**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to implement their grievance policies and procedures when Resident #81 reported her dentures were missing for 1 of 3 residents reviewed for grievances. The findings included: Review of the facility grievance policy revised 1/10/2024 defines a grievance as follows: A grievance includes but is not limited to complaints with respect to care and treatment that has been furnished to a patient, as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding the patient ' s facility stay. The grievance policy procedure includes - If the grievance is taken and a response can be started, complete the Action Taken and Findings section of the Grievance/Complaint form: Healthcare centers and give it to the Administrator or designee. -If the grievance is associated with a missing item, refer to the Missing Item Policy and associated forms. The grievance policy also reads The Administrator will be responsible for overseeing the grievance process: The administrator or designee will track the grievance on the Grievance/Complaint Log Form: Healthcare Centers. This will provide a central place for all grievances; The Administrator or designee will then refer the grievance to the appropriate department for investigation if it has not already been referred. The Administrator or designee will record the date of the referral and sig the Grievance/Complaint Log Form: Healthcare Centers. The policy also reads the Administrator, or designee will be responsible for follow-up with the patient, to determine the grievance has been resolved and to ensure the grievance process is understood, The Administrator or designee will complete the Grievance/Complaint Log form: Healthcare Centers indicating whether the problem was resolved and document reactions to the resolution. The policy also reads the Grievance/Complaint should be resolved within 3 business days. Resident #81 was admitted to the facility on [DATE] and was discharged on 12/17/2024. Resident #81 was admitted to the facility with diagnoses that included after care following joint replacement surgery, fracture of right femur. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #81 was cognitively intact. During an interview on 12/15/2024 at 4:28pm Resident #81 stated her dentures had been missing since the day after she was admitted and wanted to know what would be done about it. Resident #81 stated she had put her dentures in a napkin on her overbed table because she did not have a denture cup. Resident #81 said she had told lots of people they were missing, and staff had looked for them, but Resident #81 wanted to know what would be done since her dentures were still missing. Resident #81 stated no one had followed up with her. Review of Resident #81's progress notes revealed a note dated 12/6/2024 written by the Social Worker that read, Resident informed Director of Nursing (DON) that she took out her dentures and put them in a napkin and is concerned that dentures have been thrown in the trash. Room searched by DON and Activity Director (AD) and unable to locate. Trash was searched and DON and AD went through recent trash in the dumpster and were not able to find dentures. Review of the grievance logs revealed there was no record of a grievance filed on 12/6/2024 or in December 2024 for Resident #81. During an interview on 12/16/2024 at 1:40pm the Social Worker (SW) stated she was aware Resident #81 had dentures missing, that Resident #81 had wrapped them in a napkin and believed they were thrown away. The SW stated the facility investigated missing items and if negligent actions were found the facility will replace the item. If it cannot be decerned what happened to an item then the facility does not have to replace the item. The SW stated the Director of Nursing (DON) and Activities Director (AD) #1 had searched dietary, and the dumpster and Resident #81's bed for the missing dentures and they were not found. The SW stated Resident #81 had been informed the facility was not liable to replace dentures due to not being able to verify how they were lost, but was unsure of the exact day Resident #81 was informed. The SW stated she had talked to her about her dentures. Further review of progress notes revealed there were no other progress notes related to discussing the result of the grievance report with Resident #81. On 12/16/2024 at 1:46pm the SW stated she was completing the grievance report right now because she had forgotten to complete it, when the grievance report for Resident #81's missing dentures was requested. During a follow up interview on 12/17/2024 at 10:07am the SW stated when a resident has lost dentures and they could not be found, it was handled differently based on each situation. The SW stated she would have started the process today (12/17/2024) of trying to get an appointment for Resident #81 with her dentist, but the resident was discharging home today. The SW stated a grievance report is normally followed up on and completed within three days and that a grievance report should be started once they have looked and can't find the missing item. The SW verified the Administrator was the facility grievance official. The SW stated the Administrator #1 was going to contact his boss regarding the policy of replacing dentures. The SW verified there was no documentation that replacement dentures were offered, no documentation of follow up with Resident #81 was documented. Review of a copy of the requested grievance report was received on 12/17/2024, and revealed the grievance report was dated as being received 12/6/2024. SW signature was dated 12/6/2024, Grievance report contained Administrator #1's signature but no date, and the SW signature that she had informed Resident #81 of completed grievance report on 12/9/2024. During an interview on 12/18/2024 at 1:40pm the Director of Nursing (DON) stated Resident #81 said she had lost her dentures. DON looked in the trash and dumpster and could not find Resident #81's upper dentures. The DON stated Resident #81 had a denture cup in her room. The DON stated for long term care residents the facility would start working to get dentures replaced, with short term situations, the DON was unaware of how it would be handled. The DON stated she expected the facility to talk to Resident #81's daughter and find out who the Dentist was and the facility would make an appointment. The DON verified Resident #81 went home with upper dentures missing. The DON stated anyone involved could fill out a grievance report once the facility knew they could not be found. During an interview on 12/18/2024 at 2:35pm the Administrator #1 stated he was aware Resident #81 was missing her upper dentures, and that he had interviewed Resident #81. The result of the interview was that Resident #81 had rolled her dentures up in a napkin because she reportedly did not have a denture cup, but the Administrator stated when talking with Resident #81 regarding her dentures a denture cup was found in Resident #81 ' s room in the bedside drawers. The Administrator stated he discussed with Resident #81 that since they could not verify how the dentures were lost, the facility was not liable to replace them. The Administrator stated he would expect a grievance report to be started immediately, and that social services normally completed the form and it was reviewed by the Administrator. The Administrator stated anyone can start the Grievance report then turn it in to the social worker to determine who needs to follow up. The Administrator verified the grievance for Resident #81 was not on the grievance log for December of 2024. The Administrator was unsure why this grievance report was not on the grievance log for December 2024, he said he had not reviewed or signed it yet. The Administrator reviewed the copy of the grievance and verified it had his signature, but the Administrator was unaware of the date he signed the grievance form for Resident #81, and thought a grievance form had been started immediately. The Administrator verified he was the facility Grievance official.

Based on record review, and staff interviews, the facility failed to implement their abuse policy and procedure in the areas of reporting to administration, completing a thorough investigation and failing to notify adult protective services, when Resident #85 reported that three staff members had held his arms down in bed and would not let him go to the bathroom and yelled at him not to ring the call light. This deficient practice occurred for 1 of 3 residents reviewed for abuse. The findings included: The facility's Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Policy revised 10/27/2020, defined abuse as the willful infliction of injury, unreasonable confinement intimidation or punishment. The facility's Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Policy revised 7/29/2019 read 1. Any allegation, suspicion, or identified occurrence is identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of unknown source, exploitation, mistreatment, and misappropriation of property, including injuries of unknown source, should be reported immediately to the Administrator of the provider entity, 2. Adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of patient property. The facility's Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Policy reads The Administrator of the provider is responsible for assuring that an accurate and timely investigation is completed the policy further reads Documentation of the investigation should include, but not limited to, the following- Signed statements from pertinent parties also reads interviews should be conducted of all individuals who have relevant information, utilizing open ended questions. Written statements from any involved parties should be obtained. Statements should be gathered from the following individuals: the suspect, the person(s) making accusation(s); the patient involved; reliable patients who may have witnessed the incident and any other persons who may have information. A review of the Initial Allegation Report submitted to the state agency on 3/10/24 indicated the report was marked as an abuse investigation. The report revealed that Resident #85 had stated sometime last night or this am those 3 girls came in here and yelled at me and held my hands down and wouldn't let me go to the bathroom. One of them told me not to ring my call light again. The initial investigation report also indicated Adult Protective Services (APS) was not notified. A review of the investigation report for Resident #85 revealed there was no interview or statement of what was reported included from Resident #85, the report indicated Resident #85 reported staff had yelled at him, held his hands down and told him not to ring his call bell again, there was no statement from NA #3, there was no statement from Nurse #1 or Nurse #2, no statement from the AD #1 or the DON. Further review of the FRI revealed the AD #1 had notified the DON on 3/9/2024 at 11am by telephone, The DON interviewed Resident #85 on 3/9/2024 at 6:30pm. The DON spoke to the Administrator #2 on the phone at 9:30pm on 3/9/2024. Multiple attempts were made to contact Resident #85 for interview but were not successful. During an interview on 12/18/2024 at 1:16pm NA #3 stated she was familiar with Resident #85. NA #3 stated on 3/9/2024 Resident #85 was upset early during the shift (7am-7pm) after breakfast and reported night shift had held him down. NA #3 stated she immediately reported this to Nurse #1, who told her to notify the Activity Director (AD)#1, who was the Manager on Duty. NA# 3 stated she reported to AD #1 what Resident #85 had reported to her and saw the AD #1 go talk to Resident #85. NA #3 stated Resident # 85 had not named a specific staff member but blamed the entire shift. NA #3 stated no one interviewed her regarding what Resident #85 had reported to her, and NA #3 was not asked to give a written statement. NA #3 did not recall seeing any injuries or bruises to Resident #85. During an interview on 12/18/24 at 9:44 AM, the Activity Director (AD) #1 stated she had worked on the morning of 3/9/2024 as the manager on duty. After reviewing the daily staffing sheet from 3/9/2024, the AD #1 remembered it was NA #3 that had reported to the AD #1 on 3/9/2024. The AD #1 did not recall exactly what NA #3 had reported, but it was regarding Resident #85 had said 2 staff members had yelled at him, told him he couldn't go to the bathroom and to go to sleep, he had been up enough. The AD #1 did not recall the exact time NA #3 reported the information to her. The AD #1 stated she called the Director of Nursing (DON) and reported what Resident #85 had reported. The AD #1 stated Resident #85 was not upset when she talked to him, but he wanted to talk to the DON. The AD #1 informed Resident #85 the DON would be in later that day. The AD #1 stated as manager on duty she was not involved with the investigation, but was responsible to notify the supervisor, which is why she called the DON. The AD #1 did not recall being interviewed regarding what Resident #85 had reported to her, The AD #1 stated she did not recall writing a written statement. The AD #1 verified she had not been asked to assess Resident #85 for injuries. The AD #1 stated the DON came in later that day. During an interview with Nurse #1 on 12/18/24 at 12:06pm Nurse #1 stated she only vaguely remembered Resident #85 but had never worked with Resident #85 and had not been assigned to the hall Resident #85 had been on. During an interview on 12/18/24 at 2:02pm the DON stated the AD #1 called and said that Resident #85 was upset with night shift and reported they wouldn't let him go to the bathroom, but it can wait until you come to work tonight. The DON stated she did not go in right away because what was reported to her on the phone by the AD #1 did not require the DON to come in immediately and could wait until the DON was scheduled to come in. The DON remembered that the AD #1 had said Resident #85 had agreed to talk to the DON later that day. The DON stated she thought Resident #85 had been told he couldn't go to the bathroom alone because it wasn't safe. The DON stated if she had thought Resident #85 needed her immediately or had been abused, she would have gone to the facility immediately. The DON stated that after she was at the facility and spoke to Resident #85 she notified the Administrator #2. The DON also stated that throughout the discussion Resident #85's description of what happened changed a couple times. The DON stated she knew the accused NAs were not scheduled to be in again until 3/11/2024 and Administrator #2 thought it was not a reportable incident. The DON stated as the situation evolved the more it became evident it was a reportable incident. The DON stated the accused NAs were eventually suspended, but was not certain of the exact date the suspension was initiated. The DON stated NA# 1 and NA #2 were suspended and NA #4 turned in her resignation. The DON stated NA #1 had no previous allegations of abuse and no allegations since. The DON stated NA #2 had previous allegations regarding her demeanor and approach, but no allegations of abuse. The DON stated NA# 2 had no further allegations regarding demeanor, approach or abuse. The DON stated if there was an allegation she would call the administrator, interview alert and oriented residents. The DON stated she did not complete skin assessments on residents who are not alert and oriented. The DON stated alert and oriented residents were not interviewed until 3/11/2024, but the DON looked at residents and talked to residents, while she worked on 3/9/2024. The DON said typically a skin assessment is completed when a resident reports an allegation of abuse. The DON stated she knew to do that. The DON stated she did not notify APS. During an interview on 12/18/24 at 8:47am the former Administrator (Administrator #2) stated three third shift NAs were interviewed. The Administrator # 2 stated Resident #85 was very hard of hearing, and that Resident #85 stated NAs had held him down when he wanted to go to the bathroom. The Administrator #2 stated the 3 NAs accused were interviewed by the Administrator #2 and the DON, and NA #1 and NA #2 were suspended. The Administrator #2 stated NA #4 would have been suspended but walked out from the interview and quit. The Administrator #2 stated what she recalled from the interview with NA #2 was that NA #2 said she handed him the call bell, laid it on his chest and said to Resident #85, this is our call bell, and said to ring the call bell. The Administrator stated NA #2 denied holding Resident #85's arms down. The Administrator #2 stated she went to Resident #85's room and interviewed him the next day (did not recall the exact date). Resident #85 required help getting in and out of bed but was otherwise independent, and was stand by assist. The Administrator # 2 stated when Resident #85 was interviewed on the following Monday, she thought, Resident #85 could not remember if the alleged incident had happened over the weekend and became manipulative with the Administrator #2. The Administrator #2 further stated, she did not recall the exact dates and times from this alleged incident. The Administrator #2 stated the DON did notify her, but did not remember exactly when, just that the DON went in on a weekend to handle the complaint. The Administrator #2 stated staff was trained if there is a complaint- abuse or not- staff are trained to immediately notify the supervisor, and supervisor will determine how to proceed. The Administrator stated she would not notify APS in this instance, The Administrator stated they would only interview residents able to be interviewed or residents at risk or potential to be at risk. The Administrator #2 stated skin assessments would only be completed if the allegation was substantiated. The Administrator #2 stated normally the DON, or social worker would complete interviews of other residents. The Administrator stated she would normally interview the Nurse on the hall when the incident was reported and alleged to have happened. During an interview on 12/18/24 at 2:31pm the Administrator #1 stated he would expect protocol and policy to be followed regarding an allegation of abuse. Administrator #1 would expect an appropriate investigation to be completed and would expect law enforcement to be notified. The Administrator #1 stated an allegation of abuse required an investigation to be completed by the Administrator or designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews with staff, responsible party, the Consultant pharmacist, and the Medical Director (MD), the facility failed to have effective systems in place for the identification, storage and returning of a controlled medication (opioid) when a resident discharged home and failed to maintain the unused controlled medication for return to the pharmacy for 1 of 2 residents reviewed for pharmacy services (Resident #176). The findings included: Resident #176 was admitted to the facility on [DATE]. Resident #176 was discharged from the facility on 07/03/2024. A review of the physician's order dated 06/19/2024 revealed Resident #176 had an order to receive 1 tablet of Acetaminophen-Codeine (an opioid that acts on the central nervous system to relieve pain) 300-30 milligrams (mg) 4 times a day as needed for severe pain. The 5-day admission Minimum Data Set (MDS) dated [DATE] revealed Resident #176 had moderately impaired cognition. The investigation report dated 07/30/2024 revealed the Assistant Director of Health Services (ADHS) became aware of the missing nacrotics for Resident #176's on 07/30/2024 at 5:00 PM when she was auditing narcotics for the monthly pharmacy review and return. The audit revealed a declining inventory sheet with 13 tablets of Acetaminophen-Codeine remaining. There was no medication card for the 13 tablets of Acetaminophen-Codeine and the 13 tablets of Acetaminophen-Codeine were unaccounted for. The final investigation report dated 08/02/2024 revealed an immediate narcotic count on all medication carts was completed on 07/30/2024 by the ADHS and all narcotics were accounted for. Staff interviews were conducted by the Director of Health Services (DHS) and the ADHS with 4 nurses who had worked on the 500 Hall medication cart for the previous 24 hours. Per the facility investigation report dated 08/02/2024, staff interviews were conducted. Nurse #4 was assigned to the 500 Hall on 07/28/2024 from 7:00 AM to 7:00 PM and stated the narcotic card was in the narcotic box on the 500 Hall medication cart but could not be specific about dates or times. Nurse #5 was in orientation and assigned to work with Nurse #4 on the 500 Hall on 7/28/2024 from 7:00 AM to 7:00 PM. Nurse #5 stated the narcotic card was in the narcotic box on the 500 Hall medication cart but did not remember anything specific including dates or times. Nurse #6 was assigned to the 500 Hall on 07/29/2024 from 7:00 AM to 7:00 PM and stated the card was in the narcotic box in the 500 Hall medication cart. Nurse #7 was assigned to the 500 Hall on 07/28/2024 and 07/29/2024 from 7:00 PM to 7:00 AM and she stated she had not seen the card in the narcotic box for some time now. A review of the declining narcotic sheet for Resident #176 was conducted on 12/17/2024 at 8:15 AM and revealed 17 tablets of Acetaminophen-Codeine had been administered and 13 tablets of Acetaminophen-Codeine remained. The facility was unable to provide the July 2024 controlled substance card count sheet for the 500 Hall medication cart. An interview was conducted with Nurse #6 on 12/17/2024 at 8:45 AM. Nurse #6 stated he remembered there was a missing medication card but did not remember anything specific. An interview was conducted with Nurse #4 on 12/17/2024 at 9:00 AM. Nurse #4 stated that she remembered an issue with a missing medication card of Acetaminophen-Codeine, but she did not remember anything else about the medication or the medication card. An interview was conducted with Nurse #5 on 12/17/2024 at 9:30 AM. Nurse #5 stated she did not remember anything about a missing medication card of Acetaminophen-Codeine . Multiple attempts to contact Nurse #7 were made and were unsuccessful. During an interview with Resident #176's responsible party (RP) on 12/17/2024 at 10:10 AM, the RP stated that the facility had notified him back in the summer that Resident #176's Acetaminophen-Codeine was missing and asked him if the facility sent the medication home with Resident #176. Resident #176's RP further stated that the Acetaminophen-Codeine was not sent home with Resident #176, but he did get a prescription for the Acetaminophen-Codeine when Resident #176 was discharged from the facility in July 2024. An interview was conducted with the ADHS on 12/17/2024 at 11:00 AM. The ADHS stated on 07/30/2024 when she was reconciling the discontinued medications with the declining inventory sheets, she had a declining inclining inventory sheet which showed 13 tablets of Acetaminophen-Codeine remaining, but she could not locate the medication card for the Acetaminophen-Codeine. The ADHS further explained that she checked all of the medication carts and called Resident #176's family to make sure the medication was not sent home with Resident #176. The ADHS revealed that she notified the DHS and the Administrator that there