Health inspection·June 28, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two (#20 and #24) of six sampled residents reviewed for Activities of Daily Living were provided with personal hygiene care as per their choice during at least three of three days observed on 6/26/2023, 6/27/2023, and 6/28/2023. Residents Affected - Few Findings included: 1. On 6/26/2023 at 9:35 a.m., Resident #20 was observed in his room and in his bed. The call light was placed within his reach and he was lying under the covers with the head of his bed at approximately 40 degrees. The over the bed table was positioned over his lower chest area, over the bed. Resident #20 was pleasant to speak with, but had some cognitive impairment. He was able to answer some simple questions about his day when asked. He was wearing glasses and his television was on during the time of the interview. Further observations revealed Resident #20's face was not cleanly shaven. His cheeks, chin, neck all were observed with more than overnight stubble. The facial hair was observed between one quarter inch to one half inch in length. Resident #20 was asked if he normally liked to be shaven, and he replied, nobody really helps me with shaving every day. He continued, I get shaved maybe one time a week. The resident confirmed he did not like stubble, facial hair, or beards, liked to be cleanly shaven every day; as that was what he had done in the past. He started to scratch his neck line and all ten of his finger nails were observed elongated and with what appeared to be brown/black colored debris under all the nails. The nails were observed to be at length with some nails one quarter to one half inch over the end of the fingers. Resident #20 was asked about his finger nails and if staff ever clipped them. He looked at both his hands and stated, they are long, I don't like them long. He revealed he was supposed to receive help with his nail maintenance but did not remember the last time staff had clipped his nails. He also did not know when the last time staff helped him clean debris from under his nails. The resident did not like the current state of his nails and did not like not being shaven. On 6/26/2023 at 11:56 a.m., the resident was visited while in his room again. He was observed cheerful and still lying in bed. The call light was placed within his reach and there was an aide in the room bagging soiled sheets/clothing. The Certified Nursing Assistant (CNA) Staff B left the room. The resident was observed with a cleanly shaven face and he confirmed the staff (could not provide name) was just in the room and shaved him. He stated, I feel better. He also was observed with both the left and right hand (all ten fingers) with completed nail care. All nails were clipped to the end of his finger tips. He was asked how his hands and fingers felt, and he replied, She just clipped, I like it this way. Resident #20 confirmed he was not shaved or provided nail care on a daily basis. On 6/27/2023 at 7:40 a.m., an interview Staff D, CNA revealed she worked with Resident #20 a lot and knew him. She revealed he liked to stay in his room, talk with his roommate, and watch television. Page 1 of 5 105140 105140 06/28/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Staff D said the resident was invited but did not like to go to group activities much. Staff D the had a shower/bathing schedule and for him the schedule was during the 3-11 shift. She said is was expected that the staff who provided him with bathing/showering, would shave him and provide nail care. Staff D said Resident #20 could make his daily needs known. She said the resident liked to be cleanly shaven and with his nails clipped. She said, as far as she knew, he did not refuse care and services to include personal hygiene care. On 6/27/2023 at 7:45 a.m., an interview with North [NAME] floor nurse Staff A revealed she worked the same unit mostly and had Resident #20 on her assignment. She remembered yesterday, 6/26/2023, Resident #20 had not been shaved and had long nails. She said on 6/26/2023, the 7-3 shift Staff C, CNA clipped his nails and shaved his face after lunch time. She confirmed the resident was pleasantly confused but able to make his daily needs known. As far as she knew he did not refuse showers/bathing and/or personal hygiene care. She said if that were the case, it would be documented in the chart and the aides would the nurse know. On 6/27/2023 at 7:50 a.m., an interview with Staff C, CNA revealed she did not have Resident #20 on her assignment today, but did him routinely and knew him. She said he was pleasantly confused but was able to make his daily routine decisions. She revealed she had him on her assignment yesterday, 6/26/2023, and in the afternoon she realized he needed to be shaved. She confirmed it appeared he had not been shaven for a few days. She also looked at his finger nails and saw those too needed to be cleaned and clipped as they were very long. She revealed that the resident normally has his showers/bathing during the 3-11 shift but sometimes she would provide shower/bathing during the 7-3 shift. Staff C did not know why the resident was not shaved or why his fingernails were so long. She said the resident did not typically refuse personal hygiene care. Review of Resident #20's medical record revealed he was admitted to the facility on [DATE]. Review of the advance directives revealed the resident was his own responsible party. He had family members listed as emergency contact only. Further review of the record revealed no indication of an incapacity statement. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Abnormal posture, Dementia, Muscle weakness, Cognition deficit. Review of the current care plans with next review date 8/20/2023 revealed the following but not limited to areas: - Has self care deficit with dressing, grooming, bathing r/t generalized weakness and confusion, with interventions to include: Cue/encourage resident to participate in ADL tasks, Allow resident ample time to attempt ADL, Encourage and remind to ask for assistance with dressing, grooming, bathing, Use calm approach, explain actions during care, Therapy screen as indicated. Per review of the entire medical record to include nurse progress notes, nursing assessments, Minimum Data Set assessments, and Care Plans, all did not have any documentation to support the resident ever refusing bathing, shaving, and or nail care. 2. On 6/26/2023 at 9:40 a.m., the North East lounge/dining room, located across from the North East Unit station revealed several residents either seated in wheelchairs or seated/reclined in Geri chairs. The television was on and there were no staff in the room. However, there were staff seated at the unit station and they could see the residents from their seated position. Observations revealed Resident #24 in the lounge area and reclined next to a window, while in her 105140 Page 2 of 5 105140 06/28/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reclining chair. She was noted with a blanket over her but was shaking. She was not interviewable and could not answer any questions about her day. She was noted with her hands shaking and her hands were placed up near her neck line. Further observations revealed all ten fingernails were observed elongated and with what appeared to be a dark colored debris under her nails. Some nails appeared one quarter inch to one half inch in length. Resident #24 was not able to answer if she liked her nails like that or not. At 10:30 a.m. and at 11:40 a.m. Resident #24 was observed in the same place in the lounge area and seated next to the window. At 11:50 a.m. staff were noted assisting her with her lunch meal. On 6/27/2023 at 7:00 a.m., Resident #24 was noted reclined in her reclining chair in the North East lounge/dining area. She was noted with a blanket over her and she was positioned at the window. Resident #24 was observed with her eyes open and she was moving her hands and head back and forth. Resident #24 was not otherwise presenting with any behaviors, pain or discomfort. Resident #24's hands were still observed with all ten fingernails elongated and with dark brown/black debris under her nails. Resident #24 was not able to make her needs known nor able to speak related to her daily care and services. On 6/27/2023 at 8:00 a.m., Resident #24 was being assisted with her breakfast meal by Staff E, CNA. Staff E confirmed the resident's fingernails were long and they had debris under them. She revealed she did not have the resident on her assignment the past few days and did not know why staff during the previous days have not provided nail care. Staff E said the resident did not refuse personal hygiene care when she had her on her assignment. On 6/28/2023 at 8:00 a.m., Resident #24 was seated in her reclining chair in the 300 unit lounge/dining room. Staff F, CNA was asked to lift up the blanket so the residents fingers and hands could be observed. She lifted the blanket after awaking the resident and both the left and right hand fingernails appeared elongated and soiled with black and brown debris under most of her fingernails. Staff F confirmed the nails were long and soiled. A review of Resident #24's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. A review of the diagnosis sheet revealed diagnoses to include: Dementia, Depression, Anxiety, History of falls. A review of the current Quarterly Minimum Data Set (MDS) assessment, dated 3/18/2023 revealed: Activities of Daily Living or ADL - PERSONAL HYGIENE = Total dependent on staff with One person assist, BATHING = Total dependent on staff with one person assist. There were no indication or documentation reflective that the resident ever refused ADL care and service. There was no documentation that reflected Resident #24 ever refused showers/bathing. A review of the CNA [ brand name of a desktop file system that gives a brief overview of each patient /resident] interventions revealed the following: Personal Hygiene - 5/29/2023 - current 6/27/2023 indicated resident total dependent on staff for this task. No specific task to include fingernail care. Review of the current care plans with next review date 9/16/2023 revealed the following but not limited problem areas: 105140 Page 3 of 5 105140 06/28/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - Risk for decreased social interaction/activity participation r/t: Cognitive impairment d/c advanced dementia. She will sit in her wheelchair in the dayroom. She will tolerate at times sitting in with a group of residents. She does verbally communicate her needs/wants, staff must anticipate needs/wants, with interventions in place. (nothing to include ADL fingernail care) - Has self care deficit with dressing toileting, bathing r/t cognitive deficit r/t impaired mobility r/t generalized weakness, with interventions in pace to include but not limited to: Provide total staff assistance with dressing, grooming, bathing. Note: There was nothing listed related to fingernail care. - Has visual alteration and dx. of dementia making it difficult to accurately assess visual ability, with interventions in place to include but not limited to: Provide assistance with ADL tasks as need. Note: There was nothing listed related to fingernail care. On 6/28/2023 at 2:00 p.m., an interview with Staff G, North East and North [NAME] Unit Manager was conducted. Staff G said when residents were bathed and showered, the CNA would check for fingernail length cleanliness. He was not sure how this was documented in the chart to show if this task was completed or not. Staff G also indicated the resident care plans should also reflect if the resident should have fingernail care. Staff G said heard Resident #24's nails were long. He did not know why the resident's nails were not clipped in a more timely manner. On 6/28/2023 at 9:00 a.m. the Nursing Home Administrator provided the facility's Fingernails/Toenails, Care of Policy and Procedure with a revised date 2018, for review. The Purpose of the policy revealed; The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection. The General Guidelines indicated; (1) Nail care includes cleaning and regular trimming. (2) Proper nail care can aide in prevention of skin problems around the nail bed. (4) Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The Documentation section of the policy revealed; The following information should be record in the resident's medical record: (1) The date and time that nail care was given. (2) The name and title of the individual(s) who administered the nail care. (6) If the resident refused the treatment, the reason(s) why and the intervention taken. (7) The signature and title of the person recording the data. The Reporting section of the policy revealed; 105140 Page 4 of 5 105140 06/28/2023 The Bristol Care Center 1818 E Fletcher Ave Tampa, FL 33612

F 0677 (1) Notify the supervisor if the resident refuses the care. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 105140 Page 5 of 5