Every finding on record at Joshua Tree Care Center

Based on observation, staff interview, and policy review, the facility failed ensure food was labeled and dated in a manner to prevent food contamination and spoilage, failed to ensure expired food was disposed of timely, and failed to ensure food was served to residents in a clean and sanitary manner. This had the potential to affect all residents. The facility census was 35. Findings include: 1. Tour of the facility's main kitchen and kitchenette on [DATE] between 8:00 A.M. and 8:33 A.M. with Dietary Manager (DM) #759 revealed the following that was observed and verified at the time of discovery: a. An open plastic container of sour cream with an expiration date of [DATE]. b. Five packages of raisins with an expiration date of [DATE]. c. An open package of liquid butter with no date. d. An open package of baking soda with no date. e. An open package of sprinkles with no date. f. An open package of marshmallows with no date. g. Four packages of orange juice thickener with a best-by date of [DATE]. h. A peanut butter container in both the main kitchen area and kitchenette with expiration dates of [DATE]. i. The ceiling lights directly above the kitchenette serving area had numerous dead bugs. 2. Observation of the dinner time meal service on [DATE] between 5:00 P.M. and 5:30 P.M. revealed the meal was being served by Dietary Aide (DA) #761. During the entire observation, DA #761 was noted to not be wearing a hair net while actively engaged in the serving of the dinner time meal. An interview on [DATE] at 5:33 P.M. with the Director of Nursing (DON) verified that DA #761 was not wearing a hair net as required. Review of the policy entitled Food Safety/Sanitary Conditions dated [DATE] revealed hair restraints must be worn to prevent hair from contacting exposed food.

Based on record review and interview the facility failed to develop a person-centered care plan for post-traumatic stress disorder (PTSD). This affected two residents (Residents #10 and #24) out of 15 residents reviewed for care planning. The facility census was 35. Finding include: 1. Review of the medical record for Resident #10 revealed and admittance date of 10/04/24 with diagnoses including chronic obstructive pulmonary disease (COPD), venous insufficiency, post-traumatic stress disorder (PTSD), depression, dementia, type II diabetes, and chronic kidney disease. Review of Resident #10's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition and had moderate depression. The resident required supervision with activities of daily living. No behaviors were noted. The resident was recorded as having received antidepressant medications. Review of Resident #10's care plan dated 12/27/24 revealed the resident had potential for psychosocial well-being problems and was at risk for changes in mood related to nursing home placement. On 12/19/24, the resident was agreeable to a psychological consult at the facility and continued to see psychiatry in the community for PTSD. Interventions included psychology consult as needed and to review preferences quarterly and as needed. The plan did not identify trigger-specific interventions and ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Interview on 01/15/25 at 12:30 P.M. with Registered Nurse (RN) #850 verified she did not develop a specific care plan for PTSD for Resident #10 or Resident #24 that identified triggers or interventions to minimize or eliminate triggers. RN #850 stated that PSTD was referenced in Resident #10 nutritional, activities of daily living, and skin integrity plan. 2. Review of Resident #24's medical record revealed an admitted [DATE] with diagnoses including osteoarthritis, PTSD, traumatic brain injury, type II diabetes, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition and required substantial to maximum assistance with activities of daily living. No behaviors were noted. The resident was recorded as having received antidepressant medications. Review of Resident #24's care plan dated 12/04/24 revealed the resident was at risk for psychosocial wellbeing decline and changes in mood related to diagnosis including depression, anxiety, parkinsonism, hydrocephalus, transient ischemic attack (TIA) a brief stroke, traumatic brain injury and PTSD. Intervention included to identify factors that influence resident psycho-social wellbeing/mood. No factors were identified. The plan did not identify trigger-specific interventions or ways to decrease the resident's exposure to triggers which could re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