was a problem with the narcotic count. An interview was conducted with the DHS on 12/18/2024 at 8:00 AM. The DHS stated she collected all of the discontinued medications including narcotics and the declining inventory sheets from all of the medication carts on 07/28/2024 and placed them in the tall, locked cabinet in the [NAME] Medication Room. The DHS further explained that the ADHS was reconciling the medications with the declining inventory sheets and found the discrepancy with Resident #176's Acetaminophen-Codeine on 07/30/2024. The DHS also stated that the ADHS telephoned and informed her of the discrepancy and that she had checked all of the medication carts in the facility and all narcotics were accounted for. The DHS stated she arrived at the facility shortly after 5:00 PM and checked all of the medication carts and checked the medication storage rooms and was unable to locate the medication card containing 13 tablets of Acetaminophen-Codeine.The DHS explained that the facility did not send narcotics home with discharged residents and the pharmacy came to the facility once a month and collected all of the discontinued medications including narcotics. Prior to the monthly pharmacy visit, the ADHS and she would go through all of the medication carts and collect all of the discontinued medications and put them in the tall, locked cabinet in the [NAME] Medication Room and then the ADHS and she would reconcile the declining inventory sheets with the actual number of pills in the medication cards. The DHS further explained that this process was completed twice a month. The DHS also stated the pharmacist reviewed the reconciliation sheets with the actual medication cards during the monthly visit and the pharmacist would return the medications to the pharmacy. The DHS also stated that she and the ADHS were the only staff who had keys to access the tall, locked medication cabinet in the [NAME] Medication Storage Room. The DHS further explained that she believed when she collected all of the discontinued medications on 07/28/2024, she accidentally dropped the card containing the 13 tablets of Acetaminophen-Codeine in the trash can. The DHS explained that her arms were very full as she had collected medications from all 4 medication carts and in hindsight she should have collected all the medications and the declining inventory sheets from one medication cart and secured those in the tall, locked cabinet in the [NAME] Medication Storage room and then moved on to the next cart. She also stated that the facility had revised their medication process following this incident, and the medication(s) were now removed from the medication cart immediately and placed in the locked cabinet until the pharmacist picked them up. An interview was conducted with the Medical Director (MD) on 12/17/2024 at 2:30 PM. The MD stated that he was aware of Resident #176's missing Acetaminophen-Codeine. The MD also stated that he was involved in the facility's discussion of the incident. He also reported that he had received no further reports of missing narcotics. An interview was conducted with the Consultant Pharmacist on 12/18/2024 at 9:19 AM. The pharmacist stated that she was aware of the missing Acetaminophen-Codeine back in July and that she was involved in assisting the facility with a performance improvement plan to ensure safety of all controlled substances. She also stated that the 13 tablets of Acetaminophen-Codeine were never recovered, and it was her understanding that the DHS had lost them when she had collected the discontinued medications for pharmacy pick-up. An interview was conducted with the previous Administrator on 12/18/2024 at 10:19 AM. The previous Administrator stated that she recalled the incident and stated that the ADHS had reported to her that during her return medication rounds the declining inventory sheet for Resident #176's Acetaminophen-Codeine was present, but the medication card was not. The previous Administrator further stated that the facility was unable to locate the missing pills after searching all the medication carts and the medication storage areas. The previous Administrator revealed that the DHS reported to her that the last time she completed the return medication rounds, she had a lot of return medications, and her hands were full, and the DHS believed she accidentally dropped the medication card in the trash when she was placing them in the locked cabinet in the medication room. The previous Administrator further explained that a process change was made following the incident. An interview was conducted with the current Administrator on 12/18/2024 at 1:04 PM. The current Administrator revealed that he had only been with the facility for a few months but there had been no issues or concerns with narcotic counts or missing medications since he had started working there in October 2024. The current Administrator also stated that he had reviewed the information regarding the missing Acetaminophen-Codeine and further explained that the DHS had informed him that her hands were overflowing with medication cards and inventory sheets, and she believed the medication card was accidentally dropped in the trash. The facility provided the following corrective action plan with a completion date of 08/07/2024. Address how corrective actions will be accomplished for those residents to have been affected by the deficient practices: Resident #176 was discharged from the facility on 07/03/2024. There was no harm or negative impact to Resident #176. How will the facility identify other residents having the potential to be affected by the same deficient practice: All residents prescribed controlled medications have the potential to be affected by the deficient practice. On 07/30/2024 while auditing narcotics for monthly pharmacy review a discrepancy was noted by the Assistant Director of Health Services (ADHS). A descending narcotic sheet of Acetaminophen-Codeine 300-30 mg with a remaining 13 tablets was noted without the actual medication blister pack. The ADHS and Clinical Competency Coordinator immediately performed a narcotic count of all narcotics on each cart to ensure the descending inventory narcotic sheet had been reconciled and matched on 07/30/2024. No further discrepancies were noted. Interviews were conducted with all nurses that worked the 500 Hall within the 24-hour period prior to the medication being noted as missing. On 07/30/2024, a 24-hour report was sent to the North Carolina Department of Health and Human Services, a report was filed with local law enforcement (Report #2024-039-095). What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur: Re-education for all nurses on procedure for controlled substance reconciliation from shift to shift, storage, records, administration, acknowledgement/accounting for and what to do in the event of discrepancy was performed by the ADHS. The Director of Health Services (DHS) and ADHS will collect discontinued narcotics and reconcile narcotics daily and place them in the locked return narcotic box. The DHS and ADHS are the only designees to maintain access to the narcotic locked cabinet. Narcotics for short term rehabilitation residents will be released with the resident and or their RP with signed paperwork. Audits will be performed to ensure that narcotic sheets and descending narcotic sheets are accounted for and match. How will the facility monitor its corrective actions to ensure the deficient practice will not recur: The DHS and ADHS will audit each cart to ensure narcotic inventory sheet and blister pack and signatures match X 4 weeks, then X 2 months: begin date: 07/30/2024 and end date: 10/30/2024. Audit results will be presented at the facility's Quality Assurance Performance Improvement (QAPI) meeting by the DHS and ADHS and reviewed X 2 months. An Ad Hoc QAPI was held 08/05/2024. Any issues and trends identified will be addressed in QAPI by attendees as they arise, and the plan will be revised to ensure compliance. The Administrator and DHS will oversee this process until sufficient practice is maintained. Date of Compliance: 08/07/2024 The facility's corrective action plan with a correction date of 08/07/2024 was validated onsite by observations and interviews with the Administrator, DHS, and nursing staff. An observation was conducted during a shift transition for a medication cart between 2 nurses on 12/18/2024. Nurses started with counting the total number of blister cards that contained controlled medications stored in the double-locked compartment in the medication cart and verified the balance in the narcotic count log. The nurses then counted the total number of declining narcotic sheets and verified the balance in the narcotic count log. The nurses then proceeded to count each blister card of controlled medication to ensure the quantity listing in the declining narcotic count sheets were consistent with the actual pill count. After all counts were completed and without any discrepancies, the on-coming shift nurse and the off-going shift nurse signed the narcotic count logs, and the off-going shift nurse passed the medication cart key to the on-coming shift nurse. A Medication Administration observation which consisted of 26 medications, 6 different residents and 2 different nurses was conducted on 12/16/2024 and 12/17/2024. All the medications were administered as ordered without any issues. Controlled medication was retrieved from the double-locked compartment in the medication cart during the observation. The nurse documented the removal of the controlled medication on the declining narcotic count sheet. Random samples of 3 controlled medications were pulled from each medication cart for verification of accuracy. The controlled substance counts were consistent with the records documented in the declining narcotic count sheets. Interviews with the nursing staff including Licensed Practical Nurses (LPN), and Registered Nurses (RN) confirmed they had received education related to Misappropriation of Personal Property and Narcotic Process Policy. It included the process for shift-to-shift controlled medication count, narcotic storage, narcotic records, and what to do in the event of a narcotic discrepancy. The nurses were able to describe the policy and procedures and verbalized understanding of the education. Review of audit records revealed all residents receiving controlled medications were audited by the DHS and ADHS weekly for 4 weeks beginning on 07/30/2024. Then monthly for 8 weeks to ensure the narcotic count was correct on each cart, shift-to-shift count was completed appropriately, and discontinued controlled medications were removed from the medication carts and returned to the pharmacy. The finding were reported by the DHS to the QAPI committee monthly for 2 months for suggestions and/or recommendations; the quality improvement monitoring schedule will be modified based on finding of the monitoring. Interview with the Administrator and the DHS revealed the facility launched an in-service related to controlled medication process and accountability immediately after the incident to re-educate all the licensed nurses. The DHS and ADHS audited the medication carts randomly to ensure all controlled medication counts were conducted appropriately and the declining narcotic count sheets were documented properly. The Administrator and the DHS stated the interventions were successful as the facility did not have any similar issues with narcotics since then. The compliance date of 08/07/2024 was validated.

Based on observations, record review, and staff and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendations for storing narcotics in a locked and permanently affixed compartment for 1 of 2 medication rooms reviewed for medication storage (West Hall Medication Storage Room). Findings included: Review of the Consultant Pharmacy report dated 11/26/2024 revealed Controls in refrigerator under double lock and key; in process of getting in secured lock box that is not removable from the fridge. An observation of the [NAME] Hall medication storage room was conducted on 12/17/2024 at 8:31 AM with the Assistant Director of Nursing (ADON). The narcotic lock box was inside a locked refrigerator. The narcotic lock box was not permanently affixed to the refrigerator and was removable. The narcotic lock box contained four unopened vials of Lorazepam (scheduled IV antianxiety medication). An interview was conducted with the ADON on 12/17/2024 at 8:40 AM. The ADON revealed she thought since the medication storage room was locked and the refrigerator was also locked and the medications were appropriately secured. An interview was conducted with the Consultant Pharmacist on 12/17/2024 at 9:19 AM. The Consultant Pharmacist stated the narcotic box should be permanently affixed to the refrigerator. The Consultant Pharmacist further stated that removeable narcotic box had been identified as an issue and was included in the November 2024 pharmacy report. An interview was conducted with the Director of Nursing (DON) on 12/18/2024 at 8:03 AM. The DON stated that the narcotic box in the [NAME] Hall Medication Storage Room refrigerator had not been permanently affixed to the refrigerator since she was hired in April of 2021. The DON further revealed that she was aware the narcotic box should be secured and affixed to the refrigerator. An interview was conducted with the Administrator on 12/18/2024 at 8:30 AM. The Administrator stated he was aware of the narcotic box not being permanently affixed to the refrigerator. He further stated that the facility had been discussing how to affix the narcotic box to the refrigerator but had not come up with a resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Medical Director, Nurse Practitioner, Consulting Pharmacist, resident and staff interviews, the facility failed to prevent a significant medication error when they failed to enter an admission order for an as needed (PRN) migraine nasal spray, that was to be continued from the hospital discharge summary when Resident #81 admitted to the facility. As a result, Resident #81 did not have the PRN migraine nasal spray during her entire stay at the facility. This affected 1 of 3 residents reviewed for medication errors. (Resident #81) The findings included: Review of Resident #81's discharge orders from the hospital dated 12/5/2024 revealed under the section: CONTINUE these medications which have NOT CHANGED, was an order that read butorphanol (Stadol) 10mg/ml nasal spray. Administer 1 spray into one nostril if migraine present. May repeat in one hour if pain relief is not adequate. Resident #81 was admitted to the facility on [DATE] and was discharged on 12/17/2024. Resident #81 was admitted to the facility with diagnoses that included aftercare following joint replacement surgery, unspecified fracture of right femur. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #81 was cognitively intact. Further record review revealed there was no physician order for Stadol in Resident #81's physicians orders. A Nurse Practitioner Progress note dated 12/5/2024 revealed in part that Resident #81 had a history of migraines and read She (Resident #81) has a Stadol nasal spray as needed. During an interview on 12/15/2024 at 4:28pm Resident #81 stated she had not had her migraine nasal spray since she had been admitted . Resident #81 stated when she has a migraine she becomes sick and nauseated and she would like to have her migraine medicine. Resident #81 stated she had told multiple Nursing Assistants (NA) and Nurses that she needed her medicine for migraines but no one had gotten it for her. Resident #81 also stated she talked to the doctor about having medication for migraine while at the facility. Review of Resident #81's progress notes revealed a note written by Nurse #3 dated 12/15/2024 written at 9:58pm that read in part Resident still upset about the Stadol not under her medication list. During an interview on 12/16/2024 at 12:43pm the Nurse Practitioner (NP) stated she was familiar with Resident #81. The NP stated when a resident was admitted she would go over the medications listed on the discharge summary, if the NP was not at the facility, a nurse would call her and read the medications from the discharge summary and the NP would tell the nurse what meds to continue and a verbal order would be written. The NP stated that she remembered the Assistant Director of Nursing (ADON) had called her for medication reconciliation for Resident #81, and the NP had not ordered to stop any of those medications. The NP was unsure why Stadol was not on Resident #81's MAR and said it was supposed to be continued when Resident #81 was admitted . The NP said maybe the med was not available at their pharmacy or had not been sent from pharmacy. The NP would expect the nurse to call the Pharmacy or the NP if medication was not received from the pharmacy or not available. The NP verified she had no communication from the Pharmacy regarding Stadol not being available. The NP stated oral pain medication had been increased for Resident #81 when NP had seen the resident, but later clarified it was for hip pain. During an interview on 12/16/2024 at 2:29pm the Assistant Director of Nursing (ADON) stated when a resident is admitted she will call the doctor or NP and go over the medications on the discharge summary verbally then the ADON enters the medications into the computer system and then another nurse checks them after the ADON, normally another administrative nurse. The ADON stated it had been brought to her attention that Resident #81 did not have Stadol on her MAR, and she was not sure how that happened. The ADON stated there were a lot of admissions on 12/5/2024 then the ADON stated I think I had trouble entering that order into the computer system and I forgot to go back, probably got interrupted. The ADON verified the order for Stadol had not been entered into the computer system as it should have been. The ADON was unsure which nurse had double checked the admission orders for Resident #81. During an interview on 12/16/2024 at 2:43pm Nurse #3 stated Resident #81 had complained about headaches. Nurse #3 stated last week the doctor was notified and took care of it by increasing the oral pain medication. During an interview on 12/17/2024 at 9:19am the Consulting Pharmacist verified the facility policy for new admissions is a double check system by the nurses to verify medications are entered into the computer system correctly, and that document would be scanned into the residents electronic medical record and saved as the verified discharge summary. Further review of Resident #81's electronic medical record revealed it did not contain a verified discharge summary for Resident #81. During an interview on 12/17/2024 at 2:27pm the Medical Director stated he was familiar with Resident #81 and had seen her on 12/10/2024 and there was no complaint of headaches or migraines at that time. The Medical Director was not aware Stadol was supposed to be continued for Resident #81. The Medical Director stated he had seen it on the discharge summary but thought there had been a concern about it interacting with other medications. The Medical Director was not aware the ADON had omitted entering the Stadol order into the computer system and that the NP had intended for it to be continued. The Medical Director stated that for medication reconciliation the admission orders were to be called to the NP or medical director if they were not in the building, the nurse calling would initial medications to be continued, enter them into the computer system, then the nurse who double checks would verify and initial as the second check, then that initialed discharge summary would be scanned into the resident's record as the verified discharge summary, then it could be reviewed by the NP or Medical Director. The Medical Director reviewed Resident #81's electronic medical record and verified there was not a verified discharge summary in Resident #81's electronic medical record. The Medical Director stated the medication reconciliation for Resident #81 did not appear to have been completed correctly and he would address it at the next quality meeting. During an interview on 12/18/2024 at 1:40pm the Director of Nursing (DON) stated she had not heard complaints of headaches from Resident #81, just general pain. The DON verified the ADON completed entering the admission orders and that they were checked by another administrative nurse, then the verified discharge summary was scanned into the electronic medical record. The DON was not aware Resident #81's electronic medical record did not contain a verified discharge summary or that Resident #81 had not had her PRN migraine medication while residing in the facility. The DON expected admission orders to be completed with a double check and the verified discharge summary to be scanned into the resident's record. During an interview on 12/18/2024 at 2:33pm the Administrator stated he was not well versed in the admission process but would expect if a resident has a discharge summary with a medication list and the provider orders to continue the medication, the Administrator expected the ordered medications to continue.

Based on observations, record review, and staff interviews the facility failed to store narcotics in a locked permanently affixed compartment for 1 of 2 medication rooms reviewed for medication storage (West Hall Medication Storage Room). Findings included: An observation of the [NAME] Hall medication storage room was conducted on 12/17/2024 at 8:31 AM with the Assistant Director of Nursing (ADON). The narcotic lock box was inside a locked refrigerator. The narcotic lock box was not permanently affixed to the refrigerator and was removable. The narcotic lock box contained four unopened vials of Lorazepam (scheduled IV antianxiety medication). An interview was conducted with the ADON on 12/17/2024 at 8:40 AM. The ADON revealed she thought since the medication storage room was locked and the refrigerator was also locked and the medications were appropriately secured. An interview was conducted with the Consultant Pharmacist on 12/17/2024 at 9:19 AM. The Consultant Pharmacist stated the narcotic box should be permanently affixed to the refrigerator. The Consultant Pharmacist further stated that removeable narcotic box had been identified as an issue and was included in the November 2024 pharmacy report. Review of the Consultant Pharmacy reported dated 11/26/2024 revealed Controls in refrigerator under double lock and key; in process of getting in secured lock box that is not removable from the fridge. An interview was conducted with the Director of Nursing (DON) on 12/18/2024 at 8:03 AM. The DON stated that the narcotic box in the [NAME] Hall Medication Storage Room refrigerator had not been permanently affixed to the refrigerator since she was hired in April of 2021. The DON further revealed that she was aware the narcotic box should be secured and affixed to the refrigerator. An interview was conducted with the Administrator on 12/18/2024 at 8:30 AM. The Administrator stated he was aware of the narcotic box not being permanently affixed to the refrigerator. He further stated that the facility had been discussing how to affix the narcotic box to the refrigerator but had not come up with a resolution.

