Accel At College Station

Penalty

Inspection fine: $22,895

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide adequate supervision and appropriate assistive devices to prevent an accident during a therapy session, resulting in a right patellar fracture for one resident. The resident was an elderly female with dementia, a history of falls, generalized muscle weakness, unsteadiness on her feet, abnormal posture, cognitive communication deficit, fatigue, depression, and adjustment disorder. Her admission MDS showed a BIMS score of 1, indicating severely impaired cognition, and documented that she required partial to moderate assistance to come to a standing position and was dependent on staff for tasks requiring bending or stooping. Her care plan identified her as a moderate fall risk related to a history of falls and impaired balance, and also documented behavior problems related to impulsiveness, walking away without an assistive device, and not following verbal cues, as well as deficits in memory, judgment, decision-making, and thought processes. Prior to the incident, the resident’s care plan included fall-prevention interventions such as ensuring the call light was within reach, maintaining a safe environment, and ensuring appropriate footwear when ambulating or up in a wheelchair. The care plan also included cognitive-support interventions such as asking yes/no questions, breaking activities into manageable subtasks, giving one instruction at a time, and explaining each activity or care procedure before beginning. The resident had an actual fall history related to poor balance and unsteady gait. On the date of the incident, she was participating in a standing balance activity in the therapy gym that involved catching and throwing a ball with another resident. She was standing with a gait belt in place, with a PTA assisting her and the DOR assisting the other resident. Multiple accounts (nursing note, DOR statement, PTA statement, and PT note) describe that the resident was instructed not to bend down or reach for the ball if it bounced away, but she nonetheless bent forward and/or reached for the ball, crossed one leg over the other, lost her balance, and fell to the floor. During the fall, the resident landed on her knees and then her upper torso and face, sustaining a right patellar fracture and a laceration to the left temple. The PTA reported that he was holding the gait belt properly with his hand inside the belt, but that when the resident started to fall, the gait belt slipped out of his hand and he had to let go to avoid falling on top of her. The DOR stated that the resident bent toward the right, her foot crossed over, and she was so far out of her base of support that there was no recovering, and acknowledged in hindsight that the activity should have been done at the parallel bars. The PT, who was not present at the time of the fall, reported that the resident was unable to follow directions consistently, but considered the balance activity itself appropriate and expected staff to provide instructions and maintain hands on the gait belt during activities. The facility’s own policies required ongoing assessment of residents’ mobility, cognitive status, cooperativeness, and rehabilitation goals, and called for identification and adjustment of interventions to prevent falls and minimize serious consequences when underlying causes could not be readily corrected. Despite the resident’s severe cognitive impairment, impulsivity, and documented difficulty following verbal cues, she was engaged in a dynamic standing balance ball activity away from parallel bars, and the supervision and assistive setup in place were not sufficient to prevent her fall and resulting fracture.

Penalty

Inspection fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s expressed wishes during an acute change in condition. The resident involved was an older female with intact cognition (BIMS 15) and significant cardiac and renal comorbidities, including diastolic CHF, hypertension, paroxysmal atrial fibrillation, aortic stenosis, and end-stage renal disease on hemodialysis. Her care plan included monitoring and prompt reporting of significant changes in pulse, respirations, and blood pressure, administration of oxygen as ordered, and reporting signs and symptoms of malignant hypertension or other changes in condition. Prior oxygen saturation readings for this resident generally ranged from 91% to 98% on room air, and she had a PRN order for 2 L/min oxygen for shortness of breath. On the morning in question, video review showed the resident asking an LVN for oxygen, with the LVN acknowledging that the resident’s face looked flushed and obtaining vital signs, including an O2 saturation of 92% on room air. The resident repeatedly requested oxygen, became increasingly anxious, grimaced, breathed more heavily, and held her chest while stating she needed oxygen. The LVN left the room without immediately providing oxygen, and the resident’s distress continued, with difficulty talking and heavier breathing observed on video. Several minutes later, the LVN returned with oxygen, reported an O2 saturation of 97%, placed the oxygen on the resident, and then exited the room. The LVN later stated that the original oxygen tank in the room was not working, that the resident became flushed and more upset while waiting for oxygen, and that she did not call 911 or the physician, believing it was not necessary until she finished her assessment. Subsequently, the ADON entered the room while the resident was on 2 L/min oxygen and on the phone with a family member. Video review and nursing notes reflected that the resident was crying, repeatedly stating she could not breathe, and clearly asking for 911 to be called. The ADON questioned the resident, did not complete a documented assessment at that time, did not check O2 saturation, blood pressure, oxygen tank, or tubing as observed on video, and exited the room despite the resident’s continued complaints of shortness of breath and explicit requests for 911. When the ADON re-entered, the resident again stated she could not breathe and asked for 911; the ADON removed the resident’s phone from her chest and placed it out of her reach while the family member was still on the line, and again did not perform the assessments she later claimed in interview to have done. EMS arrived shortly thereafter, found the resident’s O2 saturation at 79% while on 2 L/min oxygen, and transported her to the hospital, where she was admitted with respiratory distress and pulmonary edema/volume overload. Facility leadership and staff interviews confirmed that facility expectations were to call 911 immediately when a resident complained of shortness of breath and requested 911, and that in this case staff did not honor the resident’s repeated requests or promptly recognize and act on the acute change in condition, leading to the identified deficiency under F684 (Quality of Care).