Based on medical record review, interview, and review of the facility policy, the facility failed to ensure showers were completed for Resident #4. This affected one resident (Resident #4) of two residents reviewed for activities of daily living. The facility census was 35. Findings include: Review of Resident #4's medical record revealed an admitted [DATE] diagnoses including type II diabetes, heart disease, depression and dementia. Review of Resident #4's care plan dated 10/15/22 revealed she required assistance with bathing and dressing. Review of Resident #4's progress notes revealed a note dated 04/21/23 at 11:18 A.M. which stated the resident requested one shower per week. The resident agreed to receive a shower on Monday mornings. Review of Resident 4's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required substantial to maximal assistance with showers. Review of Resident #4's shower documentation for December 2024 revealed the resident received a shower on 12/02/24, 12/09/24, 12/16/24 and 12/30/24. There was 13 days without a shower from 12/16/25 to 12/30/25. Interview on 01/12/25 at 3:36 P.M. with Resident #4 stated she received a shower every other week. Interview with the Director of Nursing on 01/13/25 at 2:49 P.M. verified the resident received a shower on 12/16/24 and on 12/30/24, and confirmed the resident went 13 day without receiving a shower. Review of the facility policy titled Shower and bathing schedules, revised April 2023 revealed the resident bathing schedule is set-up that each resident is given at least whirlpool tub bath or shower once a week according to their preference.

Based on record review, staff interview and policy review, the facility failed to ensure residents were given written copies of the facility bed hold policy upon discharge/transfer from the facility. This affected two (Residents #21 and #33) of two residents reviewed for hospitalization . The facility census was 35. Findings include: 1. Review of Resident #33's medical record revealed an admitted [DATE] with diagnoses including kidney failure, hypertension and bipolar disorder. Review of Resident #33's nursing progress noted revealed Resident #33 was discharged to an acute care hospital on 11/24/24 and did not return to the facility. Review of both the electronic and hard medical charts for Resident #33 revealed no evidence that Resident #33 was given a copy of the facility's bed hold policy before or immediately after his transfer to the hospital. 37096 2. Review of Resident #21's medical record revealed an admitted [DATE] with diagnoses including chronic kidney disease, depressive disorder, peripheral vascular disease, and chronic obstructive pulmonary disease (COPD). Review of Resident #21's medical record revealed Resident #21 was transferred to the hospital on two occasions, on 04/18/24 and 04/26/24. Resident #21's electronic and hard medical chart revealed no evidence that Resident #21 was given a copy of the facility's bed hold policy before or immediately after the transfer to the hospital. Interview on 01/14/25 at 1:40 P.M. with the Owner verified the facility was not providing bed hold notices. The Owner stated the employee who was responsible for bed hold notices terminated employment and she did not assign the task to another employee. However, going forward she stated she would ensure residents and/or representatives received bed hold notices. Review of the facility's policy titled Bed-Hold Policy/Payment for Services. revised November 2017 revealed should a resident be transferred to the hospital, the resident will be notified of the bed hold policy.

Based on review of the facility assessment and staff interview, the facility failed to ensure its facility assessment contained all required information. This had the potential to affect all 35 residents. The facility census was 35. Findings include: Review of the facility assessment dated [DATE] revealed the assessment did not contain information on how the facility would develop and maintain a plan to maximize recruitment and retention of direct care staff. Interview on 01/17/25 at 11:14 A.M. with the Administrator verified the assessment did not contain all required information on recruitment and retention of direct care staff.

Based on record review and staff interview the facility failed to ensure the service of a Registered Nurse (RN) for at least eight hours a day seven days a week as required. This had the potential to affect all residents. The facility census was 30. Findings Include: Review of facility staffing schedules revealed on 04/02/22, 04/03/22, 04/16/22, 04/17/22, 04/30/22, 05/01/22, 05/14/22, 05/28/22, 05/29/22, 06/12/22, and 06/25/22 the facility did not have the services of an RN for eight consecutive hours as required. Interview with the Administrator on 03/07/23 at 5:00 P.M. verified the lack of RN hours on the dates listed above.

