**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to maintain accurate advance directive information throughout the electronic and paper medical records for 1 of 3 residents reviewed for advance directive (Resident #73). Findings included: Resident #73 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and history of pulmonary embolism (blood clot blocking blood flow to the lungs). The admission Minimum Data (MDS) assessment indicated Resident #73's cognition was intact. A review of the paper medical records revealed on [DATE] Resident #73 signed a Medical Scope of Treatment (MOST) form and checked if no pulse and not breathing attempt cardiopulmonary resuscitation (CPR). A review of Resident #73's electronic medical record revealed a physician's order dated [DATE] for code status Do Not Resuscitate (DNR) created by the Unit Manager. During an interview on [DATE] at 1:05 PM Nurse #9 revealed she was Resident #73's assigned nurse and in an emergency she followed the advance directive kept in the resident's paper medical records. After review of Resident #73's electronic and paper medical records Nurse #9 confirmed the electronic records showed Resident #73's code status as a DNR but the paper records contained a MOST form signed by Resident #73 indicating his code status was to receive CPR. During an interview on [DATE] at 4:54 PM the Social Worker (SW) revealed she reviewed the MOST form dated [DATE] with Resident #73 and at that time he wanted to receive CPR. The SW revealed she clarified the advance directive with Resident #73 today ([DATE]) and he wanted to receive CPR and remain a full code. The SW revealed she reviewed the MOST form with newly admitted residents and those were updated annually or as needed and any changes in a resident's code status she communicated to the Unit Manager. During an interview [DATE] at 5:00 PM the Unit Manager revealed she checked newly admitted residents' admission paperwork to ensure everything was completed and part of her check included the advance directive. The Unit Manager revealed the discrepancy in Resident #73's electronic and paper medical records was a mistake on her part and should have been entered to reflect he was a full code and wanted to receive CPR. An interview was conducted on [DATE] at 5:25 PM with the Administrator and Director of Nursing (DON). Both the Administrator and DON stated the advanced directive in the electronic and paper medical records should match and reflect Resident #73 wished to receive CPR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with staff, the facility failed to protect a resident's right to be free from misappropriation of a controlled narcotic pain medication for 1 of 10 residents reviewed for abuse (Resident #93). Findings included: The facility's Abuse, Neglect, and Exploitation policy dated 09/01/24 revealed the policy and procedures was created to protect residents against abuse that included misappropriation of resident property defined in part as the deliberate misplacement, exploitation, or permanent use of resident's belongings without consent. Resident #93 was admitted to the facility on [DATE]. The physician orders for Resident #93 included to administer hydrocodone-acetaminophen 5-325 milligrams (mg) with directions to give two tablets every six hours for pain started on 11/19/24. A review of the Resident #93's medical record revealed the resident resided on the 400 Hall on 12/05/24 and 12/06/24. A review of the Medication Administration Records (MAR) for Resident #93 revealed the physician's order for hydrocodone-acetaminophen 5-325 mg give two tablets every six hours (4 times a day) for pain was scheduled to be administered at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. On 12/05/24 at 6:00 PM Nurse #8 initialed the MAR to indicate hydrocodone-acetaminophen 5-325 milligrams was administered. On 12/06/24 at 12:00 AM (midnight) Nurse #4 initialed the MAR to indicate hydrocodone-acetaminophen 5-325 mg was administered. A review of Resident #93's controlled medication declining record for hydrocodone-acetaminophen 5-325 mg give two tablets every six hours revealed on 12/06/24 at 12:00 AM Nurse #8 signed one dose (2 tablets) was given and one dose (2 tablets) was popped in error. There was no second nurse initials to verify Nurse #8 wasted two tablets of hydrocodone-acetaminophen that were popped in error. Both doses (4 tablets) were subtracted from the amount remaining. On 12/06/24 at 12:00 AM Nurse #4 signed one dose (2 tablets) of hydrocodone-acetaminophen 5-325 mg was given and subtracted the dose from the amount remaining. In total 6 tablets of hydrocodone-acetaminophen 5-325 mg were subtracted from the amount remaining on 12/06/24 at 12:00 AM. A review of the facility's 24-hour initial report revealed on 12/06/24 at 8:00 AM the facility became aware of an alleged diversion of Resident #93's narcotic pain medication when a staff member reported Nurse #8 signed out a dose of hydrocodone and indicated it was wasted without a second signature for verification. The report indicated Nurse #8 was suspended pending an investigation, staff education was initiated related to two signatures were needed for wasting, and the local police department was notified. The person listed as preparing the report was the Director of Nursing (DON). A review of the facility's 5-day investigation revealed Nurse #8 tested positive for opioids and did not provide documentation or a prescription for the use of medications she was taking. Nurse #8 was unable to provide documentation or reason why a second nurse signature was not obtained when wasting Resident #93's opioid hydrocodone-acetaminophen medication. The facility substantiated misappropriation of property for two unaccounted tablets of Resident #93's hydrocodone-acetaminophen and terminated Nurse #8 on 12/11/24. The investigation included written statements from nursing staff and notification to the State Agency, Board of Nursing, and Drug Enforcement Administration (DEA). The person listed as preparing the report was the DON. A review of the time clock record revealed Nurse #8 signed in at 2:03 PM and out at 11:24 PM on 12/05/24. A review of the nursing staff schedule revealed Nurse #8 was assigned to Hall 400 from 3:00 PM through 11:00 PM on 12/05/24. A review of Nurse #8's written statement dated 12/06/24 revealed she understood a second signature was needed for verification when wasting medication and named Medication Aide #1 as the person she had asked but was told no indicating that as the reason there was no second signature to verify she had wasted the narcotic medication. Nurse #8's statement named Nurse #4 as the person she asked and had agreed Nurse #8 could administer the 12:00 AM (midnight) dose of hydrocodone-acetaminophen to Resident #93 on 12/06/24 and indicated the controlled medication declining record was shown to Nurse #4 to show it was given. A review of the oral drug test dated 12/06/24 revealed Nurse #8's results were positive for oxycodone. During a telephone interview on 03/20/25 at 9:38 AM Nurse #8 revealed she was the nurse assigned to administer medication on Hall 400 where Resident #93 resided and described it was busy night, and she did not recall asking the nurse if she wanted her to administer the 12:00 AM dose of hydrocodone-acetaminophen on 12/06/24. Nurse #8 revealed she administered a dose of hydrocodone-acetaminophen 5-325 mg due at 12:00 AM (midnight) on 12/06/24 and stated Resident #93 always made sure he got his pain medication. Nurse #8 revealed she was told the expectation was to administer the medications up to the end of the shift meaning if she was scheduled from 3:00 PM through 11:00 PM on 12/05/24 she was expected to administer the medications due at midnight on 12/06/24 as the reason why she had administered Resident #93's hydrocodone-acetaminophen. Nurse #8 revealed if her initials were not on the MAR that meant she did not give the medication and if her initials were on the MAR that meant she gave the medication. When asked why she signed the controlled declining record for Resident #93's hydrocodone-acetaminophen 5-325mg on 12/6/24 at 12:00 AM and not the MAR, Nurse #8 revealed she did not sign the MAR but did give the medication and had signed the declining record. When asked about the hydrocodone-acetaminophen popped in error Nurse #8 stated she asked the nurse to waste it with her, but the nurse told her No, she was too busy and could not recall the person she asked. Nurse #8 confirmed she was drug tested at the facility on 12/06/24 and told she was positive for clonazepam. When asked if she provided her prescription for the medications she took Nurse #8 stated I had some teeth pulled and had a prescription for clonazepam but had taken the last one and thrown the bottle away and confirmed she did not provide the facility any prescriptions for medications she had taken. A review of the time clock record revealed Medication Aide #1 signed in at 1:59 PM and out at 11:08 PM on 12/05/24. A review of the nursing staff schedule revealed Medication Aide #1 was assigned to Hall 300 from 3:00 PM through 11:00 PM on 12/05/24. A review Medication Aide #1's written statement dated 12/06/24 revealed she was not asked by Nurse #8 to waste a narcotic for Resident #93 and did not hear or recall being asked to assist in wasting a narcotic during her shift. During an interview on 03/19/25 at 4:14 PM Medication Aide #1 revealed on 12/06/24 she was not asked to waste anything and was interviewed by the DON when Nurse #8 named her as the person she asked her to waste Resident #93's hydrocodone/acetaminophen. Medication Aide #1 stated she told the DON during their interview she did not witness Nurse #8 waste Resident #93's hydrocodone/acetaminophen and that's when Nurse #8 tried to say she forgot to sign the declining record. Medication Aide #1 revealed if she had to waste a controlled medication she got either her supervisor or charge nurse to witness and received education about the policy for wasting controlled medication was to verify it was the right medication you observed being wasted and ensure two signatures were included on the declining record and verify the count was correct. A review of the time clock record revealed Nurse #4 signed in at 6:07 PM on 12/05/24 and out at 6:18 AM on 12/06/24. A review of the nursing staff schedule revealed Nurse #4 was assigned to Hall 400 from 11:00 PM on 12/05/24 through 7:00 AM on 12/06/24. A review of Nurse #4's written statement dated 12/06/24 revealed she was not told in report Nurse #8 had already given the scheduled dose and noted in her statement Nurse #8 was not in the building at 12:00 AM (midnight) when the dose of hydrocodone/acetaminophen was due to be administered. On 12/05/24 for 12:00 AM (midnight) Nurse #4's statement revealed she went to give 2 tablets of hydrocodone/acetaminophen to Resident #93. During a telephone interview on 03/19/25 at 7:01 PM Nurse #4 revealed she was scheduled to work a 12 hour shift on 12/05/24 and came in at 6:00 PM and left the next morning on 12/06/24 and based on the nursing schedule she was the assigned nurse on Hall 400 and Hall 500. She revealed when she arrived Nurse #8 was at the facility and assigned the Hall 400 and had the med cart keys and together they completed the controlled medication count, and it was correct. Nurse #4 revealed Nurse Aide #1 was in the room with Resident #93 when he asked for his pain medication and reported that to her around 12:00 AM midnight. Nurse #4 stated Resident #93 specifically told her he did not get his scheduled midnight dose of pain medication on 12/06/24 and that was the reason she administer hydrocodone/acetaminophen and signed the controlled declining record and the MAR she gave it at 12:00 AM. Nurse #4 revealed she did not notice Nurse #8 had signed 2 doses of hydrocodone/acetaminophen on the declining record for the same date and time on 12/06/24 at 12:00 AM (midnight) until the next morning when completing the count of controlled medications with the oncoming nurse. Nurse #4 further revealed Nurse #8 did not ask about administering the 12:00 AM dose of hydrocodone/acetaminophen and did not say she had and when she noticed Nurse #8's signatures on the declining record she informed the DON that same morning on 12/06/24. Nurse #4 revealed she received education if wasting a controlled medication, the policy was to have a witness sign to verify the medication was being wasted and both signatures must be included on controlled medication declining record and to report any discrepancy immediately to the DON. Nurse #4 revealed no other resident had shared with her they did not get their pain medication and when checked it was already signed as given. A review of Resident #93's medical records revealed the following numerical pain levels were documented: 12/5/24 at 9:13 PM the pain level was 0, 12/6/24 at 12:11 AM and at 9:57 AM the pain level was 0, 12/7/24 at 7:05 AM and at 11:18 PM the pain level was 0, 12/8/24 at 10:27 AM the pain level was 0. Attempts to interview Resident #93 by phone on 03/20/25 were unsuccessful. During an interview on 03/19/25 at 11:12 AM the DON revealed she was notified by Nurse #4 on 12/06/24 early in the morning there was a concern with Resident #93's controlled medication declining record for hydrocodone-acetaminophen 5-325mg. After review the DON revealed Nurse #8 signed she removed two doses (4 tablets) for the same date and time on 12/06/24 at 12:00 AM and one dose (2 tablets) was popped in error without a second nurse signature to witness the medication was wasted. The DON revealed Nurse #8 was asked why she signed the medication out for the midnight (12:00 AM) dose she was not supposed give and scheduled to work from 3:00 PM through 11:00 PM on 12/06/24. The DON revealed Nurse #8 stated Nurse #4 asked for help, and she was still in building and gave the hydrocodone-acetaminophen 5-325mg midnight dose to Resident #93. The DON revealed Nurse #8 could not account or provide a reason why one dose was popped in error and reminded it was the facility's policy to have a second witness for wasting controlled medication. After Nurse #8's drug test resulted positive for oxycodone the DON revealed Nurse #8 was adamant about being allergic to oxycodone but did not provide information to support that. The DON revealed during Nurse #4's interview she stated she did not ask Nurse #8 for help or agree for her to administer Resident #93's hydrocodone-acetaminophen 5-325mg due on 12/06/24 at 12:00 AM and Nurse #4 notified her the morning of 12/06/24 after she noticed the medication was signed out by Nurse #8. The DON revealed during her interview with Medication Aide #1 she was asked about being a witness for Nurse #8 to waste hydrocodone-acetaminophen 5-325mg and stated she never heard Nurse #8 ask for a witness and wrote her statement. The DON revealed after identification of possible drug diversion Resident #93 was evaluated for pain and stated he did get the 12:00 AM dose of pain medication from Nurse #8. The DON revealed other residents controlled medication declining records were reviewed with no other issues identified, nursing staff were provided education related to facility policy to have a second nurse witness when wasting controlled medications and included abuse/misappropriation of resident property. The DON revealed weekly audits of controlled medication declining records were completed to ensure signatures were in place, the off-going nurse and oncoming nurse matched the medication cards to each controlled declining record to ensure the count was correct. The DON revealed the controlled medication declining records were kept and reviewed when all the medication was given or returned to pharmacy and compared to amounts initially received from the pharmacy to ensure count was correct. The DON confirmed Nurse #8 completed her shift on 12/05/24 and after their interview on 12/06/24 did not return and was terminated on 12/11/24. The DON revealed she reported Nurse #8 to the Board of Nursing and DEA and the total amount of hydrocodone-acetaminophen 5-325mg suspected to be diverted was 2 pills based on the interview with Resident #93 who reported he had received the scheduled dose at 12:00 AM on 12/06/24. The DON revealed all residents in the facility were evaluated for pain daily including residents that do not receive pain medications. During an interview on 03/20/25 at 10:32 AM the Staff Development Coordinator revealed on 12/06/24 she asked Resident #93 if he got his pain medicine early and he said yes I think Nurse #8 gave it to me. The Staff Development Coordinator stated she asked Resident #93 if he had a good night and he said yes and described the resident as cognitively at his baseline. The Staff Development Coordinator revealed she provided staff education and discussed verifying the controlled medication counts on declining record and reporting any discrepancy or suspicious activity of diversion. An interview was conducted on 03/20/25 at 5:17 PM with Administrator and DON. The DON revealed the number of unaccounted tablets of hydrocodone-acetaminophen 5-325mg was two and based on Resident#93's interview he did get his midnight dose from Nurse #8. The Administrator revealed the audits were reviewed during quality assurance performance improvement (QAPI) and there were no issues except the incident on 12/06/24 and that was reported to her. The facility provided the following corrective action plan with a compliance date of 12/12/24. Address how corrective action will be accomplished for resident(s) found to have been affected by the deficient practice: On 12/6/24. the Director of Nursing reviewed the narcotic requisition sheets for resident #93, comparing it to the Electronic Medical Administration Record (EMAR). The Director of Nursing identified during the review discrepancies between the medications given, wasted, and signed out on the EMAR vs Narcotic requisition sheet. The Director of Nursing identified that the following issues with documentation involved Nurse #8 during the review conducted on 12/6/24. Nurse #8 was notified of the investigation and suspended pending outcome of findings on 12/6/24 by the Administrator and Director of Nursing. 