**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a comprehensive care plan was developed for one (#21) of 18 sampled residents reviewed for comprehensive care plans. DON #1 identified 70 residents resided in the facility. Findings: A facility policy titled Care Planning - Interdisciplinary Team, revised 09/2013, read in parts, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .A comprehensive care plan for each resident is developed with seven (7) days of completion of the resident assessment (MDS) .The care plan is based on the resident's comprehensive assessment. A facility policy titled Care Plans, Comprehensive Person-Centered, revised 12/2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #21 admitted on [DATE] with diagnoses which included cerebral palsy and severe intellectual disabilities. Resident #21's admission assessment, dated 11/26/24, documented Resident #21 was dependent upon staff for all aspects of their ADLs. Resident #21's EHR contained no documentation of a comprehensive care plan. On 01/08/25 at 12:05 p.m., DON #1 stated Resident #21 did not have a comprehensive care plan.

Based on record review and interview, the facility failed to update the care plan related to wound/treatment care for one (#6) of 18 sampled residents reviewed for care plans. DON #1 identified 70 residents who resided in the facility. Findings: Res #6 admitted to the facility with diagnoses which included traumatic brain injury, dependence on respirator, and tracheostomy. A physician's order, dated 12/14/24, documented to apply Betadine to scabbed area to left dorsal lateral foot daily until resolved. The resident's record was reviewed and the care plan had not been revised to document the wound to the left foot. On 01/09/25 at 8:40 a.m., DON #2 was asked to review the resident's care plan. They stated it should have been revised to document the area to the left foot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were offered the right to formulate an advanced directive for five (#6, 12, 14, 31, and #35) of eight sampled residents reviewed for advanced directives. DON #1 identified 70 residents resided in the facility. Findings: 1. Res #6 admitted to the facility on [DATE]. Res #6's medical record did not contain an advanced directive acknowledgement form. 2. Res #14 admitted to the facility on [DATE]. Res #14's medical record did not contain an advanced directive acknowledgement form. 3. Res #31 admitted to the facility on [DATE]. Res #31's medical record did not contain an advanced directive acknowledgement form. 5. Res #35 admitted to the facility on [DATE]. Res #35's medical record did not contain an advanced directive acknowledgment form. On 01/08/25 at 11:07 a.m, the social services director reported they were unable to locate advanced directive acknowledgement forms for Residents #6, 12, 14, 31, and #35. 4. Res #12 admitted to the facility on [DATE]. Res #12's medical record did not contain an advanced directive acknowledgement form.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed, a care plan was completed, and a physician order was obtained for the use of a physical restraint for one (#25) of one sampled resident reviewed for physical restraints. The ADON identified one resident who utilized a wheelchair lap seat belt. Findings: An undated Use of Restraints policy, read in parts, All restraints must have a physician's order and an order for evaluation by designee for the least restrictive device that is appropriate for the resident .Restraints shall be used only for safety or postural support of a resident to prevent injury to self or others .An assessment regarding the need of restraint for the resident will be completed and documented .The physician's restraint order must be detailed and specific; the order must include type of device, specific duration of use, reason for use and frequency of release .Informed consent for physical restraint will be obtained from the resident or legal representative .The plan of care will identify the need for restraint use .At least every three months an assessment will be completed by the therapist to determine if the restraint continues to be the only viable option for care .Quarterly updates and care plan entries are the responsibility of the interdisciplinary care plan team. Res #25 had diagnoses which included reduced mobility, impulse disorders, and seizures. An annual assessment, dated 09/26/24, documented the resident was severely cognitively impaired, had impairment in bilateral upper and lower extremities, utilized a wheelchair, and was dependent on staff with transfers. The assessment documented the resident had no physical restraints. On 01/07/25 at 12:27 p.m., Res #25 was observed sitting in a wheelchair with a quick release seat belt fastened across their lap. Res #25 stated they wanted the lap seat belt to help prevent them from sliding out of the wheelchair. Res #25 independently unfastened the quick release belt upon request. On 01/08/25 at 10:30 a.m., Res #25 was observed sitting in a wheelchair with a quick release seat belt fastened across their lap. Res #25 independently unfastened the quick release belt upon request. There was no physician order, assessment, or documentation in the care plan regarding the lap seat belt found in Res #25's medical record. On 01/09/25 at 9:15 a.m., the ADON stated the lap belt was requested by Res #25. They stated Res #25 utilized the lap belt to feel more secure in their wheelchair. On 01/09/25 at 10:09 a.m., the ADON stated they did not know when the lap belt had been implemented for Res #25. They stated physical therapy should have assessed the resident prior to implementation and a physician order should have been obtained. On 01/09/25 at 10:32 a.m., DON #2 stated the lap seat belt was not documented in the care plan, but should have been. On 01/09/25 at 10:39 a.m., DON #1 stated the facility was unable to provide documentation of a physician order or an assessment prior to the implementation of the lap seat belt for Res #25.

