Based on observations and staff interviews, the facility failed to label and date leftover food items stored for use and failed to keep a food storage area clean. These practices occurred in the walk-in refrigerator and had the potential to affect food served to residents. The findings included: An initial tour of the kitchen occurred on 9/8/24 at 9:28 AM. The following concerns were identified: a. Items in the walk-in refrigerator that were opened and labeled, but past the use by date included: - a resealable bag of seven prepared biscuits labeled with a use by date of 9/6/24. - a resealable bag of five hamburger patties with a use by date of 9/5/24. b. Items in the walk-in refrigerator that were opened and not labeled or dated included: - one gallon of whole milk. - two resealable bags with opened bags of whipped cream. c. A plastic container of coleslaw was observed on a shelf above unopened cardboard boxes. The boxes had white stains from the coleslaw container which leaked to the shelf below. An interview with the Dietary Manager (DM) on 9/8/24 at 11:33 AM was conducted. She explained kitchen staff had been in-serviced many times before on labeling and storing food items in the refrigerator. She stated staff was rushed from breakfast and a staff member had called out and they put items back in the refrigerator too quickly. An interview with the Administrator on 9/11/24 at 10:00 AM revealed labeling and storing food items had not been an issue for the kitchen in the past. She stated the DM educated kitchen staff on proper labeling and storing of food items after the kitchen tour.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an order for oxygen was clarified and transcribed from a discharge summary on admission for a resident admitted following a re-hospitalization for COVID-19 (coronavirus disease) pneumonia. This deficient practice affected 1 of 2 residents reviewed for respiratory care (Resident #1). The findings included: A hospital Discharge summary dated [DATE] indicated Resident #1's acute on chronic respiratory failure with hypoxia (oxygen not available in sufficient amounts), community acquired pneumonia, chronic obstructive pulmonary disease with exacerbation (COPD-disease that causes breathing difficult) and COVID-19 were resolved within the hospital stay from 1/1/24 through 1/9/24 and she had returned to her baseline oxygen requirements of 3L (liters) of oxygen via nasal cannula continuously and baseline mentation and ultimately able to be discharged on 2L oxygen via nasal cannula after the exam on the date of discharge. Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included COPD and obstructive sleep apnea. A review of Resident #1's physician's orders revealed the following orders: No orders for oxygen therapy A nurses note dated 1/10/24 read in part . Resident c/o of a headache and mild nausea. VSS (vital signs), 157/77, P (pulse) 98, Resp (respirations) 20 spo2 (oxygen saturation) 94% on 4L (liters). A provider progress note written by Nurse Practitioner (NP) dated 1/11/24 indicated Resident #1's physical assessment showed no assessor muscles usage while on 3L of oxygen via nasal cannula. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact, had no behaviors, and received oxygen while a resident. An Occupational Therapy (OT) progress note date 1/17/24 indicated Resident #1 wears 4L continuous oxygen. An Occupational Therapy (OT) progress note date 1/18/24 indicated Resident #1 wears 4L continuous oxygen. An Occupational Therapy (OT) progress note date 1/20/24 indicated Resident #1 wears 4L continuous oxygen. A review of the tab labeled vital signs in Resident #1's medical record revealed the following entries: 1/9/24 at 6:30 PM: Resident #1 was on 4L of oxygen. 1/9/24 at 10:01 PM: Resident #1 was on 4L of oxygen. 1/10/14 at 10:40 AM: Resident #1 was on 3L of oxygen. 1/10/24 at 10:43 PM: Resident #1 was on 4L of oxygen. 1/12/24 at 5:42 AM: Resident #1 was on 2L of oxygen. 1/12/24 at 11:20 AM: Resident #1 was on 4L of oxygen. 1/12/24 at 9:57 PM: Resident #1 was on 2L of oxygen. 1/13/24 at 9:36 PM: Resident #1 was on 3L of oxygen. 1/15/24 at 11:08AM: Resident #1 was on 2L of oxygen. 1/15/24 at 9:45 PM: Resident #1 was on 3.5L of oxygen. 1/16/24 at 9:46 PM: Resident #1 was on 2L of oxygen. An interview with the Assistant Director of Nursing on 2/28/24 at 8:57 AM revealed she was unsure who should have transcribed the order on admission, but she acknowledged Resident #1 had continuous use oxygen in place since her readmission on [DATE] and she should have had an order entered into the electronic medical record on the date of admission which would clarify the correct liters of oxygen Resident #1 should receive via nasal cannula. An interview with the Nurse Practitioner on 2/29/24 at 10:45 AM revealed she was somewhat familiar with Resident #1 and her history. She stated Resident #1 was oxygen dependent and Resident #1 should have orders to reflect her continuous usage in the facility. An interview with the Medical Director on 3/5/24 at 2:54 PM revealed he was somewhat familiar with Resident #1. He stated he was aware of her having a history of COPD and oxygen dependency. He stated he was not aware the facility had not obtained a physician's order for usage of her oxygen following re-admission to the facility. He acknowledged Resident #1 should have an order to reflect her continuous usage in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document vital signs and an assessment when a resident complained of shortness of breath. This deficient practice affected 1 of 2 residents reviewed for inaccurate medical record (Resident #1). The findings included: Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, chronic pain syndrome with uncomplicated opioid dependence, and generalized anxiety disorder. A. An interview with Nurse Aide (NA) #3 on 2/29/24 at 9:11 AM revealed she was very familiar with Resident #1 and had worked with her several times and was assigned to work with Resident #1 from 7:00 AM to 3:00 PM on 1/20/24. She stated Resident #1 usually got out of bed for therapy but recalled saying she felt more tired and short of breath with a slight cough on 1/20/24 between late morning or early afternoon. NA#3 said she took the resident's vitals every day even when the nurse did not assign them as part of the daily vitals required to be obtained for her shift but could not recall exactly what they were on that day. A review of the medical record revealed there were no vital signs recorded by Nurse Aide (NA) #3 (or on her behalf by Medication Aide (MA) #1 or Nurse #1) on 1/20/24. B. An interview with Nurse #1 was conducted on 2/28/24 at 3:09 PM. Nurse #1 was asked if she performed an assessment on Resident #1 and documented it in the medical record, Nurse #1 was unable to locate any documentation in the medical record to reflect an assessment was completed. Nurse #1 was able to recall Resident #1 being short of breath and assessing her to be having a panic attack on 1/20/24; however, the only documentation Nurse #1 made was on the Medication Administration Record when she provided medications at 6:33 PM to Resident #1 for anxiety and pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to complete a comprehensive assessment within the required timeframes for 1 of 1 resident reviewed for resident assessment (Resident #1) and failed to complete the Care Area Assessment (CAA) that addressed the underlying causes and contributing factors for pressure ulcer for 1 of 4 sampled residents (Resident #57). The findings included: 1. Resident #1 was admitted to the facility on [DATE]. A review of Resident #1's electronic medical record revealed the most recent Minimum Data Set (MDS) assessment was coded as a quarterly with an assessment reference date (ARD) of 1/12/22. There were no other MDS assessments that were open or started. An interview was conducted with the MDS Coordinator on 5/25/22 at 11:16 AM with the Director of Nursing (DON) present. The MDS Coordinator stated an annual MDS assessment should have been completed on 4/14/22 for Resident #1 and she had no idea how she had missed it. The MDS Coordinator stated she utilized a tracker that tracked and scheduled all the MDS assessments that were due. The DON stated they usually opened a new assessment once they closed the last assessment, and a new assessment hadn't been opened for Resident #1. An interview with the Administrator on 5/25/22 at 5:50 PM revealed MDS had been a weak area at the facility, and it was mostly due to having only one MDS Coordinator to complete all the resident assessments. The Administrator stated he had just hired another MDS Coordinator to help out his full-time MDS Coordinator. 2. Resident #57 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57 was at risk of developing pressure ulcers/injuries, had no pressure ulcers on admission and received application of nonsurgical dressings. A progress note dated 4/23/22 at 3:58 PM in Resident #57's medical record indicated an open area to his sacrum was observed and measured 1.2 cm (centimeters) in length and 2 cm in width. Foam dressing applied to area. The Care Area Assessment (CAA) for pressure ulcer dated 4/26/22 indicated Resident #57 needed a special mattress or seat cushion to reduce or relieve pressure and had the following intrinsic risk factors: immobility, cognitive loss, incontinence, and poor nutrition. Under the section Analysis of Findings was a statement that read: See activities of daily living (ADL) CAA. There was no ADL CAA in the CAA Summary. An interview was conducted with the MDS Coordinator on 5/25/22 at 11:16 AM with the Director of Nursing (DON) present. The MDS Coordinator stated Resident #57 did not have a CAA for ADL because it was not triggered based on the responses to the questions on his admission MDS. She further stated that she made a mistake and thought she had placed the analysis of findings for the pressure ulcer under his cognitive CAA. The MDS Coordinator stated the pressure ulcer CAA should have been specific to pressure ulcer and she should have completed an analysis of the causes and Resident #57's risk factors that predisposed him to develop a pressure ulcer. An interview with the Administrator on 5/25/22 at 5:50 PM revealed MDS had been a weak area at the facility, and it was mostly due to having only one MDS Coordinator to complete all the resident assessments. The Administrator stated he had just hired another MDS Coordinator to help out his full-time MDS Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #82 was admitted to the facility on [DATE]. Review of Resident #82's quarterly MDS dated [DATE] revealed no diagnosis of cancer or hospice treatment. Electronic medical record review indicated Resident #82 had received a new diagnosis of malignant neoplasm of esophagus on 4/16/2022. Review of electronic hospice records revealed Resident #82 was admitted to hospice services on 4/29/2022 for diagnosis of malignant neoplasm of the esophagus with poor prognosis. Review of Resident #82's electronic medical record revealed a Significant Change in Status Minimum Data Set (MDS) Assessment was not completed after the resident was admitted to hospice services. An interview on 5/25/2022 at 11:16 AM with the MDS Coordinator and Director of Nursing (DON) revealed the MDS Coordinator was aware a significant change MDS should have been completed within 14 days of the resident's admission to hospice. The MDS Coordinator could not explain why the significant change MDS had not been started or completed. An interview on 5/25/2022 at 5:54 PM with the facility Administrator revealed having one MDS Coordinator was not enough for a facility of this size. The Administrator further revealed a recently hired MDS Nurse had been hired, but quit abruptly, leaving the one MDS Coordinator to manage the entire facility. The Administrator stated a replacement had been hired but was not yet on board. The Administrator stated he expected MDS to be completed per regulations. Based on record review and staff interviews, the facility failed to complete the required Significant Change in Status Assessment (SCSA) following admission to hospice care for 2 of 2 residents reviewed for hospice (Resident #23 and Resident #82). The findings included: 1. Resident #23 was re-admitted to the facility on [DATE] with diagnoses that included encephalopathy, dementia, and adult failure to thrive. A progress note dated 5/4/22 at 4:01 PM in Resident #23's medical record indicated a new order was received to admit Resident #23 to hospice. A review of the facility's payer source for Resident #23 indicated hospice Medicaid was active as of 5/5/22. A review of Resident #23's Minimum Data Set (MDS) assessments indicated the most recent MDS was a quarterly dated 5/9/22 and it was in process. A Significant Change in Status Assessment had not been completed within 14 days of Resident #23's admission to hospice care (5/5/22). An interview was conducted with the MDS Coordinator on 5/25/22 at 11:16 AM with the Director of Nursing (DON) present. The MDS Coordinator stated when Resident #23 was re-admitted to the facility, she was admitted to hospice care on 5/5/22. The MDS Coordinator stated she should have initiated a Significant Change in Status Assessment within 14 days of Resident #23 being admitted to hospice care. The MDS Coordinator stated she did not know how or why she missed initiating this assessment for Resident #23. An interview with the Administrator on 5/25/22 at 5:50 PM revealed MDS had been a weak area at the facility, and