Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required assistance of two staff members for all transfers, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, when on 09/28/24 Certified Nurse Aide #1 transferred him/her without assistance from another staff member, and as a result Resident #1 sustained a fractured right ankle, which required surgical intervention to repair. Findings include: The Facility's Policy, titled Safe Lifting and Movement of Residents, dated 08/01/23, indicated resident safety, dignity, comfort, and medical condition would be incorporated into goals and decisions regarding the safe lifting and movement of residents. Review of the Report submitted by the Facility via the Health Care Facilities Reporting System (HCFRS), dated 10/03/24, indicated that on 09/29/24, Resident #1's right ankle was assessed to be swollen and bruised, X-Ray results indicated his/her right ankle was fractured, and through the Facility's internal investigation, it was determined that on 9/28/24, Certified Nurse Aide #1 transferred Resident #1 without assistance from another staff member, which was identified as the source of his/her injury. Resident #1 was admitted to the Facility in September 2023, diagnoses included history of falls, dementia, rheumatoid arthritis, and osteoarthritis. Review of Resident #1's Hospital Physical Therapy Discharge Assessment Note, dated 09/11/23, indicated Resident #1 required two staff members to assist with transfers. Review of Resident #1's Post admission Care Plan Meeting Note, dated 09/26/23, indicated he/she required maximum assistance of two staff for transfers. Review of Resident #1's Certified Nurse Aide Activities of Daily Living Flowsheet for September 2024 indicated he/she was dependent on staff for all transfers (that resident does none of the effort to complete the task, and/or requires the assistance of two or more staff to complete the activity). Review of Resident #1's Annual Minimum Data Set (MDS) assessment (a comprehensive assessment of each resident's functional capabilities), dated 09/07/24, indicated he/she was dependent for transfers. Review of Resident #1's Nurse Progress Note, dated 09/29/24, indicated Resident #1's right foot was bruised and swollen, and a physician's order for an x-ray was obtained. Review of Resident #1's Radiology Report, dated 09/29/24, indicated he/she had an acute fracture of the right distal fibular shaft (long bone on the outside of the lower leg). Review of Resident #1's Hospital admission History and Physical, dated 10/02/24, indicated he/she was diagnosed with a displaced fracture of the right distal fibular shaft with valgus angulation (type of fracture where the distal part (part furthest away from the center of the body) of the bone points away from the body's midline), and required surgical intervention of a closed reduction percutaneous pinning. During a telephone interview on 10/16/24 at 01:10 P.M., Nurse #2 said she was Resident #1's nurse on 09/28/24 and 09/29/24. Nurse #2 said CNA #1, who was familiar with Resident #1 and had provided care for him/her many times, was assigned to Resident #1 during the 07:00 A.M., to 03:00 P.M., shift on 09/28/24. Nurse #2 said that on the morning on 09/29/24 Resident #1's right ankle was observed to be bruised and swollen. During a telephone interview on 10/16/24 at 01:59 P.M., Nurse Supervisor #1 said that on 09/29/24 she was called to Resident #1's room by Nurse #2 because his/her foot was bruised and swollen. Nurse Supervisor #1 said she interviewed Certified Nurse Aide (CNA) #1, who had provided care for Resident #1 on 09/28/24, and said CNA #1 told her that she had transferred Resident #1 from his/her bed to his/her chair without any help from another staff member. Nurse Supervisor #1 said CNA #1 should have gotten and had assistance from another staff member to transfer Resident #1, but did not. Review of Certified Nurse Aide (CNA) #1's signed written statement, dated 09/29/24, indicated that on 09/28/24 at 10:30 A.M., she provided ADL care to Resident #1, and that she transferred him/her from his/her bed to his/her wheelchair without assistance from another staff member. CNA #1 did not respond to the Department of Public Health telephone or letter request for an interview. During an interview on 10/15/24 at 12:25 P.M., the Director of Nurses (DON) said CNA #1 should have had another staff member present to assist her with transferring Resident #1 on 09/28/24, but did not, and as a result Resident #1 sustained a right ankle