Based on record review and interview, the facility failed to permit a resident to return to the facility after a hospitalization for one (#126) of three residents reviewed for hospitalization. The facility identified nine residents who had been discharged in the past three months. Findings: A form titled Admission, Transfer and Discharge Rights, read in part, .You may not be transferred or discharged unless your needs cannot be met, your safety is endangered, or services are no longer required .Notice of transfer or discharge must be given to you 30 days prior, except in cases of health and safety needs . Res #126 was admitted to the facility with diagnoses which included methicillin susceptible staphylococcus aureus infection, non-pressure chronic ulcer of right foot, and diabetes mellitus. The admission assessment, dated 12/25/22, documented the resident was cognitively independent for decision making and required extensive assistance with dressing and toileting. A progress note, dated 03/15/23 at 9:16 p.m., documented the resident requested to be sent to the hospital. The note documented the resident was out of the facility via emergency medical services at 9:16 p.m. A discharge summary for the resident documented the resident was discharged from the facility on 03/15/23. On 10/27/23 at 12:29 p.m., the DON stated beds were available when the resident was ready to return to the facility. The DON stated they thought passing the bed hold time allowed was a reason not to allow the resident to return to the facility.

Based on record review and interview, the facility failed to ensure recommendations from a resident's PASRR II was incorporated into the resident's plan of care for one (#56) of one sampled resident whose PASRR was reviewed. The DON documented 29 residents with PASRR II evaluations resided in the facility. Findings: Res #56 had diagnoses which included post traumatic stress disorder and schizophrenia. A PASRR level II, dated 11/14/22, documented the resident should receive a dental evaluation and treatment as required; visual examination and treatment as required; the residents room should be personalized and appear non institutional; and the resident should be encouraged to make independent choices regarding room decorations like bedding. The PASRR level II documented the resident to have ADL training in dining skills and dressing and have community integration including but not limited to shopping at a variety of stores, movie rental, going out to eat at a variety of restaurants. The PASRR evaluation documented community outings should be provided to include medical appointments; staff should continue to encourage the resident to complete as much of their care as possible; and staff should provide cuing and physical assistance as needed and encourage daily decision making even in regard to meals, clothing, and activities. A significant change assessment, dated 03/21/23, documented the resident had a PASRR II for serious mental illness. The assessment documented the resident had modified independence some difficulty in new situations only and required extensive assistance with most ADLs. The assessment documented the resident had no behaviors in the look back period. A care plan, dated 06/26/23, documented the resident had been identified as having a PASRR positive status related to a severe mental illness: PTSD and schizophrenia. The care plan documented to evaluate the resident for additional specialized services. The care plan did not incorporate the recommendations documented in the PASRR II of dental evaluation, decoration the residents room, have community integration including but not limited to shopping at a variety of stores, movie rental, going out to eat at a variety of restaurants. Community outings should be provided to include medical appointments into the POC. A quarterly assessment, dated 09/19/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident had diagnoses of depression, schizophrenia, and PTSD. The assessment documented the resident received an antipsychotic medication. The assessment documented the resident had no behaviors during the assessment period. On 10/19/23 at 2:03 p.m., Res #56 was observed in the bed playing video games and did not appear depressed at this time. Res #56 was cooperative and answered questions during the interview. On 10/24/23 at 11:13 a.m., MDS Coordinator #2 stated they had never seen the resident's PASRR II. The MDS coordinator stated they had not incorporated the PASRR II in the resident's POC. The MDS coordinator stated they were not aware the PASRR II needed to be care planned. On 10/24/23 at 11:44 a.m., MDS Coordinator #1 stated they were not aware the PASRR level II needed to be incorporated into the care plan.