Removal Plan

• Resident #1 was discharged/transferred to the hospital.
• Investigation completed; ADON A received disciplinary action and one-on-one re-education.
• In-service completed for licensed nurses, nurse aides, and medication aides on honoring resident wishes when requesting 911; comprehension to be verified by post-test.
• Director of Nurses in-serviced by Clinical Service Director on honoring resident wishes when requesting 911, with a post-test.
• Interviewable residents to be interviewed to ensure staff are honoring their wishes; any identified concerns to be addressed immediately.
• Non-interviewable residents to be observed to ensure no change in condition is present; document on life satisfaction survey forms; administrator to review and address concerns immediately.
• Director of Nurses/designee to continue in-servicing newly hired staff (including PRN and agency, if utilized) during orientation on honoring residents’ wishes when wanting 911 called.
• Department heads to conduct daily rounds on assigned rooms (documented on life satisfaction survey forms) to interview/observe residents to ensure staff are honoring wishes (including requests to call 911); administrator to review documentation and address concerns immediately.
• Impromptu QAPI review of the plan of removal completed with the Medical Director; Medical Director reviewed and agreed with the plan.

Penalty

Inspection fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a resident’s right to be treated with respect, dignity, and to communicate with family while in distress. The resident was an older female with multiple cardiac and mental health diagnoses, including unspecified diastolic CHF, essential hypertension, paroxysmal atrial fibrillation, generalized anxiety disorder, recurrent depressive disorder, and nonrheumatic aortic valve stenosis. Her Medicare MDS showed a BIMS score of 15, indicating intact cognition, and her care plan documented anxiety, depression, and use of antidepressant medication with interventions for psychosocial support. Video observation from the resident’s room on a specific morning showed the ADON telling the resident she was going to remove the resident’s phone from her chest while the resident was on a call with her son and in respiratory distress. The resident nodded her head no and held up her left hand, then became more frustrated as the ADON removed the phone and left the room. The phone was then placed on a rolling bedside table positioned approximately 10 feet away on the right side of the bed, toward the middle of the bed, where the resident could not reach it. During the period after the phone was removed, the resident attempted to reach the phone, and her hands were not shaking; she had been holding the phone in her left hand before laying it on her chest. Approximately eight minutes later, EMS entered the room, picked up the cell phone, and began talking to the resident’s son. In interviews, the ADON stated she believed the phone on the resident’s chest affected her breathing and that the resident was unable to hold the phone due to shaking hands, and she asserted the phone had been left within reach at the head of the bed. The DON and Administrator both stated that residents have the right to have their personal phones within reach and to speak with family at any time, and that staff should not remove a resident’s phone or place it out of reach while the resident is on a call. The facility’s resident rights policy stated that employees shall treat residents with kindness, respect, and dignity and that residents have the right to use a telephone in privacy and to exercise their rights to the fullest extent possible.

Penalty

Inspection fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors found that the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one resident. The resident was an adult male with diagnoses including sepsis, perforation of intestine, colostomy status, and malignant neoplasm of the rectum. His MDS assessment showed an intact BIMS score of 13 and documented septicemia, sepsis, and a colostomy. The comprehensive care plan, revised on 01/07/2026, addressed his ostomy and risks for complications such as stoma irritation and bleeding, with interventions including colostomy care each shift and monitoring for signs of infection around the stoma. However, the care plan did not include any problem, goal, or interventions related to the resident being on enhanced barrier precautions. During interviews, the DON stated that Resident #2's care plan should have been revised on 01/07/2026 and that either the ADON or DON was responsible for updating care plans at that time, as the newly hired MDS nurse had not yet started working. The DON explained that if a resident had an order for enhanced barrier precautions, the nurse reviewing the physician order could have added it to the care plan, and that all information about a resident, including enhanced barrier precautions, was to be care planned. The Administrator stated she expected any change of condition or treatment, including new orders for enhanced barrier precautions, to be immediately added to the care plan by the nurse, DON, or interim nurse completing care plans, and confirmed that the DON was ultimately responsible for ensuring care plans were completed and revised. Review of the facility’s comprehensive care plan policy, dated December 2015, showed that the IDT must review and update the care plan with significant changes in condition, unmet outcomes, readmissions from hospital, and at least quarterly, but this process was not followed for the resident’s enhanced barrier precautions.

