**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident/staff interviews, medical record review, and facility policy review, the facility failed to ensure a resident's right to be free from involuntary seclusion for one (1) of three (3) residents on transmission-based precautions (TBP). Resident #40 Findings include: Review of facility policy titled, Incident Investigation & Reporting dated 11/09/2009, reviewed 1/14/2025, revealed, .Each resident residing in this facility has the right to be free from any type of abuse .includes but is not limited to free from .involuntary seclusion .Involuntary Seclusion: Separation of a resident from other residents or from his/her room or confinement to his/her room . Review of facility policy titled, Policy for Control of Multidrug-Resistant Organism (MDRO) Infection dated 6/14 reviewed 1/14/2025, revealed, It is the policy of this facility to place residents in contact .precautions if they are displaying symptoms of active multidrug-resistant organism (MDRO) infection. Conditions requiring isolation include: .If the resident has a draining wound that is infected with an MDRO, and the drainage cannot be contained . Review of facility policy titled, Resident's Rights Policy dated 6/94, revised 12/23, reviewed 1/14/2025, revealed, Every resident in this facility has the right to .Be free of .psychological .abuse . During an observation and interview on 3/30/2025 at 3:53 PM with Resident #40 it was revealed that the resident had a red biohazard barrel in her room. The resident reported being in isolation, stating she was informed by numerous staff that she could not leave her room until 4/3/25 after her antibiotics were finished. During the interview the resident expressed frustration and stated, I'm getting tired of it, I just want to go outside, I don't even care if it's raining. The resident acknowledged that isolation has increased her anxiety and depression, stating, Just from staying in for that long, anyone would have it! She emphasized, I like to go outside and be in the air. A record review of Resident #40's Order Summary Report for the month of 3/2025, revealed an order, dated 3/13/2025, for Contact Isolation Precautions due to Methicillin Resistant Staphylococcus aureus (MRSA) of Wound. A record review of a nursing Progress Note, dated 3/13/2025 at 6:52 PM for Resident #40, revealed, Dr (proper name) evaluated and reviewed labs .Doxycycline Monohydrate .related to MRSA infection .until 4/3/2025 .contact isolation precautions due to MRSA of wound. Observation on 3/31/2025 at 9:00 AM, Resident #40 was observed to be in her room lying in bed. Record review of Resident #40's Skilled Nursing Facility (SNF) Documentation Record dated 3/13/2025 through 3/25/2025, revealed no more than a scant amount of drainage to scabbed areas with no drainage observed to the surgical site wound to her back during that timeframe. On 3/31/2025 at 1:20 PM, Resident #40 was observed to be in her room lying in bed. A record review of a psychotherapy Progress Note dated 3/12/2025 at 11:59 PM for Resident #40, revealed, Reason for referral: [AGE] year old white female with follow up for insomnia, anxiety and depression .Resident's Statement: I've had my surgery. I had a brown spot come out on the bandages and they sent it (a specimen) off .Case Conceptualization .Endorses good sleep .Says she is not depressed and does not feel anxious and thinks medications are working well. Good mood. Laughing and talking freely . A record review of Resident #40's psychotherapy Progress Note dated 3/20/2025 at 11:59 PM, revealed, Diagnosis of Anxiety .Visit Summary .She shared she is frustrated as she is currently in isolation due to MRSA .She does report frustration related to isolation. She stated it has made her feel more disoriented . A record review of Resident #40's psychotherapy Progress Note dated 3/27/25 at 11:59 PM, revealed, She has now been isolated to her room for two weeks due to MRSA. She stated she is managing but is ready to get out of her room .She has 7 more days. She reported some anxiety and depression due to isolation and shared that her daughter is not supportive of her leaving the facility. During an interview on 4/1/2025 at 8:28 AM, with Certified Nursing Assistant (CNA) #3, she stated she was unsure of the type of isolation but confirmed that Resident #40 had not left her room in two (2) weeks. She confirmed that she has never seen any drainage on the residents' clothing or bed linen and stated there is always a small dressing covering the area. During an interview on 4/1/2025 at 8:31 AM, with the Treatment Nurse, she stated Resident #40 had MRSA to her lower left back surgical incision and that the resident has been in isolation for a couple of weeks under contact precautions and is on a 21-day antibiotic regimen. She confirmed that