Based on observation, record review, and interview, the facility failed to ensure residents with a diagnosis of PTSD received culturally competent trauma informed care in order to eliminate or mitigate triggers which could cause re-traumatization of the resident for one (#56) of one resident reviewed for behaviors. The DON documented one resident with PTSD resided in the facility. Findings: Res #56 had diagnoses which included paraplegia, PTSD, and schizophrenia. A significant change assessment, dated 03/21/23, documented the resident had a PASRR II for serious mental illness. The assessment documented the resident had modified independence with some difficulty in new situations only and required extensive assistance with most ADLs. The assessment documented the resident had no behaviors during the look back period. A care plan, dated 06/26/23, documented the resident received antipsychotic medications for diagnosis of schizophrenia for target behaviors of anger, hostility, and self-harm. The care plan documented the resident had been identified as having a PASRR positive status related to a severe mental illness, PTSD, and schizophrenia. The care plan did not incorporate the recommendations in the PASRR II into the POC. A quarterly assessment, dated 09/19/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment documented the resident had diagnoses of paraplegia, depression, schizophrenia, PTSD. The assessment documented the resident received and antipsychotic medication seven days in the assessment period. The assessment documented the resident had no behaviors in the assessment period. On 10/19/23 at 2:03 p.m., Res #56 was observed in the bed playing video games and did not seem depressed at this time. Res #56 was cooperative and answered questions during the interview. On 10/24/23 11:15 a.m., MDS Coordinator #2 stated they were not sure what the resident's triggers would be for their PTSD. MDS Coordinator #2 stated the only thing they knew of was when the resident did not get their way they would act out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Res #12 had diagnoses which included shaken infant syndrome and dependence on respirator status. An annual assessment, dated 12/01/22, documented the resident was severely impaired with cognition and required total assistance with all ADLS. The assessment documented the resident was impaired in ROM on both sides of the upper and lower extremities. The assessment documented Res #12 was always incontinent of bladder and bowel, and required continuous feeding through a gastrostomy tube. A care plan, dated 12/05/22, documents Res #12 had pain related to contractures. The care plan did not document a plan of care related to prevention of worsening of the resident's contractures. On 10/23/23 at 11:06 a.m., observation was made of the resident's bilateral hand contractures. On 10/27/23 at 12:17 p.m., the restorative aide stated Res #12 had never been on any type of restorative program while residing in the facility. On 10/27/23 at 12:21 p.m., an interview with LPN #1 was conducted and they stated Res #12 had contractures in their hands for a long time and they should have placed washcloths in the resident's hands to prevent worsening contractures but now they could not get washcloths in either hand. On 10/27/23 at 12:27 p.m., MDS coordinator #1 stated Res #12 did not have contractures on the care plan therefore no interventions were on the resident's care plan to prevent contractures from worsening. 4. Res #53 had diagnoses which included cerebral palsy, congenital hydrocephalus, dependence on respirator status, and unspecified intellectual disabilities A quarterly assessment, dated 09/05/23, documented the resident was severely impaired with cognition and required total assistance with all of ADLs. The assessment documented ROM was impaired on both sides of the resident's upper and lower extremities. The assessment documented Res #53 had a catheter, incontinent of bowel, and required continuous feeding through a gastrostomy tube. A care plan, dated 03/13/23, documented Res #53 had alteration in function due to cerebral palsy and required oral care, hair care, turning and repositioning every two hours and as needed. On 10/23/23 at 11:0 a.m., an observation was made of the resident's upper and lower contractures bilaterally. On 10/27/23 at 12:17 p.m., the restorative aide stated Res #53 had never been on any type of restorative program. On 10/27/23 at 12:27 p.m., MDS coordinator #1 stated Res #53 did not have a care plan for contractures but there should have been one added. Based on observation, record review, and interview the facility failed to ensure residents with limited ROM received the appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for four (#12, 23, 53, and #69) of six residents reviewed for position/mobility. The DON documented 41 