident #77 was interviewed. The family member denied receiving any written notification of transfer from the facility to the hospital for the resident's transfer on 3/29/18. On 4/12/18 at approximately 10:16 AM, another family member was interviewed, and also denied receiving any written notification of transfer from the facility to the hospital for 3/29/18 for resident #77. The corporate nurse stated the facility social service director and business office manager would be the staff responsible for providing notice of transfer/discharge. On 4/11/18 at approximately 3:52 PM, the SSD (social service director) was interviewed. The SSD stated that she had not provided a written notification of transfer to resident #77, the family of resident #77, nor the State Ombudsman for the transfer to the hospital on [DATE]. The SSD stated that she had never provided a written notice of transfer when a resident was transferred to the hospital. On 4/11/18 at approximately 3:34 PM, the BOM (business office manager) was interviewed. The BOM stated she had not provided a written notification of transfer to resident #77, the family of resident #77, nor the State Ombudsman.

Based on observation, interviews, and record review, the facility failed to provide appropriate treatment and services to increase range of motion by specifically failing to provide appropriate splinting device and passive range of motion for 1 of 2 residents sampled for mobility (resident #41). The findings are: From (MONTH) 10, (YEAR) through (MONTH) 12, (YEAR), six observations of resident #41 were made at various times of the day. On each of these observations, the resident was observed to have her left hand contracted and not observed to be wearing a splint on her left hand. Her splint was observed to be on a dresser/table near the bedroom window during each of these observations. On (MONTH) 11, (YEAR) at approximately 8:15 am, an interview was conducted with resident #41. She stated that staff did not put the splint on her hand. On (MONTH) 12, (YEAR) at 9:40am, an additional interview was conducted with resident #41 and she again stated that the staff did not put her splint on her hand and stated that she had not refused the splint. On (MONTH) 12, (YEAR) at approximately 10:43 am, an interview was conducted with Staff P, a restorative certified nursing assistant (CNA). She stated that she provided range of motion and splinting for resident #41's lower extremities but not the upper extremities. Review of the medical record for resident #41 revealed a physician's orders [REDACTED]. A review of the resident's occupational therapy (OT) referral to the restorative nursing program, dated (MONTH) 7, (YEAR) for contracture management to the left upper extremity, detailed the wearing of a left upper extremity resting hand splint 7 days a week for 12 weeks and passive range of motion to the left upper extremity prior to donning of the splint. OT treatment encounter note dated (MONTH) 7, (YEAR) detailed where therapy staff educated the restorative nursing program on the proper donning/doffing of the left upper extremity resting hand splint. A review of the nurses' notes from (MONTH) 7, (YEAR) - (MONTH) 11, (YEAR) was completed. In those notes, there was no documentation of resident #41 refusing to wear the left upper extremity resting hand splint, no documentation of resident wearing the splint, and no documentation of the resident receiving passive range of motion of her left upper extremity. On (MONTH) 12, (YEAR) at approximately 11:12 am, an interview was conducted with Staff N, an occupational therapist. She stated that resident #41 was on her caseload from (MONTH) 4 - (MONTH) 7, (YEAR). She also stated she discharged the resident to the restorative nursing program on (MONTH) 7, (YEAR) with a left upper extremity resting hand splint with finger separators that was to be worn approximately 2-3 hours a day for twelve weeks. She stated that staff were educated to put the splint on after breakfast and then to take it off before lunch. On (MONTH) 12, (YEAR) at approximately 12:47 pm, an interview was conducted with Staff O, a restorative licensed practical nurse. He stated that resident #41 refused to wear the splint when she first got it in (MONTH) of (YEAR). He also stated that after that refusal, he never asked her again about the splint and he did not document any refusals. He also stated that he did not do passive range of motion on the resident's upper extremities. He stated that he should have documented the refusals and reported the refusals to therapy. On (MONTH) 12, (YEAR) at approximately 1:44 pm, an observation was made of Staff N completing an assessment on resident #41. Staff N asked the resident if she would wear splint and resident stated yes. Staff N proceeded to open the resident's hand without any pain to the resident. The resident stated that the splint was comfortable, was not causing her any pain, and would be willing to wear the splint on a daily basis. Staff N stated that she would leave the splint on for thirty minutes to see how well the resident tolerated the splint. On (MONTH) 12, (YEAR) at approximately 2:28 pm, an additional interview was conducted with Staff N. She stated that the resident tolerated the splint well and was being put back onto OT caseload to ensure that splinting was completed as ordered.