the treatment order included covering the incision with a dressing, and any drainage from the wound has only been a scant amount and contained by the dressings. She also noted that the resident was alert, oriented, and capable of making decisions. During an interview on 4/1/25 at 8:48 AM, with Infection Control (IC) Nurse, she confirmed the presence of MRSA in Resident #40's surgical incision. She confirmed that she was unaware that the resident has been confined to her room, and stated, Staff should have gotten her out of her room and allowed her to go out and get fresh air, maybe more staff education is warranted. During an interview on 4/1/2025 at 8:59 AM, with the Activities Director and Activities #1, confirmed that Resident #40 and other staff informed her that the resident could not come out of her room for 21 days due to being in isolation. Activities #1 went on to reveal that Resident #40 does not attend a lot of activities but enjoys walking around and going outside of the building daily. During an interview on 4/1/2025 at 9:11 AM, with Director of Nursing (DON) she stated, Residents are not supposed to come out of their room if they are on contact precautions. She stated we cannot force any residents to stay in their room but encourage them to do so. She confirmed her certification in infection control but admitted she did not review Resident #40's isolation status or continued need for isolation, as it is a facility practice for residents on isolation to remain in their rooms until the medication is completed. She acknowledged concerns that isolation could lead to depression and feelings of confinement. During an interview on 4/1/2025 at 9:16 AM, with the Social Services Director, she stated, I didn't know Resident #40 was in isolation until just now, I would have increased my visits with her if I had known. She further reported that isolation could lead to increased anxiety and depression. During an interview on 4/1/2025 at 9:33 AM, with Licensed Practical Nurse (LPN) #2, it was confirmed that Resident #40 was on contact isolation and must stay in her room to prevent contact with other surfaces or residents. She explained that residents placed in isolation are to remain on precautions until their antibiotic therapy is completed. During an interview on 4/1/2025 at 9:37 AM, with Housekeeping Staff #1, she confirmed she had recently completed in-service training that stated that a resident should remain in their room if they are on contact isolation. During a follow-up interview on 4/1/2025 at 9:40 AM, with the Infection Control Nurse, she acknowledged that the training was too broad, indicating that staff might interpret it to mean all residents on contact isolation should remain confined to their rooms. She said that she should have been more involved, but she had been teaching a CNA class for the past two (2) weeks, which limited her availability. She mentioned that had she been more present to review the infection log, she might have identified the situation sooner. She emphasized the need for treatment protocols for MDRO to be more personalized based on individual resident circumstances rather than applying a blanket policy of keeping residents in contact isolation until their medication regimen is completed. She confirmed that Resident #40 was alert, oriented, and able to follow directions. She noted that the residents' wound displayed only scant to zero drainage and remained covered. Furthermore, she stated that staff should have assisted the resident with hand hygiene and facilitated opportunities for her to go outside, acknowledging the importance of addressing the residents' emotional and mental well-being during isolation. The Administrator was interviewed on 4/1/2025 at 10:02 AM and confirmed that social isolation could lead to increased anxiety and depression among residents. An interview with CNA #1 and CNA #2 on 4/1/2025 at 2:10 PM, both verbalized they were trained to ensure that residents on isolation remain in their rooms to prevent the spread of infection. They confirmed that they had never observed any drainage from Resident #40's back as the affected areas were consistently covered. Additionally, they noted that the resident often leaves her room to approach the nurse's medication carts and frequently goes to the doorway, and requires redirection back to her room. During an interview with LPN #2 on 4/1/2025 at 2:20 PM, she also revealed that Resident #40 was alert, oriented and able to follow directions, additionally she confirmed the area to her back was always covered with a dressing and all drainage contained. She verbalized that the resident had never reported to her any increase in depression or anxiety, but stated she was not surprised as the resident has a history of both depression and anxiety. An interview with Medicare Nurse