resident with contractures resided in the facility. Findings: 1. Res #23 had diabetes mellitus, cerebral palsy, CVA, and TIA. A quarterly assessment, dated 08/09/23, documented the resident was intact in cognition and required extensive assistance with ADLs. The assessment documented the resident had limited ROM of the upper and lower extremity on one side. A care plan, updated 09/18/23, documented the resident had limited mobility due to left side hemiparesis related to CVA. A physical therapy Discharge summary, dated [DATE], documented the resident would discharge from physical therapy to the care of restorative nursing. A order for restorative care was not found in the EHR. On 10/19/23 at 11:11 a.m., Res #23 was observed in bed with contractures noted to left fingers. Res #23 stated they used to get therapy but not now. Res #23 stated they could not move their left side. On 10/26/23 at 2:08 p.m., the DON stated they could not find where the resident had been on restorative nursing after PT was completed in September of 2023. The DON stated the physician should have signed the PT discharge and then PT would have taken the notes back to the PT office. On 10/26/23 at 2:14 p.m., the restorative aide stated they did not know the resident was to receive restorative care following the completion of PT in September. On 10/26/23 at 2:29 p.m., MDS Coordinator #2 stated they typically did not get the discharge summary from therapy. 2. Res #69 had diagnoses which included seizure disorder, neuromuscular scoliosis thoracolumbar region, and spastic quadriplegic cerebral palsy. Hospital discharge instructions, dated [DATE], documented the resident had splints discharged with the resident. A admit nurse note, dated 01/17/23, documented the resident was non-verbal and unable to make wants or needs known. The assessment documented the resident had contractures to bilateral upper extremities and limited ROM to the lower extremities. A quarterly assessment, dated 07/28/23, documented the resident was severely impaired with cognition and required total assistance with ADLs. The assessment documented the resident had impaired ROM upper and lower on both sides. A care plan, last reviewed 08/02/23, documented Res #69 had impaired physical mobility in bilateral upper and lower extremities related to cerebral palsy, scoliosis, and contractures. The care plan documented the resident was totally dependent on staff for all aspects of mobility. The care plan documented the resident sat up in their own personal wheelchair and required staff to propel them. The care plan did not include the resident wrist and hand splints. A weekly nurse assessment, dated 10/22/23, documented the resident was unable to make need know but did track with their eye and smiled when saying their name. The assessment documented the resident had limited ROM to bilateral upper and bilateral lower extremities. Contractures were not identified in the assessment. The assessment documented the resident required a lift with two staff for transfers. On 10/19/23 at 11:42 a.m., the resident was observed lying in the bed awake and when the resident was spoke to, they smiled. An observation was made of the resident's right hand which was contracted the rest of the resident's extremities were not observed at that time. The resident was asked if they could move their fingers which they did not. The resident did not have any splints on. On 10/25/23 at 2:37 p.m., a restorative aide stated the resident had splints which were to be used when the resident was up in the chair. The restorative aide stated they were going to pick up the resident on the restorative program. On 10/25/23 at 3:34 p.m., the ADON stated the resident had splints for their hands. They confirmed the discharge instructions from the hospital documented splints to discharge with resident. On 10/26/23 at 9:33 a.m., the resident was observed in bed on their back with tube feeding running and the head of bed was elevated. The resident was observed to not have on splints at that time. On 10/26/23 at 9:52 a.m., CNA #1 stated they had worked at the facility three weeks and did not know when the resident got out of bed. CNA #2 stated they had worked at the facility five years and the resident was to get up on Mondays and Tuesdays. CNA #2 stated when they got Res #69 up, the splints were placed on the resident's hands. CNA #2 stated they had worked on the 200 hall during that week and did not know if the resident had been up. On 10/26/23 at 9:50 a.m., the DON stated the resident was up in their chair over the weekend. The DON stated the resident needed to be up daily but had not been up since Sunday. The DON stated the resident was very social and loved getting up and going to activities. The DON stated the resident had splints when they arrived at the facility but were missed getting an order for the splints.