fracture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to protect seven Residents (#5, #100, #19 #108, #26, #62 and #90) from abuse and neglect by staff out of a total sample of 41 residents. Specifically, the facility failed to prevent abuse 1a) after one Resident (#5) alleged that Certified Nursing Assistant (CNA) #16 forced him/her to take a shower and sprayed water in his/her face, causing emotional distress and 2) by neglecting to complete incontinence care for Residents #100, #19, #108, #26, #62 and #90. Findings include: Review of the Facility policy titled, Resident Rights/Abuse, undated, indicated the following: -Federal requirements state that each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion; And that we may not mistreat, neglect, abuse, or misappropriate the resident's property. -Emotional abuse happens when a resident is humiliated, harassed or feels threatened. -Psychological abuse - causing emotional pain or distress to a resident. Psychological abuse includes but is not limited to: humiliation. -Signs of psychological abuse may include the resident suddenly becoming fearful, withdrawn, refuses to eat, sleeps poorly at night, ringing the bell more frequently because the resident is afraid. -Neglect - the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect includes but is not limited to: failing to provide medical, dental, nursing, physical therapy, pharmacy, psychological, speech or other treatments or services; failing to carry out medical or nursing care plans or specific treatments; failing to provide for the dietary requirements of a resident; and failing to provide safety measures. Review of the facility policy titled, Abuse and Neglect - Clinical Protocol, dated 8/1/23, indicated the following: -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -The staff, with the physicians input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Review of the Facility policy titled Abuse and Neglect-Clinical Protocol, dated as updated 8/1/23, indicated the following: -Neglect as defines at 483.5, means the failure of the facility, its employer or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. -The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. 1a. Resident #5 was admitted to the facility in May 2023 with diagnoses including legal blindness, cerebral infarction, anxiety, and depression. Review of Resident #5's most recent Minimum Data Set Assessment (MDS) assessment, dated 12/17/23, indicated Resident #5 had a Brief Interview for Mental Status score of 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #5 required substantial-maximal assistance with bathing. During an interview on 3/07/24 at 12:30 P.M., with Resident #5 and Resident #5's Family Member (#2), Resident #5 reported that staff ignored his/her requests to not take a shower and not have his/hair washed and that he/she feels ignored. Resident #5 said Certified Nursing Assistant (CNA) #16 forced him/her to take a shower on 2/28/24. Resident #5 said he/she goes to the hair salon on Tuesdays and told CNA #16 he/she did not want a shower or to have his/her hair washed the following day. Resident #5 said She picked me up and made me take a shower, sprayed water in my face and used a whole bottle of shampoo. She scrubbed my nose and was a big, awful person and scared me even after I kept telling her no, she would not stop spraying me and scrubbing my hair. Resident #5 said CNA (#16) shouldn't be working and that he/she told his/her privately paid helper what had happened that afternoon. Resident #5 said, I was overpowered, and no one could help. I was frightened and I was afraid. Family Member #2 said she received a call from the privately paid aide and was notified of the incident and went to visit Resident #5 that evening and was told the same information by Resident #5. The Resident's Family Member #2 said a formal complaint was made to Unit Manager #1, and to the Director of Nurses (DON) on 2/28/24 by Resident #5's Health Care Proxy. During an interview on 3/08/24 at 2:57 P.M., with Resident #5, and Family Member (#3), the family member said the Resident and family are upset and concerned about this incident. Family Member #3 said he spoke with Nurse Unit Manager #1 a few days after the incident again because Resident #5 was still afraid and scared and had been refusing showers for 9 days. Resident #5 said I don't want a shower because I am afraid and scared still. Family Member #3 said he was very upset because this has put fear into Resident #5 and the Resident