on 4/2/2025 at 8:00 AM, revealed she is the case manager for Resident #40. She stated she was aware that the resident was on contact precautions but confirmed that the surgical wound was approximately 1 (one) CM (centimeter) in diameter and only presented with scant drainage at times, but most of the time the surgical site was scabbed over and was always covered with a bandage and any drainage would have been contained. She confirmed that the resident should have been allowed to come out of her room for activities and socialization. A phone interview with Social Services #1 for on 4/2/2025 at 8:10 AM, she revealed she is a psychiatric social worker and has Resident #40 on case load. She confirmed that Resident #40 has a history of anxiety and depression. She confirmed that she saw the resident on several occasions in March and the resident voiced her frustration of being in isolation and confirmed that the resident also spoke of her increased anxiety and depression due to the isolation. She confirmed she gives a visit recap to the nursing staff after every visit and documented her notes in the medical record. An observation of Resident #40's surgical site on 4/2/2025 at 8:45 AM, with the DON revealed a secured dressing was removed, and revealed approximately a 0.1 CM open area noted with a scant amount of red drainage of the bandage. There was no drainage on the bed linens or the residents' clothing noted during this observation. A record review of an admission Record indicated the facility admitted Resident #40 on 11/29/22 with medical diagnoses that included Cerebral Infarction due to Thrombosis of Right Posterior Cerebral Artery, Encounter for Surgical Aftercare following Surgery on the Nervous System, Basal Cell Carcinoma of Skin of Other Part of Trunk, Anxiety Disorder, Depression, Mood disorder and MRSA Infection. Record review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/3/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.

Resident #85 A record review of Resident #85's Comprehensive Care Plan with Problem Onset: dated 08/12/2022 revealed, Problem: Resident needs extensive assistance with ADLS-Limited ROM, Weakness, Poor Safety Awareness . Approaches . Prefers to keep a shaved face, combed/brushed hair, and a haircut. Prefers to keep nails kept cut short . Observation on 05/22/23 at 11:39 AM, revealed Resident #85 sitting in his wheelchair with bilateral fingernails that were approximately (approx) one half (1/2) inch long and jagged past the tip of fingers, a brown substance under each nail. Facial hair to cheeks, chin and above the residents' lip was approximately 1/2 inch long. An observation and interview on 05/22/23 at 4:10 PM, Resident #85 sitting in the dining room in his wheelchair. The Director of Nurses (DON) confirmed that he needed to be shaved. She confirmed his nails were long and jagged with a brown substance underneath and stated he could cut himself and he could get an infection if his nails were not taken care of. An interview on 05/24/23 at 11:05 AM, the Minimum Data Set (MDS) nurse revealed she is responsible for developing the care plans. She revealed the care plans are developed so the staff will know how to take care of the resident and the care plan should be so clear that anyone would know exactly how to take care of that resident to include that resident's preferences. An interview on 05/24/23 at 2:40 PM, the DON confirmed that the ADL care plan was not followed on Monday 5/22/23 in reference to Resident #85 being shaved and his nails being clean and trimmed. Based on observation, staff interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan for a resident with a urinary catheter and for residents with Activities of Daily Living (ADL) that required oral care, nail care, bathing, and facial grooming for two (2) or twenty-one residents sampled. Resident #5 and Resident #85 Findings include: A review of the facility's Care Plan Process policy, dated 06/15 with a revision date of 08/17, revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence). Resident #5 Record review of care plan revealed a care plan that resident required extensive staff assistance for activities of daily living. Interventions included oral care two times a day and as needed. Interventions also included to brush teeth each night after eating, and to swab gums with peri guard mouth rinse. Record review of Completed Care Details for Personal Hygiene Completed revealed for the months of March, April, and May, the resident did not receive oral care on these dates: 3/2/23, 3/4/23, 3/5/23, 3/9/23, 3/12/23, 3/17/23, 3/19/23, 3/24/23, 3/28/23, 3/29/23, 4/4/23, 4/8/23, 4/10/23, 4/13/23, 4/18/23, 4/19/23, 4/22/23, 4/23/23, 5/13/23. An observation and interview with the DON on 5/23/23 at 9:05 AM, revealed the resident had a broken tooth and was started