Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare and Medicaid Services (CMS) for the Fiscal Year (FY) Quarter 3 2024 (April 1-June 31). Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 3 2024 (April 1-June 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. During an interview on 09/25/2024 at 12:30 p.m. S1 Administrator reported he did not understand why the facility triggered for low staffing. S1 Administrator reported he is the only person at the facility that submits agency invoices to the corporate office. S1 Administrator further reported the corporate office submits the PBJ data to the CMS system.

Based on record review, observation and interviews the facility failed to ensure residents who were unable to complete their ADL (Activities of Daily Living) received the necessary services to maintain proper grooming for 1 (#48) of 3 (#2, #34, #48) residents reviewed for ADL. The facility failed to ensure Resident #48 received nail care. Findings: Review of Resident #48's medical diagnoses revealed the following, but not limited to cerebral infarction, type 2 diabetes mellitus with diabetic neuropathy, and systemic lupus erythematosus. Review of Resident #48's September 2024 physician orders dated 05/08/2024 revealed: Activity as tolerated. Licensed nurse may clip and trim diabetic finger and toenails as indicated. Review of Resident #48's quarterly MDS (Minimum Data Sets) dated 07/08/2024 revealed a BIMS (Brief Interview of Mental Status) was 15 out of 15 indicating cognitively intact. Review of Resident #48's care plan revealed resident has an ADL self-care performance deficit and requires assistance with ADL. Observation on 09/23/2024 at 11:03 A.M. revealed Resident #48 sitting up in wheel chair wearing sandals. Further observation revealed Resident #48's toe nails were long, thick and yellow. During an interview on 09/23/2024 at 11:03 A.M. Resident #48 confirmed her toe nails were long and she was unable to recall the last time her toe nails were trimmed. During an interview on 09/25/2024 at 1:00 P.M. S2 DON (Director of Nursing) reported S3 NP (Nurse Practitioner), from a local foot care group, performs nail care on residents every 60 days. S2 DON confirmed S3 NP's last service date, at the facility, was 08/19/2024 and reported Resident #48 did not receive services on 08/19/2024. S2 DON confirmed Resident #48 was a diabetic and should have received nail care by a podiatrist or NP.

Based on record review and interview, the facility failed to develop and implement a comprehensive care plan for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents plan of care reviewed. Findings: Review of medical records revealed Resident #1 with an admit date of 04/18/2024 and discharge date of 05/11/2024 with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's MDS (Minimum Data Set) admission Assessment revealed a date of 04/21/2024. The comprehensive care plan was initiated on 04/19/2024 with only one problem and approach - activities of daily living (ADL) self-care performance deficit. During an interview on 06/04/2023 at 8:25 a.m. S4 MDS Nurse acknowledged Resident #1's care plan included one problem and approach for ADL care. S4 MDS Nurse further acknowledged the care plan was incomplete.

Based on record reviews and interview, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to administer pain medication for 1 (#1) out of 3 (#1, #2, #3) sampled residents receiving pain medication. Findings: Review of medical records revealed Resident #1 with an admit date of 04/18/2024 with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's Physician's Orders revealed the following orders: - 05/09/24 - hydrocodone-acetaminophen oral tablet 7.5-325mg (milligram) give 1 tablet by mouth every 6 hours as needed for moderate pain - 05/09/24 - Diclofenac Sodium tablet delayed release 50mg give 50mg by mouth every 12 hours as needed for pain - 04/29/24 - Acetaminophen tablet 325mg give 2 tablet by mouth six times a day for pain every 4 hours - 04/18/24 - assess pain using verbal/non-verbal scale every shift - 04/18/24 - Diclofenac Sodium delayed release 50mg give 50mg by mouth every 24 hours as needed for inflammation Review of Resident #1's May 2024 Medication Administration Record revealed pain was assessed on 05/06/2024 during day shift with a pain level of 7. Further review revealed pain was assessed on 05/09/2024 during day shift with a pain level of 7. Further review revealed Resident #1 was not administered prn (when necessary) Diclofenac