**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 residents (Resident #30 and Resident #31) of 67 residents reviewed for abuse. The facility's failure to prevent resident to resident abuse resulted in actual HARM for Resident #31. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Property, Exploitation, and Injuries of Unknown Source, revised 10/24/2022, revealed .organizations intention to prevent the occurrence of abuse .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .stakeholder observes a resident exhibiting any form of abuse toward another resident the stake holder will intervene immediately and interrupt the incident and remove or separate the residents involved . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Anxiety, Seizures, Depression, and Stroke. Review of a comprehensive care plan for Resident #30 dated 6/30/2023, revealed the resident utilized a wheelchair for locomotion. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #30 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident utilized a wheelchair for locomotion. Review of a Nurse Practitioner note for Resident #30 dated 9/10/2024, revealed .Resident seen due to reports of him having an altercation with another resident last night .Resident states that he did hit another resident [Resident #31] yesterday .states he does not want to have another altercation . Review of a Psychiatric Nurse Practitioner note for Resident #30 dated 9/14/2024, revealed .Attempted to discuss recent altercation with peer [Resident #31] .[Resident #30] refused to provide details . Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Dementia, Psychotic Disorder, Mood Disorder, Depression, Anxiety, and Difficulty Speaking. Review of the Medication Administration Record (MAR) for Resident #31 dated 6/1/2024 through 6/30/2024, revealed .Hydroxyzine .1 tablet by mouth three times a day related to ANXIETY DISORDER . Review of an admission MDS for Resident #31 dated 7/1/2024, revealed the resident was rarely/never understood. Staff assessment for mental status revealed Resident #31 experienced short and long-term memory problems and was severely impaired for daily decision-making skills. Review of a Behavior note for Resident #31 dated 9/4/2024, revealed the resident's Hydroxyzine (antianxiety medication) was discontinued related to the resident's frequent refusal of the medication. Review of a Nurse Practitioner note for Resident #31 dated 9/6/2024, revealed .Resident seen due to aggressive behaviors .shoved a bedside table that was in front of another resident though the other resident was not hit .[Antipsychotic medication injection] administered .particular resident who is confused [Staff were unable to identify who this resident was] seemingly agitating him .Angry .not redirectable . Review of a facility investigation dated 9/9/2024, revealed a resident-to-resident altercation occurred between Resident #30 and Resident #31. Certified Nursing Assistant (CNA) G reported to the charge nurse [Licensed Practical Nurse (LPN) I] she observed Resident #31 crying and bleeding in the hallway. LPN I notified the Administrator of the resident-to-resident altercation. The Administrator reported to the building, reviewed the camera footage, and observed Resident #31 strike resident #30, who then struck back Resident #31 in the nose. Further review of the facility investigation revealed Resident #31 was sent to the hospital and was determined to have a fractured nose after the event occurred and returned to the facility the same day. The facility substantiated resident-to-resident abuse with injury in the investigation. Review of a Behavior note for Resident #31 dated 9/9/2024, revealed Resident #31 was transported to the hospital for an altercation [with Resident #30]. Review of a Computed Tomography (CT) scan result [a test that uses x-rays, and a computer to make detailed images of the body] for Resident #31 dated 9/9/2024, revealed a fractured nose. Review of a Nurse Practitioner note for Resident #31 dated 9/10/2024, revealed .[Resident #31] .resting in [wheelchair] .on 1:1 [one on one] supervision after an altercation with another resident [Resident #30] .[Resident #31] hit [Resident #30] on the arm .[Resident #30] then hit [Resident #31] in the face resulting in a broken nose .[Resident #31] was sent to ER [emergency room] and has returned to the facility .[Resident #31] frequently refuses medications which is within his right .[Resident #31] declined his medication today . Review of a comprehensive care plan for Resident #31 initiated 9/16/2024, revealed . inappropriate behaviors related to impaired communication .dementia .mood disorder .Resident gets agitated at times . During an interview on 1/7/2025 at 1:00 PM, Resident #30 was able to recall the event and stated Resident #31 hit him on the arm when he was sitting in his wheelchair waiting to go smoke and he was not harmed in the altercation. Resident #30 stated he hit Resident #31 back in the face. Resident #30 stated Resident #31 started bleeding and crying after Resident #30 hit Resident #31. Resident #30 denied any other altercations before or after this incident. During a telephone interview on 1/7/2025 at 6:00 PM, CNA G stated on the night of the event she observed Resident #30, who was waiting to go smoke, sitting in his wheelchair in the hallway and later observed Resident #31 in his wheelchair approach Resident #30. CNA G stated nothing alarmed her about the approach. CNA G stated she entered a different resident's room to provide care and when she exited the room, CNA G observed Resident #31 bleeding and crying sitting in his wheelchair in the hallway next to Resident #30. CNA G stated that she separated the residents, remained in the area, and called the nurse, who then called the Administrator. CNA G stated Resident #30 told her he was hit by Resident #31, and he hit Resident #31 back. During a facility investigation review, medical record review, and interview on 1/8/2025 at 10:30 AM, the Administrator reviewed the facility's investigation of the altercation between Resident #30 and Resident #31 on 9/9/2024, reviewed Resident #30's CT scan results which revealed a fractured nose, and the Administrator confirmed resident-to-resident abuse with injury occurred. During an interview on 1/8/2025 at 3:00 PM, the Family Nurse Practitioner (FNP) stated she was familiar with Resident #30 and Resident #31. The FNP stated she evaluated both residents after the event and stated Resident #30 told her he was hit by Resident #31 first, and he hit Resident #31 back. The FNP also stated Resident #31 had expressive aphasia, and when the FNP asked Resident #31 if Resident #30's statement was true, Resident #31 shook his head indicating Resident #30's statement was true. Further interview revealed the FNP stated the resident-to-resident altercation was the cause of Resident #31's fractured nose.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the residents' right to be free from sexual abuse for 1 resident (Resident #2) by Resident #3 and physical abuse for 2 residents (Residents #4 and #5) by Resident #1 of 7 residents reviewed for abuse. The abuse resulted in actual harm to residents #4 and #5 when Resident #1 threw a chair at Resident #4 and #5 resulting in Resident #4 receiving a scrape down his left shin and Resident #5 receiving a bruise and swelling on his right knee. The findings include : Review of the facility's policy titled, Abuse .Prevention Program, revised 4/2021, revealed .Residents have the right to be free from abuse .This includes .sexual or physical abuse .The resident abuse .prevention program consists of a facility-wide commitment .to support the following objectives .Protect residents from abuse .by anyone including .other residents . 1. Review of the medical records and facility investigation documentation revealed on 5/12/2024 a resident to residents' altercation occurred between Resident #1, Resident #4, and Resident #5 when Resident #5 punched at Resident #4 and threw a chair at Resident #4 and Resident #5. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Anxiety, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was cognitively intact. Review of facility incident report dated 5/12/2024 for Resident #4 revealed the resident had a scrape down his left shin approximately (approx.) 8 inches in length due to Resident #1 hitting Resident #4 with a chair no other injuries were noted. Review of a Progress note for Resident #4 dated 5/15/2024 revealed the resident was seen by the Social Services Director (SSD) Resident #4 did not have any concerns following the incident. Review of a psychiatric note for Resident #4 dated 5/15/2024 revealed the resident denied any symptoms of anxiety or depression. The resident reported I am fine. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Dementia, and Depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5's BIMS score was 13 indicating the resident was cognitively intact. Review of facility incident report dated 5/12/2024 for Resident #5 revealed the resident had a bruise and swelling on his right knee approx. 2 inches by 2 inches due to Resident #1 hitting Resident #5 with a chair no other injuries were noted. Review of a Progress note for Resident #5 dated 5/15/2024 revealed the resident was seen by SSD. Resident #5 did not have any concerns following the incident. Review of psychiatric notes for Resident #5 dated 5/15/2024 revealed the resident denied any signs or symptoms of anxiety or depression. The resident reported he was doing okay. Review of the medical record revealed Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Wernicke's Encephalopathy (Neurological Disorder), History of Traumatic Brain Injury, and Schizophrenia, he was discharged to the hospital on 5/12/2024. Review of the quarterly MDS assessment dated [DATE] revealed Resident #1's BIMS score was 6 indicating the resident had severe cognitive impairment. Review of Resident #1's current care plan revealed .The resident is/has potential to be verbally/physically aggressive. He kicks and swats at staff at times .Date initiated 06/19/2022 . Review of a Psychiatric Progress note for Resident #1 dated 5/7/2024 revealed .Patient has been having increased behaviors, agitation, Seroquel increased, and he was sent to the hospital. He was seen today .He was pleasant and talkative . Review of a facility investigation revealed on 5/12/2024 at 4:05 PM, in the smoking area Resident #1 became agitated and began punching at Resident #4 striking him in the face Resident #1 grabbed a chair. The Activities Assistant attempted to remove the chair from the resident who threw the chair at Resident #4 striking him on his lower leg. Resident #1 grabbed the chair again and threw it at Resident #5 striking him on his knee. The facility substantiated abuse for Resident #4 and Resident #5. During an interview on 7/8/2024 at 9:00 AM, Resident #4 stated .he [Resident #1] hit me with a chair in the hand and in the leg .he swung at me and hit me in the face he didn't leave no marks on me or noting .yeah [feels safe at facility] .no [no concerns] .I am okay . During an interview on 7/8/2024 at 1:40 PM the Activities Assistant stated .I was out there [smoking area] before he [Resident #1] got there and when he come out he sat there and he talked to people [other residents] .after a while [Resident #4] come out to smoke and [Resident #1] started talking to him and I couldn't hear what [Resident #4] said but he [Resident #1] just got agitated .[Resident #1] picked up a chair and I thought he was going to move the chair but then he hit [Resident #4] with it and I tried to get the chair but before I could get to him he already hit [Resident #5] .when I tried to get the chair he grabbed my arm but he didn't hurt it .they [Resident #4 and #5] are fine I aint seen anything different with them they just got some bruises it wasn't nothing major . During an interview on 7/9/2024 at 11:30 AM, Resident #5 stated he [Resident #1] just got mad for no reason he started arguing .he got the chair and he hit me on the knee it was bruised .it didn't have no cut or nothing like that I've been hit worse than that before that wouldn't nothing .oh yeah [feels safe at facility] .oh yeah I'm doing fine . During an interview on 7/10/2024 at 12:45 PM, the Administrator stated .yes they [Resident #4 and Resident #5] got hit . 2. Review of the medical records and facility investigation documentation revealed on 5/17/2024 a resident-to-resident sexual act occurred when Resident #3 was observed performing a sexual act on Resident #2 . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, and Mild Cognitive Impairment Unknown Etiology. Review of the admission MDS assessment dated [DATE] revealed Resident #2's BIMS score was 9 indicating the resident had moderate cognitive impairment, A Social Services (SS) BIMS was completed on 5/17/2024 revealing the residents BIMS was 3, indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADL's). Medical record review of a current care plan for Resident #2 revealed .Resident has Impaired cognition related to difficulty recalling things short and long term secondary to diagnoses of Dementia .Redirect as needed .Date Initiated 05/15/2024 . Review of psychiatric notes for Resident #2 dated 5/21/2024 and 5/28/2024 revealed the resident was involved in a resident-to-resident event no noted psychosocial harm was noted the resident stated he felt safe at the facility and voiced no concerns staff denied any depression, anxiety, mood, or behavior changes. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Cerebral Ischemic Attack, the resident was discharged to assisted living on 5/20/2024. Continued review revealed Resident #3 had no prior history of sexual behaviors. Review of the admission MDS assessment dated [DATE] revealed Resident #3's BIMS score was 13 indicating the resident was cognitively intact. Resident #3 came from an assisted living facility he is no longer at the facility no prior history of sexual behaviors, Resident #1 was sent out to the hospital and was still in the hospital, care plans were updated and psych was consulted for all residents safeguards were implemented it was immediately reported investigation was conducted and result was reported, all notifications were made. Review of the facility investigation documentation revealed on 5/17/2024 at 5:15 PM, Certified Nurse Assistant (CNA) H and CNA G witnessed Resident #3 in Resident #2's room on the floor on his knees in front of Resident #2 who was seated in his wheelchair. Resident #2's shirt was up, and his shorts were down exposing his penis. Resident #3's hands were on Resident #2's knees. The facility did not verify or refute the allegation. During an interview with Resident #2 on 7/8/2024 at 11:20 AM, in the dining room the resident stated .no I don't have any [concerns] .no I haven't had any problems with nobody [staff or residents] .yes I do feel safe 100% safe .no [no abuse including sexual abuse] I don't remember anything wrong I don't have no problems with nobody . During an interview on 7/8/2024 at 1:50 PM License Practical Nurse (LPN) C stated .I conducted an interview on [Resident #3] his BIM score turned out to be a 13 or 12 and then I asked him about the incident and I let him know right away this was a safe space and we just had questions .he told me I plead the fifth .I told him I have to make sure that you know what is going on as well as [Resident #2] .he said he gave me a look earlier in the day and I just wanted to repay the favor and when I asked him what does that mean and he said I plead the fifth again .he did say he put the cushion in the floor so his knees don't get banged up .I did talk to [Resident #2's] wife .she said she was shocked her husband was a lady's man and he never gave any kind of inclination to that . During an interview on 7/8/2024 at 2:45 PM Registered Nurse (RN) B stated .I did interview [Resident #2] .I asked him how he was doing he said he was doing fine .I asked him if there was anything going on and he acted like he didn't know what I was talking about .I said I think you had a visitor from one of the other residents and he said yes and I said did you invite him in and he said no he just came in and I said so were you talking and he said yeah we were talking .I said did anything else happen and he said no .I talked to him a little bit more and asked him again before I left if he was okay and he said everything was fine .he looked the same he had a smile on his face he was his normal self he wasn't upset in any way or nervous or anything .I went back a little bit later to check on him and to do a BIMS and I think it was about a 3 or a 4 .he was his same self he did not seem upset at all . During a telephone interview on 7/9/2024 at 11:55 AM, CNA G stated .me and [CNA H] were doing our round .it was around 5:00 [5:00 PM] .when we walked up there the door [Resident #2's room door] was closed so she [CNA H] knocked on the door and opened the door the door bumped [Resident #3s] wheelchair .she stuck her head in the room to see what she bumped .she looked back .give me a look and I knew something wasn't right .she asked [Resident #3] did you fall he was on his knees in front of [Resident #2's] wheelchair . and [Resident #2] had his shirt pulled up and his shorts pulled down in the front and had his penis out .[Resident #3] said no I didn't fall .she [CNA H] went to get the nurse and I stayed there with them [Resident #2 and #3] .I don't know if he [Resident #2] understood what was going on .[Resident #3] had a pad in the floor and he had his knees on it when he was in front of the chair .he got the pad and put it back in his chair and got back up in his chair. [Resident #2] still did not pull his pants up or pull his shirt down he just sat there . During a telephone interview on 7/9/2024 at 12:45 PM, CNA H stated .I went to the door and I knocked on the door and I pushed the door open a little bit and when I got through the door [Resident #3] was on his knees on a pad in the floor in front of [Resident #2s] wheelchair with his hands on [Resident #2's] knees and his head was between [Resident #2's legs] and I saw [Resident #2's] privates were pulled out and his t shirt was pulled up .I did not see him doing the physical part .I said are you okay and he [Resident #3] said your rude and I said I'm sorry and I asked him if he fell and he said no and then [Resident #2] kind of laughed he was laughing he wasn't upset at all it was like he thought it was funny .he [Resident #3] did not ever say I was doing this or that and [Resident #2] didn't say anything happened or seemed upset he was just laughing .they were separated I didn't leave them in the room alone .[Resident #2] is just the same person he always has been he's not sad at all .I have him during the day when I work he seems fine and he didn't act like he was upset that [Resident #3] was in there and they were both talking in the hallway just before that happened .I don't know whether [Resident #2] could consent to something like that .based on what I did see there is no doubt what was happening he [Resident #3] was doing the dirty to [Resident #2] he was giving him a blow job he was doing a sexual act with him .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (Resident #1) of 5 residents reviewed for medication administration was free of a significant medication error after receiving another resident (Resident #2's) prescribed medication which resulted in actual harm to Resident #1. The findings include: Review of the facility's policy titled, Administering Medications, revised 4/2019, revealed .Medications are administered in a safe and timely manner .as prescribed .Medication errors are documented, reported, and reviewed by the QAPI [Quality Assurance Performance Improvement] committee to inform process changes and or need for additional staff training .The individual administering medications verifies the resident's identity before giving the resident his/her medications . Review of the facility's undated policy titled, Medication Error guidelines, revealed .The licensed nurses shall ensure medications will be administered .According to physician's orders . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Diabetes Mellitus, Hypertension, Obstructive Sleep Apnea, Other Disorders of the Lungs, Chronic Obstructive Pulmonary Disorder (COPD) and Pickwickian Syndrome (also called obesity hypoventilation syndrome, throws off the balance of oxygen and carbon dioxide in your lungs). Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had moderate cognitive impairment and received antianxiety, antidepressants, diuretic, and opioid medications. Review of a comprehensive care plan dated 11/27/2023, revealed Resident #1 had .risk for adverse side effects related to anti-anxiety medication, ineffective breathing patterns r/t [related to] COPD, OSA [Obstructive Sleep Apnea], and Pickwickian Syndrome-she is dependent on CPAP [Continuous Positive Airway Pressure/a machine to keep breathing airways open while asleep] at HS [night] .chronic pain d/t [due to] osteoarthritis, cerebral palsy, thoracic spondylosis [the natural wearing down in the mid-back] . Review of the Physician's Orders for Resident #1 dated 4/2024, revealed Resident #1 had the following orders: oxygen 2-4 liters via (by) nasal cannula, Hydrocodone-Acetaminophen tablet (medication used to treat pain) 5-325 milligram (mg) every 6 hours, and Lorazepam (medication used to treat anxiety) 0.5 mg as needed. Further review revealed the resident had a physician's order to wear the CPAP device at night. The nurse was to assist the resident in placing the CPAP device on . Review of the Nurse's Note for Resident #1 dated 4/6/2024, revealed .[Resident #1] was given wrong medication buprenorphine 8-2mg [buprenorphine 8mg-a medication used to opioid use disorder and naloxone 2 mg-an opioid antagonist to treat opioid overdose] .Resident was lethargic .V/S [vital signs] decreased .Resident [Resident #1] became responsive and refused to go to ER [Emergency Room]. Resident was sent to ED [Emergency Department] for Eval [Evaluation]. Resident family and medical director notified of incident . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis, Osteoporosis, Crohn's Disease, and Opioid Dependence. Review of a quarterly MDS assessment dated [DATE], revealed Resident #2 was cognitively intact, received antianxiety, antidepressant, and opioid medications. Review of the comprehensive care plan dated 4/1/2024, revealed Resident #2 .received Suboxone for opioid abuse treatment, at risk for adverse side effects .administer medications as ordered .has chronic pain r/t rheumatoid arthritis and osteoporosis . Review of the Physician's Orders for Resident #2 dated 4/2024, revealed Narcan Nasal Liquid (medication used to treat narcotic overdose) 4 MG/0.1ML (milliliter) and Buprenorphine HCl (hydrochloride)-Naloxone HCl (Suboxone) Sublingual (under the tongue) Tablet 8-2 MG (buprenorphine 8mg-a medication used to opioid use disorder and naloxone 2 mg-an opioid antagonist to treat opioid overdose). Review of the Individual Resident's Controlled Substance Record for Resident #2 dated 4/6/2024 at 6:00 AM, revealed .med [medication] error . Review of the emergency room documentation for Resident #1 dated 4/6/2024, revealed the resident presented with altered mental status after receiving another resident's medications (Resident #2's). The resident was believed to have received Suboxone.She received Narcan . no change [in condition] .hypoxic [low oxygen] requiring a non-rebreather [mask] .rhonchi [movement of fluids and secretions in larger airways in asthma and respiratory infections] .hypercarbia [an increase in carbon dioxide in the blood stream] .CPAP was not on last night . Review of a Medication Error Incident/Investigation report for Resident #1 dated 4/6/2024, revealed the time of the incident 5:00 AM-5:45 AM, .Nurse supervisor [Registered Nurse/RN B] was advised by agency nurse [Licensed Practical Nurse /LPN A] she gave [Resident #1] .suboxone 8-2ml [milliliter] that was intended for [Resident #2] . Review of the hospital documentation for Resident #1 dated 4/6/2024-4/19/2024 revealed during the course of the hospital stay the resident was admitted to the hospital with hypercarbic respiratory failure and was intubated after arrival on 4/6/2024. A hospital ICU stay from 4/6/2024-4/19/2024 occurred and the patient was discharged on 4/19/2024 to a higher level of care. During an interview on 5/6/2024 at 10:10 AM, Resident #2 stated an agency nurse (unable to recall the nurse's name) handed her a cup of medications and Resident #2 informed the nurse the medication was not her medication and told the nurse .go get me my .suboxone . Resident #2 stated she knew it was not suboxone because suboxone was a strip that goes under the tongue and the medication given to her was pills. During a telephone interview on 5/8/2024 at 8:38 AM, LPN A stated she was able to recall the medication error regarding Resident #1 which occurred on 4/6/2024. LPN A stated Resident #1 and Resident #2's names were similar, the rooms were close together, and thought this was the reason she made the error. LPN A stated Resident #1 was awake until 4:00 AM and had refused to wear her (Resident #1) CPAP and at 6:00 AM the nurse went in and administered Resident #1 her medication wrong medication). LPN A stated she went into Resident #2's room to administer medications and resident [#2] refused the medications and stated those medications did not belong to her (Resident #2). LPN A stated she went to assess Resident #1, took the resident's blood pressure, attempted to arouse the resident, and notified the RN Supervisor of the medication error. The RN supervisor and LPN A notified EMS (Emergency Medical Service), physician, and the Resident #1's family of the medication error. LPN A stated she cooperated with the facility staff to investigate the medication error and had not been reassigned to the facility. During an interview on 5/9/2024 at 1:50 PM, the Director of Nursing confirmed LPN A had not followed the five rights of medication administration and Resident #1 received the wrong medication which belonged to Resident #2 on 4/6/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interviews, and observations, the facility failed to implement the comprehensive care plan for providing showers and bed baths for 28 residents (#9, #13, #20, #22, #26, #28, #31, #36, #37, #40, #41, #2, #5, #10, #12, #14, #15, #17, #18, #19, #21, #23, #24, #25, #27, #32, #33, and #39) and failed to ensure the comprehensive care plan was person centered for shower and bathing preferences for 6 residents (#13, #1, #16, #30, #34, and #38) of 42 care plans reviewed. The facility's failure resulted in psychosocial harm to 11 residents (#9, #13, #20, #22, #26, #28, #31, #36, #37, #40, and #41). The findings include: Review of the facility policy titled, Care Plan Comprehensive, Revised 11/8/2022, showed .To ensure .each resident's person-centered, comprehensive care plan .is reviewed and revised by the interdisciplinary team .who have knowledge of the resident and .needs .The care plan must be reviewed after each assessment .and revised based on .preferences and needs of the resident . Resident #9 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Type 2 Diabetes Mellitus, Schizophrenia, Fusion of Spine, and Intraspinal Abscess. Review of the comprehensive care plan dated 9/9/2022 showed, Resident #9 had an Activities of Daily Living (ADL) self-care performance deficit with an intervention including .showers 2xs [times] .week . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 required extensive 2 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #9 had received 2 showers and 4 bed baths from 11/1/2022-2/5/2023. During an interview and observation on 1/10/2023 at 2:40 PM, Resident #9 stated he had not received a shower. The staff provide peri-care (perineal care - cleaning of the private parts) routinely and he was unsure why he had not received the scheduled showers. The resident's hair appeared greasy. During an interview on 2/6/2023 at 10:35 AM, Certified Nurse Aide (CNA) #7 stated Resident #9 had reported to her (unsure of the exact date) he had not received showers and felt nasty. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Chronic Pain Syndrome, and Dementia. Review of the comprehensive care plan dated 6/5/2021 and revised on 3/18/2022, showed Resident #13 had an ADL self-care performance deficit and the resident's shower schedule and preference for bathing was not indicated. Review of a quarterly MDS assessment dated [DATE], showed Resident #13 was independent with set up help for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #13 received 4 showers and 1 bed bath from 11/1/2022-2/5/2023. During an observation and interview on 1/9/2023 at 3:44 PM, Resident #13 was asked if he had received a shower and the resident stated .you must be joking .I have not had a shower in over a month . The resident's hair was greasy, and he stated he would like to have a shower. During an interview on 2/9/2023 at 7:40 AM, Resident #13 stated he felt .unclean . when he did not receive a shower. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Depressive Disorders, Diabetes Mellitus, Morbid Obesity, Overactive Bladder, Chronic Pain Syndrome, and Bipolar Disorder Disease. Review of the comprehensive care plan dated 9/9/2022, showed Resident #20 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #20 required extensive 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #20 received 3 showers and 3 bed baths from 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 9:05 AM, Resident #20 stated she had not received showers and it made her feel crappy when she had not received the scheduled showers. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fusion of Spine Cervical Region, Major Depressive Disorder, Chronic Pain Syndrome, and Dementia. Review of the comprehensive care plan dated 9/9/2022, showed Resident #22 had an ADL self-care performance deficit with an intervention including .Showers 2xs .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #22 required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #22 received 11 showers and 1 bed bath between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 2:25 PM, Resident #22 stated .it [showers] was a problem .I felt bad because I was not getting a shower . Resident #26 was admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, and Depression. Review of the comprehensive care plan dated 7/23/2022, showed Resident #26 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #26 required limited 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #26 received 9 showers and no bed baths between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 5:30 AM, Resident #26 stated she had not received scheduled showers. The resident stated when she did not receive the showers .it upsets me .I want to be clean . Resident #28 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Type 2 Diabetes Mellitus, Chronic Pain Syndrome, and Personality Disorder. Review of the comprehensive care plan dated 6/8/2021, showed Resident #28 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week .Assist with shower/bed bath per residents preference as scheduled 2xs per week .PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #28 required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #28 received 9 showers and 7 bed baths between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 4:40 AM, Resident #28 stated she had not received the scheduled showers .I was mad .I was not getting my showers . Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Depression. Review of the comprehensive care plan dated 7/15/2022, showed Resident #31 had an ADL self-care performance deficit with an intervention including .May have showers 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #31 required extensive 1 staff assistance for dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #31 had received 15 showers and 2 bed baths between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 8:05 AM, Resident #31 stated she had not received scheduled showers. The resident stated when she had not received a shower, it made her feel .terrible and yucky .I wiped myself off, but it was not doing the job . Resident #36 was admitted to the facility on [DATE], was discharged on 1/1/2023, and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, Depression, and Morbid (Severe) Obesity. Review of the comprehensive care plan dated 4/5/2022, showed Resident #36 had an ADL self-care performance deficit with an intervention including .showers 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #36 required extensive 2 staff assistance with dressing, personal hygiene, and required extensive 1 person assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #36 had received 1 shower and 6 bed baths between 11/1/2022-2/5/2023 (Resident #36 was out of the facility from 1/1/2023-1/6/2023). During an interview on 2/6/2023 at 12:00 PM, Resident #36 stated .I want to feel clean .I don't like to be dirty .I don't want to get in trouble for telling you this . Resident #37 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Lack of Coordination, Major Depressive Disorder, and Seizures. Review of the comprehensive care plan dated 9/11/2022, showed Resident #37 had an ADL self-care performance deficit with an intervention including .showers offered 2xs .week and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #37 required limited 1 staff assistance with dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #37 received 4 showers and no bed baths between 11/1/2022-2/5/2023. During an interview on 1/9/2023 at 2:15 PM, Resident #37 stated .they .don't give me a shower . During an interview on 2/6/2022 at 9:22 AM, Resident #37 stated she had not received routine showers and it made her .feel dirty . Resident #40 was admitted to the facility on [DATE], discharged on 11/19/2022 and readmitted [DATE] with diagnoses including Osteomyelitis of Vertebra, Lumbar Region, Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Depression, Essential Hypertension, and Chronic Kidney Disease. Review of the comprehensive care plan dated 9/19/2022, showed Resident #40 had an ADL self-care performance deficit with an intervention of .may have showers 2xs .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #40 required extensive 1 staff assistance with dressing, personal hygiene, and totally dependent on 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #40 received 8 showers and 6 bed baths between 11/1/2022-11/19/2023 and 11/30/2023-2/5/2023. During an interview on 2/6/2023 at 5:15 AM, Resident #40 stated she had not received the scheduled showers. Resident #40 stated .when I didn't get a shower .It made me angry . Resident #41 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Acute Respiratory Failure with Hypoxia, Repeated Falls, Systemic Lupus Erythematosus, Morbid Obesity with Alveolar Hypoventilation, Depression, Congestive Heart Failure, and Anxiety Disorder. Review of the comprehensive care plan dated 9/19/2022 showed Resident #41 had an ADL self-care performance deficit with an intervention of .showers offered 2xs .week . Review of a quarterly MDS assessment dated [DATE], showed Resident #41 required extensive 1 staff assistance for dressing, 1 staff supervision assistance with personal hygiene, and totally dependent of 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #41 received 14 showers and no bed baths between 11/1/2022-2/5/2023. During an interview on 2/6/2023 at 5:20 AM, Resident #41 stated .I kept asking for a shower and they [the facility staff] said they couldn't get to me .I went 12 days without a shower .I felt nasty .I didn't get a shower .I like to maintain my appearance . Resident #2 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Diabetes Mellitus, Hepatic Failure, Cirrhosis of the Liver, Acute Hepatitis C, and Rheumatic Heart Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #2 required limited 1 staff assistance with dressing, personal hygiene, and was totally dependent on staff for bathing. Review of a quarterly MDS assessment dated [DATE], showed Resident #2 required limited 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the comprehensive care plan revised 12/21/2022, showed Resident #2 had an Activities of Daily Living (ADL) self-care performance deficit with an intervention including .Showers offered 2xs .week and prn . Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #2 received 4 showers from 11/1/2022-2/5/2023. Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dislocation of other Internal Joint Prosthesis, Repeated Falls, Lack of Coordination, Essential Hypertension, and Dementia with Severe Psychotic Disturbance. Review of the comprehensive care plan dated 9/9/2022, showed Resident #5 had an ADL self-care performance deficit with an intervention including .May have showers 2xs .week and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #5 required extensive assistance of 2 staff members for dressing, personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #5 had received 5 showers from 11/1/2022-2/4/2023. Resident #10 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Adult Failure to Thrive, and Repeated Falls. Review of the comprehensive care plan dated 9/11/2022, showed Resident #10 had an ADL self-care performance deficit with an intervention including .showers 2xs per week and PRN [as needed] . Review of a quarterly MDS assessment dated [DATE], showed Resident #10 required total dependence of 2 staff assistance for dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #10 received 10 showers and 14 bed baths from 11/1/2022-2/5/2023. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Muscle Weakness, Chronic Pain Syndrome, Moderate Protein-Calorie Malnutrition, Schizoaffective Disorder, Recurrent Depressive Disorders, Generalized Anxiety Disorder, and Dementia. Review of a comprehensive care plan dated 11/11/2020 and revised 12/8/2022, showed Resident #12 had an ADL self-care deficit with an intervention including .May have showers 2 x .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #12 required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #12 received 2 showers and 2 bed baths between 11/1/2022-2/5/2023. Resident #14 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Diabetes Mellitus, Stage 3 Chronic Kidney Disease, Major Depressive Disorder, and Interstitial Pulmonary Disease. Review of a comprehensive care plan dated 4/24/2022, showed Resident #14 had an ADL self-care performance deficit with an intervention including .showers 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #14 required extensive 1 staff assistance for dressing, personal hygiene and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #14 received 12 showers and 2 bed baths between 11/1/2022-2/5/2023. Resident #15 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Vascular Dementia, Hemiplegia and Hemiparesis. Review of a comprehensive care plan dated 9/9/2022, showed Resident #15 had an ADL self-care deficit with an intervention including .showers offered 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #15 required extensive 2 staff assistance with dressing, extensive 1 staff assistance with personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #15 received 6 showers and 8 bed baths between 11/1/2022-2/5/2023. Resident #17 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit, Chronic Pain Syndrome, Cirrhosis of the Liver, and Generalized Anxiety Disorder. The resident was discharged from the facility on 1/23/2023. Review of a comprehensive care plan dated 8/26/2022, showed Resident #17 had an ADL self-care performance deficit with an intervention including .showers 2xs per week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #17 had moderate cognitive impairment, required limited 1 staff assistance for dressing, extensive 1 staff assistance with personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #17 received 7 showers and no bed baths between 11/1/2022-1/23/2023. Resident #18 was admitted to the facility on [DATE], discharged on 12/24/2022, and readmitted on [DATE] with diagnoses including Cerebral Infarction, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Gastrostomy Status. Review of the comprehensive care plan revised 12/29/2022, showed Resident #18 had an ADL self-care performance deficit with an intervention including .showers 2xs per week and prn . Review of a discharge MDS assessment dated [DATE], showed Resident #18 required extensive assistance for dressing, personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #18 had received 1 shower and 2 bed baths between 11/12/2022-2/5/2023. Resident #19 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Bipolar Disorder, and Schizoaffective Disorder. Review of the comprehensive care plan dated 9/9/2022, showed Resident #19 had an ADL self-care performance deficit with an intervention including .showers offered 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #19 required limited 1 staff assistance for dressing, extensive 1 staff assistance for personal hygiene, and was totally dependent of 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #19 received 11 showers and no bed baths between 11/1/2022-2/5/2023. Resident #21 was admitted to the facility on [DATE] with diagnoses including Dementia, Major Depressive Disorder, Bipolar Disorder, and Adult Failure to Thrive. Review of the comprehensive care plan dated 9/9/2022, showed Resident #21 had an ADL self-care performance deficit with an intervention including .showers offered 2xs .week and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #21 required extensive 2 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #21 received 10 showers and 7 bed baths from 11/1/2022-2/5/2023. Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Nontraumatic Subdural Hemorrhage, Atrial Fibrillation, and Dementia. Review of the comprehensive care plan revised 9/10/2022, showed Resident #23 had an ADL self-care performance deficit with an intervention including .Offer Showers x [times] 2 .week . Review of a quarterly MDS assessment dated [DATE], showed Resident #23 required extensive assistance 2 staff members for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #23 received 5 showers and 1 bed bath from 11/1/2022-2/5/2023. Resident #24 was admitted to the facility on [DATE] with diagnoses including Nontraumatic Intracerebral Hemorrhage, Psychosis, and Dementia. Review of the comprehensive care plan dated 9/11/2022, showed Resident #24 had an ADL self-care performance deficit with an intervention including .Showers 2xs .week and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #24 required limited assistance of 1 staff member for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #24 received 1 shower and 1 bed bath from 11/1/2022-2/5/2023. Resident #25 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Fracture of Vertebra, Nontraumatic Subdural Hemorrhage, and Schizophrenia. Review of the comprehensive care plan dated 6/8/2022, showed Resident #25 had an ADL self-care performance deficit with an intervention including .May have showers 2xs per week .and PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #25 required supervision of 1 staff assistance for dressing, extensive 1 staff assistance for personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #25 received 9 showers and no bed baths between 11/1/2022-2/5/2023. Resident #27 was admitted to the facility on [DATE], discharged from the facility 12/17/2022, and readmitted on [DATE] with diagnoses including Muscle Weakness, Chronic Obstructive Pulmonary Disease, and Depression. Review of the comprehensive care plan dated 11/30/2022, showed Resident #27 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week . Review of an admission MDS assessment dated [DATE], showed Resident #27 required total assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #27 received 9 showers and 2 bed baths between 11/28/2022-2/5/2023. Resident #32 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Hemiplegia and Hemiparesis, Traumatic Brain Injury, and Dementia. Review of the comprehensive care plan revised 7/31/2022, showed Resident #32 had an ADL self-care performance deficit with an intervention in place including .Showers/bed bath offered 2xs per week per his preference . Review of a quarterly MDS assessment dated [DATE], showed Resident #32 required extensive 2 staff assistance with dressing, extensive 1 staff assistance with personal hygiene, and required 2 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #32 received 5 showers and 10 bed baths between 11/1/2022-2/5/2023 Resident #33 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Dementia, and Type 2 Diabetes Mellitus. Review of the comprehensive care plan dated 6/17/2022, showed Resident #33 had an ADL self-care performance deficit with an intervention including .showers offered 2xs per week . Review of a quarterly MDS assessment dated [DATE], showed Resident #33 required extensive 1 staff assistance with dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #33 received 14 showers and 1 bed bath between 11/1/2022-2/5/2023. Resident #39 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Hemiparesis and Hemiplegia following Cerebral Infarction, Dementia without Behavior Disturbance, Lack of Coordination, Depression, Essential Hypertension, and Gangrene. Review of the comprehensive care plan dated 9/9/2022, showed Resident #39 had an ADL self-care performance deficit with an intervention of .showers 2xs .week . Review of a quarterly MDS assessment dated [DATE], showed Resident #39 required extensive 1 person staff assistance with dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #39 had received 13 showers and 2 bed baths between 11/1/2022-2/5/2023. Resident #1 was admitted to the facility on [DATE] with diagnoses including Polyneuropathy, Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, Respiratory Failure with Hypoxia, and Alzheimer's Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #1 required extensive 1 staff assistance with dressing, personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the comprehensive care plan dated 11/14/2022, showed Resident #1 had an ADL self-care performance deficit with no interventions to address a schedule for showers or the resident's shower preference. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #1 had received 8 showers from 11/4/2022-2/5/2023, a period of 94 days. Resident #16 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Paranoid Schizophrenia, Cerebral Infarction, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], showed Resident #16 required extensive 1 staff assistance for dressing, limited 1 staff assistance for personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of a comprehensive care plan revised 11/4/2022, showed Resident #16 had an ADL self-care deficit with an intervention including .Assist with ADLs as needed by providing one staff assist . Continued review showed the care plan did not reflect scheduled shower days or the resident's preference for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #16 had received 1 shower on 2/1/2023 and no bed baths. Resident #30 was admitted to the facility on [DATE] with diagnoses including Fracture of Femur, Essential Hypertension, and Dementia. The resident was discharged from the facility on 1/27/2023. Review of an admission MDS assessment dated [DATE], showed the activity of bathing had not occurred. Review of the comprehensive care plan dated 12/22/2022, showed Resident #30 had an ADL self-care performance deficit care plan and did not reflect scheduled shower days or the resident's preference for bathing. The facility did not provide shower documentation from 12/22/2022-12/31/2022. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/21/2022-1/27/2023 showed Resident #30 had received 1 shower and no bed baths. Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis, Heart Failure, and Hyperlipidemia. Review of the comprehensive care plan dated 6/29/2022, showed Resident #34 had an ADL self-care performance deficit with no intervention to address a schedule for showers. Review of a quarterly MDS assessment dated [DATE], showed Resident #34 required extensive 2 staff assistance with dressing, extensive 1 person assistance with personal hygiene, and 2 staff total dependence for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #34 received 1 shower and no bed baths between 11/1/2022-2/5/2023. Resident #38 was admitted to the facility on [DATE] with diagnoses including, Cerebral Infarction, Dementia, Anxiety Disorder, Hemiparesis and Hemiplegia. Review of the comprehensive care plan dated 12/2/2022, showed Resident #38 had an ADL self-care performance deficit with no intervention to include a shower schedule or preference for bathing. Review of an admission MDS assessment dated [DATE], showed Resident #38 required extensive 1 staff assistance with dressing, total dependence of 2 staff assistance for personal hygiene, and extensive 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #38 had received 4 showers and 7 bed baths between 12/3/2022-2/5/2023. During an interview on 1/13/2023 at 3:32 PM, the Director of Nursing (DON) stated the expectation was for the residents to receive a shower 2 times a week according to their care plan and confirmed the resident care plans were not followed. During an interview on 1/13/2023 at 3:53 PM, the MDS Coordinator stated the resident's bathing schedule and bathing preference should be placed on the resident's care plan. She also stated, I try to place it [bathing schedule or preference] on there [the care plan] but missed some. During an interview on 2/7/2023 at 10:30 AM, the MDS Coordinator stated after she had identified the activity of bathing had not occurred during the MDS assessments on several of the residents, she notified the DON. The MDS Coordinator stated she informed the DON the staff had not documented the showers. Refer to tags F-677

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, medical record review, interviews, and observations, the facility failed to provide showers and bathing for 33 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, #41, #1, #2, #5, #12, #15, #16, #17, #18, #19, #21, #23, #24, #25, #27, #30, #32, #33, #34, #38, and #39) of 64 residents reviewed. The facility failed to provide incontinence care for 4 residents (#10, #14, #32, and #11) of 14 residents reviewed for incontinence care. The facility's failure resulted in psychosocial harm to 13 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, and #41). The facility was cited F-677 at a scope and severity of H (Harm) which constitutes Substandard Quality of Care. The findings include: Review of the facility policy titled, Aspects of Daily Nursing Care, effective date 9/22/2022, showed .Residents will be provided with care, treatment and services to assist the resident in attaining and maintaining .psychosocial well-being to ensure quality of life .Clinical services is responsible for the assessment and delivery of nursing needs .activities of daily living [ADL] .to prevent complications of psychosocial intervention . Resident #9 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Type 2 Diabetes Mellitus, Schizophrenia, Fusion of Spine, and Intraspinal Abscess. Review of the comprehensive care plan dated 9/9/2022 showed Resident #9 had an Activities of Daily Living (ADL) self-care performance deficit with an intervention including .showers 2xs [2 times] .week . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, required extensive 2 staff assistance for dressing, and personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #9 had not received a shower or bed bath for the 30-day period. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #9 had received 1 shower on 12/4/2022 and 1 bed bath for the period. The documentation showed a period of 33 days between 11/1/2022-12/4/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #9 had received 1 shower on 1/11/2023 and 2 bed baths. The documentation showed a period of 58 days between 12/4/2022-1/31/2023 the resident had not received showers or baths. Review of the ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023 showed Resident #9 had not received a shower and had received 1 bed bath. Review of the ADL-Bathing and Skin Alert documentation showed Resident #9 had received 2 showers and 4 bed baths from 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #9 had not refused any baths or showers. During an interview and observation on 1/10/2023 at 2:40 PM, Resident #9 stated he had not received a shower. The staff provide peri-care (perineal care - cleaning of the private parts) routinely and he was unsure why he had not received the scheduled showers. The resident's hair appeared greasy. During an interview on 2/6/2023 at 9:56 AM, Resident #9 stated he had not received the scheduled showers and it made him feel .dirty .I have bad under arm odor, and I didn't smell too good . During an interview on 2/6/2023 at 10:35 AM, Certified Nurse Aide (CNA) #7 stated Resident #9 had reported to her (unsure of the exact date) he had not received showers and felt nasty. Resident #10 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Adult Failure to Thrive, and Repeated Falls. Review of the comprehensive care plan dated 9/11/2022, showed Resident #10 had severe cognitive impairment, and an ADL self-care performance deficit with an intervention including .showers 2xs per week and PRN [as needed] .has bowel/bladder incontinence r/t [related to] dementia, impaired mobility .Check resident every 2 hours and assist with toileting . Review of a quarterly MDS assessment dated [DATE], showed Resident #10 scored a 6 on the BIMS, indicating cognitive impairment, and required total dependence of 2 staff assistance for dressing, personal hygiene, and bathing. The resident was always incontinent of bladder and bowel. