**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident interviews, and record reviews, the facility failed to ensure two of three residents (R) (R55 and R69) sampled for Activity of Daily Living (ADLs) care, out of a total sample of 38, received care and services for ADLs. Specifically, the facility failed to ensure the removal of facial hair for R69 and baths and showers for R55. The deficient practice had the potential to place R55 and R69 at increased risk for unmet needs and a diminished quality of life. Findings include: 1. Review of the electronic medical record (EMR) for R69 revealed diagnoses including, but not limited to, muscle weakness, difficulty in walking, unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Review of the Quarterly Minimum Data Set (MDS) assessment for R69, dated 7/8/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 5 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that R69 required substantial to maximal assistance with ADLs. Review of the care plan for R69 revealed a Focus area of Resident requires assistance with ADLs related to muscle weaknesses. Interventions included, but were not limited to, the resident needing assistance with ADLs as needed, bathing/showering as needed or as required, and requiring substantial to maximal assistance for personal hygiene and care. Observation on 8/12/2025 at 12:10 pm revealed R69 had a reasonable amount of thick white and black facial hair visible under her chin. Observation on 8/13/2025 at 9:14 am revealed R69 continued to have a reasonable amount of thick white and black facial hair visible under her chin. Observation on 8/14/2025 at 1:00 pm revealed R69 was sitting in a wheelchair in her room watching television, and continued to have a reasonable amount of thick white and black facial hair visible under her chin. In an interview on 8/12/2025 at 3:10 pm, a family member stated she visited R69 often. She stated she noticed R69 had facial hair, and she was sure the resident would want it removed if she was cognitively aware. In an interview on 8/14/2025 at 1:23 pm, Certified Medical Aide (CMA) EE stated staff was required to shave residents on their scheduled shower days unless they saw a need to do it immediately. In an interview on 8/14/2025 at 1:31 pm, Certified Nursing Assistant (CNA) FF revealed that she was responsible for the care of R69 more, and she had just received a bath on 8/13/2025. CNA FF confirmed that R69’s ADLs, including facial hair removal, should be done on her scheduled shower days. In an interview on 8/14/2025 at 1:50 pm, Licensed Practical Nurse (LPN) GG revealed that R69's scheduled shower days were Monday, Wednesday, and Friday on the day shift. LPN GG verified that R69 had visible facial hair on her chin and stated it needed to be removed and should have been done during her scheduled shower days. In an interview on 8/14/2025 at 2:30 pm, the Director of Nursing (DON) stated the facility did not have an ADL policy. She confirmed that R69 had visible facial hair on her chin. She revealed her expectation was for staff to provide ADL care and showers to residents as scheduled. 2. Review of the EMR for R55 revealed he was admitted to the facility with diagnoses to include Alzheimer's disease with early onset, unspecified disorientation, cognitive communication deficit, and major depressive disorder. Review of the Quarterly Minimum Data Set assessment, dated 5/10/2025, for R55 revealed Section C (Cognitive Patterns) documented a BIMS score of 4 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident was dependent on staff for oral hygiene, toileting hygiene, showers/bathing, and personal hygiene. Review of the care plan for R55 revealed a “Care Area/Problem” related to self-care deficit, last reviewed and continued on 8/12/2025. The goal was for R55 to accept assistance with ADLs, and needs will be met during the next review period, last reviewed and continued on 8/12/2025. Interventions included assistance with ADLs as needed, reviewed, and continued on 8/12/2025. Review of the EMR revealed R55 resided in room [ROOM NUMBER]. Review of the “Bath Schedule” revealed room [ROOM NUMBER] (R55) was scheduled for showers on Tuesdays, Thursdays, and Saturdays. Review of the “Point of Care” data sheets, dated 7/14/2025 through 8/14/2025, revealed that out of 14 shower opportunities, R55 received six showers on 7/19/2025, 7/26/2025, 7/31/2025, 8/2/2025, 8/9/2025, and 8/14/2025. There was no documentation to indicate that R55 refused his scheduled showers during the specified time period. In an interview on 8/14/2025 at 3:30 pm, CNA AA confirmed that R55 had 14 opportunities for showers from 7/14/2025 through 8/14/2025, but only six showers were documented. CNA AA stated that if the shower was not documented, the shower did not happen. In an interview on 8/14/2025 at 3:45 pm, CNA BB stated he was not sure why showers for R55 were not documented. In an interview on 8/14/2025 at 4:20 pm, the DON stated she expected showers to be completed as scheduled or as needed, and should include nail care and grooming needs. She stated the documentation of ADL care needed to be consistent and reflect the care and services provided. She stated she was unable to determine if the showers were given during the identified period and confirmed that, without documentation, she would assume they were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility's policy titled Medication Administration-General, the facility failed to ensure medications were administered as ordered by the physician to one of nine residents (R) (R20) observed for medication administration. This deficient practice had the potential to place R20 at an increased risk of adverse effects from the medication and a diminished quality of life. Findings include:Review of the facility's policy titled Medication Administration-General, review date 4/15/2025, revealed the Intent section stated, To facilitate that medications are administered as prescribed, in accordance with good nursing principles. The