Sodium tablet delayed release 50mg give 50mg by mouth every 12 hours as needed for pain as ordered on 05/06/2024 during day shift and on 05/09/2024 during day shift. During an interview on 06/04/2024 at 2:10 p.m. S3 LPN (licensed practical nurse) reported did not know why Resident #1 did not receive prn Diclofenac Sodium tablet delayed release 50mg on May 6th (pain score of 7) and May 9th (pain score of 7) during the day shifts she worked. During an interview on 06/04/2024 at 3:30 p.m. S1 DON acknowledged Resident #1 did not receive prn Diclofenac Sodium tablet delayed release 50mg pain medication on May 6th and May 9th for a pain level of 7 after reviewing the May MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) out of 4 (#1, #2, #3, #4) sampled residents reviewed for pressure ulcers and skin conditions. The facility failed to perform a skin and wound evaluation upon admission and weekly for Resident #1. Findings: Review of medical records revealed Resident #1 with an admit date of 04/18/2024 with the following diagnosis, in part: muscle wasting and atrophy, not elsewhere classified/multiples sites, primary generalized (osteo) arthritis, mild protein-calorie malnutrition, Chronic Obstructive Pulmonary Disease/unspecified, muscle weakness (generalized), difficulty walking/not elsewhere classified, unsteadiness on feet, Peripheral Vascular Disease/unspecified, and cellulitis of right lower limb. Review of Resident #1's MDS (Minimum Data Set) assessment dated of 04/21/2024 revealed Section M: venous and arterial ulcers - 1. Review of Resident #1's Baseline Care Plan dated 04/19/2024 revealed skin risk - current skin integrity issue - RLE (right lower extremity) cellulitis with ulceration. Review of Resident #1's Skin & Wound Total Body Skin assessment dated [DATE] revealed 1 new wound upon admission. Review of Resident #1's Skin & Wound Evaluations revealed the initial evaluation was completed on 05/01/2024 - wound bed eschar 100%; no exudate; surrounding tissues fragile/intact; treatment: betadine/no dressing; no infection; 9 x 5.5cm (centimeter) intact eschar Education: Keep clean-dry. CV (cardiovascular) consult ordered .Further review revealed Skin & Wound Evaluation was not completed upon admission. Review of Resident #1's Nurse Practitioner (NP) Progress Note dated 04/19/2024 revealed - Chief complaint: Status post hospitalization . RLE (right lower extremity) arterial ulcer. Review of Facility's Pressure Ulcers/Skin Breakdown Policy (revised April 2018) revealed: - Assessment and Recognition: 3. In addition, the nurse shall describe and document/report the following wound conditions when identified within the EMR (electronic medical record): a. full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. 4. The DON (Director of Nursing) or designee will examine the skin of newly admitted /readmitted residents for evidence of existing pressure ulcers or other skin conditions; reporting any abnormalities to the physician. - Documentation: Newly identified skin concerns will be added to the Wound Assessment Manager and EMR upon identification and updated weekly with assessments recording the progress of the skin concern. During an interview on 06/04/2024 at 3:40 p.m. S2 Corporate Nurse reported Skin & Wound Evaluations should be completed every 7 days. During an interview on 06/05/2024 at 8:50 a.m. S2 DON acknowledged Resident #1 did not have a Skin & Wound Evaluation completed upon admission and every 7 days and should have.

Based on record review and interview the provider failed to ensure a Medical Director or designee attended a quarterly QAA (Quality Assessment and Assurance) Committee meeting for the second quarter of the year 2023. Findings: Record review of the provider's quarterly QAA Committee meetings failed to reveal a signature of the Medical Director or designee for the second quarter of the year 2023. During an interview on 08/09/2023 at 4:50 p.m., S2 Director of Nursing reviewed the quarterly QAA Committee meetings that were held on the months of April, May, and June of 2023. S2 Director of Nursing verified a signature was not completed by the Medical Director or designee for the second quarter of 2023 QAA Committee meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to treat each resident with respect, dignity and care in a manner that promotes maintenance of his or her quality of life, recognizing each resident's individuality for 1 resident (#102) of 3 residents (#62, #102, #106) residents investigated for dignity. Findings: Review of Resident #102's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 13 which indicated the resident was cognitively intact. Review of Resident #102's clinical record revealed an admission date of 03/02/2023 with the following diagnoses in part: aphasia, hemiplegia affecting the left side, muscle wasting and atrophy, cognitive communication deficit. Review of Occupational Therapy Notes dated 06/30/2023 revealed Resident #102 was feeling mistreated at the facility due to CNAs (Certified Nursing Assistant) not answering the call light. During an interview on 08/07/2023 at 1:49 a.m. Resident #102 reported every time S6CNA changes her brief, his hands hurt her bottom because he pushes her over in the bed forcefully. Resident #102 reported S6CNA was rough and tried to tell her when she needed to go to bed. Resident #102 indicated S7Therapy and S1Administrator were aware of S6CNA's rough treatment. During an interview on 08/07/2023 at 4:25 p.m. S6CNA confirmed he changed briefs of female residents without another female in the room. S6CNA reported he will ask the female resident if it is okay for him to change their brief. S6CNA report if the residents are okay with him changing their brief, he will change the brief. During an interview on 08/08/2023 at 3:40 p.m. S7Therapy reported on 06/30/2023 Resident #102 was crying and upset when in therapy and reported S6CNA was rough with her when changing her brief and when she asked him to stop being rough, he ignored her and kept going. S7Therapy reported they sent S8Therapy to get S1Administrator and they both reported what Resident #102 told them regarding S6CNA to S1Administrator. S7Therapy further reported Resident #102 was completely aware and in a clear state of mind when she reported S6CNA was being rough with her. S7Therapy indicated they were under the impression S1Administrator handled the situation. During an interview on 08/08/2023 at 4:00 p.m. S1Administrator confirmed having a meeting on 06/30/2023 with therapy about the care Resident #102 received from S6CNA. During an interview on 08/09/2023 at 7:45 a.m. S9PTA (Physical Therapy Assistant) recalled a day around 06/30/2023 when Resident #102 was in the therapy room and was visibly upset, tearful and frustrated with the care S6CNA was giving her. S9PTA reported remembering S1Administrator being aware of the situation and that S1Administrator was going to handle it but nothing was done. During an interview on 08/09/2023 at 8:30 a.m. Resident #102 reported when she sees S6CNA, he makes her a little nervous. Resident #102 reported preferring a female CNA when her brief gets changed. During an interview on 08/09/23 at 10:06 a.m. S8Therapy reported on 6/30/23 Resident #102 was visibly upset and crying. S8Therapy reported leaving to get S1Administrator and S1Administrator came to the gym with Resident #102. During a phone interview on 08/09/2023 at 2:26 p.m. Resident #102's RP (Responsible Party) reported S6CNA was the only staff they noticed Resident #102 did not care for. RP reported Resident #102 would roll her eyes when S6CNA entered the room. During an interview on 08/09/2023 at 3:15 p.m. S10COTA (Certified Occupational Therapist Assistant) reported on 6/30/23 S7Therapy was working with Resident #102 and S10COTA recalled Resident #102 felt like she had been mistreated by a male CNA. S10COTA reported knowing about S6CNA being rough with her during a transfer or rolling in bed. S10COTA reported S1Administrator had knowledge S6CNA had been rough with Resident #102 while transferring or rolling Resident #102 in the bed. S10COTA reported Resident #102 seemed to have a clear mind on 6/30/23. During an interview on 08/09/2023 at 4:10 p.m. S11ADON (Assistant Director of Nursing) reported she was told S6CNA needed to be retrained in patient care, transfers, and customer service. S11ADON reported did not have knowledge of Resident #102 being handled roughly and no one reported Resident #102 being handled roughly to S11ADON. S11ADON reported she just knew what areas S6CNA needed to be retrained. S11ADON could not recall who told her to retrain S6CNA. During an interview on 08/09/2023 at 4:25 p.m. S2DON (Director of Nursing) reported the facility did not offer another CNA to care for Resident #102 and S6CNA continued to work with Resident #102 after 06/30/2023. The facility did not ask or let the residents know they may have a male CNA changing their brief. S2DON reported no knowledge of S6CNA handling Resident #102 roughly when changing her brief.

