**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #12, Resident #58, Resident #159, and Resident #160) reviewed for infection control. RN A failed to disinfect vital signs equipment between each resident while performing morning medication administration for Resident #12, Resident #58, Resident #159, and Resident #160. This deficient practice could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings included: Review of Resident #12's face sheet, dated 5/14/2025, revealed Resident #12 was an [AGE] year-old female admitted on [DATE] with diagnoses of spine fracture and type 2 diabetes. Review of Resident #58's face sheet, dated 5/14/2025, revealed Resident #58 was an [AGE] year-old female admitted on [DATE] with diagnoses of critical illness myopathy (diseases related to the muscles), dementia and hypothyroidism (underactive thyroid). Review of Resident #159's face sheet, dated 5/14/2025, revealed Resident #159 was an [AGE] year-old female admitted on [DATE] with diagnoses of asthma and lack of coordination. Review of Resident #160's face sheet, dated 5/14/2025, revealed Resident#160 was a [AGE] year-old admitted on [DATE] with diagnoses of muscle wasting, asthma, and vitamin D deficiency. Review of Resident #160's care plan, dated 5/13/2025, revealed that the resident has a wound on right forearm and wound was at risk for infection. The goal listed for the wound was wound will be free of signs or symptoms of infection. In an observation on 5/14/2025 at 7:24am, RN A was measuring vital signs for Resident #12, Resident#58, Resident #159, and Resident #160 during morning medication administration. RN A did not disinfect blood pressure cuff and oximeter in between the 4 residents. In an interview on 5/14/2025 at 9:24am, RN A stated that she was nervous and forgot to disinfect vital signs equipment. She stated that the risk of not sanitizing equipment was the spread of infection between residents. In an interview on 5/15/2025 at 12:15pm, DON stated that RN A approached her on 5/14/2025 and admitted that she failed to sanitize equipment in between residents. DON started in-service on disinfecting vital signs equipment immediately on the same day. DON stated that the risk of not disinfecting equipment can lead to spread of infection between residents which could affect residents and staff. Review of in-service record dated 5/14/2025, with training topic Disinfecting vital signs equipment between each resident revealed RN A and other nursing staff were included in the training. On 5/14/2025 at 12:00pm, attempt to review facility's policy on disinfecting equipment was unsuccessful. DON stated that the facility did not have a specific policy on disinfecting equipment. Review of facility's Infection Control Policy, dated 8/2024, revealed under Prevention of Infection section, facility implemented infection prevention by .educating staff and ensuring that they adhere to proper techniques and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Patient #1) of 6 patients reviewed for ADLs. -The facility failed to provide showers or bed baths and oral care consistently for Patient #1 according to the facility's ADL schedule. This failure could place all patients who require assistance with ADL care at risk for poor personal hygiene, odors and a decline in their quality of life. Findings included: Record review of Patient #1's Face Sheet, dated 11/21/24, revealed the resident was a [AGE] year old male who admitted to the facility on [DATE] and discharged on 11/17/24 with diagnoses which included: morbid (severe) obesity, reduced mobility, heart failure, peripheral vascular disease (circulation disorder), and urogenital implants (implanted medical device used to treat urinary incontinence). Record review of Patient #1's Nursing Home PPS MDS Assessment, dated 11/11/24, reflected the resident had a BIMS score of 15 which indicated cognition was intact. The MDS Assessment also reflected Patient #1 required set-up assistance for most ADLs and refused shower/bath task. Further review reflected the patient was dependent on staff for all mobility. Record review of Patient #1's care plan, dated 11/08/24, reflected the resident had a focus in personalized care and activity with interventions that included providing favorite items and preferences and having family and close friends involved in discussions about care. Record review of Patient #1's ADL tasks in the electronic health record, dated 11/08/24-11/16/24, reflected the following: Oral hygiene: -11/08/24- dependent-required all effort by helper (staff) to complete activity -11/09/24- no documentation -11/10/24- no documentation -11/11/24- setup/clean-up assistance to complete activity -11/12/24- setup/clean-up assistance to complete activity -11/13/24- oral hygiene not applicable -11/15/24- independent-pt completed activity by themselves -11/16/24- no documentation Shower/bathe self: -11/08/24- shower not applicable -11/11/24- shower not applicable -11/12/24- shower not applicable -11/13/24- shower not applicable -11/15/24- dependent- required all effort by helper (staff) to complete activity In an interview on 11/21/24 at 1:55 PM, Patient #1 stated he admitted to the nursing facility for rehabilitation to regain his strength after a hospital stay. He stated he resided at the nursing facility for about 10 days and did not receive the best care. Patient #1 stated a staff wiped his lower legs and abdomen off with a wet wipe on one occasion; however, he never received a full shower or bed bath during his entire stay. He stated staff informed him that he would have to be transferred using a mechanical lift due to his large size for all care/treatment. Patient #1 stated he was very anxious about getting on the mechanical lift and may have refused it once. However, he later informed staff that he would get on it. Patient #1 stated even after agreeing to get on the mechanical lift, staff never attempted to transfer him for a shower or provide a bed bath. He stated not being bathed made him more concerned about the wounds on his body, although he was receiving wound care. Patient #1 stated he also was not provided toiletries or a setup for him to brush his teeth daily as he would have liked. Patient #1 stated that made him feel ashamed and unclean. He stated his friends would help as much as they could when they visited. In an interview on 11/21/24 at 03:02 PM, CNA A stated she worked at the facility for about one month. She stated she sometimes worked with Patient #1 and his shower days were every Monday, Wednesday, and Friday. CNA A stated she worked with Patient #1 on 11/15/24 and she initially stated she took the patient to the shower room to shower him. When asked if she used a mechanical lift to transfer the patient, she stated No, then said she must have given him a bed bath. CNA A stated she marked Patient #1's ADL task sheet in the electronic health record as not applicable for his shower and stated it was a mistake. CNA A stated Patient #1 was able to complete oral care independently, so she never assisted him with it. CNA A stated she recalled seeing a toothbrush, toothpaste, and basin in his room. CNA A stated staff would have to provide water for the basin if a patient was unable to get out of bed and she could not recall if she did so. CNA A stated Patient #1 never complained to her about not receiving a shower/bed bath or oral care. CNA A stated most day there