does not want family to leave him/her alone since this incident. During an interview on 3/08/24 at 3:14 P.M., Family Member (#1) said Resident #5 was very upset and crying during a phone call and said he/she felt overpowered, frightened, and afraid of this staff member. Family Member #1 said Resident #5 told CNA #16 he/she did not want a shower and that he/she had a shower on Monday. Family member #1 said Resident #5 said CNA #16 said he/she must take a shower because her family told him/her to and brought him/her into the shower very upset and proceeded to shower him/her. Resident #5 reported that CNA #16 continued to spray water on the Resident after repeat attempts at telling the CNA to stop. Resident #5 said please don't do my hair, I just paid to have it done, and the CNA took the hose and put it over Resident #5's head and sprayed water down his/her face and head. Family Member #1 said the Resident started screaming and said to the CNA you son of a bitch I told you not to wash my hair and I told you no. I just had my hair done!. Resident #5 said CNA #16 continued washing his/her hair and continued to spray water over his/her face and hair. Resident #5 said he/she was man powered and had no control when the CNA overtook her, and said and none of his/her family could protect him/her. Family Member #1 said she immediately reported all the information to the Director of Nursing on 2/28/24 and told her she wanted to file a grievance regarding all of the information reported by Resident #5. The family member said she has not heard back from the facility since the incident and has not received a copy of the grievance report. Family Member #1 said she also spoke with Unit Manager #1 on 2/28/24 and was told that a formal grievance was in the works. Family Member # 1 said she feels this was emotional abuse and it has caused Resident #5 to refuse showers since the incident because he/she is scared. During an interview on 3/07/24 at 12:40 P.M., the hairdresser said she provides salon services to Resident #5 and washed and styled his/her hair and the Resident has been very upset since then, because the CNA made him/her take a shower. During an interview on 3/07/24 at 3:12 P.M., the Director of Nursing (DON) said she does not remember this incident and will check her list of incidents tomorrow. The DON said if Resident #5 refused a shower the CNA should not have forced her to take a shower and should have documented the refusal, notified the nurse and the nurse would enter a note into the computer. The DON said if a resident is forced into doing something, that would be considered a type of abuse. During an interview on 3/08/24 at 4:01 P.M., Nurse Unit Manager #1 said she was made aware of the situation on 2/28/24 by Resident #5's family member and notified the DON of the incident. Nurse Unit manager #1 said the CNA should not have made Resident #5 take a shower, and it is a form of abuse. Unit manager #1 said if Resident #5 said no, and she did it anyway, that is abuse. During an interview on 3/08/24 at 4:08 P.M., with the DON and Administrator, the DON said she was notified of the incident that took place on 2/28/24 and that she spoke with Resident #5's family member on the day of the incident. The DON said CNA #16 should not have showered him/her after the Resident said no. The DON and Administrator said forcing a resident to do something against their will is a form of abuse. 2a. Resident #100 was admitted to the facility in March 2022 with diagnoses including Alzheimer's disease, benign prostatic hyperplasia, and muscle weakness. Review of Resident #100's most recent Minimum Data Set (MDS) assessment, dated 12/02/24, indicated Resident #100 was unable to complete the Brief interview for Mental Status exam and the staff had assessed him/her to have severe cognitive impairment. The MDS also indicated Resident #100 is dependent on staff for toileting. On 3/07/24 from 2:28 P.M. to 7:19 P.M., Resident #100 was observed out of bed in his/her wheelchair without incontinence care being provided to him/her or any staff members checking the Resident to assess if incontinence had occurred. At 7:19 P.M., the surveyor observed a puddle of urine smelling liquid dripping from the bottom of Resident #100's wheelchair seat. The puddle was gathering enough liquid that it began to stream from his/her chair to approximately 4 feet across the floor. At this time, the surveyor had Resident #100's nurse observe the Resident and the liquid, and the Nurse said he would get the Resident's