12/6/2024 (Nurse #8) Resident #93- hydrocodone/acetaminophen 5-325mg- What was noted was that on the narcotic requisition form a notation of Nurse #8 signing out a hydrocodone/acetaminophen 5-325mg tab at 12:00 AM on 12/06/24, another signed out hydrocodone/acetaminophen 5-325mg at 12:00 AM and written beside it (popped in error) with no nurse witness signature verification for the waste of the mediation popped in error. Upon initiation of investigation, Resident #93 did verify that he received a midnight dose from Nurse #8 resulting in no notation or location of the popped in error tablet. Upon interview with Nurse #8, she stated that she had asked oncoming night shift nurse # 4 if she wanted her to administer Resident #93's scheduled 12:00 AM dose of hydrocodone/acetaminophen 5-325mg, to which she understand Nurse #4 to agree to. Resident #93 did verify he received a dose from Nurse #8 for his nighttime dose. Nurse #8 stated that she asked another staff member to waste the accidentally popped medication with her but was unable to get a second staff member to validate and waste the popped medication. Therefore, there was no account for one blister containing 2 tablets of hydrocodone/acetaminophen 5-325mg. In review of medication administration record, it is noted that Nurse #8 signed out the 6:00 PM dose. Nurse # 8 was notified immediately that she would be suspended pending the results of the investigation and was removed from the schedule until the investigation conclusion by the Administrator and Director of Nursing. Drug screening was completed for nurse # 8 due to potential narcotic discrepancy. Employee tested positive for oxycodone with completion of iScreen Oral Fluid Test Drug Screen Cube on 12/6/2024. Nurse #8 stated that she was allergic to oxycodone and was adamant that she did not take any medications. Provided oral confirmation that she was taking gabapentin and Wellbutrin. Nurse #8 stated she had just finished her medications and did not currently have a script. Nurse #8 advised by the Administrator to provide documentation of allergies and type and scripts for current medications. As of 12/11/24, Nurse #8 failed to provide any documentation for medications or allergies. The Administrator and Director of Nursing spoke with Nurse #8 on 12/11/24 at approximately 12:30 PM. Nurse #8 stated she did not have documentation providing medication scripts and/or allergies and stated she understood the consequences. Nurse #8 was terminated on 12/11/24. Upon investigation findings a report was filed by the Director of Nursing to the Board of Nursing in the state of which the licensure was held on 12/11/24. No negative outcomes were identified by Resident #93's assigned nurses on 12/5/24 day and evening shift and no complaints of pain were verbalized by Resident #93 on 12/5/24 to his assigned nurses on day, evening and night shift, which was documented on his Medication Administration Record. On 12/11/24, the Director of Nursing notified the pharmacy of the medications and Resident #93 involved and the need for the medication requiring replacement and that the cost of the medications would be billed to the facility. The facility has additional medication available for the resident in the pharmacy provided CUBEX medication dispensing system. Director of Nursing completed the 24-hour report to the Division of Health and Human Services (DHHS) on 12/6/2024 and will submit the five-day report upon completion of investigation on 12/11/2024 to DHHS. The local police department was notified on 12/6/2024 upon the discovery of the missing narcotic by the Director of Nursing. The Director of Nursing notified the rounding Nurse Practitioner (NP) of the alleged narcotic discrepancies and the residents involved on 12/6/24. Resident #93 was assessed on 12/6/24 by the Nurse Practitioner with no adverse effects noted and medications were available for Resident #93 when scheduled and/or needed. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 12/6/24, the Staff Development Coordinator and Director of Nursing reviewed the pharmacy requisitions for all residents receiving narcotics within the facility for the presence and accuracy of declining narcotic count sheet to ensure all medications were signed out correctly and any wastes had documentation for reason and a second nurse witness signature. All residents residing in the facility were evaluated for pain by their assigned nurse 7:00 AM-3:00 PM shift on 12/6/24. No issues or complaints were identified. 100% audit was conducted 12/6/24 by the Director of Nursing, Staff Development Coordinator and Nursing Supervisor of the control sheets and each medication on all medication carts to verify that all narcotic medication and control sheets were present. No other discrepancies were identified with all as needed and scheduled narcotics accounted for. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Education was initiated 12/6/24 in person and via phone for all licensed nursing staff and Medication Aides by the Director of Nursing or Staff Development Coordinator on the facility policy related to maintaining narcotics on the medication carts and signing of shift-to-shift count sheets, counting and verifying the narcotic count is correct. Education included expectations and requirement regarding a second witness for all wasted controlled substances. Additional education topics provided included abuse, neglect, and exploitation regarding controlled substance administration and accountability, diversion, misappropriation of facility and or resident property with the education to be completed by 12/11/24. Clinical nurses and Med Aides, including agency clinical staff will not be permitted to work until education completed after 12/11/2024. Education will be a part of the orientation process for all new hire and agency licensed staff prior to working their first shift. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On 12/06/24 the Director of Nursing and/or Designee will audit medication carts related to the narcotic count being correct to ensure the medication cards matches the control sheets and the shift-to-shift count sheets are being signed at the start and at the end of the shift. The audit will also include review of narcotic declining sheets to ensure that wasted narcotics have 2 signatures. Auditing will be completed 5 X Per week Monday through Friday for 1 week then 3x week Monday through Friday for 1 week, then 2 x weekly Monday through Friday for 1 week, then 1x weekly for 1 week and then weekly thereafter until compliance established or no other issues are identified. The Director of Nursing will report all the findings of audits to the Quality Assurance Performance Improvement committee monthly for 3 months for any needed improvement. Date of Compliance 12/12/2024. The facility's corrective action plan with a correction date of 12/12/24 was validated onsite by record review, observations, and interviews. A review of the audit tool revealed the narcotic books on Halls 200, 300, 400, and 500 were checked for accuracy of the controlled medication declining record to ensure 2 nurse signatures for verification witnessed wasting of controlled medications. The audit tool included checks for any changes made to the controlled medication declining records and validation of the witness signature to ensure the nurse had worked the shift for the date and time they signed the controlled declining record. The audit tool dated 12/06/24 noted Nurse #8 had no nurse second witness signature for wasting a dose of hydrocodone/acetaminophen. Staff education sign in record dated 12/06/24 included the summary of topics covered as follows: med pass policy and procedure related to signing out and wasting narcotics; two nurse signatures were required and verifying meds. The record was signed by 26 nurses and Medication Aide staff members. Review of the report for theft or loss of controlled substances revealed it was submitted to DEA on 12/11/24 by the DON and identified 2 tablets of hydrocodone/acetaminophen 5-325 mg were lost or stolen. Notification of the Board of Nursing in the state Nurse #8 was licensed included her license number, date of termination, and dates of employment from 08/29/24 through 12/11/24 and noted the positive oral drug screen for oxycodone with confirmation the information was received on 12/11/24 and an investigation into issue would be opened and necessary action taken if needed. Audit tools of the narcotic books on Halls 200, 300, 400, and 500 continued and were completed on 12/9/24, 12/10/24, 12/11/24, 12/16/24, 12/17/24, 12/19/24, 12/23/24, 12/27/24 with no issues identified. On 1/2/25, 1/10/25, 1/17/25, 1/24/25, 1/31/25, 2/7/25, 2/14/25, 2/21/25, 2/28/25, 3/7/25, and 3/14/25 with no issues identified. Interviews conducted with Nurse and Medication Aide staff revealed they were able to explain misappropriation of resident property was abuse and drug diversion could result in loss of their job and licensure. They had received in-service education to report abuse and suspected drug diversion immediately to their Supervisor, DON, or Administrator. Nurse and Medication Aide staff explained when administering a controlled medication, they wrote the date, time, and number of pills given and subtracted from amount remaining and verification of the controlled declining records for accuracy was done with the oncoming staff member to ensure the count was correct. Nurse and Medication Aide staff explained the policy for wasting a controlled medication included always get a second signature to witness and verify the medication was wasted. Interviews with family members of dependent residents revealed no concerns were shared related to pain. Interviews with alert and oriented residents revealed no concerns were shared related to receiving pain medication or ineffective pain medication. Observations revealed no resident concerns were identified related to uncontrolled pain. The compliance date of 12/12/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #94 was admitted to the facility on [DATE]. A nurse progress note dated 01/29/25 at 10:30 AM revealed all medications and follow-up appointments were reviewed with Resident #94 and his family member. Resident #94 discharged home from the facility with family at 10:35 AM. The discharge-return not anticipated Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #94 was discharged to an acute hospital. The MDS assessment further noted there was an active discharge plan in place for Resident #94 to return to the community. During an interview on 03/19/25 at 12:15 PM, the MDS Coordinator confirmed Resident #94 discharged home on [DATE]. She explained the discharge status on the MDS assessment dated [DATE] indicating Resident #94 discharged to the hospital was a coding error and should have reflected Resident #94 discharged to the community. During a joint interview on 03/20/25 at 5:10 PM, both the Administrator and Director of Nursing stated they would expect for MDS assessments to be completed accurately. Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of pressure ulcer care (Resident #96), fall (Resident #35), and discharge (Resident #84) for 3 of 20 residents reviewed for MDS accuracy. 1. Resident #96 was admitted to the facility 05/28/24 with a diagnosis including rhabdomyolysis (breakdown of muscle tissue). Review of Resident #96's physician orders dated 05/30/24 included to apply betadine three times a day to bilateral (both sides) knee unstageable wounds, left forearm unstageable wound, right cheek unstageable wound, right thigh unstageable wound, and unstageable wound to right heel. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had one stage 3 pressure ulcer (an ulcer that extends through the top two layers of skin) present upon admission, eight unstageable pressure ulcers due to coverage of wound bed by slough (soft dead tissue) and/or eschar (hard dead tissue), and one deep tissue injury (a pressure injury that damages tissue under the skin) present on admission. The MDS further indicated Resident #96 had a pressure reducing device for her bed and did not receive pressure ulcer/injury care. Review of Resident #96's May 2024 and June 2024 Treatment Administration Record (TAR) revealed she received pressure ulcer care as ordered. An interview with the MDS Coordinator on 03/20/25 at 2:11 PM revealed Resident #96's quarterly MDS assessment dated [DATE] should have reflected she received pressure ulcer care, and it was an oversight. During a joint interview on 03/20/25 at 5:10 PM, both the Administrator and Director of Nursing (DON) stated they would expect MDS assessments to be completed accurately. 2. Resident #35 was admitted to the facility 04/01/22 with a diagnosis including lack of coordination. Review of the discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed he had one fall with injury since the prior assessment. Nursing documentation dated 03/07/25 at 7:25 AM noted Resident #35 had a fall this morning and was noted with a bruise on his nose, an abrasion (scraped area) on his forehead and left hip. Resident #35 was able to move all his extremities with no signs or symptoms of pain. Nursing documentation dated 03/07/25 at 5:46 PM noted Resident #35 reported pain in his left shoulder, the Nurse Practitioner (NP) was notified, and an order was received to obtain an x-ray of his left shoulder. A NP note dated 03/07/25 at 11:02 PM noted Resident #35's x-ray revealed a left shoulder dislocation and orders were given to send him to the hospital. The hospital Discharge summary dated [DATE] noted a left shoulder CT-scan (detailed x-ray) dated 03/08/25 showed a chronic healed glenohumeral dislocation (the upper arm bone comes out of the shoulder socket), and a head CT-scan dated 03/08/25 revealed Resident #35 had an acute (sudden onset) left subdural hematoma (when a blood vessel between the skull and brain is damaged). A joint interview with the MDS Coordinator and Director of Nursing (DON) on 03/18/25 at 3:38 PM revealed when the discharge MDS was coded, they were not aware that Resident #35 had a subdural hematoma. They stated they were more focused on possible injury to his shoulder and did not completely read the hospital discharge summary when he returned to the facility. A follow-up interview with the MDS Coordinator on 03/18/25 at 3:54 PM revealed she would have coded Resident #35's discharge MDS assessment as having had a fall with major injury if she had been aware of the subdural hematoma. During a joint interview on 03/20/25 at 5:10 PM, both the Administrator and DON stated they would expect MDS assessments to be completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) level II was completed after a new mental health diagnosis for 1 of 3 residents (Resident #77) reviewed for PASRR. The findings include: Review of Resident #77's medical record revealed the resident was admitted to the facility on [DATE] and a PASRR level I was completed. The resident was diagnosed with schizoaffective disorder on 2/13/25 and no PASRR level II was completed. During an interview on 3/20/25 at 10:59 AM with the Social Worker (SW) she revealed PASRR level II should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. She stated she had begun working at the facility in January 2025 and was currently receiving training from the Minimum Data Set (MDS) Coordinator on how and when level II PASRR should be completed. She revealed that given Resident #77's newly added mental health diagnosis of schizoaffective disorder, PASRR level II should have been completed, and believed it had just been overlooked. During an interview on 3/20/25 at 2:02 PM with the MDS Coordinator she revealed PASRR level II should be completed upon admission for residents with a mental health diagnosis and when a resident has had a change of condition or a newly added mental health diagnosis. She stated Resident #77 received a new mental health diagnosis of schizoaffective disorder in February 2025 and a PASRR level II should have been completed and believed it was just an oversight on her part. During an interview on 3/20/25 at 5:26 PM with the Administrator she revealed PASRR level II should be completed in a timely manner upon the admission of a resident with a mental health diagnosis or anytime a resident has had a change of condition or a newly added mental health diagnosis. She stated based on Resident #77's newly added mental health diagnosis in February 2025 a PASRR level II should have been completed.

