Based on observations, record review and interview the facility failed to maintain good grooming and personal hygiene for one resident (Resident #62) out of 24 residents sampled, as evidenced by observations of dirt under Resident #62's fingernails. There were 74 residents residing in the facility at the time of survey. The findings included: On 07/08/24 at 9:30 AM Resident #62 was observed lying in bed awake alert, nonverbal and used left upper extremity to gesture. Dirt was observed under Resident # 62's fingernails on the left hand. On 07/11/24 at 8:35 AM Resident #62 was observed lying in bed awake alert and dirt was observed under the fingernails of left hand. Record review of demographic sheet for Resident #62 revealed an admission date of 9/15/2023 with diagnosis that included Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side. Record review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 6/3/2024 Section C for cognitive status revealed a Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated moderate cognitive impairment. Section GG for functional abilities and Goals revealed dependent for personal hygiene care. Section E for behaviors revealed no indicators of psychosis. Record review of a Care Plan started on 9/18/23 and revised on 6/5/24 for Resident #62 revealed total care was required to maintain personal hygiene. The interventions included: Aid with oral care, washing, drying face hands, and perineum. Record review of physician orders revealed an order dated 10/25/2023 to check that fingernails are clean and trimmed every day. On 07/11/24 at 8:35 AM, Registered Nurse (RN) Unit Manager acknowledge Resident #62's fingernails are dirty and should have been cut and cleaned. The schedule indicates that residents' nails are to be cut and cleaned on Sundays on the evening shift; the schedule is kept in the CNA's (Certified Nursing Assistants) binder. Record review of a Policy entitled, Giving a Bed bath revised October 2010 revealed Purpose: The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. 15. Arms and Hands: d. Check the resident's fingernails, nail beds, and between the fingers. Provide nail care only when instructed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview facility failed to ensure that one (Resident #46) out of 24 sampled residents received adequate support services as evidenced by dry and scaly skin on Resident # 46's legs. There were 74 residents residing in the facility at the time of survey The findings include. On 07/08/24 at 8:56 AM Resident #46 was observed lying in bed, the skin of bilateral lower extremity appeared dry and scaly. The resident was constantly rubbing one leg against the other in an up and down motion. On 07/10/24 at 9:55 AM Resident #46 was seated in a wheelchair in the Main dining area, for activities. No distress or rubbing of legs noted. Record review of the demographic sheet revealed Resident #46 was admitted on [DATE] with diagnosis that included: Rash and other nonspecific skin eruption. Review of the Quarterly Minimum Data Set (MDS) with assessment reference date of 5/6/2024 Section C for Cognitive Status revealed a Brief Interview for Mental Status (BIMS) score was 13, out of a scale of 00-15, indicating intact cognition. Section GG for Functional abilities and Goals revealed partial/moderate assistance for eating/oral hygiene/transfer and dependence for toileting/shower. Section M for skin revealed no skin problems. Record review of Care Plan started on 2/2/2024 and revised on 5/8/2024 revealed Resident #46 is at risk for pressure ulcers and skin impairments related to impaired mobility and decline in function. Interventions included: Use moisture barrier (Vitamin A & D Ointment) product as indicated. Report any signs of skin breakdown (sore, tender, red, or broken areas) and Podiatry/Wound care consults as needed. Record review of Electronic Health Record revealed a progress note dated 07/07/2024 that indicated Resident #46's skin was warm and dry to touch, signed by licensed nurse. Further review of Electronic Health Records revealed Certified Nursing Assistant with dates 7/08/24, 7/09/24, and 7/10/24 indicated no skin issues. Record review of Electronic Health Record revealed physician orders dated 2/01/2024: Facility skin care protocol and Skin check every shift during care and report any unusual findings to nurse and 4/12/2024: Weekly skin check once a day on Sundays. On 07/11/24 at 8:44 AM Surveyor asked Staff A, Registered Nurse, (RN) to observe skin of lower extremities of R#46. Staff A, RN brought Resident #46 into the room and evaluated resident's skin. On 07/11/24 at 8:54 AM Staff A, RN stated: I completed a visual skin assessment on [Resident #46] legs and observed dryness, no swelling, and no open area. [Resident #46] denied itching. I will inform the physician. There are no current physician orders pertaining to [Resident #46] legs. The facility protocol is to assess the skin every week for the nurse and the Certified Nursing Assistants (CNA) are to do a daily inspection and to report any change to nursing. Record review of Policy, Pressure Ulcer and Skin Assessment revised September 2013 Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation: 1. Review the resident's care plan to assess any special needs of the resident. Assessment: Monitoring: a. Staff will perform routine skin inspections (with daily care).

Based on interview and record review, it was determined the facility failed to ensure residents, their representatives and families were notified by 5:00 pm, the next calendar day following the occurrence of a single confirmed infection of COVID 19 with a staff member. The findings included: On May 8, 2020, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule titled, Medicare and Medicaid Programs, Basic Health Program, and Exchanges: Additional Policy and Regulatory Revisions in Response to the COVID 19 Public Health Emergency and Delay of Certain Reporting Requirements for Skilled Nursing Facility Quality Reporting Program. Included in this final interim rule was the facility requirement to Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19. This information must: (i) Not include personally identifiable information; (ii) Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and (iii) Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. During an interview with the facility's Infection Preventionist/Director of Nurses (DON)/Staff A, on 7/14/2021 at 11:20 am, it was reported that the last COVID 19 positive case in the facility was on 06/18/2021. The documentation to demonstrate that the facility's residents and their families were notified was requested. Staff A reported, Social Services notified residents and families by phone about the COVID 19 positive case. On 7/14/2021 at approximately 1:30 pm, the requested information was brought to the conference room by the Social Services Director, Staff B. During a review of the information, it was noted that the information titled, Resident Contacts and written at the top of the list was Call log positive 6-18-21. The list was 21 pages and included resident names, with the residents' emergency contact, family member, responsible representative, and/or their legal guardian. The list included a date of June 2021, but the day on the list was illegible. Information documented on the list included: Key West. Birthday, monthly, no visit, Sunday, California, daily, Georgia, no answer confirm. When, notified person, guardian notified and days of the week. Staff B, also brought in a blank log used to schedule family visits. During an interview with Staff B, the Social Services Director on 7/15/2021 at 2:30 pm, Staff B was asked to explain the information that was provided on 7/14/2021. Staff B was asked, how we would confirm she had notified the residents and families related to the 6/18/21 positive COVID 19 case. Staff B reported, she documented the completion of the notification by documenting, completed 6/20/21 [her initials]. There was no information to confirm the date and time each resident or family member was notified and the information provided during the phone calls. At approximately 2:45 pm on 7/15/2021, Staff B brought an email copy of the positive employee's notification of the positive COVID 19 results that was dated 6/19/2021 at 9:03 pm. The email was presented to demonstrate the facility did not know about the employee's results until 6/19/2021 and that they were in compliance because they documented the notification was completed on 6/20/2021. After review of the positive COVID 19 results, it still could not be determined that the residents and families were notified about the positive case by 5:00 pm the next day. During the review of the facility's Infection Prevention and Control Program, with an effective date of 2016 and revised on 11/2020 revealed, The Infection Prevention and Control Program shall be conducted in accordance with all applicable federal and state rules and regulations .Including evidenced-based guidelines and recommendations .Centers for Medicare and Medicaid Services (CMS).