**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #272 was admitted to the facility on [DATE]. Review of Resident #272's admission health and physical dated 3/31/23 revealed the resident was alert and oriented to person, place, and time. During observation on 4/3/23 at 10:31 AM Nurse #4 was observed to enter Resident #272's room through the open door without knocking or announcing her presence. During an interview on 4/3/23 at 10:33 AM Resident #272 stated it bothered her when staff entered her room and did not knock or announce her presence. During an interview on 4/3/23 at 10:38 AM Nurse #4 stated it was facility culture to knock or announce presence prior to entering resident rooms to provided privacy and dignity to the residents. She concluded she thought she had announced her presence at the door and should have done so. During an interview on 4/4/23 at 9:22 AM the Director of Nursing stated staff were to announce their presence prior to entering the resident's room for privacy and dignity. Based on observations, interviews with residents and facility staff and record review the facility failed to maintain residents' dignity by not providing assistance when requested while a resident was in the shower room(Resident #3) and when staff did not announce their presence prior to entering the Resident's room (Resident # 272) for 2 of 4 residents reviewed for dignity. Resident #3 stated this made her feel angry and like a piece of trash. The findings included: 1. Resident #3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #3 was cognitively intact. On 4/4/23 at 9:46 AM Resident #3 said she was in the shower room for her shower on 4/1/23 when Nursing Assistant (NA) #6 went back to Resident #3's room to make her bed. Resident #3 said she told the NA to do it quickly and to come back to the shower room to get her. She said she pulled the call light when she was finished with her shower, but no one came so she began to call out. She said no one could hear her calling out for assistance. She said she thought the call light was not working so she started hollering. She said it was about an hour she thought. She said she did not see a clock in the shower room. On 4/6/23 at 11:05 AM Resident #3 reported having to holler and wait for someone to come and get her from the shower room on 4/1/23 made her feel angry and like a piece of trash. On 4/6/23 at 10:28 AM NA #6 stated she was the NA assigned to Resident #3 on 4/1/23. NA #6 said she took Resident #3 to the shower room. She said Resident #3 was able to complete her own shower after everything was set up for her. She said Resident #3 gave her permission to go back to the Resident's room to make her bed. She said she did go to make up the bed, but she needed some other supplies, so she went to the supply room to obtain the needed items. She said when she returned to the hall and was going to the shower room, she could hear Resident #3 calling her, so she went straight into the shower room. NA #6 said it was about 15 minutes from the time she left Resident #3. On 4/6/23 at 10:58 AM NA #7 who was also working on 4/1/23 stated she was not aware of the call bell not working in the shower room until Resident #3 told her she was not able to get help while in the shower room because the call light was not working and there were no staff members at the nursing station just across from the shower room. On 4/6/23 the Director of Nursing was not available to interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to provide a working Packaged Terminal Air Conditioner (PTAC) unit (a type of heating and air conditioning system used in a single living space) in the resident's room for 1 of 1 resident (Resident #281) reviewed for a clean and homelike environment. Findings included: Resident #281 was admitted to the facility on [DATE]. The physician's history and physical for Resident #281 dated 3/22/23 read in part that he was alert and oriented to person, place, and time. An observation on 4/03/23 at 11:33 AM Resident #281 was observed to be sitting in a wheelchair in his room. He was observed to be wearing a toboggan, shirt, hooded sweatshirt with the hood pulled over his head, and a jacket. He was not observed to be shivering. There were no other sources of heat noted in the room and the PTAC unit under the window was not plugged in. An interview on 4/03/23 at 11:33 AM with Resident #281 revealed his PTAC had not worked since he was admitted to the facility. He stated he did not remember which staff members he had notified but had told several staff members. He also stated he was very cold natured. A review of www.wunderground.com revealed the outside temperature on 4/3/23 was 45 degrees Fahrenheit at 1:51 AM and was 64 degrees Fahrenheit at 10:51 AM. An observation and interview on 4/03/23 at 11:43 AM with the Facilities Maintenance Coordinator revealed the PTAC unit was unplugged. He also revealed he was unaware