**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 3 sampled residents reviewed for PASRR (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses that included moderate intellectual disabilities and anxiety disorder. A PASRR Level II determination notification letter dated 12/31/18 revealed Resident #7 had a Level II PASRR with no expiration date. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. The North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry dated 03/19/25 revealed Resident #7 received a Level II PASRR effective 12/31/18 with no expiration date. There were no requests for re-evaluation after 12/31/18. During an interview on 03/19/25 at 12:15 PM, the MDS Coordinator revealed the previous Social Worker (SW) left employment in December 2024 and since that time, she had been submitting requests for PASRR re-evaluations until the current SW learned the process. The MDS Coordinator explained the previous SW would have been the one who would have submitted a request for a re-evaluation following Resident #7's significant change MDS assessment dated [DATE], if needed. The MDS Coordinator explained Resident #7 already had Level II PASRR at the time the significant change was identified and she (MDS Coordinator) wasn't aware that a referral needed to be made when a resident had a physical decline in condition. During an interview on 03/20/25 at 5:10 PM, the Administrator revealed the MDS Coordinator filled in to cover the PASRR process during the transition of the previous SW leaving in December 2024 and the new SW starting in January 2025. She stated once the SW was acclimated to the position, she would be responsible for requesting PASRR Level II evaluations when needed. The Administrator stated requests for a Level II PASRR re-evaluation should be made when a resident had a significant change in condition and per the regulatory guidelines.

Based on observations, and staff interviews the facility failed to protect private resident health information by leaving confidential medical information unattended in an area accessible to the public on 1 of 4 medication carts (400 hall medication cart). Findings include: An observation on the 400-hall medication cart on 11/29/23 at 9:45AM revealed a report sheet on top of the cart with resident's names, room numbers, and care information. The sheet was turned right side up so anyone walking by could see the private resident information. Nurse#1 was observed in a room giving medications in a nearby room and then returned to medication cart at 9:52 AM. Interview with Nurse #1 on 11/29/23 at 4:00 PM revealed that she was aware that any resident identifying information should be secured by ensuring nothing was on top of the medication cart and the electronic health record screen was placed in privacy mode before leaving it unattended. Nurse #1 stated she should have turned the report sheet over so that the information on it could not be viewed by anyone walking by. Interview with Nurse #2 on 11/30/23 at 10:05 AM she made sure nothing was on top of the cart and the electronic health record screen was placed in privacy mode so no information could be viewed by anyone that walked by the medication carts. Interview with the Director of Nursing on 12/1/23 at 2:30 PM revealed staff were expected to clear the top of medication carts before leaving the cart to help ensure privacy for the residents. Interview with the Administrator on 12/1/23 at 2:40 PM revealed that expectations were that HIPPA compliance should be maintained at all times, screens closed, and report sheets turned over to protect resident's information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #8 was admitted to the facility on [DATE] with diagnoses including hypertension. Review of the Smoking Safety Screen dated 01/24/23 for Resident #8 revealed he was able to verbalize he understood the smoking policy and indicated Resident #8 required supervision with smoking. The admission MDS assessment dated [DATE] indicated Resident #8 did not use tobacco. During an interview on 12/01/23 at 11:33 AM the MDS Coordinator stated Resident #8 used tobacco during the lookback period of the admission MDS assessment dated [DATE]. The MDS Coordinator confirmed the assessment was incorrectly coded no for tobacco use and she would make a modification to indicate Resident #8 used tobacco. An interview was conducted on 12/01/23 at 12:41 PM with the Administrator and DON. The Administrator stated the MDS should be correctly coded and reflect Resident #8 used tobacco. 3. Resident #88 was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis. The discharge MDS assessment dated [DATE] indicated Resident #88 discharged from the facility to the hospital and return to the facility was not anticipated. Review of a nurse progress note written on 09/01/23 indicated Resident #88 discharged from the facility and left with his daughter against medical advice. Review of the document, Leaving Against Medical Advice, revealed Resident #88 signed the document on 09/01/23 that he understood the consequences and acknowledged he was leaving the facility against the advice of the attending physician and facility administration. During an interview on 11/30/23 at 9:40 AM the MDS Coordinator confirmed she completed the discharge MDS assessment for Resident #88 dated 09/01/23. She recalled Resident #88 left the facility against medical advice and the discharge MDS assessment would be coded to the community. After review of the MDS assessment and section for discharge status to the hospital the MDS Coordinator stated it was coded incorrectly Resident #88 discharged to the community and she would do a correction to reflect he discharged to the community. An interview was conducted on 12/01/23 at 12:41 PM with the Administrator and Director of Nursing (DON). The DON stated Resident #88 left the facility against medical advice and the discharge MDS indicated he was discharged to the hospital was coded incorrect. The Administrator stated the MDS should be coded correctly and reflect the discharged status of Resident #88 to the community. Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set Assessments (MDS) in the areas of smoking and discharge location for 3 of 7 residents reviewed for accidents and hospitalization (Residents #43, #8 and #88). Findings included: 1. Resident #43 was admitted to the facility on [DATE] with diagnosis that included diabetes. Review of the Smoking Safety Screen dated 04/27/23 revealed Resident #43 was assessed as safe to smoke with supervision. The admission MDS assessment dated [DATE] revealed Resident #43 did not currently use tobacco. During an interview on 11/30/23 at 9:11 AM, the MDS Coordinator revealed Resident #43 had smoked since her admission to the facility. She stated it was an oversight that Resident #43's MDS assessment dated [DATE] was not marked 'yes' to reflect she used tobacco during the MDS assessment period and a modification would be submitted. During an interview on 12/01/23 at 12:34 PM, the Administrator stated it was her expectation for MDS assessments to be completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #62 was admitted to the facility on [DATE] with diagnoses including: Hip Fracture, cerebrovascular Accident, Atrial fibrillation, coronary artery disease, heart failure, hypertension, orthostatic hypotension, Renal insufficiency renal failure. The admission Minimum Data Set (MDS) dated [DATE] indicated that Resident # 62 under activities of daily living needed maximum assistance with bed mobility, transfers, personal hygiene, bathing, and locomotion on and off the unit. and always incontinent of bowel and bladder during the MDS assessment period. Review of #62 active care plans, initiated on 11/30/23 revealed that the resident did not have care plans that addressed Activities of Daily living (ADL) and incontinence had not been initiated. During an interview on 12/1/23 at 8:41AM with MDS Coordinator who stated she had not been getting care plans initiated in the required timeline. Stated that all care plans should be completed to have a comprehensive care plan. MDS Coordinator revealed that she did not know residents care plans were missing until the Regional Consultant did an audit on 11/30/23. Regional was present and stated that this all occurred due to an update of the charting system and this is why the MDS Coordinator missed some care plans. During a interview with the Administrator on 12/1/23 he stated that the expectations was for the MDS staff to keep care plans up to date and initiated as soon as possible since this is what drives the resident care. Based on record review and staff interviews the facility failed to develop a person-centered comprehensive care plan for 2 of 21 (Resident #241 and Resident #62) residents reviewed for comprehensive care plans. Findings included: 1. Resident #241 was admitted to the facility 06/08/23 with diagnoses including pulmonary embolism (a blood clot in the lung) and heart failure. Resident #241 was discharged to the community 08/29/23. Review of Resident #241's medical record revealed a physician's order dated 06/08/23 for Apixaban (anticoagulant) 5 milligrams (mg) twice a day for pulmonary embolism. Review of Resident #241's Medication Administration Record (MAR) for June 2023 revealed he received Apixaban as ordered. Resident #241's comprehensive care plan last updated 06/12/23 was reviewed and did not reveal any care plan focus or interventions related to receiving anticoagulation medication. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #241 was cognitively intact and received anticoagulant (blood thinner) medication 7 out of 7 days during the look back period. An interview with the MDS Coordinator on 11/28/23 at 2:03 PM and 11/30/23 at 9:36 AM revealed she was responsible for developing Resident #241's comprehensive care plan and it should be a reflection of all the care and medications Resident #241 required. She stated it was an oversight that Resident #241 did not have a comprehensive care plan for the use of anticoagulant medication. In an interview with the Director of Nursing (DON) on 11/30/23 at 11:14 AM she confirmed Resident #241's care plan updated in June 2023 was not complete and should reflect all the care he required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to ensure a resident did not receive a straw for 1 of 7 residents (Resident #54) reviewed for accidents. This failure placed Resident #54 at risk for choking/aspiration (inhaling food or fluids into the lungs). Findings included: Resident #54 was admitted to the facility 04/25/23 with diagnoses including dysphagia (difficulty swallowing) and malnutrition. A Speech Therapy (ST) Discharge summary dated [DATE] revealed Resident #54 received dysphagia therapy from 06/20/23 through 07/28/23. The note read in part provided skilled ST to address swallow function in order to determine least restrictive/safest diet, maximize overall safety and efficiency during PO (oral) intake, reduce risk of aspiration and associated respiratory compromise, and maintain adequate nutrition and hydration. To facilitate safety and efficiency it is recommended the patient use the following strategies and/or maneuvers during oral intake: no straws and general swallow techniques/precautions upright posture during meals. An Occupational Therapy (OT) Discharge summary dated [DATE] revealed Resident #54 received OT from 07/06/23 through 08/02/23. The note read in part: self-feeding-patient is independent in all components of task using assistive device. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was moderately cognitively impaired. The nutrition care plan last updated 09/19/23 revealed Resident #54 was at risk for malnutrition related in part to medical conditions, age, and a history of dysphagia. Interventions included monitoring Resident #54 for signs or symptoms of dysphagia, providing diet as ordered, and not providing straws with meals. An observation of Resident #54 on 11/27/23 at 12:20 PM revealed she was using a straw to drink milk from a carton without difficulty. Resident #54 was not observed to cough or choke while drinking the milk. An observation of Resident #54's meal ticket at the same date and time revealed she was not to receive straws and was supposed to receive a [NAME] cup (a cup with a lid that has an opening for a straw and a handle). No [NAME] cup was observed on Resident #54's meal tray. A joint interview with Nurse Aide (NA) #1 and NA #2 on 11/27/23 at 12:30 PM revealed they could not recall who set up Resident #54's meal tray for the lunch meal. An interview with NA #3 on 11/27/23 at 12:31 PM revealed he could not recall who set up Resident #54's lunch meal tray, but whoever set up the tray was responsible for making sure items on the tray matched the tray card. NA #3 confirmed Resident #54's meal tray ticket stated she was not to receive straws and should have received a [NAME] cup. He removed the straw from Resident #54's milk and went to the kitchen to request a [NAME] cup. An interview with NA #1 on 11/28/23 at 12:25 PM revealed she set up Resident #54's lunch meal tray and placed the [NAME] cup in the lid of the meal tray and sat the lid on the resident's dresser. When NA #1 was asked why she did not pour Resident #54's beverage into the [NAME] cup, she stated she was told by therapy when Resident #54 was moved to 300 hall that she could hold a cup from the kitchen or a carton of milk and did not require use of the [NAME] cup. NA #1 was unable to recall which staff member from therapy told her Resident #54 did not need to use a [NAME] cup. An interview with the Speech Therapist (ST) on 11/28/23 at 12:42 PM revealed Resident #54 was not currently on caseload, but she had previously recommended Resident #54 did not receive straws due to the risk of aspiration (when food or fluid is breathed into the airway). She stated occupational therapy probably recommended the [NAME] cup for Resident #54. An interview with the Occupational Therapist (OT) on 11/28/23 at 1:57 PM revealed Resident #54 was not currently on caseload, but she had previously recommended Resident #54 use a [NAME] cup to enable her to be able to drink fluids more independently. She stated she was not aware of the speech therapy recommendation that Resident #54 not use straws due to the risk of aspiration and the aspiration risk outweighed the use of a [NAME] cup. An interview with the Director of Nursing (DON) on 11/30/23 at 11:13 AM revealed the staff member setting up a resident's tray was responsible for ensuring the meal tray matched the tray ticket. She stated she expected staff to obtain the needed item if it did not come on the tray, or to remove the item that was not supposed to be on the tray before delivering the tray to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. a. An observation of room [ROOM NUMBER] on 11/27/23 at 11:50 AM revealed multiple scrapes with exposed dry wall behind the resident's bed. On wall behind the residents over bed table contained 4 to 5 quarter sized dried red/brown spots on the wall. Subsequent observations made on 11/28/23 at 9:30 AM and 11/30/23 at 2:15 PM revealed the room unchanged. b. On 11/27/23 at 12:12 PM an observation of the dining room entrance doors revealed the bottom corner of both doors contained a broken door covering that was sticking out from the door. The Door covering was jagged to touch and contained sharp edges and was at foot and ankle level. Subsequent observations made on 11/29/23 at 8:39 AM and 11/30/23 at 2:15 PM revealed the door to be unchanged. c. An observation of room [ROOM NUMBER] on11/27/23 at 2:11 PM revealed 6 continuous floor tiles directly adjacent to the wall behind the door entrance to be broken and indented. Subsequent observations made on 11/30/23 at 2:15 PM revealed the room to be unchanged. An interview with the Maintenance Director on 11/30/23 at 12:39 PM revealed each manager was assigned 4 resident rooms to round on daily and report any concerns, including any needed repairs. He stated he knew there were some walls that needed painting or patching but he did not have any outstanding requests for other repairs. The Maintenance Director reported he knew that some floor tiles needed to be repaired but was unable to find matching floor tile for the replacement. An interview with the Administrator on 11/30/23 at 1:50 PM revealed she knew the building was old and needed some repairs, but she was not aware of how many rooms needed painting and patching of sheet rock. She stated management rounded twice a week on resident rooms to look for any concerns, including needed repairs. The Administrator stated she felt management staff were not completing their room rounds and that contributed to her not being aware of how many resident rooms needed repairs. She stated she expected the walls to be maintained in good repair. 