Guidelines section included, . Prior to medication administration, the Nurse or Certified Medication Aide (CMA): . Reads the administration directions on the MAR [medication administration record] and verifies correct medication, dose, and directions for use.Review of the Face Sheet for R20 revealed admission on [DATE]. Diagnoses included, but were not limited to, spastic diplegic cerebral palsy, anxiety disorder, essential hypertension, and muscle weakness.Review of the physician's orders for R20 revealed an order dated 5/9/2025 for amlodipine 5 milligrams (mg) tablet [a medication used to treat high blood pressure], one tablet by mouth one time per day. Hold if blood pressure (BP) is less than 110/60. Hold if systolic BP less than 110. Hold if diastolic BP less than 60. Review of the MedAid (medication aide) MAR dated 8/1/2025 to 8/14/2025 for R20 revealed amlodipine 5 mg tablet was administered on 8/3/2025, and the BP was documented as 90/67, and on 8/13/2025, and the BP was documented as 88/77.In an interview on 8/14/2025 at 4:09 pm, the Director of Nursing (DON) confirmed that the MedAid MAR for R20 documented that amlodipine 5 mg oral tablet was administered when the resident's BP was below the ordered parameters for holding the medication on 8/3/2025 and 8/13/2025. The DON stated the charge nurse should have been notified, and a follow-up should have been completed. In an interview on 8/14/2025 at 4:19 pm, Licensed Practical Nurse (LPN) CC verified that the MedAid MAR for R20 documented that amlodipine 5 mg oral tablet was administered when the resident's BP was below the ordered parameters for holding the medication on 8/3/2025 and 8/13/2025. She stated that the CMA should have notified her, she would have notified the physician, and the resident would have been monitored for changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide right hand splint to prevent further contractures as recommended by the Occupational Therapist (OT) for one resident (R) (R#49). The sample was 28 residents. Findings include: Record review revealed that R#49 was admitted on [DATE] with diagnoses of cerebral infraction, unspecified intracranial injury without loss of consciousness, hemiplegia, unspecified affecting right dominant side, and aphasia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that R#49 was severely cognitively impaired, required total assistance of staff for activities of daily living (ADLs) and had limitations in range of motion (ROM) on one side of his upper and lower extremities. Review of the OT Discharge summary dated [DATE] revealed that the resident had received OT services from 2/17/22 to 4/8/22 for contracture management. Continued review revealed that the resident was discharged on 4/8/22 to the Restorative Nursing Program/ Functional Maintenance Program for Passive Range of Motion (PROM) and application of right-hand splint and that nursing staff had received education on the application, wear schedule and precautions related to the hand splints. However, there was no indication in the medical record that R#49 received consistent restorative services or a functional maintenance program for splint application. Observations on 10/14/22 at 10:01 a.m., 10/15/22 at 8:51 a.m. and 1:44 p.m. and 10/16/22 at 10:01a.m. R#49 was lying in the bed. The resident had bilateral hand contractures but, there were no devices in place to prevent further contractures. Observation on 10/16/22 at 10:28 a.m., revealed that staff had placed rolled washcloths in the resident's left hand. The Occupational Therapist was not available an interview during this survey. Observation and interview on 4/27/18 at 12:10 p.m., revealed that the Director of Rehab Services (DRS) assessed the resident's bilateral hands and was able to extend his fingers slightly. She stated that the resident's ROM in his hands had not declined significantly since she last assessed him in January 2018 but, that he needed to be evaluated by therapy again for any needed interventions. Interview with Restorative Assistant (RA) GG on 4/27/18 at 12:26 p.m. revealed that R#22 had never received Restorative Services. Interview with Certified Nursing Assistant (CNA) HH on 4/27/18 at 12:34 p.m. revealed that she provided ROM exercises for the resident during care but, she did not apply hand splints. An interview with the Director of Nursing (DON) on 4/27/18 at 12:45 p.m. revealed that she did not know that the resident was supposed to wear bilateral hand splints. Continued interview revealed that the facility had identified a problem with the previous Director of Rehabilitation Services who failed to communicate discharge recommendations to nursing staff. During an interview on 10/16/22 at 10:01 a.m. Licensed Practical Nurse (LPN) BB stated that the facility does not have restorative aides and the CNAs on the floor are responsible for the ADL and restorative plan of care. During an interview on 10/16/22 at 10:34 a.m., CNA AA stated that she is a restorative aide and has worked in restorative for the last year. CNA AA stated that she usually puts R# 49's splint on daily, but she has not been able to locate his hand splint after his room was changed. CNA AA further stated that she tried to put a washcloth in R#49s right hand, but he would not allow her to. CNA AA told surveyor that she has not informed anyone that residents hand splint was missing. CNA AA further stated that she does not always document the restorative care provided. During an interview on 10/16/22 at 11:03 a.m. with DON revealed she was not aware that R#49 resists care or that his right-hand splint was missing. She further stated that she will make sure the resident gets a new splint. DON stated that it is her expectation that residents received the restorative plan of care as outlined by the therapist. During an interview 10/16/22 at 11:24 a.m. with Administrator revealed that it is her expectation that the restorative aides apply the splints and to performs the restorative plan of care as provided by the team.