were enough staff to accommodate all patients and denied concerns that any patients were being neglected. In an interview on 11/21/24 at 03:15 PM, the Interim DON stated staff were expected to provide all patients' showers or baths on scheduled days. The DON stated if a patient refused, the aides were supposed to notify the nurse so they could offer alternatives and ask about concerns. The Interim DON stated they would involve the family if refusals were persistent. The Interim DON stated staff were expected to document all encounters, whether the task was completed or refused. In an interview on 11/22/24 at 10:58 AM, CNA B stated she worked at the facility for about 5 months. She stated she sometimes worked with Patient #1. CNA B stated Patient #1 required a 2-person assist with most care, but he was able to help some. CNA B stated she recalled giving the patient a bed bath one day but could not remember the date. She stated there was another day Patient #1 was due for a shower or bath, but the facility was short-staffed, and he was unable to get it during the morning shift. CNA B stated if they were unable to provide a shower due to being short-staffed, they would inform the oncoming staff so they could provide it. CNA B stated she could not recall if she informed the oncoming staff that Patient #1 did not receive a shower or bath on that day. CNA B stated it was important for patients to receive their showers or baths as scheduled to keep the body clean from bacteria and prevent odor. In an interview on 11/22/24 at 11:39 AM, the Administrator stated the expectation was for the staff to document each time a patient received a shower/bath. The Administrator stated a patient had the right to refuse showers or baths, but it also needed to be documented. She stated the facility did not use paper shower sheets and documented all ADL tasks in the electronic health record. The Administrator stated not providing hygiene care to patients could place them at risk for infections and further skin breakdown. In a further interview on 11/22/24 at 1:35 PM, the Interim DON stated the risk of not providing patients with proper ADL care could place them at risk of skin breakdown, dignity issues, and infection. Record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, revised 8/2024, reflected in part the following: Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made. If the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 8 residents (Resident #193) reviewed for neglect reporting. The facility failed to report an unwitnessed fall with injury to the head by unknown source for Resident #193 on 03/16/24. This failure could place residents at risk of not receiving timely investigations and reporting of injuries of unknown source. Findings included: Review of Resident #193's admission record dated 03/20/24, revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral ischemia (a brain injury caused by a lack of blood flow to the brain aka stroke), dehydration, unspecified dementia without behaviors (a brain disorder of cognitive confusion and forgetfulness), muscle wasting and atopy, fall from bed, other reduced mobility, altered mental status (a brain condition of confusion, disorientation, and disorder), and weakness. Review of Resident #193's admission MDS section C dated 03/11/24, revealed a BIMS score of 3, indicating severe cognitive impairment. Record review of progress notes dated 03/19/24 at 12:10 pm by Care Manager reflected BIMS Evaluation completed. BIMS summary score: 7.0, BIMS of 7 indicated severe cognitive impairment. Review of Resident #193's care plan dated 03/07/24 reflected Focus: The resident had an actual fall 3/16/24; unwitnessed fall with injury. Date initiated 03/17/24. Goal: The resident will resume usual activities without further incidents through the review date. Date initiated 3/17/24. Interventions: Monitor/document /report as needed (PRN) x 72h(hour) to Medical Doctor (MD) for signs/symptoms: Pain, bruises, Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation o Neuro-checks o Re-educate guest on use of call light o Staff to perform frequent visual safety checks o TRANSFER GUEST TO ED [emergency department] TO EVAL AND TREAT FOR LACERATION due to FALL Date Initiated: 03/17/2024. Focus: wound management post-surgical general (stapled laceration to rear of head. Initiated 03/20/24. Goal: wound will be free of signs or symptoms of infection. Intervention: notify provider if no signs of improvement on current wound regime, provide wound care per treatment order, weekly documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate [discharge], and any other notable changes or observations. Date initiated 03/20/24. Record review of progress note for Resident #193's entry by RN C on 03/16/24 at 09:20 pm reflected At 2120hr [09:20 PM], this nurse had heard a shout for help. Upon entering the room, guest was seen lying on the floor. Upon assessment, with GCS 14/15, with PERRLA, able to move all extremities, with a large swelling and a laceration on occipital area [back of head], with skin tear and swelling on left leg, with complaints of dizziness when sitting up and generalized pain. Guest was transferred to bed, cleansed wound on left leg and applied steri-strip [tape used to hold torn skin together], applied ice pack on occipital area. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: Hold Eliquis for 3 days, Neurocheck monitoring [checking if the resident is alert, can they follow commands], send to ER. Interview with Resident #193 and family on 03/20/24 at 12:51 pm revealed Resident#193 could not remember what happened when he fell. His family said the facility called her around 9 pm on 03/16/24 stating that Resident #193 had a fall. Family said she was told that Resident #193 got out of bed and was walking towards the walker when he fell and hit his head and sustained a cut on his head and leg. The family said the facility told her that they could not stop the bleeding due to the blood thinners and he was sent to the emergency room. Interview with RN C on 03/20/24 at 01:05 pm could not be completed voicemail was left for RN C to return phone call. The facility schedule indicated that RN C worked night shift from 6 PM to 6 AM. Interview with RN H on 03/17/24 at 10:31 AM revealed that she did not work with Resident #193 the day he fell. She was aware that Resident 193 was a fall risk, and she maked sure his bed was in low position, his call light was within reach, she rounded more frequently on him and those residents with high fall risks. She said that she was in-serviced about falls and reporting timely. She said that she is expected to notify the DON, Administrator, the physician, and family immediately. She said that she is expected to report any incidents as soon as they happen. She said Failure to report can cause delay in resident getting medical attention. Interview with the DON on 03/20/24 at 12:19 pm revealed that she was notified on Monday morning 3/18/24 about Resident #193's fall. She said that she was waiting for the IDT meeting to figure out the next step. She said the administrator did the reporting of incidents. She said she expected nursing staff to report all falls to either the ADON and/or to herself immediately. She said, she started to in-service on timely reporting falls with injury, and abuse and neglect was always an ongoing in-service for the facility. She