on antibiotics for a mouth infection. She stated an x-ray was also done to ensure her tooth was not abscessed. The DON revealed the broken tooth on the right upper side and a decayed tooth on the lower right and one on the upper right side. Resident #5's teeth appear clean except for a small amount of food. She stated the physician ordered daily brushing of her teeth after the evening meal and a mouth rinse to ensure oral care was done. An interview with the DON on 5/24/23 at 11:15 AM, revealed that according to the documented care logs, the resident did not receive oral care each day as needed for the dependent resident's oral health. She confirmed the facility failed to ensure the resident received oral hygiene. During an interview with the DON on 5/24/23 at 1:55 PM, she confirmed that according to the documentation in the care log, the resident did not receive oral hygiene two times each day as directed in the care plan. She confirmed the care plan is a guide for the needed care for each resident and Resident #5's care plan was not followed. Record review of Electronic Medication Administration Record revealed the resident did not receive the ordered brushing of teeth or mouth rinse on 5/13/23. Record review of Physician's Progress Notes dated 4/25/23 revealed, Has Gingivitis. Has broken incisor tooth upper right. No pain to palpation. No lymphadenopathy in neck. Will give local treatment with chlorohexidine mouth rinse, tooth brushing, and PO (by mouth) antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #39 An observation and interview on 5/22/23 at 4:00 PM, revealed Resident #39 sitting in a wheelchair in his room. Resident #39 revealed he has not had a shower today and that he needs to be shaved. He stated, I've been waiting all day and they told me they didn't have anybody to do it. Resident observed to have long facial hair. An observation and interview on 5/22/23 at 4:05 PM, with Certified Nurse Aide (CNA) # 7 revealed she works 3-11 shift. She revealed that the day shift was responsible for all the showers. She stated that today, all the odd rooms, which are located on the left side of the hall would have been scheduled for a shower. She confirmed that the resident was in an odd number room, so he should have got a shower on the 7-3 shift today. She confirmed that the facility doesn't have a shower team, but the day shift aide assigned to Resident #39 would have been responsible for his shower and she confirmed that Resident #39 did have long facial hair and that he needed shaved. She stated, He can tell you if he had a shower today, he knows. If he tells you that he didn't get a shower today, then he didn't. An observation and interview with the DON on 5/22/23 at 4:15 PM, confirmed that Resident #39 had not been showered or shaved and that today was the residents shower day. She revealed the resident should have been showered and shaved today. Record review of Resident #39's ADL's revealed under, Reason not bathed dated 5/22/23 and timed 11:45 AM documentation recorded, No. Record review of the Face Sheet revealed Resident #39 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and Unspecified Dementia. Record Review of Resident #39's MDS with an ARD of 5/19/23 revealed under section C a BIMS score of 9, which indicated resident is moderately cognitively impaired. Resident #85 Observation on 05/22/23 at 11:39 AM, revealed Resident #85 sitting in his wheelchair, bilateral fingernails approximately one-half (1/2) inch long and jagged past the tip of fingers, and a brown substance was under each nail. Facial hair was approximately 1/2 inch long and was noted to cheeks, chin and above the residents' lip. Observation on 05/22/23 at 2:00 PM, Resident #85 sitting in the dining room at activities. A red stain was observed around his mouth and on his chin. His nails were long and jagged with a brown substance noted. Facial hair was approximately (approx) 1/2 inch long to his chin, above his lip and to the sides of his cheeks. Observation on 05/22/23 at 3:39 PM, Resident #85 sitting in the front foyer with other residents. Visitors observed entering and exiting facility. Resident was noted with a red stain around his mouth area and on his chin. His nails were long and jagged and had a brown substance noted under the nails. Facial hair approx. 