Penalty

Inspection fine: $17,345

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during colostomy care for one resident. The resident was an adult male with a history of sepsis, septicemia, perforation of the intestine, colostomy status, and malignant neoplasm of the rectum. His MDS showed intact cognition with a BIMS score of 13, and his care plan noted an ostomy secondary to bowel perforation with colostomy care ordered every shift as needed and monitoring for signs of infection. Physician orders reflected that the resident was to be on enhanced barrier precautions related to his colostomy and drain, and an enhanced barrier precaution sign and PPE supplies were present outside his room. On the observed date and time, RN C was at the medication cart preparing a colostomy bag for this resident. While preparing, she touched scissors and the left side of her shirt, both of which the DON later identified as contaminated items. Without performing hand hygiene after these contacts, RN C then touched the wafer of the colostomy appliance. She proceeded to walk down the hall to the resident’s room without sanitizing her hands. Upon entering the resident’s room, which was posted for enhanced barrier precautions, RN C did not don a gown and only applied gloves after entry, again without washing or sanitizing her hands. While donning the gloves, she touched the outside (fourchettes) of the gloves with her contaminated fingers and hands, and then proceeded to change the colostomy and apply a new colostomy bag. In subsequent interviews, RN C acknowledged she had not sanitized her hands after using the scissors and touching her shirt, confirmed she was expected to perform hand hygiene before donning gloves, and agreed that the gloves were contaminated by her technique. She also admitted she had no reason for not wearing a gown despite the enhanced barrier precaution signage and available PPE, and the DON confirmed that this conduct did not follow facility infection control protocols.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident who was dependent on staff for activities of daily living, including bathing, did not receive showers according to her scheduled shower days. The resident, who was admitted following ankle surgery and was non-weight bearing, required substantial to maximal assistance for bathing and was coded as dependent for tub/shower transfers. Review of her care plan showed interventions to keep her skin clean and dry due to surgical wounds, but there were no specific entries addressing bathing or hygiene. Electronic medical records indicated that the resident missed scheduled showers on three occasions, and there were no progress notes documenting reasons for these missed showers. Interviews with family members and the resident revealed that showers were not consistently provided as scheduled, and staff often did not ask the resident if she wanted a bath. Family members reported having to prompt staff to provide bathing, and the resident recalled only one instance of refusing a bath, which was not on one of the missed dates. The Director of Nursing (DON) and Administrator confirmed that it was the responsibility of nursing staff to ensure showers were given per schedule and that refusals should be documented, but there was no evidence of such documentation for the missed showers. Facility policy required documentation of showers, refusals, and any interventions taken, as well as notification of supervisors if a resident refused a shower. The lack of documentation and failure to provide scheduled showers represented a failure to ensure necessary services for maintaining personal hygiene for a resident unable to perform these activities independently.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not discontinuing several medications as ordered by the resident’s nephrologist. The resident, who was cognitively intact and had diagnoses including type 2 diabetes, asthma, and a history of falls, attended a nephrology appointment where the specialist ordered the discontinuation of metformin, potassium citrate, prenatal vitamins, and valsartan-hydrochlorothiazide. Despite these clear instructions, the resident continued to receive these medications for nearly three weeks after the appointment, as documented in the medication administration records. The after-visit summary with the discontinuation orders was reportedly handed to facility staff by the resident upon return from the appointment. However, there was no documentation in the progress notes regarding the medication changes until two weeks later, when concerns were raised by a family member. Interviews revealed confusion and lack of follow-up among staff regarding the receipt and processing of the specialist’s orders. The nurse responsible did not promptly verify or act on the nephrologist’s instructions, and the facility’s process for handling post-appointment paperwork and communication with physicians was not effectively followed. Facility leadership, including the DON and administrator, confirmed that the expectation was for transportation staff to deliver all paperwork to the nurse, and for the nurse to follow up with the specialist or the facility physician if documentation was missing. The failure to follow these procedures resulted in the resident receiving medications that had been ordered discontinued, with no timely communication or documentation of the specialist’s orders in the resident’s medical record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a male resident with dementia, muscle weakness, and frequent bowel incontinence was found lying sideways on his bed, covered in dried feces, and wearing a full, soiled brief. The incident was documented with a photograph showing brown stains consistent with fecal matter on the resident, his brief, and the bed sheets. The resident's care plan included interventions for checking and changing him, and his records indicated a medium bowel movement earlier that day, but there were no further entries or progress notes documenting additional care or checks on the date of the incident. Interviews with multiple staff members, including CNAs, LVNs, the ADON, and the DON, revealed that facility policy and staff understanding required residents to be checked and changed every two hours or as needed. Staff were expected to document these activities in the resident's POC, but there was inconsistency in oversight and documentation practices. Some staff were unsure who was responsible for ensuring that checks and changes occurred as scheduled, and there was no evidence of in-service training related to dignity and resident rights during the relevant period. The resident's representative reported observing the resident in this undignified state, and staff acknowledged the importance of regular checks and changes to maintain dignity and prevent skin breakdown. Facility policies reviewed emphasized the need to treat residents with dignity and respect, maintain privacy, and document perineal care, but these standards were not met in this instance, resulting in the resident being left in soiled conditions without timely intervention or documentation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an ongoing program of activities tailored to the comprehensive assessment, care plan, and preferences of each resident, specifically for two residents who were either bedfast or required