Based on observation and staff interview the facility failed to ensure food was labeled and dated properly and the walk in freezer was maintained in good working condition. This had the potential to affect all residents. The facility census was 30. Findings Include: Observation during tour of the kitchen on 03/06/23 between 7:15 A.M. and 7:33 A.M. revealed the following. 1. The walk in in freezer had significant ice build up. Multiple chunks of ice more then six inches in diameter with ice crystals formed were stuck to the freezer shelves. One of the chunks of ice had engulfed a box of tater tots and the box of tater tots was stuck to the ice block and immovable. Hanging from the top of freezer were over ten, six inch long icicles. In addition, there was an undated and opened bag chicken patties, an undated and opened bag of chicken tenders, an undated unlabeled and opened bag of cheese omelettes, an undated and opened box of pork egg rolls, and two undated and opened packages of ham. 2. In the dry storage area there was a dented can of sweet peas, an undated and opened bag of elbow macaroni, an undated and opened bag of rainbow rotini, an undated and opened bag of rigatoni, and an undated and open container of liquid butter. Interview with Dietary Manager (DM) #800 at the time of the discovery, on 03/06/23 between 7:15 A.M. and 7:33 A.M., confirmed the observations.

Based on record review and interview the facility failed to implement and maintain a comprehensive Quality Assurance Performance and Improvement (QAPI) plan. This had the potential to affect all 30 residents residing at the facility. Findings Include: Review of the QAPI program documentation revealed no evidence the plan addressed the full range of care and services provided by the facility which was comprehensive, data driven and ongoing. There were no indicators focusing on outcomes of care, quality of life or resident rights. Interview with Director of Nursing (DON) on 03/09/23 at 2:10 P.M. revealed the facility did not have a plan to provide the survey team. The last QAPI plan was completed on 03/16/21. Interview with the Administrator on 03/09/23 at 2:15 P.M. verified the facility was not participating in any data driven ongoing QAPI programs. Several weeks ago she started considering programs for participation. Review of the facility's policy titled Quality Assurance Program, undated revealed the facility would have a program in effect, in order to continue to identify, monitor, evaluate and promote the maintenance and enhancement of every resident's quality of life and quality of care.

Based on record review and interview the facility failed to implement and monitor measures to prevent the potential spread of Legionella. This had the potential to affect all 30 residents residing at the facility. Findings include: Review of the facility's policy titled Legionella Prevention Program dated November 2017, revealed control measures including physical control measures, water temperature management, disinfectant level controls, visual inspections, environmental testing for pathogens and specific testing protocols with acceptable ranges for control measures. Parameters included: Hot water to be maintained above a temperature of 122 degrees Fahrenheit (F). Cold water temperatures to be maintained below 77 degrees F. Maintain chlorine residual levels at Center of Diseases Control and Prevention (CDC) recommended levels. Maintain chlorine residual logs to ensure safe levels. Review of the Legionella water testing log from 03/01/22 through 03/01/23 revealed one entry indicating on 05/12/22 the water from the faucet at the eye wash station located in the kitchen was tested and negative for Legionella. There was no documented evidence the other control measures listed in the facility's legionella prevention program were implemented/monitored. Interview with the Administrator on 03/09/23 at 11:00 A.M. revealed the facility had no additional documentation to support the facility's legionella prevention program was implemented/monitored. Review of CMS Survey and Certification letter 17-30-All, dated 06/02/17, revealed facilities were to implement a water management program that considered the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the Center of Disease Control and Prevention (CDC) toolkit, and included control measures such as physical controls, temperature management, disinfection level control, visual inspections, and environmental testing for pathogens.

Based on record review and staff interview the facility failed to ensure notices of Medicare non-coverage (NOMNC) contained all required information. This affected two of two residents (Residents #133 and #134) reviewed for beneficiary notices. The facility census was 30. Findings Include: Medical record review revealed Resident #133 was admitted to the facility [DATE] with diagnoses that included heart failure and high blood pressure. Resident #133 discharged home [DATE]. Review of the NOMNC given to Resident #133 on [DATE] prior to his discharge revealed the notice stated Your Medicare provider and/or health plan have determined that Medicare with not pay for your current {insert type} services after the effective date indicated above. Medical record review revealed Resident #134 was admitted to the facility on [DATE] with diagnoses that included left femur fracture, anxiety disorder and depression. Resident #134 expired at the facility on [DATE]. Review of the NOMNC given to Resident #134 on [DATE] prior to ending skilled services and electing hospice services revealed the notice stated Your Medicare provider and/or health plan have determined that Medicare with not pay for your current {insert type} services after the effective date indicated above. Interview with Social Worker (SW) #998 on [DATE] at 3:30 P.M. verified the notices given to Residents #133 and #134 did not contain what service type was ending.