1/2 inch long to his chin, above his lip and to the sides of his cheeks. An observation and interview on 05/22/23 at 4:00 PM, with CNA#1 confirmed Resident #85 had spaghetti on his face and that his nails were long and jagged, and had a brown substance under each nail. She stated it doesn't look like he has had a shower and been shaved in a while. She revealed she would make sure he got taken care of this evening. An observation and interview on 05/22/23 at 4:10 PM, with the DON revealed Resident #85 sitting in the dining room in his wheelchair. The DON confirmed that he needed to be shaved, and he had spaghetti on his face since that's what they had for lunch. She confirmed his nails were long and jagged with a brown substance underneath. She revealed he could cut himself and he could get an infection. She stated, Do you have any staff, and continued to state that the facility had some staffing problems lately and wasn't sure who got showers today but would make sure he got taken care of right away. An interview on 05/23/23 at 11:25 AM, with CNA #2 revealed she worked yesterday 7a-3p and the residents on her B-hall only got hygiene care which was a wipe down. She revealed Resident #85 only got a wipe down and didn't get a shower yesterday like he was supposed to. She stated none of the residents got a shower yesterday on her shift because there was only two aides on B-hall and it is a very busy hall with a lot of two people assist. She revealed one aide can't work the Hoyer-lift alone. She stated it is very frustrating and she has reported this several times to upper management. A record review of Resident #85's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy and Chronic obstructive pulmonary disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/2023 revealed Resident #85 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderate cognitive impairment. Based on observation, staff, resident, and resident representative interviews, record review, and facility policy review, the facility failed to provide personal hygiene as evidenced by long, jagged nails with brown substance underneath nails, unshaven facial hair, unbathed, and poor oral hygiene for three (3) of 21 sampled residents. Resident #5, #39, #85 Findings included: Record review of facility policy titled, A.M. Care, dated 10/17, revealed, Purpose: to prepare the resident for their day, to maintain oral health and bodily hygiene, to provide for physical comfort, to maintain the resident's desired physical appearance, to observe the resident's physical and emotional state. Record review of facility policy titled, Activities of Daily Living, dated 12/20, revealed, Policy: An Activities of Daily Living flow sheet (ADL) will be utilized by the facilities and documented on a daily basis by the CNA (Certified Nursing Assistant) to reflect actual care rendered the resident. Record review of facility policy titled, Oral Hygiene, dated 10/17, revealed, Purpose: to clean the mouth, teeth and gums, to remove particles of food, to remove bacteria and odor, to provide comfort to the resident, to keep the mouth moist. The policy also revealed, inspect mouth and gums for irritation and open areas and observe the resident's mouth for dryness, redness, sores and general condition. Resident #5 An interview with Resident #5's daughter on 5/21/23 at 5:20 PM, revealed on the right upper side, the resident had a tooth that was broken off at the gum line and the tooth next to that one was decayed. She stated on the lower right side there was also a decayed tooth. She stated Resident #5 was not receiving adequate oral hygiene and that she had spoken with the Director of Nursing (DON), the Administrator, and the Physician about her concerns that the resident was not receiving adequate oral care since her teeth appeared unbrushed. She stated after speaking to several staff members, her mother was placed on a daily brushing and rinse schedule and was also given an antibiotic to treat gingivitis and this has improved the appearance of her mother's teeth. She stated her main concern was she wanted to know that her mother was comfortable and not in pain. An observation on 5/21/23 at 5:20 PM, of Resident #5's mouth revealed slight redness noted, but the daughter stated that this was much improved since the resident started on an antibiotic. An observation and interview with the DON on 5/23/23 at 9:05 AM, revealed the resident had a broken tooth and was started on antibiotics for a mouth infection. She stated an x-ray was also done to ensure her tooth was not abscessed. The DON revealed the broken tooth on the right upper side and a decayed tooth on the lower right and one on the upper right side. Resident #5's teeth appear clean except for a small amount of food. She stated the physician ordered daily brushing of her teeth after the evening meal and a mouth rinse to ensure oral care was done. An interview with the DON on 5/24/23 at 11:15 AM, revealed that according to the documented care logs, the resident did not receive oral care each day as needed for dependent residents' oral health. She confirmed the facility failed to ensure the resident received oral hygiene and this could have led to gingivitis. During an interview with the DON on 5/24/23 at 1:55 PM, she confirmed that according to the documentation in the care log, the resident did not