it was mostly due to having only one MDS Coordinator to complete all the resident assessments. The Administrator stated he had just hired another MDS Coordinator to help out his full-time MDS Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, family and staff interviews, the facility failed to provide showers or complete bed baths for 1 of 6 dependent residents (Resident #150) reviewed for activities of daily living (ADL). The findings included: Resident #150 was admitted to the facility on [DATE] and discharged home on [DATE]. The resident's admitting diagnoses included nondisplaced fracture of the left fibula, unsteadiness on feet, diabetes, and repeated falls. Review of Resident #150's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact, displayed no behaviors for refusing care and required total assistance of 1 staff with bathing. Review of Resident #150's care plan dated 10/25/21 revealed a focus area for ADL functional/rehab potential related to resident being limited in ability to transfer self. The approach was to follow physical therapy/occupational therapy recommendations. Review of the master shower schedule revealed Resident #150 was scheduled for showers on Wednesday and Saturdays on 2nd shift (3:00 PM to 11:00 PM). Review of Resident #150's electronic medical record and bathing sheets documented the following showers and/or complete bed baths: - On Wednesday 10/13/21, Sunday 10/17/21 and Saturday 10/30/21 a shower and/or complete bed bath were documented as completed - There was not a shower or completed bed bath documented as completed on Wednesday 10/20/21, Saturday 10/23/21 and Wednesday 10/27/21. During the month of October 2021, there were 12 consecutive days when a shower or complete bed bath were not documented as completed. - For the month of November 2021, it was documented the resident received her showers or complete bed baths on Wednesday and Saturday. Phone interview on 05/23/22 with Resident #150's responsible party (RP) revealed she visited the resident at least 2 to 3 times per week while at the facility. The RP stated there was a period during her stay that she had not received a shower or bed bath and had a strong scent of body odor. The RP further stated she did not get her hair combed consistently. According to the RP, when she asked staff (could not remember specific names) about Resident 150's showers she was told she had not gotten them due to admissions and COVID positive residents in the building. Interview on 05/23/22 at 3:28 PM with the Unit Coordinator for the rehab unit revealed she remembered Resident #150. The Unit Coordinator stated she did not recall her not getting showers as scheduled and said she was one of the residents she made rounds on daily and recalled giving her a washcloth to wash her face and assisting her with brushing her teeth. The Unit Coordinator stated she did not recall ever noticing the resident having a body odor when she had assisted her. Several attempts were made to contact Nurse Aide (NA) #6 who took care of Resident #150 without success. Interview on 05/25/22 at 5:46 with the Director of Nursing (DON) revealed she was not sure why Resident #150 had not received her showers as scheduled. The DON stated it was her expectation that each resident received their showers as scheduled unless they refused. She further stated if the resident refused, she expected the NAs to try again later in the day to get them to shower. Interview on 05/25/22 at 7:22 PM with NA #3 who took care of Resident #150 revealed when the NAs documented they did not give the resident their complete bed bath or shower it was because of call outs or just a busy evening. NA #3 further stated when they could not get the shower done on 2nd shift, they would pass it on to the next shift and try to get the shower done the next day if not done that evening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews with resident, staff and the physician, the facility failed to conduct blood glucose monitoring as ordered by the physician for 1 of 2 sampled residents (Resident #252). The findings included: Resident #252 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #252 was cognitively intact. A review of Resident #252's Physician's Order summary revealed Resident #252 had an active order for blood glucose monitoring before meals and at bedtime at 7:30 AM, 11:30 AM, 4:30 PM and 8:00 PM. An observation on 5/24/22 at 5:26 PM revealed Nurse #2 was performing Resident #252's blood glucose monitoring. Upon entering Resident #252's room, an empty dinner plate was observed on her bedside table in front of her. Resident #252 stated she had just finished eating her supper. Nurse #2 checked Resident #252's blood sugar by sticking the tip of her right second finger. Nurse #2 told Resident #252 that her blood sugar reading was 194 and that it was high because she had just eaten her supper. During an interview with Nurse #2 on 5/24/22 at 5:50 PM, she stated she should have checked Resident #252's blood sugar before eating but she was late starting her medication pass, so she didn't get to her until after she had already eaten. Nurse #2 further stated Resident #252 did not have a sliding scale insulin related to the blood glucose monitoring order and had a scheduled set dose of regular insulin that should have been given prior to the meal as well. A phone interview with the physician revealed blood glucose monitoring should be done before meals because the result would not be an accurate representation of the blood sugar record for Resident #252. The physician stated eating a meal would cause the blood sugar to be higher than if it was taken before the meal. An interview with the Director of Nursing (DON) on 5/25/22 at 12:14 PM revealed blood glucose monitoring should be done before meals because blood sugar taken after a meal would not be accurate. The DON stated Nurse #2 should have followed the physician's order that indicated to check Resident #252's blood sugar before meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews with staff and pharmacists, the facility failed to maintain a medication error rate of less than 5% as evidenced by omission of 1 medication and failure to administer 4 medications according to physician's orders. These errors constituted 5 out of 29 opportunities, resulting in a medication error rate of 17.24% for 2 of 7 residents (Residents #26 and Resident #252) observed during medication administration. The findings included: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (enlarged prostate gland) (BPH). The Physician's Orders in Resident #26's medical record indicated an active order for the following medications: 12/14/21 - Finasteride 5 mg (milligrams) 1 tablet by mouth once a day at 8:00 AM for BPH. 4/25/22 - Tamsulosin 