Based on record review and interview, the facility failed to have a program designed to help prevent the development of Legionellosis and Pontiac fever caused by Legionella Bacteria. The Resident Census and Conditions of Residents form documented 77 residents resided in the facility. Findings: A policy titled Legionella Surveillance and Detection documented .Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella . On 10/26/23 at 10:08 a.m., the maintenance staff stated they did not have a documented plan for Legionella. On 10/26/23 at 10:19 a.m., the ADON stated the plan for Legionella was a work in progress.

Based on observation, record review, and interview, the facility failed to ensure regular inspection of all bed frames, mattresses, and bed rails, were conducted as part of a regular maintenance program to identify areas of possible entrapment. The DON documented 75 residents living in the facilty had bed rails in use. Findings: A Proper Use of Side Rail policy, undated, read in part, .2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents .13. When side rail usage is appropriate, the facility will assess the space between mattress and side rail to reduce the risk for entrapment (the amount of safe space may very, depending on the type of bed and mattress being used) . On 10/26/23 at 10:09 a.m., the maintenance man stated the side rails on the beds were not inspected as the policy stated. The maintenance man stated if there was a problem with the bed or rails nursing would report the problem to them and the problem would be fixed immediately.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The DON documented 40 residents received meals from the kitchen. Findings: 1. On 10/19/23 at 9:21 a.m., an initial tour of the kitchen was conducted. A cut tomato in a sealed bad, dated 10/17/23, a cut up onion in a sealed bad, dated 10/13/23, and vegetable soup in a sealed container, dated 10/09/23 were observed in the refrigerator. On 10/19/23 at 9:30 a.m., [NAME] #1 entered the kitchen with a sack containing salad and other items. [NAME] #1 was not observed to wash their hands when they entered the kitchen. [NAME] #1 was observed to start dating the bags of salad and placing them in the refrigerator. On 10/25/23 at 11:09 a.m., [NAME] #1 was observed to touch their face and put their hand on their hip and then continue to prepare the pureed meals. [NAME] #1 was not observed to wash their hands during this observation. On 10/25/23 at 11:14 a.m., [NAME] #1 was observed to touch their glasses, cleaned the can opener, opened another can of milk, and poured some more milk in the noodles puree. Hand washing was not observed. On 10/25/23 at 11:21 a.m., [NAME] #1 was observed to rub their her nose with the back of their hand, did not wash their hands, and continued the puree. On 10/25/23 at 11:50 a.m., [NAME] #1 was observed to touch their glasses and continue the puree without washing their hands. On 10/25/23 at 12:11 p.m., DA #2 and DA #3 were observed to enter the kitchen without washing their hands. At 12:13 p.m., they were observed to return a cart to the kitchen and take another cart of meals to the dining room without washing their hands. On 10/25/23 at 12:17 p.m., DA #2 and #3 returned a cart to the kitchen, hand washing was not observed, and another cart with meals was taken to the dining room. On 10/25/23 at 12:23 p.m., DA #2 returned to the kitchen with a cart which had been out to the dining room. DA #2 was not observed to wash their hands. DA #2 was observed retrieving a bowl from the cabinet in the kitchen and take the bowl to the dining room. DA #2 returned to the kitchen and hand washing was not observed. 