Certified Nursing Assistant (CNA) to provide incontinence care for the Resident. On 3/07/24 at 7:36 P.M., 17 minutes after the Nurse said he would be getting Resident #100 assistance, the Resident remained in his/her wheelchair and the surveyor and Administrator observed the Resident together. The Administrator said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. On 3/08/24 at 7:03 A.M., the Surveyor observed Resident #100 lying in his/her bed. The Resident's wheelchair was observed in his/her room across from his/her bed. The Surveyor put on clean gloves and with a finger pushed on the wheelchair cushion which caused a yellow liquid to leak out of the cushion and around the Surveyor's finger. The Surveyor then lifted the saturated cushion and noted the seat of the wheelchair seat was observed to be soaked with yellow liquid and had an ammonia smell similar to urine. During an interview on 3/08/24 at 11:06 A.M., Resident #100's daughter said she has been very upset with the level of care provided to the Resident. The Resident's daughter said she has often come in to visit Resident #100 and the Resident is soiled with feces and his/her pants are wet from an incontinent episode with a strong smell of urine. Review of Resident #100's current Activity of Daily Living (ADL) care plan, last revised, 12/28/23, indicated the following: -Bladder: (the Resident) is incontinent of bladder. -Bowel: (the Resident) is incontinent of bowel. -Toilet hygiene: (the Resident) is dependent. -Toilet transfer: (the Resident) is dependent. Review of Resident #100's current bowel incontinence care plan, last revised 12/28/23 indicated the following interventions: -Keep resident clean and dry -Provide peri-care after each incontinent episode. Review of Resident #100's current bladder incontinence care plan, last revised 12/28/23 indicated the following interventions: -Clean peri-area with each incontinence episode -Monitor skin during incontinence care and s/s of UTI. -Remedy cream to be used with incontinent care Review of Resident #100's current potential for pressure area care plan, last revised 12/28/23 indicated the following interventions: -Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of Resident #100's most recent bowel and bladder assessment, dated 3/1/24, indicated Resident #108 was incontinent of both bowel and bladder, was totally incontinent, and had an inconsistent voiding pattern. The assessment also indicated Resident transferred back to bed BID to be toileted/changed and cleaned before final transfer back to be at night to sleep. Review of Resident #100's Kardex (a form indicating the level of assistance a resident requires) indicated Resident #100 is incontinent of both bladder and bowel and was dependent on staff for toileting tasks. Review of the nursing note, dated 3/8/24, the day after the incontinence care was not provided, indicated the following: -This am during am care, (the Resident) was noted to have a 0.125 x 1 cm (centimeter) slightly raised blister/pustule on buttocks, pustule is red with surrounding skin pink, md updated order for nystatin cream area until healed. During an interview on 3/08/24 at 7:23 A.M., Nurse Unit Manager #2 observed Resident #100's skin and said he/she definitely had a new area that was not there prior to today. Nurse Unit Manager #2 said she couldn't say if the skin area was open, but it was definitely a new skin alteration area. Nurse Unit Manager #2 said Resident #100 is incontinent and should receive incontinence care as needed. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. 2b. Resident #19 was admitted to the facility in July 2021 with diagnoses including Alzheimer's Disease and dysphagia (difficulty chewing and swallowing). Review of Resident #19's most recent Minimum Data Set (MDS) assessment, dated 12/20/23, indicated Resident #19 had a Brief Interview for Mental Status exam score of 3 out of a possible 15, which indicated the Resident had severe cognitive impairment. The MDS also indicated Resident # 19 required moderate assistance with self-feeding tasks. On 3/07/24 from approximately 8:25 A.M. to 11:45 A.M., and from 2:28 P.M. to 7:19 P.M., Resident #19 was observed out of bed in his/her wheelchair without incontinence care being provided to him/her or any staff members checking the Resident to assess if incontinence had occurred. On 3/07/24 at 7:36 P.M., the surveyor and Administrator observed the Resident together. The Administrator said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. Review of