**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the staff and Medical Doctor (MD) the facility failed to notify the physician of a newly identified open area on the right heel resulting in a delay in treatment for wound that developed signs of infections for 1 of 3 residents reviewed for notification (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes mellitus, and peripheral vascular disease. Resident #3 was discharged to the community on 08/29/22. Review of the admitting 3-day skin assessments for Resident #3 revealed on 08/09/22 and 08/10/22 Nurse #1 documented a blanchable open area was present on the right posterior heel. On 08/11/22 Nurse #2 documented a blanchable open area was present on right posterior heal. Review of Resident #3's medical records revealed no evidence or documentation the Medical Doctor (MD) or Nurse Practitioner (NP) were notified of the open area on the right heel identified on the admitting skin assessments. Review of the document titled; Weekly Pressure Wound Observation Tool dated 08/18/22 revealed the MD or NP were notified on 08/18/22 of an unstageable pressure ulcer (a wound obscured by dead tissue) on the right heel of Resident #3. Treatment orders were provided, and the note indicated the wound was acquired on 08/09/22. Review of the Wound Care NP progress note revealed on 08/18/22 an initial exam of Resident #3's right heel identified an unstageable pressure ulcer measured 2.9 cm in length and 3 cm in width and 0 cm in depth. Treatment orders were to clean the area with normal saline and apply a debriding ointment and cover with a silicone foam dressing every day and as needed. Review of the Wound Care NP progress note dated 08/25/22 revealed the size of right heel pressure ulcer increased and measured 3.9 cm in length and 3 cm in width and 0.3 in depth with 80 % slough (moist non-viable tissue). The Wound Care NP recommended antibiotics and noted the reason as being increased drainage, odor, pain, and redness. During an interview on 11/01/22 at 2:43 PM the Wound Care Nurse revealed she first saw Resident #3's wound on 08/17/22 and described it as an unstageable pressure ulcer with eschar (scab like dead skin either black, brown, or tan in color). She cleaned the wound and covered it with a dressing and notified the Wound Care NP who saw Resident #3 right heel wound on 08/18/22. The Wound Care Nurse confirmed there were no treatments in place for an open area identified on the admitting skin assessments done on 08/09/22, 08/10/22, and 08/11/22. During an interview on 11/01/22 at 4:22 PM Nurse #1 confirmed he documented the skin assessments for Resident #3 on 08/09/22 and 08/10/22. Nurse #1 revealed he didn't verbally report Resident #3 had an open area on the right heel to the MD or NP. Nurse #1 stated the Wound Care Nurse reviewed the weekly skin assessments therefore he didn't report the open area on Resident #3's right heel. An interview was conducted on 11/02/22 at 11:22 AM with the MD. The MD revealed the skin assessments done on 08/09/22, 08/10/22, and 08/11/22 identified an open area on the right heel he would expect the nurse to notify the physician, or the NP to obtain treatment orders. The MD revealed a delay in treatment would put Resident #3 at risk for developing an infection if the area on the right heel was left untreated. During an interview on 11/02/22 at 1:56 PM Nurse #2 confirmed she documented the skin assessment on 08/11/22. Nurse #2 revealed she didn't report an open area on heel of Resident #3 because there were 2 previous assessments prior to hers and the physician should've already been notified with treatment orders in place. An interview was conducted on 11/03/22 at 3:08 PM with the Director of Nursing (DON). The DON revealed she expected Nurses to notify the Wound Care Nurse, her, and the MD or NP to ensure concerns related to the skin weren't missed and the area was evaluated right away. The DON revealed after her review of the admitting skin assessments she couldn't find any evidence to support the open area to the right heel was reported or a treatment was in place prior to 08/18/22. During an interview on 11/03/22 at 3:31 PM the Administrator revealed the process in place if the Nurse finds something abnormal during a resident's skin assessment, they need to call either the on-call or inform NP or MD so treatment orders can be put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the staff, the Wound Care Nurse Practitioner, and Medical Doctor the facility failed to provide necessary care and services for a newly identified open area on the right heel and failed to accurately complete the weekly skin assessment and shower audit tool for an existing wound on the right heel that developed signs of infection for 1 of 3 residents reviewed for pressure ulcers (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses including dementia, diabetes mellitus, and peripheral vascular disease. Resident #3 was discharged to the community on 08/29/22. Review of the admitting 3-day skin assessments for Resident #3 revealed on 08/09/22 and 08/10/22 Nurse #1 documented a blanchable open area was present on the right posterior heel. On 08/11/22 Nurse #2 documented a blanchable open area was present on right posterior heal. Review of the bathing records revealed on 08/12/22 Nurse Aide #1 initialed the shower audit tool to indicate Resident #1 received a bed bath and documented the skin was intact and good. Review of Resident #3's weekly skin assessment revealed on 08/15/22 Nurse #3 documented the skin was intact. Review of the admission Minimum Data Set (MDS) dated [DATE] assessed the cognition of Resident #3 as being moderately impaired and indicated extensive assistance was needed with bed mobility, transfers, and toilet use. The MDS indicated Resident #3 was at risk but did not have any unhealed pressure ulcers or other skin conditions and treatments included a pressure reducing device for the bed and chair. Review of a progress note dated 08/17/22 revealed the Wound Care Nurse documented Resident #3 was notified of treatment orders and a plan of care for the right heel. The treatment was to apply an antiseptic solution of povidone-iodine and cover with a silicone foam dressing and scheduled to be changed three times a week and as needed when soiled or dislodged for a deep tissue injury (non-blanchable, darkly pigmented skin resulting from prolonged pressure). Review of the document titled; Weekly Pressure Wound Observation Tool signed by the Wound Care Nurse revealed on 08/18/22 the Medical Doctor (MD) or alternate was notified, and the current treatment in place was to clean the right heel with normal saline and apply a nickel thick amount of a debriding ointment (removes dead tissue) to the wound bed and cover with a silicone foam dressing. The treatments were scheduled to be changed daily and as needed. An air mattress and heel boots were recommended to offload pressure. The documentation indicated this was the first observation of a pressure ulcer that was present on admission on [DATE] and currently measured 2.9 centimeter (cm) in length and 3.2 cm in width and 0 cm in depth with a moderate amount of bloody drainage. Review of the Wound Care Nurse Practitioner (NP) progress note revealed on 08/18/22 the initial exam of Resident #3's right heel identified an unstageable pressure ulcer (a wound obscured by dead tissue) measuring 2.9 cm in length and 3 cm in width and 0 cm in depth. The Wound Care NP recommended to clean the area with normal saline and apply a debriding ointment and cover with a silicone foam dressing every day and as needed. Review of the care plan initiated on 08/18/22 identified Resident #3 had the potential for pressure ulcer development related to limited physical mobility, diagnosis of dementia, and diabetes mellitus. Interventions included skin assessments per protocol or Medical Doctor order and report any skin changes or abnormalities. Review of the Wound Care NP progress note dated 08/25/22 revealed the size of right heel pressure ulcer increased to 3.9 cm in length and 3 cm in width and 0.3 in depth with 80 % slough (moist non-viable tissue). The Wound Care NP recommended antibiotics and noted the reason as being increased drainage, odor, pain, and redness. Review of the NP progress note dated 08/25/22 revealed Resident #3 was evaluated for a right heel wound. The note revealed the Wound Care NP reported increased redness and slough with signs of possible infection. The note revealed Resident #3 had no increased pain associated to the worsening wound and remained afebrile (no fever). A wound culture and pain management were ordered. Review of the wound culture report revealed on 08/26/22 a culture