substantial assistance. Both residents had significant medical and cognitive needs, including conditions such as osteomyelitis, multiple sclerosis, major depression, metabolic encephalopathy, and severe obesity. Despite these needs, the facility did not ensure that daily activities occurred regularly for these residents, nor were individualized room visits conducted to meet their interests and psychosocial well-being. Observations and interviews revealed that one resident, who was bedbound and severely cognitively impaired, was unable to see the activity calendar posted in her room and reported that the activity director had never visited her. She expressed a desire for more activities and stated she would try activities other than bingo if offered. Another resident, who was cognitively intact but required partial assistance, also reported not knowing the activity director, not having an activity calendar, and not receiving any in-room activities. Both residents were observed multiple times in their rooms without any activities being provided. The activity director admitted to not maintaining accurate participation logs and stated that she had fabricated the logs when requested by surveyors. She also reported difficulty keeping up with all residents due to lack of assistance from CNAs. The facility's own policy required individualized and group activities based on resident preferences and needs, as well as proper documentation and communication of activity offerings, but these were not followed for the residents in question. No activity assessments or participation logs were provided for the two residents when requested by surveyors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety in the kitchen, as evidenced by two specific incidents involving dietary staff. In the first instance, a Dietary Aide was observed standing over clean dishes on a food preparation table without properly wearing a beard guard, despite having approximately 8 inches of facial hair. The aide acknowledged not wearing the beard guard correctly and recognized the potential for hair to fall onto clean plates, which could then be transferred to food served to residents. The aide also confirmed he had been trained to wear beard guards and hair nets but could not recall the date of the training. In the second incident, another dietary staff member was observed handling shredded lettuce and sliced tomatoes with bare hands while preparing food for residents' lunch. During this process, she placed her right hand inside her pants pocket to retrieve a permanent marker, wrote a date on a label, and then touched the lettuce with her fingers without washing or sanitizing her hands. The staff member admitted to not washing her hands after touching her pocket and acknowledged the possibility of transferring germs from her clothing to the food. She also stated she had received in-service training on hand hygiene but could not remember when it occurred. Interviews with the Dietary Manager and the Administrator confirmed that all male staff were expected to wear beard nets and that staff were required to wash hands between tasks or after touching contaminated items. Both acknowledged the potential for contamination if these protocols were not followed. Review of facility policies and the FDA Food Code supported the need for proper hand hygiene and hair restraint to prevent foodborne illness.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was fully informed and able to participate in her treatment decisions, specifically regarding the administration of an antipsychotic medication. Record review showed that a female resident with severe cognitive impairment, diagnosed with unspecified dementia with psychotic features and major depressive disorder, was prescribed and administered Risperdal daily. Despite facility policy and regulatory requirements, there was no documented informed consent (form 3713 Medication Consent Form) signed by the resident or her representative prior to the administration of this medication. The resident's care plan and physician orders indicated ongoing use of antipsychotic medication, and the medication administration record confirmed daily dosing. A pharmacy consultant had previously identified the lack of a signed consent form and instructed the Director of Nursing (DON) to obtain the necessary signature, but this was not completed. Interviews with nursing staff and the interim DON confirmed awareness of the requirement for informed consent and acknowledged that the process for obtaining signatures was not followed in this case. Facility policy outlined the need for clear identification of medication indications, risks, and alternatives, as well as the importance of informed consent prior to administration of high-risk medications such as antipsychotics. Despite these protocols, the required consent was not obtained, resulting in the resident receiving medication without documented agreement or understanding of the associated risks and benefits.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's right to formulate an advance directive was honored. Specifically, a female resident with cognitive impairment and multiple medical diagnoses was admitted with a care plan indicating Full Code status, meaning CPR would be performed if needed. However, a physician's order for Do Not Resuscitate (DNR) was later entered without a completed and signed Out of Hospital-Do Not Resuscitate (OOH-DNR) form in the resident's medical record. The responsible party for the resident confirmed that the OOH-DNR paperwork had not been signed or returned, despite the resident's wishes to be DNR. Interviews with facility staff revealed that the code status was documented on the face sheet and admission orders, and that a copy of the OOH-DNR must accompany the resident if transferred to a hospital. Staff stated that the signed OOH-DNR form should be on file before changing code status orders, and the facility's policy required the original DNR order and completed OOH-DNR to be filed in the medical record. The lack of a completed OOH-DNR prior to the physician's DNR order resulted in the resident's advance directive wishes not being properly documented or honored according to facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a required quarterly Minimum Data Set (MDS) assessment for a resident within the mandated three-month timeframe. Record review showed that the resident, a female with diagnoses including Type 2 Diabetes Mellitus, Morbid Obesity, and Asthma, had her last completed quarterly MDS assessment on 01/09/2025, with the next assessment remaining open and incomplete past the required due date. This lapse was identified during a review of the resident's electronic health record. Interviews with facility staff revealed that the MDS Coordinator had recently taken on additional responsibilities for Medicaid assessments, previously handled by a regional MDS nurse. The MDS Coordinator acknowledged awareness of the MDS timing schedule and confirmed that a missed assessment was discovered during a consultant's review. The Interim DON stated that the expectation is for MDS assessments to be completed when due and recognized that incomplete assessments could result in staff not being aware of changes in a resident's condition, as the MDS drives care planning.