the PTAC unit in Resident #281's room was not functioning and had not received a work order or any other type of notification that the unit needed repair. Another interview on 4/03/23 at 11:55 AM with the Facilities Maintenance Coordinator revealed the PTAC unit in Resident #281's room heating element trip switch had been tripped. He revealed he reset the trip switch, plugged in the unit and it was now working. An interview on 4/03/23 at 2:43 PM with Nurse #1 revealed when Resident #281 had told her he was cold, she opened the window blinds so he could get sunshine to get warm. She stated she had not attempted to turn on his heat or noticed his PTAC unit was not working. She had not notified maintenance or entered a work order or notified maintenance. An interview on 4/03/23 at 2:56 PM with the Director of Nursing (DON) revealed the facility process was for staff to enter a work order for maintenance for repairs or to move the resident to a room with a functional heater. She was unaware if a work order had been entered for the heating unit in Resident #281's room. An interview on 4/05/23 at 11:22 AM with the Administrator revealed he did not know why the work order process did not go as planned for notification of maintenance for the PTAC unit in Resident #281's room. An interview on 4/06/23 at 8:44 AM with Nursing Assistant #1 revealed that Resident #281 had told her he was cold, and she had offered him another jacket. She also revealed she was aware the PTAC unit was not plugged in or working and thought maintenance knew.

Based on observations and staff interviews the facility failed to lock a treatment cart while unattended for 1 of 2 treatment carts observed (Treatment Cart #1). Findings included: During a continuous observation on 4/4/23 from 7:50 AM until 7:55 AM Treatment Cart #1 was observed next to the 300-hall nursing station unlocked and unattended. No residents were observed passing by the treatment cart during the observation. During an interview on 4/4/23 at 7:55 AM Nurse #3 stated the treatment cart was the responsibility of herself and the other hall nurse on 300-hall. The nurse stated they had not needed the treatment cart that morning and she did not notice the cart was unlocked. She concluded Treatment Cart #1 should have been locked when unattended. During observation with Nurse #3 on 4/4/23 at 7:56 AM the treatment cart was observed to contain items including triamcinolone cream 0.1%, gold bond cream 1-1%, hydrocortisone cream 1%, 10% povidone-Iodine, and triple antibiotic cream. During an interview on 4/4/23 at 9:22 AM the Director of Nursing stated treatment carts should be locked when unattended.

Based on observations and interviews with facility staff the facility failed to keep the dumpster area free of debris for 1 of 1 enclosed dumpster area observed. The findings included: An observation of the dumpster area was conducted on 4/5/23 at 12:20 PM with the Dietary Coordinator and the Administrator. The observation revealed there were 4 wheelchairs located behind the dumpster on the right side of the enclosed dumpster area. Behind the middle dumpster was a broken metal office desk. There was also a 6-foot-tall wall cabinet with the top sagging from being wet and the shelves were broken and had the appearance of being wet. The back of the wall cabinet had fallen off and was laying on the ground behind the wall cabinet. It also appeared to have been wet. There was a 6-foot-long piece of countertop behind the dumpster on the left side of the enclosure. During the observation on 4/5/23 at 12:20 PM the Administrator stated the items appeared to be discarded from the Occupational Therapy (OT) room renovation. He said the items were too large to fit into the dumpster, so they needed to have a dump truck from the main facility to come to this facility to pick up the items. On 4/6/23 at 9:20 AM the Occupational Therapist stated the OT room was demolished in November 2022. On 4/6/23 at 9:30 AM the Facilities Maintenance Coordinator said the desk was put into the dumpster area in November 2022 and the 6-foot-tall wall cabinet was placed there in early December 2022. He said he was responsible to call for the dump truck to pick up the items that would not fit into the dumpster but he was waiting until he had a full load before he called for the dump truck. The Facilities Maintenance Coordinator said he thought placing the items in the dumpster area was better than just having them sitting in the parking lot. On 4/6/23 at 9:53 AM the Administrator said he was not aware the items had been in the dumpster area since November 2022. He said he had them removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with facility staff and record review the facility failed to maintain the call light in working condition which caused a Resident (Resident #3) to be unable to obtain assistance while in the shower room for 1 of 1 shower room with a malfunctioning call system. The findings included: Resident #3 was admitted to the facility on [DATE]. Her diagnoses included spinal cord dysfunction and diabetes. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #3 was cognitively intact. On 4/4/23 at 9:46 AM Resident #3 said she was in the shower room for her shower on 4/1/23 when the Nursing Assistant (NA) went back to Resident #3's room to make her bed. Resident #3 said she told the NA to do it quickly and to come back to the shower room to get her. She said when she finished her shower she pulled the call light, but no one came so she began to call out. She said no one could hear her calling out for assistance. She said she thought the call light was not working so that was the reason she started hollering out for help. Resident #3 said it took a long time, but the NA finally came back. On 4/6/23 at 10:14 AM an observation of the shower room used by Resident #3 revealed there were 2 call pull stations. One was in the shower area near the rear of the room and the other was near the front of the shower room near the entry door. During this observation the call lights were activated. The activation of the call lights did not light up call light system in the hall on the outside the shower room. No sound from the alarm was heard coming from the nursing station located just across the hall from the shower room door. On 4/6/23 at 10:20 AM the Facilities Maintenance Coordinator stated he was aware the call light in the shower room was not functioning. He added the call light in the resident room to the left of the shower room was also not functioning and the resident had an alternative means of communication since his call light did not work. He stated the call lights had not been working for about 1 month. He added he had tried to determine why the call light was not working and was unable to fix it. He said he had an email to verify he had contacted the biomed support person when he was not able to repair the call light. A review of the email from the Facilities Maintenance Coordinator to the biomed engineering department was dated 3/9/23 and read the call bell is not working in the wall. Attempted multiple call bells that were verified to work. The system is not making any noises/alerts on the system in the wall, visible alert in the hall or audible alert at the nursing station. On 4/6/23 at 10:28 AM NA #6 stated she was the NA assigned to resident #3 on 4/1/23. NA #6 said she took Resident #3 to the shower room. She said Resident #3 was able to complete her own shower after everything was set up for her. She said Resident #3 gave her permission to go back to the Resident's room to make her bed. She said she did go to make up the bed, but she needed some other supplies, so she went to the supply room to obtain the needed items. She said when she returned to the hall and as she was going to the shower room, she could hear Resident #3 calling her, so she went straight into the shower room. NA #6 said it was about 15 minutes from the time she left Resident #3. NA #6 said she was not aware the call light in the shower room was not working. On 4/6/23 at 10:58 AM NA #7 said she worked on 4/1/23 and she was not aware the call light in the shower room was not working until 4/1/23 when Resident #3 was in the shower room. On 4/6/23 at 10:38 AM the Administrator stated he was aware the call light in the shower room was not working and he was aware that someone came and looked at the call light. The Administrator said he was told the unit needed to be replaced but it had not been replaced yet. He added if someone needed assistance they could just call out because the shower room was just across the hall from the nursing station. The Facilities Maintenance Coordinator was interviewed again on 4/6/23 at 10:38 AM and stated it was in January or February 2023 when he replaced the call light in both the shower room and the room to the left of the shower room but that did not fix the problem. He said he asked the biomed engineer for assistance because he thought the problem could be related to the moisture from when the pipe in the shower room ceiling burst and flooded the whole hall on 12/25/2022. On 4/6/23 at 11:00 AM the Clinical Manager stated they began moving residents back onto the hall at the end of February 2023, but the shower room was not in use until 2 weeks ago because the floor in the shower room was not finished until then. On 4/6/23 at 11:24 AM the Administrator said the biomed engineer had received emails about the shower room call light not working and the [NAME] President of the health care system was now trying to get this worked on. During the interview with the Administrator on 4/6/23 at 11:24 AM the Facilities Maintenance Coordinator was also present. He said had called a consulting clinical engineering biotechnology service and they were on the way to look at the shower room call light system.