6. (a) An observation of the wall behind 311-A on 11/27/23 at 10:24 AM revealed 2 areas of missing paint with exposed sheet rock and the corner of the wall beside the bathroom in room [ROOM NUMBER] revealed an area of exposed sheet rock. Additional observations of room [ROOM NUMBER] on 11/28/23 at 8:34 AM, on 11/29/23 at 8:39 AM, and 11/30/23 at 8:35 AM revealed 2 areas of missing paint with exposed sheet rock behind 311-A and the corner of the wall beside the bathroom revealed an area of exposed sheet rock. (b). An observation of the wall in room [ROOM NUMBER] across from A and B beds on 11/27/23 at 10:29 AM revealed multiple areas of missing paint across the wall with exposed sheet rock. Additional observations of the wall in room [ROOM NUMBER] across from A and B beds on 11/28/23 at 8:36 AM, on 11/29/23 at 8:41 AM, and on 11/30/23 at 8:40 AM revealed multiple areas of missing paint across the wall with exposed sheet rock. (c). An observation of the corners of both walls beside the bathroom in room [ROOM NUMBER] and the wall behind B-bed on 11/27/23 at 10:35 AM revealed multiple linear areas of missing paint with exposed sheet rock. Additional observations of the corners of both walls beside the bathroom in room [ROOM NUMBER] and the wall behind B-bed on 11/28/23 at 8:38 AM, on 11/29/23 at 8:50 AM, on 11/30/23 at 8:43 AM revealed multiple linear areas of missing paint with exposed sheet rock. (d). An observation of the corners of both walls beside the bathroom in room [ROOM NUMBER] and the wall behind A-bed on 11/27/23 at 10:41 AM revealed multiple linear areas of missing paint with exposed sheet rock. Additional observations of the corners of both walls beside the bathroom in room [ROOM NUMBER] and the wall behind A-bed on 11/28/23 at 8:42 AM, 11/29/23 at 8:47 AM, and 11/30/23 at 8:41 AM revealed linear areas of missing paint with exposed sheet rock. (e). An observation of the corners of both walls beside the bathroom in room [ROOM NUMBER] and the wall behind 310-A on 11/27/23 at 10:47 AM revealed linear areas of missing paint with exposed sheet rock. Additional observations of the corners of both walls beside the bathroom in room [ROOM NUMBER] and the wall behind 310-A on 11/28/23 at 8:48 AM, on 11/29/23 at 8:34 AM, and 11/30/23 at 8:35 AM revealed linear areas of missing paint with exposed sheet rock. (f). An observation of the wall behind the bed in room [ROOM NUMBER] on 11/27/23 at 10:57 AM revealed multiple linear areas of missing paint with exposed sheet rock. Additional observations of the wall behind the bed in room [ROOM NUMBER] on 11/28/23 at 8:53 AM, on 11/29/23 9:03 AM, and on 11/30/23 at 8:45 AM revealed multiple linear areas of missing paint with exposed sheet rock. (g). An observation of the corners of both walls beside the bathroom and the wall behind the bed in room [ROOM NUMBER] on 11/27/23 at 11:02 AM revealed multiple linear areas of missing paint with exposed sheet rock. Additional observations of the corners of both walls beside the bathroom and the wall behind the bed in room [ROOM NUMBER] on 11/28/23 at 8:55 AM, on 11/29/23 at 9:06 AM, and on 11/30/23 at 8:46 AM revealed multiple linear areas of missing paint with exposed sheet rock. (h). An observation of the corner of the wall beside the bathroom in room [ROOM NUMBER] on 11/27/23 at 11:05 AM revealed a linear area of missing paint with exposed sheet rock. Additional observations of the corner of the wall beside the bathroom in room [ROOM NUMBER] on 11/28/23 at 8:57 AM, 11/29/23 at 9:01 AM, and on 11/30/23 at 8:42 AM revealed a linear area of missing paint with exposed sheet rock. (i). An observation of the wall across from A and B beds in room [ROOM NUMBER] revealed multiple areas of exposed sheet rock and the bathroom wall across from the toilet in room [ROOM NUMBER] revealed 2 exposed metal brackets on 11/27/23 at 11:15 AM. Additional observations of the wall across from A and B beds in room [ROOM NUMBER] revealed multiple areas of exposed sheet rock and the bathroom wall across from the toilet in room [ROOM NUMBER] revealed 2 exposed metal brackets on 11/28/23 at 9:01 AM, 11/29/23 at 9:10 AM, and 11/30/23 at 8:52 AM. (j). An observation of the corners of both walls beside the bathroom, the wall behind A-bed, and the wall across from A-bed in room [ROOM NUMBER] on 11/27/23 at 11:21 AM revealed multiple linear areas of missing paint with exposed sheet rock. Additional observations of the corners of both walls beside the bathroom, the wall behind A-bed, and the wall across from A-bed in room [ROOM NUMBER] on 11/28/23 at 9:06 AM, on 11/29/23 at 9:14 AM, and 11/30/23 at 8:53 AM revealed multiple linear areas of missing paint with exposed sheet rock. An interview with the Maintenance Director on 11/30/23 at 12:39 PM revealed each manager was assigned 4 resident rooms to round on daily and report any concerns, including any needed repairs. He stated he knew there were some walls that needed painting or patching but he did not have any outstanding repair requests and he did not have a schedule for painting or patching walls in resident rooms. An interview with the Administrator on 11/30/23 at 1:50 PM revealed she knew the building was old and needed some repairs, but she was not aware of how many rooms needed painting and patching of sheet rock. She stated management rounded twice a week on resident rooms to look for any concerns, including needed repairs. The Administrator stated she felt management staff were not completing their room rounds and that contributed to her not being aware of how many resident rooms needed repairs. She stated she expected the walls to be maintained in good repair. 7. (a). An observation of the bathroom wall below the sink in room [ROOM NUMBER] on 11/27/23 at 10:24 AM revealed multiple areas of dried brown stains. Additional observations of the bathroom wall below the sink in room [ROOM NUMBER] on 11/29/23 at 8:39 AM and 11/30/23 at 8:35 AM revealed multiple areas of dried brown stains. (b). An observation of the wall across from A and B bed of room [ROOM NUMBER] on 11/27/23 at 10:29 AM revealed multiple dried stains. Additional observations of the wall across from A and B bed of room [ROOM NUMBER] on 11/29/23 at 8:41 AM and 11/30/23 at 8:40 AM revealed multiple dried stains. (c). An observation of the wall near the entry door of room [ROOM NUMBER] on 11/27/23 at 10:35 AM revealed multiple dried stains. Additional observations of the wall near the entry door of room [ROOM NUMBER] on 11/28/23 at 8:38 AM, 11/29/23 at 8:50 AM, and 11/30/23 at 8:43 AM revealed multiple dried stains. (d). An observation of the wall near the entry door of room [ROOM NUMBER] on 11/28/23 at 8:48 AM revealed multiple dried stains. Additional observations of the wall near the entry door of room [ROOM NUMBER] on 11/29/23 at 8:34 AM and 11/30/23 at 8:35 AM revealed multiple dried stains. (e). An observation of the wall behind the bed in room [ROOM NUMBER] on 11/27/23 at 10:53 AM revealed multiple dried stains. Additional observations of the wall behind the bed in room [ROOM NUMBER] on 11/28/23 at 8:47 AM, 11/29/23 at 8:54 AM, and 11/30/23 at 8:42 AM revealed multiple dried stains. (f). An observation of the wall across from A and B beds in room [ROOM NUMBER] on 11/27/23 at 11:10 AM revealed multiple areas of dried stains. Additional observations of the wall across from A and B bed in room [ROOM NUMBER] on 11/28/23 at 8:59 AM, on 11/29/23 at 9:09 AM, and on 11/30/23 at 8:50 AM revealed multiple areas of dried stains. (g). An observation of the bathroom wall beside and behind the toilet in room [ROOM NUMBER] on 11/27/23 at 11:15 AM revealed multiple areas of dried brown stains. Additional observations of the bathroom wall beside and behind the toilet in room [ROOM NUMBER] on 11/28/23 at 9:01 AM, 11/29/23 at 9:01 AM, and 11/30/23 at 8:52 AM revealed multiple areas of dried brown stains. An interview with the Maintenance Director on 11/30/23 at 12:39 PM revealed each manager was assigned 4 resident rooms to round on daily and report any concerns, including any issues with cleanliness, to himself or the Director of Nursing (DON). He stated he was not aware of any concerns with room cleanliness. An interview with the Director of Nursing (DON) on 11/30/23 at 1:50 PM revealed there was no Environmental Services Director, but she completed the housekeeping schedule and made housekeeping assignments. She stated there was no checklist of items that housekeeping cleaned daily but housekeeping staff were to clean any areas of resident rooms or bathrooms that were visibly soiled. The DON stated she expected resident rooms and bathrooms to be clean. An interview with Housekeeper #1 on 12/01/23 10:19 AM revealed she was working on the 300 hall and had been employed at the facility for three weeks. She stated daily cleaning of resident rooms included sweeping and mopping the floor, cleaning the bathroom, and dusting if needed. Housekeeper #1 stated she had been instructed to wipe stains off walls in resident rooms if she observed them, but she hadn't seen any walls that needed to be cleaned. 8. (a). An observation of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/27/23 at 10:24 AM revealed the vent was covered in a thick layer of gray dust. Additional observations of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/28/23 at 8:34 AM, 11/29/23 at 8:34 AM, 11/29/23 at 8:39 AM, and 11/30/23 at 8:35 AM revealed the vent was covered in a thick layer of gray dust. (b). An observation of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/27/23 at 10:29 AM revealed the vent was covered in a thick layer of gray dust. Additional observations of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/28/23 at 8:36 AM, on 11/29/23 at 8:41 AM, and on 11/30/23 at 8:40 AM revealed the vent was covered in a thick layer of gray dust. (c). An observation of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/27/23 at 10:35 AM revealed the vent was covered in a thick layer of gray dust. Additional observations of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/28/23 at 8:38 AM, 11/29/23 at 8:50 AM, and 11/30/23 at 8:43 AM revealed the vent was covered in a thick layer of gray dust. (d). An observation of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/27/23 at 10:41 AM revealed the vent was covered in a thick layer of gray dust. Additional observations of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/28/23 at 8:42 AM, 11/29/23 at 8:47 AM, and 11/30/23 at 8:41 AM revealed the vent was covered in a thick layer of gray dust. (d). An observation of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/27/23 at 10:47 AM revealed the vent was covered in a thick layer of gray dust. Additional observations of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/28/23 at 8:48 AM, 11/29/23 at 8:34 AM, and 11/30/23 at 8:35 AM revealed the vent was covered in a thick layer of gray dust. (e). An observation of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/27/23 at 10:53 AM revealed the vent was covered in a thick layer of gray dust. Additional observations of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/28/23 at 8:47 AM, 11/29/23 at 8:54 AM, and 11/30/23 at 8:42 AM revealed the vent was covered in a thick layer of gray dust. (f). An observation of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/27/23 at 10:57 AM revealed the vent was covered in a thick layer of gray dust. Additional observations of the ceiling vent in the bathroom of room [ROOM NUMBER] on 11/28/23 at 8:53 AM, 11/29/23 at 8:53 AM, and 11/30/23 at 8:45 AM revealed the vent was covered in a thick layer of gray dust. An interview with the Maintenance Director on 11/30/23 at 12:39 PM revealed maintenance was responsible for cleaning ceiling vents. In a follow-up interview with the Maintenance Director on 11/30/23 at 1:50 PM he stated the bathroom ceiling vents were last cleaned six months ago and he did not have a routine schedule for cleaning the ceiling vents. An interview with the Administrator on 11/30/23 at 1:50 PM revealed she expected ceiling vents to be clean. 9. (a). An observation of the packaged terminal air conditioner (PTAC) unit of room [ROOM NUMBER] on 11/28/23 at 8:34 AM revealed a missing slat to the top vent. Additional observations of the PTAC unit in room [ROOM NUMBER] on 11/29/23 at 8:39 AM and 11/30/23 at 8:35 AM revealed a missing slat to the top vent. (b). An observation of the PTAC unit of room [ROOM NUMBER] on 11/27/23 at 10:29 AM revealed the top vent was dislodged and sitting crooked on the unit. Additional observations of the PTAC unit in room [ROOM NUMBER] on 11/28/23 at 8:36 AM, 11/29/23 at 8:41 AM, and 11/30/23 at 8:40 AM revealed the top vent was dislodged and sitting crooked on the unit. (c). An observation of the PTAC unit in room [ROOM NUMBER] on 11/27/23 at 10:53 AM revealed a missing slat to the top vent. Additional observations of the PTAC unit in room [ROOM NUMBER] on 11/28/23 at 8:47 AM, 11/29/23 at 8:54 AM, and 11/30/23 at 8:42 AM revealed a missing slat to the top vent. (d). An observation of the PTAC unit in room [ROOM NUMBER] on 11/27/23 at 11:10 AM revealed the top of the vent was dislodged and sitting crooked on the unit. Additional observations of the PTAC unit in room [ROOM NUMBER] on 11/28/23 at 8:59 AM, 11/29/23 at 9:09 AM, and 11/30/23 at 8:50 AM revealed the top of the vent was dislodged and sitting crooked on the unit. An interview with the Maintenance Director on 11/30/23 at 12:39 PM revealed each manager was assigned 4 resident rooms to round on daily and report any concerns, including any needed repairs. He stated he was not aware of any concerns with PTAC units in resident rooms. An interview with the Administrator on 11/30/23 at 1:50 PM revealed management rounded twice a week on resident rooms to look for any concerns, including needed repairs. The Administrator stated she felt management staff were not completing their room rounds and that contributed to repair of PTAC units in rooms not being identified and completed. She stated she expected PTAC units in resident rooms to be in good repair. 