Based on observation, interview and record review, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was properly stored. This affected 47 out 47 residents residing in the facility who received meals from the dietary department. Findings include: A tour of the kitchen was conducted on 01/21/10 with the Registered Nurse #100 from 8:04 [NAME]M. through 8:15 [NAME]M. Dietary Manager (DM) #101 was not yet at the facility. Observation of the kitchen revealed a black cart had food particles on both shelves, dried cake batter on the mixer which was covered by a plastic bag and considered clean, two bags of noodles and black eyed peas were not labeled or dated in the dry storeroom, there was ice was build-up along the back of the walk-in freezer that created ice on top of a box of dinner rolls and two pizza crusts were not labeled or dated. A follow-up visit was conducted on 01/22/20 at 9:14 [NAME]M. and revealed food splatter and white icing were on the ceiling. DM #101 and Registered Dietitian (RD) #102 verified the findings at time of observation. Review of the policy titled, Food Safety/Sanitary Conditions, dated 11/2019, revealed that food sanitary conditions must be present in healthcare food service settings.

Based on observation, record review and staff interview the facility failed to ensure the necessary assessments, care and services were provided to prevent Resident #50 from developing a pressure ulcer to the left hand. Actual Harm occurred when the facility failed to timely identify the pressure ulcer, which developed from the use of a palm protector device, to the resident's hand until there was an exposed tendon. This affected one resident (Resident #50) of one resident reviewed for pressure ulcers. Findings include: Clinical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility admitting nursing assessment dated [DATE] revealed no pressure ulcers were present at the time of admission. The Minimum Data Set (MDS) 3.0 assessments, dated 03/04/17 and 06/06/17 indicated Resident #50 was at risk for the development of pressure ulcers, did not have any pressure ulcers at that time and did not exhibit any behavior of rejection of evaluation or care. Record review revealed a physician order, dated 12/28/16 for a palm protector to the left hand at all times. The order indicated the palm protector may be removed for hygiene care and skin check before and after application. Record review revealed a physician order, dated 07/13/17 for a right-hand palm protector at all times. The order indicated may remove for hygiene care, meals and for skin checks to be done before and after application. Left hand palm protector at all times, may remove for hygiene care, meals and skin check before and after application was also noted to be in place. A facility Weekly Skin Grid form, dated 07/19/17 documented a left medial thumb wound that measured 2.5 centimeters (cm) in length (L) by 1.4 cm in width (W) with 0.4 cm depth (D). This was the first documentation of a wound on the left thumb. Record review revealed a physician order [REDACTED]. A treatment order was also obtained for the medial left thumb wound which included to cleanse with normal saline, apply Hydrogel oil [MEDICATION NAME], gauze and [MEDICATION NAME] (a transparent dressing). Change daily and as needed until healed, check every shift. Record review revealed a physician order, dated 07/19/17 for a consult to a wound management service to evaluate and treat the wound. Apply pads to bilateral palms to pad and protect, check every shift and replace if needed. A wound management service visit note dated 07/20/17 documented that on 07/19/17 upon examination of left medial/proximal thumb an open wound was discovered with the tendon being exposed. Nursing suspected the wound developed due to the palm protector. A nurse practitioner (NP) note dated 07/24/17 documented a new problem, left thumb ulcer. The resident was now found to have a deep pressure ulcer on the palmar aspect of left first digit. A left palmar first digit with full thickness skin ulcer with exposed flexor pollicis tendon. An NP note dated 08/08/17 documented the NP was in the facility to follow up on left thumb pressure ulcer with tendon exposed. A left palmar first digit with full thickness skin ulcer with exposed flexor pollicis tendon was noted. Observation of the wound on 08/23/17 at 9:30 A.M. revealed the wound bed was bright red and measured 3.5 cm L by 1.5 cm W by 0.1 cm D. Review of the treatment administration record (TAR) for July, 2017 revealed the original palm protector for the left hand ordered 12/28/16 was discontinued 07/13/17. A new order for palm protectors for bilateral hands was initiated 07/13/17 and discontinued 07/19/17. Interview with the director of nursing (DON) on 08/21/17 at 3:55 P.M. verified the above information. The DON stated at first Resident #50 used palm protectors made of lamb's wool. Resident #50 did not have any pressure ulcers while he used the lamb's wool protectors. However, there was moisture between Resident #50's fingers, except for the thumb area. The facility ordered a new kind of palm protector with finger separators. After application of the new palm protectors, Resident #50 developed the pressure ulcer on the left medial thumb. The DON verified the ulcer was not identified until after the tendon was already exposed. This deficiency substantiates Complaint Number OH 905.