0.4 mg 1 capsule by mouth once day at 6:00 PM for BPH. An observation was made on 5/24/22 at 7:53 AM of Nurse #1 while she prepared and administered Resident #26's medications. Nurse #1 looked at Resident #26's electronic Medication Administration Record (MAR) and pulled the resident's medications off the medication cart. Nurse #1 did not make a final check to make sure she pulled all of Resident #26's medications that were scheduled to be given at that time. Nurse #1 then proceeded to administer the medications she had pulled to Resident #26 which included one capsule of Tamsulosin 0.4 mg. The medications did not include Resident #26's Finasteride 5 mg tablet. An interview with Nurse #1 on 5/24/22 at 9:12 AM revealed she did not know how she missed giving Resident #26's Finasteride tablet and thought she had included it in the medication cup. Nurse #1 stated she had flipped the screen to show the medications that were due later so she could see any medications that were scheduled for 9:00 AM and include them with the medications that were scheduled for 8:00 AM. Nurse #1 stated she failed to read the full medication order for Tamsulosin and did not see that it was scheduled to be given at 6:00 PM. A phone interview with Pharmacist #1 on 5/24/22 at 11:42 AM revealed Finasteride and Tamsulosin were different medications which could be used together. Finasteride was often used for BPH and to control urinary urgency while Tamsulosin was often used to treat an overactive bladder. Pharmacist #1 stated both medications could not be interchanged because each medication belonged to a different drug class. An interview with the Director of Nursing (DON) on 5/25/22 at 12:14 PM revealed Nurse #1 should have looked at the entire order on the MAR and verified the time the medications were supposed to be given. 2. Resident #252 was admitted to the facility on [DATE] with diagnoses that included gastroesophageal reflux disease (GERD) and diabetes mellitus (DM). The Physician's Orders in Resident #252's medical record indicated an active order for the following medications: 5/13/22 - Insulin aspart 100 units/ml (milliliters) 7 units subcutaneous before meals at 7:30 AM, 11:30 AM and 4:30 PM. Insulin aspart is a short-acting, manmade version of human insulin used to treat diabetes. 5/17/22 - Esomeprazole magnesium 40 mg (milligrams) 1 capsule by mouth twice a day at 6:00 AM and 4:30 PM, give before meals. Esomeprazole is a medication used to treat GERD. 5/23/22 - Sucralfate 1 gram 1 tablet by mouth twice a day at 6:00 AM and 4:00 PM, give before meals. Sucralfate is a medication used to treat ulcers. An observation was made of Nurse #2 on 5/24/22 at 5:22 PM while she administered medications to Resident #252. Upon entering Resident #252's room, an empty dinner plate was observed on her bedside table in front of her. Resident #252 stated she had just finished eating her supper. Nurse #2 proceeded to administer Resident #252's pills which included one capsule of Esomeprazole 40 mg and one tablet of Sucralfate 1 gram. Nurse #2 checked Resident #252's blood sugar by sticking the tip of her right second finger. Nurse #2 told Resident #252 that her blood sugar reading was 194 and that it was high because she had just eaten her supper. Nurse #2 left Resident #252's room and obtained 7 units of Insulin aspart from the medication cart. Nurse #2 then administered Insulin aspart 7 units to Resident #252's right upper arm. An interview with Nurse #2 on 5/24/22 at 5:50 PM revealed she had been late starting her medication pass. Nurse #2 stated she knew she should have checked Resident #252's blood sugar and given her medications before meals but she wasn't familiar with all the residents, and she often got assigned to different halls. A phone interview with Pharmacist #2 on 5/25/22 at 10:40 AM revealed all medications should be given the way they were ordered so if the order stated to give before meals, the medications should be given before meals. Pharmacist #2 stated Sucralfate was a medication used to coat the stomach and act as a barrier to prevent discomfort and indigestion. He also stated Esomeprazole was a medication that prevented acid production and was usually prescribed to be given on an empty stomach because food would affect its absorption. He further stated Insulin aspart was a short-acting insulin that should be given before meals to combat the sugar spike in the blood after consumption of a meal. An interview with the Director of Nursing (DON) on 5/25/22 at 12:14 PM revealed Nurse #2 should have given Resident #252's medications to her before meals.

Based on observations and staff interviews, the facility failed to secure 1 of 4 medication carts (Laurel medication cart) observed during medication administration. The findings included: During an observation of medication administration with Nurse #2 on 5/24/22 from 4:55 PM to 5:08 PM on the Laurel hall, Nurse #2 stepped away from the medication cart to administer medications to Resident #355 in her room. Nurse #2 did not lock the medication cart which was parked outside Resident #355's room and was not within eyesight of Nurse #2 when she went inside Resident #355's room. After administering medications to Resident #355, Nurse #2 pushed the medication cart to the adjacent hall and parked it in front of Resident #68's room. She prepared Resident #68's medication and entered Resident #68's room without locking the medication cart. The medication cart was not within reach or eyesight of Nurse #2 when she was inside Resident #68's room. Other staff members were observed walking in the hallway and Resident #20 in her wheelchair passed by the unlocked medication cart in the hallway. After Nurse #2 administered Resident #68's medication, she exited the room and saw the unlocked medication cart and stated that she forgot to lock the medication cart. An interview with Nurse #2 on 5/24/22 at 5:11 PM revealed that she should have locked the medication cart whenever she stepped away from it. Nurse #2 stated she forgot to do so. An interview with the Director of Nursing (DON) on 5/25/22 at 12:14 PM revealed Nurse #2 should have locked the medication cart whenever she had to step away from it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments to reflect the diagnoses for 2 of 2 residents reviewed for dementia care (Resident #67 and Resident #90) and 1 of 5 residents reviewed for unnecessary medications (Resident #85), use of hearing aid for 1 of 7 residents reviewed for activities of daily living (Resident #55) and urinary continence for 2 of 2 residents reviewed for urinary appliance (Resident #61 and Resident #66). Findings included: 1. Resident #67 was admitted to the facility on [DATE]. Diagnosis included cognitive communication deficit and dementia. Review of Resident #67's annual MDS assessment dated [DATE] revealed resident was not coded as having a dementia diagnosis. Review of Resident #67 revised care plan dated 04/18/22 revealed no care plan specific to dementia. An interview with the MDS Coordinator and Director of Nursing (DON) on 05/25/22 at 12:04 PM revealed Resident #67 has an active diagnosis for dementia and verified resident is not coded for dementia on the MDS assessment and there is no approach for dementia in resident's care plan. The MDS Coordinator and DON further revealed the MDS assessment should reflect active diagnosis and had no knowledge as to why the resident was not coded as having dementia on the MDS or why there is no approach for dementia in resident's care plan. An interview with the Administrator on 05/25/22 at 06:37 PM stated the MDS assessment should reflect current diagnosis for resident. 