said CNA's and nurses check on fall risk residents every 15 minutes. She said the facility has interventions in place including floor mats however if a resident has a history of shuffling gait, then a floor mat can be a fall risk. She said both CNA's and nurses have been in serviced about offering bathroom needs more frequently and or making sure a urinal is within reach or in other cases the use of a bedside commode. She did not say what the failure in delayed reporting to State Agency may have affected the resident. Interview with the administrator on 3/19/24 at 12:30 pm revealed that he was aware of Resident #193's unwitnessed fall with injury of unknown origin. He said that he was responsible for reporting incidents to State Agency. He said that he was waiting for the BIMS score to determine if the unwitnessed fall with injury for Resident #193 was a reportable incident. He did not see risk to the resident because the facility followed interventions put in place. The administrator reported a self-report incident to State Agency after the State surveyor interview on 3/19/24. The administrator did not say the failure this delay may have affected the resident because he said they did everything they were supposed to do for the resident post fall. Review of in service dated 03/19/24 by DON titled Abuse & Neglect, Fall Prevention, reporting falls w/injury was completed in the following departments: Nursing, administration, MDS, Rehabilitation, and therapy. Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 09/22, reflected: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to the local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Finding of all investigations are documented and reported .All allegations are thoroughly investigated. The administrator initiates the investigation . The facility Reportable Incident Protocol, dated November 2017, reflected: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 1. Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of patient property, are reported immediately, but no later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the Facility to other officials (including State Survey Agency .)in accordance with state law through established procedures. 2. Have evidence that all alleged violations are thoroughly investigated. 3. Prevent further potential abuse, neglect, exploitation, or mistreatment while investigation is in progress. 4. Report the results of all investigations to the executive director or his or her designee and to other officials in accordance with state law, including state survey agency within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. Injuries of unknown source: Any injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person, or the source of the injury could not be explained by the patient and the injury is suspicious because of the extent of the injury or location of the injury .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #139) of five residents reviewed for quality of care. The facility failed to identify a significant change of condition in Resident #139 between 03/14/24 to 03/19/24. This failure could place residents at risk for diminished quality of care and worsening conditions. Findings included: Review of Resident #139's admission record, dated 03/21/24, revealed Resident #139 was a [AGE] year-old male who was admitted into the facility on 2/9/2023 with a diagnosis of Encephalopathy (disease of the brain), muscle wasting, hypertension (high-blood pressure), and Dysphagia (difficulty swallowing). Review of Resident #139's nursing notes dated, 03/19/2022 revealed on 02/22/24 Resident #139 experienced a fall. The resident was assessed and at the time, there were no concerns at the time. Resident was not sent out to the hospital and x-rays were not ordered. The physician was notified. Review of Resident #139's Quarterly MDS Assessment, dated 02/13/24, revealed that resident active diagnoses included Encephalopathy, muscle wasting, cognitive communication deficit, sleep apnea, acute myocardial infraction, heart disease, and hearing loss. Review of Resident #139's Care Plan, dated 02/12/24, revealed the resident had impaired cognitive function as evidenced by his BIMs score of 8. Observation and interview on 3/19/2024 at 11:15 am with Resident #139 revealed that the resident had to be assisted with drinking. The resident was unable to hold a cup of water up to his mouth to take a sip of water. Interview on 03/19/24 at 10:15 AM with Resident #139's family member revealed 2-3 days (02/24/24 - 02/25/24) after Resident #139's 02/22/24 fall, family noticed cognitive decline. Resident #139 used to be able to do 500-piece puzzles prior to fall. However, after the fall, he couldn't match 2 pieces of a puzzle together. Observation on 03/21/24 at 11:10am revealed Resident #139 could not support his upper body and a gait belt was used to help keep him upright on the wheelchair. Resident was unable to speak to the state surveyor. Observation on 03/21/24 at 2:33 revealed Resident #139's family member holding the resident upright to cut his hair. Resident #139 was unable to support himself. Interview on 03/21/24 at 12:09 PM with Physician D revealed he was not concerned with Resident #139's decline, stated it was age-related and his nutrition was not the best. Physician D stated Resident #139 was at his baseline. Primary physician had not seen Resident #139 . He stated he would see Resident #139 on Sunday, 03/25/24. Interview on 03/21/24 at 12:45 PM with the DON revealed Resident #139 had been gradually declining since he was first admitted . Interview on 03/21/24 at 7:00 AM with RN G revealed she had been providing care to Resident #139 since he had admitted to the unit. She stated when Resident #139 first arrived, he was able to move around on his own she could recall a time when he was able to walk to the bathroom on his on with the assistance of the walker or cane. She stated that she even recalled when Resident #139 first admitted , and he was able to walk to and from the bathroom back to bed on his own. She stated that his decline happened around two weeks from today (around 03/07/24). RN G stated she noticed that Resident #139 had been weaker than normal in that he's had a total decline. She stated she thought it was due to him being nervous due to the fall, but his decline was more than what she would consider to be from nerves. RN G stated the protocol for change in condition was to inform the physician immediately and then to follow the updated orders. Review of Resident #139's progress notes from 03/02/24, RN G charted change in condition altered mental status in progress notes. Resident disoriented with things around him, unable to stand on his own. Family concerned with abrupt change. Wants further evaluation. Physician notified. Blood work done, given saline. Review of Resident #139's PT notes from 03/06/24 to 03/14/24 revealed the following: 03/06/24 - Resident #139 was able to do leg strength training. 03/07/24 - Resident #139 noted with fatigue, requiring extra time with energy conservation techniques. O2 SAT monitored. 03/08/24 - Resident #139 wearing O2 during therapy. 