Based on observation, record review, and staff interview the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect 51 of 52 residents that consume food prepared in the kitchen daily. Findings include: 1. The initial tour of kitchen was conducted on 03/09/15 at 10:00 A.M. The ansul system over the stoves and deep fryer was observed to be coated with a heavy layer of dust, grease and cobwebs. At the time of the observation, three pots of uncovered food (tomato soup, gravy and Swiss steak for puree) were cooking on the stove. This was confirmed with the food service manager at 10:15 A.M.. The food service manager stated he is responsible for cleaning the ansul system in between service visits from the outside contractor. He stated he does not keep a cleaning log for the ansul system. On 10/29/14, the outside contractor had serviced and cleaned the ansul system. 2. Kitchen Staff (KS) #1 was identified during the tour and was observed wearing her hairnet at the back of her head. Her hair at the sides and her bangs were loose and not contained in the hairnet. KS#1 was observed cooking over three open pots of soups and sauce at the stove and making meat patties and did not have her hair contained in the hairnet. Observation of KS #2 and KS #3 revealed both had hairnets that contained only their ponytails at the back of their heads leaving the hair on the sides and front loose and exposed while cleaning dishes. 3. On 03/09/15 at 11:15 A.M. lunch tray line was observed. KS #1 was plating the food and KS #2 and KS #3 were participating in tray line. KS #1's hairnet remained at the back of her head exposing her bangs and hair on the sides and not contained in the hairnet. Both KS #2 and KS #3 hairnets remained at the backs of their head containing only the ponytails leaving loose and flowing hair on the sides and front not contained in their hairnets. 4. On 03/09/15 at 1:30 P.M. the food service manager was observed peeling potatoes without a hairnet. KS #1's hairnet remained at the back of her head leaving the hair at the sides and bangs loose and exposed while frying bacon on the griddle. KS #2 and KS #3 were observed with their hairnets remaining at the backs of their heads containing their ponytails only, leaving hair at the sides and front loose. 5. On 03/10/15 at 10:25 A.M., KS #1 was observed with hairnet remaining at the back of her head leaving the hair at the sides and bangs loose and exposed while pureeing stuffed peppers and peas and carrots. On 03/10/15 at 11:30 A.M. a copy of the facility hairnet policy dated November, 2013 was provided by the facility dietitian. The policy revealed that staff is to wear a hair restraint such as a hairnet, hat and/or beard restraint to maintain control of their hair to prevent hair from contacting exposed food.

Based on on observation and interview the facility failed to ensure milk and milk based foods were maintained at an appropriate temperature. This had the potential to affect the 33 residents who received milk products at lunch on 12/18/13. There are 55 residents who receive their meals from the kitchen. Findings include : The lunch meal was observed on 12/18/13 from 11:15 A.M. to 11:45 A.M. Lunch was served from a steam table in the dining room. There was an open silver cart positioned in the dining room. The cart contained lunch that had the drinks pre-poured and ready for the meal to be placed on the trays. There were seven trays that had glasses of milk on them. At 11:30 A.M., just prior to the beginning of meal service, this surveyor asked Dietary Aid (DA) # 17 to take the temperature of a glass of milk that was on one of the trays on the cart. The milk was 50 degrees Fahrenheit (F). There were other glasses of milk on the side of the steam table waiting to be placed on trays to be served in the dining room and resident room trays. DA #17 was asked if she knew what the temperature of the milk was supposed to be for safe consumption. DA #17 stated she did not. The milk was discarded. The cook continued with tray line. There were two bowls of cucumber salad dressed with sour cream on the trays waiting to be served. At 11:40 A.M. this surveyor requested the cook take the temperature of the cucumber salad. The cucumber salad was sixty degrees F. The cook discarded the salad.