was collected. The report revealed the lab received and reported the results on 08/31/22 the specimen was out of stability and no culture was obtained. An interview was conducted on 11/01/22 at 2:43 PM with the Wound Care Nurse. The Wound Care Nurse revealed she first saw Resident #3's wound on 08/17/22 and described it as an unstageable pressure ulcer with eschar (scab like dead skin either black, brown, or tan in color). She cleaned the area and covered it and notified the Wound Care NP. The Wound Care NP assessed Resident #3's pressure ulcer and provided treatment orders on 08/18/22. The Wound Care Nurse confirmed no treatment orders were in place when the wound was first identified on the admitting skin assessments on 08/09/22, 08/10/22, and 08/11/22. During an interview on 11/01/22 at 4:22 PM Nurse #1 confirmed he documented the skin assessments for Resident #3 dated 08/09/22 and 08/10/22. Nurse #1 revealed he didn't verbally report Resident #3 had an open area on the right heel and stated he documented the results on the skin assessments. Nurse #1 stated the Wound Care Nurse reviewed the weekly skin assessments therefore he didn't report the open area on Resident #3's right heel. A second interview was conducted on 11/02/22 at 12:52 PM with the Wound Care Nurse. The Wound Care Nurse revealed she did not review weekly skin assessments for residents unless a concern was communicated to her then she would and physically looked at the area. The Wound Care Nurse revealed when she became aware of the area on the right heel and after reviewing Resident #3's skin assessments she determined the wound was present upon admission. During an interview on 11/02/22 at 1:56 PM Nurse #2 confirmed she documented the skin assessment dated [DATE]. Nurse #2 revealed she would've reported her findings to the Wound Care Nurse but since Resident #3 was admitted on [DATE] and there were 2 previous assessments prior to hers she assumed treatment orders were in place. Nurse #2 revealed she checked treatment orders when she identified an open area on a Resident's skin and if not in place would notify the Wound Care Nurse. When informed no treatments were in place until 08/18/22 Nurse #2 stated something was missed. An interview was conducted with Nurse #3 on 11/02/22 at 9:52 AM. Nurse #3 confirmed she documented the weekly skin assessment for Resident #3 indicating the skin was intact on 08/15/22. Nurse #3 stated she was unsure if the skin was intact since the previous assessments identified an open area on the right heel. Nurse #3 stated she would report to the Unit Supervisor or Wound Care Nurse if a resident had an open area on the heel or skin. An interview was conducted on 11/02/22 at 11:22 AM with the Medical Doctor (MD). The MD revealed Resident #3 was at risk for the development of pressure ulcers due to predisposing diagnoses including peripheral vascular disease. The MD revealed a delay in treatment would put Resident #3 at risk for developing an infection if an open area on the right heel was identified upon admission and left untreated. An interview was conducted on 11/02/22 at 3:13 PM with Nurse Aide (NA) #1. NA #1 confirmed she documented the shower audit sheet dated 08/12/22 indicating Resident #3's skin was intact and good. NA #1 revealed she documented the skin was good on 08/12/22 meaning there were no open areas or nothing new on the skin she hadn't previously observed. NA #1 stated she would report to the nurse when she identified an open area on the skin. A second interview was conducted on 11/03/22 at 8:04 AM with Nurse #1. Nurse #1 didn't recall providing a treatment to the right heel of Resident #3. Nurse #1 stated he could only recall doing the necessary paperwork for the skin assessment. During an interview on 11/03/22 at 10:40 AM the Wound Care NP revealed her first assessment on 08/18/22 Resident #3 had an unstageable pressure ulcer on her right heel. Resident #3 denied pain to area and there was no odor to indicate infection. On her next visit on 08/25/22 the pressure ulcer presented with increased redness, slough, and had an odor. With Resident #3 having pain to the area and the other changes she noted those were signs of an infection. The Wound Care NP revealed she couldn't say how long the wound was present but if an open area on the right heel was identified on the admission skin assessments and the area was left uncovered or without treatments in place that would increase the risk of a pressure ulcer becoming infected. An interview was conducted on 11/03/22 at 3:08 PM with the Director of Nursing (DON). The DON revealed she expected Nurses to notify the Wound Care Nurse, her, and the MD or NP to ensure concerns related to skin weren't missed and the area was evaluated right away. The DON revealed after her review of the admitting skin assessments she couldn't find any evidence to support the open area to the right heel was reported or a treatment was in place prior to 08/18/22. During an interview on 11/03/22 at 3:31 PM the Administrator revealed the process in place if the Nurse finds something abnormal during a resident's skin assessment, they need to call either the on-call physician or inform NP or MD so treatment orders can be put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #13 was admitted to the facility on [DATE] with diagnoses which included anxiety and depression. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #13 was cognitively intact and required physical assistance with one staff for bathing and transfers. An observation conducted on 11/15/21 at 10:35 AM revealed Resident #13's hair appeared to be oily and unbrushed. An interview conducted with Resident #13 on 11/15/21 at 10:37 AM revealed staff stated to Resident #13 showers and baths were being missed due to staff quitting. Resident #13 further revealed her shower schedule was on Tuesday and Fridays but rarely received a bed bath or shower on her scheduled days. Resident #13 indicated she felt dirty and was embarrassed that her hair was oily and nasty. An interview conducted with Nurse Aide (NA) #1 on 11/18/21 at 10:55 AM revealed Resident #13's showers had been missed due to staff shortages for the last four to five months. NA #1 indicated Resident #13 needed limited assistance with showers and transfers. NA #1 indicated Resident #13 had complained about missing showers and Resident #13 had stated she felt dirty and unclean. An Interview with the Director of Nursing (DON) on 11/19/21 at 3:32 PM revealed she would like for all residents to get showers at least 2 times each week. The DON further she felt like showers had not been provided as scheduled due to staffing. The DON revealed she could not recall if Resident #13 had missed showers or baths, but indicated many residents had. 3. Resident #50 was admitted to the facility on [DATE] with diagnoses which included anxiety and depression. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #50 was cognitively intact and was totally dependent with two person staff assistance for bathing and transfers. An observation was conducted on 11/15/21 at 10:35 AM revealed Resident #50's hair appeared to be disheveled with white flakes throughout the hair. An interview conducted with Resident #50 on 11/15/21 at 10:40 AM revealed staff had stated to Residents #50's scheduled showers had been missed due to a shortage of staff the last few months. Resident #50 indicated she felt uncomfortable and dirty when her scheduled shower days were missed. An interview conducted with Nurse Aide (NA) #1 on 11/18/21 at 10:55 AM indicated Resident #50 required extensive assistance and there had not been staff to assist with Resident #50's showers. NA #1 further revealed Resident #50 had complained about not receiving a shower or bath on scheduled days and indicated she felt dirty and was mad. An interview conducted with direct care Nurse #1 on 11/18/21 at 2:44 PM revealed scheduled showers and baths had been missed due to not having enough staff. Nurse #1 stated Resident #50 had complained about not receiving a shower or bath on schedule days and Resident #50 stating she felt gross and dirty. An Interview with the Director of Nursing (DON) on 11/19/21 at 3:32 PM revealed she would like for all residents to get showers at least 2 times each week. The DON further she felt like showers had not been provided as scheduled due to staffing. The DON revealed she could not recall if Resident #50 had missed showers or baths, but indicated many residents had. Based on record reviews, observations, staff interviews, and resident interviews, the facility failed to maintain residents' dignity by not providing showers, bathing, and incontinence care resulting in residents feeling like a homeless person, like staff did not like them, dirty and embarrassed, uncomfortable, and dirty. This affected 3 out of 6 (Resident #27, Resident #13, and Resident #50) sampled residents. 1. Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included coronary artery disease, congestive heart failure, hypertension, chronic respiratory failure, and diabetes mellitus type II. Review of Resident #27's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact for daily decision making, had no behaviors for refusal of care, and required total assistance of 2 staff for bathing and toileting. Observation and interview on 11/15/21 at 2:38 PM of Resident #27 revealed her lying in bed in her room watching her TV. Resident #27 expressed concerns about not being provided incontinence care until she had wet through her clothing down to her knees and wet the linens on her bed. Resident #27 stated just yesterday on 11/14/21 she had been told by Nurse Aide (NA) #3 she would have to wait for care until NA #3 completed her charting. She stated she had a shower yesterday and it was the first one she had in 3 weeks. Resident #27 further stated her hair was matted to her head and she could smell her own body odor and it made her feel degraded and like a homeless person. Resident #27 indicated there was not enough staff at the facility to properly care for the residents and make sure their needs were met. Resident #27 revealed it made her feel like the NAs did not like her or like taking care of her because of her size and she depended on them for her care. Observation on 11/17/21 at 2:42 PM of incontinence care on Resident #27 revealed the resident in bed with brief on with large amount of urine in the brief. NA #3, with gloved hands, cleaned the resident and applied a new brief. Resident #27 requested her draw sheet be changed because she could feel on her legs that it was wet. NA #3 felt of the draw sheet with gloves on and the resident said to her you can't feel the wetness with gloves on. NA #3 proceeded to change the draw sheet and then took the dirty linens and trash out of the room. Resident #27 then said to the surveyor NA #3 would not have changed my draw sheet if you had not been in here. Interview on 11/17/21 at 3:58 PM with NA #3 revealed she frequently worked from 7:00 AM to 3:00 PM or 7:00 AM to 7:00 PM on Resident #27's hall. NA#3 stated she had worked on 11/14/21 and recalled telling Resident #27 she would be right with her as soon as she finished charting on another resident. She stated she did not want to get in trouble for not getting her charting done and sometimes it was hard when you had so many residents to provide care. NA #3 further stated she probably should not have said that to Resident #27. NA #3 indicated she should not have tried to feel wetness on the resident's draw sheet and should have just changed it as the resident requested. NA #3 further indicated she was usually only able to provide 2 incontinence rounds to the residents in an 8-12-hour shift and said it was difficult to do more. Interview was conducted on 11/18/21 at 11:16 AM with NA #1 who worked 7:00 AM to 3:00 PM most of the time and sometimes stayed over to 7:00 PM to help cover the schedule. NA #1 stated had cared for Resident #27 and said it was difficult with 18 to 20 residents to get incontinence care done every 2 hours. NA #1 further stated they did the best they could and worked together to provide incontinence care to residents that require 2 staff. NA #1 indicated it was hard to do residents that require 2 staff every 2 hours because you had to wait until someone was available to assist with care. NA #1 revealed Resident #27 required 2 staff to transfer her in and out of bed but once in the shower room she could be assisted by one staff member. NA #1 stated there were only 2 NAs on the hallway and they usually had 18 or more residents each and it was difficult to do showers because it left only one NA on the hall to answer call lights and provide care. NA #1 further stated residents had not been receiving their showers as scheduled because it was all they could do to keep them clean, dry, and safe. Interview was conducted on 11/18/21 at 11:16 AM with NA #2 who worked 7:00 AM to 3:00 PM most of the time and sometimes stayed over to 7:00 PM to help cover the schedule. NA #2 stated had cared for Resident #27 and said it was difficult with 18 to 20 residents to get incontinence care done every 2 hours and sometimes were only able to complete care 2 times a shift. NA #2 further stated they did the best they could and worked together to provide incontinence care to residents that require 2 staff. NA #2 indicated it was hard to do residents that require 2 staff every 2 hours because you had to wait until someone was available to assist you with the care. NA #2 further indicated the nurses were not always able to assist you because they were busy with their duties, and you just had to wait on someone. NA #2 revealed Resident #27 has missed showers and bed baths due to the workload of the NAs. NA #2 stated Resident #27 required 2 staff to get her on the shower bed and into the shower room which took both NAs off the floor for a period of time. NA #2 further stated when she was in the shower the NA assigned to her had to remain with her through the entire shower which left only one NA on the floor for the rest of the 30 plus residents. NA #2 indicated it was impossible to get all the showers done due to staffing. Interview on 11/19/21 at 3:32 PM with the Director of Nursing revealed she expected residents to receive incontinence care at least every 2 hours and as needed. The DON stated she knew there were staffing concerns and they were working on trying to hire more staff and were offering sign on bonuses to try to recruit staff and using agency staff. She further stated if staff were having difficulties providing care, she would expect them to ask the nurses or administrative nurses for assistance. The Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to protect a resident right to be free from abuse (Resident #55) from Nurse Aide (NA) #8 for 1 of 3 residents reviewed for abuse. The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses which included anxiety, depression, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #55 was severely cognitively impaired and was totally dependent for majority of activities of daily living (ADL). The MDS further revealed Resident #55 was coded for physical and verbal behaviors directed toward others 1 to 3 days a week through the look back period. Review of the incident report dated 8/28/21 revealed Resident #55 was witnessed getting struck in the stomach by nursing staff during care. Resident #55 did not observe to sustain any injuries after the incident. Review of the investigation completed by the Administrator related to Resident #55's incident revealed the following: - Nurse Aide (NA) #5 statement dated 8/28/21 read in part, NA #8 and I went into Resident #55's room to change him and his bed sheets. While NA #8 and I were changing Resident #55 he began to curse and hit NA #8. NA #8 then slapped Resident #55 on his stomach, and Resident #55 continued to hit NA #8. I then turned around to grab Resident #55 pillow and heard NA #8 get loud with Resident #55 and hit Resident #55 again and when I turned around NA #8 hand was balled in a fist. - Nurse Aide (NA) #8 statement dated 8/28/21 read in part, I went into Resident #55's room to change him with NA #5. Resident #55 was soaked so we had to do a complete bed change and change Resident #55's shirt. Resident #55 was fine the first half then as we had to keep rolling Resident #55, he got more and more aggravated cussing and grabbing at stuff. Resident #55 grabbed my left arm and dug his fingernails in my skin. Before he could break skin, I grabbed his hand to remove it and I got my flat hand pushed it away. Resident #55 grabbed me on my left arm, and I grabbed his hand with my right hand to pull it off then turned my wrist to finish pushing his hand away towards his stomach. I think in the moment I might have had a little too much force and accidently with flat hand barely popped Resident #55 in the belly. I was blocking then Resident #55 punched me in the right arm and I finished fastening his brief, pulled blanket up, grabbed dirty linen and trash, and walked out. - Review of investigative actions dated 8/28/21 revealed employment actions taken was NA #8 was asked to not return to the facility. The facility notified the Medical Director, resident's responsible party, and suspended identified potential suspected perpetrator until investigation was complete. A phone interview conducted with Nurse Aide (NA) #5 on 11/22/21 at 3:10 PM