receive oral hygiene two times each day as directed in the care plan. She confirmed that gingivitis is mainly caused by poor oral hygiene and the resident was diagnosed with gingivitis. She confirmed the facility failed to provide adequate oral hygiene which could have led to her gingivitis and teeth concerns. Record review of Completed Care Details for Personal Hygiene Completed revealed for the months of March, April, and May, the resident did not receive oral care on these dates: 3/2/23, 3/4/23, 3/5/23, 3/9/23, 3/12/23, 3/17/23, 3/19/23, 3/24/23, 3/28/23, 3/29/23, 4/4/23, 4/8/23, 4/10/23, 4/13/23, 4/18/23, 4/19/23, 4/22/23, 4/23/23, 5/2/23, 5/3/23, 5/6/23, 5/9/23, 5/12/23, 5/13/23, 5/16/23, 5/19/23, 5/20/23, 5/21/23, and 5/22/23. Record review of Electronic Medication Administration Record revealed the resident did not receive the ordered teeth brushing or mouth rinse on 5/13/23. Record review of Departmental Note dated 4/25/23, revealed, physician saw resident at facility regarding tooth pain. New order for Doxycycline, to brush teeth each night after eating, and to swab gums with peri guard. Record review of Physician's Progress Notes dated 4/25/23 revealed, Has Gingivitis. Has broken incisor tooth upper right. No pain to palpation. No lymphadenopathy in neck. Will give local treatment with chlorohexidine mouth rinse, tooth brushing, and PO (by mouth) antibiotics. Record review of Physician's Progress Notes dated 5/2/23 revealed, Mouth Gingivitis much improved. Will continue daily mouth care and teeth brushing. Does have plaque. Not a candidate for deep cleaning. Right upper broken tooth. Not infected. No abscess noted on facial x-ray. Record review of Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Dementia, Anxiety Disorder, and Depression. Record review of quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/28/23, revealed a Brief Interview for Mental Status (BIMS) of 99 which indicated severe cognitive impairment and inability to complete the interview.

Based on observation, staff and resident interviews, record review and facility policy review the facility failed to assure that there was sufficient qualified nursing staff available at all times to assist the residents in getting the care they needed for three (3) of 24 days of staffing reviewed. Findings include: Record review of the facility policy titled, Nursing Services-Staffing with the latest revision date of 11/17 revealed 1. Staffing-The facility will have sufficient nursing staff twenty-four hours every day to provide nursing and nursing related services to attain or help maintain the highest practicable, physical, mental, and psychosocial well-being of each resident as is determined in the comprehensive assessment and the resident care plan . An interview on 5/21/23 at 6:50 PM, with Certified Nurse Aide (CNA) #5, revealed she works the 3-11 shift and that they usually have two (2) aides per hall. She revealed it can be a struggle at times, but they (the aides) must use time management to get everything done. Record review revealed that the facility triggered low weekend staffing and the State Agency (SA) entered the facility on a Sunday 05/21/23 at 3:00 PM to observe for any weekend staffing concerns or care concerns related to low staffing. Staffing Data Report for Fiscal Year 2023 Payroll Based Journal, revealed, Excessively Low Weekend Staffing Triggered, Triggered = Submitted Weekend Staffing data is excessively low. An interview with the Director of Nursing (DON), on 5/22/23 at 3:30 PM, confirmed they have been experiencing staffing issues and stated they are actively looking for CNAs and have increased their pay rate as an incentive for new hires and included a shift differential as an extra incentive. She revealed they must use agency staffing because they do not have enough facility staff and that staffing has been increasingly difficult since Covid-19. She revealed that she does the nurse staffing schedule, and the Assistant Director of Nursing (ADON) does the aides. She revealed that she addresses call-ins by having a nurse on call during the weekend, so if someone should call in, the nurse will replace that shift, even working as an aide. The SA inquired whether the residents were receiving adequate care, she stated, We also have several office personnel that are CNA's and come out to assist. She stated, There have been many days that I have come out of the office and have given showers. She revealed that they staff two (2) aides to a hall, except for A hall that has a lower census. She confirmed that they do not have a shower team and the aides were responsible for giving their assigned halls/units showers. On 5/21/23 at 5:20 PM, an interview with Resident #5's daughter revealed on the right upper side, the resident had a tooth that was broken off at the gum line and the