Based on record review and interview the facility failed to ensure that appeals of discontinued skilled Medicare services were submitted for review as requested by Residents #5, #52, #80 and #19. This affected four of five residents reviewed. The census was 55 residents. Findings include: 1 Resident #52 received a notice of Medicare non-coverage on 10/04/13 indicating his skilled services would end on 10/10/13. The form titled "Skilled Nursing Facility Advance Beneficiary Notice" explained two options for Resident #52. The options were to continue to receive skilled services and have Medicare review the case or to accept the decision to discontinue skilled, Medicare services. Resident #52 marked that he wanted to continue skilled services and have the decision reviewed by Medicare. On 12/18/13 at 11:15 A.M., LSW #11 reviewed the notice of non-coverage for Resident #52 and verified it was marked yes for a review. LSW #11 verified the facility did not continue to provide skilled services and did not submit the denial of services for formal review. Resident #52 was no longer in the facility. 2. Resident #5 received a notice of Medicare non-coverage on 11/06/13 indicating that her skilled services would end on 11/04/13. Resident #5 indicated on the form that she wanted to continue skilled services and have the termination decision reviewed by Medicare. On 12/18/13 at 11:15 A.M., LSW #11 reviewed the notice of non-coverage for Resident #5. LSW #11 verified the facility did not continue to provide skilled services for Resident #5 and did not submit the termination decision for formal review. Resident #5 was no longer in the facility. 3. Resident #19 received a notice of Medicare non-coverage on 10/08/13 indicating her skilled services would be discontinued on 10/11/13. Resident #19 indicated on the form that she wanted to continue skilled services and have the termination decision reviewed by Medicare. On 12/18/13 at 12:20 P.M., LSW #11 verified the facility did not submit Resident #19's termination decision for review and skilled services ended. Resident #19 was no longer in the facility. 4. Resident #80 received a notice of Medicare non-coverage on 10/04/13 that her skilled services would be discontinued on 10/07/13. Resident #80 indicated on the form that she wanted to continue skilled services and have the termination decision reviewed by Medicare. On 12/18/13 at 12:20 P.M., LSW #11 verified the facility did not submit Resident #80's termination decision for review and skilled services ended. Resident #80 was no longer in the facility.