Based on record review, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns and/or suggestions voiced by residents during Resident Council meetings for 12 of 14 months reviewed (October 2023, November 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, October 2024, and November 2024). Findings included: Review of the Resident Council Minutes for the period 10/26/23 through 11/21/24 revealed the following: a. The Resident Council meeting minutes dated 10/26/23 revealed the section for old business noted resident concerns with dietary and showers. There was no indication of the facility's response to these concerns listed under old business. Under New Business there were noted concerns from residents with residents being able to go shopping and staff being loud in hallways. b. The Resident Council meeting minutes dated 11/30/23 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held on 10/26/23 were read, approved, revised and/or resolved. Further review of Resident Council minutes revealed documented resident concerns of them still being upset with dietary related to food, resident being able to go shopping for themselves, not being able to open door to dining room, and resident bed in room needing fixed. c. The minutes from the Resident Council meeting held on 12/28/23 were not available for review due to the president and other members of the resident council being sick and the meeting was cancelled. d. The Resident Council meeting minutes dated January 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held on 11/30/23 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and food, night shift being short staffed, and timeliness of call lights being answered. e. The Resident Council meeting minutes dated February 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in January 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus, dessert portions, and making sure nourishment rooms were being stocked nightly specifically with sandwiches. f. The Resident Council meeting minutes dated March 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in February 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and food, night shift being short staffed, and timeliness of call lights being answered. g. The Resident Council meeting minutes dated April 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in March 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and food, night shift being short staffed, and timeliness of call lights being answered. h. The Resident Council meeting minutes dated May 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in April 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding holiday meals, mold in the shower room and on the shower curtain, and the coffee machine located in the lobby being broken. i. The Resident Council meeting minutes dated June 2024 revealed no indication that the minutes from the Resident Council meeting held in May 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and food portions, and bathrooms not being large enough. j. The Resident Council meeting minutes dated July 2024 revealed no indication that the minutes from the Resident Council meeting held in June 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with dietary regarding menus and condiments, coffee machine located in the lobby needing to be repaired, and more outings for residents. k. The Resident Council meeting minutes dated August 2024 revealed no sections for old or new business and no indication the minutes from the Resident Council meeting held in July 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with windows and pictures needing to be cleaned and nursing staff not cleaning off toilets after a resident accident. l. The minutes from the Resident Council meeting held on September 2024 were not available for review due to members of the Resident Council being sick and the meeting was cancelled. m. The Resident Council meeting minutes dated October 2024 revealed no indication that the minutes from the Resident Council meeting held in August 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under old business from the previous resident council meeting. Further review of the Resident Council minutes revealed documented resident concerns with doors to resident's rooms not staying open on their own, staff vacuuming halls during resident meals, and more activities scheduled for residents and their families. n. The Resident Council meeting minutes dated November 2024 revealed no indication that the minutes from the Resident Council meeting held in October 2024 were read, approved, revised and/or resolved. There was nothing documented on the minutes under the section for old business from the previous Resident Council meeting. Further review of the resident council minutes revealed no new business. A Resident Council group interview was conducted on 12/17/24 at 3:30 PM. During the interview, Residents #4, #44, #51, and #56, who attend Resident Council meetings regularly, all stated they felt facility staff did not really address their concerns or suggestions because the only response they typically received from staff, if they received one at all, was it was being looked into but never any satisfactory resolution and some of the issues continued to happen. Resident #4, who was the Resident Council President, added they understood some of the concerns they voiced couldn't be fixed right away but it would be nice to receive some form of communication back as to what was being done. The residents all agreed they would like to know they were being heard and receive feedback from the administration on the efforts that had been made or attempted to resolve their concerns and/or suggestions. Review of facility grievance log from October 2023 through December 2024 revealed no grievances had been received from Resident Council. During an interview on 12/16/24 at 10:35 AM, the Activity Director (AD) confirmed she attended and recorded the minutes for the Resident Council monthly meetings. The AD explained that she had not received any formal training on how to conduct or record minutes from the Resident Council meetings and was not aware that she needed to document during each meeting old business and how any concerns from the previous meetings had been addressed or resolved. She stated she had asked the previous Administrator about completing a grievance form for any Resident Council concerns and the previous Administrator had informed her that when residents voiced any concerns and/or suggestions during the Resident Council meetings, the AD was to inform the Social Worker (SW), or the Director of Nursing (DON) and they would look into them. The AD stated sometimes the residents would let her know during the meetings if an issue or concern had been resolved or was improving, but she never received an actual response back from the SW or the DON as to how the concerns had been resolved. She revealed most of the same concerns were mentioned during the meetings each month and she continued to document those concerns in the Resident Council minutes and inform the SW or DON. The AD revealed moving forward she would prefer to write any concerns or suggestions from Resident Council meetings on a grievance form so she could have some form of a paper trail showing the concerns had been reviewed and were being addressed. During an interview on 12/17/24 at 10:18 AM, the Social Worker (SW) revealed the AD would come to her with concerns from Resident Council and she would usually just pass those concerns to the correct department head. She stated that she would have only completed a grievance form brought to her from Resident Council if it involved a specific resident concern and if she felt like that concern rose to the level of a grievance. She revealed once she informed the department heads of the concerns from Resident Council, she was never made aware of the resolutions, so she was never able to inform the AD of any resolutions to the concerns. The SW stated that moving forward she could see where it would be more beneficial for grievance forms to be completed during Resident Council so a resolution could be addressed and documented. A telephone interview with the former Administrator on 12/17/24 at 1:45 PM revealed she had informed the AD to notify the SW or the DON with any concerns or suggestions brought to her during Resident Council so they could be discussed with the appropriate department heads. She stated the only time a grievance would have been completed during Resident Council meetings was if a specific resident had a concern or grievance. She revealed she was not aware the AD had not been informed of the resolutions regarding the concerns from Resident Council. When asked if she had reviewed any of the minutes from Resident Council over the past year or had discussed with the AD on how to document minutes from resident council, the previous Administrator stated that she was sure she had reviewed some of the Resident Council minutes but could not recall any specific details of the minutes or how they were documented. During an interview on 12/18/24 at 1:31 PM, the Director of Nursing (DON) revealed previously the AD would bring to her or the SW any concerns from the Resident Council. She stated she would address those concerns with the department heads, but there was no written grievance of the concern and no documented resolution. She revealed she could see where it would be more beneficial to have a grievance from completed for any concerns brought up during Resident Council so those concerns could be addressed and the resolutions documented, and they could be addressed with the council during the following meeting. During an interview on 12/18/24 at 2:31 PM, the current Administrator revealed he began his employment at the facility on October 28, 2024. He stated although he could not speak to the exact process of the former Administration, he did not believe they were completing grievance forms regarding grievances from resident council. He revealed his preference would be for the AD to complete grievance forms for any concerns/suggestions brought up during Resident Council meetings. The Administrator also revealed once the grievance forms from Resident Council meetings were completed, they would be given to the SW for them to be distributed out to the responsible departments for their review. He stated he would also be notified of the grievances as he was the facility grievance official and they would also be discussed during morning meeting. The Administrator revealed once the grievances were resolved, those grievances would be distributed back to the AD for review at the following Resident Council meeting. He stated that moving forward with this process would help with making sure any grievances or suggestions from Resident Council were being addressed and the departments responsible were being held accountable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interviews, the facility failed to ensure evening and weekend group activities were planned for the facility to meet the needs of residents who expressed that it was important to them to attend group activities for 4 of 4 residents reviewed for activities (Resident #4, #44, #51, and #56). The findings included: A review of the December 2024 activity calendar revealed group activities for the facility were only scheduled in the mornings and afternoons during the week, Monday through Friday. There were no activities scheduled for evenings or weekends at the facility except for a 10:30 AM church service every other Sunday. An interview with the Activities Director (AD) on 12/16/24 at 10:35 AM revealed she had been employed as the AD at the facility since December 2023 and typically worked Monday through Friday 8 AM to 5PM. She stated she did not have an activity assistant, so she was responsible for all the activities in the facility and since she only worked dayshift Monday through Friday, it was up to the nursing staff to assist residents with activities in the evenings and weekends. The AD stated she does have activity packets with coloring sheets, word search puzzles, and some other different worksheets available for nursing staff, so they can be set out in the dayroom for residents to do in the evenings and over the weekends. She revealed they also have a church service every other Sunday, for residents who like to attend but other than that they typically have no other scheduled group activities during the evenings or on the weekends. She revealed she has had some residents complain about not having activities on the weekend or being bored on the weekends and she will try and set up an individual activity for them when she can. She stated she knew how important activities were to the residents and agreed they could benefit from having scheduled group activities in the evenings and on the weekends and could understand why residents could feel lonely, sad, or depressed and get bored with just watching television or coloring. The Activities Director revealed she would discuss with the Administrator possibly switching up some of the schedules or times for her to be able to help cover some evening and weekend activities until they could find someone to fill an activities assistant position. a. Resident #4 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #4 felt that it was very important to have activities that included inside and outside of the facility and doing things in an independent and group setting. The assessment further indicated Resident #4 was cognitively intact. An interview was conducted with Resident #4 on 12/17/24 at 3:30 PM during resident council meeting revealed there had not been scheduled evening and weekend group activities at the facility for the past year. She stated the facility does offer a church service every other Sunday morning, but nothing else and she would like to have some activities scheduled for the evenings and the weekends, so they had something to do other than watch television in their rooms or the dayroom. Resident #4 also revealed not having evening and weekend activities caused her to feel bored and lonely. She stated to her knowledge they had discussed having scheduled evening and weekend activities during resident council, but nothing had changed. b. Resident #44 was admitted to the facility on [DATE]. A significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #44 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #44 was cognitively intact. An interview was conducted with Resident #44 on 12/17/24 at 3:30 PM during resident council meeting revealed since she had been at the facility they have had no scheduled evening and weekend activities. She stated the facility does offer a church service every other Sunday but usually only residents that can take themselves attend the service. She revealed she felt residents would benefit from having scheduled activities in the evenings and weekends because it would give them something to look forward to and that it can get sad and lonely in the evenings and on weekends especially if you don't have any visitors and nothing to do but watch television. c. Resident #51 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #51 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #51 was cognitively intact. An interview was conducted with Resident #51 on 12/17/24 at 3:30 PM during resident council meeting revealed she enjoyed activities and there had been no activities scheduled for the evenings and weekends since she was admitted to the facility. She stated she often gets bored, lonely, and sometimes a little depressed especially when all she had to do in the evenings and on the weekends was watch television. d. Resident #56 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) dated [DATE] indicated Resident #56 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #56 was cognitively intact. An interview conducted with Resident #56 on 12/17/24 at 3:30 PM during resident council meeting revealed the facility had not offered scheduled evening or weekend activities other than a church service every other Sunday mornings. She stated she enjoyed participating in activities because it gave her reasons to get up out of bed and socialize with other residents and not having them in the evenings and on weekends, the time goes by slowly and she gets lonely, bored, and sometimes depressed. Resident #56 revealed she had not addressed her concerns with the Activities Director but had discussed them with other members of resident council and they also felt residents would benefit from having scheduled activities in the evenings and on the weekends. An interview with Nurse #2 on 12/18/24 at 10:00 AM revealed she had worked at the facility on both 1st and 2nd shift and could not recall ever seeing any scheduled group activities during the evenings or on weekends. She stated some of the residents attend a church service on Sunday mornings but other than that they can watch television in their rooms or in the dayroom, read the paper, color, or do crossword puzzles if they are able. She revealed there are not enough nursing staff on nights and weekends to assist with activities, so residents basically had to find their own activities to do. Nurse #2 stated she felt that residents get bored and depressed when they don't have activities to do and would benefit from activity staff being in the building in the evenings and on the weekends to assist with group scheduled activities. An interview with Nursing Assistant (NA) #3 on 12/18/24 at 10:45 AM revealed she worked at the facility on both 1st and 2nd shift and was not aware of any scheduled activities being offered in the evenings or weekends except for a church service on Sunday mornings. She stated most activities are scheduled during the mornings and afternoons through the week and then after that residents either had to watch television in their rooms or the dayroom or read if they are able. She revealed some of the residents have family that take them out for visits but most of them are stuck in the facility 24 hours a day and would benefit from scheduled activities in the evenings and the weekends, so they have something to pass the time and feel bored and depressed. An interview with the Administrator on 12/18/24 at 2:31 PM revealed the facility has had activity assistants, off and on, who would specifically work evenings and weekends but then they would leave and the last one they had left this past December. He stated they were currently in the process of discussing possibly hiring an activity assistant to work the evening and weekends and in the meantime would be discussing with the Activities Director about possibly changing up her schedule to see if she could cover some evening and weekend shifts and incorporate some other administrative staff to assist as well. He stated he understood scheduling resident activities for evenings and on the weekends was very important and he would try his best to accommodate those needs.

Based on staff interviews, the facility failed to have a qualified professionals to direct the facility's activity program. This practice had the potential to affect all of the residents at the facility. The findings included: On 12/16/24 at 10:35 AM an interview was conducted with the Activity Director (AD). She stated that she had worked at the facility for the past several years as a nursing assistant and then became the Life Enrichment Specialist on the memory care unit around May 2023 and then moved into the AD position for the facility in December 2023 after the previous AD resigned. She stated she had never received any formal activities training from the facility, completed any state training courses, and to her knowledge was not certified. She revealed several months ago she had received an email about some state training for activities and she showed the email to the previous Administrator and was told that she did not need any training and did not have to be certified. The AD stated she had researched on-line activities for residents, reviewed the previous AD calendars and notes to assist her with making activities calendars but had received no real training on what activities should be included for residents, how to adjust her schedule so she could include evening and weekend activities, training other staff to assist her with activities, or how Resident Council minutes should be documented. She revealed the Life Enrichment Specialist who was responsible for activities in the memory care unit was also not certified and had not received any formal activities training except for the training she provided to her. The AD stated she would like to have some formal activities training and to become certified in activities so that she could provide the best activities program for her residents. On 12/17/24 at 11:15 AM an interview was conducted with the Life Enrichment Specialist for the memory care unit. She stated she began her position as the Life Enrichment Specialist for the memory care unit in December 2023 after the previous AD for the facility resigned and the previous Life Enrichment Specialist who had been working the memory care unit was moved into the facility AD position. She revealed prior to taking the Life Enrichment Specialist position she had worked at the facility as a nursing assistant. The Life Enrichment Specialist revealed the only training she received prior to taking the position was from the current AD, which consisted of how to make an activities calendar and which activities the residents preferred. She stated she had researched activities for memory care residents on-line on her own time but had never received any formal activities training from the facility, completed any state training courses, and to her knowledge was never activities certified. The Life Enrichment Specialist revealed she would like to receive formal activities training and to become certified so that she could make sure she was providing the best activities program to her residents. A telephone interview with the former Administrator on 12/17/24 at 1:45 PM revealed she was aware the current facility AD and the Life Enrichment Specialist for the memory care unit were not formally activities trained and had not received their certifications. She stated she believed that maybe they had tried to schedule those trainings, but they got cancelled and maybe they were never re-scheduled. She revealed she just really could not recall exactly what happened or why the AD and the Life Enrichment Specialist had never been formally trained or certified in activities prior to her leaving. On 12/18/24 at 2:31 PM an interview was conducted with the Administrator. The Administrator stated he began his employment at the facility on October 28, 2024, and was just recently made aware that neither the facility AD nor the Life Enrichment Specialist were trained and certified in activities. He stated although he could not speak as to why the former Administrator had not inquired about both the AD and the Life Enrichment Specialist receiving their activities training and certification, he had spoken with their regional office about setting up formal activities training for both the AD and the Life Enrichment Specialist and had also inquired about setting them up on-line for their certifications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews the facility failed to assess the ability of a resident to self-administer medications for 1 of 6 residents reviewed for medication administration (Resident #52). Findings included: Resident #52 was admitted to the facility 03/31/22 with diagnoses including heart failure, anemia, and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired. Review of the medical record revealed no documentation Resident #52 had been assessed for self-administration of medication. An observation of Resident #52's overbed table on 08/13/23 at 11:06 AM revealed a cup containing 3 white pills and 1 blue pill sitting on the table. An interview with Resident #52 on 08/13/23 at 11:07 AM revealed he did not know what pills were in the medication cup on his overbed table or how long the cup had been sitting on the table. He stated sometimes nursing staff left cups of medication in his room without ensuring he took the medication. An interview with Nurse #3 on 08/13/23 at 11:13 AM revealed she was working the 7:00 AM to 7:00 PM shift and was assigned to care for Resident #52. She stated she gave Resident #52 his morning medications around 7:30 AM the morning of 08/13/23 and watched him swallow his medications. Nurse #3 stated Resident #52 liked to leave his light off, so it was not very bright in his room when she gave his medications, and she did not see the cup of medications sitting on his overbed table. She stated she did not know what medications were in the medication cup found on the overbed table and removed the medications from Resident #52's room. An interview with Nurse #4 on 08/15/23 at 12:14 PM revealed she worked the 7:00 PM to 7:00 AM shift on 08/12/23 and was assigned to care for Resident #52. She stated she gave Resident #52 his evening medications between 9:00 PM and 9:30 PM the evening of 08/12/23 and watched him swallow his medications. Nurse #4 stated she did not see a cup of pills on Resident #52's overbed table at any time she was in Resident #52's room throughout her shift on 08/12/23 and did not know what the medications were in the cup found on the overbed table. An interview with the Director of Nursing (DON) on 08/17/23 at 11:55 AM revealed she expected nursing staff to stay with residents when they took their medication unless they had an order to self-administer medication. She stated if the resident didn't want their medicine when it was brought to them, it should be removed from the room and discarded. The DON stated no cups of medication should be left in resident rooms. The DON confirmed Resident #52 did not have an order to self-administer his medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #52 was admitted to the facility 03/31/22. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired and was able to make his needs known. The care plan last updated 07/13/23 revealed Resident #52 had the potential for social isolation and low activity participation and interventions included interviewing him about preferences, past roles, customary routines, and interests and introducing him to residents with similar interests. An observation made on 08/13/23 at 12:25 PM revealed the meal tray cart had arrived on the 400 hall and included Resident #52's lunch meal to be eaten in his room. There were no residents observed in the main dining room. An interview with Resident #52 on 08/17/23 at 9:35 AM revealed he would like to eat all his meals in the dining room if possible. He stated the dining room was usually only open for lunch during the week. Resident #52 stated the dining room was never open on the weekend, but he would choose to eat in the dining room if given the choice. An interview with the Director of Nursing (DON) on 08/17/23 at 4:19 PM revealed lunch was served in the main dining room Monday through Friday and all other meals were served in resident rooms due to not having enough staff to assist residents to the main dining room. She stated residents who preferred to eat their meals in the main dining room was a choice and should be honored. Based on observations, record review, interviews with residents and staff, the facility failed to honor the residents choice to eat their meals in the main dining room (Resident #181 and Resident #52) and provide their preferred number of showers each week (Resident #181) for 2 of 2 residents reviewed for choices. The findings included: 1. a) Resident #181 was admitted to the facility on [DATE] with diagnoses including debility, heart failure, and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #181 was assessed as cognitively intact. The care plan initiated on 07/31/23 revealed there was a potential for social isolation and low activity participation related to Resident #181 being new to the facility. Interventions included introduce to other residents with similar interest. During an interview on 08/16/23 at 2:42 PM Resident #181 stated he liked to eat lunch and dinner meals in the dining room so he could be around people and talk. An observation made on 08/16/23 at 5:33 PM revealed the tray cart had arrived on the hall and included Residents #181's dinner meal to be eaten in the room. There were no residents observed in the main dining room eating. During an interview on 08/17/23 at 8:36 AM Resident #181 revealed lunch was typically served in dining room but the dinner meals were served in his room, and he preferred to eat in the main dining room for socialization. During an interview on 08/17/23 at 4:19 PM the Director of Nursing (DON) revealed residents who preferred to eat their meals in the main dining room was a choice and should be honored. b) Resident #181 was admitted to the facility on [DATE] with diagnoses including debility, heart failure, and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #181's cognition was assessed as being intact. Review of the bathing schedule revealed during the day shift on Tuesday and Friday Resident #181 was to receive a type of bathing (a shower or bed bath). Review of the paper bathing records revealed NA staff were to document the type of bathing provided or if the resident refused. For Tuesday and Friday on 07/25/23, 07/28/23, 08/01/23, 08/08/23 and 08/11/23 the NA did not document a shower or bed bath were provided or refused by Resident #181. On 08/15/23 the NA documented Resident #181 received a shower. Review of the point of care documentation from 07/25/23 through 08/11/23 revealed the type of bathing and the amount of assistance provided to Resident #181 was included. The documentation showed bathing was either left blank or NA staff put 8/8 indicating bathing did not occur and no assistance was provided during the day or night. The NA documentation did show Resident #181 had received total assistance with one shower since admission on [DATE] and indicated no bed baths were provided. During an interview and observation on 08/13/23 at 3:29 PM Resident #181 was in bed wearing a pajama top. There were no obvious body odors and Resident #181's hair and fingernails did not appear unclean. Resident #181 stated he had not received a shower since his admission to the facility and indicated nursing staff wiped him off using the premoistened wipes located on the overbed table. An interview was conducted on 08/17/23 at 1:50 PM with NA #1 assigned to provide care on 08/01/23. NA #1 revealed Resident #181 needed total assistance with bathing and did receive a shower on 08/15/23. NA #1 revealed showers were documented when done and indicated she had assisted Resident #181 with a shower prior to 08/15/23 but she was unable to recall when. NA #1 revealed if there were only 2 NA staff assigned to work on the west wing it was hard to get everything the residents needed done including showers. An interview was conducted on 08/17/23 at 1:33 PM with NA #2 scheduled to provide care on 08/11/23. NA #2 stated she provided assistance with bathing and completed a bed bath for Resident #181 but had not provided assistance with a shower. An interview was conducted with DON on 08/17/23 at 4:33 PM. The DON revealed for bathing the NA staff were doing their best and there were times a resident might not get their shower on the exact day it was scheduled but NA staff did try to make it up on the following day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to maintain a resident's dignity by not providing privacy when changing her shirt for 1 of 1 resident reviewed for dignity (Resident #29). The reasonable person concept was applied to this deficiency. A reasonable person would be upset if observed having their clothing changed without a privacy curtain in place or their room door being closed. Findings included: Resident #29 was admitted to the facility 04/12/22 with diagnoses including non-Alzheimer's dementia and cerebrovascular accident (stroke). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was moderately cognitively impaired and required extensive assistance with dressing. On 08/15/23 at 2:43 PM Resident #29 was observed lying in bed with food stains on the front of her shirt. An observation of Nurse Aide (NA) #3 on 08/15/23 at 2:59 PM revealed she entered Resident #29's room and removed Resident #29's shirt without closing the door to the room or pulling the privacy curtain between the resident's bed and the door to her room. From the hallway, Resident #29 could be seen without her shirt on. An interview with NA #3 on 08/15/23 at 3:10 PM revealed she should have pulled the privacy curtain or shut the door to Resident #29's room when she changed her shirt but did not because she was in a hurry and distracted. An interview with the Director of Nursing (DON) on 08/17/23 at 11:55 AM revealed she expected staff to either close the door to the room or pull the privacy curtain when changing a resident's clothes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews the facility to accurately code Minimum Data Set (MDS) assessments in the areas of transfers (Resident #52), eating (Resident #52), and oxygen use (Residents #29 and #39) for 3 of 24 sampled residents. Findings included: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses including unsteadiness on feet and diabetes. The quarterly Minimum Data Set (MDS) dated [DATE] reflected Resident #52 was moderately cognitively impaired, received a therapeutic diet, and only transferred or ate once or twice during the look back period. The nutrition care plan last updated 08/15/23 revealed Resident #52 received a therapeutic diet and the intervention was to monitor the percent of his meal intakes. An interview with Resident #52 on 08/17/23 at 9:35 AM revealed he ate his meals in the dining room as often as possible. An interview with the MDS Coordinator on 08/17/23 at 1:32 PM revealed she received assistance with some parts of the MDS by a staff member who worked remotely. She explained the staff member who worked remotely coded the transfer and eating portions of Resident #52's quarterly MDS and would not have known Resident #52 usually ate in the dining room and required supervision assistance with transfers. She stated the quarterly MDS should have reflected Resident #52 transferred and ate with supervision assistance. An interview with the Director of Nursing (DON) on 08/17/23 at 4:19 PM revealed she expected the MDS to be coded accurately. 2. Resident #29 was admitted to the facility 04/12/22 with diagnoses including heart failure and chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe). Review of Resident #29's Physician orders revealed an order dated 04/12/22 for oxygen at 3 liters per minute continuously. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was not coded as receiving oxygen therapy. Observations of Resident #29 on 08/14/23 at 4:55 PM, on 08/15/23 at 8:37 AM, on 08/16/23 at 8:11 AM, and 08/17/23 at 9:47 AM revealed she had oxygen in place at 3 liters per minute. An interview with the MDS Coordinator on 08/17/23 at 1:32 PM revealed she received assistance with some parts of the MDS by a staff member who worked remotely. She explained the staff member who worked remotely coded the oxygen portion of Resident #29's quarterly MDS incorrectly and the MDS should have reflected the resident required the use of oxygen. An interview with the Director of Nursing (DON) on 08/17/23 at 4:19 PM revealed she expected the MDS to be coded accurately. 3. Resident #39 was admitted to the facility on [DATE] with diagnoses including chronic obstruction pulmonary disease with dependence on supplemental oxygen. Review of Resident #39's physician orders included to apply oxygen via nasal cannula at 2 liters per minute (LPM) continuously every day and night shift with a start date of 10/07/22 and end date 07/24/23. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #39 did not use oxygen during the assessment lookback period. Review of the Medication Administration Record (MAR) for May 2023 revealed a physician order was transcribed to apply oxygen at 2 LPM continuously every shift with a start date of 10/07/2022 and end date of 07/24/2023. The MAR included nursing staff initials for the assessment lookback period from 05/24/23 through 05/30/23 to indicate Resident #39 received oxygen every day and night shift. During an interview on 08/17/23 at 3:12 PM the MDS Coordinator revealed an offsite nurse helped with the quarterly MDS dated [DATE] and signed oxygen was not in use. The MDS Coordinator stated the nurses' initials on the MAR showed Resident #39 used oxygen during the lookback period and the MDS assessment was incorrectly coded. During an interview on 08/17/23 at 4:28 PM the Director of Nursing stated she would expect MDS assessments were accurate and coded correctly to show oxygen was in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in physical or mental status for 1 of 2 sampled residents reviewed for PASRR (Resident #13). Findings included: Resident #13 was admitted to the facility on [DATE]. His diagnoses included bipolar disorder, depression and anxiety. A PASRR Level II determination notification letter dated 03/05/21 revealed Resident #13 had a Level II PASRR with no expiration date. The North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry provided by the Social Worker (SW) and dated 08/14/23 revealed Resident #13 received a Level II PASRR effective 03/05/21 with no expiration date. There were no requests for re-evaluation after 03/05/21. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was considered by the state Level II PASRR process to have a serious mental illness. During an interview on 08/16/23 at 2:24 PM, the SW revealed she was responsible for submitting requests for PASRR re-evaluations when needed. The SW confirmed Resident #13 had a Level II PASRR and explained she did not know to request a PASRR re-evaluation when a resident had a significant change in physical or mental status. The SW confirmed she had not requested a Level II PASRR re-evaluation for Resident #13 after the significant change in status MDS assessment dated [DATE]. During an interview on 08/17/23 at 4:19 PM, the Director of Nursing stated the regulation guidance should be followed and a request for a Level II PASRR re-evaluation should be made when a resident had a significant change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews the facility failed to provide incontinence care (Resident #52 and Resident #29), a shave (Resident #47), and oral care (Resident #181) for 4 of 6 dependent residents reviewed for activities of daily living (ADL). Findings included: 1. Resident #52 was admitted to the facility 03/31/22 with diagnoses including diabetes and heart failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired, had rejection of care 1 to 3 days during the look back period, and was always incontinent of bowel and bladder. Review of Resident #52's care plan last revised 08/15/23 revealed he had a history of incontinence care refusal, and the intervention was to encourage him to allow care to be provided and explain care needed to be provided to prevent skin breakdown. An interview with NA #4 on 08/15/23 at 3:38 PM revealed she was working 5:00 AM to 5:00 PM on 08/15/23 and had been assigned to care for Resident #52 from 7:00 AM until 3:00 PM. She stated the last time she provided incontinence care to Resident #52 on 08/15/23 was at 12:00 PM. NA #4 stated after she provided incontinence care to Resident #52 on 08/15/23 at 12:00 PM meal trays arrived, she assisted another NA on 600 hall put 2 residents to bed because they required complete transfer assistance, and answered call lights. She stated around 2:30 PM she went on break for 30 minutes and when she returned from break at 3:00 PM, she was assigned to provide showers. NA #4 stated she had not provided incontinence care for Resident #52 since 12:00 PM due to being pulled to other tasks and did not inform the nurse on the hall or other NAs she had not done an incontinence round since before lunch when she left for her break around 2:30 PM. She stated Resident #52 had not rung his call light to request incontinence care after lunch on 08/15/23 that she was aware of. NA #4 stated Resident #52's scrotum was reddened when she provided incontinence care at noon, but she had not yet had a chance to notify his nurse. An observation of Resident #52 on 08/15/23 at 3:20 PM revealed he was lying in bed and a strong odor of stool was noted in his room. Resident #52's call light was not engaged. An observation of Nurse Aide (NA) #3 on 08/15/23 at 3:24 PM revealed she entered Resident #52's room and checked his incontinence brief. Soft stool with a dried ring around it was noted on Resident #52's bed pad and his incontinence brief contained a large amount of soft stool. Resident #52's scrotum was reddened. NA #3 provided incontinence care. An interview with NA #3 on 08/15/23 at 3:30 PM revealed she started her shift at 3:00 PM on 08/15/23. An interview with Resident #52 on 08/15/23 at 3:32 PM revealed he received incontinence care on 08/15/23 before lunch and had not received further incontinence care until just a few minutes ago. He stated he rang his call light after lunch to request incontinence assistance but could not recall who answered his call light. An interview with NA #5 on 08/15/23 at 4:39 PM revealed she did not answer Resident #52's call light on 08/15/23. An interview with NA #1 on 08/15/23 at 4:42 PM revealed she did not answer Resident #52's call light on 08/15/23. An interview with the Director of Nursing (DON) on 08/17/23 at 11:55 AM revealed she expected NAs to perform incontinence rounds every 2 hours and as needed. She stated even though Resident #52 was able to use his call light and request assistance for incontinent episodes, NAs should still be checking on residents routinely to see if they were alright. 2. Resident #29 was admitted to the facility 04/12/22 with diagnoses including non-Alzheimer's dementia and cerebrovascular accident (stroke). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #29 was moderately cognitively impaired, had no behaviors or rejection of care, and was always incontinent of bowel and bladder. Review of Resident #29's care plan last revised 08/13/23 revealed she had the potential for impaired skin integrity related to incontinence and decreased mobility and the intervention was to provide a low air loss mattress. An interview with NA #4 on 08/15/23 at 3:14 PM revealed she was working 5:00 AM to 5:00 PM on 08/15/23 and had been assigned to care for Resident #29 from 7:00 AM until 3:00 PM. She stated the last time she provided incontinence care to Resident #29 on 08/15/23 was between 11:30 AM and 11:45 AM. NA #4 stated after she provided incontinence care to Resident #29 on 08/15/23 around 11:30 AM meal trays arrived, she assisted another NA on 600 hall put 2 residents to bed because they required complete transfer assistance, and answered call lights. She stated around 2:30 PM she went on break for 30 minutes and when she returned from break at 3:00 PM, she was assigned to provide showers. NA #4 stated she had not provided incontinence care for Resident #29 since between 11:30 AM and 11:45 AM due to being pulled to other tasks and did not inform the nurse on the hall or other NAs she had not done an incontinence round since before lunch when she left for her break around 2:30 PM. She stated Resident #29 did not usually use her call light and depended on staff to monitor her for incontinence and provide care when needed. An observation of Resident #29 on 08/15/23 at 2:59 PM revealed she was awake and lying in bed. A strong odor of urine was noted in her room. Resident #29's call light was not engaged. An observation of Nurse Aide (NA) #3 on 08/15/23 at 3:00 PM revealed she entered Resident #29's room and checked Resident #29's incontinence brief. Resident #29 was noted to have a urine saturated brief. No bottom sheet was on Resident #29's bed, her bed pad was lying under her back, and a large moist area was noted to her mattress below the bed pad. No redness or open areas were noted to Resident #29's skin. NA #3 provided incontinence care. An interview with NA #3 on 08/15/23 at 3:10 PM revealed she started her shift at 3:00 PM on 08/15/23. An interview with the Director of Nursing (DON) on 08/17/23 at 11:55 AM revealed she expected NAs to perform incontinence rounds every 2 hours and as needed. 3. Resident #47 was admitted to the facility 04/04/22 with diagnoses including non-Alzheimer's dementia, lack of coordination, and metabolic encephalopathy (impaired brain function due to disease or toxins). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #47 was severely cognitively impaired, had no behaviors or rejection of care, and bathing did not occur during the look back period. Review of the care plan last revised 06/28/23 revealed Resident #47 was at risk for activities of daily living (ADL) decline related to metabolic encephalopathy and interventions included providing her set-up assistance for ADL. Observations of Resident #47 on 08/13/23 at 10:53 AM, on 08/15/23 at 8:22 AM, on 8/16/23 at 5:23 PM, and 08/17/23 at 9:25 AM revealed she had multiple white long chin hairs and long white hairs extending down the front of her neck. During a telephone interview with Resident #47's emergency contact on 08/15/23 at 11:32 AM, he confirmed Resident #47 liked to look nice and the presence of hairs on her chin and neck would be bothersome for her if she was cognitively intact. An interview with Nurse Aide (NA) #5 on 08/15/23 at 2:32 PM revealed she gave Resident #47 a shower on 08/14/23 and noted she had chin and neck hairs but did not shave her due to Resident #47 being distracted by a fire alarm that had been activated during the shower. An interview with the Director of Nursing (DON) on 08/17/23 at 11:55 AM revealed she expected residents to be shaved during bathing and as needed. 4. Resident #181 was admitted to the facility on [DATE] with diagnoses including debility, heart failure, and dementia. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #181 was assessed as being cognitively intact and needed extensive assistance with personal hygiene and had no rejection of care behaviors during the lookback period. The MDS indicated there were no oral or dental issues present. During an interview and observation on 08/13/23 at 3:29 PM Resident #181 revealed he was able to brush his own teeth but had not and was unsure if he had a toothbrush available to use. Observation of Resident #181's upper and lower teeth revealed a buildup of a white colored substance around multiple teeth and the gums. A toothbrush was being stored in a plastic container on a shelf in room but was out of reach and sight of Resident #181. During an observation and interview on 08/17/23 at 1:33 PM Nurse Aide (NA) #2 confirmed she was assigned to provide care for Resident #181 on 08/13/23 and 08/17/23. NA #2 observed Resident #181's teeth that continued to have a buildup of a white colored substance around the teeth and gums. NA #2 stated Resident #181 would need setup assistance with oral hygiene and confirmed she had not offered or provided oral care. NA #2 asked Resident #181 if he would like to brush his teeth and the resident was accepting of the care. NA #2 removed a tube of toothpaste from the nightstand drawer and the toothbrush stored in the plastic container and stated she was going to provide Resident #181 assistance with oral hygiene. An interview was conducted on 08/17/23 at 4:33 PM with the Director of Nursing (DON). The DON revealed residents should be offered assistance with oral hygiene twice a day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to prevent four cognitively impaired residents from exiting the locked Memory Support Unit (MSU) unsupervised for 4 of 10 residents reviewed for accidents (Residents #35, #59, #66, and #68). Findings included: a. Resident #35 was admitted to the facility on [DATE]. His diagnosis included vascular dementia, major depressive disorder and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had severe impairment in cognition. He required supervision with walking and locomotion and wandered 1 to 3 days during the MDS assessment period. A staff progress note dated 07/26/23 at 3:35 PM and written by the Director of Nursing (DON) revealed in part, the DON was informed by the MSU nurse that Resident #35 had exited the MSU gate and was seen from the window walking outside the building. Resident #35 was returned to the facility without difficulty. An Observation Report dated 07/26/23 completed by Nurse #3 revealed in part, Resident #35 was alert and oriented to person, his hand grasp strength and foot press were strong bilaterally, he had no visual disturbances and displayed no shortness of breath. He had no range of motion limitations, weakness, swelling or inflammation in his extremities and his lower extremities were of equal length. He voiced no complaints of pain, and his skin was warm, dry and of normal color. b. Resident #59 was admitted to the facility on [DATE]. Her diagnosis included dementia, age-related cognitive decline, delirium, and anxiety. A quarterly MDS assessment dated [DATE] revealed Resident #59 had severe impairment in cognition. She required supervision with walking and locomotion and wandered 4 to 6 days during the MDS assessment period. A staff progress note dated 07/26/23 at 3:35 PM and written by the DON revealed in part, the DON was informed by the MSU nurse that Resident #59 had exited the MSU gate and was seen from the window walking outside the building. Resident #59 was returned to the facility without difficulty. An Observation Report dated 07/26/23 completed by Nurse #3 revealed in part, Resident #59 was alert and oriented to person, her hand grasp strength and foot press were strong bilaterally, she had no visual disturbances, and displayed no shortness of breath. She had no range of motion limitations, weakness, swelling or inflammation in her extremities and her lower extremities were of equal length. She voiced no complaints of pain, and her skin was warm, dry and of normal color. c. Resident #66 was admitted to the facility on [DATE]. His diagnosis included Alzheimer's disease, dementia of unspecified severity with other behavioral disturbance and depression. A quarterly MDS assessment dated [DATE] revealed Resident #66 had a short-term memory problem and was moderately impaired with cognitive skills for daily decision making. He required supervision with walking and locomotion and displayed no wandering behaviors during the MDS assessment period. A staff progress note dated 07/26/23 at 3:35 PM and written by the DON revealed in part, the DON was informed by the MSU nurse that Resident #66 had exited the MSU gate and was seen from the window walking outside the building. Resident #66 was returned to the facility without difficulty. An Observation Report dated 07/26/23 completed