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #10 had received 4 showers, on 11/1/2022, 11/5/2022, 11/13/2022, 11/19/2022, and 2 bed baths. The documentation showed a period of 7 days between 11/5/2022-11/13/2022 and 10 days between 11/19/2022-11/30/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #10 had received 5 showers on 12/3/2022, 12/17/2022, 2/24/2022, 12/28/2022, 12/30/2022 and 4 bed baths. The documentation showed a period of 14 days between 11/19/2022-12/3/2022 and 14 days between 12/3/2022-12/17/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #10 had received 2 showers and 6 bed baths. The documentation showed a period of 14 days between 12/28/2022-1/11/2023, and a period of 13 days between, 1/18/2023-1/31/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #10 had not received a shower and received 2 bed baths. The documentation showed a period of 18 days between 1/18/2023-2/5/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #10 received 11 showers and 14 bed baths from 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #10 had not refused any baths or showers. During an observation and interview in the resident's room with the Director of Nursing (DON) and CNA #2 on 1/11/2023 at 6:10 AM, Resident #10 was lying in bed with her eyes closed and the bed linens and gown was saturated with urine, a brown ring was on the resident's incontinence pad, and a strong odor of urine was noted. CNA #2 confirmed Resident #10 was saturated with urine. The DON stated her expectation was for residents to be provided incontinence care every 2 hours. Resident #10 was unable to be interviewed on 1/11/2023 due to her severe cognitive impairment. During an observation and interview on 2/6/2023 at 4:30 AM, with CNA #11 and Licensed Practical Nurse (LPN) #4, Resident #10 was lying in bed with eyes closed, the bed linen and gown was saturated with urine, the incontinence pad had a brown ring, and the room smelled of urine. CNA #11 stated she had provided incontinence care around 3:00 AM. CNA #11 and LPN #4 confirmed Resident #10 was saturated with urine, the incontinence pad had a brown ring, and the room smelled of urine. During an interview on 2/6/2023 at 8:28 AM, CNA #5 stated she had witnessed Resident #10 saturated with urine multiple times (unable to recall the exact dates) and had reported it to the nurses and DON. During an interview on 2/7/2023 at 10:43 AM, CNA #16 stated she had often observed Resident #10 saturated with urine when she arrived on shift. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Chronic Pain Syndrome, and Dementia. Review of the comprehensive care plan dated 6/5/2021 and revised on 3/18/2022, showed Resident #13 had an ADL self-care performance deficit and did not reflect a shower schedule or the resident's preference for bathing. Review of a quarterly MDS assessment dated [DATE], showed Resident #13 scored a 12 on the BIMS, indicating moderate cognitive impairment. The resident was independent with set up help for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed the resident had received 1 shower on 11/29/2022 and 1 bed bath. The documentation showed a period of 28 days between 11/1/2022-11/29/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #13 had received 1 shower on 12/16/2022 and no bed baths. The documentation showed a period of 16 days between 11/29/2022-12/16/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #13 had received 1 shower on 1/20/2023 and no bed baths. The documentation showed a period of 34 days between 12/16/2022-1/20/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #13 received 1 shower on 2/3/2023 and no bed baths. Review of the ADL-Bathing and Skin Alert documentation showed Resident #13 received 4 showers and 1 bed bath from 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #13 had not refused any baths or showers. During an observation and interview on 1/9/2023 at 3:44 PM, Resident #13 was asked if he had received a shower and the resident stated .you must be joking .I have not had a shower in over a month . The resident's hair was greasy, and he stated he would like to have a shower. During an interview on 2/9/2023 at 7:40 AM, Resident #13 stated prior to 2 weeks ago, he had not received scheduled showers. The resident stated he wanted a shower and felt .unclean . when he did not receive a shower. Resident #14 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Diabetes Mellitus, Stage 3 Chronic Kidney Disease, Major Depressive Disorder, and Interstitial Pulmonary Disease. Review of a comprehensive care plan dated 4/24/2022, showed Resident #14 had an ADL self-care performance deficit with an intervention including .showers 2xs per week . TOILET USE .The resident requires assistance .for toileting needs .Incontinence Care Plan .Check and change monitor for incontinence . Review of a quarterly MDS assessment dated [DATE], showed Resident #14 scored a 14 on the BIMS which indicated the resident was cognitively intact. The resident required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing. The resident was totally dependent on 2 staff assistance for toilet use. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #14 had received 3 showers on 11/20/2022, 11/27/2022, 11/29/2022, and had received 1 bed bath. The documentation showed a period of 19 days from 11/1/2022-11/20/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #14 received 4 showers on 12/9/2022, 12/13/2022, 12/16/2022, 12/20/2022, and no bed baths. The documentation showed a period of 10 days between 12/20/2022-12/31/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #14 had received 3 showers on 1/11/2023, 1/17/2023, 1/31/2023, and 1 bed bath. The documentation showed a period of 21 days between 12/20/2022-1/11/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #14 had received 1 shower on 2/1/2023 and no bed baths. Review of the ADL-Bathing and Skin Alert documentation showed Resident #14 received 12 showers and 2 bed baths between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #14 had not any refused baths or showers. During an observation and interview with Registered Nurse (RN) #2 on 1/11/2023 at 5:02 AM, Resident #14 was lying in bed with eyes closed and bed linens, gown, and brief were saturated with urine, with a brown ring on the incontinence pad. RN #2 stated .yeah that one is pretty wet .It's saturated with urine both the brief and pad .its brown ringed . During an interview on 2/6/2023 at 5:05 AM, LPN #4 stated she observed Resident #14 saturated with urine when she arrived on shift and was unable to recall the exact dates. LPN #4 stated Resident #14 .seemed upset because she hadn't been changed and was left wet during the night . Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Depressive Disorders, Diabetes Mellitus, Morbid Obesity, Overactive Bladder, Chronic Pain Syndrome, and Bipolar Disorder Disease. Review of the comprehensive care plan dated 9/9/2022, showed Resident #20 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #20 scored a 12 on the BIMS which indicated moderate cognitive impairment. The resident required extensive 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #20 received 1 shower on 11/1/2022 and 1 bed bath. The documentation showed a period of 29 days between 11/2/2022-11/30/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #20 had not received a shower, and received 1 bed bath. The documentation showed a period of 60 days between 11/1/2022-12/31/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #20 had received 2 showers on 1/11/2023, and 1/2023, and 1 bed bath. The documentation showed a period of 70 days between 11/2/2022-1/31/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #20 had not received a shower or a bed bath. Review of the ADL-Bathing and Skin Alert documentation showed Resident #20 received 3 showers and 3 bed baths from 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #20 had not refused any baths or showers. During an interview on 2/6/2023 at 9:05 AM, Resident #20 stated she had not received showers and it made her feel crappy when she had not received the scheduled showers. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fusion of Spine Cervical Region, Major Depressive Disorder, Chronic Pain Syndrome, and Dementia. Review of the comprehensive care plan dated 9/9/2022, showed Resident #22 had an ADL self-care performance deficit with an intervention including .Showers 2xs .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #22 scored a 14 on the BIMS which indicted the resident was cognitively intact. The resident required extensive 1 staff assistance for dressing and personal hygiene and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #22 had received 3 showers on 11/5/2022, 11/6/2022, 11/30/2022, and 1 bed bath. The documentation showed a period of 23 days between 11/6/2022-11/30/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #22 had received 3 showers on 12/16/2022, 12/22/2022, 12/28/2022, and no bed baths. The documentation showed a period of 15 days between 11/30/2022-12/16/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #22 had received 3 showers on 1/6/2023, 1/11/2023, 1/20/2023, and no bed baths. The documentation showed a period of 8 days between 12/28/2022-1/6/2023, and 8 days between 1/11/2023-1/20/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #22 had received 2 showers on 2/1/2023, 2/4/2023, and no bed baths. The documentation showed a period of 11 days between 1/20/2023-2/1/2023 the resident had not received showers or baths. Review of the ADL-Bathing and Skin Alert documentation showed Resident #22 received 11 showers and 1 bed bath between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #22 had not refused any baths or showers. During an interview on 2/6/2023 at 2:25 PM, Resident #22 stated she received showers currently, but prior to 2 weeks ago .it [showers] was a problem .I felt bad because I was not getting a shower . Resident #26 was admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, and Depression. Review of the comprehensive care plan dated 7/23/2022 showed Resident #26 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/11/2022-11/30/2022, showed Resident #26 had received 1 shower on 11/13/2022 and no bed baths. The documentation showed a period of 17 days between 11/11/2022-11/30/2022 the resident had not received showers or baths. Review of a quarterly MDS assessment dated [DATE], showed Resident #26 scored a 14 on the BIMS which indicated the resident was cognitively intact. The resident required limited 1 staff assistance for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #26 had received 2 showers on 12/6/2022, 12/16/2022, and no bed baths. The documentation showed a period of 9 days between 12/6/2022-12/16/2022 and 14 days between 12/16/2022-12/31/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #26 had received 5 showers on 1/4/2023, 1/11/2023, 1/20/2023, 1/21/2023, 1/24/2023, and no bed baths. The documentation showed a period of 18 days between 12/16/2022-1/4/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #26 had received 1 shower on 2/3/2023 and no bed baths. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #26 received 9 showers and no bed baths between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #26 had not refused any baths or showers. During an interview on 2/6/2023 at 5:30 AM, Resident #26 stated prior to 2-3 weeks ago, she had not received scheduled showers. The resident stated when she did not receive the showers .it upsets me .I want to be clean . Resident #28 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus, and Chronic Pain Syndrome. Review of the comprehensive care plan dated 6/8/2021, showed Resident #28 had an ADL self-care performance deficit with an intervention including .Showers offered 2xs per week .Assist with shower/bed bath per residents preference as scheduled 2xs per week .PRN . Review of a quarterly MDS assessment dated [DATE], showed Resident #28 had a BIMS of 13, indicating cognitively intact, required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #28 received 2 showers on 11/4/2022, 11/29/2022, and 4 bed baths. The documentation showed a period of 24 days between 11/4/2022-11/29/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #28 had received 4 showers on 12/9/2022, 12/13/2022, 12/16/2022, 12/23/2022, and had received 1 bed bath. The documentation showed a period of 7 days between 11/29/2022-12/9/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #28 had received 3 showers on 1/6/2023, 1/17/2023, 1/31/2023, refused a shower on 1/10/2023, and had received 2 bed baths. The documentation showed a period of 10 days between 12/27/2022-1/6/2023 the resident had not received showers or baths. The facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #28 had not received a shower or a bed bath and refused a shower on 2/3/2023. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #28 received 9 showers and 7 bed baths between 11/1/2022-2/5/2023, a period of 97 days. During an interview on 2/6/2023 at 4:40 AM, Resident #28 stated prior to the past 2 weeks, she had not received scheduled showers .I was mad .I was not getting my showers . Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Depression. Review of the comprehensive care plan dated 7/15/2022, showed Resident #31 had an ADL self-care performance deficit with an intervention including .May have showers 2xs per week . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #31 received a total of 4 showers on 11/13/2022, 11/14/2022, 11/23/2022, 11/27/2022, and had received 2 bed baths. The documentation showed a period of 12 days between 11/1/2022-11/12/2022 and 8 days between 11/14/2022-11/23/2022 the resident had not received showers or baths. Review of a quarterly MDS assessment dated [DATE], showed Resident #31 scored a 13 on the BIMS which indicated the resident was cognitively intact. The resident required extensive 1 staff assistance for dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #31 received 3 showers on 12/4/2022, 12/6/2022, 12/24/2022, and 1 bed bath. The documentation showed a period of 17 days between 12/4/2022-12/24/2022 the resident did not receive showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #31 had received 3 showers on 1/6/2023, 1/18/2023, 1/25/2023, and no bed baths. The documentation showed a period of 12 days between 12/24/2022-1/6/2023 and 11 days between 1/6/2023-1/18/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #31 had received 1 shower on 2/4/2023 and no bed baths. The documentation showed a period of 9 days between 1/25/2023-2/4/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #31 had received 11 showers and 3 bed baths between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #31 had not refused any baths or showers. During an interview on 1/10/2023 at 2:31 PM, CNA #5 stated Resident #31 had not received scheduled showers. During an interview on 2/6/2023 at 8:05 AM, Resident #31 stated prior to the past 2 weeks she had not received scheduled showers. The resident stated when she had not received a shower, it made her feel .terrible and yucky .I wiped myself off, but it was not doing the job . The resident stated the staff had informed her there was not enough staff to assist her with a shower. Resident #36 was admitted to the facility on [DATE], discharged on 1/1/2022 and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, Depression, and Morbid (Severe) Obesity. Review of the comprehensive care plan dated 4/5/2022, showed Resident #36 had an ADL self-care performance deficit with an intervention including .showers 2xs per week . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #36 had not received a shower and received 3 bed baths. The documentation showed a period of 30 days between 11/1/2022-11/30/2022 the resident did not receive showers or baths. Review of a quarterly MDS assessment dated [DATE], showed Resident #36 scored an 11 on the BIMS which indicated moderate cognitive impairment. The resident required extensive 2 staff assistance with dressing and personal hygiene and required extensive 1 person assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #36 had not received a shower and received 2 bed baths. The documentation showed a period of 61 days between 11/1/2022-12/31/2022 the resident did not receive showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #36 had received no showers and 1 bed bath. The documentation showed a period of 87 days between 11/1/2022-1/31/2023 the resident had not received showers or baths (the resident was out of the facility from 1/1/2023-1/6/2023). Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed the resident had a shower on 2/4/2023 and no bed baths. Review of the facility's ADL-Bathing and Skin Alert showed Resident #36 had received 1 shower and 6 bed baths between 11/1/2022-1/11/2023, a period of 92 days. Medical record review showed Resident #36 had not refused any baths or showers. During an interview on 2/6/2023 at 12:00 PM, Resident #36 stated she had a .glorious shower on Saturday [2/4/2023] . Resident #36 stated prior to 2/4/2023, she had not received scheduled showers .I want to feel clean .I don't like to be dirty .I don't want to get in trouble for telling you this . Resident #37 was admitted to the facility on [DATE] with diagnosis including Parkinson's Disease, Lack of Coordination, Major Depressive Disorder, and Seizures. Review of the comprehensive care plan dated 9/11/2022, showed Resident #37 had an ADL self-care performance deficit with an intervention including .showers offered 2xs .week and PRN . Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/30/2022, showed Resident #37 had not received a shower or a bed bath. The documentation showed a period of 30 days between 11/1/2022-11/30/2022 the resident had not received showers or baths. Review of a quarterly MDS assessment dated [DATE], showed Resident #37 scored an 11 on the BIMS which indicated moderate cognitive impairment. The resident required limited 1 staff assistance with dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #37 had received 1 shower on 12/9/2022 and no bed baths. The documentation showed a period of 38 days between 11/1/2022-12/9/2022 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #37 had received 3 showers on 1/11/2022, 1/19/2023, 1/31/2023, and no bed baths. The documentation showed a period of 32 days the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Check documentation dated 2/1/2023-2/5/2023 showed, Resident #37 had not received a shower or a bed bath. Review of the facility's ADL-Bathing and Skin Alert documentation showed Resident #37 received 4 showers and no bed baths between 11/1/2022-2/5/2023, a period of 97 days. Medical record review showed Resident #37 had not refused any baths or showers. During an interview on 1/9/2023 at 2:15 PM, Resident #37 stated .they .don't give me a shower . During an interview on 2/6/2022 at 9:22 AM, Resident #37 stated she received showers now. The resident stated she had not received routine showers prior to the past couple of weeks and it made her .feel dirty . Resident #40 was admitted to the facility on [DATE], discharged from the facility on 11/19/2022, and readmitted [DATE] with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, and Depression. Review of the comprehensive care plan dated 9/19/2022, showed Resident #40 had an ADL self-care performance deficit with an intervention of .may have showers 2xs .week and prn . Review of a quarterly MDS assessment dated [DATE], showed Resident #40 scored a 15 on the BIMS which indicated the resident was cognitively intact. The resident required extensive 1 staff assistance with dressing, personal hygiene, and totally dependent on 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Alert documentation dated 11/1/2022-11/19/2022, showed Resident #40 had received 1 shower on 11/1/2022 and 2 bed baths. The documentation showed a period of 18 days between 11/1/2022-11/19/2022 the resident did not receive showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 12/1/2022-12/31/2022, showed Resident #40 had received 4 showers on 12/9/2022, 12/13/2022, 12/16/2022, 12/23/2022, and 1 bed bath. The documentation showed a period of 37 days between 11/1/2022-12/9/2022 the resident did not receive showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 1/1/2023-1/31/2023, showed Resident #40 had received 2 showers on 1/6/2023, 1/17/2023, and 3 bed baths. The documentation showed a period of 13 days between 12/23/2022-1/6/2023 and 14 days between 1/17/2023-1/31/2023 the resident had not received showers or baths. Review of the facility's ADL-Bathing and Skin Alert documentation dated 2/1/2023-2/5/2023, showed Resident #40 received 1 shower on 2/3/2023 and no bed baths. The shower documentation showed Resident #40 received 8 showers and 6 bed baths between 11/1/2022-11/19/2023 and 11/30/2023-2/5/2023, a period of 83 days. Medical record review showed Resident #40 had not refused any baths or showers. During an interview on 2/6/2023 at 5:15 AM, Resident #40 stated she had not received scheduled showers prior to the past 2 weeks. Resident #40 stated .when I didn't get a shower .It made me angry . Resident #41 was admitted to the facility on [DATE] with diagnoses including Systemic Lupus Erythematosus, Morbid Obesity, Depression, and Congestive Heart Failure. Review

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Facility Assessment, review of Resident Census and Conditions of Residents Form Center for Medicare and Medicaid Services (CMS)-672, review of Job Descriptions, medical record review, observations, interviews, and review of staffing schedules and time punches, the facility failed to ensure sufficient staffing levels to meet Activities of Daily Living (ADL) care needs of 33 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, #41, #1, #2, #5, #12, #15, #16, #17, #18, #19, #21, #23, #24, #25, #27, #30, #32, #33, #34, #38, and #39) of 64 residents reviewed for bathing. The facility failed to ensure sufficient staffing levels to meet the care needs related to incontinence care for 4 dependent residents (#10, #11, #14, and #32) of 13 residents reviewed for incontinence care. The facility's failure resulted in psychosocial harm to 13 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40 and #41). The findings include: Review of the document titled, Facility Assessment, dated 9/21/2022, showed .Our Resident Profile .average daily census .65 [residents] .Staffing plan .Based on .resident population and their needs for care and support .overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs .Position .Nurse Aides [Certified Nursing Assistants] [CNA] .Total Number Needed .13-15 a day [penciled in a change of 12-14] . Review of the facility's document titled, CMS-672 Resident Census and Conditions of Residents, dated 1/9/2023, showed the facility had a census of 64 residents, 39 residents with occasional or frequent incontinence of bladder, and 37 residents with occasional or frequent incontinence of bowel. The form showed 24 residents required assistance of 1-2 staff for bathing and 40 residents were dependent on staff for bathing. Review of the facility's document titled, CMS-672 Resident Census and Conditions of Residents, dated 2/6/2023, showed the facility had a census of 64 residents, 48 residents with occasional or frequent incontinence of bladder, and 44 residents with occasional or frequent incontinence of bowel. The form showed 24 residents required assistance of 1-2 staff for bathing and 40 residents were dependent on staff for bathing. Review of the facility document titled, Certified Nursing Assistant [CNA] Job Description, Updated 9/4/2020, showed .Essential Functions .Provide basic nursing care to patients [residents] .that includes actions that meet psychosocial needs and physical needs .Perform basic patient care responsibilities considering needs specific to the standard of care .Maintain awareness of the needs of the .geriatric .patient population .Coordinate .patient care under the direct supervision of an RN [Registered Nurse] .Ability to complete work assignments .in a timely manner . Review of the facility document titled Licensed Practical Nurse (LPN) Job Description, Updated 9/4/2020, showed .Under supervision of a registered nurse, provides quality care to patients .Provide basic nursing care to patients .that meet psychosocial needs and physical needs .Ensures quality .nursing services to patients .Assist patients with personal hygiene .Provide emotional support to patients .listen to concerns and feedback . Review of the facility document titled Registered Nurse (RN) Job Description, Updated 9/4/2020, showed .Job Summary Registered Nurses at the Skilled Nursing Facility provide direct bedside care and act as patient advocate .Provide basic nursing care to patients .that meet psychosocial needs and physical needs .Provides direct and individualized nursing care .under the supervision of the Director of Nursing [DON] .patient advocate and ensuring that other health care team members are providing care according to the resident's care plan and personal wishes . Resident #9 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Type 2 Diabetes Mellitus, Schizophrenia, Fusion of Spine, and Intraspinal Abscess. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #9 was cognitively intact, required extensive 2 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL (Activities of Daily Living)-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #9 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #9 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #9 had received 1 shower. Review of the ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #9 had not received a shower. During an interview on 2/6/2022 at 5:09 AM, Certified Nurse Aide (CNA) #11 stated Resident #9 had not received a shower in a couple of weeks (unsure of the exact dates). During an interview on 2/6/2023 at 9:56 AM, Resident #9 stated .I wasn't getting them [showers] before you [surveyors] came . The resident stated when he had not received the scheduled showers, it made him feel .dirty .I have bad under arm odor, and I didn't smell too good . During an interview on 2/6/2023 at 10:35 AM, CNA #7 stated Resident #9 had reported to her (unsure of the exact date) he had not been receiving showers and felt nasty. The CNA stated the nurses did not assist the CNAs with resident care. Resident #10 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Adult Failure to Thrive, and Repeated Falls. Review of a quarterly MDS assessment dated [DATE], showed Resident #10 had severe cognitive impairment, required total dependence of 2 staff assistance for dressing and toilet use, total dependence of 1 staff assistance for personal hygiene, and was always incontinent of bladder and bowel. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #10 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #10 had received 5 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #10 had received 2 showers. During an observation and interview in the resident's room with the Director of Nursing (DON) and CNA #2 on 1/11/2023 at 6:10 AM, Resident #10 was lying in bed with her eyes closed, the bed linens and gown were saturated with urine, and a brown ring was observed on the resident's incontinence pad. CNA #2 confirmed Resident #10 was saturated with urine. The DON stated her expectation was for resident's to be provided incontinence care every 2 hours. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #10 had not received a shower. During an observation and interview on 2/6/2023 at 4:30 AM, with CNA #11 and Licensed Practical Nurse (LPN) #4, Resident #10 was lying in bed with eyes closed, the bed linens and gown were saturated with urine, and a brown ring was observed on the resident's incontinence pad. Further observation showed the resident's room smelled of urine. CNA #11 stated she had provided incontinence care around 3:00 AM. CNA #11 and LPN #4 confirmed Resident #10 was saturated with urine, the incontinence pad had a brown ring, and the room smelled of urine. During an interview on 2/6/2023 at 8:28 AM, CNA #5 stated she had witnessed Resident #10 saturated with urine multiple times (unable to recall the exact dates). During an interview on 2/7/2023 at 10:43 AM, CNA #16 stated she had observed Resident #10 saturated with urine multiple times when she arrived on shift. The CNA stated the nurses did not routinely assist the CNAs with resident care. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Anxiety Disorder, Chronic Pain Syndrome, and Dementia. Review of a quarterly MDS assessment dated [DATE], showed Resident #13 had moderate cognitive impairment, was independent with set up help for dressing, personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed the resident had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #13 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #13 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #13 had received 1 shower. During an observation and interview on 1/9/2023 at 3:44 PM, Resident #13 stated .I have not had a shower in over a month . The resident's hair appeared greasy. During an interview on 2/9/2023 at 7:40 AM, Resident #13 stated prior to 2 weeks ago he had not received the scheduled showers. The resident stated he wanted a shower and felt .unclean . when he did not receive a shower. Resident #14 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dementia, Diabetes Mellitus, Stage 3 Chronic Kidney Disease, Major Depressive Disorder, and Interstitial Pulmonary Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #14 had moderate cognitive impairment, required extensive 1 staff assistance for dressing, personal hygiene, and was totally dependent on 2 staff assistance for bathing and toilet use. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #14 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #14 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #14 had received 3 showers and refused 1. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #14 had received 1 shower. During an observation and interview with Registered Nurse (RN) #2 on 1/11/2023 at 5:02 AM, Resident #14 was lying in bed with eyes closed, bed linens, gown, and brief were saturated with urine, and a brown ring was on the incontinence pad. RN #2 stated .yeah that one is pretty wet .It's saturated with urine both the brief and pad .its brown ringed . During an interview on 2/6/2023 at 5:05 AM, LPN #4 stated she observed Resident #14 saturated with urine when she arrived on shift and was unable to recall the exact dates. LPN #4 stated Resident #14 .seemed upset because she hadn't been changed and was left wet during the night . During an interview on 2/6/2023 at 5:19 AM, LPN #5 stated Resident #10 and Resident #14 were often observed saturated with urine when she arrived on shift and .they [residents] would feel bad and not be able to sleep . when saturated with urine. Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Depressive Disorders, Diabetes Mellitus, Morbid Obesity, Overactive Bladder, Chronic Pain Syndrome, and Bipolar Disorder Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #20 had moderate cognitive impairment, required extensive 1 staff assistance for dressing and personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #20 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #20 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #20 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #20 had not received a shower. During an interview on 2/6/2023 at 9:05 AM, Resident #20 stated she had not received showers, there was not enough staff, and it made her feel crappy when she had not received the scheduled showers. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Fusion of Spine Cervical Region, Major Depressive Disorder, Chronic Pain Syndrome, and Dementia. Review of a quarterly MDS assessment dated [DATE], showed Resident #22 was cognitively intact, required extensive 1 staff assistance for dressing and personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #22 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #22 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #22 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #22 had received 2 showers. During an interview on 2/6/2023 at 2:25 PM, Resident #22 stated .it [showers] was a problem .I felt bad because I was not getting a shower . Resident #26 was admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy, Chronic Obstructive Pulmonary Disease, and Depression. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/11/2022-11/30/2022, showed Resident #26 had received 1 shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #26 was cognitively intact, required limited 1 staff assistance for dressing and personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #26 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/10/2023, showed Resident #26 had received 5 showers. Review of the ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #26 had received 1 shower. During an interview on 2/6/2023 at 5:30 AM, Resident #26 stated she had not received the scheduled showers. The resident stated when she did not receive the showers .it upsets me .I want to be clean . Resident #28 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction and Type 2 Diabetes. Review of a quarterly MDS assessment dated [DATE], showed Resident #28 had moderate cognitive impairment, required extensive 1 staff assistance for dressing and personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #28 had received 2 showers and 4 bed baths. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #28 had received 4 showers and 1 bed bath. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #28 had received 3 showers and 2 bed baths. The resident had refused 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #28 had not received a shower or a bed bath and had refused 1 shower. During an interview on 2/6/2023 at 4:40 AM, Resident #28 stated prior to the past 2 weeks, she had not received scheduled showers .I was mad .I was not getting my showers . Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Parkinson's Disease, Diabetes Mellitus, and Depression. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #31 had received 4 showers. Review of a quarterly MDS assessment dated [DATE], showed Resident #31 had moderate cognitive impairment and required extensive 1 staff assistance for dressing, personal hygiene, and bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #31 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #31 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #31 had received 2 showers. During an interview on 1/10/2023 at 2:31 PM, CNA #5 stated Resident #31 had not received the scheduled showers and Resident #31 had stated night shift had not provided the scheduled showers. The resident was scheduled for showers on Wednesdays and Saturdays and night shift was responsible for the resident's shower. During an interview on 2/6/2023 at 8:05 AM, Resident #31 stated when she had not received a shower, it made her feel .terrible and yucky .I wiped myself off, but it was not doing the job . The resident further stated the staff had informed her there was not enough staff to assist her with a shower. Resident #36 was admitted to the facility on [DATE], discharged on 1/1/2023 and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Disease, Depression, and Morbid (Severe) Obesity. Review of the facility's shower documentation dated 11/1/2022-11/30/2022, showed Resident #36 had not received a shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #36 had moderate cognitive impairment, required extensive 2 staff assistance with dressing and personal hygiene, and required extensive 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Care Alert shower documentation dated 12/1/2022-12/31/2022, showed Resident #36 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #36 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #36 had received 1 shower. During an interview on 2/6/2023 at 12:00 PM, Resident #36 stated she had not received scheduled showers and .I want to feel clean .I don't like to be dirty .I don't want to get in trouble for telling you this .when you all [surveyors] are here .there is more people [staff] .there are no problems at all . Resident #37 was admitted to the facility on [DATE] with diagnosis including Parkinson's Disease, Lack of Coordination, Major Depressive Disorder, and Seizures. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #37 had not received a shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #37 had moderate cognitive impairment, required limited 1 staff assistance with dressing and personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #37 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #37 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #37 had not received a shower. During an interview on 2/6/2022 at 9:22 AM, Resident #37 stated she had not received routine showers and it made her .feel dirty . Resident #37 further stated the facility did not have enough staff to provide the showers .people quit . Resident #40 was admitted to the facility on [DATE], discharged from the facility on 11/19/2022, and readmitted [DATE] with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, and Depression. Review of a quarterly MDS assessment dated [DATE], showed Resident #40 was cognitively intact, required extensive 1 staff assistance with dressing and personal hygiene, and totally dependent on 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/19/2022, showed Resident #40 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #40 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #40 had received 2 showers. Revie of the facility's ADL-Bathing and Skin Care Alert documentation showed Resident #40 had received 1 shower. During an interview on 2/6/2023 at 5:15 AM, Resident #40 stated .when I didn't get a shower .It made me angry . Resident #41 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Systemic Lupus Erythematosus, Morbid Obesity, Depression, and Congestive Heart Failure. Review of the facility's shower documentation dated 11/1/2022-11/30/2022, showed Resident #41 had received 4 showers. Review of a quarterly MDS assessment dated [DATE], showed Resident #41 was cognitively intact, required extensive 1 staff assistance for dressing, 1 staff supervision assistance with personal hygiene, and totally dependent of 1 staff assistance with bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #41 had received 5 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #41 had received 4 showers. Review of the ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #41 had received 1 shower. During an interview on 2/6/2023 at 5:20 AM, Resident #41 stated .they [the facility staff] told me there was not enough staff to give me my showers .I kept asking for a shower and they said they couldn't get to me .I went 12 days without a shower .I felt nasty .I didn't get a shower .I like to maintain my appearance . Resident #1 was admitted to the facility on [DATE] with diagnoses including Polyneuropathy, Type 2 Diabetes Mellitus, Chronic Pulmonary Edema, Respiratory Failure with Hypoxia, and Alzheimer's Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had moderate cognitive impairment. The resident required extensive 1 staff assistance with dressing and personal hygiene and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/4/2022-11/30/2022, showed Resident #1 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #1 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #1 had received 3 showers. Review of a Skin Alert sheet dated 1/30/2023, showed the resident refused a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #1 had not received a shower. Resident #2 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Diabetes Mellitus, Hepatic Failure, Cirrhosis of the Liver, Acute Hepatitis C, and Rheumatic Heart Disease. Review of a quarterly MDS assessment dated [DATE], showed Resident #2 was cognitively intact, required limited 1 staff assistance with dressing and personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #2 had received 1 shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #2 required limited 1 staff assistance for dressing and personal hygiene, and the activity of bathing had not occurred. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #2 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #2 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023 showed Resident #2 had received a shower on 2/4/2023. Review of a nursing note dated 2/2/2023, showed the resident was offered a shower on this date and refused. During an interview on 2/6/2023 at 4:20 AM, Resident #2 stated he received showers when the staff were not busy. Sometimes .they do not have enough staff to supervise me in the shower . Resident #5 was admitted to the facility on [DATE], was discharged on 12/21/2022 and was readmitted on [DATE] with diagnoses including Dislocation of other Internal Joint Prosthesis, Repeated Falls, Lack of Coordination, Essential Hypertension, and Dementia with Severe Psychotic Disturbance. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #5 had received 1 shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #5 had moderate cognitive impairment. The resident required extensive assistance of 2 staff members for dressing and personal hygiene and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/21/2022, and 12/22/2022-12/31/2022, showed Resident #5 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #5 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #5 had received 1 shower on 2/4/2023. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Muscle Weakness, Chronic Pain Syndrome, Moderate Protein-Calorie Malnutrition, Schizoaffective Disorder, Recurrent Depressive Disorders, Generalized Anxiety Disorder, and Dementia. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #12 had not received a shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #12 had moderate cognitive impairment, required extensive 1 staff assistance for dressing, personal hygiene and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #12 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #12 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #12 had not received a shower. Resident #15 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Dementia, Hemiplegia, and Hemiparesis. Review of a quarterly MDS assessment dated [DATE], showed Resident #15 had severe cognitive impairment, required extensive 2 staff assistance with dressing, extensive 1 staff assistance with personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #15 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #15 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #15 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #15 had not received a shower. Resident #16 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Paranoid Schizophrenia, Cerebral Infarction, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], showed Resident #16 required extensive 1 staff assistance for dressing, limited 1 staff assistance for personal hygiene, and was totally dependent on 1 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #16 had received 1 shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #16 had received 5 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Resident #16 had received 4 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 2/1/2023-2/5/2023, showed Resident #16 had received 1 shower. Resident #17 was admitted to the facility on [DATE] with diagnoses including Cognitive Communication Deficit, Chronic Pain Syndrome, Cirrhosis of the Liver, and Generalized Anxiety Disorder. The resident was discharged on 1/23/2023. Review of a quarterly MDS assessment dated [DATE], showed Resident #17 required limited 1 staff assistance for dressing, extensive 1 staff assistance with personal hygiene, and was totally dependent on 2 staff assistance for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/1/2022-11/30/2022, showed Resident #17 had received 2 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #17 had received 3 showers. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/23/2023, showed Resident #17 had not received showers. Resident #18 was admitted to the facility on [DATE], discharged on 12/24/2022, and readmitted on [DATE] with diagnoses including Cerebral Infarction, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Gastrostomy Status. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 11/12/2022-11/30/2022, showed Resident #18 had not received a shower. Review of a quarterly MDS assessment dated [DATE], showed Resident #18 had moderate cognitive impairment, required extensive 1 staff assistance for dressing and personal hygiene, and was totally dependent on staff for bathing. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 12/1/2022-12/31/2022, showed Resident #18 had not received a shower. Review of the facility's ADL-Bathing and Skin Care Alert documentation dated 1/1/2023-1/31/2023, showed Reside[TRUNCATED]

Based on the review of the facility policy, review of facility documentation, and interview, the facility failed to take action aimed at performance improvement, to measure the success of the intervention, and track performance to ensure improvements after identifying insufficient staffing needs in the facility. The facility failed to identify care needs had not been provided including showers and baths, incontinence care, and cleanliness for 33 dependent residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, #41, #1, #2, #5, #12, #15, #16, #17, #18, #19, #21, #23, #24, #25, #27, #30, #32, #33, #34, #38, and #39) of 64 residents reviewed for care needs. The facility's failure resulted in psychosocial harm to 14 residents (#9, #10, #13, #14, #20, #22, #26, #28, #31, #36, #37, #40, and #41). The findings include: Review of the facility policy, titled Quality Assurance and Performance Improvement (QAPI) Program, revised 2/2020, showed .This facility shall develop, implement, and maintain an ongoing .QAPI Program that is focused on .care and quality of life for our residents .The QAPI plan describes the process for identifying and correcting quality deficiencies .Identifying and prioritizing quality deficiencies .Systematically analyzing underlying causes of systemic quality deficiencies .Developing and implementing corrective action .Monitoring or evaluating the effectiveness of corrective action .and revising as needed . During an interview on 1/10/2023 at 3:38 PM, the former Social Service Director (SSD) stated she had multiple residents complain they had not received a shower.They wanted a shower .I let the nurse know .I know [Resident #25 and Resident #26] has requested a shower .One told me she would like to get her hair washed but can't think of her name .[Resident #26's daughter] has mentioned she didn't feel like they [the residents] were getting showered . The former SSD stated she had notified the Administrator and the DON of Resident #26's daughter and the residents' complaints. During an interview on 1/11/2023 at 10:57 AM, the Nurse Practitioner (NP) stated the residents had complained about not getting showers and she had noticed residents being more unkempt. The NP stated she had notified the Administration of the facility (date of notification was not specified). During an interview on 2/6/2023 at 4:29 AM, Certified Nursing Assistant (CNA) #12 stated the CNAs were unable to complete the scheduled showers and she had reported to the charge nurse when she was unable to provide the showers. During an interview on 2/6/2023 at 5:05 AM, Licensed Practical Nurse (LPN) #4 stated she had noticed a month or so ago, the resident showers were not being completed for 3-4 weeks on the night shift and she reported the concerns to Registered Nurse (RN) #4. During an interview on 2/6/2023 at 5:13 AM, RN #4 stated the showers had not been provided .not enough staff . The RN stated she had reported her concerns to the Director of Nursing (DON) .about a month ago . During an interview on 2/6/2022 at 5:19 AM, LPN #5 stated RN #4 was aware the scheduled showers had not been provided on the night shift .said she knew . LPN #5 stated she had observed Resident #10 and Resident #14 often saturated with urine when she arrived on shift, and she had reported it to RN #4. During an interview on 2/6/2023 at 5:20 AM, Resident #41 revealed .I kept asking for a shower and they [facility staff] said they could not get to me . The resident stated she reported the concern to the shift supervisor (date and supervisor unknown). During an interview on 2/6/2023 at 5:30 AM, Resident #26 stated prior to about 2-3 weeks ago, she had not received the scheduled showers and stated she had complained to the Social Worker (no longer employed at the facility) and the Administrator but was unable to recall the date. During an interview on 2/6/2023 at 8:05 AM, Resident #31 stated she had not received routine showers. The resident stated she had reported to someone at the facility (unsure who) she had not received showers. During an interview on 1/10/2023 at 2:31 PM, CNA #5 stated Resident #31 had not received the scheduled showers. Resident #31 stated night shift had not provided the scheduled showers and it had been reported to the DON (date unknown). During an interview on 2/6/2022 at 9:20 AM, CNA #13 stated residents did not receive the scheduled showers consistently. The DON was made aware (date unknown) residents were not provided showers as scheduled. During an interview on 2/6/2023 at 9:56 AM, Resident #9 stated .I wasn't getting them [showers] before you [surveyors] came. Resident #9 stated he reported to multiple staff at the facility (unable to recall who) he did not receive the showers. During an interview on 2/6/2023 at 10:35 AM, CNA #7 stated multiple residents had complained the showers were not provided and the residents looked unkempt. Resident #9 reported to CNA #7 (unsure of the exact date) he had not received a shower and felt nasty. CNA #7 stated the DON had been made aware multiple residents had complained showers had not been provided. During an interview on 2/6/2023 at 12:00 PM, Resident #36 stated she complained to staff (unable to remember who she spoke with) at the times she had not received the showers. The resident stated staff informed her she received a bed bath which was considered a shower. During an interview on 2/6/2023 at 2:15 PM, Resident #41 stated she had not received the scheduled showers and had reported it to the shift supervisor. During an interview on 2/6/2023 at 2:25 PM, Resident #22 stated .it [showers] was a problem .I reported it to the nurse on my hall . During an interview on 2/7/2023 at 8:11 AM, LPN #8 stated .I don't know if the administration asks about staffing needs . During an interview on 2/7/2023 at 8:42 AM, LPN #9 stated the facility did not have enough staff to care for the residents. Multiple residents had complained the showers were not given, incontinence care was not provided timely, and it had been reported to RN #1. During an interview on 2/7/2023 at 9:28 AM, CNA #15 stated on 2/3/2023 when she arrived on shift, Residents #10 and Resident #32 were saturated with urine and she reported it to LPN #8. During an interview on 2/7/2023 at 9:54 AM, LPN #10 stated the night shift staff often report they were not able to provide the scheduled showers .too busy . and stated the night shift supervisor was aware. During an interview on 2/7/2023 at 10:30 AM, the Minimum Data Set (MDS) Coordinator stated after she had identified the activity of bathing had not occurred during the MDS assessments on several of the residents and she notified the DON. The MDS Coordinator stated she informed the DON the showers had not been documented. During an interview on 2/7/2023 at 1:34 PM, CNA #8 stated when the facility was short staffed .we can't get showers done . The CNA stated she had reported residents not receiving showers to the supervisor (date unknown). During an interview on 2/8/2023 at 9:30 AM, the district Ombudsman stated she had concerns related to multiple residents not receiving scheduled showers. She also stated she had reported the concerns to the Administrator and the DON on 8/4/2022. The Ombudsman also stated she had several follow up conversations and emails with the Administrator and the DON related to the residents bathing schedule concerns. The Ombudsman stated the concerns had not been resolved and was .dismayed to be told by the residents it was still an issue . The Ombudsman provided emailed documentation which showed the concerns were discussed on 10/28/2022, 11/4/2022, and 11/15/2022. During an interview on 2/8/2023 at 1:35 PM, the Medical Director stated the previous administration and the previous DON .made a big deal with corporate that I had harassed the nurses because I had asked for the residents to get the showers .we [facility current QAPI members] had monthly QAPI meetings and discussed showers not being given .night shift should help with the shower burden .the problems have been discussed . The Medical Director stated 2 things happened which attributed to the showers not being provided, and stated it was related to the natural flow of things with the change in administration, and implementation of a system. During an interview on 2/9/2023 at 4:00 PM, the DON stated there was enough staff to meet the needs of the residents due to the number of nurses on each shift and incontinence care should be provided every 3 hours and as needed. She also stated she was not aware of the extent of the problems with showers until about 2 weeks ago when surveyors entered the building on 1/9/2023. The DON further stated she and the Administrator had met with the Ombudsman (did not give an exact date) about concerns related to the showers for Resident #2 and Resident #13. The DON stated it was a lack of shower documentation, she had interviewed the residents (#2 and #13) and .they did not have problems . The DON further stated she had not interviewed additional residents to determine if showers had been provided. She also stated the Medical Director and the NP had not reported a problem or issues with the resident showers .it was never brought up . During an interview on 2/9/2023 at 4:00 PM, the Administrator stated he was not aware the residents had not received the showers as scheduled for weeks or days at a time until .this very moment [2/9/2023] .not aware of the extent of the problems with showers and timely incontinence care . The Administrator stated the residents, nor the staff had reported concerns related to showers or incontinence care. He also stated he and the DON had met with the Ombudsman (did not give an exact date) about her concerns related to the showers for Resident #2 and Resident #13. The Administrator confirmed residents at the facility had not received the showers .like they [residents] wanted .or like they were supposed to .residents should be changed every 2 hours . He also stated the showers needed to be addressed and there was a Performance Improvement Plan (PIP) in place. The Administrator stated the Medical Director and the NP had not reported a problem or issues with the resident showers. Review of the PIP dated 12/2022 showed the facility identified concerns related to the documentation of bathing. Continued review showed the PIP had not identified the actual activities of bathing had not occurred. Refer to tags F-656, F-677, and F-725