revealed she and NA #8 was giving care to Resident #55 and Resident #55 became aggravated and combative. NA #5 observed NA #8 slapped Resident #55 in the stomach with the back side of her hand and it made a popping sound. NA #5 indicated Nurse #8 continued to give care and shouted to Resident #55 in a loud tone to stop. NA #5 revealed Resident #55 had quit being combative at this time and NA #5 turned her back away from Resident #55 to get a sheet and heard a pop sound and turned to find NA #8 fist balled up like she had punched the resident. NA #5 and NA #8 completed care and left Resident #55's room. NA #5 stated she was training with NA #5 and was educated by other staff members if Resident #55 was combative to step away. NA #5 indicated she was in shock when NA #8 struck at Resident #55 during care and did not know what to do. NA #5 stated she reported the incident to Nurse #8 immediately after leaving the Resident #55 room. A phone interview conducted with NA #8 on 11/19/21 at 10:20 AM revealed she had worked with Resident #55 multiple times and was aware he could be combative during care. It was further revealed NA #8 and NA #5 was giving care to Resident #55 and he became aggravated slapping at NA #8. NA #8 put up her arm blocking Resident #55 and pushed it away. NA #8 indicated Resident #55's arm could have swung back and hit him but could not recall. NA #8 revealed she continued to give care and Resident #55 grabbed NA #8 arm and NA #8 jerked away. NA #8 revealed she jerked away but denied hitting or speaking to Resident #55 in a loud tone. Na #8 indicated she was educated by upper management if Resident #55 had become combative or agitated to rush through care. NA #8 stated he had a bad day and was aggravated but denies hitting or speaking to Resident #55 in a loud tone. An interview conducted with Nurse #8 on 11/19/21 at 11:40 AM revealed NA #5 reported that NA #8 was frustrated when giving care to Resident #55 because the resident had become combative. Nurse #8 further revealed NA #5 witnessed NA #8 hit Resident #55 in the stomach and when NA #5 had turned away and turned back NA #8 had her fist in a ball. Nurse #8 indicated Resident #55 was sometimes combative, but nursing staff was educated to step away and let Resident #55 calm down. Nurse #8 completed a body check and checked for markings all over Resident #55 and did not observe any marks or bruises. Nurse #8 stated she contacted the DON right after the incident occurred. An interview was conducted with the Director of Nursing (DON) on 11/19/21 at 2:53 PM revealed Nurse #8 contacted her right after the incident occurred, and the DON contacted the Administrator immediately. The DON indicated Resident #55 was combative at time with care, but nursing staff was educated to step away to deescalate the situation. The DON further revealed she had no prior issues with NA #8 and feels that she did not hit Resident #55. An interview conducted with the Administrator on 11/19/21 at 1:08 PM revealed Resident #55 could be combative during care, but staff was educated to stay calm and back away if they need too. It was further revealed when the incident was reported by the DON she immediately went to the facility to investigate. The Administrator indicated she spoke to all staff involved and did not substantiate because it was he said she said, and Resident #55 sustained no injuries. The Administrator revealed NA #8 was asked to not come back and work until the investigation was over.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #13 was admitted to the facility on [DATE] with diagnoses which included hypertension and hyperlipidemia. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #13 was cognitively intact and required physical assistance of one person for bathing and transfers. Review of the shower schedule revealed Resident #13 was scheduled for showers on Tuesday and Fridays during evening shift. Resident #13's shower schedule for October and November 2021 revealed a shower or bath was not documented as given on 10/1/21, 10/5/21, 10/12/21, 10/19/21, 10/22/21, 11/5/21, and 11/12/21. An observation was conducted on 11/15/21 at 10:35 AM revealed Resident #13 hair appeared to be oily and unbrushed. An interview conducted with Resident #13 on 11/15/21 at 10:37 AM revealed multiple showers had been missed the last two months due to staff quitting. Resident #13 further revealed her shower schedule was on Tuesday and Fridays but stated she rarely received a bed bath or shower on her scheduled days. An interview conducted with Nurse Aide (NA) #2 on 11/18/21 at 1:32 PM revealed there has not been enough staff to complete showers as scheduled in the past few months. NA #2 further revealed they had worked evening shifts multiple times and Resident #13 had not received a shower or bath because there was a staff shortage. NA #2 indicated that showers and baths had been missed often. An interview conducted with Nurse #1 on 11/18/21 at 2:44 PM revealed Resident #13 had never refused showers or care. Nurse #1 further revealed Resident #13's scheduled showers and baths had been missed due to not having enough staff during evening shifts. Nurse #1 stated she had worked evening shifts multiple times and it was hard to give 100% care to the residents in a timely manner. An interview with the Director of Nursing (DON) on 11/19/21 at 3:32 PM revealed she would like for all residents to get showers at least 2 times each week. The DON further revealed if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like showers had not been provided as scheduled due to staffing. 7. Resident #50 was admitted to the facility on [DATE] with diagnosis which included hypertension. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #50 was cognitively intact and was total dependent of two staff for bathing and transfers. Review of the shower schedule revealed Resident #50 was scheduled for showers on Tuesday and Fridays during day shift. Resident #50's shower schedule for October and November 2021 revealed a shower or bath was not documented as given on 10/1/21, 10/5/21, 10/8/21, 10/15/21, 10/19/21, 10/22/21, 10/26/21, and 11/5/21. An observation was conducted on 11/15/21 at 10:35 AM revealed Resident #50's hair appeared to be disheveled and flakey with dandruff. An interview conducted with Resident #50 on 11/15/21 at 10:40 AM revealed most scheduled shower days Resident #50 had not received a bath or shower consistently in several weeks. Resident #50 further revealed she preferred and loved her showers and would never refuse them. Resident #50 indicated scheduled showers had been missed weekly due to shortage of staff. An interview conducted with Nurse Aide (NA) #1 on 11/18/21 at 10:55 AM revealed Resident #50 had never refused care or showers. NA #1 further stated Resident #50's showers had been missed due to staff shortages. NA #1 indicated Resident #50 required extensive assistance and there had not been staff to assist with showers. An interview conducted with Nurse #1 on 11/18/21 at 2:44 PM revealed Resident #50 preferred showers and recalled Resident #50 missing scheduled bath days. Nurse #1 further revealed scheduled showers and baths had been missed due to not having enough staff and would be pushed to the next shift but rarely got done. Nurse #1 stated it was hard to give 100% care to the residents in a timely manner. An interview with the Director of Nursing (DON) on 11/19/21 at 3:32 PM revealed she would like for all residents to get showers at least 2 times each week. The DON further revealed if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like showers had not been provided as scheduled due to staffing. 