by Nurse #3 revealed in part, Resident #66 was alert and oriented to person, his hand grasp strength and foot press were strong bilaterally, he had no visual disturbances and displayed no shortness of breath. He had no range of motion limitations, weakness, swelling or inflammation in his extremities and his lower extremities were of equal length. He voiced no complaints of pain, and his skin was warm, dry and of normal color. d. Resident #68 was admitted to the facility on [DATE]. His diagnosis included vascular dementia and anxiety disorder. The quarterly MDS assessment dated [DATE] revealed Resident #68 had long and short-term memory problems and was severely impaired with cognitive skills for daily decision making. He required supervision with walking, was independent with locomotion and displayed wandering behaviors daily during the MDS assessment period. A staff progress note dated 07/26/23 at 3:35 PM and written by the DON revealed in part, the DON was informed by the MSU nurse that Resident #68 had exited the MSU gate and was seen from the window walking outside the building. Resident #68 was returned to the facility without difficulty. An Observation Report dated 07/26/23 completed by Nurse #3 revealed in part, Resident #68 was alert and oriented to person, his hand grasp strength and foot press were strong bilaterally, he had no visual disturbances and displayed no shortness of breath. He had no range of motion limitations, weakness, swelling or inflammation in his extremities and his lower extremities were of equal length. He voiced no complaints of pain, and his skin was warm, dry and of normal color. Review of the facility's investigation of the incident on 07/26/23 revealed a typed statement signed by the Director of Nursing (DON) that read in part, a telephone interview was conducted with the housekeeper who recalled that day she was in the hall just outside of MSU, when she looked out the window and saw Resident #35 walking outside the building. The housekeeper stated she opened the MSU door, informed NA #6 who immediately went out the front door of MSU to go get the residents while she started running toward the back of the building so that she could try and catch the residents that way. During an interview on 08/16/23 at 2:59 PM, Nurse Aide (NA) #6 confirmed she was working on the MSU 7:00 AM to 7:00 PM on 07/26/23 when Resident #35, Resident #59, Resident #66, and Resident #68 exited the building through an unlocked gate in the back patio area. NA #6 explained residents on the MSU liked to go outside to the patio to sit, there was a flower garden for them to enjoy and it was cooler, and the gate was kept locked; however, on 07/26/23 for some reason the gate had been unlocked and neither she nor Nurse #3 were made aware. NA #6 stated when there were only two staff members scheduled on MSU, they had gotten permission from the Administrator to keep the exit doors propped open for the residents to go in and out to the patio area and that was what they had done on 07/26/23. NA #6 could not recall the exact time but thought it was likely around lunchtime when a family member requested she get another resident on MSU dressed and up out of bed. NA #6 stated most of the residents on MSU congregated out in the main area of the unit or walked around. She could not recall where Resident #35, Resident #59, Resident #66, and Resident #68 were at on the unit when she and Nurse #3 went in the resident's room to provide care but did recall the exit doors to the back patio were propped open. NA #6 stated she and Nurse #3 had not been in the resident's room long when they were notified by a housekeeper that some residents were outside the gate and walking behind the building. NA #6 stated she immediately left the room, went outside the building where the residents had exited, went toward the right to go behind the building where they had been observed by the housekeeper and saw Resident #35, Resident #59, Resident #66, and Resident #68 walking together toward the back middle part of the building as if they were on a stroll. She stated they hadn't walked very far as they had not even gotten halfway to the back middle part of the building when she reached them and redirected them back inside the building without further incident. NA #6 recalled all four residents displayed no signs of distress during and after the incident. She added it was less than 5 minutes from the time she and Nurse #3 were notified the residents were outside, the residents were located and returned inside the building. NA #6 explained the residents on MSU required a lot of constant supervision and there was consistently only one NA and one Nurse scheduled during the shift which made it difficult for staff to provide direct supervision for 19 to 20 residents especially when both staff members were in a resident's room providing care. During an interview on 08/16/23 at 3:29 PM, Nurse #3 confirmed she was the assigned nurse for MSU on 07/26/23 during the hours of 7:00 AM to 7:00 PM when Resident #35, Resident #59, Resident #66, and Resident #68 exited the building through an unlocked gate in the back patio area. Nurse #3 was unable to recall the exact time but stated it was sometime mid-morning when a family member requested they assist a resident up out of bed. She stated as she and NA #6 were starting to get him dressed, they heard a someone (could not recall who) telling them there were residents outside the building and NA #6 immediately ran outside to look for the residents while she lowered the resident's bed and made sure he was in a safe position before leaving the room. Nurse #3 stated she then went out to the patio area and noticed the gate was swinging back and forth and there were other residents in the area so she stayed at the exit doors to make sure no one else got out. She then called the Maintenance Director and Administrator to inform them of the situation and a code pink was called to inform all staff of the elopement. Nurse#3 explained she and NA #6 had not been in the other resident's room long and her best guess was that it was a maximum of 3 minutes from the time they had entered the other resident's room, was informed residents were outside the building and Resident #35, Resident #59, Resident #66, and Resident #68 were all located and returned back inside safely. She stated once the residents were returned inside the building, she completed full-body assessments and vitals on each resident with no injuries identified. She stated since the incident, the Maintenance Director had fixed the gate so that it could only be unlocked from the main control panel and the exit doors to the patio were no longer left propped open and all residents who went outside to the patio were supervised. During an interview on 08/16/23 at 4:20 PM, the Maintenance Director recalled he was notified on 07/26/23 by Nurse #3 of residents that had gotten out of the facility through the MSU patio gate. He stated he immediately went to MSU to assess the situation and discovered the gate had been unlocked. He could not determine who unlocked the date or why, so he disabled the lock on the gate completely for it to only be unlocked via the main control panel located at the MSU nurses' station when there was an emergency, such as a fire. An online website named Time and Date was used to obtain the outside weather in the [NAME] area on 07/26/23 and noted at 10:54 AM the temperature was 80 degrees with the highest temperature reaching 87 degrees from 2:54 PM to 5:17 PM. An observation of the back patio area in the Memory Support Unit (MSU) was conducted on 08/16/23 at 4:30 PM. The exit doors at the back of the MSU opened to a gated patio. To the left side of the patio was a locked gate leading out to a sidewalk. To the right of the gate as you exited the patio was an area of grass leading to the side road that circled the perimeter of the building. The side road to the right of the building was approximately 30 feet from the sidewalk when standing directly in front of the patio gate. Resident #35, Resident #59, Resident #66, and Resident #68 were noticed walking along the side road toward the middle, back area of the building where the dumpsters, kitchen, parking spaces and maintenance building were located. The side road around the perimeter of the building had trees along the left side that separated the facility from other residential homes and wooded areas. During interviews on 08/16/23 at 4:43 PM and 08/17/23 at 4:19 PM, the DON confirmed MSU staff had gotten permission to leave the back patio doors propped open for residents to go in and out. She explained the back patio was usually secure and on 07/26/23 MSU staff had no idea the back patio gate wasn't locked which was how Resident #35, Resident #59, Resident #66, and Resident #68 were able to get outside the building. She stated they could not determine who had unlocked the gate or why. She stated when she spoke with the housekeeper via telephone, the housekeeper reported after she had opened the doors to MSU to inform the staff she had noticed the residents outside the building, MSU staff went outside through the MSU exit doors and the housekeeper went down to the back of the building to go outside to try and catch the residents from that area. The DON added a code pink for elopement was called, all staff assumed their positions, the residents were located quickly and returned back into the building without further incident or injuries. The DON stated when they reviewed the video footage as part of the investigation, they had determined it was only about 3 to 5 minutes from the time Resident #35, Resident #59, Resident #66, and Resident #68 had exited through the gate, were located behind the back of the building and returned back inside. The DON stated it was an unfortunate event and while having more staff scheduled on MSU would help, she did not feel the elopement was the direct result of staffing but rather due to the patio doors being left propped open. The Administrator was out of the country and unable to be interviewed. The facility provided the following Corrective Action Plan with a completion date of 07/27/23: The facility failed to supervise four (4) cognitively impaired residents with wandering behaviors from exiting the facility unsupervised on 07/26/23. What corrective action will be accomplished for the residents found to have been affected by the deficient practice? *Resident #35, Resident #59, Resident #66, and Resident #68 exited the facility unsupervised from the Memory Support Unit on 07/26/23 and were observed by housekeeping staff at approximately 3;28 PM walking around the bend, behind the Memory Support Unit. All four residents were assisted back inside the building at approximately 3:34 PM. Assessments were completed upon return to the facility. No injuries were found. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? *Elopement Book was reviewed by the Director of Health Services (DHS) on 07/26/23 and 07/27/23 to ensure all high-risk elopement residents have appropriate intervention identified on facility elopement book. Elopement Book is kept at each nurses' station and at the front desk. Each resident on MSU and residents with a Wanderguard (elopement device) has a facesheet and picture in the book for ease of identification. This is to identify residents at high risk for elopement. *Elopement Risk Assessment was also completed on all residents 07/26/23 and 07/27/23. *Facility will continue to complete elopement risk assessments upon admission, every quarterly and significant change to identify high risk wanderers per policy. *Mag lock switch to gate at Memory Support Unit (MSU) back porch was disabled. There is a mag lock at the nurses' station that will unlock the gate for emergency. There is a keypad that can be used to unlock the gate for emergency exit. What measures will be put in place or what systemic changes will be made to ensure that the deficient practice will not reoccur? *The Director of Health Services and Clinical Care Coordinator provided education to all staff on 07/26/23 on not propping the back door open leading to the back porch on the Memory Support Unit. Signs were also posted on both doors on 07/26/23 to remind staff on not propping these doors open. Education was also provided on keeping all mag locks always engaged, exit doors will remain locked. All other staff who are on FMLA (Family and Medical Leave Act) or otherwise out will receive in-service prior to returning to work. *Maintenance Director and Assistant Maintenance Director will round at the beginning of each shift and at the end of their shift on all exit doors, including Memory Support Unit back porch gate, to ensure mag locks are engaged and audible alarms are activated. *On 07/27/23, the Physician Assistant reviewed Resident #35's medications for increased behavior and exit seeking. No changes were made on medications at that time. *A Town Hall Meeting is scheduled for 08/03/23 for all staff members/all departments. Agenda items included but were not limited to significance of resident elopement, completing Elopement Risk Assessment form upon admission, every quarterly, meaningful change, and/or annually per policy, and elopement book location at nurses' station and front desk. Facility had memory support residents who were able to elope from facility so systems were put into place so this incident will not happen again and staff was explained as to what their roles are to prevent his from happening again. Roles to include but not limited to the doors locked and door alarms functioning. Staff were also educated on resident behavior indicators, resident verbalizing wanting to leave the facility and history of exit seeking. Previous Director of Health Services followed up with employees that did not attend the Town Hall Meeting and ensured that they were education on materials presented at the meeting. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: *Ad Hoc QAPI held on 07/27/23. Elopement incident and controls were discussed. This includes the checking of Wanderguard door to ensure functioning. This is done by using the Wanderguard checker, the light on the Wanderguard checker turns green to conform the Wanderguard system on door is functional. The Maintenance Director checks Wanderguard system door which include front door and MSU door daily during the week, Manager on Duty on the weekends, to ensure function of keypad. Residents residing on the locked MSU do not require a Wanderguard. *The mag lock switch operation and location of mag lock switches was discussed. Thes switches are not to be disengaged or turned off. Exit doors have audible alarms and should not be turned off as well. *The elopement program was also reviewed during the Ad Hoc QAPI meeting. MDS Coordinator reviewed the process utilizing the Elopement Risk Assessment From and reviewed Wanderguard orders. *The Elopement Book was reviewed on 07/26/23. The Elopement Book is in each nurses' station and at the front desk. Each resident at high risk for elopement has a face sheet and a picture printed and placed in the Elopement Book. This is determined by completing an Elopement Risk Assessment Form upon admission, quarterly, significant change and/or annually. A resident with a score of 11 or higher will be considered a high risk and interventions put into place. Facesheets of residents on MSU are in the Elopement Book and residents with Wanderguards are also in the Elopement Book. *The Director of Health Services and/or designee will audit the Elopement Book every week x 4 weeks then monthly x 4 months. The audits began on 07/27/23. *The MDS Coordinator will audit Elopement Risk Assessment Form completion every week x 4 weeks then monthly x 4 months. These audits began on 07/27/23. *The Maintenance Director and/or Assistant Maintenance Director will audit mag lock/doors daily x 4 weeks, Manager on Duty on weekends, then monthly x 2 months. These audits began on 07/27/23. *Ongoing audits will be determined based on the results of prior audits. Audit tools will be reviewed by Administrator and or Director of Health Services weekly and results will be presented during the monthly Quality Assurance and Performance Improvement Committee meetings until substantial compliance is achieved. Date of completion: 07/27/23. The Corrective Action Plan was validated on 08/17/23 and concluded the facility implemented an acceptable corrective action plan on 07/27/23 once the mag lock on the gate was fixed and staff were educated not to leave the exit doors propped open. The daily monitoring report of the facility exit doors and MSU gate for July 2023 and August 2023 were reviewed with no concerns identified. Observations of the MSU exit doors leading out to the patio area revealed they were kept closed, locked and had signage posted not to prop the doors open. Elopement books were observed at each nurses' station throughout the facility and reception desk. The elopement books contained information and pictures for each resident identified as high risk. Interviews conducted with multiple staff on various shifts and departments were interviewed and verified they received re-education related to elopement in July 2023 and were able to describe facility processes for: what to do when a resident demonstrated elopement/exit seeking behaviors, where the elopement books were located, what information they contained, responding to window/door alarms, making sure entry/exit doors were locked before leaving the area, and what to do in the event of an elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Pharmacy Consultant, Nurse Practitioner (NP) #1, and Physician interviews the facility failed to implement a pharmacy recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident #25). Findings included: Resident #25 was admitted to the facility 01/11/22 with diagnoses including diabetes and gastroesophageal reflux disease (acid reflux). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was severely cognitively impaired. Review of Resident #25's Physician orders revealed an order dated 07/19/22 for Omeprazole (a medication that decreases stomach acid production) 20 milligrams (mg) once a day for gastroesophageal reflux disease and discontinued 05/24/23 and an order for Famotidine (a medication that decreases stomach acid production) 20 mg twice a day for gastroesophageal reflux disease ordered 09/09/22. Review of Resident #25's Medication Administration Record (MAR) from April 2023 through May 2023 revealed she received Omeprazole and Famotidine as ordered. A pharmacy medication regimen review dated 04/24/23 stated Resident #25 had Physician orders for Omeprazole and Famotidine and asked the Physician to address whether Omeprazole could be discontinued to allow for single drug therapy. The Nurse Practitioner (NP) responded with writing an order to discontinue Omeprazole on 04/26/23. A pharmacy medication regimen review dated 05/23/23 stated per the pharmacy recommendation on 04/24/23 Resident #25's order for Omeprazole should have been discontinued and there was still an active order in the computer for her to receive the medication. The pharmacy asked nursing staff to address the recommendation. An interview with the Assistant Director of Nursing (ADON) on 08/16/23 at 10:55 AM revealed she was in charge of handling pharmacy recommendations. She stated each month pharmacy sent her nursing and physician recommendations and she distributed the recommendations to the appropriate department. The ADON explained Nurse Practitioner #1 usually made any medication changes based off pharmacy recommendations in the computer himself, and she double-checked to make sure the orders were correctly placed in the computer. She stated both she and NP #1 missed discontinuing Resident #25's Omeprazole in April 2023 and she was not sure how that happened. An interview with the Pharmacy Consultant on 08/16/23 at 11:49 AM revealed he performed the medication regimen review for Resident #25 on 04/24/23. He stated if there had been no evidence of a gastrointestinal bleed (bleeding in the digestive tract) in quite a while and a resident was on 2 medications for the same problem, he usually asked the Physician to discontinue one of the medications. The Pharmacy Consultant stated Omeprazole and Famotidine both treated gastroesophageal reflux disease, but they had different mechanisms of action and Famotidine use by itself seemed to work well. He stated once the recommendation was addressed by the Physician the facility should have implemented the recommendation. An interview with Nurse Practitioner #1 on 08/16/23 at 11:53 AM revealed when he received pharmacy recommendations that involved making medication changes, he usually made the changes himself in the computer. He stated he missed putting the order in the computer to discontinue the Omeprazole on 04/26/23 and the Omeprazole should have been discontinued. An interview with the Physician on 08/17/23 at 1:47 PM revealed he expected pharmacy recommendations be implemented as ordered. An interview with the Director of Nursing (DON) on 08/17/23 at 4:19 PM revealed she expected pharmacy recommendations be implemented as ordered.

Based on observations, record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the annual recertification and complaint survey conducted on 01/07/22. This was for two deficiencies originally cited in the area of Infection Prevention and Control and Personal Privacy and Confidentiality. For one deficiency originally cited in the area of Free of Accidents and Hazards during the complaint survey conducted on 06/16/21 and one deficiency originally cited in the area of Infection Prevention and Control during the Covid-19 Focused Infection Control survey conducted on 12/23/20. The deficient practice were subsequently recited on the current annual recertification and complaint survey of 08/17/23. The repeated deficient practice during four federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag was cross referenced to: F880: Based on observations, record review, and staff interviews the facility failed to implement their infection control policy for hand hygiene when 1 of 2 facility staff (Nurse #2) did not remove his gloves and perform hand hygiene during wound care for 1 of 2 residents reviewed for pressure ulcers (Resident #44), failed to implement infection control for hand hygiene when 1 of 2 facility staff (Nurse Aide #3) did not remove her gloves and perform hand hygiene after providing incontinence care for 2 of 3 residents observed for incontinence care (Residents #29 and #52), and failed to implement infection control for hand hygiene when 1 of 2 facility staff (Nurse Aide #3) failed wear gloves when touching wet linen that contained a wet brief while providing incontinence care for 2 of 3 residents observed for incontinence care (Resident #29). During the annual recertification and complainant survey conducted on 01/07/22, the facility failed to implement infection prevention for hand hygiene by not sanitizing hands or removing gloves when providing incontinence care to residents. During the focused Covid-19 survey conducted on 12/23/20 the facility failed to ensure dietary staff implemented the facility's infection control measures for wearing surgical masks when 1 of 3 dietary staff failed to wear their surgical masks covering both the mouth and nose while working in the kitchen. This failure occurred during a COVID-19 pandemic. F583: Based on observations and staff interviews the facility failed to maintain a resident's dignity by not providing privacy when changing her shirt for 1 of 1 resident reviewed for dignity (Resident #29). The reasonable person concept was applied to this deficiency. A reasonable person would be upset if observed having their clothing changed without a privacy curtain in place or their room door being closed. During the annual recertification survey conducted on 01/07/22, the facility failed to protect the private health information for 1 of 1 sampled resident by leaving confidential medical information unattended in an area visible and accessible to the public in [NAME] Wing nurse station. F689: Based on observations, record review and staff interviews, the facility failed to prevent four cognitively impaired residents from exiting the locked Memory Support Unit (MSU) unsupervised for 4 of 10 residents reviewed for accidents (Residents #35, #59, #66, and #68). During the complainant survey conducted on 06/02/21 the facility failed to prevent a cognitively impaired resident with known wandering and exiting seeking behaviors from exiting the facility unsupervised on three separate occasions. This affected 1 of 3 residents reviewed for accidents. While the resident was outside unattended, there was a high likelihood for serious injury. The Administrator was out of the country and unable to be interviewed. During an interview on 08/17/23 at 4:36 PM the Director of Nursing (DON) revealed monthly Quality Assurance (QA) meetings were held to review measures put in place and discussed with the Medical Director and other departments for their response and feedback for issues identified. When issues were identified the root cause was reviewed and corrective actions implemented and if there was no improvement it was revisited by QA. For the repeat deficient practice the DON revealed there were several reasons including newly hired staff for the position of Staff Development Coordinator and newly hired Infection Prevention Nurse that have a lot to do in a short amount of time.