10. (a). An observation of the shared bathroom in room [ROOM NUMBER] on 11/27/23 at 10:24 AM revealed an unlabeled and uncovered round pink pan with dried stains sitting under the sink. Additional observations of the shared bathroom in room [ROOM NUMBER] on 11/28/23 at 8:34 AM, 11/29/23 at 8:39 AM, and 11/30/23 at 8:35 AM revealed an unlabeled and uncovered round pink pan with dried stains sitting under the sink. (b). An observation of the shared bathroom in room [ROOM NUMBER] on 11/28/23 at 08:36 AM revealed an unlabeled and uncovered bath basin was sitting on top of the towel dispenser. Additional observations of the shared bathroom in room [ROOM NUMBER] on 11/29/23 at 8:41 AM and 11/30/23 at 8:40 AM revealed an unlabeled and uncovered bath basin sitting on top of the towel dispenser. (c). An observation of the shared bathroom in room [ROOM NUMBER] on 11/27/23 at 10:47 AM revealed an unlabeled and uncovered bed pan sitting between a grab bar and the wall. Additional observations of the shared bathroom in room [ROOM NUMBER] on 11/28/23 at 8:48 AM, 11/29/23 at 8:34 AM, and 11/30/23 at 8:35 AM revealed an unlabeled and uncovered bed pan sitting between a grab bar and the wall. (d). An observation of the shared bathroom in room [ROOM NUMBER] on 11/27/23 at 11:10 AM revealed 3 unlabeled and uncovered bath basins stacked inside each other sitting on a dresser. Additional observations of the shared bathroom in room [ROOM NUMBER] on 11/28/23 at 8:59 AM, 11/29/23 at 9:09 AM, and 11/30/23 at 8:50 AM revealed 3 unlabeled and uncovered bath basins stacked inside each other sitting on a dresser. (e). An observation of the shared bathroom in room [ROOM NUMBER] on 11/27/23 at 11:15 AM revealed an unlabeled and uncovered bath basin sitting on the floor near the sink. Additional observations of the shared bathroom in room [ROOM NUMBER] on 11/28/23 at 9:01 AM, 11/29/23 at 9:10 AM, and 11/30/23 at 8:52 AM revealed an unlabeled and uncovered bath basin sitting on the floor near the sink. An interview with the Director of Nursing (DON) on 11/30/23 at 1:50 PM revealed personal items should be labeled and stored appropriately, and it was the responsibility of all staff to ensure items were labeled and stored appropriately. 11. (a). An observation of the overbed table in room [ROOM NUMBER] on 11/27/23 at 10:57 AM revealed rust to the wheels and frame. Additional observations of the overbed table in room [ROOM NUMBER] on 11/28/23 at 8:53 AM, 11/29/23 at 9:03 AM, and 11/30/23 at 8:45 AM revealed rust to the wheels and frame. (b). An observation of the overbed tables in room [ROOM NUMBER] A and B bed on 11/27/23 at 10:35 AM revealed dried stains to the frames of both tables. Additional observations of the overbed tables of room [ROOM NUMBER] A and B bed on 11/28/23 at 8:38 AM, 11/29/23 at 8:50 AM, and 11/30/23 at 8:43 AM revealed dried stains to the frames of both tables. (c). An observation of the overbed table in room [ROOM NUMBER] on 11/27/23 at 10:53 AM revealed multiple dried stains to the frame of the table. Additional observations of the overbed table in room [ROOM NUMBER] on 11/28/23 at 8:47 AM, 11/29/23 at 8:54 AM, and 11/30/23 at 8:42 AM revealed multiple dried stains to the frame of the table. An interview with the Director of Nursing (DON) on 11/30/23 at 1:50 PM revealed there was no Environmental Services Director, but she completed the housekeeping schedule and made housekeeping assignments. She stated there was no checklist of items that housekeeping cleaned daily but housekeeping staff were to clean any areas of resident rooms that were visibly soiled. The DON stated she expected overbed tables to be clean and in good repair. An interview with Housekeeper #1 on 12/01/23 10:19 AM revealed she was working on the 300 hall and had been employed at the facility for three weeks. She stated daily cleaning of resident rooms included sweeping and mopping the floor, cleaning the bathroom, and dusting if needed. Housekeeper #1 stated she had been instructed to wipe stains off overbed tables in resident rooms if she observed them, but she hadn't seen any tables that needed to be cleaned. 12. (a). An observation of the geriatric chair in room [ROOM NUMBER] B bed on 11/27/23 at 11:21 AM revealed multiple dried stains on both arm rests and the seat of the chair. Additional observations of the geriatric chair in room [ROOM NUMBER] B bed on 11/28/23 at 9:06 AM, 11/29/23 at 9:14 AM, and 11/30/23 at 8:53 AM revealed multiple dried stains on both arm rests and the seat of the chair. (b). An observation of the geriatric chair for the resident in room [ROOM NUMBER] B bed on 11/27/23 at 2:32 PM revealed multiple dried stains on the arm rests and frame of the chair. Additional observations of the geriatric chair for the resident in room [ROOM NUMBER] B bed on 11/28/23 at 9:08 AM, 11/29/23 at 9:16 AM, and 11/30/23 at 8:57 AM revealed multiple dried stains on the arm rests and frame of the chair. An interview with the Director of Nursing (DON) on 11/30/23 at 1:50 PM revealed there was no formal schedule for cleaning geriatric chairs and any staff member could clean them when visibly soiled. She stated she expected wheelchairs to be clean. 13. An observation of the floor on the upper part of 400 hall on 11/27/23 at 2:32 PM revealed an approximately 2-inch round area of missing tile in the middle of the floor. Additional observations of the floor on 400 hall on 11/28/23 at 9:08 AM, 11/29/23 at 9:12 AM, and 11/30/23 at 8:54 AM revealed an approximately 2-inch round area of missing tile in the middle of the floor. An interview with the Maintenance Director on 11/30/23 at 1:50 PM revealed the tile on 400 hall had been missing for approximately two months and he was holding off repairing the tile as long as possible due to not having replacement tile of the exact color and thickness. He stated he could repair the tile with a different color and use the buffing machine to smooth out the replacement tile being a little thicker. An interview with the Administrator on 11/30/23 at 1:50 PM revealed she expected the floors to be in good repair. Based on observations and interviews with staff, the facility failed to ensure the doors to resident rooms (rooms 407, 409, 412, 414, and 503), the closet doors (room [ROOM NUMBER]), and the main dining room doors were kept in good repair; failed to ensure door guards were in good repair and secured to the door to prevent sharp edges (rooms [ROOM NUMBER]); failed to ensure the floors and walls in resident rooms and bathrooms were kept clean and in good repair (rooms 301, 306, 310, 311, 312, 313, 314, 315, 316, 317, 318, 401, 402, 403, 408, 412, 413, 414, 503, and hall 400); failed to address lingering odors resembling urine (rooms [ROOM NUMBER]); failed to maintain clean bathroom ceiling vents (bathrooms 310, 311, 312, 313, 314, 315, 316, and 317); failed to maintain packaged terminal air conditioner (PTAC) units in good repair (rooms 311, 312, 316, and 401); failed to ensure resident personal care items were labeled and stored correctly (bathrooms 310, 311, 312, 401, 402, 413, and 414); failed to maintain clean overbed tables in good repair (rooms 314-A, 314-B, 316, 317); failed to maintain clean geriatric chairs (rooms 312-B and 403-B); failed to replace a missing top drawer to a nightstand (room [ROOM NUMBER]); and failed to maintain flooring in good repair (400 Hall) for 3 of 4 halls reviewed for environment (Halls 300, 400, and 500). Findings included: 1. a. Observations of room [ROOM NUMBER] on 11/27/23 at 3:43 PM, 11/28/23 at 1:38 PM, and 11/29/23 at 4:41 PM revealed the wood door to enter the room had several damaged areas along the edges of the door, mostly located below the doorknob. There were chunks of wood missing causing it to splinter and the door guard placed below the doorknob covering the bottom portion of the door was damaged with areas of jagged plastic and had begun to separate from the door creating a sharp edge. The metal framing around the door had several areas where the paint was missing and appeared it had chipped or was scraped off the frame. b. Observations of the bathroom in room [ROOM NUMBER] were made on 11/27/23 at 3:43 PM, 11/28/23 at 1:38 PM, and 11/29/23 at 4:41 PM revealed the bathroom had a strong odor resembling urine that lingered outside to the room and onto hall 400. The flooring surrounding the base of the toilet was stained a black color and the floor appeared dirty and sticky. The wall beside the toilet had a brownish colored stain that ran down the wall and appeared as if a liquid splashed on the wall and was left to dry. An interview with Housekeeper #1 on 12/01/23 10:19 AM revealed daily cleaning of resident rooms included sweeping and mopping the floor and cleaning the bathroom. c. Observations of room [ROOM NUMBER] on 11/27/23 at 3:43 PM, 11/28/23 at 1:38 PM, and 11/29/23 at 4:41 PM revealed the wall by the wardrobe closet had a hole approximately 1.5 inch wide and 3 inches long. The wall was stained and scuffed in several areas, mostly affecting the middle and lower areas of the wall. There was an orange-colored stain on the wall, and it appeared a liquid had splashed on the wall and was left to dry. There were several gray and black colored scuff marks on the lower part of the wall. d. Observations of room [ROOM NUMBER] on 11/27/23 at 3:43 PM, 11/28/23 at 1:38 PM, and 11/29/23 at 4:41 PM revealed the closet wardrobe doors from the handles to bottom of the doors had large horizontal marks where the paint was missing and peeling off the doors. e. An observation of room [ROOM NUMBER] on 11/27/23 at 3:43 PM and 11/28/23 at 1:38 PM revealed six unlabeled wash basins were stacked inside one another. Two of the wash basins were placed directly on the floor in the bathroom. During an observation and interview on 11/28/23 at 1:38 PM Nurse Aide (NA) #3 observed the wash basins stacked inside one another and the two placed directly on the floor. She stated those should not be stacked inside one another and placed directly on the floor. She revealed it was the NA staff's responsibility to label and properly store residents' personal care items. 2. a. Observations of room [ROOM NUMBER] on 11/27/23 at 10:11 AM and 11/29/23 04:23 PM revealed the lower portion of the wall by the bathroom had several scrape marks and areas of damaged sheetrock. The bathroom door frame had several scrape marks and areas where the framing was chipped and missing paint. b. Observations of room [ROOM NUMBER] on 11/27/23 at 10:11 AM, 11/29/23 04:23 PM, and 11/30/23 at 11:37 AM revealed a strong urine-like odor lingered in the room and bathroom and out onto hall 400. The flooring surrounding the base of the toilet was stained black and gray. The bathroom wall had multiple gray colored scuff marks along the lower part of the wall. The floor appeared dirty and sticky and the baseboard behind the toilet had dried brown stains. An interview with Housekeeper #1 on 12/01/23 10:19 AM revealed daily cleaning of resident rooms included sweeping and mopping the floor and cleaning the bathroom. c. Observations of room [ROOM NUMBER] on 11/27/23 at 10:11 AM, 11/29/23 at 4:23 PM, and 11/30/23 at 11:37 AM revealed 2 unlabeled wash basins stacked together with the one placed directly on the floor. A toothbrush placed directly on sink. During an interview on 11/28/23 at 1:38 PM NA #3 revealed it was the responsibility of NA staff to label and properly store residents' personal care items. 3. a. Observations of room [ROOM NUMBER] on 11/29/23 at 1:29 PM and 11/30/23 at 2:01 PM revealed the wood door entering the room had several areas along the edges below the doorknob where chunks of wood were missing and splintered. b. Observations of the bathroom in room [ROOM NUMBER] on 11/29/23 at 1:29 PM and 11/30/23 at 2:01 PM revealed the flooring surrounding the toilet was heavily stained and buckled and not secured to the subflooring. A wall covering at the lower part of the wall was buckled and peeling away from the wall. The bathroom flooring appeared dirty and sticky. The baseboard along the bottom of the wall and bathroom floor had a black/brown buildup of debris mostly behind the toilet and appeared dirty. An interview with Housekeeper #1 on 12/01/23 10:19 AM revealed daily cleaning of resident rooms included sweeping and mopping the floor and cleaning the bathroom. c. Observations of room [ROOM NUMBER] on 11/29/23 at 1:29 PM and 11/30/23 at 2:01 PM revealed the top drawer of the nightstand was missing. Walkthrough observations were completed to share environmental concerns for rooms 413, 414 and 503 on 11/30/23 from 12:39 PM through 2:01 PM with the Maintenance Director and Administrator and included interviews. The environmental issues were unchanged for rooms [ROOM NUMBER]. The Maintenance Director explained painting and patching walls and doors was a continual process due to residents' wheelchairs bumping into walls, door frames, and closet doors causing damage to the sheetrock and scuff marks, and he was aware those repairs needed to be done. The Maintenance Director and Administrator observed the splintered wood and damaged door guards with sharp edges. The Maintenance Director revealed the doors need to be sanded and smoothed and guards replaced to prevent a resident from a possible skin tear. He revealed the Maintenance Department consisted of 2 staff and there were several things to do, and repairs were prioritized based on emergency problems and special needs of residents were done first. The Maintenance Director stated the urine like odors in rooms [ROOM NUMBER] were caused by the male residents missing the toilet. He stated approximately 6 months ago the lower portion of the wall in bathroom [ROOM NUMBER] was replaced and the use of odor eliminating products including bleach were tried to eliminate the urine-like odor. The Administrator stated attempts to rid the urine-like odors were unsuccessful and at this point it was time to replace the flooring in the bathrooms of rooms [ROOM NUMBER]. The Maintenance Director revealed he was not aware of the missing nightstand drawer in room [ROOM NUMBER] and it was an easy fix, and he would replace it. The Maintenance Director and Administrator revealed resident room rounds were assigned to the managers and each person checked 4 rooms. The Administrator revealed it was the responsibility of NA staff and rounding managers to ensure residents personal care items were labeled and properly stored. She revealed Housekeeping staff clean each resident room daily and confirmed the observed bathrooms had urine like odors and the floors were sticky. The Maintenance Director revealed he received phone notifications from the computer work order system used by staff to report environmental issues or they verbally report concerns. The Administrator revealed management not doing their assigned resident room rounds contributed to the breakdown in communication related to environmental issues observed during the walkthrough and she expected the facility to be clean and in good repair. 5. a. An observation of the bathroom door in room [ROOM NUMBER] on 11/27/23 at 11:29 AM revealed the door protector attached to the front, middle to lower half of the door had lifted from the bottom and the inner edge bent outward with a sharp pointed edge. Subsequent observations of the bathroom door in room [ROOM NUMBER] on 11/28/23 at 8:24 AM and 11/30/23 at 8:53 AM revealed the condition of the door protector remained the same. b. An observation of the corner wall by the bathroom door in room [ROOM NUMBER] on 11/27/23 at 10:39 AM revealed the corner of the wall was busted creating an open hole with splintered and exposed sheetrock from the floor to approximately 6 inches up the corner of the wall. Subsequent observations on 1/28/23 at 12:10 PM and 11/29/23 at 9:00 AM revealed the condition of the wall remained the same. c. An observation of the bathroom door in room [R