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate completion of Pre-admission Screening and Resident Review (PASARR) Level I screenings and did not provide a required PASARR Level II assessment for a resident with a mental illness. Specifically, a 76-year-old resident admitted with a diagnosis of Post-Traumatic Stress Disorder (PTSD) was not properly identified as having a mental illness on the initial PASARR Level I screening completed by the hospital prior to admission. The facility's own PASARR Level I screening, completed on the day of admission, also failed to document the resident's mental illness, despite the diagnosis being present in the medical record and care plan. The MDS Coordinator (MDSC) acknowledged that the initial PASARR Level I screening was inaccurate and explained that a second screening was completed later the same day after the mental health diagnosis was discovered upon closer review of the resident's record. The MDSC admitted that a referral for a PASARR Level II assessment was not made due to a mistake by the facility. Interviews revealed that the MDSC was new to the role and was not fully familiar with the facility's process for identifying and referring residents with mental disorders, intellectual disabilities, or related conditions. Further interviews with the Interim Director of Nursing (DON) indicated a lack of clear understanding and consistent process for ensuring PASARR screenings are completed accurately and referrals are made when necessary. The facility's policy required PASARR screenings to be completed prior to admission and referrals for Level II assessments to be made when a mental health diagnosis is identified, but this was not followed in the case of the resident with PTSD.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a medication aide (MA) failed to ensure the complete administration of medications to a resident. The MA left a cup containing five medications at the bedside of a male resident with multiple chronic conditions, including type 2 diabetes mellitus, heart failure, chronic respiratory failure, generalized anxiety disorder, and major depressive disorder. The resident had an intact cognitive status, as indicated by a BIMS score of 15, and was prescribed pain medication, antidepressants, opioids, and hypoglycemics. The resident reported that the nurse left the medications on his table and that he had not taken them until after the surveyor's observation, at which point he ingested the pills in the presence of the surveyor. Upon interview, the MA confirmed that she left the medications in the resident's room without observing him take them, acknowledging that she was expected to remain with the resident until all medications were ingested. She recognized the risks associated with this action, including the possibility that the resident might not take the medications or that another resident could enter the room and ingest them, potentially leading to serious health consequences. The MA also stated that the resident did not have an order to self-administer medications and that she had previously received in-service training instructing her not to leave medications unattended. Further interviews with the Interim Director of Nurses and the Administrator confirmed that facility policy and their expectations required staff to observe residents taking their medications and not to leave medications in resident rooms. Both acknowledged the potential for harm if medications were not administered as intended. Review of the facility's medication administration policy indicated that medications should be administered safely and as prescribed, with proper documentation by the individual administering the medication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when Medication Cart #1 was found unattended and unlocked near the nurses' desks in the 500-hall at 4:35 AM. The LVN assigned to the cart was observed administering medications to residents in their rooms and confirmed during an interview that the cart was left unlocked. The Director of Nurses stated that medication carts are expected to be locked when not in use or when the nurse steps away from the cart, and acknowledged that the responsibility for ensuring the carts are locked lies with the nursing staff. The unlocked cart was accessible while the nurse was away from it, contrary to facility policy and accepted professional principles for medication storage.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a medication aide (MA) failed to properly sanitize or wash hands prior to preparing and administering medications to a resident during a morning medication pass. The observation took place while the MA prepared and handled multiple medications, including Bumetanide, Famotidine, Tamsulosin, Entresto, Amiodarone, Eliquis, Docusate sodium, Vitamin C, a multivitamin, MiraLAX, Mucinex, and Zyrtec, without performing hand hygiene as required by facility policy. The MA acknowledged having received training on handwashing and recognized the risk of spreading germs and infection due to this lapse. Further interviews with the Interim DON confirmed that all staff are expected to wash hands or use hand sanitizer before and after medication administration, and that in-services and check-offs are conducted to reinforce this practice. However, the Interim DON was uncertain about the frequency of medication pass check-offs. Review of the facility's hand hygiene policy indicated that handwashing or use of alcohol-based hand rub is required before preparing or handling medications, which was not followed in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, consistent with the resident's rights and needs as identified in the comprehensive assessment. The care plan specified that the resident, who had diagnoses including congestive heart failure, varicose veins, and morbid obesity (BMI 45.0 - 49.9), required two-person assistance for activities of daily living (ADLs) such as bathing, bed mobility, transfers, and toileting. Despite these documented requirements, the care plan was not followed during an incident in which a certified nursing assistant (CNA) provided a bed bath to the resident alone, without the required second staff member. On the day of the incident, the CNA turned the resident to her right side during a bed bath, causing the resident to slide off the bed and fall to the floor. The resident sustained a severe laceration to her right hip and a comminuted intertrochanteric fracture to her left hip, requiring emergency medical intervention. The CNA admitted to not reading the Kardex (which contained the care plan and assistance requirements) prior to providing care and acknowledged that she was aware the resident required two-person assistance but did not request help, citing that other aides were busy. Other staff confirmed that the Kardex was accessible and that the resident's need for two-person assistance was clearly indicated. Interviews with facility staff, including the administrator, DON, ADON, and other CNAs, revealed that all direct care staff were expected to refer to the Kardex to determine the level of assistance required for each resident. Staff also stated that it was never appropriate to provide care alone to a resident who required two-person assistance, and that help should always be sought if needed. The failure to follow the care plan and ensure the required level of assistance directly resulted in the resident's fall and injuries.