Based on observations, record review, and staff interviews the facility failed to implement their infection control policy for hand hygiene when 1 of 2 facility staff (Nurse #2) did not remove his gloves and perform hand hygiene during wound care for 1 of 2 residents reviewed for pressure ulcers (Resident #44), failed to implement infection control for hand hygiene when 1 of 2 facility staff (Nurse Aide #3) did not remove her gloves and perform hand hygiene after providing incontinence care for 2 of 3 residents observed for incontinence care (Residents #29 and #52), and failed to implement infection control for hand hygiene when 1 of 2 facility staff (Nurse Aide #3) failed wear gloves when touching wet linen that contained a wet brief while providing incontinence care for 2 of 3 residents observed for incontinence care (Resident #29). Findings included: Review of the facility's policy titled Infection Prevention-Hand Hygiene revised 03/08/19 read in part as follows: This policy applies to all healthcare centers in the organization. Definition: Alcohol-based hand rub is an alcohol containing preparation designed for application to the hands for reducing the number of viable microorganisms on the hands. Hand hygiene applies to handwashing, antiseptic hand wash, and alcohol-based hand rub to minimize the spread of microorganisms acquired on the hands during daily duties and when there is contact with blood and body fluids. Hand washing applies to washing hands with soap and water. Indications for hand hygiene is the moment during health care when hand hygiene must be performed to prevent harmful germ transmission and/or infection. Indications requiring hand wash or hand rub: 1. Before and after contact with the resident 2. Before donning gloves 3. After contact with a resident's intact skin 4. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, and wound dressings 5. When hands move from a contaminated body site to a clean body site during resident care 6. Immediately after removal of personal protective equipment (gloves, gown, facemasks) Other aspects of hand hygiene: a. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur b. Perform hand hygiene and change gloves during resident care if moving from a contaminated body site to a clean body site. 1. A continuous observation of Nurse #2 on 08/15/23 from 10:51 AM to 11:03 AM revealed he provided wound care for Resident #44. With gloved hands Nurse #2 removed a dressing from Resident #44's sacrum, removed his gloves, applied clean gloves, cleansed the wound with normal saline (salt water), patted the wound dry, applied silver alginate (an antimicrobial dressing) to the wound, covered the wound with a foam dressing, and removed his gloves. Nurse #2 then applied a clean pair of gloves, removed a dressing to Resident #44's right heel, removed his gloves, applied clean gloves, cleansed the wound with normal saline, patted the wound dry, applied Medi-honey (medical grade honey for wound care) to a gauze pad, applied the gauze pad to the wound, covered the wound with additional gauze, and removed his gloves. Nurse #2 secured the gauze to Resident #44's heel dressing with tape, gathered the trash bag containing the soiled wound dressings and took the trash bag to the soiled utility room, and performed hand hygiene using alcohol-based hand rub. Nurse #2 did not perform hand hygiene after removing soiled gloves and before applying clean gloves and before moving from a dirty body site to a clean body site during wound care. In an interview with Nurse #2 on 08/15/23 at 11:04 AM he confirmed he did not do hand hygiene after completing the wound care to Resident #44's sacrum and before starting the wound care to Resident #44's right heel due to an oversight. He stated he would usually only perform hand hygiene in between changing gloves if the wound had a lot of drainage. An interview with the Infection Preventionist (IP) on 08/16/23 at 10:31 AM revealed he expected hand hygiene to be performed each time gloves were changed. An interview with the Director of Nursing (DON) on 08/16/23 at 10:42 AM revealed she expected hand hygiene to be performed each time gloves were changed. She stated hand hygiene audits were performed periodically to ensure staff were performing hand hygiene correctly but sometimes staff got nervous and rushed when being observed. 2. A continuous observation of Nurse Aide (NA) #3 on 08/15/23 from 2:59 PM through 3:08 PM revealed she performed incontinence care for Resident #29. With gloved hands NA #3 cleaned urine and stool with resident care wipes, placed the used wipes in the trash can, rolled the wet bed pad and brief under Resident #29, wiped the mattress to remove urine that leaked onto the mattress with a resident care wipe, removed her gloves and put on a clean pair of gloves, placed the clean bed pad under Resident #29, applied barrier cream to Resident #29's bottom, removed her gloves, placed a clean brief under the resident, picked up the wet brief enclosed in the wet bed pad with bare hands and placed them in a trash bag, fastened Resident #29's incontinence brief, placed a clean gown on the resident, gathered the trash bags containing the soiled bed pad and used resident care wipes and placed them in a bin outside the resident's room, and performed hand hygiene by using alcohol-based hand rub. NA #3 did not perform hand hygiene after cleaning urine and stool and before putting on clean gloves, did not perform hand hygiene after applying barrier cream to Resident #29's bottom and before touching the clean brief, did not wear gloves while handling a wet bed pad which contained a wet brief, and did not perform hand hygiene after touching a wet bed pad containing a wet brief and before touching the resident's clean brief and clean gown. An interview with NA #3 on 08/15/23 at 3:10 PM revealed she usually changed gloves after cleaning urine or stool but did not usually perform hand hygiene each time she changed gloves. She stated she should not have handled the wet bed pad containing the wet brief with her ungloved hands but did so because she was in a hurry and was distracted. An interview with the Infection Preventionist (IP) on 08/16/23 at 10:31 AM revealed he expected hand hygiene to be performed each time gloves were changed. He stated staff should not handle wet linen or briefs without wearing gloves. An interview with the Director of Nursing (DON) on 08/16/23 at 10:42 AM revealed she expected hand hygiene to be performed each time gloves were changed. She stated hand hygiene audits were performed periodically to ensure staff were performing hand hygiene correctly but sometimes staff got nervous and rushed when being observed. The DON stated gloves should be worn when touching dirty linen or briefs. 3. A continuous observation of Nurse Aide (NA) #3 on 08/15/23 from 3:24 PM through 3:36 PM revealed she performed incontinence care for Resident #52. With gloved hands NA #3 removed Resident #52's incontinence brief, cleaned stool with resident care wipes, removed her gloves and applied clean gloves, rolled a clean bed pad under the resident, removed the soiled bed pad and placed it in a trash bag, removed her gloves, got a tube of barrier cream from Resident #52's dresser, put on gloves, applied barrier cream to the resident's scrotum, removed her gloves, fastened the incontinence brief, gathered the trash bag and placed it in a bin outside Resident #52's room, and performed hand hygiene using alcohol-based hand rub. NA #3 did not perform hand hygiene after cleaning stool and before putting on clean gloves and did not perform hand hygiene after removing the gloves worn to apply barrier cream and before touching Resident #52's clean brief. An interview with NA #3 on 08/15/23 at 3:37 PM revealed she usually changed her gloves after cleaning urine or stool but did not usually perform hand hygiene each time she changed gloves. An interview with the Infection Preventionist (IP) on 08/16/23 at 10:31 AM revealed he expected hand hygiene to be performed each time gloves were changed. An interview with the Director of Nursing (DON) on 08/16/23 at 10:42 AM revealed she expected hand hygiene to be performed each time gloves were changed. She stated hand hygiene audits were performed periodically to ensure staff were performing hand hygiene correctly but sometimes staff got nervous and rushed when being observed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to maintain doors in good repair (rooms 408, 405, 502, 506, 507, 609, 610, both doors of the main dining room, and both doors of the television room), maintain clean and sanitary floors (rooms 402, 405, 408), ensure a bathroom was free of lingering odors (bathroom in room [ROOM NUMBER]), maintain clean and sanitary hallway floors (400 hall and 600 hall), label and properly store personal care equipment in shared bathrooms (rooms 401, 402, 405, and 506), maintain clean and sanitary privacy curtains (rooms 407, 408, 501-A, and 610), maintain a bedside commode in good repair (bedside commode in the bathroom of room [ROOM NUMBER]), and maintain walls and baseboards in good repair (rooms [ROOM NUMBERS]) for 1 of 2 units (West Wing) on 3 of 3 halls (400 hall, 500 hall, 600 hall) reviewed for safe, clean, and homelike environment. Findings included: 1.a. An observation of the inside of the bathroom door of room [ROOM NUMBER] on 08/13/23 at 3:10 PM revealed a linear area roughly 2 inches long at approximately wheelchair armrest height of wood peeled away from the door exposing a rough, unfinished layer of wood. Additional observations of the inside of the bathroom door of room [ROOM NUMBER] on 08/14/23 at 4:54 PM, 08/15/23 at 8:47 AM, and 08/16/23 at 8:36 AM revealed a linear area roughly 2 inches long at approximately wheelchair height of wood peeled away from the door exposing a rough, unfinished layer of wood. An observation of the inside of the bathroom door of room [ROOM NUMBER] on 08/17/23 at 9:50 AM revealed an area approximately wheelchair height of wood peeled away from the door exposing a rough, unfinished layer of wood with an approximately one-inch splinter hanging off the door. b. An observation of the inside of the room entrance door of room [ROOM NUMBER] on 08/13/23 at 11:04 AM revealed a linear area at approximately wheelchair armrest height of wood peeled away from the door exposing a rough, unfinished layer of wood. Additional observations of the inside of the room entrance door of room [ROOM NUMBER] on 08/14/23 at 9:38 AM, 08/15/23 at 8:34 AM, 08/16/23 at 8:04 AM and 08/17/23 at 9:39 AM revealed a linear area at approximately wheelchair armrest height of wood peeled away from the door exposing a rough, unfinished layer of wood. c. An observation of the inside of the bathroom door of room [ROOM NUMBER] on 08/13/23 at 11:25 AM revealed multiple areas of wood peeled away from the door exposing a rough, unfinished layer of wood to the lower one third of the door. Additional observations of the inside of the bathroom door of room [ROOM NUMBER] on 08/14/23 at 9:39 AM, 08/15/23 at 8:33 AM, 08/16/23 at 8:02 AM and 08/17/23 at 9:42 AM revealed multiple areas of wood peeled away from the door exposing a rough, unfinished layer of wood to the lower one third of the door. In an interview with the Maintenance Director on 08/17/23 at 11:12 AM he stated a safety inspection performed in 2022 revealed all the doors in the facility needed to be replaced and a quote to replace the doors had been obtained in 2022, but the doors had not arrived. He stated the only thing he could do for the rough edges of the doors was sand them down. The Maintenance Director was unable to provide a schedule for sanding the doors down. 2.a. An observation of the floor of room [ROOM NUMBER] on 08/13/23 at 12:03 PM revealed food particles and dirt scattered across the floor and the floor was so sticky the surveyor's shoes stuck to the floor. Additional observations of the floor of room [ROOM NUMBER] on 08/14/23 at 9:29 AM, 08/15/23 at 8:26 AM, 08/16/23 at 7:54 AM, and 08/17/23 at 9:29 AM revealed food particles and dirt scattered across the floor and the floor was so sticky the surveyor's shoes stuck to the floor. b. An observation of the floor of room [ROOM NUMBER] on 08/13/23 at 11:04 AM revealed the floor was so sticky the surveyor's shoes stuck to the floor. Additional observations of the floor of room [ROOM NUMBER] on 08/14/23 at 9:17 AM, 08/15/23 at 8:34 AM, 08/16/23 at 8:04 AM, and 08/17/23 at 9:39 AM revealed the floor was so sticky the surveyor's shoes stuck to the floor. c. An observation of the floor of the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 11:25 AM revealed dried yellow/brown stains to the floor in front of the toilet. d. An observation of the floor of room [ROOM NUMBER] on 08/14/23 at 9:12 AM revealed multiple dried tan stains scattered across the floor. Additional observations of the floor of room [ROOM NUMBER] on 08/15/23 at 8:42 AM and 08/17/23 at 9:49 AM revealed multiple dried tan stains scattered across the floor. An interview with the Housekeeping Supervisor on 08/17/23 at 11:12 AM revealed floors should be clean and free of debris and stains. She stated daily cleaning of rooms included sweeping and mopping, but there were days when rooms did not get cleaned due to not having enough housekeeping staff. The Housekeeping Supervisor also stated the floor tech had been out due to a family emergency and that also contributed to the floors not being clean. 3. A lingering odor of urine was noted to the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 11:25 AM, 08/14/23 at 9:39 AM, 08/15/23 at 8:33 AM, 08/16/23 at 8:02 AM, and 08/17/23 at 9:42 AM. An interview with the Housekeeping Supervisor on 08/17/23 at 11:12 AM revealed bathrooms should be free of lingering odors. She stated daily cleaning of bathrooms included sweeping and mopping, but there were days when rooms did not get cleaned due to not having enough housekeeping staff. The Housekeeping Supervisor also stated the floor tech had been out due to a family emergency and that also contributed to the floors not being clean. 4. Observations of the hallway of the 400 hall on 08/13/23 at 10:52 AM revealed food debris and dirt scattered along the entire hallway. Additional observations of the hallway of 400 hall on 08/14/23 at 9:42 AM, 08/15/23 at 8:34 AM, 08/16/23 at 5:13 PM, and 08/17/23 at 9:34 AM revealed food debris and dirt scattered along the entire hallway. An interview with the Housekeeping Supervisor on 08/17/23 at 11:12 AM revealed the hallways should be vacuumed daily but there were days the hallways did not get vacuumed due to not having enough housekeeping staff. 5.a. An observation of the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 2:41 PM revealed 3 unlabeled toothbrushes and 3 tubes of toothpaste were sitting on the sink. Additional observations of the shared bathroom of room [ROOM NUMBER] on 08/14/23 at 9:27 AM, 08/15/23 at 8:24 AM, 08/16/23 at 7:59 AM, and 08/17/23 at 9:26 AM revealed 3 unlabeled toothbrushes and 3 tubes of toothpaste were sitting on the sink. b. An observation of the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 12:14 PM revealed an unlabeled comb and toothbrush were sitting on the sink and an unlabeled bottle of roll-on deodorant sitting on a handrail above the toilet. Additional observations of the shared bathroom of room [ROOM NUMBER] on 08/14/23 at 9:29 AM, 08/15/23 at 8:26 AM, 08/16/23 at 7:54 AM, and 08/17/23 at 9:29 AM revealed and unlabeled comb and toothbrush were sitting on the sink and an unlabeled bottle of roll-on deodorant sitting on a handrail above the toilet. c. An observation of the shared bathroom of room [ROOM NUMBER] on 08/13/23 at 11:25 AM revealed an unlabeled toothbrush and tube of toothpaste sitting on the sink. Additional observations of the shared bathroom of room [ROOM NUMBER] on 08/14/23 at 9:17 AM, 08/15/23 at 8:33 AM, 08/16/23 at 8:02 AM, and 08/17/23 at 9:42 AM revealed an unlabeled toothbrush and tube of toothpaste sitting on the sink. An interview with the Director of Nursing (DON) on 08/17/23 at 11:12 AM revealed all personal care equipment should be labeled and covered if needed by nurse aides (NAs). She explained there was no staff member assigned to round on rooms to check for labeled and properly stored personal care equipment. 6.a. An observation of the privacy curtain between a-bed and b-bed in room [ROOM NUMBER] on 08/13/23 at 3:21 PM revealed multiple orange/brown stains scattered across the curtain. An additional observation of the privacy curtain between a-bed and b-bed in room [ROOM NUMBER] on 08/17/23 at 9:54 AM revealed multiple orange/brown stains scattered across the curtain. b. An observation of the privacy curtain of room [ROOM NUMBER]-a and the privacy curtain between a-bed and b-bed in room [ROOM NUMBER] on 08/13/23 at 2:55 PM revealed multiple orange/brown stains scattered across both curtains. Additional observations of the privacy curtain of room [ROOM NUMBER]-a and the privacy curtain between a-bed and b-bed in room [ROOM NUMBER] on 08/14/23 at 9:12 AM, 08/15/23 at 8:42 AM, and 08/17/23 at 9:49 AM revealed multiple orange/brown stains scattered across both curtains. An interview with the Housekeeping Supervisor on 08/17/23 at 11:12 AM revealed she started replacing all privacy curtains approximately 2 months ago but had to stop due to a lack of housekeeping staff. She stated privacy curtains should be replaced when soiled and housekeeping staff also depended on the nursing staff to notify them when privacy curtains were soiled so they could be changed. 7. An observation of the bedside commode in the bathroom of room [ROOM NUMBER] on 08/13/23 at 3:10 PM revealed an approximately nickel-sized circular area of rust to both of the parallel metal bars on the top of the bedside commode. Additional observations of the bedside commode in the bathroom of room [ROOM NUMBER] on 08/14/23 at 4:54 PM, 08/15/23 at 8:47 AM, 8/16/23 at 8:36 AM, and 08/17/23 at 9:50 AM revealed an approximately nickel-sized circular area of rust to both of the parallel metal bars on the top of the bedside commode. An interview with the Director of Nursing (DON) on 0817/23 at 11:12 AM revealed nursing staff should have either replaced the rusty bedside commode with a new bedside commode or notified her so she could have replaced the bedside commode. 8. An observation of the corner of the wall to the right of the bathroom door in room [ROOM NUMBER] on 08/13/23 at 3:18 PM revealed missing sheetrock approximately half-way up the wall and the baseboard was missing. Additional observations of the corner of the wall to the right of the bathroom door in room [ROOM NUMBER] on 08/15/23 at 8:47 AM and 08/17/23 at 9:54 AM revealed missing sheetrock approximately half-way up the wall and the baseboard was missing. An interview with the Maintenance Director on 08/17/23 at 11:12 AM revealed he tried to repair damage sheetrock as quickly as possible, but he was unaware of the damaged sheetrock and missing baseboard in room [ROOM NUMBER]. He stated he relied on nursing or housekeeping staff to notify him of needed repairs, and he did not have a schedule for checking rooms for damage to walls in resident rooms. 11. a) An observation made on 08/13/23 at 11:36 AM of room [ROOM NUMBER] revealed the sheetrock was missing or peeling away from the lower portion of the wall by the bathroom door. The wood door entering the room had several areas along the edges that were splintered and mostly affected the edge of door located by the doorknob and below. b) An observation made on 08/13/23 at 12:03 PM of room [ROOM NUMBER] revealed the wood door to enter the room had several areas of splintered wood along the edges and mostly affected the edge of door located from the doorknob and below. c) An observation made on 08/15/23 at 12:22 PM of room [ROOM NUMBER] revealed the wood door to enter the room had several areas of splintered wood along the edges and mostly affected the edges of door from the doorknob and below. An observation of the environment issues and interview were conducted on 08/17/23 at 11:12 AM with the Maintenance Director. The doors to rooms 502. 506, and 507 remained in the same condition and the sheetrock in room [ROOM NUMBER] continued to be in disrepair. The Maintenance Director revealed the facility had discussed replacing the doors after a previous inspection and provided documentation dated 08/2022. He stated he could sand the rough places on the doors smooth until they were replaced. The Maintenance Director revealed he was not aware of the damaged sheetrock in room [ROOM NUMBER] and explained a book was kept at each nurse station for staff guiding them on how to create a work order in TELS (maintenance tracking computer software) or if an emergency staff verbally told him. 12. Observations made on 08/13/23 at 11:10 AM and 08/14/23 at 8:37 AM of room [ROOM NUMBER]A revealed approximately half of the privacy curtain was unhooked and on the floor. There were multiple areas on the curtain with light brown stains mostly on the middle and lower portion of the curtain. An environment observation and interview were conducted on 08/17/23 at 11:12 AM with the HK Supervisor. The HK Supervisor observed the stains on the privacy curtain and stated the curtain should be replaced when dirty. The HK Supervisor revealed she had started changing privacy curtains about 2 months ago but got sidetracked and was not able to do room rounds and ensure the Housekeepers were doing their job due to not enough staff. 9. a. An observation of the room entrance door of room [ROOM NUMBER] on 08/14/23 at 8:05 AM revealed the wood door had several areas of rough, unfinished layers of wood along the edges of the door, approximately wheelchair height, from the doorknob and below. A subsequent observation of the room entrance door on 08/17/23 at 9:40 AM revealed the condition of the door remained the same. b. An observation of the room entrance door of room [ROOM NUMBER] on 08/14/23 at 8:06 AM revealed the wood door had several areas of rough, unfinished layers of wood along the edges of the door, approximately wheelchair height, from the doorknob and below. A subsequent observation of the room entrance door on 08/17/23 at 9:41 AM revealed the condition of the door remained the same. c. An observation of the entrance doors to the main dining room on 08/14/23 at 8:10 AM revealed the wood door had several areas of rough, splintered and unfinished layers of wood along the edges of the door from the middle edge of the door and below. A subsequent observation of the entrance doors to the main dining room on 08/17/23 at 9:50 AM revealed the condition of the doors remained the same. d. An observation of the entrance doors to the television room on 08/14/23 at 8:13 AM revealed the wood door had several areas of rough, unfinished layers of wood along the edges of the door from the middle edge of the door and below. A subsequent observation of the entrance doors to the television room on 08/17/23 at 9:54 AM revealed the condition of the doors remained the same. During an observation and interview with the Maintenance Director on 08/17/23 at 11:12 AM, he stated a safety inspection performed in 2022 revealed all the doors in the facility needed to be replaced and a quote to replace the doors had been obtained in 2022 but the doors had not arrived. The Maintenance Director stated the only thing he could do for the rough edges of the doors was to sand them down until they could be replaced. The Maintenance Director was unable to provide a schedule for sanding the doors down. 10. An observation was made of the privacy curtain in room [ROOM NUMBER] on 08/13/23 at 1:00 PM. Along the inside bottom portion of the curtain, were vertical and horizontal reddish-brown stains of various sizes, widths and lengths. There were also several round reddish-brown stains, approximately the size of a dime, scattered throughout the middle portion of the curtain. Subsequent observations on 08/14/23 at 4:48 PM and 08/17/23 at 9:38 AM revealed the condition of the privacy curtain remained the same. During an observation and interview on 08/17/23 at 11:12 AM, the Housekeeping Supervisor observed the stains on the privacy curtain and stated privacy curtains should be replaced when dirty. The Housekeeping Supervisor explained she had started changing privacy curtains about 2 months ago but got sidetracked and was not able to do room rounds to follow up to ensure housekeepers were doing their job due to not having enough staff.