2. Resident #90 was admitted to the facility on [DATE]. Diagnosis included cognitive communication deficit and dementia. Review of Resident #90's admission MDS assessment dated [DATE] revealed resident was not coded as having a dementia diagnosis. Review of Resident #90's admission care plan dated 05/12/22 for dementia with interventions that included assess degree of disorientation to time, place and person and provide orientation to resident in conversation and monitor response. An interview with the MDS Coordinator and Director of Nursing (DON) on 05/25/22 at 12:07 PM revealed Resident #90 has an active diagnosis for dementia and verified resident is not coded for dementia in MDS assessment. The MDS Coordinator and DON further stated the MDS assessment should reflect active diagnosis and had no knowledge as to why resident was not coded on the MDS assessment as having dementia. An interview with the Administrator on 05/25/22 at 06:37 PM stated the MDS assessment should reflect current diagnosis for resident. 3. Resident #85 was admitted to the facility on [DATE]. Diagnosis included cognitive communication deficit and depression. Review of Resident #85's quarterly MDS assessment dated [DATE] revealed resident was not coded as having a diagnosis of depression. Review of Resident #85's revised care plan dated 04/29/22 for anti-depressant medication use with interventions that included assess and record effectiveness of drug treatment and monitor and report signs of sedation, hypotension, or anticholinergic symptoms. An interview with the MDS Coordinator and Director of Nursing (DON) on 05/25/22 at 12:12 PM revealed Resident #85 has an active diagnosis for depression and verified resident is not coded for depression on the MDS assessment. The MDS Coordinator and DON further revealed the MDS assessment should reflect active diagnosis and had no knowledge as to why resident was not coded on the MDS assessment as having depression. An interview with the Administrator on 05/25/22 at 06:37 PM stated the MDS assessment should reflect current diagnosis for resident. 4. Resident #55 was admitted to the facility on [DATE]. His quarterly Minimum Data Set (MDS) dated [DATE] revealed he had moderate difficulty hearing and did not use a hearing aid. Observation of Resident #55 on 05/22/22 10:38 AM revealed he was wearing a hearing aid in his left ear. Interview with Resident #55 revealed he only wore a left ear hearing aid and kept it in a drawer of his nightstand. Resident #55 stated Nurse Aides (NA) helped him get his hearing aid out of its box every morning. Interview with NA #11 on 5/25/2022 at 2:57 PM revealed Resident #55 did ask for assistance with his hearing aid in the mornings. A joint interview with the MDS Coordinator and Director of Nursing (DON) on 05/25/22 at 11:16 AM revealed the MDS Coordinator was not aware Resident #55 wore a hearing aid. The MDS Coordinator and DON both stated the use of the hearing aid should have been included on the MDS. Interview with the Administrator on 5/25/2022 at 5:54 PM revealed he expected MDS to accurately reflect the current condition of each resident. 6. Resident #66 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 was cognitively intact and had an ostomy appliance particularly a urostomy. The MDS further indicated Resident #66 was occasionally incontinent of urine (less than 7 episodes of incontinence). An observation and interview with Resident #66 on 5/24/22 at 3:19 PM revealed a urostomy bag on the right lower quadrant of her abdomen. Resident #66 stated she had the urostomy for about a year and all her urine went straight into the bag. An interview was conducted with the MDS Coordinator on 5/25/22 at 11:16 AM with the Director of Nursing (DON) present. The MDS Coordinator stated that she made an error in coding the urinary continence in Resident #66's admission MDS and that she should have coded her as not rated because she had a urostomy. The MDS Coordinator stated it might have been a finger slip and she meant to code Resident #66's urinary continence as not rated. An interview with the Administrator on 5/25/22 at 5:50 PM revealed the MDS assessments should be coded accurately. 5. Resident #61 was admitted to the facility on [DATE] with diagnoses which included neurogenic bladder, and obstructive uropathy among others. Review of Resident #61's electronic medical record (EMR) revealed during the look back period of 7 days beginning 04/06/22 and ending 04/12/22 the resident had a urinary catheter during the entire time. Resident #61's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he had an indwelling catheter and was occasionally incontinent of urine. Interview on 05/25/22 at 11:15 AM with the MDS Coordinator and the Director of Nursing (DON) revealed the MDS assessment should have been coded as not rated instead of occasionally incontinent of urine. The MDS Coordinator and the DON both stated it was an error and should have been coded as not rated. Interview on 05/25/22 at 5:54 PM with the Administrator revealed it was his expectation that all MDS assessments accurately reflect the current condition of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #67 was admitted to the facility on [DATE]. Diagnosis included cognitive communication deficit and dementia. Review of Resident #67's annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident was not coded as having a dementia diagnosis. Review of Resident #67 revised care plan dated 04/18/22 revealed no care plan specific to dementia. An interview with the MDS Coordinator and Director of Nursing (DON) on 05/25/22 at 12:04 PM revealed Resident #67 has an active diagnosis for dementia and verified resident was not coded for dementia in the MDS assessment dated [DATE] and there is no approach for dementia addressed in resident's care plan. The MDS Coordinator and DON further revealed resident's care