tooth next to that one was decayed. She stated on the lower right side there was also a decayed tooth. She stated Resident #5 was not receiving adequate oral hygiene and that she had spoken with the DON, the Administrator, and the Physician about her concerns that the resident was not receiving adequate oral care since her teeth appeared unbrushed. She stated after speaking to several staff members, her mother was placed on a daily brushing and rinse schedule and was also given an antibiotic to treat gingivitis, and this has improved the appearance of her mother's teeth. On 5/24/23 at 11:15 AM, an interview with the DON revealed that according to the documented care logs, the resident did not receive oral care each day as needed for dependent residents' oral health. She confirmed the facility failed to ensure the resident received daily oral hygiene and this could have led to the resident's gingivitis diagnosis. Record review of Completed Care Details for Personal Hygiene Completed revealed for the months of March, April, and May, the resident did not receive oral care on these dates: 3/2/23, 3/4/23, 3/5/23, 3/9/23, 3/12/23, 3/17/23, 3/19/23, 3/24/23, 3/28/23, 3/29/23, 4/4/23, 4/8/23, 4/10/23, 4/13/23, 4/18/23, 4/19/23, 4/22/23, 4/23/23, 5/2/23, 5/3/23, 5/6/23, 5/9/23, 5/12/23, 5/13/23, 5/16/23, 5/19/23, 5/20/23, 5/21/23, and 5/22/23. Record review of Electronic Medication Administration Record revealed the resident did not receive the ordered teeth brushing or mouth rinse on 5/13/23. An observation on 5/22/23 at 5:45 PM, from C and D wing nurses' station, revealed three (3) call lights sounding on the call alert system behind the nurses' desk. SA observed call lights blink for approximately 13 minutes. One (1) aide was observed passing out supper trays on C hall with no other staff observed in the hallways. SA observed two (2) nurses seated behind the nurse's station with their heads down. SA inquired from Licensed Practical Nurse (LPN) # 5 as to what that sound was that was alarming. She stated, That's the call light system. SA inquired how the system worked and she stated, The residents push their call light when they need help or need something, and it will sound out here. SA inquired from LPN #5 whether she should go and answer the light. She replied, Yes. SA observed both nurses seated behind the desk get up to respond to the call lights after being cued. An interview with Licensed Practical Nurse (LPN) #3 on 5/23/23 at 9:10 AM, revealed that they have three (3) aides today on the D wing. She revealed that two (2) aides work the floor and one (1) will do the showers. She stated, I'm not going to lie to you; we are having staffing issues. She stated, Nobody wants to work right now, and I think everyone is having staffing issues. An interview on 5/23/23 at 9:45 AM, with Registered Nurse (RN) # 2, revealed that she works Monday-Friday as the charge nurse. She stated she usually works 9-10 hours a day and stated that the facility does not have enough staff to take care of the residents. She revealed that after Covid -19, the hospitals began sending more and more residents to the facility with higher acuity. She stated, They think we are the ICU step down. She revealed that the facility was having trouble finding and keeping staff and that they have a lot of high-level care residents that require one on one, and they do not have the staff to properly care for them. She revealed that the aides are overwhelmed with all that they have to do with the available staff and stated, It's frustrating. An interview on 5/23/23 at 4:10 PM, with the Assistant Director of Nursing (ADON), confirmed that the facility has been experiencing staffing concerns. She revealed that they've had trouble with staffing since Covid-19, but more so in the past year. She stated that they have just as many call-ins throughout the week as they do on the weekends. She revealed the facility has tried to discipline staff with excessive call-ins with verbal warnings, write-ups, and suspension but it doesn't work and stated, It doesn't do any good. Sometimes we struggle, especially with showers. Sometimes they (the residents) don't get a shower, or it may be the next day. It can be a struggle; We just need more staff. She revealed that they do use an agency, but those shifts must be scheduled ahead of time, and agency staff were only required to work two (2) weekends out of a month. She revealed that she often does shift trading with the aides to get a shift filled and stated that money doesn't work anymore, people still call in. She revealed the facility has increased the base pay for the aides and given a shift differential. She stated, We've done everything. We do have a lot of high-acuity residents here. When the SA inquired about the facility's willingness to hold off on admissions due to low