2. On 10/19/23 at 12:00 p.m., 16 residents were observed in the dining room. On 10/19/23 at 12:11 p.m., CNA #1 was observed to use hand hygiene then the CNA touched their hair. At 12:15 p.m., CNA #1 was observed to assist a resident eat their meal. The CNA was not observed to use hand hygiene before assisting the resident. On 10/19/23 at 12:14 p.m., DA #1 was observed returning a cart to the kitchen. DA #1 used hand sanitizer before entering the kitchen and returning with more resident meals. DA #1 was not observed to wash their hands when they entered the kitchen. On 10/19/23 at 12:23 p.m., DA #1 was observed to use hand sanitizer, entered the kitchen, did not wash their hands. The DA was observed to retrieve a drink and return to the dining room. DA #1 was observed to use hand sanitizer again and entered the kitchen for a straw and was observed to not wash their hands before getting bread. The DA was then observed to touch their clothing and continue with meal service without performing hand hygiene. On 10/19/23 12:27 p.m., DA #1 was observed to use hand sanitizer and enter the kitchen without hand washing. On 10/25/23 at 2:09 p.m., the DM stated stated when the staff entered the kitchen they should have washed their hands. The DM stated the staff used the sanitizer before they entered the kitchen to get more trays to pass. The DM stated they were not aware you could not use hand sanitizer and then go into the kitchen. The DM stated when preparing meals, if staff touched something dirty, they had to change your gloves, and wash your hands. The DM stated if glasses or faces were touched they should have washed their hands. The DM stated they believed food could be kept 48 hours unless it was in its original container then it could be kept longer. The DM stated any items should be dated when they were received and before putting items away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review it was determined the facility failed to ensure a comprehensive care plan was in place for one (#68) of 16 residents who were reviewed for care plans. The administrator reported there were 71 residents in the facility. Findings: Resident #68 was admitted on [DATE] with diagnoses of heart failure, hypertension, and end stage renal disease. An admission assessment, dated 01/18/22, documented the resident's cognition was moderately intact and required assistance with ADLs. The clinical record contained no comprehensive care plan. On 02/07/22 10:25 a.m., the minimum data set (MDS) coordinator reported the resident's comprehensive care plan had not been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information concerning the right to formulate an advanced directive for three (#55, 56, and #122) of three sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 01/31/22, documented 71 residents resided in the facility. Findings: The Advance Directive policy read in part, .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . 1. Resident (Res) #55 was admitted to the facility on [DATE]. There was no documentation the resident had been provided information related to formulating an advance directive. On 02/01/22 at 4:40 p.m., the director of nurses (DON) stated an advance directive acknowledgement form was in the resident's clinical record, but had not been signed by the resident or the resident's representative. She stated information regarding formulating an advance directive should be offered and if the resident declined an advance directive acknowledgment form should be signed. 2. Res #56 was admitted to the facility on [DATE]. There was no documentation the resident had been provided information related to formulating an advance directive On 02/02/22 at 3:57 p.m., the business office manager (BOM) reviewed the resident's clinical record and stated no documentation could be found related to the resident being offered information to formulate an advance directive. 3. Res #122 was admitted to the facility on [DATE]. There was no documentation the resident had been provided information related to formulating an advance directive On 02/01/22 at 4:18 p.m., the social services director (SSD) stated she was responsible for completing the admission packet information for the residents. She stated the admission packet no longer contained information to formulate an advance directive. At 4:20 p.m., the DON stated the information to formulate an advance directive was removed from the admission packet a few months ago. She stated the information regarding formulating an advance directive would be returned to the admission packet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide baths/showers as scheduled for four (#14, 25, 68 and #10) of five sampled residents. The census and condition, dated 1/31/22, documented census of 71 residents residing in the facility. Findings: A facility policy and procedure, revised February 2018, documented female residents would shower on Monday, Wednesday, and Friday. The policy documented male residents would shower on Tuesday, Thursday, and Saturday. The policy documented the staff would report to the supervisor/charge nurse if the resident refused a shower, and the staff would document the refusal and why the resident refused. 