8. Resident #23 was admitted to the facility 10/21/19 with diagnoses including anemia and non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 was severely cognitively impaired and was totally dependent on staff assistance for bathing. The care plan for activities of daily living (ADL) last updated 09/06/21 revealed Resident #23 had an ADL self-care performance deficit related to activity intolerance and dementia. Interventions included extensive assistance of 1 to 2 staff members with bathing/showering on shower days and as necessary and encouraging Resident #23 to participate to the fullest extent possible with each interaction. An observation of Resident #23 on 11/16/21 at 8:44 AM revealed she was lying in bed with uncombed hair and jagged edges to her fingernails. An observation of Resident #23 on 11/18/21 at 8:42 AM revealed she was lying in bed with uncombed hair. [NAME] material was noted under Resident #23's fingernails and her fingernail edges remained jagged. An observation of Resident #23 on 11/19/21 at 8:29 AM revealed she was in bed feeding herself. Resident #23's hair was uncombed, brown material was noted under her fingernails, and her fingernails had jagged edges. Review of the master shower schedule revealed Resident #23 was scheduled to receive her shower on Tuesdays and Fridays on the 3:00 PM to 11:00 PM shift. Review of bathing documentation for Resident #23 for October 2021 and November 2021 is as follows: October: Partial bed baths were documented as performed 10/22/21, 10/23/21, 10/27/21, 10/28/21. Showers were documented as being provided 10/25/21, 10/26/21, and 10/30/21. November: Partial bed baths were documented as being provided 11/01/21, 11/02/21, 11/04/21, 11/05/21, 11/06/21, 11/07/21, 11/10/21, and 11/11/21. No showers were documented as being provided in November. An interview with Nurse Aide (NA) #7 on 11/17/21 at 3:46 PM revealed when there were only 2 NAs assigned to Resident #23's hall she was unable to get all her showers or nail care done. She stated when she wasn't able to complete the scheduled showers or nail care she notified the nurse on the hall. An interview with NA #2 on 11/18/21 at 1:32 PM revealed when there were only 2 NAs scheduled for Resident #23's hall he was not able to get all his showers or nail care done. He explained that when a partial bed bath was documented that meant the resident received cleaning assistance with the underarm, genitals, and buttock areas. An interview with the Director of Nursing (DON) on 11/19/21 at 3:31 PM revealed if residents were scheduled for 2 showers a week she liked for residents to receive 2 showers a week. She stated staffing was the reason showers were not getting done as scheduled. The DON stated when possible an effort was made to make up a missed shower the next day but that did not always happen. She stated nail care should be done if needed when showers were given. An interview with the Administrator on 11/22/21 at 12:13 PM revealed she was aware of the residents not receiving their showers as scheduled. She explained showers were not getting done due to lack of staff. The Administrator stated staff did make every effort to get showers done when possible. She stated nail care should be performed when showers were done or when needed. 9. Resident #45 was admitted to the facility 10/8/19 with diagnosis including major depressive disorder. A review of the activity of daily living (ADL) care plan revised on 9/29/21 identified Resident #45 as having an ADL self-care performance deficit with the goal to maintain the current level of ADL function through the review date. Interventions included provide limited to extensive assistance by 1 or 2 staff with bathing and/or showering on preferred shower days and as necessary and provide limited assistance with personal hygiene. A review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #45's cognition as being moderately impaired. The MDS assessment of functional status revealed Resident #45 required supervision with 1-person assist with personal hygiene and was totally dependent on staff for bathing. The MDS assessment of behaviors revealed no rejection of care. A review of the shower schedule revealed Resident #45 was scheduled to receive a shower on Sunday and Thursday. The last shower documented was provided by Nurse Aide #2 on 11/14/21. An observation on 11/16/21 at 10:26 AM revealed Resident #45's fingernails on both hands extended approximately 2.5 to 3 centimeters pass the tip of the finger. Resident #45 had several patches of white chin hairs approximately 0.5 to 1 centimeter in length on both sides and underneath the chin. During an interview on 11/16/21 at 10:26 AM Resident #45 revealed her nails needed to be clipped and the patches of hairs on her chin were unwanted. Resident #45 revealed she was able to dress and toilet herself and did not use the call light to ask for help. A second observation on 11/17/21 at 11:06 AM revealed Resident #45's fingernails on both hands extended approximately 2.5 to 3 centimeters pass the tip of the finger. Resident #45 had several patches of white chin hairs approximately 0.5 to 1 centimeter in length on both sides and underneath the chin. A third observation on 11/18/21 at 9:55 AM revealed Resident #45's fingernails on both hands extended approximately 2.5 to 3 centimeters pass the tip of the finger. Resident #45 had several patches of white chin hairs approximately 0.5 to 1 centimeter in length on both sides and underneath the chin. During an interview and observation on 11/18/21 at 9:59 AM Nurse #4 revealed she was responsible for the care of but hadn't noticed Resident #45 patches of chin hairs or long fingernails. Nurse #4 stated the Nurse Aide (NA) should shave chin hairs and clip fingernails during the shower and she tried to get with NA staff to ensure resident care was done. Nurse #4 revealed at times there had been 1 NA on the hall and care was missed. During an interview on 11/18/21 at 2:09 PM NA #2 stated during a shower chin hair would be shaved and nail care done. NA #2 revealed Resident #45 didn't make her needs known to staff and needed to be checked and if chin hairs weren't shaved and fingernails weren't cut, it was missed. NA #2 revealed there were times he and 1 other NA were assigned the unit making it difficult to complete assigned task and check on residents. During an interview on 11/19/21 at 3:32 PM the Director of Nursing (DON) revealed nail care and shaving were supposed to be part of the bathing routine and expected it would be done. The DON revealed she was aware of issues with bathing when short of staff. Based on record reviews, resident, and staff interviews the facility failed to provide showers or complete bed baths for 6 of 18 residents (Resident #27, Resident #26, Resident #81, Resident #82, Resident #13, and Resident #50) and failed to provide nail care and grooming for 3 of 18 residents (Resident #54, Resident #23, and Resident #45) reviewed for activities of daily living (ADL). Resident #27 stated because of not getting her showers, her hair was matted to her head, and she could smell her own body odor and it made her feel degraded and like a homeless person. The findings included: 1. Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included coronary artery disease and congestive heart failure. Review of Resident #27's most recent quarterly MDS dated [DATE] revealed she was cognitively intact for daily decision making, had no behaviors for refusal of care, and required total assistance of 2 staff for bathing. Review of Resident #27's care plan dated 11/11/21 revealed a plan of care for ADL self-care performance deficit related to debility, disease process, fatigue, chronic respiratory failure and pain. The interventions included the resident requires extensive assistance of 2 staff with bathing/showering on preferred shower days and as necessary, the resident requires extensive assistance of 1 staff with personal hygiene and oral care, the resident requires total assistance of 2 staff to move between surfaces as necessary and monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course or declines in function. Observation and interview on 11/15/21 at 2:38 PM of Resident #27 revealed her lying in bed in her room watching her TV. Resident #27 stated she had a shower yesterday and it was the first one she had in 3 weeks. Resident #27 further stated her hair was matted to her head and she could smell her own body odor and it made her feel degraded and like a homeless person. Resident #27 indicated there was not enough staff at the facility to properly care for the residents and make sure their needs were met. Review of the master shower schedule revealed Resident #27 was scheduled for showers on Sunday and Wednesday on 2nd shift (3:00 PM to 11:00 PM or 7:00 PM to 7:00 AM). Review of the documented bathing for Resident #27 August through November 2021 revealed the following: ·August: 08/04/21 (SH), 08/09/21 (SH), 08/19/21 (SH), 08/20/21 (SH) 08/21/21 (BB), 08/24/21 (SH), 08/27/21 (BB) and 08/30/21 (BB) and there were 2 missed showers/bed baths that were not documented as completed. ·September: 09/08/21 (BB), 09/10/21 (SH), 09/28/21 (SH) and 09/30/21 (BB) and there were 6 showers/bed baths that were not documented as completed. ·October: 10/25/21 (SH) and 10/26/21 (BB) and there were 7 missed showers/bed baths that were not documented as completed. ·November: 11/14/21 (SH) and there were 3 missed showers/bed baths that were not documented as completed. Interview on 11/18/21 at 11:16 AM with Nurse Aide (NA) #1 revealed Resident #27 required 2 staff to transfer her in and out of bed but once in the shower room she could be assisted by one staff member. NA #1 stated there were only 2 NAs on the hallway and they usually