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #1 was admitted to the facility 03/09/23 with diagnoses including severe intellectual disabilities and paranoid schizophrenia. The admissions Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Review of Resident #1's medical record revealed an undated North Carolina Medicaid Uniform Screening Tool (NC MUST) indicated Resident #1 had a Level I PASRR effective 03/07/23. There were no requests for a Level II PASRR evaluation submitted or completed since 03/07/23. An interview with the Admissions Director on 11/28/23 at 4:17 PM revealed she submitted requests for PASRR evaluations through NC MUST when notified. She stated the MDS Coordinator was the staff member who was aware of a resident's diagnoses and would notify her. The Admissions Director stated she had not received any notifications to submit requests for Level II PASRR evaluations. Interviews on 11/29/23 at 9:24 AM and 11/30/23 at 2:40 PM with the Social Worker (SW) revealed the Admissions Director handled residents' PASRR. The SW explained the previous SW did not tell her anything about PASRR during her training and she did not know to request a Level II PASRR evaluation for a resident with a mental health disorder or the process for doing so. An interview with the Administrator on 12/01/23 at 12:34 PM revealed the Admissions Director was responsible for requesting Level II PASRR evaluations for residents admitted with mental health disorders and Resident #1's just got missed. Based on record review and staff interviews, the facility failed to refer residents who were admitted with mental health disorders for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination of specialized services for 3 of 3 residents reviewed for PASRR (Residents #14, #43 and #1). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included anxiety, major depressive disorder, and personality disorder. The admissions Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Review Resident #14's medical record revealed an undated North Carolina Medicaid Uniform Screening Tool (NC MUST) which indicated Resident #14 had a Level I PASRR effective 02/10/10. There were no requests for a Level II PASRR evaluation submitted or completed since 02/10/10. During an interview on 11/28/23 at 4:17 PM, the Admissions Director revealed she submitted requests for PASRR evaluations through NC MUST when notified. She explained the MDS Coordinator was the one who was aware of a resident's diagnoses and would notify her. The Admissions Director stated she had not received any notifications to submit requests for Level II PASRR evaluations. During interviews on 11/29/23 at 9:24 AM and 11/30/23 at 2:40 PM, the Social Worker (SW) revealed the Admissions Director handled residents' PASRR. The SW explained the previous SW did not tell her anything about PASRR during training and she did not know to request a Level II PASRR evaluation for a resident with a mental health disorder or the process for doing so. During an interview on 12/01/23 at 12:34 PM, the Administrator revealed the Admissions Director was responsible for requesting Level II PASRR evaluations for residents admitted with mental health disorders and Resident #14's just got missed. 2. Resident #43 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, major depressive disorder, agoraphobia (abnormal fear of places or situations that could cause feelings of panic or embarrassment) with panic disorder, and post-traumatic stress disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Review Resident #43's medical record revealed an undated North Carolina Medicaid Uniform Screening Tool (NC MUST) which indicated Resident #43 had a Level I PASRR effective 04/26/23. There were no requests for a PASRR Level II evaluation submitted or completed since 04/26/23. During an interview on 11/28/23 at 4:17 PM, the Admissions Director revealed she submitted requests for PASRR evaluations through NC MUST when notified. She explained the MDS Coordinator was the one who was aware of a resident's diagnoses and would notify her. The Admissions Director stated she had not received any notifications to submit requests for Level II PASRR evaluations. During interviews on 11/29/23 at 9:24 AM and 11/30/23 at 2:40 PM, the Social Worker (SW) revealed the Admissions Director handled residents' PASRR. The SW explained the previous SW did not tell her anything about PASRR during training and she did not know to request a Level II PASRR evaluation for a resident with a mental health disorder or the process for doing so. During an interview on 12/01/23 at 12:34 PM, the Administrator revealed the Admissions Director was responsible for requesting Level II PASRR evaluations for residents admitted with mental health disorders and Resident #43's just got missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and medical director interviews the facility failed to monitor a resident's blood sugar for a resident with insulin-dependent diabetes for 1 of 5 residents reviewed for unnecessary medication (Resident # 69). The findings included Resident # 69 was re-admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus type 1, heart failure, vascular dementia, and respiratory failure. Resident # 69's admission Minimum Data Set (MDS) was still in progress. A review of Resident # 69's physicians orders on 11/20/23 read in part: Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML Inject 20 unit subcutaneously at bedtime for DM (11/20/23). Insulin Lispro Injection Solution 100 UNIT/ML Inject 6 unit subcutaneously with meals for diabetes (11/20/23). A review of Resident # 69's medication administration record (MAR) for November 2023 revealed blood sugar checks had not been checked prior to Resident # 69 receiving insulin before meals from his readmission dated of 11/20/23 - 11/28/23. Further review of the MAR revealed blood sugar level checks were completed prior to administering insulin before meals each day until discharged to hospital on [DATE]. After discovery of the missing blood sugar checks, Resident # 69's assigned nurse (Nurse # 4) and admitting nurse was interviewed on 11/28/23 at 1:58 PM. Nurse # 4 said she had been assigned to Resident # 69 for a long time and knew him well and Resident # 69 was alert and oriented to himself. Nurse # 4 stated Resident # 69 did receive blood sugar checks before she administered insulin at mealtimes prior to his discharge to the hospital on [DATE]. Nurse # 4 said when Resident # 69 returned from the hospital he did not have orders for checking blood sugars before his insulin was administered. Nurse # 4 stated she should have clarified the blood sugar checks with the doctor and was unsure why the blood sugar checks were not reinstated. Nurse # 4 said she had given Resident # 69 his insulin without checking his blood sugar level. Nurse # 4 stated she monitored his behaviors( lethargic) compared to his baseline, vital signs, and the amount of meal intake to determine if he had hypoglycemia ( low blood sugar). She stated she would then notify the provider. Nurse # 4 stated when a resident admits to the facility, the orders from the hospital are reviewed by the admitting nurse, nurse supervisor and verified by a provider prior to placing them on the resident's MAR. The Director of Nursing (DON) was interviewed on 11/28/23 at 4:14 PM. She stated she was not aware Resident # 69 was not receiving blood sugar checks prior to receiving insulin at meals. She stated the facility did not have a standing order for checking blood sugar levels for diabetic residents. The physician made the decision on whether a resident needed to have blood sugar levels checked. The DON said the nurse supervisor reviews every resident's chart before they are admitted and should have reviewed Resident # 69's. NA #1 was interviewed on 11/29/23 at 9:24 AM. NA # 1 stated Resident # 69 was alert and oriented to himself. The Medical Director (MD) was interviewed on 11/30/23 at 3:32 PM. He stated Resident # 69 was to receive his insulin before each meal regardless of his blood sugar level. The MD said Resident # 69 should've had his blood sugar level checked prior to administering insulin. The Administrator, DON, and Administrator In Training (AIT) were interviewed on 12/1/23 at 12:33 PM. The Administrator stated Resident # 69's blood sugar check order should have been reinstated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure physician progress notes were documented and completed as required for each physician visit for 2 of 2 sampled residents (Residents #14 and #84). Findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (weakness on one side of the body) and hemiparesis (complete paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, diabetes, chronic respiratory failure, chronic obstructive pulmonary disease (difficulty breathing), and hypertension. Review of Resident #14's medical record revealed a progress note which indicated he was seen by the facility Medical Director in conjunction with the Physician Assistant (PA) on 10/13/23. There were no progress notes of physician visits conducted by the Medical Director every 30 days for the first 90 days following Resident #14's admission to the facility. Review of Resident #14's medical record revealed he was seen by the Nurse Practitioner (NP) on 06/22/23 and 11/21/23 and the Physician Assistant on 07/18/23 and 08/02/23. During a telephone interview on 11/30/23 at 3:42 PM, the Medical Director revealed the Administrator had contacted him to discuss the regulatory requirement regarding frequency of physician visits. The Medical Director explained the NP or PA was at the facility most days and when he was there, he often rounded with them but did not document a progress note of his visit in the residents' medical records. The Medical Director stated all the residents at the facility were usually seen by him 2 to 3 times a month and he realizes his visits should have been documented. During a joint interview with the Administrator on 12/01/23 at 12:34 PM, the Director of Nursing (DON) stated she was under the impression the Medical Director was keeping track of when regulatory visits were due. The DON explained they have now developed a log for nursing staff to track when regulatory visits were due, remind the Medical Director and follow-up to ensure progress notes were documented. During a joint interview with the DON on 12/01/23 at 12:34 PM, the Administrator stated she was under the impression the Medical Director was keeping track of when regulatory visits were due. The Administrator stated Resident #14 should have been seen by the physician per regulatory guidelines and facility policy. 2. Resident #84 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), and gastroesophageal reflux disease (digestive disease in which stomach acid or bile irritates the food pipe lining). Review of Resident #84's medical record revealed no progress notes of physician visits conducted by the Medical Director. Review of Resident #84's medical record revealed he was seen by the Nurse Practitioner (NP) on 10/02/23, 10/09/23, 10/10/23, and 11/13/23 and the Physician Assistant (PA) on 10/11/23. During a telephone interview on 11/30/23 at 3:42 PM, the Medical Director revealed the Administrator had contacted him to discuss the regulatory requirement regarding frequency of physician visits. The Medical Director explained the NP or PA was at the facility most days and when he was there, he often rounded with them but did not document a progress note of his visit in the residents' medical records. The Medical Director stated all the residents at the facility were usually seen by him 2 to 3 times a month and he realizes his visits should have been documented. During a joint interview with the Administrator on 12/01/23 at 12:34 PM, the Director of Nursing (DON) stated she was under the impression the Medical Director was keeping track of when regulatory visits were due. The DON explained they have now developed a log for nursing staff to track when regulatory visits were due, remind the Medical Director and follow-up to ensure progress notes were documented. During a joint interview with the DON on 12/01/23 at 12:34 PM, the Administrator stated she was under the impression the Medical Director was keeping track of when regulatory visits were due. The Administrator stated Resident #84 should have been seen by the physician per regulatory guidelines and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to store a 30 dose bubble pack of Metformin (an hyperglycemic medication) in the medication cart for 1 of 4 carts observed during medication pass. The facility failed to dispose of an expired medication, an unopened bottle of expired medication, Ferrex (an iron supplement), which was discovered in the 100/200 hall medication room for 1 of 2 medication rooms reviewed. The facility also failed to secure medicated creams, powder and sprays that were in clear view at the bedside for 1 of 1 sampled resident (Resident #14). Findings included: 1. An observation conducted during a medication pass on the 400 hall on 11/29/2023 at 9:45AM revealed a full bubble pack of 30 doses of Metformin that Nurse #1 left on top of the medication cart and walked away leaving the card and information unsecured. The nurse was out of the line of sight to observe the medication which was left on the medication cart. There were residents sitting in their doorways around the cart while unattended. An interview with Nurse #1 was conducted on 11/30/23 at 10:05AM and she said medications should have been secured before she walked away from the cart. Nurse #1 reported the medication cart should be locked, and no medications should be left on top of the cart. Nurse#1 stated leaving unattended medications on top of the cart can cause potential hazards for confused residents who could take the card and possibly the medication. During an interview with Director of Nurse on 11/30/23 at 9:25AM, she stated that all medications should be secured before the nurse walked away from the cart. An interview with the Administrator on 11/30/23 at 12:55PM revealed she would not expect a nurse to leave any medication unattended. 2. An observation of the 100/200 hall medication room, on 11/30/23 at 9:25AM with Director of Nursing revealed an unopened and expired bottle of medication Ferrex-150 150mg tabs which had an expiration date of 9/2023. During an interview with the Director of Nursing on 11/30/23 at 9:25AM, conducted in the medication room in conjunction with the observation, she stated the person responsible for ordering and stocking supplies was responsible for checking dates and over-the -counter medications, which was the Medical Record/Central Supply employee. She stated expectations are to check medications to ensure no expired medications are left in the cabinet. An interview was conducted with the Medical Records/Central Supply employee on 11/30/23 at 11:15AM who stated she checked for outdated mediations twice a month. She stated she would go through medications that were in the medication room and would pull older bottles to the front and place newer bottles in the back of the cabinet. She further stated she just missed one expired medication, but she did check routinely. An interview with the Administrator on 11/30/23 at 12:55PM revealed she expected the Medical Records/Central Supply person to check all stock medications and remove any expired medications before the expiration date. She stated she did not feel like this was an issue and it was just an accident. 