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Based on documentation review and interview ,the nursing staff failed to offer and/or document daily shower, bath, and/or grooming for 1 of 10 medical records (MR) reviewed. (P1)

Findings include:

1. The facility policy titled, "Patient Personal Care", PolicyStat ID 12197137, last approved 08/2022, indicated under Policy: All patients admitted to the hospital will be supported and educated in activities of daily living (ADLs), focusing on personal hygiene and grooming. Articles for grooming and personal hygiene are available and accessible. Procedure: CMS defines ADLs as activities related to person care, which includes the following: Bathing/showering, Dressing, Getting in and out of bed/chair, Walking, Using the toilet, and Eating. All patients shall be encouraged or assisted in grooming daily or more often as needed.

2. MR documentation indicated P1 did not receive a daily shower, bath, and/or grooming (which includes a change in clothes and bed linen change) by facility staff for dates 2/29/24, 3/2/24, 3/3/24, 3/4/24, 3/5/24, 3/6/24, 3/17/24, 3/18/24, 3/19/24, 3/22/24, 3/23/24, 3/24/24, 3/31/24, 4/1/24, and 4/5/24.

3. In an interview on 4/16/24 at approximately 1:10 pm with B1 (Behavioral Health Associate-BHA) confirmed showers/bathing/grooming are offered daily, daily linen changes are to occur daily, facility BHA's are to document on the 15-minute observation rounding sheet when the patients have a shower/bath/grooming.

4. In an interview on 4/22/24 at approximately 1:15 pm with A1 (Director of Nursing) P1's chart lacked documentation of daily showers and/or grooming for numerous days. P1's showers/bathing/grooming should have been documented daily and were not.

Based on document review, observation, and interview, the facility failed to ensure the safety and/or quality of facility linen in 1 of 1 areas toured. (Clean Linen Room)

Findings include:

1. The facility policy titled, "Storage and Transportation of Clean Linen", PolicyStat ID 12507957, last approved 10/2022, indicated all linens will be stored, handled, transported, and processed in a manner that prevents the transmission of micro-organisms to other patient areas.

2. During facility tour on 4/22/24 at approximately 12:55 pm with A1 (Director of Nursing), facility clean linen room was observed to have a non-facility single air mattress donned with blankets and pillow on the floor that appeared to be recently used.

3. In an interview on 4/22/24 at approximately 2:15 pm with N1 (Registered Nurse) confirmed he/she brought the air mattress, pillow, and blanket to the facility's clean linen room to rest between shifts on 4/22/24 from 3:00 am to 7:00 am.

4. In an interview on 4/22/24 at approximately 2:45 pm with A3 (Chief Executive Officer), confirmed N1 should not have been using the facility's clean linen room to rest between shifts and therefore cannot ensure the safety and quality of linen stored in the clean linen room.

Based on documentation review and interview, the facility failed to complete and/or document daily room cleaning for 1 of 10 patient room cleaning logs reviewed. (P1)

Findings include:

1. The facility policy titled, "Cleaning Occupied Rooms", PolicyStat ID 12508564, last approved 10/2022, indicated under Policy: All patient rooms will be cleaned on a daily basis.

2. In an interview on 4/22/24 at approximately 2:45 pm with A3 (Chief Executive Officer) confirmed the facility should have had record of P1's daily room cleanings for the length of the hospitalization, but does not. P1's room should have been cleaned daily but the facility does not have documentation that the patient's room was cleaned each day per policy.