03/14/24 - Resident #139 followed all instructions but was confused and impulsive. PT focused on energy conserving techniques. Review of Resident #139's Appeal Determination Letter, dated 03/14/24, revealed Resident #139 was able to walk 75 feet with minimal assistance, was able to perform ADLs independently with some assistance, and was able to sit/stand with minimal assistance. Interview on 03/22/24 at 11:38 AM with PT F revealed Resident #139 a week ago (approximately 03/14/24) was able to walk 75 feet but shortly after was only able to walk 10 feet sometime last week (date unknown). He stated he notified the nurse and DOR. Interview on 03/22/24 at 1:01 PM with RN E revealed the only change of condition she was aware of was on 03/02/24, in which she reported to the physician. From 03/03/24 to 03/21/24, RN R revealed the resident had not had any changes to his condition and that it was Resident #139's baseline to have good days and bad days (worsening/improving function .) RN E stated she was not aware of any changes to Resident #139 from therapy. She stated she noticed a change in condition in Resident #139 on 03/21/24 and notified the physician. The physician saw Resident #139 and assessed the resident. Review of Resident #139's progress notes from 03/03/24 - 03/19/24 revealed no issues or indication of Resident #139's decline or improvement. Review of Resident #139's progress notes dated 03/21/24 revealed a change of condition related to hypertension and symptoms of increased confusion, increased weakness, and increased need for assistance. Physician D recommended Clonidine 0.1 mg 6hrs PRN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accurate administration of medications for 1 of 1 resident observed for medication administration. (Resident # 34) RN A administered an incorrect dose of Acetaminophen to Resident #34. This failure could place the 11 residents who received medications administered by RN A at risk of not receiving the intended therapeutic benefit of their medications. Findings included: Review of Resident #34's face sheet reflected a [AGE] years old female admitted to the facility on [DATE] with the diagnoses of: displaced tri malleolar fracture of left lower leg, subsequent encounter for closed fracture with routine healing (happens when there is a break in the lower leg sections that form the ankle joint that help move the foot and ankle); depression, unspecified (a person is experiencing significant distress or impairment); and anxiety disorder, unspecified ( a person's phobias that are significant enough to be distressing and disruptive. Review of Resident #34's Minimum Data Set (MDS) resident assessment, dated 03/04/2024, reflected Resident #34's Brief Interview for Mental Status score (BIMS Score) of 15/15. Resident #34's decisions are reasonable and consistent. Resident #34's Care Plan dated 03/01/2024 reflected: Resident #34 is to be administered analgesia (Acetaminophen) as per orders and Anticipate Resident #34's need for pain relief and respond immediately to any complaint of pain. Clinical Physician Orders dated 03/21/2024 for Resident #34 reflected: Acetaminophen Tablet 325 mg - Give 2 tablet by mouth every 4 hours as needed for fever - Start Date - 03/03/2024. Acetaminophen Tablet 325 mg - Give 2 tablet by mouth every 4 hours as needed for pain. The MAR (Medication Administration Record) reflected that RN A initialed that she administered Acetaminophen at 8:08 AM and 13:13 (1:13 PM),17:17 (5:17 PM) on Wednesday 03/20/2024. On 03/21/2024, Resident #34 reported to the state surveyor that the nurse who worked evening shift the day before gave her the wrong dose of Acetaminophen. Resident # 34 saved one of the tablets in a Kleenex to show the state surveyor. State surveyor observed round tablet labeled AZ 011. Resident #34 revealed that she looked up the number of the pill on google. The pill was Acetaminophen 500 mg (milligrams). Resident # 34 revealed that she takes Acetaminophen 325 mg (milligrams). Reviewed the Progress Notes for Resident #34 dated 03/22/2024, documentation revealed RN A was the last nurse to give Resident #34 Acetaminophen at 8:08 AM, 9:38 AM, 13:13 (1:13 PM), and 17:17 (5:17 PM). Documentation revealed that LPN B did not give Resident # 34 any Acetaminophen on the following shift. During an interview on 03/22/2024 at 3:00 PM., RN A revealed that she had worked the 6:00 AM to 2:00 PM shift on 03/20/2024 and did not administer the wrong dose of Acetaminophen to Resident #34. She gave 2 caps of 325 mg to Resident #34. RN A revealed that LPN B was on duty. During an interview with the DON on 03/22/2024 at 3:30 PM, revealed that she had spoken to Resident #34's brother concerning medication error. Revealed to DON that RN A stated that she was not working after 2:00 PM on 03/20/2024. Documentation showed that she was working and was the nurse who administered the last dose of Acetaminophen to Resident #34 at 17:17 (5:17 PM). The DON revealed that the Acetaminophen 325 mg (milligrams) and Acetaminophen 500 mg (milligrams) were in the medication cart beside each other. Numbers on 500 mg (milligrams) were AZ 011. The bottles have been separated. A roster dated 03/19/2024 indicated 11 residents resided on Hall East 2 where RN A administered medications. Reviewed facility's policy on Adverse Consequences and Medication Errors. Revised April 2014. Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. c. Wrong dose Record review completed on Resident (#34's) file on Thursday, 03/21/2024. Findings showed that resident's Clinical Physician Orders dated 03/21/2024 for Resident #34 reflected: Acetaminophen Tablet 325 mg - Give 2 tablet by mouth every 4 hours as needed for fever - Start Date - 03/03/2024. Acetaminophen Tablet 325 mg - give 2 tablets by mouth every 4 hours as needed for pain. Further findings showed that RN A was working after 2:00 PM when the last Acetaminophen Tablet was given to resident at 17:17 (5:17PM) on 03/20/2024. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for eight residents (Residents #3, #12, #24, #27, #38, #40, and #47 ) of 17 residents reviewed for ADL care. The facility failed to ensure current Residents #3, #12, #24, #27, #38, #40 and discharged Resident #47 were provided bathing as scheduled. These failures could place residents at risk of not receiving personal care services and of having a decreased quality of life. Findings included: Resident #3 Review of Resident #3's face sheet, dated 02/15/23, reflected she was an [AGE] year-old female resident admitted to the facility on [DATE] with the following diagnoses open wound of right buttock, Type 2 Diabetes Mellitus, age-related physical debility, need for assistance with personal care, congestive heart failure, atherosclerotic heart disease of native coronary artery (plaque buildup in the wall of the artery that supplies blood), dementia, cerebral infarction (stroke), encephalopathy (disease that alters brain function), osteoarthritis, spondylosis lumbar region (abnormal wear on the cartilage and bones), dysphagia (swallowing difficulties), and cognitive communication deficit. Review of Resident #3's admission MDS assessment, dated 02/03/23, reflected the BIMS score was 7 or severely impaired cognitively. Resident #3 had no psychosis or behaviors (including refusal of care) during the past seven days. Resident #3 required extensive assistance of two persons for transfers, extensive assist of one person for dressing, toilet use, and personal hygiene. It further reflected that she was totally dependent on one person for bathing. Review of Resident #3's care plan, dated 01/27/23, reflected she had an ADL