3. Resident #14 was admitted to the facility on [DATE] with multiple diagnoses that included hemiplegia (weakness on one side of the body) and hemiparesis (complete paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 had intact cognition. Review of Resident #14's medical record revealed no documentation he was assessed for self-administering medications. Review of Resident #14's November 2023 Medication Administration Record and Treatment Administration Record revealed the following active physician orders: • 06/19/23: May apply barrier cream or equivalent with each incontinent episode and as needed (unlicensed personnel to administer, nurse to monitor) every shift for preventative care. • 07/12/23: Hydrocortisone (used to treat redness, itching and discomfort of the skin) topical cream 1% apply to face topically daily for rash as needed. • 08/07/23: 12-hour nasal solution 0.05% oxymetazoline hydrochloride (used to relieve nasal discomfort caused by colds, allergies and hay fever) - two sprays in nostril twice a day as needed. • 11/16/23: Nystatin Powder (used to treat fungal or yeast infections of the skin) 100,000 units/gram - apply topically to groin twice a day for 7 days. There were no other physician orders for medicated creams, powders or sprays. During observations on 11/27/23 at 10:39 AM, 11/28/23 at 12:10 PM, and 11/29/23 at 12:00 PM, in clear view on top of Resident #14's nightstand were an 8-ounce (oz) bottle of wound cleanser spray containing zinc acetate and alcohol formula, a 2 oz bottle of skin protectant spray containing 25% of zinc oxide and 20% of dimethicone, a 1 oz bottle of nasal decongestant spray containing 0.05% of oxymetazoline hydrochloride, and a 2 oz tube of ointment containing 20% zinc oxide. In addition, there was a bottle of Nystatin powder 60 grams labeled with a pharmacy sticker that had Resident #14's name and an expiration date of 09/24/24. During an interview on 11/27/23 at 10:39 AM Resident #14 stated staff administered the nasal decongestant spray when his nose got stuffy and the medicated creams, powder, wound cleanser and protectant sprays were to treat the skin breakdown he had in his groin area from yeast. Resident #14 stated staff applied the creams, powder and sprays and left them on top of his nightstand. An observation and interview was conducted with the Director of Nursing (DON) on 11/30/23 at 11:14 AM. The DON explained that the medicated creams, powder and sprays should not have been left in his room. A joint interview was conducted with Nurse #1 (Wound Nurse) and Nurse #2 (Hall nurse) on 11/30/23 at 12:19 PM. Nurse #2 stated when she went into Resident #14's room to administer his medications, she had noticed the wound cleanser spray and other bottles on his nightstand but was not sure who left them there or when they were left there. Both Nurse #1 and Nurse #2 stated the wound cleanser spray should be stored on the treatment cart and not at beside. In addition, both Nurse #1 and Nurse #2 stated they were not sure where the decongestant spray came from and didn't think it was a brand they typically ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews the facility failed to provide an alternative meal choice when requested for 1 of 3 residents reviewed for accommodating resident allergies, intolerances, and preferences (Resident #14). Additionally, the facility failed to provide a nutrional supplement as ordered by a physcian for 1 of 3 residents (Resident #37) . This practice had the potential to impact other residents. The findings included: 1. Resident #14 was admitted on [DATE] with diagnosis that included diabetes, hypertension, and dysphagia. A review of Resident #14's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact. On 11/28/23 at 12:10 PM Resident #14 was observed lying in bed with his overbed table across the bed containing an untouched meal tray. Resident #14 stated he can't eat that meal and when asked if he wanted something else to eat, he stated if he did, they would tell him he waited too late and should have told them before lunch. Resident #14 stated he could not ask before the meal because he did not know what meal he would be served. On 11/29/23 at 10:39 AM Resident #14 was interviewed and stated when he receives a meal that he does not like and asks for an alternative meal, the kitchen tells him it's too late and he should have let them know before the meal. On 11/29/23 at 12:15 PM Resident #14's assigned Nursing Aide (NA) #3, stated Resident #14 did not like a lot of the food served for meals and he would ask for alternates. NA #3 said if she asked the kitchen for an alternate meal choice, she was told it's too late. NA #3 said once the tray line had started for a meal, the residents had to wait for the next meal to get an alternative. NA #3 stated she would go to the nourishment room to get alternatives such as soup and fruit cups for the residents. The Dietary Manager (DM) was interviewed and stated on 11/29/23 at 3:32 PM the residents have a choice of the previous day's main meal (lunch, dinner) and grilled cheese or alternated sandwiches. Additionally, the residents always have an alternate vegetable available for meals. The kitchen had told the NAs to report which residents would like the alternated meal choice by 10:30 AM for lunch and 4:00 PM for dinner. After those times (10:30 AM, 4:00 PM) it became difficult for the cooks to make more food after the tray-line had started. The DM stated the daily menu was posted in front of the dining room doors and at the nurses' stations. The NAs let the residents know what was on the menu and the residents can request an alternate for the upcoming meal. Interviews with NA #1 and NA #2 occurred at the same time 11/29/23 at 09:24 AM. The two NAs stated residents received a monthly calendar at the beginning of each month that contained the menu for each day of the month. The NAs had to check with each resident to find out if they wanted the regular menu choice or the alternative. Both NAs agreed that food requests had to be delivered to the kitchen by 4:00 PM, if the request comes in after 4:00 PM the Kitchen tells them it was past the cutoff time and too late to request an alternate. NA #1 said when a resident receives a dinner meal and states they would like the alternative, the NAs had to tell the resident it was too late to receive the alternate meal choice. NA #1 and NA #2 said they relied on the food in the nourishment room to provide an alternative for the residents that normally consists of soup and peanut butter sandwich. A cook was interviewed on 11/29/23 at 3:51 PM and stated there was a cutoff time for resident request for alternative. For dinner the time was 3:00 PM, and after that there were no more request from NAs accepted, and the NAs are told it was past the cut off time. On 12/1/23 at 12:33 PM the Director of Nursing (DON), Administrator in Training (AIT), and Administrator were interviewed. The Administrator stated the kitchen should not have a cut-off time for residents to request an alternative food choice. 2. Resident #37 was admitted to the facility on [DATE]. His active diagnoses included protein-calorie malnutrition, underweight and adult failure to thrive. An active physician's order dated 05/23/23 for Resident #37 read, health shake with meals for weight support related to protein-calorie malnutrition. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #37 had moderate impairment in cognition. He required supervision with set-up help only for eating, weighed 68 pounds, received a mechanically altered diet, and had no significant weight loss or gain during the MDS assessment period. Review of Resident #37's care plans, last reviewed/revised on 10/12/23, revealed he was at risk for altered nutritional status related in part to being underweight, adult failure to thrive, and protein-calorie malnutrition. Interventions included monitor and document any signs of dysphagia (difficulty swallowing), notify nurse of any refusals to eat and offer alternative if he will accept, serve diet as ordered, provide and serve supplements as ordered: health shake three times a day, and set-up all meals and snacks. Review of a Registered Dietician (RD) progress note dated 11/08/23 revealed in part, Resident #37's current weight was 66 pounds and he received a health shake with all meals. He appears to be meeting/exceeding all estimated nutritional needs with his current intake and nutritional interventions in place as ordered. His intake of meals appears increased since previous RD review, however his weight continues to decline. The RD's recommendations included to continue current nutritional interventions. Review of a RD progress note dated 11/24/23 revealed in part, Resident #37's current weight was 66 pounds. The RD noted Resident #37 had significant weight loss times one week, likely due to low body weight for his height, but his weight loss appeared stabilized at this time and fluctuated between 66 to 68 pounds. The RD's recommendations included to obtain weekly weights to track weight trend and noted no changes to his current nutritional interventions. An observation on 11/28/23 at 8:30 AM, revealed Resident #37 sitting up in bed with his head covered by a bed sheet. His breakfast tray was placed on the overbed table directly in front of him and he was served pureed grits, sausage and eggs of which he ate a few bites. There was no health shake served with his breakfast tray. The meal card on his breakfast tray included no instructions to send a health shake with his meal. An observation on 11/28/23 at 11:57 AM revealed Resident #37 sitting up in bed with his lunch tray placed on the overbed table directly in front of him, eating and drinking independently. There was no health shake served with Resident #37's lunch tray. The meal card on his lunch tray included no instructions to send a health shake with his meal. An observation on 11/29/23 at 12:20 PM revealed Resident #37 sitting up in bed with his lunch tray placed on the overbed table directly in front of him, eating and drinking independently. There was no health shake served with Resident #37's lunch tray. The meal card on his lunch tray included no instructions to send a health shake with his meal. An observation and interview was conducted with Nurse Aide (NA) #3) on 11/30/23 at 8:50 AM. Resident #37 was lying in bed and sleeping peacefully, his breakfast tray already removed from his room. NA #3 retrieved Resident #37's meal tray from the meal cart and stated he ate 50% of his meal and drank almost all of his coffee but did not drink his orange juice. NA #3 confirmed there was no health shake served with Resident #37's breakfast tray. An observation and interview was conducted with with NA #3 on 11/30/23 at 12:09 PM. NA #3 was observed retrieving Resident #37's lunch tray and delivering it to his room. There was no health shake served with his lunch tray. NA #3 explained health shakes were provided by the kitchen and sent out with the resident's tray. NA #3 confirmed there was no health shake served on Resident #37's lunch tray. She explained he used to get a health shake with his meals but hadn't in some time and she didn't know why. NA #3 further explained the health shake was not listed on his meal card and if it was, they would have known to request one from the kitchen. During an interview on 11/30/23 at 2:15 PM, [NAME] #1 revealed he didn't have access to put orders into the dietary computer to print on the residents' meal card. [NAME] #1 explained if the order for Resident #37's health shake was not put into the dietary computer to print on the meal card, dietary staff would not have known to put it on his meal tray. During an interview on 11/30/23 at 2:47 PM, the Therapy Director stated he was informed by [NAME] #1 that Resident #37 had not been getting health shakes with his meals as ordered. The Therapy Director stated he reviewed Resident #37's orders and confirmed he had an active order to receive a health shake with all meals. The Therapy Director stated he was not sure what happened or why the order wasn't put into the dietary computer to print on Resident #37's meal card. He explained he didn't have access to change or input orders in the dietary computer; however, the Dietary Manager (DM) did but she was out for a medical procedure. The Therapy Director stated in the interim, he put notes on Resident #37's meal card to send a health shake with his meals until the DM could correct it in the dietary computer to print on the meal card. During a telephone interview on 12/01/23 at 11:41 AM, the RD revealed she had just found out yesterday (11/30/23) that Resident #37 was not receiving health shakes with his meals as ordered. The RD explained when she spoke to the DM, the DM stated she was almost certain Resident #37 was getting the health shake with meals at one point and was not sure what happened for it not to print on his meal card. The RD stated she spoke with dietary staff and instructed them to make sure the health shake was marked on any meal cards that had already been printed for Resident #37 so that he would receive it with his meals. The RD explained with Resident #37's low weight, any type of nutrition he could get to promote weight stabilization would be beneficial. She stated Resident #37 could still eat and did so independently and she would want him to receive health shakes as ordered just for him to get some sort of nutrition, as much as he would allow. During an interview on 12/01/23 at 12:34 PM, the Administrator stated Resident #37's order should have been followed and health shakes provided with his meals.

Based on observations and staff interviews the facility failed to maintain clean ceiling vents located in the dry storage room and in the kitchen, failed to maintain a clean walk-in refrigerator and remove food with signs of spoilage from the walk-in refrigerator. Additionally, the facility failed to clean and maintain 3 of 3 ice makers, and clean and maintain ice cooler scoops and holders (the kitchen ice maker, North and South nourishment room ice makers). This practice had the potential to affect food and beverages served to residents. The findings included: a. On 11/27/23 at 9:23 AM an observation of a ceiling vent in the dry storage area of the kitchen contained a build up of fluffy debris with spider webs spread across the vent. An approximately 4 foot long by 6-inch strip of ceiling in front of the vent contained a black splotchy/and spotted substance covering the area. b. On 11/27/23 at 9:28 AM the walk-in refrigerator circulatory fan contained a thick build up of crumbly to touch debris that was spread to the ceiling of the walk-in refrigerator. During the same observation, a box of fresh cucumbers contained multiple cucumbers with splotchy white fuzzy substance on them. c. On 11/27/23 at 9:31 AM an observation of the kitchen's ice maker contained black/brown substance on the back inside wall of the ice maker with the ice not touching the substance. The ice maker mechanism (freezes the water into ice) contained multiple small round white spots. d. On 11/27/23 at 9:35 AM a large ceiling vent approximately 3 x 3 foot located above the cook's food preparation table had a thick buildup of crumbly debris spanning the entirety of the vent. The cook's food preparation table had clean serving utensils positioned below the vent. A follow-up observation of the kitchen area with the Dietary Manager (DM) occurred on 11/29/23 at 10: 43 AM. All observed areas on 11/27/23 remained unchanged. The DM wa interviewed during the observation. She Stated the ceiling in the dry storage area had been repaired several months ago due to a leak and had not been aware of the dirty air vent in walk-in refrigerator. She stated the ice maker in the kitchen was cleaned by her a couple months ago and was not aware of the debris on the walls of the ice maker. On 11/29/23 at 3:32 PM the DM stated the ceiling and ceiling vents in the kitchen had been overlooked and would be added to a cleaning schedule. e. An observation of the south nourishment room with the DM on 11/29/23 at 10: 49 AM revealed the ice maker contained multiple pinpoint size black specks on both the right and left inside wall of the ice maker. The same observation revealed an ice scoop in holder attached to the ice cooler contained standing water with hair and other debris visible. f. On 11/29/23 at 11:06 AM the north nourishment room was observed with the DM. The ice maker contained multiple pinpoint size black spots on the left and right inner sides of the ice maker. The ice cooler scoop and holder were observed to contain a cold wet to touch cloth towel in the bottom of the scoop holder with the ice scoop placed on top of the towel. The DM stated on 11/29/23 at 11:01 AM she was unsure of who was responsible for cleaning and maintaining the ice makers in the nourishment rooms. The DM stated she would add the nourishment room ice makers to the cleaning schedule and that she last cleaned the ice maker in the kitchen about 2 months ago. The ice maker in the kitchen was to be deep cleaned every 6 months and as needed. Additionally, the DM stated the nurse aides bring the ice coolers to the kitchen at night to be cleaned but was unaware how often that occurred. The Administrator stated on 12/1/23 at 12:33 PM the kitchen should not contain any expired food, the kitchen including the ceiling vents should be cleaned when needed. The ice makers and ice coolers should be cleaned on a regular schedule or as needed.