plan should reflect active diagnosis and had no knowledge as to why the resident was not coded as having dementia on the MDS assessment or why there is no approach for dementia in resident care plan. An interview with the Administrator on 05/25/22 at 06:37 PM stated the resident's care plan should reflect current diagnosis for resident. Based on record review, observations and resident and staff interviews, the facility failed to develop a comprehensive person-centered plan of care to address specific needs of the residents in the areas of activities of daily living for 2 of 7 residents reviewed (Resident #57 and Resident #66) and dementia care for 1 of 2 residents reviewed (Resident #67). The findings included: 1. Resident #57 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #57 was severely impaired for cognitive skills for daily decision making and had fluctuating altered level of consciousness. The MDS further indicated Resident #57 required extensive physical assistance with all activities of daily living including transfer and had impairment to both sides of upper and lower extremities. Resident #57 was always incontinent of both urine and bowel. A review of Resident #57's care plans indicated the following information: a. Initiated on 4/26/22 - Resident #57 was limited in ability to transfer self. The goal of Resident #57 to safely transfer self independently was listed and the only approach was to follow therapy recommendations. b. Initiated on 4/26/22 - Resident #57 had actual skin integrity issues related to weakness and incontinence. The goal that Resident #57 would not have any signs and symptoms of infection was listed and the only approach was to keep call light in reach. c. Initiated on 5/18/22 - Resident #57 required an indwelling urinary catheter. An observation of incontinence care on Resident #57 on 5/24/22 at 12:59 PM revealed Resident #57 did not have an indwelling urinary catheter. An interview with Nurse Aide (NA) #1 on 5/24/22 at 1:13 PM revealed she had taken care of Resident #57 ever since he was admitted to the facility, and she did not remember him ever having an indwelling urinary catheter. An interview with the Rehabilitation Director on 5/24/22 at 10:23 AM revealed Resident #57 received therapy services when he was admitted to the facility, but they were stopped on 4/27/22 when his family member had deferred therapy services. An interview was conducted with the MDS Coordinator on 5/25/22 at 11:16 AM with the Director of Nursing (DON) present. The MDS Coordinator stated she did not know why Resident #57 had a care plan for both urinary incontinence and indwelling urinary catheter. She couldn't remember if Resident #57 had a urinary catheter when he was first admitted to the facility. The MDS Coordinator further stated Resident #57 being able to transfer self was not reflective of Resident #57's current functional ability. An interview with the Administrator on 5/25/22 at 5:50 PM revealed care plans should be tailored to reflect the specific resident they were developed for and should not be generic. He stated Resident #57's care plan should indicate his current level of functional status including his continence and should not indicate both urinary incontinence and the presence of a urinary indwelling catheter. 2. Resident #66 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 was cognitively intact, required extensive physical assistance with toileting and had an ostomy appliance specifically a urostomy. A review of Resident #66's care plan initiated on 5/18/22 indicated Resident #66 required a nephrostomy related to neurogenic bladder. The following goal was listed: Resident #66 will have nephrostomy catheter care managed appropriately as evidenced by: not exhibiting obstruction, signs of infection, dislodgment of catheter, bowel perforation or trauma. An observation and interview with Resident #66 on 5/24/22 at 3:19 PM revealed a urostomy bag on the right lower quadrant of her abdomen. Resident #66 stated she had the urostomy for about a year and all her urine went straight into the bag. Resident #66 stated she did not have a nephrostomy tube. An interview was conducted with the MDS Coordinator on 5/25/22 at 11:16 AM with the Director of Nursing (DON) present. The MDS Coordinator stated she did not know why Resident #66 had a care plan for nephrostomy instead of urostomy. The DON stated she got confused when staff asked her about Resident #66's urostomy and she noted that Resident #66 had been care planned for nephrostomy instead of urostomy. An interview with the Administrator on 5/25/22 at 5:50 PM revealed care plans should be tailored to reflect the specific resident they were developed for and should not be generic. He stated Resident #66's care plan was not accurate and should have indicated that she had a urostomy instead of a nephrostomy tube.

Based on record reviews, observations and staff interviews, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19 when 2 of 2 staff members (Nurse #2) failed to wear an N95 mask prior to entering a room of a COVID-19 positive resident (Resident #252) and (Nurse Aide #1) failed to remove her N95 mask, disinfect her goggles and perform hand hygiene after leaving a room of a COVID-19 positive resident (Resident #251). In addition, 2 of 3 staff members (Nurse #3 and Nurse #1) failed to perform hand hygiene during wound care on 2 of 3 residents (Resident #57 and Resident #61) reviewed. These failures occurred during a COVID-19 pandemic. The findings included: The Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 2/2/22 indicated the following information under Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection: *HCP (healthcare personnel) caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). The facility's infection control policy entitled, Personal Protective Equipment, revised on 4/22/22 indicated the following Personal Protective Equipment (PPE) were required in the COVID-19 positive unit: N95 mask at all times, face shield and/or goggles must be worn at all times and must be cleaned upon being visibly soiled and when leaving the unit, gown must be worn in all rooms and with patient contact and gloves must be worn in residents' rooms and must be changed when soiled and between residents. During the entrance conference with the Director of Nursing (DON) on 5/22/22 at 10:03 AM, the DON stated that the facility had 4 residents who had tested positive for COVID-19 and were on enhanced droplet precautions. 2 of the 4 COVID-19 positive residents were Resident #252 and Resident #251. 