Self-care Performance Deficit due to impaired mobility. The goal indicated: The resident will improve current level of function. The interventions was: Encourage the resident to participate to the fullest extent possible with each interaction. An observation on 02/13/23 at 3:06 PM, revealed Resident #3 in bed under her covers, her hair appeared to be oily and unbrushed, she was in a gown and had O2 at 2.5 L via a NC. It further revealed she had a family member visiting. In an interview on 02/13/23 at 3:06 PM, the family member revealed Resident #3 had a pressure ulcer on her coccyx. The family member reported they had not seen her get a shower when they had been there, but there were 4 in her family that came up and sat with her. The family member said she would generally brush Resident #3's hair and had noticed it felt dirty, so they were wondering if Resident #3 had been getting bathed. They also stated they were going to call the other family members to ask if anyone had seen Resident #3 get bathed. The family member came by later that day and said they had reached 3 of the 4 other family members and none of them had ever seen Resident #3 get bathed. Review of Resident #3's EMR reflected no refusals of ADL care for January or February 2023. Review of Resident #3's bathing EMR documentation from 01/27/23 to 02/15/23 reflected Resident #3 received showers Tuesday, Thursday and Saturdays on the 6:00 AM to 2:00 PM shift, so Resident #3 should have received a total of eight showers. The EMR documentation reflected she received showers on the following days: -01/31/23 -02/07/23 -02/14/23 There was no documentation of showers given for Resident #3 on the following days and were marked NA for Not Applicable or left blank. -01/28/23 -02/04/23 -02/09/23 -02/11/23 Resident #12: Review of Resident #12's face sheet , dated 02/15/23, reflected a [AGE] year-old woman, admitted to the facility on [DATE] with diagnoses of dislocated left elbow joint, history of falling, morbid obesity, respiratory failure, muscle wasting and atrophy, cognitive communication deficit, degeneration of vertebral discs in her lower back, bipolar disease, depression, and end-stage renal disease. Review of Resident #12's admission MDS assessment, dated 01/31/23, reflected a BIMS of 12, indicating moderate cognitive impairment. Further review of the MDS reflected Resident #12 had no psychosis or behaviors (including refusal of care) during the past seven days. Resident #12 was always incontinent of bowel and bladder. Resident #12 only transferred once or twice, with the assistance of two people, and required extensive assistance of one person for dressing, and moving around in her bed, and extensive two-person assistance for toilet use, and personal hygiene. She was totally dependent, with one-person assistance for bathing. She required help from one person for part of her bathing activity. The assessment indicated Resident #12 answered that choosing between a tub bath, shower, bed bath, or sponge bath ranked as very important to her while in the facility. Review of Resident #12's care plan, dated 01/23/23, reflected she had limited mobility due to weakness, and had a goal of remaining free of complications related to immobility, including contractures, thrombus (blood clot) formation, skin breakdown, and fall related injury. I interventions included providing supportive care, assistance with mobility as needed, and documenting assistance as needed. Careplans did not reflect specific information about Resident #12's bathing, or any behaviors of refusing bathing. Review of Resident #12's care plan, dated 02/07/23, reflected she had a behavior of removing her left arm splint, and telling staff therapy removed it. Review of Resident #12's care plans, current as of 02/14/23, reflected no refusals of bathing or other care, or specific information about Resident #12's bathing. Review of Resident #12's progress notes from 01/25/23 through 02/15/23 reflected mild cognitive impairment, with memory loss, and some confusion, occasional tearful and anxious behavior, and an unwanted behavior of removing her splint from her left arm, but no notes regarding bathing. Review on 02/14/23 of the ADL (Activities of Daily Living) task for bathing in Resident #12's EMR (Electronic Medical Record) reflected the resident's scheduled bath times were on Tuesdays, Thursdays, and Saturdays, during the 6:00 AM to 2:00 PM shift, so Resident #12 should have received a total of nine showers. The record reflected the following documentation on scheduled bath days: 01/26/23- received bathing 01/28/23- no documentation 01/31/23- no documentation 02/02/23- not applicable 02/04/23- not applicable 02/07/23- received bathing 02/09/23- not applicable 02/11/23- not applicable 02/14/23- resident not available Observation and interview on 02/13/23 at 11:17 AM, revealed Resident #12 was tearful, moaning, and was in pain. She stated she could not talk to the surveyor, but if her husband was there, he could talk, but he was dead. When asked if we could talk later in the day, when she felt better, Resident #12 shook her head to indicate she did not want to. On this observation, her hair appeared oily or wet, and sticking up from her head in some areas. Observation on 02/13/23 at 12:19 PM, of Resident #12 revealed her to be sleeping soundly, and her hair to appear the same as earlier observation. Observation and interview on 02/15/23 at 12:58 PM, revealed Resident #12 awake in bed, and agreeable to an interview, but confused, and giving delayed and irrelevant answers at times. She said she was waiting for a shower until she got to her next place and could not go into the shower because she would fall. She said the staff gave her 20 baths a day and wiped her in her bed, and that they used to spray her with the hose. When asked if anyone had washed her hair, she did not confirm or deny, but said she would like a shower, and for someone to wash her hair. Her hair appeared oily and mussed, the same as on earlier observations. Resident #24 Review of Resident #24's admission record dated 02/15/23 reflected an [AGE] year-old woman, admitted to the facility on [DATE] with diagnoses of acute respiratory failure, epilepsy and epileptic syndrome (types of seizures, age at which the seizures began, causes of the seizures), age-related physical debility, need for assistance with personal care, dependence on renal dialysis, atrial fibrillation (an irregular or rapid heart rate), multiple myeloma (a cancer of plasma cells), hypertensive heart disease, anemia (blood does not have enough healthy red blood cells), unspecified osteoarthritis, renal and perinephric abscess and acute kidney failure (a collection of pus that occurs due to a bacterial infection in the perinephric fat and fascia surrounding the kidney). Review of Resident #24's admission MDS assessment, dated 01/04/23, reflected a BIMS of 14, indicating she was cognitively intact. Further review of the MDS reflected Resident #24 had no psychosis or behaviors (including refusal of care) during the past seven days. Resident #24 required extensive assistance of one person for transfers, and toilet use. She also required limited assistance of one person for personal hygiene, dressing and that bathing had not occurred over the entire 7-day period. Review of Resident #24's care plan, dated 01/19/23, reflected she had an ADL Self-care Performance Deficit due