staffing, she shook her head and stated, No, there is no way that they are going to do that. An interview on 5/24/23 at 10:20 AM, with Certified Nurse Aide (CNA) #6 revealed that the staffing has been a concern for a while. She revealed she had spoken with the administration, but they told her, We know, and that the facility was using agency staffing but stated, They are not reliable. She stated that the agency comes in late which makes it harder on them because they must cover the residents until agency arrives. She revealed the residents are not being cared for properly. She stated that this past Monday, 5/22/23 they had call-ins and none of the residents got a shower that day, just a wash-up in their bed. She revealed that the facility has a lot of high-level of care residents that must be transferred with lifts and must be fed. An interview with Resident # 3 on 5/24/23 at 10:35 AM, revealed the facility had a change in the administration about two (2) years ago and since then the care has gone down. She revealed that the aides work hard and provide good care, it's just not enough of them. She stated, They care for the residents, and they are doing all they can do. She stated when they have two (2) aides to a hall, they don't get everything they need. She revealed that when they are short it takes a long time to get assistance after pushing the call light and she also revealed there are days when she doesn't get a shower. She stated, It's not their fault, it's management's. She stated the two (2) aides usually have an entire hall and that's over twenty-something people to take care of. An interview on 5/24/23 at 3:35 PM, with the Corporate Nurse confirmed they were having staffing concerns and confirmed that the facility failed to have sufficient staff for three (3) of the 24 days reviewed on the staffing grid and the staff working schedule with the dates of 3/25/23, 5/20/23 and 5/22/23. She stated, We have done everything we can concerning staffing. She stated, I'm sure we're not the only ones like this. The Corporate Nurse confirmed that the facility had not held off on admissions due to low staffing. An interview on 5/24/23 at 3:40 PM, with the Director of Nursing (DON), revealed they are continuing to try and come up with ideas to help resolve the call-ins. She revealed some of the aides are now working sixteen hours on the weekend and taking the week off and that has helped. They've gotten a pay increase along with shift differential. She stated that money does not matter with the aides at this point. She acknowledges that the facility failed to meet the requirements for sufficient staff for three (3) of the 24 days reviewed on the staffing grid and working schedule with the dates of 3/25/23, 5/20/23 and 5/22/23. On 5/22/23 at 4:00 PM, an observation and interview revealed Resident #39 sitting in a wheelchair in his room. Resident #39 revealed he has not had a shower today and that he needs to be shaved. Resident stated, I've been waiting all day and they told me they didn't have anybody to do it. Resident observed to have long facial hair. On 5/22/23 at 4:05 PM, an observation and interview with CNA # 7 revealed she works 3-11 shift. She revealed that the day shift was responsible for all the showers. She stated that today, all the odd rooms, which are located on the left side of the hall would have been scheduled for a shower. She confirmed that the resident was in an odd number room, so he should have got a shower on the 7-3 shift today. She confirmed that the facility doesn't have a shower team. The day shift aide assigned to Resident #39 would have been responsible for his shower. She confirmed that Resident #39 did have long facial hair and that he needed to be shaved. She stated, He can tell you if he had a shower today, he knows. If he tells you that he didn't get a shower today, then he didn't. On 5/22/23 at 4:15 PM, an observation and interview with the DON confirmed that Resident #39 had not been showered or shaved and that today was the residents shower day. She revealed the resident should have been showered and shaved today. Record review of Resident #39's Activities of Daily Living (ADL's) revealed under, Reason not bathed dated 5/22/23 and timed 11:45 AM documentation recorded, No. Record review of Physician Orders revealed the facility had a total of 26 residents requiring the use of a total lift and two (2) staff members for transfers. The facility provided documentation on letterhead dated 5/24/23 with the attached census, highlighting a total number of 16 residents, which require two (2) person physical assistance for most of their activities of daily living (ADL's). The facility provided documentation on letterhead dated 5/24/23 with the attached census, highlighting a total number of 17 residents, which require staff assistance to be fed.