1. During a medication pass observation on 5/24/22 at 5:22 PM with Nurse #2, she was observed preparing to give medications to Resident #252. The door to Resident #252's room was closed, and PPE was located on a hanging organizer on the door as well as a plastic drawer cart next to Resident #252's door. Nurse #2 put on a gown and gloves in addition to the goggles and a black KN95 mask that Nurse #2 was wearing. Prior to entering the room to administer Resident #252's medications, Nurse #2 was asked if she needed to change her mask into one of the N95 masks on the hanging organizer. Nurse #2 stated she didn't need to and didn't like the way the N95 mask fit on her face. Nurse #2 went inside Resident #252's room while wearing a KN95 mask, goggles, gown, and gloves and administered Resident #252's medications. While inside, a staff member knocked on the door and handed Nurse #2 an N95 mask. Nurse #2 placed the N95 mask in her pocket. When she was done administering Resident #252's medications, Nurse #2 removed her gown, gloves and KN95 mask and discarded them into the trash can inside Resident #252's room. While exiting the room, she placed the N95 mask that was in her pocket on her face, disinfected her goggles with a disinfecting wipe and used hand sanitizer to both hands. An interview with Nurse #2 on 5/24/22 at 5:50 PM revealed she did not know that the black mask that she was wearing was a KN95 mask and was different from the N95 masks that were available at Resident #252's room. Nurse #2 stated she was wondering why a staff member handed her an N95 mask when she was inside Resident #252's room and thought it was just a mask she could change into when she exited Resident #252's room. An interview with the Infection Preventionist (IP) on 5/25/22 at 5:04 PM revealed Nurse #2 had received education regarding PPE use especially for COVID-19 positive residents and she should have looked at the signs on the door. The IP stated he had talked to Nurse #2, and she did not know the difference between the KN95 masks and N95 masks, and Nurse #2 thought they were the same. The IP stated he needed to work on providing more education to staff regarding the COVID-19 unit. He also stated the facility had plenty of PPE supplies including the N95 masks that were required to be used for COVID-19 positive residents. An interview with the Director of Nursing (DON) on 5/25/22 at 12:14 PM revealed Nurse #2 was fairly new to the facility, and she was not sure if Nurse #2 had worked with COVID-19 positive residents before but they needed to provide education to her so she would know what PPE to use when providing care to COVID-19 positive residents. 2. The Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 2/2/22 indicated the following information under Manage Residents with Suspected or Confirmed SARS-CoV-2 Infection: *HCP (healthcare personnel) caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). The facility's infection control policy entitled, Personal Protective Equipment, revised on 4/22/22 indicated the following Personal Protective Equipment (PPE) were required in the COVID-19 positive unit: N95 mask at all times, face shield and/or goggles must be worn at all times and must be cleaned upon being visibly soiled and when leaving the unit, gown must be worn in all rooms and with patient contact and gloves must be worn in residents' rooms and must be changed when soiled and between residents. During the entrance conference with the Director of Nursing (DON) on 5/22/22 at 10:03 AM, the DON stated that the facility had 4 residents who had tested positive for COVID-19 and were on enhanced droplet precautions. 1 of the 4 COVID-19 positive residents were Resident #251. During an observation of the COVID unit on 05/23/22 at 9:00 AM there were 4 rooms on the left side of the hall that were designated as COVID (+) rooms with signage and personal protective equipment either in caddies on the door or in cabinets outside the door. Nurse Aide (NA) #1 was observed coming out of Resident #251's room with N95 mask on, goggles, gloves and gown and placed the resident's meal tray inside the dining cart. NA #1 then removed her gown and gloves and without sanitizing her goggles, changing her mask or sanitizing her hands she proceeded down the hall to a non-COVID area to another dining cart talking with another staff member. Interview on 05/23/22 at 9:06 AM with NA #1 revealed she had taken the breakfast tray out of Resident #251's room and stated she forgot to sanitize her goggles and change her mask because she was busy. NA #1 stated she knew she was supposed to change her mask and clean her goggles but had failed to do so when she came out of the resident's room and before going to the non-COVID area of the building. Interview on 05/23/22 at 9:20 AM with the Director of Nursing (DON) who was at the nurse's station and heard part of the interview with NA #1 revealed she would provide more education to NA #1 about proper use of personal protective equipment (PPE). The DON stated NA #1 had been educated to change her mask and clean her goggles but said they would provide additional education to her one on one. Interview on 05/25/22 at 5:04 PM with the Infection Preventionist revealed NA #1 had received education regarding PPE use specifically for COVID-19 positive residents and she should have looked at the signs on the door. The IP preventionist stated he needed to work on providing more education to staff regarding the COVID-19 unit and PPE use when working on the unit. He also stated the facility had plenty of personal protective equipment (PPE) supplies including the N95 masks that were required to be used for the COVID-19 positive residents. Follow up interview on 05/25/22 at 12:14 PM with the Director of Nursing (DON) revealed NA #1 had worked with COVID-19 residents before during an outbreak but said they needed to provide education again to her about proper use of PPPE when providing care to COVID-19 positive residents. 