to impaired balance. The goal included she will maintain the current level of function through the review date (04/19/23). Interventions included Bathing: check nail length and trim and clean on bath day, and as necessary. Report all changes to nurse. Provide sponge bath or shower as tolerated. The resident requires limited to extensive assist by 1 staff with showering as necessary. Review of Resident #24's EMR reflected no refusals of ADL care for January or February 2023. An observation and interview on 02/13/23 at 11:27 AM Resident #24 was up in a WC in her room, dressed and appeared well groomed. When asked about showers/baths she stated she had one shower since she had been there and had a bed bath yesterday (02/12/23). She stated when she would ask for one staff would say she could not have one today. She had been there since 12/29/22 and only had one shower. She said most of the time she had diarrhea and that lately it was watery diarrhea that hurt when she had it. Review of Resident #24's bathing EMR documentation from 12/29/22 to 02/15/23 reflected Resident #24 received showers/baths on the 6:00 AM to 2:00 PM shift (it did not specify any certain days, so it was undetermined exactly how many showers Resident #24 should have received, but approximately ten) and received a bath or shower on the following days: -01/24/23 -01/28/23 -02/14/23 There was no documentation of showers given for Resident #24 on the following days and were marked with an X -01/01/23 through 01/12/23. The EMR further reflected she did not receive any assist due to being hospitalized from [DATE] through 01/19/23. Per the EMR, there was no documentation of showers given for Resident #24 on the following days and were marked NA for Not Applicable, or left blank. -01/21/23 -01/26/23 -01/31/23 -02/02/23 -02/04/23 -02/07/23 -02/11/23 Resident #27: Review of Resident #27's face sheet dated 02/15/23 reflected an [AGE] year-old man, admitted to the facility on [DATE], with diagnoses of fractured vertebra, history of falling, muscle wasting and atrophy, leukemia, aphasia , heart failure, stroke, depression, and macular degeneration . Review of Resident #27's admission MDS assessment, dated 01/23/23, reflected a BIMS of 10, indicating moderately impaired cognition. Further review of the MDS reflected Resident #27 had no psychosis or behaviors (including refusal of care) during the past seven days. Resident #27 was frequently incontinent of bowel and bladder. Resident #27 required extensive assistance of one person for moving in bed, and using his wheelchair and the toilet, and for hygiene. He required extensive assistance from one person for transferring, and limited assistance of one person for dressing. Resident #27 did not bathe during the past seven days. The assessment indicated Resident #27 answered that choosing between a tub bath, shower, bed bath, or sponge bath ranked as very important to him while in the facility. Review of Resident #27's care plan, dated 01/16/23 reflected he had an ADL Self-care Performance Deficit due to vertebra fracture. The careplan goal was to improve his current level of function in ADLs. Interventions included the resident was totally dependent on one staff to provide a shower on shower days three times a week, and as necessary. Resident #27's careplans did not reflect any behaviors of refusing bathing. Review of Resident #12's progress notes from 01/16/23 through 02/13/23 reflected various levels of confusion, high fall risk and actual falls, and reflected no pattern of refusals of bathing. Review on 02/13/23 of the ADL task for bathing in Resident #27's EMR reflected the resident's scheduled bath times were on Mondays, Wednesdays, and Fridays during the 2:00 PM - 10:00 PM shift, during which period Resident #27 should have received thirteen baths. The record reflected the following documentation on scheduled bath days: 01/16- no documentation 01/18- no documentation 01/20- no documentation 01/23- no documentation 01/25- no documentation 01/27- received bathing 01/30- received bathing 02/01- not applicable 02/03- received bathing 02/06- received bathing 02/08- resident refused bathing 02/10- received bathing 02/13- not applicable An interview and observation on 02/13/23 at 3:35 PM, revealed Resident #27 was up in a chair, and his wife sitting next to him. Resident #27 nodded sometimes to answer questions but was unable to have a conversation with the surveyor. He appeared clean, and fully dressed. Resident #27's wife said that since the resident admitted on the 16th, she had been there nearly 24/7. She said that when they arrived, there was no orientation about the rules, and nobody told her about the bath schedule, so she did not know when he was eligible to take a bath, and did not know to ask, because the staff were always changing. She said he had been in the facility approximately 14 days with no bathing, and she finally spoke with the DON about it, and he was then provided a bed bath. She said after that, he went a long time again without a bath, and she appealed to one of the CNAs who took good care of him, even though it was not her shift and she bathed him on her shift. Resident #38 Review of Resident #38's admission record, dated 02/15/23, reflected a [AGE] year-old man, admitted to the facility on [DATE] with diagnoses of wedge compression fracture (small breaks or cracks in the vertebrae) of the 3rd lumbar vertebra, history of falling, muscle wasting and atrophy (waste away), other symbolic dysfunction (social impairment), cognitive communication deficit, hypertensive heart disease, benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), retention of urine, calculus of kidney and cerebral infarction (stroke occurring as a disrupted blood flow to the brain). Review of Resident #38's admission MDS assessment, dated 01/17/23, reflected a BIMS of 10, indicating moderate cognitive impairment. Further review of the MDS reflected Resident #38 had no psychosis or behaviors (including refusal of care) during the past seven days. Resident #38 required total extensive assistance of one person for transfers, dressing, toilet use, and personal hygiene. It further reflected that bathing did not occur the entire 7-day period. Review of Resident #38's care plan, dated 01/11/23, reflected he had a self-care deficit performance related to pain and compression fracture. The goals included he will improve the current level of function in ADLS through the review date (04/24/23). Resident will be able to perform ADLS with supervision. Interventions included Bathing: check nail length and trim and clean on bath day, and as necessary. Report all changes to nurse. Review of Resident #38's care plans, current as of 02/15/23, reflected no refusals of care, or other behavioral issues. Observation on 02/13/23 01:54 PM, revealed Resident #38 up in a WC, in his room, dressed and appeared well groomed, and had a family member visiting. An interview on 02/13/23 at 1:54 PM with Resident #38's family member revealed no one had helped him or even suggested to brush his teeth and she had only realized it the previous day so they had helped him. They further revealed he had been there 2 months and had only one shower since he was there. They said he was treated with respect, no roughness or meanness, just not much help. Review of the undated bathing schedule reflected Resident #38 was scheduled to be bathed on