Based on record reviews and interview, the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 8 of 25 weekend days reviewed. Findings: Review on the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1 to March 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for weekends from FY Quarter 2 2023 revealed the facility provided 238 hours on 01/08/2023 and were required to provide 268 hours. Further review revealed the facility provided 267 hours on 01/14/2023 and were required to provide 277 hours, provided 249 hours on 01/22/2023 and were required to provide 280 hours, provided 260 hours on 01/29/2023 and were required to provide 261 hours, provided 247 hours on 02/19/2023 and were required to provide 260 hours, provided 214 hours on 02/26/2023 and were required to provide 265 hours, provided 226 hours on 03/4/2023 and were required to provide 277 hours, and provided 230 hours on 03/19/2023 and were required to provide 275 hours. During an interview on 08/09/2023 at 4:20 p.m. S1 Administrator reviewed the facility's staffing pattern reports for weekends from FY Quarter 2 2023, and acknowledged the facility did not provide the minimum hours required on 01/08/2023, 01/14/2023, 01/22/2023, 01/29/2023, 02/19/2023, 02/26/2023, 03/4/2023, 03/19/2023, and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record reviews and interviews, the facility failed to ensure nursing staff demonstrated competencies to provide care, assure residents' safety, and maintain the residents' highest practicable physical well-being. The facility failed to ensure nursing staff assessed a resident for injury in a timely manner and before the resident was moved following a witnessed fall for 1 (#16) of 3 (#2, #16, #77) residents reviewed for falls. Findings: Review of Resident #16's record revealed an admit date of 11/07/2020 and diagnoses including Paraplegia unspecified, unspecified muscle weakness, lack of coordination, and a history of falling. Review of Resident #16's Minimum Data Set Assessment with an Assessment Reference Date of 05/14/2023 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. Review of the facility's incident logs revealed Resident #16 had a witnessed fall in his room on 07/09/2023 at 6:58 a.m. Further review of the incident report for the associated fall revealed Resident #16 fell while S4 CNA (Certified Nursing Assistant) was providing care in the resident's room. The report was written by S3 LPN (Licensed Practical Nurse). The report included in part: Immediate actions taken-resident was helped from floor back to bed. Writer assessed. S3 LPN's report narrative further indicated she saw no visible signs of injury, but the resident did complain of bilateral knee pain. The resident was already on scheduled pain medication which he had received that day at 6:00 a.m. The 24 hour follow-up done on 07/10/2023 revealed the resident had no visible signs of injury, but continued to complain of bilateral knee pain, and X-ray of bilateral knees was obtained. Review of Resident #16's X-ray report dated 07/10/2023 revealed Resident #16 had a closed fracture of the lateral portion of the right tibial plateau, a closed fracture of the right fibula, and a closed fracture of the right proximal tibia. Review of S4 CNA's written statement dated 07/10/2023 revealed she was providing care for Resident #16 when he fell from the bed. The statement indicated S4 CNA asked S3 LPN if she could help her and she told me she wasn't going down the hall because I was down there. Review of S3 LPN's personnel records revealed a Confidential Employee Corrective Action Form dated 02/25/2022 for Unsatisfactory Performance. Further review revealed Conduct that was observed and/or substantiated included not assessing a resident that had fallen & was sent out to the hospital on [DATE]. Suggestions for improvement or immediate action that needed to take place included any resident that falls must be assessed by the charge nurse in a timely manner. The form was signed by S3 LPN and S2 DON (Director of Nursing) on 03/01/2022, and signed by S1 Administrator on 03/03/2022. Further review of S3 LPN's personnel records revealed a second Confidential Employee Corrective Action Form dated 07/11/2023 for unsatisfactory Performance. Type of action warranted=Final. Conduct that was observed and/or substantiated: Resident suffered a fall on 07/09/2023 that was assigned to employee. Employee failed to assess the resident promptly after she was notified by the CNA of the incident. Employee (nurse) gave instructions to another CNA to assist getting resident up off the floor despite her not assessing the resident for injuries. The resident suffered major injury from this fall. Suggestions for improvement or immediate action that needs to take place: Employee (nurse) will be immediately terminated due to lack of urgency to care for a post fall injury that the resident sustained. The form was signed by S3 LPN, S2 DON, and S1 Administrator of 07/11/2023. During an interview on 08/08/2023 at 10:45 a.m. S2 DON confirmed S3 LPN was terminated 07/11/2023 as a result of not assessing Resident #16 in a timely manner after his fall. S2 DON confirmed S4 CNA