Based on observations, record review and interviews with residents and staff, the facility failed to provide sufficient nursing staff to ensure residents choices were honored for bathing preferences and eating meals in the main dining room, residents received assistance with incontinence care and personal and oral hygiene as needed, and cognitively impaired residents received constant supervision on a locked memory care unit for 7 of 8 sampled residents (Residents #181, #52, #29, #47, #35, #59, #66, and #68). This tag is cross-referenced to: F 561: Based on observations, record review, interviews with residents and staff, the facility failed to honor the residents' choice to eat their meals in the main dining room (Resident #181 and Resident #52) and provide their preferred number of showers each week (Resident #181) for 2 of 2 residents reviewed for choices. F 677: Based on observations and resident and staff interviews the facility failed to provide incontinence care (Resident #52 and Resident #29), a shave (Resident #47), and oral care (Resident #181) for 4 of 6 dependent residents reviewed for activities of daily living (ADL). F 689: Based on observations, record review and staff interviews, the facility failed to prevent four cognitively impaired residents from exiting the locked Memory Support Unit (MSU) unsupervised for 4 of 10 residents reviewed for accidents (Residents #35, #59, #66, and #68). Review of the facility's census dated 08/13/23 revealed there were a total 70 residents currently in the facility with 51 residents residing on the 400, 500 and 600 halls and 19 residents residing on the Memory Support Unit. During an interview on 08/13/23 at 2:47 PM, Nurse Aide (NA) #3 revealed she worked during the hours of 3:00 PM to 11:00 PM five days a week and most times, was asked to come in early due to there only being 2 NAs scheduled to cover the 400, 500 and 600 Halls. NA #3 stated when there were only 2 NAs, they each had to cover a hall and a half which made it difficult to get care provided. During an interview on 08/15/23 at 9:45 AM, NA #1 indicated the facility was often short-staffed. NA #1 stated when there were only 2 NAs scheduled to cover 400, 500 and 600 halls it was difficult to get care provided. In addition, there were times she has had approximately 31 residents on her assignment. NA #1 explained when there were only 2 NAs scheduled, they barely had enough time to wash the resident's face, assist residents with meals and provide incontinence care. She also indicated when there were only 2 NAs, they weren't able to provide residents with their scheduled shower, offer oral care, or assist residents with getting out of bed if they required a two-person assist with transfers. NA #1 revealed when working short-staffed, residents were not taken to the main dining room for meals and ate in their rooms instead. During an interview on 08/16/23 at 2:59 PM, NA #6 revealed she was not always able to get showers or other care needs provided when there was consistently only one NA and Nurse assigned to the MSU. NA #6 explained the residents on MSU needed a lot of constant supervision which was difficult if there was only one NA and Nurse for the 19 to 20 residents residing on MSU. She added on the rare occasion another NA was scheduled, they were pulled to another assist on another unit. During an interview on 08/16/23 at 3:45 PM, the Scheduler revealed staffing was based on the resident census. She explained for each 12-hour shift, there were usually 2 Nurses scheduled to cover the 400, 500 and 600 Halls and one nurse assigned to cover MSU. The Scheduler stated for NAs, she tried to schedule 2 NAs on MSU during the 7:00 am to 7:00 pm shift but most times there was only one and for the 400, 500, and 600 halls she tried to have 4 NAs but most times she only had 2 or 3 NAs scheduled. She stated they do not use staffing agencies to supplement the schedule and she had reached out to sister facilities for help but it had not worked out due to their own staffing challenges. The Scheduler stated when there were call-outs or shifts that weren't covered, she asked for volunteers to pick up extra shifts and reached out to their PRN (as needed) staff and/or asked staff to swap days. If they still couldn't get the shift scheduled, then administrative staff would fill in and the Director of Nursing, Infection Preventionist and Clinical Competency Coordinator worked a medication cart quite often. The Scheduler stated Administration has tried to fill the open positions by running ads on social media for current job openings, offered sign on bonuses, posted signage outside the building, and hosted an open house and job fair in order to recruit applicants. She revealed there were currently 7 open nurse positions, 5 for the 7:00 AM to 7:00 PM shift and 2 for the 7:00 PM to 7:00 AM shift and 13 open NA positions, 8 for the 7:00 AM to 7:00 PM shift and 5 for the 7:00 PM to 7:00 AM shift, which only added to the staffing challenges they currently faced. During interviews on 08/16/23 at 8:55 AM and 08/17/23 at 4:19 PM, the Director of Nursing revealed in the evenings and/or weekends, meals were not served in the main dining room and residents ate in their room due to staffing challenges. The DON explained the facility did not use agency staff to help supplement the schedule but they had administrative staff that could be pulled to cover shifts and help with resident care such as the Activities Director who was a NA, the Clinical Competency Coordinator who was a nurse, the Infection Preventionist, the Assistant Director of Nursing, and/or herself. The Administrator was out of the country and unable to be interviewed.

Based on observations, record review, and staff, Physician and Pharmacy interviews, the facility failed to remove expired medications and secure medications stored at the bedside for 7 of 9 storage rooms, medication carts, and residents (West Wing and Memory Support Unit medication rooms and 400 Hall and Memory Support Unit medication carts, and for Resident #29, Resident #52, and Resident #71) reviewed for medication storage. The findings include: 1. An observation of the locked west wing medication room on 08/17/23 at 2:08 PM with the Director of Nursing (DON) revealed in the cabinet was 1 unopened bottle of aspirin regular strength enteric coated tablets, 325 milligrams (MG) each, that had an expiration date of 6/2023. Also, on the shelf were 2 one-ounce tubes of triple antibiotic ointment that both had an expiration date of 06/2023. An interview with the DON on 08/17/23 at 2:08 PM revealed that her expectation was that expired medications be removed prior to its expiration date. She further revealed that night shift nursing was responsible for checking expiration dates and restocking the over-the-counter medications. She stated expired medications are placed in a box and sent back to pharmacy with a list of the medications being returned. 2. An observation of the locked Memory Support Unit (MSU) medication room on 08/17/23 at 2:36 PM with the DON revealed 20 containers of sterile water 110 milliliters (ML) that had an expiration date of 4/6/23. An interview with the DON on 08/17/23 at 2:36 PM indicated that her expectation was that expired medication be removed prior to its expiration date. She further revealed the saline containers belonged to a resident that no longer resided at the facility for their Continuous Positive Airway Pressure (CPAP) machine. She stated they should have discarded the saline. 3. a. An observation of the locked MSU medication cart on 08/17/23 at 2:40 PM with the DON and Nurse #1 revealed 24 white round pills, identified as lorazepam 0.5 MG tablets, that had an expiration date of 4/24/23 for Resident #68. An interview on 8/17/23 at 2:41 PM with Nurse #1 revealed this was a medication Resident #68 was admitted with and did not take it any longer. b. A continued observation of the locked MSU medication cart on 08/17/23 at 2:42 PM revealed an opened 30-fluid ounce bottle of active liquid protein concentrate nutrition supplement that had an expiration date of 7/19/23. An interview with the DON on 8/17/23 at 2:42 PM indicated that her expectation is that expired medication be removed prior to its expiration date. She further revealed the night shift nurse was responsible for checking expiration dates in the medication carts. 4. An observation of the locked 400 hall medication cart on 08/17/23 3:04 PM with the DON revealed 14 blue oval pills, identified as meclizine tab 12.5 MG tablet in individual pill packs, with an expiration date of 5/2023 for Resident #36. An interview with the DON on 8/17/23 at 3:05 PM indicated that her expectation is that expired medication be removed prior to its expiration date. She further revealed the night shift nurse is responsible for checking expiration dates in the medication carts. 5. An observation of Resident #71's room on 08/15/23 at 8:47 AM revealed a 4-ounce tube of barrier cream containing menthol 44%, white petrolatum (petroleum jelly) 53%, and zinc oxide (a skin protectant) 20.6% was sitting on his overbed table. Additional observations of Resident #71's room on 08/15/23 at 2:44 PM, 08/16/23 at 8:16 AM, and 08/17/23 at 9:54 AM revealed a 4-ounce tube of barrier cream containing menthol 44%, white petrolatum 53%, and zinc oxide 20.6% was sitting on his overbed table. An observation of Resident #52's room on 08/13/23 at 11:06 AM revealed a 4-ounce tube of barrier cream containing menthol 44%, white petrolatum 53%, and zinc oxide 20.6% was sitting on his overbed table. An additional observation of Resident #52's room on 08/15/23 at 3:30 PM revealed a 4-ounce tube of barrier cream containing menthol 44%, white petrolatum 53%, and zinc oxide 20.6% was sitting on his overbed table. An observation of Resident #29's room on 08/15/23 at 8:29 AM revealed a 4-ounce tube of barrier cream containing white petrolatum 57% and zinc oxide 17% was sitting on top of her dresser. An additional observation of Resident #29's room on 08/16/23 at 8:10 AM revealed a 4-ounce tube of barrier cream containing white petrolatum 57% and zinc oxide 17% was sitting on top of her dresser. An interview with the Director of Nursing (DON) on 08/17/23 at 11:12 AM revealed there were several different types of barrier cream available at the facility but she did not consider creams containing zinc to be medicated creams. She stated she would need to educate herself more on the ingredients of the different creams available. The DON stated she felt that barrier cream should not be stored on the overbed table, but she felt it was ok for the cream to be stored inside the resident's dresser.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to protect the private health information for 1 of 1 sampled resident (Resident #11) by leaving confidential medical information unattended in an area visible and accessible to the public in [NAME] Wing nurse station. The findings included: Resident #11 admitted to the facility on [DATE]. A continuous observation was made on 01/05/22 from 3:34 PM through 3:41 PM of an unattended computer in [NAME] Wing nurse station. Nurse #6 left the computer with the physician order for Resident #11 visible on the computer screen when she was away with no other staffs in the nurse station. The surveyor could see the physician order of Resident #11 from the perimeter of the nurse station without any problems. The unattended computer was accessible by anyone who was not authorized to view this confidential information in the nurse station. During an interview with Nurse #6 on 01/05/22 at 3:36 PM, she explained while she was reviewing the physician order for Resident #11, the Assistant Director of Nursing (ADON) wanted to see her in the ADON's office. She was distracted and had forgotten to turn on the privacy protection screen before leaving the nurse station. She stated it was an oversight and acknowledged that it was inappropriate to leave the computer unattended. She indicated that she had received the Health Insurance Portability and Accountability Act (HIPAA) training during orientation and yearly from the facility. In an interview conducted on 01/05/22 at 4:38 PM, the Director of Nursing (DON) expected the nurse to turn on the privacy protection screen before leaving the computer unattended to protect Resident's confidential personal and medical information. It was her expectation for all the staff to follow the HIPAA guidelines when working in the facility. During an interview with the Administrator on 01/05/22 at 4:45 PM, she stated all the staff had received training on HIPAA and added nursing staff had to secure the computer before leaving it unattended. It was her expectation for the staff to follow the HIPAA guidelines all the times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and Responsible Party (RP), Family Member, and staff interviews, the facility failed to allow a resident to remain in the facilty and provide written documentation which stated the reason the facility could not meet the resident's needs for 1 of 2 residents reviewed for transfer and discharge (Resident #108). The findings included: Resident #108 was admitted to the facility on [DATE] with multiple diagnoses that included Parkinson's disease and dementia with behavioral disturbance. A discharge care plan initiated on 07/20/21 revealed Resident #108's discharge planning would begin upon admission. An identified approach included long-term care/skilled nursing facility versus assisted living facility and involve the resident, representative and interdisciplinary team in the discharge planning process. A staff progress note dated 09/10/21 completed by the Social Worker (SW) noted in part, a meeting was held with Resident #108 to discuss the events of last night. Resident #108 was observed in a female resident's room, touching her thigh area. When questioned, Resident #108 stated he did not remember doing that. Resident #108 stated he was a people person and tended to be touchy feely. Resident #108 was made aware that he is making other female residents feel nervous and uncomfortable. Resident #108 stated he meant no harm and was reminded that the perception of these female residents may differ. Resident #108 agreed that he would remain in the halls or public areas, not go into other resident's rooms, and would keep his hands to himself. SW spoke with Resident #108's RP. Staff continuing to monitor Resident #108's whereabouts. A behavioral care plan initiated on 09/10/21 revealed Resident #108 displayed inappropriate touching, especially toward females. The approaches identified were for staff to encourage him to participate in activities to keep him busy and redirect him when he attempted to touch others. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #108 with severe cognitive impairment and displaying no behaviors during the MDS assessment period. The MDS noted Resident #108's RP did not wish to talk to anyone about the possibility of Resident #108 leaving the facility and returning to the community to live and receive services. A staff progress note dated 10/25/21 completed by the SW noted in part, Resident #108 was observed by staff in a female resident's room, lying in bed with the female resident, and he was immediately removed from the room. Resident #108's RP was notified of the incident on 10/25/21, as well as previous instances of him going into female residents' rooms, and came into facility to speak with the Administrator and SW. The Administrator and SW explained to the RP that Resident #108 was not compliant with staying out of female resident's room and his behavior had now escalated to this morning's incident. The RP was informed that Resident #108 would not be able to remain at facility due to the potential threat to others. The RP has chosen to take Resident #108 home. A physician's progress note dated 10/25/21 revealed Resident #108 was evaluated due to agitated behavior and worsening Parkinson's disease and read in part, Resident #108 was admitted to the facility for rehabilitation services after hospitalization for multiple falls, weakness and need for increased assistance with care. While at the facility, Resident #108's medication was increased due to anxiety and visual hallucinations associated with Parkinson's disease. His hallucinations overall have improved; however, his mental status continues to decline. He has wandered into other resident rooms with witnessed behavior of inappropriate touching of other female residents, a meeting was held with his RP and he will be discharged from the facility. Medications for a 30-day supply along with home health services will be sent with the patient. There was no notation describing the specific needs that could not be managed or met at the facility and the facility efforts to meet those needs. The discharge MDS dated [DATE] for Resident #108 was coded as return not anticipated. During a telephone interview on 01/04/22 at 10:35 AM, Resident #108's Family Member recalled when Resident #108's RP told him about the incident that occurred on 10/25/21, the RP stated she was informed by facility staff that Resident #108 could not remain in the facility and she had to take him home that same day. During a telephone interview on 01/05/22 at 9:55 AM, Resident #108's RP confirmed she was notified of the incident involving Resident #108 and another resident on 10/25/21 and came to the facility. The RP stated once at the facility, she spoke with the Administrator and SW and during the conversation, was informed Resident #108 had to be out of the facility within 24 hours. The RP added this came as a shock to her because she had planned for Resident #108 to remain at the facility for long-term care. The RP did not recall anyone offering to assist with finding alternate placement for Resident #108. The RP added during the conversation, she was made to believe there were no other options and she felt she had no choice but to take him home on [DATE]. The RP reported Resident #108 was recently placed in another skilled nursing facility approximately one hour from her home and she was no longer able to visit with him daily. A telephone attempt on 01/06/22 at 9:35 AM to speak with the facility's former physician who evaluated Resident #108 on 10/25/21 was unsuccessful. During an interview on 01/06/22 at 4:41 PM, the Administrator explained on 10/25/21 she and the SW spoke with Resident #108's RP at the facility to discuss the incident involving him and another resident. The Administrator stated prior to the incident on 10/25/21, there were complaints from other female residents that Resident #108 was too friendly, such as sitting too close and talking too much, but nothing about him touching them inappropriately, just that they didn't like it when he got into their personal space. The Administrator recalled Resident #108's RP stated Resident #108 told her he did not do what was accused and the RP felt he wouldn't lie to her. The Administrator explained to the RP they had to protect the safety of other residents and could not have Resident #108 displaying that type of behavior. She added they discussed with the RP finding alternate placement at other skilled nursing facilities or assisted living facilities; however, Resident #108's RP wanted to visit facilities before referrals were made. The Administrator stated she explained to the RP that until alternate placement could be found for Resident #108, he would remain under one-to-one staff supervision. On 10/25/21 mid-morning, the Administrator stated she was informed by the SW that Resident #108's RP had returned to the facility with luggage to take Resident #108 home. The Administrator recalled when she spoke with Resident #108's RP again, the RP stated she did not want Resident #108 going to another facility and wanted to take him home. The Administrator stated they then discussed the home health services Resident #108 would need, all services were arranged, remaining medications were given to the RP, prescriptions were called in to the preferred pharmacy, and he was discharged home with the RP on 10/25/21. The Administrator stated that although they discussed sending referrals for placement to other facilities, neither she nor the SW told Resident #108's RP she had 24 hours to remove him from the facility and was not sure how the RP misconstrued the conversation thinking she had no choice but to take Resident #108 home. During a joint interview on 01/07/22 at 1:34 PM, the SW and Administrator confirmed they both met with Resident #108's RP on 10/25/21 to discuss his behaviors. Both the SW and Administrator confirmed they did not mention an official discharge or imply to the RP Resident #108 had to be removed from the facility within 24 hours. Both the SW and Administrator stated the RP's recollection of their discussion was not how it was presented and explained during the conversation, they only mentioned the possibility of finding alternate placement in the event Resident #108's behaviors did not improve and at the time, there were no plans for his discharge. The Administrator confirmed there was no written physician statement in Resident #108's's medical record summarizing the specific needs that could not be met, facility efforts to meet those needs or the specific services another facility could provide that would meet his needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the Responsible Party (RP) and staff, the facility failed to provide a resident's RP written notification explaining the reason why the resident was being discharged 30 days before discharge that included a statement of the resident's appeal rights for 1 of 2 residents reviewed for transfer and discharge (Resident #108). The findings included: Resident #108 was admitted to the facility on [DATE]. A staff progress note dated 10/25/21 completed by the SW noted in part, Resident #108 was observed by staff in a female resident's room, lying in bed with the female resident, and he was immediately removed from the room. Resident #108's RP was notified of the incident on 10/25/21, as well as previous instances of him going into female residents' rooms, and came into facility to speak with the Administrator and SW. The Administrator and SW explained to the RP that Resident #108 was not compliant with staying out of female resident's room and his behavior had now escalated to this morning's incident. The RP was informed that Resident #108 would not be able to remain at facility due to the potential threat to others. The RP has chosen to take Resident #108 home. During a telephone interview on 01/05/22 at 9:55 AM, Resident #108's RP confirmed she spoke with the Administrator and SW on 10/25/21 to discuss Resident #108's behaviors. During the same conversation, the RP stated she was informed Resident #108 had to be out of the facility within 24 hours. The RP added this came as a shock to her because she had planned for Resident #108 to remain at the facility for long-term care. The RP did not recall anyone offering to assist with finding alternate placement for Resident #108. The RP added during the conversation, she was made to believe there were no other options and she felt she had no choice but to take him home on [DATE]. The RP reported Resident #108 was recently placed in another skilled nursing facility approximately one hour from her home and she was no longer able to visit with him daily. During a joint interview on 01/07/22 at 1:34 PM, the SW and Administrator confirmed they both met with Resident #108's RP on 10/25/21 to discuss his behaviors. Both the SW and Administrator confirmed they did not mention an official discharge or imply to the RP Resident #108 had to be removed from the facility within 24 hours. Both the SW and Administrator stated the RP's recollection of their discussion was not how it was presented and explained during the conversation, they only mentioned the possibility of finding alternate placement in the event Resident #108's behaviors did not improve and at the time, there were no plans for his immediate discharge. The Administrator confirmed there was no written documentation provided to Resident #108's RP explaining the reason he was discharged since it was the RP's