had 18 or more residents each and it was difficult to do showers because it left only one NA on the hall to answer call lights and provide care. NA #1 further stated residents had not been receiving their showers as scheduled because it was all they could do to keep them clean, dry, and safe. Interview on 11/18/21 at 1:45 PM with NA #2 revealed Resident #27 has missed showers and bed baths due to the workload of the NAs. NA #2 stated Resident #27 required 2 staff to get her on the shower bed and into the shower room which took both NAs off the floor for a period of time. NA #2 further stated when she was in the shower the NA assigned to her had to remain with her through the entire shower which left only one NA on the floor for the rest of the 30 plus residents. NA #2 indicated it was impossible to get all the showers done due to staffing. Interview on 11/18/21 at 3:38 PM with Nurse #1 revealed Resident #27 had missed showers/bed baths due to the number of residents the NAs had to provide care. Nurse #1 stated it was impossible for 2 NAs to do showers, vitals, turning and repositioning and incontinence care for 18-20 residents each and be able to complete their work and documentation. Nurse #1 further stated the nurses were so busy with medications, orders and required charting that it was difficult for them to provide any assistance to the NAs with resident care. Interview on 11/19/21 at 3:32 PM with the Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses which included hypertension, chronic obstructive pulmonary disease (COPD) and chronic pain. Review of Resident #26's most recent admission Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact for daily decision making and displayed no behaviors for refusal of care. The resident's MDS also revealed bathing coded as not being provided; however, the resident required total assistance of 1 to 2 staff members with all ADL except eating. Review of Resident #26's care plan dated 09/28/21 revealed a plan of care for ADL self-care deficit related to activity intolerance, disease process, impaired balance, impaired mobility and generalized weakness. The interventions included the resident required total assistance of 2 staff with personal hygiene, oral care, and bathing, praise all efforts at self-care, monitor/document/report any changes, any potential for improvement, reasons for self-care deficit, expected course or declines in function, encourage resident to participate to the fullest extent possible with each interaction. Review of a wound note dated 11/11/21 written by the wound care Nurse Practitioner (NP) read in part: Treatment recommendations: #1 Moisture associated skin damage (MASD) buttocks bilaterally - instruction: shower 3 times weekly, no brief while in bed. Apply antifungal and skin prep barrier two times daily (bid). Keep buttocks area clean and dry. Recommend no briefs in bed and optimize nutrition. Plan of care discussed with facility staff. Observation and interview on 11/15/21 at 2:09 PM with Resident #26 revealed he was not getting bathed as often as he should and had missed some baths since being admitted to the facility. The resident stated the facility was not equipped with a shower chair or bed to accommodate his size. The facility had told Resident #26 they were looking into getting a shower bed to accommodate his height but said he was not aware a shower bed had been purchased. Observation on 11/17/21 at 10:30 AM with the wound care Nurse Practitioner and wound treatment nurse of Resident #26's area on his buttocks revealed areas on both buttocks that were red and not open. As the resident was turned over there was stool on the resident's skin and on his draw sheet. The NP asked the wound treatment nurse if the resident was due for a shower on 11/17/21 and the wound care nurse responded she did not know but would check the schedule. The NP after removing her gloves and sanitizing her hands put on the resident's call light so he could be cleaned. The NP commented the wounds looked better and seemed to be healing but it was important for staff to keep the area clean and dry. Review of the master shower schedule revealed Resident #26 was scheduled for showers on Tuesdays and Fridays on day shift (7:00 AM to 3:00 PM or 7:00 AM to 7:00 PM). Review of the documented bathing for Resident #26 for September through November 2021 revealed the following: ·September: 09/01/21 shower (SH), 09/07/21 bed bath (BB), 09/08/21 (BB), 09/10/21 (SH), 09/20/21 (BB) and 09/28/21 (SH) and there were 4 missed showers/bed baths that were not documented as completed. ·October: 10/15/21 (BB) and 10/26/21 (BB) and there were 7 missed showers/bed baths that were not documented as completed. ·November: 11/09/21 (BB) and 11/12/21 (BB) and there were 2 missed showers/bed baths that were not documented as completed. Interview on 11/17/21 at 3:58 PM with Nurse Aide (NA) #3 revealed she was not aware Resident #26 had physician ordered showers three times weekly. NA #3 stated Resident #26 received bed baths because he was too long or too tall for the shower bed and was afraid it would not support him in the shower room to get a shower. NA #3 further stated the facility was supposed to be getting another shower bed that would support him so he could get the showers he preferred but said she had not seen it yet. NA #3 indicated it was impossible to get all the showers done with only 2 NAs on the hall. Interview on 11/17/21 at 4:41 PM with NA #4 revealed she was not aware Resident #26 had physician ordered showers three times weekly. NA#4 stated Resident #26 was difficult to get into the shower room and was not comfortable with the shower chair or shower bed the facility currently had for residents. NA #4 further stated Resident #26 was receiving bed baths instead of showers but was only scheduled for 2 per week. NA #4 indicated the facility was supposed to be purchasing a shower bed to accommodate Resident #26 but said it had not been brought to their attention that the bed had been delivered to the facility. She further indicated she was not sure how they would be able to provide Resident #26 3 bed baths or shower per week because it was impossible to get all the showers done with only 2 NAs on the hallway. Interview on 11/18/21 with Nurse #1 revealed she was not aware Resident #26 had physician ordered showers three times weekly. Nurse #1 stated Resident #26 was afraid to get up in the shower chair or onto the shower bed at the facility because he didn't think the chair or bed would support him due to his size. Nurse #1 further stated showers three times weekly were not possible and the NP probably needed to re-evaluate the order. Nurse #1 indicated the staff was having a hard time even getting 2 showers done on residents each week and 3 showers may not be possible especially for Resident #26 because it took 2 staff to provide his bed bath. Interview on 11/19/21 at 3:32 PM with the Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident ' s shower on their scheduled day, she expected the NAs to let the resident know and provide them a make up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions. 3. Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cancer, hypertension, and diabetes mellitus. Review of Resident #54's most recent admission MDS dated [DATE] revealed he was cognitively intact for daily decision making, communicated via a dry erase board, and required extensive to total assistance with all activities of daily living (ADL). Review of Resident #54's care plan dated 10/05/21 revealed a plan of care for ADL self-care performance deficit related to activity intolerance, external devices, fatigue, impaired balance, limited mobility and pain. The interventions included the resident required extensive assistance by 1 to 2 staff with bathing/showering on preferred shower days and as necessary, the resident requires extensive assistance by 1 to 2 staff with personal hygiene and oral care, encourage resident to use bell to call for assistance, resident requires a white board to communicate and ensure availability and functioning of adaptive communication equipment and monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function. Observation and interview on 11/15/21 at 10:47 AM revealed Resident #54 lying in bed with head of bed elevated 45 degrees. The resident was able to shake his head to yes/no questions and mouthed he was not feeling well today. There was a white board with dry erase markers available on his overbed table to enable him to communicate with staff. It was noted he had written on his board I would please like for my fingernails to be trimmed. Observation of his fingernails revealed they were ¼ to ½ inch beyond the end