gave a statement that the nurse did not come assess the resident prior to him being assisted back in bed, but instead instructed another CNA to help get him in bed. During an interview on 08/08/2023 at 1:45 p.m. S5 CNA reported S4 CNA came to the nursing station the morning of 07/09/2023 to get S3 LPN to assess Resident #16 and to get help to get him up, and S3 LPN said she wasn't going down there while the CNA was down there. S5 CNA further reported S3 LPN told her to go down and help S4 CNA get the resident back in bed. S5 CNA confirmed she and S4 CNA assisted resident #16 back to bed before the nurse assessed him for injuries. S5 CNA further reported she asked S3 LPN again to go assess resident #16 after they got him back in bed, and she said no she wasn't going. During an interview on 08/08/2023 at 3:18 p.m. Resident #16 reported S4 CNA was changing his linens and his diaper on 07/09/2023 when he rolled of the bed and landed on his knees. Resident #16 indicated he was able to participate in his care, and S4 CNA was the only staff member in the room when he fell from the bed. Resident #16 indicated S4 CNA left the room to get S3 LPN to come assesses him, and returned with another CNA who helped put him back in the bed. Resident #16 reported he could not remember when the nurse came to assess him but he knew it was not before the CNAs put him back in bed. During a telephone interview on 08/09/2023 at 6:55 a.m. S4 CNA confirmed she was the CNA providing care for Resident #16 on 07/09/2023 when he fell out of the bed. S4 CNA indicated she assisted him to sit and then went and got the nurse to tell her Resident #16 was on the floor and she needed to come assess him so they could get him back in bed. S4 CNA reported the nurse, S3 LPN, said she was not coming down there while I was down there and told S5 CNA to go help me put him back to bed, which we are not supposed to do until after a nurse assesses. S4 CNA reported she did not know when S3 LPN got up and went to check on him, but knew it was not right away because she got up and started passing medications to other residents. During an interview on 08/08/2023 at 4:35 p.m. S1 Administrator and S2 DON reported video footage had been reviewed and it was approximately 1.5 hours after S3 LPN was notified of Resident #16's fall before she went in his room to assess him. S1 Administrator and S2 DON indicated S3 LPN was on video passing medications to other residents. S1 Administrator and S2 DON confirmed S3 LPN had been previously written up for failing to assess a resident in a timely manner after a fall in February of 2022. S1 Administrator and S2 DON indicated S3 LPN was terminated when it was determined she had not assessed Resident #16 when the CNAs notified her of the fall, and before the CNAs moved the resident.

Based record reviews and interview the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 4 of 26 weekend days reviewed. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 1 2023 (October 1-December 31) revealed the submitted weekend staffing data was excessively low. Review of the facility's staffing pattern reports for weekends from FY Quarter 1 2023 revealed the facility provided 245.85 hours on 10/30/2022 and were required to provide 282.0 hours. Further review revealed the facility provided 262.34 hours on 12/3/2022 and were required to provide 272.6 hours, and the facility provided 265.48 hours on 12/10/2022 and were required to provide 282.0 hours and the facility provided 274.6 hours on 12/11/2022 and were required to provide 282.0 hours. During an interview on 6/21/2023 at 2:44 p.m. S1 Director of Nursing and S2 Regional [NAME] President reviewed the facility's staffing pattern reports for weekends from FY Quarter 1 2023 and acknowledged the facility did not provide the minimum hours required on 10/30/2022, 12/03/2022, 12/10/2022 and 12/11/2022 and should have.

Based on record reviews, the facility failed to ensure that 1 (#1) resident out of 40 sampled residents reviewed who experienced a significant change in status was comprehensively assessed using the CMS (Center for Medicare & Medicaid Services)-specified Resident Assessment Instrument. Resident #1 was hospitalized for a femur fracture following a fall. Findings: Review of Resident #1's MDS (Minimum Data Set) Assessments failed to reveal a significant change assessment for a fall resulting in a femur fracture occurring on 7/10/22. Review of Facility's Incident Log revealed a fall on 7/10/22 in resident room resulting in a fracture. Resident #1 was sent to the emergency room. Review of Resident #1's Care Plan revealed: At risk for falls - 7/10/22 - incontinent care being provided; resident turned to her side and turned too far causing lower body to slide off bed and resulted in fall to floor; transferred to hospital admitted with diagnosis of right femur fracture. During an interview on 7/27/22 at 11:50am S2 MDS LPN (licensed practical nurse) confirmed a MDS Assessment was not completed for Resident #1 after a significant change occurred following a fall with fracture and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #125 Record review of Resident #125's Progress