Based on the record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 4 of 60 days (12/7/24, 12/24/24, 1/3/25, and 1/28/25) reviewed for staffing. Findings included: Review of the facility's daily staff posting and staffing schedules from 12/1/24 through 1/28/25 revealed the following: a.) On 12/7/24 the daily staff posting indicated daily census of 67 and 1 RN working for both evening shift (3PM - 11 PM) and night shift (11 PM to 7 AM). Review of the staffing schedule revealed there was no RN working on any shift that day. b.) On 12/24/24 the daily staff posting indicated daily census of 65 and 1 RN working for both evening shift (3PM - 11 PM) and night shift (11 PM to 7 AM). Review of the staffing schedule revealed there was one RN working from 7 PM to 12 PM, which was for 4 consecutive hours that day. c.) On 1/3/25, the daily staff posting and staffing schedule indicated the daily census of 62 and 0 (zero) RN on duty. d.) On 1/28/25, the daily staff posting and staffing schedule indicated daily census of 67 and 0 (zero) RN on duty. During an interview on 1/30/25 at 12: 00 PM, the Scheduler indicated she had included the Minimum Data Set (MDS) nurses and Assistant Director of Nursing (ADON) as RN for the day. There were RNs available in the facility but were not on the cart or assigned to the residents. During an interview on 1/30/25 at 12:18 PM, the Director of Nursing (DON) stated she overlooked the daily staffing schedule to ensure the staff were properly scheduled for the day. There was no difference in the number of staff scheduled for weekdays or weekends. Staffing was based on census and acuity of the resident. The DON indicated the scheduler was in constant contact with the DON related to staffing. The DON stated she does not review the Payroll Based Journal (PBJ) report to ensure there was an RN working 8 consecutive hours a day for 7 days. The Administrator reviews and submits the PBJ report. The DON stated she was only assigned to work on the medication cart when needed which was very rare and the facility was unable to find an RN to work the shift. During an interview on 1/30/25 at 12:45 PM, the Administrator indicated that he does the validation and submission of PBJ report to Center for Medicare and Medicaid (CMS). The DON and the scheduler work closely to ensure adequate staff and RN for 8 consecutive hours/ day were available for patient care. The staffing was based on the census and acuity of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to revise a care plan intervention for 1 of 2 sampled residents (Resident #26) reviewed for range of motion. The findings included: Resident #26 was admitted to the facility on [DATE] with diagnoses that included right hand contracture and right hemiplegia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #26's cognition was impaired and he had range of motion impairment on one side. Review of Resident #26's care plan dated 6/10/22 revealed a problem that sated resident required supervision to total assistance with Activities of daily living related to Dementia and impaired mobility secondary to Cerebral Vascular Accident with right hemiparesis. The goals stated he would have his needs met by staff and would participate as able. The interventions were not updated to include Resident #26's splinting device. A review of Occupational Therapy discharge recommendation dated 6/17/22 indicated Resident #26 was to have range of motion to wrist, digits, and thumb prior to donning splint and have patient wear splint for 4 hours every day. An interview was conducted with the Rehab Director on 8/17/22 at 9:46 AM. The Rehab Director explained that Resident #26 received therapy for splinting and once released from therapy, training was conducted with the nursing staff. The Rehab Director further explained therapy gave their recommendations to the nursing staff and MDS staff on a form in everyday language which included directions for wearing the splint. An interview with the MDS Coordinator #2 on 8/17/22 at 1:39 PM revealed she was made aware of devices through a form from therapy and was also in-serviced along with nursing floor staff. She further revealed splinting would be included in care planning and added under the Activities of Daily Living (ADL) interventions, however for Resident #26 it was missed. An interview with MDS Coordinator #1 on 8/17/22 at 1:43 PM revealed splinting and skin integrity checks should be on the care plan, however it was not on Resident #26's care plan. She further revealed when the overall update of the annual care plan was completed splinting was not added to the care plan. An interview was conducted with the Director of Nursing (DON) on 8/18/22 at 10:33AM, The DON indicated the care plan interventions should have been revised to reflect Resident #26's splinting and staff education needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident, and staff interviews the facility failed to anchor an indwelling urinary catheter for 1 of 1 resident reviewed for indwelling urinary catheters (Resident #54). The findings included: Resident #54 was admitted to