Based on record review and interview the facility failed to ensure Residents #71 and #36 were given choices regarding frequency of showers and Resident #68 was given a choice regarding what time to get up in the morning. This affected three of 17 residents interviewed regarding their ability to make choices. Findings include: 1. Resident #71 had [DIAGNOSES REDACTED]. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. The assessment also revealed the resident required limited to extensive assistance for activities of daily living. An interview with Resident #71 on 12/18/13 at 8:30 A.M. revealed he was not given a choice regarding the frequency of taking showers. He stated he was instructed by the staff that he was scheduled to take a shower once a week. He stated he would prefer taking a shower twice a week. He verified he required assistance to take a shower. An interview with the director of nursing (DON) on 12/18/13 at 2:20 P.M. verified there was no documentation that indicated the Resident #71 chose to shower once a week in the evening. 2. Resident # 36 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] indicated Resident #36 had moderate cognitive impairment. The MDS also indicated the resident required extensive assistance of one person for hygiene. Resident #36 was interviewed on 12/17/13 at 10:55 A.M. and was asked if he had a choice concerning the number of showers he could take each week. The resident said when he was at home he showered once a day and he would like to take more here, "but all we get is once a week." The resident stated his hair is dirty and he would like to take at least two showers per week. The resident stated no one asked him how many times per week he would like a shower. Review of Resident #36's recent care kardex dated 10/17/13 indicated the resident received a shower once a week. The admission care plan initiated 10/17/13 stated the resident would be bathed weekly. The nursing admission assessment dated [DATE] indicated the facility's bathing policy was explained to the resident and that the resident preferred showers. There was nothing to indicate the resident had been asked the number of times per week he would like to shower. Interview with Registered Nurse (RN) # 10 on 12/19/13 at 9:15 A.M. revealed the facility's policy was to give residents one tub bath or shower per week and wash up in the room daily. RN #10 stated some residents get more than one shower or tub bath per week if they request it. Resident #36's kardex and admission assessment were reviewed with RN # 10 RN #10 verified there was nothing in the record that indicated the resident was given a choice on the number of showers he would like to receive each week. 3. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interview with Resident #68 on 12/17/2013 at 10:28 A.M. revealed the state tested nursing assistants (STNA) woke the resident up at 7:00 A.M. The resident stated breakfast and medications are at 7:30 A.M. but that she would like to get up at 8:00 A.M. On 12/18/2013 at 2:55 P.M. an interview with STNA #12 revealed the facility had a get up list. STNA #12 revealed the night shift STNAs get the residents up that are assigned to them. When day shift STNAs come in they get up the rest of the residents on the get up list. An interview on 12/18/13 at 3:06 P.M. with the Director of Nursing (DON) revealed she was unable to provide documentation that residents were asked what time they would like to get up in the morning. An interview on 12/18/13 at 3:15 P.M. STNA #14 revealed that the STNA's start getting residents up at 5:00 A.M.

Based on record review and interview the facility failed to ensure Resident #77 received restorative services as recommended by physical therapy services. This affected one of three residents reviewed regarding rehabilitation services. The facility census was 55 residents. Findings include: Resident #77 was admitted with [DIAGNOSES REDACTED]. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #77 required limited assistance of one person for bed mobility, transfers, ambulation and locomotion on the unit. Review of the physical therapy discharge summary dated 11/21/13 revealed Resident #77 had reached maximum potential with skilled services and functional abilities had progressed as a result of skilled interventions. The summary indicated the prognosis to maintain the current level of function was good with consistent staff follow through. The physical therapist recommended a restorative nursing program for ambulation and active range of motion to maintain the current level of performance and prevent a decline in function. Interview with Licensed Practical Nurse (LPN) #19, the restorative nurse, on 12/19/13 at 10:05 A.M. verified there was no care plan for an active range of motion program for Resident #77. LPN #19 verified the physical therapy summary indicated Resident #77 should continue with a restorative active range of motion and ambulation program to maintain the current level of function and prevent a decline. LPN #19 indicated she assessed Resident #77 regarding a restorative program. LPN #19 stated she made the decision not to include an active range of motion program for Resident #77 because restorative staffing was minimal and she did not feel Resident #77 needed active range of motion. LPN #19 verified there was no documentation that indicated any communication with physical therapy regarding her decision not to follow the physical therapist's recommendations. Interview with Physical Therapist (PT) #20 and Physical Therapist Assistant (PTA) #21 on 12/19/13 at 11:40 A.M. revealed a therapy discharge recommendation form was given to the restorative nurse when residents were discharged from therapy services. They indicated the restorative nurse was also given a booklet with instructions regarding the restorative exercises that were to be done. PT #20 verified Resident #77 was recommended to receive restorative active range of motion and ambulation to maintain the current level of performance and prevent a decline. PT #20 stated there was no communication from nursing that the range of motion restorative program was not initiated for Resident #77 as recommended.

Based on observation and interview the facility failed to post required staffing information as required. This would have the potential to affect all of the 55 residents residing in the facility. Findings include: The initial tour was completed on 12/16/13 beginning at 4:30 P.M. The staffing information was posted on the bulletin board in the central hallway. The staffing sheet did not list how many licensed practical nurses or state tested nursing assistants were working on the afternoon or night shifts. This was reviewed and verified with the nursing supervisor, Registered Nurse #10. She indicated it should be updated at the beginning of the shift. The facility's afternoon shift is from 3:00 P.M. until 11:00 PM. and the staffing information was not up to date.