Resident #19's current Activity of Daily Living (ADL) care plan, last revised 1/02/24, indicated the following: -Bladder: (the Resident) is incontinent of bladder. -Bowel: (the Resident) is incontinent of bowel. -Toilet hygiene: (the Resident) is substantial to max assist. -Toilet transfer: (the Resident) is substantial to max assist. Review of Resident #19's current incontinence care plan, last revised 1/02/24, indicated the following interventions: -Check as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. -Clean peri-area with each incontinence episode. Review of Resident #19's current potential for pressure areas care plan, last revised 1/02/24, included the following intervention: -Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of Resident #19's most recent bowel and bladder assessment, dated 12/30/23, indicated Resident #19 was incontinent of both bowel and bladder, was totally incontinent, had an inconsistent voiding pattern, and needed to be toileted during care and around meals to reduce episodes of incontinence. Review of Resident #19's Kardex (a form indicating the level of assistance a resident requires) indicated Resident #19 is incontinent of both bladder and bowel and was dependent on staff for toileting tasks. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. 2c. Resident #108 was admitted to the facility in July 2023 with diagnoses including dementia, chronic kidney disease, and benign prostatic hyperplasia. Review of Resident #108's most recent Minimum Data Set (MDS) assessment, dated 1/27/24, indicated Resident #108 was unable to complete the Brief Interview for Mental Status (BIMS) and staff had assessed him/her to have severe cognitive impairment. The MDS also indicated the Resident required moderate assistance from staff for toileting hygiene. On 3/07/24 from approximately 2:28 P.M. to 7:19 P.M., Resident #108 was observed out of bed in his/her wheelchair without incontinence care being provided to him/her or any staff members checking the Resident to assess if incontinence had occurred. The Resident was not toileted after either the lunch or dinner meals. On 3/07/24 at 7:36 P.M., the surveyor and Administrator observed the Resident together. The Administrator said the expectation of the facility is that incontinent residents be toileted every two hours and as needed. During an interview on 3/08/24 at 11:30 A.M., Resident #108's spouse said she had to request that Resident #108 be toileted after every meal to keep him/her clean because incontinence care was not being provided regularly. Review of Resident #108's Activity of Daily Living care plan, last revised 2/01/24, indicated the following: -Bladder: (the Resident) is incontinent of bladder. -Bowel: (the Resident) is incontinent of bowel. -Toilet hygiene: (the Resident) is dependent. -Toilet transfer: (the Resident) is substantial to max assist. Review of Resident #108's incontinence care plan, last revised 1/02/24, indicated the following interventions: -Incontinent: check as well as prompt toilet around meals and care times to decrease episodes as (he/she) allows and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. -Offer toileting to (the Resident) immediately after leaving the dining room. -Brief Use: the resident uses disposable briefs. Change PRN. -Clean peri-area with each incontinence episode. Review of Resident #108's most recent bowel and bladder assessment dated [DATE], indicated Resident #108 was incontinent of both bowel and bladder, was totally incontinent, and had an inconsistent voiding pattern. Review of Resident #108's Kardex (a form indicating the level of assistance a resident requires) indicated the Resident is incontinent of both bladder and bowel and was dependent on staff for toileting tasks. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect.2d. Resident #26 was admitted to the facility in May 2022 and has diagnoses that includes dementia without behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/15/24, indicated that Resident #26 scored a 7 out of a possible 15 on Brief Interview for Mental Status exam, indicating severe cognitive impairment. The MDS further indicated that Resident #26 had no behaviors, is dependent on staff for toileting hygiene and is always incontinent of bowel and bladder. Review of the current Activities of Daily Living (ADL) care plan, dated 10/31/23, indicated that Resident #26 has been identified as having potential or actual deficits in Activities of Daily living while a resident at our facility. Interventions