of his fingers. There was a message written across the room on another white board for staff to please provide oral care. Observation and interview on 11/16/21 at 10:34 AM revealed Resident #54 with the message about his fingernails still on his white board and his fingernails remained ¼ to ½ inch beyond the end of his fingers. Resident once again mouthed he was not feeling well today. Interview on 11/17/21 at 3:58 PM with NA #3 revealed had not noticed the message on Resident #54's white board about wanting his fingernails trimmed. NA #1 stated since he had diabetes, the NAs were not allowed to trim his nails but said she had not reported the message to the nurse assigned to the resident. Observation and interview on 11/18/21 at 10:29 AM revealed Resident #54 resting in bed. He mouthed he finally got his nails trimmed and mouthed in a whisper they felt much better since being trimmed. Interview on 11/18/21 at 11:16 AM with NA #1 revealed had not noticed the message on Resident #54's white board about wanting his fingernails trimmed. NA #1 stated since he had diabetes, the NAs were not allowed to trim his nails, but the nurse would be able to trim them. Interview on 11/18/21 at 1:45 PM with NA #2 revealed had not noticed the message on Resident #54's white board about wanting his fingernails trimmed. NA #2 stated would not be able to trim his nails because the resident had diabetes but stated the nurse would be able to trim them. NA #2 further stated had not reported the message on the board to the nurse or noticed the resident's fingernails. Interview on 11/18/21 at 3:38 PM with Nurse #1 revealed she had not noticed the message on his white board about wanting his fingernails trimmed but stated the wound care nurse had brought it to her attention after she saw it and had trimmed his nails. Interview on 11/19/21 at 3:32 PM with the Director of Nursing (DON) revealed nail care was to be provided to residents on shower days and as needed. The DON stated she would have expected someone to have looked at the message on the white board and provided Resident #54 nail care as soon as the note was written. The DON further stated it was her expectation that resident's nails be checked on every shower day and be trimmed and filed as needed or requested. 4. Resident #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included upper end of left humerus fracture, cardiomyopathy, chronic pain, and weakness. The significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #82 had severe impairment in cognition for daily decision making and required total assistance of 1 staff member with bathing. Review of Resident #82's care plans, last reviewed/revised on 11/17/21, revealed a plan of care that addressed an ADL self-care performance deficit related to activity intolerance, fatigue and was at risk for changes and decline in functional status related to the disease process. Interventions included extensive assistance by 1 to 2 staff members with bathing/showering on preferred shower days and as necessary, personal hygiene and oral care, and moving between surfaces as necessary. Review of the master shower schedule revealed Resident #82 was to receive showers on Wednesday and Saturday on the evening shift during the hours of 3:00 PM to 11:00 PM or 7:00 PM to 7:00 AM. Review of the Nurse Aide (NA) bathing documentation reports for Resident #82 for the months of October 2021 and November 2021 revealed the following: • October: Partial bed baths were documented as provided on 10/02/21, 10/03/21, 10/04/21, 10/05/21, 10/07/21, 10/08/21, 10/13/21, 10/14/21, 10/16/21, 10/22/21, 10/23/21, 10/24/21, 10/27/21, and 10/28/21. Showers were documented as provided on 10/11/21, 10/15/21, 10/25/21, 10/26/21, and 10/30/21. • November: Partial bed baths were documented as provided on 11/01/21, 11/02/21, 11/04/21, 11/05/21, 11/06/21, 11/07/21, 11/09/21, 11/10/21, and 11/11/21. Showers were documented as provided on 11/13/21 and 11/17/21. Review of the nurse progress notes for the months of October 2021 and November 2021 revealed no entries related to Resident #82 refusing bathing assistance. During an interview on 11/18/21 at 11:16 AM, NA #1 revealed Resident #82 required staff assistance with bathing needs and on occasion, would refuse to take a shower. NA #1 revealed if the documentation stated partial bed baths were provided that meant he only cleaned the underarms and the genital and buttock areas. NA #1 confirmed resident showers were not being provided as scheduled and explained there were only 2 NAs assigned to Resident #82's hall with 18 or more residents each and it was difficult to do showers because it left only one NA on the hall to answer call lights and provide care. During an interview on 11/18/21 at 1:45 PM, NA #2 stated when there were only 2 NAs assigned to Resident #82's hall with 19 to 20 residents each, he wasn't able to provide resident showers as scheduled. NA #2 revealed he had not provided Resident #82 with a shower during the months of October 2021 and November 2021; however, in lieu of a shower, he provided him with a partial bed bath which he described as lathering with soap and water and washing the hair, face, and neck. NA #2 stated Resident #82 wanted to take a shower and would be cooperative with taking one if the NAs had time to provide. During an interview on 11/19/21 at 3:32 PM, the Director of Nursing (DON) revealed she would like for all residents to get showers at least 2 times each week. The DON stated if staff were not able to complete the resident's shower on their scheduled day, she expected the NAs to let the resident know and provide them a make-up shower on the next shift or the next day. The DON indicated she felt like the showers were not being provided as scheduled due to staffing. She further indicated they were offering a competitive salary with sign on bonuses but were not getting a lot of candidates for open positions. 5. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses that included Parkinson's disease, osteomyelitis of the left ankle and foot, chronic pain, contracture of muscle-multiple sites, and diabetes. Review of Resident #81's care plans, last reviewed/revised on 09/01/21, revealed a plan of care that addressed an ADL self-care performance deficit related to activity intolerance, Parkinson's disease, impaired balance and limited mobility. Interventions included extensive assistance by 1 to 2 staff members with bathing/showering on preferred shower days and as necessary. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #81 had intact cognition and required extensive assistance of one staff member with bathing. Review of the master shower schedule revealed Resident #81 was to receive showers on Monday and Thursday on the day shift during the hours of 7:00 AM to 3:00 PM or 7:00 AM to 7:00 PM. Review of the Nurse Aide (NA) bathing documentation for Resident #81 for the months of October 2021 and November 2021 revealed the following: • October: Partial bed baths were documented as provided on 10/02/21, 10/05/21, 10/07/21, 10/08/21, 10/11/21, 10/12/21, 10/14/21, 10/15/21, 10/16/21, 10/22/21, 10/23/21, 10/24/21, 10/26/21, 10/27/21, and 10/28/21. Showers were documented as provided on 10/01/21, 10/13/21, 10/25/21, and 10/30/21. [TRUNCATED]

Based on observations, record reviews, and interviews with residents and staff, the facility failed to maintain sufficient nursing staff to assure preferred choices were honored for showers and transfer in and out of bed; failed to assure dependent residents received weekly bathing and timely assistance with incontinence care, nail care, and grooming for 12 of 22 residents reviewed for dignity and respect, choices, and activities of daily living (Resident #7, Resident #8, Resident #9, Resident #13, Resident #23, Resident #26, Resident #27, Resident #45, Resident #50, Resident #54, Resident #81, and Resident #82). The findings included: This tag was cross-referred to: F-550: Based on record reviews, observations, staff interviews, and resident interviews, the facility failed to maintain residents' dignity by not providing showers, bathing, and incontinence care resulting in residents feeling like a homeless person, like staff did not like them, dirty and embarrassed, uncomfortable, and dirty. This affected 3 out of 6 (Resident #27, Resident #13, and Resident #50) sampled residents. F-561: Based on observations, record review and resident, family, and staff interviews, the facility failed to provide residents with their preference for a shower instead of a partial bed bath (Residents #7 and #9) and accommodate resident requests to be assisted to and from bed when requested (Residents #27 and #8) for 5 of 14 residents reviewed for