Removal Plan

• Resident discharged from the facility to the hospital and did not return to the facility.
• The Clinical Service Director in-serviced the nurse managers to include the DON to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care.
• DON/designees in-serviced all direct care (full-time, part-time, and PRN) nursing staff to utilize Kardex to determine the level of assistance required to provide care.
• The Administrator educated CNA A to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care. CNA A last day worked.
• All direct care nursing staff (full-time, part-time, and PRN) will demonstrate and acknowledge that they are aware of how to identify and utilize the Kardex to review resident's care plan to identify the level of assistance: including 2 person assistance) required to provide ADL care.
• The Kardex was in the POC dashboard which is accessible by all direct care nursing staff in the facility. To access the employee will log into their POC, select the resident and then select the Kardex button located on the right-hand side of their screen. This will then display the level of care required to provide care as directed in their care plan including 2 person assistance.
• DON/designees audited residents' Kardex to ensure the level of required assistance was stated as directed by resident's care plan. Residents were identified as needing 2-person assistance for bed mobility.
• DON/designees audited employee roster to ensure 100% of direct care nursing staff (full-time, part-time, and PRN) are in-serviced to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care.
• The training regarding to refer the Kardex for the level of assistance: including 2 person assistance required to provide ADL care will be ongoing. Continuous training to be conducted during the orientation of newly hired direct care nursing staff (full-time, part-time, and PRN). The DON/designees provide oversight and ensure compliance.
• No direct care nursing staff will be allowed to work without receiving the in-service on the utilization of the residents' Kardex to determine the level of assistance that is required to provide care.
• DON/designees will conduct random direct care observation audit for compliance with the utilization of the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care daily for 1 week, weekly for 1 month and monthly thereafter until compliance is sustained for 3 consecutive months. Noncompliance identified will be corrected immediately.
• The facility Administrator notified the Medical Director via phone.
• Quality Assurance and Performance Improvement review of the plan of removal was completed with the Medical Director.
• Random direct care observation audit will be conducted by DON/designees for compliance with the utilization of the Kardex to determine the level of assistance that is required to provide care to the residents daily for 1 week, weekly for 1 month and monthly thereafter until compliance is sustained for 3 consecutive months.
• Noncompliance identified will be corrected immediately.
• This will be reviewed monthly in QAPI until sustained compliance is achieved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) provided activities of daily living (ADL) care to a resident who required a two-person assist for toileting, transfers, bed mobility, and bathing, without the required second staff member. The resident, who had diagnoses including congestive heart failure, varicose veins, and morbid obesity (BMI 45.0 - 49.9), was cognitively intact and had a care plan specifying the need for two-person assistance for all major ADLs. During the incident, the CNA attempted to turn the resident alone while providing a bed bath, resulting in the resident sliding off the bed and sustaining a severe laceration to the right hip and a fracture to the left hip. The CNA admitted to not reading the Kardex on the day of the incident, despite knowing that the resident required two-person assistance. The CNA stated that she did not want to bother other staff members, felt the facility was short-staffed, and had previously assisted the resident alone. Other staff interviews confirmed that the Kardex was available and indicated the required level of assistance, and that there were enough staff present to provide help if requested. The charge nurse and other CNAs stated that it was standard procedure to refer to the Kardex and to wait for the appropriate number of staff before assisting residents who required two-person assistance. Facility policy required staff to identify and implement interventions to prevent falls and minimize complications, and to avoid neglect by providing necessary care to prevent physical harm. The failure to follow the resident's care plan and facility protocols resulted in the resident's injury. The incident was reported, and staff interviews and documentation confirmed that the CNA acted alone, contrary to the resident's care requirements and established procedures.

Removal Plan

• Resident #1 involved in alleged deficient practice was discharged to the hospital and did not return to the facility.
• CNA A was in-serviced on referring to the Kardex for the level of assistance required by residents with ADL care and the Abuse and Neglect Policy by the administrator.
• CNA A was suspended pending investigation findings.
• The Administrator notified the Medical Director of the alleged deficient practice.
• CNA A's last day employed.
• The Corporate Clinical Service Director re-educated the nurse management team on referring to the Kardex for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy.
• The Administrator and Nurse Managers re-educated the nursing staff on referring to the Kardex for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy.
• An audit was conducted by the Corporate Clinical Service Director and the nurse management team to ensure the level of ADL care required, including residents needing 2-person assistance was noted in the Kardex. Discrepancies found were immediately corrected.
• The Corporate Clinical Service Director reviewed facility policy regarding change in condition and no revisions were deemed necessary.
• The Regional Nurse completed Resident Life Satisfactory Surveys for residents that require 2-person assistance, no concerns were noted.
• The nurse management team re-educated the nursing staff (Full-time, Part-time, and PRN) on referring to the Kardex for the level of assistance required, including residents needing 2-person assistance with ADL care and the Abuse and Neglect Policy. Nursing staff will not be allowed to return to work until they receive this in-service.
• Newly hired nursing staff will be in-serviced upon hire during staff orientation by nurse management/designee on referring to the Kardex for the level of assistance required, including residents needing 2-person assistance with ADL care and the Abuse and Neglect Policy.
• DNS/designee will conduct random observations of ADL care including residents needing 2-person assistance is being provided daily for one week, then weekly for one month, and monthly thereafter until compliance is sustained for three consecutive months. Noncompliance identified will be addressed immediately.
• The ADONs will review the change in condition daily for any changes in residents' ADL level of assistance requirements and ensure the Kardex is updated as applicable. Discrepancies noted during reviews will be immediately corrected. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. The review will be documented on an audit report form.
• The Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction. The review will be documented on an audit report form.
• A Quality Assurance and Performance Improvement review of the plan of removal was completed with the Medical Director. The Medical Director has reviewed and agrees with this plan.

Penalty

Inspection fine: $20,7917 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the proper administration and management of parenteral fluids for two residents, leading to a deficiency in care. Resident #1 had a peripherally inserted central catheter (PICC) line dressing that was not changed for 27 days, despite physician orders requiring a change every seven days. This oversight was observed on multiple occasions, with the dressing dated 02/20/2025 and not changed on subsequent required dates. Additionally, there was a lack of enhanced barrier precautions (EBP) for both Resident #1 and Resident #2, who also had a PICC line. The deficiency was further compounded by the absence of personal protective equipment (PPE) and EBP signage for residents with central lines. Observations revealed that staff were not consistently using gowns and gloves when handling PICC lines, as required by facility policy. Interviews with staff, including licensed vocational nurses (LVNs) and the assistant director of nursing (ADON), indicated a lack of awareness and adherence to EBP protocols. The facility's central supply had also run out of necessary dressings, contributing to the failure to change Resident #1's dressing in a timely manner. Resident #2 was similarly affected by the lack of EBP, with no signage or PPE available at the time of observation. The director of nursing (DON) and other staff members acknowledged the oversight and the potential risk of infection due to the failure to change dressings and implement EBP. The facility's policies on central venous catheter dressing changes and EBP were not followed, leading to the identification of an Immediate Jeopardy situation by surveyors.