Mondays, Wednesdays, and Fridays, on the 6:00 AM to 2:00 PM shift. Review of Resident #38's bathing EMR documentation from 01/11/23 - 02/15/23, during which time Resident #38 should have received an estimated 15 baths, reflected: -Resident #38 received bed baths or showers on 01/11/23, 01/13/23 and 01/16/23. There was no documentation of showers given for Resident #38 on the following days and were marked NA for Not Applicable or left blank. -01/18/23 -01/20/23 -01/23/23 -01/25/23 -01/27/23 -01/30/23 -02/01/23 -02/03/23 -02/06/23 -02/08/23 -02/10/23 -02/13/23 -02/15/23 Resident #40: Review of Resident #40's face sheet, dated 02/15/23, reflected a [AGE] year-old female, admitted on [DATE] with diagnoses of stroke, diabetes, muscle wasting and atrophy, heart disease, and osteoarthritis. Review of Resident #40's admission MDS assessment, dated 02/01/23, reflected a BIMS score of 13, indicating intact cognition. The assessment reflected no behaviors, or indicators of psychosis. Resident #40 required extensive one-person with bed mobility, dressing, and toilet use. She required extensive two-person assistance with hygiene, and total assistance of one person for bathing. Resident #40 was frequently incontinent of bladder, and always incontinent of bowel. The assessment indicated Resident #40 answered that choosing between a tub bath, shower, bed bath, or sponge bath ranked as very important to her while in the facility. Review of Resident #40's care plan, revised 01/25/23, reflected she had an ADL self-care performance deficit related to right sided weakness from a stroke, with a goal of improving her current level of function in ADLs. The interventions included the resident was totally dependent on staff for staff to provide showers three times a week, and as needed. Careplan documentation reflected no refusals of bathing. Review on 02/13/23 of the ADL task for bathing in Resident #40's EMR reflected the resident's scheduled bath times were on Tuesdays, Thursdays, and Saturdays, during the 6:00 AM to 2:00 PM shift. During the period reviewed, Resident #40 should have received eight baths. The record reflected the following documentation on scheduled bath days: 01/26- no documentation 01/28- received bathing 01/31- no documentation 02/02- not applicable 02/04- no documentation 02/07- not applicable 02/09- not applicable 02/11- received bathing Review of Resident #40's progress notes from 01/25/23 through 02/14/23 reflected the resident was normally alert and oriented 2-3 with some confusion, and isolation precautions for a urinary tract infection. The notes did not reflect any refusals of bathing or other care. Review of Resident #47's face sheet, dated 01/26/23, reflected a [AGE] year-old man, admitted on [DATE], and discharged to his home on [DATE], with a primary diagnosis of a broken femur. Review of a facility Grievance Resolution Form, dated 01/26/23, reflected a grievance form for Resident #47. He had a concern that he had not received a shower during his stay and wanted to get one prior to his discharge. The resolution was the resident received a shower on 01/27/23. Review of the ADL bathing documentation of Resident #47 for the period of his stay reflected no bathing documentation for the entirety of his stay. An interview and observation on 02/13/23 at 2:00 PM revealed Resident #40 was on isolation precautions for a urinary tract infection, and she stayed in bed. She said she was not feeling very good that day, and her memory was not very good, and the surveyor should speak with her daughter about details, because she could not remember dates. She said she got a bath when she first arrived, then she did not get one for a while, because of the ice storm (referring to a weather event occurring the week of 01/30/23 through 02/03/23) causing staffing problems. She said they told her it would get better after the storm, and it was some better than it was at first, but she felt she only got about one bed bath a week. She said if the staff offered baths, she accepted most times. She said it depended on which staff was working, whether she got a bath, or had to wait to get changed. She said her daughter complaint to the Administrator and it did get some better after that, but she still did not think she was getting three baths per week. An interview on 02/13/23 at 2:23 PM with the family member of Resident #40 revealed the family's main concern regarding bathing was that the resident was in the facility for at least four days before she received a bath. She said it was not explained to the resident, or to the family, that there was a bath schedule, until another relative contacted the Administrator, and complained that the resident was being neglected. She was not sure if the resident was currently getting baths on schedule. In a confidential group interview on 02/14/23 at 12:03 PM, one resident stated she did not ask to get bathing for approximately three weeks after she was admitted , and nobody offered, so she did not get any. She said she did not know to ask for one, and was not aware that there was a schedule. She said she did not blame the staff, because they were so busy, and there were real sick people there, and she felt staff had to prioritize them. She said they gave her a bath during the week of this interview, and It makes you feel so much better to be clean. I even washed my hair! Another resident stated when she was admitted , she was not offered a shower for several days (she did not know how long), and not informed of the process or schedule for getting one. When she felt she needed one badly enough, she decided to ask for one. She said it was at night, and the staff member turned the water on for her, and left her alone to shower herself, but the floor was flooded, and she was scared about falling. She said she very quickly showered herself, and turned the water off, and did not ask again. She said she had received showers since, and a staff member stayed with her, but at first she was on her own. An interview on 02/15/23 at 1:11 PM with the DON revealed the facility did not have a policy on ADLs, but she provided the bathing procedures. She said they had realized they had a problem with the documentation on bathing, and all of the missing dates were related to agency staff. They provided the logins for them, and oriented them all, and she even told her staff to remind them to do ADLs, but with agency staff, they had a lot of problems with accountability, and they worked hard to get agency staff out of the building. They had a lot of new staff at the time of this interview, after trying to get rid of agency staff for over a year, finally sometime during the week of 02/05/23-02/11/23 they had eliminated agency staff use. She said sometime during January was the worst time they had with the agency staff, and documentation. The DON stated she did speak to Resident #27s wife about procedures at the facility after he admitted , but his wife came to her later, and did not remember having that conversation. She said his wife had talked to her about many concerns but had never mentioned any concerns regarding his ADL care. She said she thought it was in early January when she noticed a change for the worse in agency documentation and expressed her significant frustration about being cited for this issue when she thought they had already fixed the problem. She stressed how difficult it had been to deal with