choice to take him home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Physician Assistant (PA) and the Medical Director (MD), the facility failed to discontinue a probiotic as ordered resulting in 23 additional administrations of the supplement for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #14). The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses included urinary tract infection (UTI). The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #14 with severe impairment in cognition. A physician's order dated 01/25/21 indicated Resident #14 was ordered to receive 1 capsule of probiotic 1.5 milligram (mg) by mouth once a day. Review of Consultant Pharmacist's recommendation dated 08/16/21 revealed the Consultant Pharmacist had recommended to discontinue the probiotic as Resident #14 was no longer on antibiotic therapy. The Physician Assistant (PA) agreed and had signed and dated the recommendation on 08/31/21. Review of the Medication Administration Records (MARs) revealed Resident #14 had received 1 capsule of probiotic 1.5 mg once daily from 09/01/21 through 09/23/21. Further review of the MARs indicated Resident #14 was not receiving any antibiotic throughout September 2021. During an interview conducted on 01/06/22 at 2:43 PM, Nurse #7 confirmed Resident #14 had received 23 capsules of probiotic in September 2021. An interview was conducted with the Assistant Director of Nursing (ADON) on 01/06/22 at 3:12 PM. She stated every month after the Consultant Pharmacist had reviewed all the medication regimens for the residents, the Consultant Pharmacist would forward all the recommendations to her. Then, she would sort all the recommendations and forward it to the 3 physicians working under the Medical Director (MD) to address the recommendations. Resident #14's Consultant Pharmacist's recommendation were handled by the PA who was also responsible to implement all the accepted recommendations in the computer system. The PA failed to discontinue the probiotic order and did not notify her to discontinue it for him. When the PA returned the recommendations to her on 09/23/21, she noticed that the probiotic order was still active, and she discontinued the order immediately. During an interview conducted on 01/06/22 at 3:25 PM, the Director of Nursing (DON) stated it was her expectation for all the Consultant Pharmacist's recommendations accepted by the physician to be in place in a timely manner. During a phone interview conducted on 01/06/22 at 5:15 PM, the MD stated it was very unlikely that 23 additional doses of probiotic would cause any physical harm to Resident #14. It was his expectation for all the Consultant Pharmacist's recommendations approved by the physician to be implemented in a timely manner. An interview was conducted with the Administrator on 01/06/22 at 5:34 PM. She stated it was her expectation for all the Consultant Pharmacist's recommendations agreed by the physician to be executed in a timely manner. During a phone interview conducted on 01/07/22 at 12:07 PM, the PA recalled after he had reviewed the Consultant Pharmacist's recommendation and decided to discontinue the probiotic, he had forgotten to discontinue the order in the computer system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to provide adaptive equipment for meals for 4 of 5 residents reviewed for adaptive equipment (Resident #9, Resident #14, Resident #30, and Resident #39). Findings included: 1. Resident #9 was admitted to the facility 03/27/20 with diagnoses including non-Alzheimer's dementia and cerebrovascular accident (abbreviated as CVA and meaning a stroke). A regular mechanical soft diet with built-up utensils (utensils with large handles that decrease the amount of hand strength needed to grip silverware), a divided plate (a plate with partitions that help push food onto the utensil), and a cup with a lid and a straw was ordered 04/17/21. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was severely cognitively impaired, required supervision assistance with eating, and received a mechanically altered diet. The nutrition care plan last revised 01/06/22 revealed Resident #9 had difficulty feeding herself and required a cup with a lid and a straw, built-up utensils, and a divided plate to support self-feeding with meals. An observation of Resident #9's tray card on 01/03/22 at 12:26 PM revealed she was to receive a cup with a lid and a straw. An observation of Resident #9's meal tray revealed there was no cup with a lid and a straw. An interview with Nurse Aide (NA)#7 on 01/03/22 at 12:41 PM revealed she did not check the tray card for Resident #9 when she set up the meal tray and did not notice Resident #9 did not receive a cup with a lid and a straw. An interview with the Dietary Manager on 01/03/22 at 1:02 PM revealed a dietary aide checked the meal trays for accuracy, including the presence of adaptive equipment, before the trays left the kitchen and she did not know why Resident #9 did not receive a cup with a lid and a straw on her meal tray. A joint interview with Dietary Aide #1 and the Dietary Manager on 01/03/22 at 1:08 PM revealed Dietary Aide #1 was responsible for ensuring accuracy of meal trays before they left the kitchen for the lunch meal on 01/03/22. The Dietary Manager and Dietary Aide #1 stated Resident #9 not receiving a cup with a lid and straw on her meal tray was an oversight. An observation of Resident #9's meal tray on 01/05/22 at 12:45 PM revealed her food was served on a regular plate instead of a divided plate. A follow-up interview with the Dietary Manager on 01/05/22 at 12:53 PM revealed approximately 2 weeks ago the Occupational Therapist saw a number of residents and recommended their food be served on divided plates. She stated since that time there had not been enough divided plates to serve every resident's food on a divided plate that had an order for a divided plate. The Dietary Manager provided an invoice on 01/05/22 at 12:53 PM for 15 divided plates that were ordered on 12/31/21. An interview with the Occupational Therapist (OT) on 01/06/22 at 9:08 AM revealed the recommendation for Resident #9 to receive a cup with a lid and a straw was to decrease the chances of her spilling her beverages. She stated the divided plate helped Resident #9 scoop her food onto her utensils and allowed more independence with feeding herself. The OT stated if adaptive equipment was not available she would like to be notified so she could suggest an alternative. An interview with the Director of Nursing (DON) on 01/07/22 at 12:07 PM revealed she expected nursing staff to check the tray card to make sure all adaptive equipment was in place when setting up the meal tray and if it was not to notify the nurse, herself, or the kitchen to obtain the correct equipment. An interview with the Administrator on 01/07/22 at 12:36 PM revealed she expected staff in the kitchen to ensure trays left the kitchen with the correct adaptive equipment in place. She also stated she expected the staff serving the tray to make sure all adaptive equipment was present on the tray and if it was not to go to the kitchen or the Rehab Department to get the correct equipment. 2. Resident #14 was admitted to the facility 05/09/11 with diagnoses including Alzheimer's disease and non-Alzheimer's dementia. Review of Resident #14's medical record revealed an order for a divided plate dated 05/21/19. Review of the quarterly MDS dated [DATE] revealed Resident #14 was severely cognitively impaired, required supervision assistance with eating, and received a mechanically altered therapeutic diet. The nutrition care plan last revised 12/22/21 revealed Resident #14 experienced weight loss related to dementia and should be encouraged with oral intake of food and fluids. An observation of Resident #14's tray card on 01/03/22 at 12:32 PM revealed Resident #14 was to receive her food in a divided plate. An observation of Resident #14's meal tray at the same date and time revealed her food was served on a regular plate instead of a divided plate. An interview with NA #7 on 01/03/22 at 12:41 PM revealed she did not check the tray card when she set up Resident #14's meal tray and did not notice Resident #14 did not receive her food on a divided plate. An interview with the Dietary Manager on 01/03/22 at 1:02 PM revealed a dietary aide checked the meal trays for accuracy, including the presence of adaptive equipment, before the trays left the kitchen and Resident #14 did not receive her food on a divided plate because the kitchen ran out of divided plates. She stated trays were delivered to the Memory Service Unit (MSU) first and most of those residents received their food on a divided plate so sometimes the kitchen ran out of divided plates. An interview with the Occupational Therapist (OT) on 01/06/22 at 9:12 AM revealed Resident #14 needed a divided plate to help her scoop her food onto her utensils to allow more independence with feeding herself. The OT stated if adaptive equipment was not available she would like to be notified so she could suggest an alternative. An interview with the Director of Nursing (DON) on 01/07/22 at 12:07 PM revealed she expected nursing staff to check the tray card to make sure all adaptive equipment was in place when setting up the meal tray and if it was not to notify the nurse, herself, or the kitchen to obtain the correct equipment. An interview with the Administrator on 01/07/22 at 12:36 PM revealed she expected staff in the kitchen to ensure trays left the kitchen with the correct adaptive equipment in place. She also stated she expected the staff serving the tray to make sure all adaptive equipment was present on the tray and if it was not to go to the kitchen or the Rehab Department to get the correct equipment. 3. Resident #30 was admitted to the facility 09/09/20 with diagnoses including CVA and paraplegia (paralysis of one side of the body). Review of the quarterly MDS dated [DATE] revealed Resident #30 was cognitively intact and required supervision assistance with eating. The nutrition care plan last revised 11/30/21 revealed Resident #30 was at nutrition risk related to facility admission and was to have Speech Therapy evaluation and treatment as ordered. Review of the medical record revealed an order for red foam handles for utensils on 03/22/21. An observation of the tray card for Resident #30 revealed he was to receive red foam handles for his utensils. An observation of Resident #30's meal tray at the same date and time revealed no red foam handles were on his tray. An interview with the Dietary Manager on 01/03/22 at 1:02 PM revealed red foam handles were kept in resident rooms. The Dietary Manager looked in Resident #30's room on 01/03/22 at 1:04 PM and was unable to locate red foam handles in his room. An interview with NA #6 on 01/03/22 at 1:05 PM revealed she did not look at the tray card when she delivered Resident #30's meal tray and did not notice he did not have red foam handles on his utensils. An interview with the Occupational Therapist (OT) on 01/06/22 at 9:12 AM revealed Resident #30 usually kept his red foam handles for utensils in his room. She stated the red foam handles aided Resident #30 with gripping objects, including his utensils. The OT stated she had plenty of red foam available in the therapy department and no one had notified her there were no red foam handles in Resident #30's room. An interview with the Director of Nursing (DON) on 01/07/22 at 12:07 PM revealed she expected nursing staff to check the tray card to make sure all adaptive equipment was in place when setting up the meal tray and if it was not to notify the nurse, herself, or the kitchen to obtain the correct equipment. An interview with the Administrator on 01/07/22 at 12:36 PM revealed she expected staff in the kitchen to ensure trays left the kitchen with the correct adaptive equipment in place. She also stated she expected the staff serving the tray to make sure all adaptive equipment was present on the tray and if it was not to go to the kitchen or the Rehab Department to get the correct equipment. 4. Resident #39 was admitted to the facility on [DATE] and current diagnoses included Alzheimer's Disease, dementia, and dysphagia (difficulty with swallowing). Review of the annual Minimum Data Set (MDS) dated [DATE] assessed Resident #39's cognition as being severely impaired with limited assistance needed for eating and no identified swallowing disorders. Resident #39's care plan last revised on 12/21/21 identified a problem with nutrition and potential for altered nutritional status related to the diagnosis of dysphagia with a mechanically altered and therapeutic diet in place and included interventions to observe for signs and symptoms of aspiration and notify the Medical Doctor as needed and serve the diet as ordered. During the dining observation made on 1/3/22 at 12:24 PM Resident #39 was feeding himself using a regular spoon and drinking juice from a regular plastic cup without difficulty. Review of the physician orders on 1/3/22 at 4:43PM revealed adaptive equipment included a maroon spoon (spoon with narrow, shallow bowls) and nosey cup (adaptive cup with a U-shaped cut out on one side). A second dining observation made on 1/5/22 at 12:31 PM revealed Resident #39 was served a maroon spoon but no nosey cup. Resident #39 was able to feed himself using the maroon spoon and drink from the regular plastic cup without difficulty. An interview was conducted with Nurse #3 on 1/5/22 at 12:37 PM. Nurse #3 revealed when a food tray was delivered missing adaptive equipment he would go to kitchen and ask if available if really needed and stated Resident #39 wasn't cognitively capable of using the nosey cup and tried to drink from the back of the cup. Nurse #3 revealed Resident #39 could drink from a regular plastic cup and didn't think it was necessary to go the kitchen and inquire about the nosey cup. An interview was conducted on 1/6/22 at 9:07 AM with the Occupational Therapist (OT). The OT revealed Resident #39 attempts to use the nosey cup the wrong way and could be discontinued but the maroon spoon was in place to slow down eating. The OT stated Resident #39 was known to shovel food at a fast pace placing him at risk for aspiration and should always have the maroon spoon when eating. An interview was conducted with Director of Nursing on 1/7/22 at 12:07 PM. The DON revealed when staff serve resident meals, they should check the tray cards to make sure there were no problems and if they discover problems should ask the kitchen to try to resolve.

Based on observations and staff interviews the facility failed to discard potentially hazardous food with signs of spoilage and discard expired food items available for resident use in 1 of 1 walk-in coolers, label and date food in 1 of 2 nourishment room freezers (in the nourishment room for 400, 500, 600 halls), remove expired food from 1 of 1 dry storage areas, and remove expired food from 1 of 2 storage bins. Findings included: 1. An initial observation of the walk-in cooler on 01/03/22 at 10:14 AM revealed a tray of white grapes with signs of spoilage, a bag of parsley with signs of spoilage, a pack of salami with an expiration date of 01/01/22, and 2 bags of collard greens with a use-by date of 12/11/21. 2. An observation of the dry storage room on 01/03/22 at 10:35 AM revealed 5 packs of hamburger buns with a use by date of 12/31/21. 3. An observation of a flour bin that was approximately ¼ full revealed an expiration date of 12/24/21. 4. An observation of the nourishment room freezer for 400, 500, and 600 halls revealed 2 unlabeled frozen meals, an unlabeled frozen taco, and an unlabeled frozen sandwich. An interview with the Dietary Manager on 01/06/22 at 2:51 PM revealed all food should be used by or discarded by the expiration date. She stated she checked the cooler and dry storage for expired food weekly and she had not had time to check the cooler and dry storage the morning of 01/03/22. The Dietary Manager stated the nourishment room freezers were checked daily for unlabeled food and unlabeled food was removed but staff continued to place unlabeled items in the freezer. An interview with the Administrator on 01/07/22 at 12:36 PM revealed she expected all food to be labeled and used or discarded by the expiration date.

4. A continuous observation of Nurse Aide (NA) #3 providing Resident #22 with incontinence care was made on 01/05/22 from 6:19 AM through 6:26 AM. With her gloved hands NA #3 was observed cleaning stool, removing the soiled brief, and applying the clean brief. NA #3 assisted Nurse #5 pull Resident #22 up in bed, placed a pillow under Resident #22's left side, placed a pillow under Resident #22's head, raised the head of Resident #22's bed, pulled the sheet over Resident #22, and pulled the blanket over Resident #22. NA #3 placed the soiled brief in the trash can, pulled back the privacy curtain, and removed her gloves. NA #3 did not remove her gloves and perform hand hygiene after providing incontinence care and continued to touch other items in Resident #22's room while wearing soiled gloves. During an interview with NA #3 on 01/05/22 at 6:28 AM she confirmed she wore the same gloves after providing incontinence care that she used to touch other items in Resident #22's room. She stated she did not normally remove her gloves and perform hand hygiene after providing incontinence care because she didn't know she was supposed to. An interview with the Director of Nursing (DON) on 01/07/22 at 12:07 PM revealed she expected staff to remove soiled gloves and perform hand hygiene after providing incontinence care and before touching other items in the resident's room. Based on observations, record review, and interviews with staff and the Infection Preventionist the facility failed to implement infection prevention for hand hygiene by not sanitizing hands and/or removing gloves when providing incontinence care to residents for 4 of 5 facility staff (Nurse #1, NA #1, NA#2, and NA #3) observed for infection control. The findings included: A review of the facility's policy and procedure titled, Infection Prevention - Hand Hygiene revised on 3/8/19 stated indications requiring hand washing with soap and water or the use of an alcohol-based antiseptic hand rub included before and after contact with the resident, after contact with body fluids or excretions, and when hands move from a contaminated body site to a clean body site during resident care. 1. A continuous observation of Nurse #1 assisting Resident #33 with dressing, transfers, and incontinence care was made on 1/3/22 from 2:49 PM to 3:00 PM. Without performing hand hygiene Nurse #1 donned gloves then removed a pair of wet pants from Resident #33 and begun to wipe the resident's perineal and buttocks area with disposable wipes to assist with an episode of urinary incontinence. When completed with peri-care and while wearing the same gloves Nurse #1 removed Resident #33's wet shirt and place a clean shirt then physically assisted the resident by the arm to sit in a wheelchair Nuse #1 had pulled close while wearing the same gloves then dressed the resident in a pair of clean pants. While wearing the same gloves Nurse #1 wiped both of Resident #33's hands using disposable wipes. When Nurse #1 completed resident care, she removed her gloves and used an alcohol-based hand rub before exiting the room. During an interview on 1/3/22 at 3:29 PM when asked about hand hygiene Nurse #1 revealed she wore the same gloves to assist Resident #33 with urinary incontinence care, dressing, transfer, and personal hygiene. Nurse #1 revealed she knew incontinence care was a dirty process and when completed gloves should be removed and hand hygiene done. Nurse #1 stated she should've removed her gloves and washed her hands before putting gloves on and after urinary incontinence care before she continued to assist Resident #33. An interview was conducted with the Infection Preventionist (IP) on 1/5/22 at 10:19 AM. The IP revealed she had performed a hand hygiene audit back in November and observed concerns related to staff performing hand hygiene during resident care. The IP revealed she provided staff with education related to preventives of urinary tract infections including hand hygiene. During an interview on 1/7/22 at 12:07 PM the DON expected after incontinence care nursing staff should remove soiled gloves and perform hand hygiene. The DON also expected gloves be removed and hand hygiene performed before other items were touched. 2. A continuous observation of incontinence care provided by NA #1 and NA #2 was made on 1/5/22 from 5:54 AM to 6:07 AM. NA #2 was observed to don gloves without performing hand hygiene. NA #1 and NA #2 assisted Resident #39 on his side and was held in position by NA #1 while NA #2 begun to provide incontinence care and wipe the resident's buttocks area to remove a small amount of stool. NA #1 squeezed a tube of protective cream into NA #2's hand who then applied the cream to the buttocks area. While wearing the same gloves NA #2 placed a clean brief and helped NA #1 reposition the resident then pulled up with the bed linens. While wearing the same gloves NA #2 touched the closet door handle to open and close the door. When completed with incontinence care NA #1 and NA #2 removed their gloves and used an alcohol-based hand rub before exiting the room. An interview was conducted on 1/5/22 at 6:15 AM with NA #1 and NA #2. NA #1 and NA #2 were asked about the facility's infection control policy and training for hand hygiene. NA #1 revealed incontinence care was dirty process and both NA #1 and NA #2 stated gloves should be removed, and hand hygiene done before the resident or items in the room were touched. An interview was conducted with the Infection Preventionist (IP) on 1/5/22 at 10:19 AM. The IP revealed she had performed a hand hygiene audit back in November and observed concerns related to staff performing hand hygiene during resident care. The IP revealed she provided staff with education related to preventives of urinary tract infections including hand hygiene. During an interview on 1/7/22 at 12:07 PM the DON expected after incontinence care nursing staff should remove soiled gloves and perform hand hygiene. The DON also expected gloves be removed and hand hygiene performed before other items were touched. 3. A continuous observation of incontinence care provided by NA #1 and NA #2 was made on 1/5/22 from 6:07 AM to 6:15 AM. Both NA #1 and NA #2 used an alcohol-based hand rub prior to donning gloves. NA #1 assisted Resident #5 on her side while NA #2 wiped the resident's buttocks area from front to back. When finished NA #2 repositioned the resident on her back while NA #1 wiped the resident's front perineal area from front to back. After NA #1 and NA #2 assisted Resident #5 with urinary incontinence care and while wearing the same gloves both placed pillows under and between the resident's legs then pulled the bed linens over the resident. While wearing the same gloves NA #2 pushed buttons on the bed remote located on foot board to adjust the height. NA #1 and NA #2 remove their gloves and use an alcohol-based hand rub before exiting the room. An interview was conducted on 1/5/22 at 6:15 AM with NA #1 and NA #2. NA #1 and NA #2 were asked about the facility's infection control policy and incontinence care being a dirty process they potentially could come in contact with body fluids. NA #1 stated yes incontinence care was dirty process and both stated gloves should be removed, and hand hygiene done after incontinence care was provided to a resident. An interview was conducted with the Infection Preventionist (IP) on 1/5/22 at 10:19 AM. The IP revealed she had performed a hand hygiene audit back in November and observed concerns related to staff performing hand hygiene during resident care. The IP revealed she provided staff education related to prevention of urinary tract infections including hand hygiene. During an interview on 1/7/22 at 12:07 PM the DON expected after incontinence care nursing staff should remove soiled gloves and perform hand hygiene. The DON also expected gloves be removed and hand hygiene performed before other items were touched.