Removal Plan

• Resident #1's PICC line dressing change was done by Nurse Manager A.
• Resident #1 was placed on enhanced barrier precautions and signage posted on resident #1's door by Nurse Manager A.
• Resident #2 was placed on enhanced barrier precautions and signage posted on resident #2's door by Nurse Manager A.
• The Administrator notified the Medical Director of the alleged deficient practice.
• The Corporate Clinical Service Director in-serviced the Nurse Managers on ensuring PICC line dressing change is done every 7 days.
• Nurse Manager A and B completed an assessment of 2 residents with PICC line to ensure the dressing change date is less than 7 days, and no concerns were identified.
• Nurse Managers completed a 100% audit of residents residing in the facility to assess the need for barrier precautions, no concerns were identified.
• Licensed nurses were in-serviced on ensuring PICC line dressing change is done every 7 days by Nurse Manager A and B. The facility audited all residents with PICC line for dressing change dates less than 7 days old, no concerns were identified by Nurse Manager A and B.
• The Corporate Clinical Service Director reviewed facility policy regarding PICC line dressing change and no revisions were deemed necessary.
• The Corporate Clinical Service Director reviewed facility policy regarding enhanced barrier precautions and no revisions were deemed necessary.
• An in-service was completed by the Corporate Clinical Service Director with the Director of Nursing on ensuring residents PICC line dressing change is done every 7 days.
• An in-service was completed by the Corporate Clinical Service Director with the Director of Nursing on ensuring residents requiring enhanced barrier precautions have signage posted on the door.
• The Director of Nursing completed an in-service with the licensed nursing staff on ensuring PICC line dressing change is done every 7 days.
• The Director of Nursing completed an in-service with the licensed nursing staff on ensuring residents requiring enhanced barrier precautions have signage posted on the door.
• Nurses will not be allowed to return to work until they receive this in-service. Nursing staff who are unable to physically attend the in-service training in person will be in-serviced via phone by Nurse Manager A. The completion date is 3/19/2025.
• Newly hired nurses will be in-serviced by the Director of Nursing or designee to ensure PICC line dressing change is done every 7 days during facility orientation upon hire.
• Newly hired nurses will be in-serviced by the Director of Nursing or designee to ensure residents requiring enhanced barrier precautions have signage placed on the door during facility orientation upon hire.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from neglect, as evidenced by the lack of assessment and care provided to a newly admitted resident. The resident, who had multiple medical conditions including generalized weakness, chronic renal failure, and dementia, was admitted to the facility in the evening. Despite the resident's inability to assist himself to the bathroom, no staff member assessed or observed him for nearly two hours after his arrival. This resulted in the resident urinating on himself and experiencing distress. Interviews with staff revealed a lack of clarity and responsibility regarding the admission process. RN A, who was on duty when the resident arrived, did not conduct an assessment or greet the resident, citing a supposed cut-off time for admissions. LVN B, who took over the shift, also failed to perform an assessment or take vital signs until the family expressed dissatisfaction. Treatment Nurse C only became involved after being informed of the family's concerns, at which point she found the resident soiled and provided care. The facility's administration, including the Administrator and Director of Nurses, acknowledged that the staff did not meet the expected standards of care. They confirmed that the resident should have been assessed upon arrival and that there was no official cut-off time for admissions. The family of the resident reported that he was left unattended, leading to his distress and the decision to discharge him from the facility. The facility's neglect policy defines neglect as the failure to provide necessary goods and services to avoid physical harm or mental anguish, which was evident in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient preparation and orientation for a resident's safe and orderly transfer or discharge. The resident, who had Alzheimer's disease and other cognitive impairments, was discharged without being informed about the transfer or the reasons behind it. The resident's responsible party (R/P) was not adequately notified about the discharge process, and there was no documentation of an orientation being provided to the resident prior to the discharge. The Admission Coordinator had attempted to contact the resident's R/P multiple times to discuss the need for a secure unit due to the resident's exit-seeking behavior. However, the R/P did not return the calls, and the facility did not provide a 30-day discharge notice. On the day of the discharge, the resident was transferred to another facility without the R/P being present or informed about the exact timing of the transfer. The nurse on duty did not contact the R/P or explain the discharge to the resident, which could have led to confusion and anxiety for the resident. The facility's discharge policy requires that residents be consulted about their discharge and informed about the new facility, the services it offers, and the reasons for the discharge. However, these steps were not followed in this case. The nurse on duty admitted to forgetting to call the R/P and failing to explain the discharge to the resident, which is a deviation from the facility's policy and could have resulted in the resident being discharged without understanding the situation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that three residents received the necessary assistance with activities of daily living, specifically in maintaining good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in the cases of three residents who were dependent on staff for bathing. The facility's records indicated that these residents did not receive their scheduled showers consistently, which could lead to embarrassment and unidentified skin issues. Resident #1, a female with severe cognitive impairment and multiple medical conditions, was dependent on staff for bathing. Her care plan required staff assistance for bathing, but records showed that she missed several scheduled showers during her stay. Similarly, Resident #2, who also had severe cognitive impairment and multiple health issues, was dependent on staff for bathing. Despite being scheduled for showers three times a week, she missed several, and the charge nurse was unaware of these missed showers. Resident #3, who had intact cognition but was dependent on staff for bathing, also missed several scheduled showers. She filed a grievance about not receiving showers, which was documented but not adequately addressed. Interviews with staff revealed a lack of awareness and oversight regarding the missed showers. The charge nurse and CNAs were responsible for ensuring showers were given, but there was no system in place to monitor compliance. The Director of Nursing acknowledged the responsibility of the nursing staff to ensure showers were given as scheduled, and