on the care plan include: -Toilet hygiene: Resident #26 is dependent; -Bladder: Resident #26 is incontinent of bladder; -Bowel: Resident #26 is incontinent of bowel. Review of the current bowel and bladder incontinence care plan, indicated the following interventions: -INCONTINENT: check (as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN (as needed) after incontinence episodes. -Remedy cream to be used with incontinent care. Review of the current skin integrity care plan, indicated that Resident #26 had the potential for skin impairment due to incontinence. Interventions included: -Incontinent care if applicable. Review of Resident #26's current Resident ADL Guide/Kardex indicated the following care instructions for Resident #26: -Is incontinent; -Dependent for toileting hygiene. On 3/07/24 between 10:30 A.M., to 1:30 P.M., the surveyors were on the unit and observed that Resident #26 was not provided with incontinence care. The Resident was observed in his/her room, sitting on a hoyer pad (the pad used on a mechanical lift), in his/her wheelchair during that entire time. During an interview on 3/07/24 at 2:30 P.M., Certified Nursing Assistant (CNA) #2 said that he was assigned to Resident #26 that day. CNA #2 said that he changes residents on his assignment twice a shift (8 hours). CNA #2 said that he first changed Resident #26 at approximately 7:30 A.M., that morning before he used a mechanical lift to transfer him/her out of bed to a wheelchair. According to CNA #2 he then provided incontinence care to Resident #26 again at 11:00 A.M., contrary to direct observation by 2 surveyors. CNA #2 said that with the assist of CNA #3 they used a mechanical lift to transfer Resident #26 back to bed and then he provided incontinence care. CNA #2 said that CNA #3 then assisted him to mechanically transfer Resident #26 back to the wheelchair. CNA #2 said that he had not checked or changed Resident #26 since 11:00 A.M., 3.5 hours earlier. CNA #2 also said that since he just got back from his break, Resident #26 could next be changed by the staff on the 3-11 shift. During an interview on 3/07/24 at 2:36 P.M., with CNA #3 she said that she had not assisted CNA #2 at any point that day with using the mechanical lift to transfer Resident #26 to or from bed and that she was unsure who had provided Resident #26 with incontinence care. During an interview on 3/07/24 at 2:48 P.M., with the Director of Nursing (DON) she was updated on the observations and interviews and the DON said the following: -It is her expectation that staff provide incontinence care every two hours; She said that every two hours incontinent residents should be both checked and changed, as well as changed as needed at other times. On 3/07/23 between 3:15 P.M., and 7:16 P.M., the surveyor observed Resident #26 seated in a wheelchair in his/her room. During that time Resident #26 was not observed to have been checked for incontinence, nor was he/she changed. At 7:16 P.M., 4 hours and 1 minute since the last time Resident #26 received incontinence care, CNA #9 entered Resident #26's room carrying incontinence supplies and pulled the curtain around him/her. During an interview on 3/07/24 at 7:36 P.M., with the Administrator (NHA) he was updated on the observations. The NHA reiterated the expectation that incontinent residents be changed every two hours and as needed. Review of the CNA assignment on 3/08/24 at 7:20 A.M., indicated CNA #2 was presently working and was again assigned to Resident #26. During an interview with the DON on 3/08/24 at 7:26 A.M., she said that she had not yet had a chance to look at statements collected regarding the allegation of neglect twice the previous day. The DON said that CNA #2 should not be working and should not be assigned to Resident #26 when she had not yet completed the neglect investigation. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 10:33 A.M., the facility submitted a report that Resident #26 did not receive incontinence care the morning of 3/7/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the NHA said that for staff to not have provided the incontinence care for Resident #26, for the length of time they did on 3/07/24, was neglect. 2e. Resident #62 was admitted to the facility in June 2020 and had diagnoses that include neuromuscular dysfunction of bladder. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/06/24, indicated that on the Brief Interview for Mental Status exam Resident #62 scored a 1 out of possible 15, indicating severely impaired cognition. The MDS further indicated Resident #62 had no behavior of rejecting care, is incontinent of bowel and bladder and is dependent for toileting hygiene. Review of Resident #62's current Activity of Daily Living (ADL) care plan indicated Resident #62 is dependent for toileting care. The care plan failed to indicate refusal of incontinence care. Review of Resident #62's current bowel incontinence care plan indicated the following interventions: -Please keep me clean and dry; -Skin care after incontinent episodes. Review of Resident #62's current Resident ADL Guide/Kardex indicated the following care instructions for Resident #62: -Is incontinent; -Dependent for toileting hygiene. Review of the most recent Bladder assessment, dated 1/6/24, indicated: -voiding pattern inconsistent -Staff continues to check and change resident when incontinent. Resident offered urinal/bedpan at care times to decrease episodes when possible. Staff to monitor skin for s/sx of breakdown/infection during care and address as needed. Resident OOB daily for meals. Briefs provided for dignity and containment. On 3/07/23 between 3:15 P.M., and 7:16 P.M., the surveyor observed Resident #62. Resident #62 was not checked for incontinence during that time, nor was he/she changed. During an interview on 3/07/24 at 6:55 P.M., with Certified Nursing Assistant (CNA) #9, who was supervising the unit dining room where Resident #62 was seated, he said that he had been supervising the dining room since approximately 4:30 P.M., which is why the residents present had not been checked or changed for incontinence. CNA #9 said that Resident #62 was on his assignment, however said that he hadn't had a chance to provide incontinence care since his shift started at 3:00 P.M., 3 hours and 55 minutes earlier, and that he wasn't sure when he was going to be able to, as he was responsible to supervise the dining room. On 3/11/24 between 7:28 A.M., and 10:42 A.M., Resident #62 was observed in bed. During that time no staff checked Resident #62 for incontinence or provided incontinence care. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. During a follow-up interview on 3/12/24 at 10:49 A.M., the Administrator said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. During a follow-up interview on 3/12/24 at 10:49 A.M., the NHA said that for staff to not have provided the incontinence care for the length of time they did on 3/07/24 was neglect. 2f. Resident #90 was admitted to the facility in November 2023 and had diagnoses that include vascular dementia and unspecified urinary incontinence. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/27/24, indicated that on the Brief Interview for Mental Status exam Resident #90 scored a 3 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #90 is frequently incontinent of bladder and occasionally incontinent of bowel. Review of Resident #90's current ADL care plan indicated Resident #90 is dependent for toileting care. The care plan failed to indicate refusal of incontinence care. Review of Resident #90's current Resident ADL Guide/Kardex indicated the following care instructions for Resident #90: -Is incontinent; -Dependent for toileting hygiene. Review of the most recent Bladder assessment, dated 1/27/24, indicated: -voiding pattern inconsistent -cooperative with care On 3/07/23 between 3:15 P.M., and 7:16 P.M., the surveyor observed Resident #90. During that time Resident #90 was not checked for incontinence, nor was he/she changed. During an interview on 3/07/24 at 6:55 P.M., with Certified Nursing Assistant (CNA) #9, who was supervising the unit dining room where Resident #90 was seated, he said that he had been supervising the dining room since approximately 4:30 P.M., which is why the residents present had not been checked for incontinence or changed. During an interview on 3/07/24 at 2:48 P.M., the Director of Nursing (DON) said it is her expectation that staff provide incontinence care every two hours. The DON said residents who are incontinent should be both checked and changed every two hours, as well as changed as needed at other times. During an interview on 3/07/24 at 7:36 P.M., the Administrator reiterated the expectation that incontinent residents be toileted every two hours and as needed. Review of the Department of Public Health (DPH) Health Care Facility Reporting System (HCFRS) system indicated on 3/08/24 at 12:44 P.M., the facility submitted a report that 6 residents did not receive incontinence care the evening of 3/08/24. Duri[TRUNCATED]