choices. F-677 Based on record reviews, resident, and staff interviews the facility failed to provide showers or complete bed baths for 6 of 18 residents (Resident #27, Resident #26, Resident #81, Resident #82, Resident #13, and Resident #50) and failed to provide nail care and grooming for 3 of 18 residents (Resident #54, Resident #23, and Resident #45) reviewed for activities of daily living (ADL). Resident #27 stated because of not getting her showers, her hair was matted to her head, and she could smell her own body odor and it made her feel degraded and like a homeless person. During an interview on 11/15/21 at 3:20 PM Nurse #9 explained she had approximately 26 residents and was working with NA #9 who had the same assignment. Nurse #9 stated weekend staffing was harder due to no support help from the management team who help pass meal trays, answer call lights and the phone. Nurse #9 revealed agency staff picked up what they want and usually don't want the weekend shift. During an interview on 11/15/21 at 3:38 PM NA #9 revealed her assignment included 5 residents needing total assistance using a mechanical lift, 1 resident needing total assistance with feeding and 10 residents that were incontinent. NA #9 revealed her assignment was to provide care for approximately 26 residents and she hadn't been able to provide residents with their scheduled showers at this time. An interview was conducted on 11/17/21 at 9:40 AM with the Staffing Scheduler (SS). The SS revealed he judged the number of nursing staff needed based on the number of residents, their acuity and/or complexity of care needs discussed with him during meetings with the Interdisciplinary Team. The SS stated there were days the facility was short of nursing staff and one Nurse Aide (NA) would be assigned to provide care for 20 or more residents. The SS revealed residents have told him they didn't get a shower and he tried to ensure it would be done that day or the next. The SS used multiple agency staffing companies and his goal was to have 5 nurses working the day shift and 4 for the evening shift and 3 for the night shift. The SS revealed the goal for NA staff was to have 6 working during the day and evening shifts and 5 working on the night shift. The SS revealed the facility census hovered around 90 residents and if he couldn't find staff coverage leadership personnel came in to cover the shift and were on call 24 hours 7 days a week. The SS revealed the facility offered $50 or $100 bonuses for staff who pick up shifts and a list of shifts needing coverage was provided to nursing staff. During an interview on 11/22/21 at 3:45 PM the Director of Nursing (DON) revealed there had been times the facility was short of staff. Bonuses were provided when staff come in to cover shifts and the SS, Unit Manager, and herself have covered when unable to find coverage. The DON explained the hiring process was ongoing, and the facility was actively trying to recruit new staff and offered sign-on bonuses but was hit or miss with applicants and the facility was doing their best to get positions filled. During an interview on 11/22/21 at 4:12 PM the Administrator revealed she received reports from staff they couldn't get their work completed or showers done due to working short staffed. The Administrator revealed the facility currently worked with 5 different staffing agencies to supplement the schedule but there were times when call outs occurred and nursing worked short of staff. Bonuses were offered when staff pick up shifts but if unable to get anyone to cover, the Administrator revealed she would come in and help out on the floor as a Personal Care Aide along with other administrative staff and understood staffing was a concern and stated they were doing the best they could with staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident, staff, former Nurse Practitioner (NP) and Medical Director interviews, the facility failed to prevent a medication error by not administering Lithium (a mood stabilizer medication that works in the brain) to a resident (Resident #12) for four consecutive days resulting in increased anxiety for the resident and feeling of being all to pieces without the medication. The findings included: Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, anxiety disorder, and bipolar disorder. Resident #12's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact for daily decision making and was on antianxiety and antidepressant medications daily. Review of a psychotherapy progress noted dated 08/04/21 revealed the following under patient objective quote: They ran out of my Lithium again. I'm all to pieces. The note further revealed under patient reports and progress observed: Patient was assured this provider would consult with Nurse Practitioner (NP) to assist the patient to access her medication in a timely manner. NP was consulted and she stated she would attempt to source the medication from a local pharmacy to assist the patient. Review of a Lithium lab drawn on 11/08/21 and reported on 11/09/21 revealed a Lithium level of 0.50 millimoles per liter (mmol/L) with a therapeutic range of 0.50 to 1.20. Review of Resident #12's care plan dated 11/13/21 revealed a plan of care for impaired cognitive function/impaired thought processes related to unspecified bipolar disorder. The interventions included administer medications as ordered and monitor/document for side effects and effectiveness. Observation and interview on 11/18/21 at 2:45 PM revealed Resident #12 in her wheelchair attending the Resident Council meeting. Resident #12 stated she had missed 4 days of her Lithium about 3 to 4 months ago. Resident #12 further stated being without her Lithium made her feel crazy and said she knew she acted different. Review of Resident #12's physician orders for July through November 2021 revealed an order for Lithium Carbonate Capsule 150 mg - give 3 capsules by mouth one time a day related to bipolar disorder at 12:00 noon. Review of Resident #12's Medication Administration Record (MAR) for July and August 2021 revealed Resident #12 missed doses on 07/30/21, 07/31/21, 08/01/21, and 08/02/21. Review of Resident #12's nursing progress notes revealed notes written on 07/30/21, 07/31/21, and 08/01/21 indicating awaiting arrival of medication. Interview on 11/19/21 at 10:14 AM with Nurse #2 assigned to care for the resident on 07/31/21 and 08/01/21 revealed Resident #12 was out of her Lithium those days and it was not given. Nurse #2 stated usually if medication is ordered before 5:00 PM it was delivered the evening on the same day. She further stated sometimes they had to call several days to get medications and it just depended on the medication as to how long it would take to be delivered. Nurse #2 indicated she was not aware if there was a contract with a local pharmacy for emergency dispensing of medications. She stated the resident was on Lithium and took 3 capsules daily. According to Nurse #2 she remembered calling about the Lithium both days she worked but couldn't recall if the pharmacy had received the original refill request so she stated she sent the refill request again for the Lithium. Nurse #2 indicated she remembered Resident #12 being upset at the time and anxious but said she was not sure if it was because she had not taken her meds or because her room was being changed. Phone interview on 11/19/21 at 10:54 AM with the former NP for the facility revealed she recalled the psychotherapist had called her because she was concerned about Resident #12 not receiving her Lithium. The NP further revealed the psychotherapist was concerned if the resident did not get her Lithium, she could easily decompensate so the NP stated she called the pharmacy directly and the medication was delivered. The NP agreed that it could be concerning for the resident to decompensate if she did not receive her Lithium and it was not ideal for her to go days without the Lithium. Phone interview was attempted with the Psychotherapist, but she was out of the country and could not be reached. Phone interview on 11/19/21 at 1:00 PM with the Medical Director (MD) revealed Resident #12 missing doses of her Lithium was familiar and remembered the resident mentioning to him her medication had run out but could not recall if the facility had notified him of the resident missing 4 consecutive doses. The MD stated in an unstable resident missing 4 consecutive doses of Lithium could potentially present a problem but said Resident #12 was stable and had been on the medication for a long time. He further stated he was not terribly concerned about her missing the doses of Lithium but said he would prefer residents received their medications as ordered.