the facility on [DATE] with multiple diagnoses including acute kidney injury, retention of urine, and chronic kidney disease. Review of the physician's order dated 06/16/22 indicated staff were to ensure the urinary catheter was anchored to resident's inner thigh and ensure the urinary catheter was anchored at a level below the resident's bladder. The most recent Minimum Data Set (MDS) for significant change in status assessment dated [DATE] indicated Resident #54 to be cognitively intact and totally dependent on bed mobility, transfer, dressing, toilet use, and personal hygiene. The resident was coded as having an indwelling urinary catheter. The Care Area assessment dated [DATE] noted a focus area of indwelling urinary catheter which was to be addressed in the care plan. Review of the care plan dated 07/22/22 revealed Resident #54 to have a focus area for the potential of complications and infection related to indwelling urinary catheter and closed drainage system. The goal indicated Resident #54 would not develop urinary tract infections related to urinary catheter use and drainage bag would remain patent. Interventions included do not allow drainage tube to be become kinked or coiled causing obstruction flow of urine and to anchor the urinary catheter to leg per facility policy to prevent pulling on the urinary catheter during movement by resident or staff. An observation on 08/17/22 at 8:17 AM revealed the Treatment Nurse turning Resident #54 on her side. The urinary catheter tubing was observed to have not been anchored to her thigh. An additional observation on 08/17/22 at 9:51 AM revealed Resident #54 to be lying in bed and was in the process of being transferred by 2 Nursing Assistants (NA #1 and NA #2). NA #1 and NA #2 were observed to lift resident's left leg up, which revealed the urinary catheter was not anchored to Resident #54's thigh. NA #1 was interviewed on 08/17/22 at 10:01 AM. She stated she was trained on urinary catheter care which included placement of the urinary catheter, cleaning the urinary catheter, and anchoring the urinary catheter. She indicated residents who had urinary catheters should have their urinary catheter below their bladder as well as the urinary catheter should be anchored to their inner thigh. She stated Resident #54's urinary catheter was not anchored to her inner thigh and did not know why it was not anchored. She did not indicate where the urinary catheter anchoring device was located. An interview with NA #2 on 08/17/22 at 10:05 AM revealed she was assigned to work with Resident #54 and had not worked with Resident #54 in the past. She indicated she was trained on urinary catheter care which included placement of the urinary catheter, cleaning the urinary catheter, and anchoring the urinary catheter. She stated Resident #54's urinary catheter was not anchored to her thigh nor was it anchored to her thigh when she arrived to start her shift. She further indicated Resident #54's urinary catheter should have been anchored to ensure the catheter did not get pulled. An interview with Resident #54 on 08/17/22 at 12:40 PM revealed she had gotten the urinary catheter during her last hospital stay. She indicated the reasoning for her urinary catheter was because she had urinary retention. She stated she had never had a urinary catheter anchoring device since she had resided at the facility. She indicated the urinary catheter had been tugged in the past by a facility staff member, but it did not cause discomfort. Nurse #1 was interviewed on 08/17/22 at 1:14 PM which revealed she was familiar with Resident #54's urinary catheter care needs. She indicated to prevent pulling of the urinary catheter, the urinary catheter needed to be anchored to the resident's thigh. She indicated it was important to prevent pulling on the urinary catheter as this may cause bleeding, discomfort, and pain. She further stated she always checked residents with urinary catheters to ensure the urinary catheter was anchored to their inner thigh. She indicated she thought Resident #54 had a urinary catheter anchoring device on her inner thigh. She stated she did not know why Resident #54 did not have a urinary catheter anchoring device on. An interview with the Assistant Director of Nursing (ADON) on 08/17/22 at 1:51 PM revealed Resident #54 did not have her urinary catheter anchored to her thigh because the previous anchoring device had fallen off. She stated they had placed another one on after the surveyor's observation 08/17/22 on Resident #54's left upper thigh. She indicated she did not know when the previous one had fallen off. An interview with the Director of Nursing (DON) on 08/17/22 at 1:35 PM revealed urinary catheter anchoring devices were placed on residents who had urinary catheters to prevent excessive tension and pulling of the urinary drainage tubing. She stated standing physician orders included ensuring the urinary catheter was anchored to the resident's thigh. She indicated if the urinary catheter anchoring device falls off or gets soiled, a NA or Nurse can go to the supply room to retrieve another one.