Note dated 06/07/2022 revealed, in part: - Resident #125 had a care plan conference with the interdisciplinary team and Resident #125's responsible party. The conference confirmed Resident #125 planned to discharge home with family. Record review of Resident #125's telephone order dated 06/15/2022 revealed, in part: - Resident #125 had a physician's order to discharge home on [DATE] with home health. Record review of Resident #125's Discharge MDS with ARD of 06/17/2022 revealed, in part: - Resident #125 had a planned discharge; return was not anticipated; and discharged to an acute hospital. Record review of Resident #125's progress noted dated 06/17/2022 revealed, in part: - Resident #125 discharged home in stable condition with all medications and personal belongings. During an interview on 07/27/2022 at 08:55 AM, S1DON (Director of Nursing) acknowledged Resident #125 discharged home on [DATE] with her family. S1DON confirmed the Discharge MDS with an ARD date of 06/17/2022 indicated Resident #125 discharged to an acute hospital was inaccurate. During an interview on 07/27/2022 at 11:20 AM, S5LPN/MDS (Licensed Practical Nurse) acknowledged she completed the discharge status on Resident#125's Discharge MDS with an ARD date of 06/17/2022 inaccurately. S5 LPN/MDS confirmed the discharge status should have indicated Resident #125 discharged to the community (private home). Based on record review and interview, the facility failed to ensure assessments were completed accurately and reflected the residents status for two (Resident #48 and Resident #125) out of a total of 40 sampled residents. Findings: Resident #48 Resident # 48 was admitted to the facility on [DATE]. Record review of Resident #48's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 02/04/2022 revealed the following, in part: - Section G- Functional Status: Resident #48 required setup help with bed mobility, transfers, toileting, and eating. Record review of Resident #48's Quarterly 5day MDS with an ARD of 05/06/2022 revealed the following, in part: - Section G showed the resident required one person assist with bed mobility, transfers, toileting, and eating. During an interview on 07/27/2022 at 3:50 PM, S2MDS nurse indicated Resident #48 did not have a decline of ADLs (activities of daily living) from 02/04/2022 MDS to 05/06/2022 MDS section G functional status. S2MDS nurse further indicated the CNAs (Certified Nursing Assistants) were not charting appropriately and that caused the MDS from 02/04/2022 to be inaccurate and the resident's functional status should have been the same as the functional status that was on the MDS dated [DATE].

Based on record review and interview the facility failed to provide documentation of a CNA (Certified Nursing Assistant) registry check upon hire for one (S4CNA) of five (S4CNA, S6CNA, S7CNA, S8CNA, S9CNA) CNA personnel files reviewed. Findings: Record review of S4CNA's personnel file revealed a hire date of 10/05/2017. S4CNA's registry check was dated 11/04/2020. During an interview on 07/27/2022 at 5:40 PM, S10Administrator indicated he could not provide documentation that a CNA registry check was completed upon hire for S4CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #51 Review of Resident #51's medical record revealed Resident #51 was admitted to facility on 1/18/22 with diagnoses including but not limited to spinal stenosis, schizoaffective disorder, muscle wasting and atrophy, and primary arthritis. Review of Resident #51's quarterly MDS (Minimum Data Set) dated 5/30/22 revealed in part: -Section C Cognitive patterns: BIMS (Brief Interview for Mental Status) score of 14 indicating cognition intact. -Section G Functional status: Requires extensive assist of one person with bathing, personal hygiene, and dressing. Review of Resident #51's current care plan revealed problem of self care deficit and incontinence care with approaches including but not limited to assist as needed in aspects of self care that are problematic to resident. Review of Resident #51's Bath Day Roster for 6/1/22 thru 7/27/22 revealed Resident #51 received a complete bed bath on 8 of the 30 days in the month of June, received zero showers during the month of June, and received zero bed baths or showers during the month of July. During an interview on 7/25/22 at 8:56 AM Resident #51 reported she was not receiving baths. During an interview on 7/27/22 at 7:25 AM S3 CNA (Certified Nursing Assistant) reported residents should receive a bath every day except Sunday. S3 CNA further reported Sundays were not scheduled bath days. During an interview on 7/27/22 at 10:20 AM Resident #51 reported she was unable to recall when she last received a shower. During an interview on 7/27/22 at 10:40 AM S4 CNA reported residents can have a shower or bath whenever they need it but the facility does have a bathing schedule. S4 CNA further reported CNAs document each resident's bath or shower in the kiosk bath day roster. During an interview on 7/27/22 at 10:45 AM S1 DON (Director of Nursing) confirmed Resident #51 did not have documentation of receiving a bath or shower for the month of July and should have. Resident #84 Review of