the Administrator admitted to not having developed a system to oversee compliance due to being new to the facility. The facility's policy required documentation of showers and refusals, but this was not consistently followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish a grievance policy that ensured the prompt resolution of grievances related to resident rights and did not maintain evidence of grievance resolutions for at least three years. This deficiency was identified during a review of grievances for a resident who had multiple medical conditions, including metabolic encephalopathy, spinal stenosis, and dementia, and was noted to have severely impaired cognition. The resident's family member reported filing at least three grievances regarding the resident's care between November and December 2024, but did not receive any feedback on the outcomes of these grievances. Interviews with facility staff revealed that the grievances were not properly documented or resolved. The Director of Nursing (DON) recalled communication with the family member but could not remember the specifics of the grievances or their outcomes. The Administrator, who assumed the role in December 2024, was unable to locate the grievances and had no contact with the previous administrator. The facility's policy required grievances to be investigated and resolved within five working days, with findings communicated to the complainant, but this process was not followed, leading to unresolved grievances and a lack of documentation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary treatment and services for a resident with a stage III pressure ulcer, as per professional standards of practice. The resident, a female with multiple diagnoses including dementia and spinal stenosis, was not repositioned during the overnight shift after developing a stage III pressure ulcer. This lack of repositioning occurred despite the resident's care plan indicating the need for such interventions due to decreased mobility and the presence of a pressure injury. Additionally, the facility did not refer the resident to a registered dietitian (RD) after the wound care doctor (WCD) recommended a dietitian consult. This recommendation was made to address the resident's impaired nutritional status, which was a factor complicating wound healing. The RD confirmed that a consult should have been requested shortly after the physician's recommendation, but no such referral was made during the resident's stay. Interviews with facility staff revealed that the resident was difficult to work with due to her refusal to offload and her declining condition. The staff acknowledged that the resident's wound was clinically unavoidable due to these factors, but also admitted that the facility's policy of repositioning every two hours was not consistently followed. The facility's failure to adhere to its own policies and the physician's recommendations contributed to the resident's risk of worsening pressure ulcers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required. The resident, a male with multiple complex medical conditions including sepsis, type 2 diabetes with a foot ulcer, and essential hypertension, was admitted and readmitted to the facility. Despite these conditions, the baseline care plan did not document critical information such as the resident's nausea and vomiting, diabetic alert, and infection alert. This omission was identified during a record review and interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), who acknowledged the incomplete documentation. Interviews with facility staff revealed that the responsibility for completing the baseline care plan fell to the DON, or the nurse supervisor if the admission occurred after hours. However, the baseline care plan for this resident was not completed in its entirety, leaving out essential information related to the resident's medical conditions. The MDS Coordinator and other staff members confirmed that the lack of a complete baseline care plan could hinder the ability of CNAs to provide appropriate care. The facility's policy on baseline care plans was not provided at the time of the survey exit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a working call system was available for a resident, identified as Resident #1, in their room. This deficiency was observed during a survey where it was noted that the call light in Resident #1's room was nonfunctional. The resident, who had been moved to this room on a previous date, reported that the call light had not worked since the move. The resident expressed concerns about not being able to call for help, which was particularly troubling given their medical conditions, including heart failure, chronic atrial fibrillation, and a history of falls. During the survey, it was observed that the call light system in Resident #1's room was physically broken, with the base plate detached and wires exposed. The resident had to resort to propelling themselves into the hallway or shouting for assistance, as the call light did not activate any indicators. Despite the resident's attempts to report the issue to staff, no action had been taken prior to the survey to address the malfunctioning call light. Interviews with various staff members, including an LVN, CNA, MA, MNT, DON, ADON, and ADM, revealed that there was an expectation for call lights to be functional and within reach at all times. However, there was no record of a maintenance request for the call light issue in Resident #1's room, indicating a lapse in communication or follow-up on reported issues. The staff acknowledged the importance of functional call lights for resident safety and the potential negative outcomes of a nonfunctional system.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. This deficiency was observed in eight residents who were reviewed for activities of daily living. Specifically, the facility did not ensure that residents had clean and well-groomed hair, received regular baths, and had their nails trimmed and groomed. These failures were documented through observations, interviews, and record reviews, which indicated that the residents were at risk of not receiving adequate help with their daily living activities. Resident #10, a male with multiple diagnoses including metabolic encephalopathy, epilepsy, and major depressive disorder, was found to have long fingernails with no documented refusals of nail care. Similarly, Resident #26, a male with type 2 diabetes and dementia, had long and dirty fingernails despite being bathed on specific dates. Resident #63, a female with chronic respiratory failure and type 2 diabetes, had greasy hair and long fingernails, and there were no documented refusals of baths or nail care. Other residents, including Resident #60, Resident #36, Resident #96, Resident #16, and Resident #49, also exhibited similar issues with personal hygiene and grooming. Interviews with residents and staff revealed that the residents were aware of their grooming deficiencies and expressed a need for assistance. Staff members, including CNAs and LVNs, acknowledged the issues but did not provide consistent care. The facility's policies and in-service training on ADL care and showers were not effectively implemented, leading to the observed deficiencies. The DON and ADM confirmed that the facility's expectations for nail care and showers were not met, resulting in potential quality-of-life issues and risks of infection for the residents.