agency staff and said that she could not intervene with problems when she was not told about them, and she had not been made aware that residents were having problems with bathing by any of them. She said they had gone through the QAPI (Quality Assurance and Performance Improvement) process, and were still looking at it, but she felt agency staff was the problem and they had fixed that. She said Resident #12 did not want to get up at all, and the staff bathed her, but she presented a very short time window for any care, because she would be fine at first, then start screaming and want them to stop. She said because they did short-term only, they had a very high turnover, and the type of residents they had at one time might be drastically different from what they had the next month. An interview on 02/15/23 at 1:58 PM with CNA A revealed she only had worked in the facility for a few days, and there was a paper at the nurses' station with the resident shower schedule on it, which had the shift, and the room number, so they would know what day and shift a resident was scheduled for bathing. She said she did not think the residents seemed like they were lacking bathing, except Resident #12, who had an odor sometimes, and refused her bathing. She said she documented the bathing task in the EMR, where it had the bath days for that resident. She said if nobody documented on a bath day, it would turn red. She said the only times she used not applicable was when the bath task was red, but their bath was scheduled on a different day. She said it was important to bathe residents to keep their skin healthy. An interview on 02/15/23 at 2:14 PM with CNA B revealed she had worked in the facility for a few months. She said she knew when residents were supposed to be bathed by what room they were in, and the bath schedule was also in PCC, where she documented how much help a resident needed, and how many people they needed, and if they refused. She said Resident #12 did not like baths, but she did what she could with her. She said usually when she was asked if she was ready for a bath, she would cry, and say she was too tired, and it was too cold. She said she would tell the nurse, and try again twice, before she documented the refusal. She said she had to catch the resident in a really good mood to even provide any care for her, and it was even difficult to do her incontinent care. She said she had given Resident #40 bed baths twice, and she was cooperative, but she had not worked with Resident #27. She said bathing was important because not doing it could cause bed sores, and emotional distress, and it was also neglect. She was not aware of problems with bathing, and if she was, she would tell the Administrator. An interview on 02/15/23 at 2:35 PM with CNA C revealed that when asked about each resident surveyors found with bathing problems, she said they were not on her hall. She said the EMR told her when a resident needed bathed, and she bathed them in the shower in her room, or a bed bath, depending on what the resident needed and wanted. She said if they refused, she told the nurse, made three attempts, and documented the refusal. She said she had not noticed residents looking like they had not been bathed, and if she did, she would bathe them if it was her resident, or notify their nurse and CNA. CNA C said she only used not applicable when it was not the resident bath day. An interview on 02/15/23 at 2:44 PM with CNA D revealed she did work with Resident #38, and he refused on the day of the interview, and on 02/20/23, saying he did not care if he was dirty or not, and she could not make a resident care. She said she documented bathing in PCC, and never used not applicable for bathing. She said she only used it for things like if a resident did not walk at all, and they did not walk in their room or on the unit, the part of the documentation about walking would be not applicable. She said she had not noticed residents being dirty, and some residents would forget if they had a bath. CNA D said not bathing residents would be considered neglect, and if she found residents were not getting bathed, she would inform the DON. An interview on 02/15/23 at 6:51 PM with the DON revealed one day Resident #40's family member visited the facility and said Resident #40 was not showered. She spoke with CNA E, who said she gave her a shower, and had even had a conversation with the resident about it, got the things she needed set up, and gave her a bed bath. CNA E said she did not understand why anyone was saying Resident #40 didn't get a bath. The DON said she could not recall some of the details, but she knew the family member who had complained to the Administrator apologized for it, and that Resident #40 did get a shower. An interview on 02/15/2023 at 7:03 PM with the Administrator revealed he heard about the complaint about bathing from a family member of Resident #40. The family member emailed him about it, and he reached out and asked for more information, because the initial email did not identify which patient wash having the problem. He said the family member, who turned out to be Resident #40's secondary emergency contact, identified Resident #40. He spoke with that family member, and another family member who was the primary emergency contact, and they both repeated what the email said initially, that the resident had not been bathed on 01/28/23. The family member who was the primary contact said she felt it was neglect, so he reported the allegation to HHSC (Health and Human Services.) He went to Resident #40, and asked her specific questions about bathing, and other ADLs, and she only had a complaint about long call light wait times. They in-serviced the staff on her concern and contacted the family member who was her primary emergency contact, and told her about the conversation with Resident #40, and what they had done to address the concern, and she said she was satisfied with that. When talking to the family members, he learned another family member had been visiting, and when CNA E went into the room to shower the resident, that family member took leave, to protect Resident #40's privacy, and did not stay to see that the resident was bathed. When the secondary contact family member visited Resident #40 on 01/29/23, Resident #40 told her she did not get a shower the day before, and that the aide had only left the shower things there and did not bathe her. The aide confirmed the bathing did occur and she had documented it. At Resident #40's careplan meeting, both of her emergency contact family members went to the nurses station, and repeated the same complaint, but after Resident #40 told them she had been bathed, they came out and apologized. Review of a facility Quality Improvement Plan reflected a goal of removing all agency staff by 02/01/23, due to problems which included lack of documentation, and lack of ADL care (brushing hair and teeth, and showers/baths. The goal was modified, extending the date to 02/06/23, after which date no agency staff scheduled to work in the building for the remainder of the month were cancelled. Review of in-service education documentation, dated 01/10/23, reflected the DON provided an in-service to CNAs on showers, checking the EMR assignment for showers due, and completing the ADL documentation. Review of in-service education documentation, dated 01/23/23, reflected[TRUNCATED]