1. Resident (Res) #14 was admitted on [DATE] with diagnoses which included heart failure, hypertension, anemia, diabetes, and hyponatremia. A quarterly assessment, dated 11/27/21, documented the resident was cognitively intact and required one person assist for bathing. On 01/31/22 at 9:42 a.m., the resident reported she had one bath since she moved rooms. On 02/01/22 at 2:00 p.m., the ADON was asked about resident's getting showers while in isolation/quarantine. She reported they are offered bed baths because they only have one working shower and they did not want to mix isolated/quarantined residents with the other residents. Res #14's record documented the resident went 14 days without a shower/bed bath. 2. Res #25 was admitted on [DATE] with diagnoses of atrial fibrillation, hypertension, and diabetes. A change in status assessment, dated 11/15/21, documented the resident was intact with cognition. The assessment documented the resident required one person assist with bathing. On 02/01/22 at 1:30 p.m., the resident reported she had not had a shower in three weeks. The resident reported she was not offered a bed bath while in isolation. The resident reported she was removed from isolation this morning. On 02/01/22 at 2:00 p.m., the ADON/IP was asked if residents getting showers/bed baths while in isolation. She reported they were given bed baths during quarantine/isolation because the facility only had one working shower and did not want to expose the other residents. CNA #1 was shown the shower log for resident #25 and was asked if she gave the resident a shower on 01/24/22 and 01/31/22. CNA #1 reported she did not give the resident a shower on those days because she was in isolation. CNA #1 reported she did not work with the covid positive residents on 01/31/22. CNA #1 reported she did not fill out the log for 01/31/22 and it was not her handwriting. The record documented the resident was in isolation from 01/21/22 through 01/31/22. The record documented the resident went seven or more days without a shower/bed bath. 3. Res #68 was admitted on [DATE] with diagnoses of heart failure, hypertension, and end stage renal disease. An admission assessment, dated 01/18/22, documented the resident's cognition was moderately intact. The assessment documented the resident required one person assist with bathing. On 02/01/22 at 9:19 a.m., the resident complained he did not get his showers like he should. The record documented the resident did not receive a shower for the month of January 2022. The record of the shower log documented one refusal for a shower and no documentation the resident was out of the facility. On 02/01/22 at 2:00 p.m., the ADON reported the resident refuses showers at times. The ADON was shown the resident's shower log and asked if there should be documentation for refusal. The ADON reported it should have been documented if he refused. 4. Res #10 was admitted on [DATE] with diagnoses of anxiety, depression, and hypertension. An admission assessment, dated 11/08/21, documented the resident's cognition was moderately intact. The assessment documented the resident required one person assist with bathing. On 01/31/22 at 8:48 a.m., the resident reported getting one shower a week or one shower every two weeks. The record documented the resident received two showers for the month of January 2022. On 02/01/22 at 2:00 p.m., the ADON reported the resident refused showers at times. The ADON was shown the resident's shower log and asked if there should be documentation for refusal. The ADON reported it should have been documented if she refused. On 02/07/22 at 10:11 a.m., the DON was asked what the procedure was for when a resident refused a shower. The DON reported the CNA's are supposed to have the resident sign a refusal sheet and notify the charge nurse. The DON reported the staff are supposed to ask the resident three times with the resident refusing each time.