Based on observations, record review, and interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions previously put in place following a COVID-19 focused survey that occurred 12/04/20. This failure was for one deficiency that was originally cited in the area of Infection Control (F-880) and was subsequently recited on the current recertification and complaint investigation survey of 12/01/23. The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. Findings included: This tag is cross referenced to: F880: Based on observations, record review and staff interviews, the facility failed to assess the facility's water system to identify where Legionella and other waterborne pathogens could grow and spread which had the potential to affect 92 of 92 residents. The facility also failed to ensure staff implemented their infection control policies and procedures when Nurse #1 did not place a barrier between the wound care supplies and an overbed table that had crumbs and dried debris on the surface and did not change her gloves after removing a wound dressing and before cleaning the wound for 1 of 1 sampled resident (Resident #54). During the COVID-19 focused survey conducted 12/04/20 the facility failed to follow their Infection Control COVID-19 policy by allowing an employee to complete her shift after she reported to her supervisor that she had a fever and was not feeling well. In an interview with the Administrator on 12/01/23 at 12:34 AM she stated she was not aware a Legionella risk assessment needed to be completed. A follow-up interview with the Administrator on 12/01/23 at 1:26 PM revealed the quality assurance (QA) team met monthly and included the Medical Director, administrative staff, and most department managers. She stated audits were put in place based on concerns identified in the meetings. The Administrator stated she attributed the current concern with hand hygiene and no barrier being place between the surface and dressing supplies to staff being nervous.

2. Review of the facility's policy titled Handwashing/Hand Hygiene revised in April 2012 read in part as follows: This facility considers hand hygiene the primary means to prevent the spread of infection. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 2. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropranol for the following situations: (a). Before handling clean or soiled dressings (b). Before moving from a contaminated body site to a clean body site during resident care (c). After handling used dressings (d). After removing gloves. A continuous observation of wound care for Resident #54 on 11/29/23 from 12:02 PM through 12:12 PM revealed dressing change supplies were sitting directly on her overbed table and the table had scattered crumbs and dried debris on the surface. Dressing change supplies included a cup containing gauze moistened with a bleach solution, a cup containing medical grade honey and collagen (an aid for wound healing), a packaged abdominal pad, 2 unpackaged rolls of gauze, and tape. With gloved hands Nurse #1 cut Resident #54's dressings to both heels off with scissors, removed her gloves and applied clean gloves, removed the old dressings to both heels, and cleaned both heels with bleach moistened gauze, and removed her gloves. Nurse #1 did not perform hand hygiene after removing her gloves and before applying clean gloves when she cut the dressings off Resident #54's heels and did not remove her gloves and perform hand hygiene after removing the old dressings and before cleaning both heel wounds. An interview with Nurse #1 on 11/29/23 at 12:13 PM revealed she placed the dressing change supplies directly on Resident #54's overbed table before beginning wound care. She stated she did not notice the crumbs and dried debris on the overbed table and did not usually place a barrier between wound care supplies and the surface where they were placed. Nurse #1 stated she didn't usually perform hand hygiene every time she changed her gloves during wound care and she did not usually change her gloves after removing a used dressing and before cleaning a wound. An interview with the Infection Preventionist (IP) on 11/30/23 at 10:21 AM revealed she expected a barrier to be placed between dressing change supplies and the surface on which they were placed. She stated staff should perform hand hygiene after removing gloves and should change their gloves after removing used dressings and before cleaning wounds. An interview with the Director of Nursing (DON) on 11/30/23 at 11:13 AM revealed she expected a barrier to be placed between dressing change supplies and the surface on which they were placed. She stated staff should perform hand hygiene after removing gloves and should change their gloves after removing used dressings and before cleaning wounds. Based on observations, record review and staff interviews, the facility failed to assess the facility's water system to identify where Legionella and other waterborne pathogens could grow and spread which had the potential to affect 92 of 92 residents. The facility also failed to ensure staff implemented their infection control policies and procedures when Nurse #1 did not place a barrier between the wound care supplies and an overbed table that had crumbs and dried debris on the surface and did not change her gloves after removing a wound dressing and before cleaning the wound for 1 of 1 sampled resident (Resident #54). Findings included: 1. Review of the facility's Emergency Preparedness Plan revealed no evidence a facility water safety risk assessment was completed to identify where Legionella or other waterborne pathogens could grow and spread in the facility's water system. During an interview on 11/30/23 at 8:56 AM, the Maintenance Director confirmed he had not completed a water safety risk assessment for the facility. He explained the facility utilized town water and it was his understanding they did not need to complete a water safety risk assessment as the facility did not have a boiler system and there was nowhere for Legionella to grow. He further explained the facility's water pipes were primarily overhead and were constantly pushing water through the pipes leaving little chance of standing water where bacteria could grow. During a follow-up interview on 11/30/23 at 1:08 PM, the Maintenance Director provided a document titled, Legionella Environmental Assessment Form, which noted the date of assessment as 0/28/22. The Maintenance Director clarified he had completed the assessment today (11/30/23). During an interview on 12/01/23 at 12:34 PM, the Administrator revealed she did not realize they were required to complete a facility water safety risk assessment for Legionella and she would be the person responsible for ensuring one was done. The Administrator reviewed the Legionella Environmental Assessment Form provided by the Maintenance Director and confirmed the date of 0/28/22 was an error. She stated it should have been dated 11/30/23 which was when the assessment was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide tracheostomy care as prescribed by the physician for 1 of 1 resident reviewed for tracheostomy care. (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including respiratory failure and tracheostomy. A nursing evaluation dated 12/23/21 revealed Resident #1 was admitted into the facility the day prior with a tracheostomy that she was able to care for daily but needed help with monthly inner cannula changes. A physician order dated 08/23/22 revealed an order that read, please assist resident with supplies to perform peri stoma care twice a day for the resident's tracheostomy. Review of Resident #1's physician orders dated 12/22/21 through 06/26/23 revealed no orders for Resident #1 to complete tracheostomy care independently. Review of Resident #1's care plan dated 08/22/23 revealed a focus area for tracheostomy. The goal was for Resident #1 to have clear and equal breath sounds bilaterally through the next review date. Interventions included change the trach collar every month and as needed. Another intervention included providing tracheostomy care per physician orders and as needed. Resident #1 did not have a care plan related to completing tracheostomy care independently. Resident #1's Treatment Administration Record dated May 2023 revealed an order initiated on 11/18/22 which read, Trach care ½ strength peroxide performed twice a day every day and evening shift. The order was initialed as completed by Nurse #1 on 05/01/23 through 05/22/23 with the exception of one day. The order was discontinued on 05/22/23. Resident #1's Treatment Administration Record dated May 2023 revealed an order initiated on 05/23/23 which read, Trach care ½ strength peroxide performed twice a day every day and evening shift. The order was initialed as completed by Nurse #1 on 05/23/23 through 05/26/23. The order was initialed by Nurse #2 on 05/29/23 and 05/30/23. An additional order read, Tracheostomy cannula to be changed monthly and as needed by the Medical Director every day shift starting on the last day of the month every month. The order was initialed as completed by Nurse #2. Resident #1's Treatment Administration Record dated June 2023 revealed an order initiated on 05/23/23 which read, Trach care ½ strength peroxide performed twice a day every day and evening shift. Resident #1 was documented as being at the hospital on [DATE] through 06/12/23. Nurse #1 initialed as completing the order on 06/13/23 through 06/19/23, 06/22/23, 06/23/23 and 06/26/23. Nurse #2 initialed as completing the order on 06/20/23. An interview was conducted with Resident #1 on 06/26/23 at 10:05 AM. She stated she had the tracheostomy from the time she was admitted into the facility. The interview revealed Resident #1 had been responsible for cleaning her tracheostomy since admission. Resident #1 stated she had cleaned it some in the past but had never been shown how to clean it and thought the staff should be cleaning the site instead of her being responsible. She stated, I figured it out on my own. The interview revealed staff did not stand with her while she was cleaning the tracheostomy or ask her if she had cleaned it. Resident #1 stated she had not cleaned her tracheostomy for the last month. The interview revealed she had to tell staff and ask several times in the months prior to change it. On 06/26/23 at 11:25 AM an interview was conducted with Nurse #1. During the interview she stated she did not do all of Resident #1's tracheostomy care. She stated she changed the tracheostomy cannula at the end of each month and allowed Resident #1 to perform her own cleaning care and change the tube daily. Nurse #1 stated she ensured the resident had the supplies she needed at bedside and that it was Resident #1's preference to clean the tracheostomy herself. She stated nurses on the hall could change the tracheostomy cannula and that it didn't not have to be a Physician. Nurse #1 stated she had never witnessed Resident #1 clean her tracheostomy, but she initialed it on the monthly TAR as being completed because she thought the resident was doing it. On 06/26/23 at 12:20 PM an interview was conducted with Nurse #2. Nurse #2 stated Resident #1 completed the task of cleaning her tracheostomy herself and the staff ensured she had the supplies to do so. Nurse #2 stated on the days she signed off on the TAR she stood with Resident #1 and watched her clean her tracheostomy. On 06/26/23 at 1:56 PM a follow up interview was conducted with Resident #1. Resident #1 stated no staff member had ever stood and watched her complete tracheostomy care. She stated, they don't even ask me if I've done it. During the interview Nurse #1 entered the room to provide tracheostomy care with the surveyor present. An observation was conducted of Nurse #1 cleaning Resident #1's tracheostomy site with no debris noted on the Q-tip used to clean the site. After completion of the task Resident #1 stated to Nurse #1 that she had not been cleaning the site. Resident #1 stated she had never seen anyone clean her tracheostomy in the facility as Nurse #1 just had. Resident #1 explained to the surveyor and Nurse #1 that nobody had ever instructed her to clean inside of the tracheostomy and that when she did clean in the past, she was only cleaning the exterior. On 06/26/23 at 2:06 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated Nurses should be following the physician orders. She stated she thought it was in the resident's care plan that she could provide her own tracheostomy care but realized that it wasn't. The DON stated she realized if Resident #1 was going to do her own tracheostomy care she would need a physician order to do so. She stated a previous Nurse Practitioner had a discussion with the resident about performing her own tracheostomy care and that's why staff though she was doing it all along. On 06/26/23 at 2:58 PM an interview was conducted with Nurse #3. During the interview she stated over a year ago Resident #1 had expressed to her that she would like to do her own tracheostomy care. She stated she observed the resident demonstrate back to her how to complete the task and felt like she was competent enough to take on the task. She stated she did not know if the orders were ever changed, nor had she seen her complete tracheostomy care since. On 06/26/23 at 2:25 PM an interview was conducted with the Administrator. The Administrator stated she wasn't aware Resident #1 had not been cleaning her tracheostomy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Resident interviews, the facility failed to maintain accurate Advanced Directives information throughout the medical record for 1 of 1 resident (Resident #54) reviewed for Advanced Directives. The finding included: Resident #54 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD). A review of Resident #54's medical record revealed a pink MOST (Medical Orders for Scope of Treatment) form dated [DATE] that indicated Cardiopulmonary Resuscitation (CPR) should be attempted if the Resident had no pulse and was not breathing. The form was filed face up in the medical record and signed by Resident #54. The admission Minimum Data Set assessment dated [DATE] indicated Resident #54 was cognitively intact. A further review of Resident #54's medical record revealed a yellow DNR (Do Not Resuscitate Order) dated [DATE] which was filed on the back side of the MOST form. An interview was conducted with the Nurse Practitioner on [DATE] at 3:32 PM who explained that Resident #54 was receiving Hospice services for COPD and was a DNR. An interview was conducted with the Director of Nursing (DON) on [DATE] at 9:28 AM. The DON explained that Resident #54 was receiving Hospice services and was a DNR. The DON was asked to review the discrepancy in Resident #54's medical record and noted that there were two Advanced Directives in the medical record with the pink MOST form being the first form that was visible in the record. The DON stated the Hospice nurse must have filed the DNR form in the medical record without informing the facility. The DON continued to explain that the Advanced Directive process was overseen by the Social Worker (SW) (who was on vacation) and the DNR form should have been given to the SW to file on the medical record. The DON indicated that the discrepancy could have had a negative outcome because if in the event Resident #54 was found not breathing and the code status had to be decided, the pink MOST form would have been the first Advanced Directive form in the medical record and would have been acted upon. During an interview with the Administrator on [DATE] at 1:59 PM she explained that the Hospice nurse should not have filed the DNR on the medical record and that the DON should have been informed of the Resident's change in code status so that the proper process could be followed.