Resident #84's medical record revealed Resident #84 was admitted to facility on 1/3/22 with diagnoses including but not limited to idiopathic progressive neuropathy, COPD (Chronic Obstructive Pulmonary Disease), generalized arthritis, muscle wasting and atrophy, PVD (Peripheral Vascular Disease), hypertension, and Bradycardia with a pacemaker. Review of Resident #84's quarterly MDS (Minimum Data Set) dated 6/17/22 revealed in part: -Section C Cognitive pattern: BIMS (Brief Inteview for Mental Status) score of 12 indicating mildly impaired cognition. -Section G Functional status- Requires extensive assist of one person with bathing and dressing. Requires limited assist of one person with personal hygiene. Review of Resident #84's current care plan revealed problem of assistance with all ADLs (Activities of Daily Living) with approaches including but not limited to give verbal cues to help prompt, allow rest breaks between tasks, break tasks up into smaller steps. Review of Resident #84's Bath Day Roster for 6/1/22 thru 7/27/22 revealed Resident #84 received a complete bed bath or a shower on 6 days out of the 30 days in the month of June and received zero bed baths or showers during the month of July. During an interview on 07/25/22 at 9:13 AM Resident #84 reported she had not received a bath very often and further reported when she received a bath, the staff simply wiped her off. During an interview on 7/27/22 at 7:25 AM S3 CNA (Certified Nursing Assistant) reported residents should receive a bath every day except Sunday. S3 CNA further reported Sundays were not scheduled bath days. During an interview on 7/27/22 at 10:15 AM Resident #84 reported she had received one shower since she had been at the facility. Resident #84 further reported she received the one shower last Friday when her daughters came to visit and assisted her with showering. Resident #84 reported she would like to get a shower, but only receives a bed bath sometimes. During an interview on 7/27/22 at 10:40 AM S4 CNA reported residents can have a shower or bath whenever they need it but the facility does have a bathing schedule. S4 CNA further reported CNAs document each resident's bath or shower in the kiosk bath day roster. During an interview on 7/27/22 at 10:45 AM S1 DON (Director of Nursing) confirmed Resident #84 did not have documentation of receiving a bath or shower for the month of July and should have. Resident #275 Record review of Resident #275's medical record revealed Resident #275 was admitted to the facility on [DATE] with an admitting diagnosis of aftercare following joint replacement surgery and was discharged from the facility on 7/13/22. Record review of Resident #275's MDS dated [DATE] revealed the following, in part: - Section G, bathing self-performance was marked 3, physical help in part of bathing activity, one person physical assist. During a telephone interview on 7/27/22 at 7:10 AM, Resident #275's resident representative (daughter) indicated Resident #275 did not receive bathing services during the resident's stay at the facility. During an interview on 7/27/22 at 10:10 AM, S1 DON verified there was not documentation of Resident # 275 getting bathed during her eight day stay at the facility. Based on interviews and record reviews, the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain grooming and personal hygiene by failing to ensure residents received a bath or shower for 4 (#1, #51, #84, #275) of 9 (#1, #25, #48, #51, #66, #84, #103, #106, #275) residents reviewed for activities of daily living. Findings: Resident #1 Review of Resident #1's Medical Records revealed admit date [DATE] with the following diagnoses but not limited to: primary generalized osteoarthritis, muscle wasting and atrophy, pressure ulcer of left buttock/stage 4, cognitive communication deficit, major depressive disorder/single episode, and obesity. Review of Resident #1's Care Plan revealed: - Always incontinent of bowel - assist me to bathroom or commode as needed - Require staff assistance for all ADLs - Risk for pressure ulcers r/t impaired mobility - daily observation of skin with routine care; need a full skin evaluation weekly by a nurse Review of Resident #1's MDS (Minimum Data Set) dated 3/24/22: - Section C: Cognitive Pattern - BIMS (Brief Interview for Mental Status) score of 11 indicating mildly impaired cognition - Section G: Functional Status - bed mobility limited assistance/1 person; transfer, personal hygiene extensive/2 person; dressing, bathing total dependence/1 person; eating supervision/1 person; toilet use extensive/1 person. - Section H: Bladder and Bowel - always incontinent of both - Section M: Skin Conditions - resident has (1) unhealed stage 4 pressure ulcer Review of Resident #1's June and July 2022 Bath Day Roster failed to reveal a bath/shower was provided daily on the following days: June: 1, 3, 4, 5, 7, 8, 10, 11, 12, 13, 15, 16, 17, 20, 21, 23, 25, 26, 27, and 29th July: 1-5, 8, 9, 21-26th During an interview on 7/27/22 at 10:45 AM S1 DON (Director of Nursing) confirmed Resident #1 did not have documentation of receiving a bath or shower daily for the months of June and July and should have.