3. The facility's infection control policy entitled, Handwashing/Hand Hygiene, revised in August 2015 indicated the following statements: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. After removing gloves 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. An observation of wound care on Resident #57 was made on 5/24/22 at 12:59 PM by Nurse #3. Nurse #3 was observed using hand sanitizer to both hands prior to putting gloves on to start the procedure. Nurse #3 removed an old dressing from Resident #57's left hand which revealed a skin tear. Nurse #3 removed her gloves and put a new one on without sanitizing her hands. She cleaned the skin tear with a normal saline-soaked gauze and applied a foam dressing. Nurse #3 removed her gloves and put on a new one without sanitizing her hands. Nurse #3 proceeded to remove an old dressing from Resident #57's sacrum and wiped Resident #57's bottom with an incontinence wipe. She removed her gloves and put on a new pair without sanitizing her hands. She cleaned Resident #57's sacral wound with a normal saline-soaked gauze and then removed her gloves. She put on new gloves without sanitizing her hands first and then applied the ordered treatment to Resident #57's wound and covered it with a foam dressing. She then repositioned Resident #57 and placed a pillow underneath his legs. Nurse #3 removed her gloves and washed her hands in the sink inside the room. An interview with Nurse #3 on 5/24/22 at 4:34 PM revealed she had received education on hand hygiene during wound care which consisted of washing hands before starting procedure and making sure to change gloves after removing an old dressing. Nurse #3 stated she had missed the step of doing hand hygiene after removing her gloves and that she realized it as soon as she was done with performing wound care on Resident #57. Nurse #3 stated she was focused on making sure that she changed her gloves that she forgot to do hand hygiene in between. She further stated she should have kept a hand sanitizer handy or washed her hands in the sink prior to putting on clean gloves during the procedure. An interview with the Infection Preventionist (IP) on 5/25/22 at 5:04 PM revealed all staff members had been educated to wash their hands or use a hand sanitizer after removing gloves especially while performing wound care. The IP stated Nurse #3 should have sanitized her hands whenever she removed her gloves when she changed Resident #57's wound dressing. An interview with the Director of Nursing (DON) on 5/25/22 at 12:14 PM revealed Nurse #3 should have done hand hygiene after removing her gloves. The DON stated the facility used to have hand sanitizer that were small and could be carried around by staff, so they had something convenient to use but they no longer had those available. 4. The facility's infection control policy entitled, Handwashing/Hand Hygiene, revised in August 2015 indicated the following statements: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. After removing gloves 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Observation on 05/24/22 at 3:02 PM of wound care on Resident #61 by Nurse #1 was made. Nurse #1 washed her hands and donned clean gloves to start the procedure. Nurse #1 removed the old dressing from Resident #61's right leg. Without removing her gloves or sanitizing her hands she moved to the left leg and removed the old dressing from the left leg. Both legs were resting on a clean pad Nurse #1 had placed under the resident's legs before starting the procedure. With the same gloves on and without sanitizing her hands Nurse #1 opened a gauze pack and poured normal saline into the package and with her gloved hand removed the gauze and cleansed the right foot wound. Without removing the gloves or sanitizing her hands she opened a 2nd gauze packet and patted dry the wound she had cleansed and rested the resident's leg on the pad. Without changing her gloves or sanitizing her hands she opened a third packet of gauze and poured saline into the packet and cleansed the wound on the left calf area. Without removing her gloves or sanitizing her hands she opened a 4th packet of gauze and patted the area on the left calf dry. Without removing her gloves or sanitizing her hands she moved back to the resident's right leg and wrapped the leg from the toes to 3 fingers below the knee with kerlix. Without removing her gloves or sanitizing her hands, she then wrapped the leg with Coban (light weight cohesive elastic that adheres to itself for compression or support) over the kerlix. Nurse #1 without removing her gloves or sanitizing her hands moved to the left leg and wrapped the left leg with kerlix and then without removing her gloves or sanitizing her hands she wrapped Coban over the kerlix. After completing the wound care to Resident #61, Nurse #1 tossed the remaining supplies in the trash, and she removed her gloves and washed her hands in the sink inside the room with soap and water. Interview on 05/24/22 at 3:53 PM with Nurse #1 revealed she had received education on hand hygiene during wound care which consisted of washing hands before starting procedure and making sure to change gloves after removing an old dressing. Nurse #1 stated she was nervous and forgot to sanitize her hands and change her gloves after removing the old dressings and forgot to sanitize her hands and change gloves when moving from one leg to the other leg. She stated there was no hand sanitizers in the rooms but said she should have gotten some to use in the room during the wound care. Interview on 05/25/22 at 5:04 PM with the Infection Preventionist (IP) revealed all staff members had been educated to wash their hands or use a hand sanitizer after removing gloves especially while performing wound care. The IP stated Nurse #1 should have sanitized her hands and removed her gloves after removing the old dressings and repeated the procedure when moving from the left leg to the right leg during Resident #61's wound care. Interview on 05/25/22 at 12:14 PM with the Director of Nursing (DON) revealed Nurse #1 should have changed her gloves and performed hand hygiene after removing her gloves. The DON stated the facility used to have hand sanitizers that were small and could be carried around by staff, so they had something convenient to use but they no longer had those available.

Based on record review and staff interviews the facility failed to implement an effective process for tracking COVID-19 vaccination status of 5 of 5 facility staff (Nurse Aide (NA) #3, NA #7, NA #8, NA #9, and NA #10) reviewed for COVID-19 Vaccination Status. The facility was currently in outbreak status and failed to have 100% of staff vaccinated. The findings included: The facility's COVID-19 Vaccine policy with no reviewed or revised date, read in part: It is the policy that all persons be offered the COVID-19 vaccine. This includes residents and staff. Staff includes all fulltime, part-time and prn employees, contract staff such as therapy, staffing agency, management company and consultants. The COVID-19 vaccine is not considered a condition of employment. Review of the facility's surveillance line list for residents and staff received on 05/22/22 revealed a COVID outbreak was identified on 05/20/22 and 2 residents tested positive for COVID-19. In addition, 2 other residents were admitted from the hospital with COVID-19 so there was a total of 4 residents at the facility who were positive for COVID-19 and on transmission-based precautions. The facility COVID-19 staff vaccination spreadsheet provided by the Administrator on 05/22/22 was reviewed and included in-house staff and contract staff. NA #8 was listed on the facility employee line list with no vaccine status indicated by her name. NA #3, NA #7, NA #9, and NA #10 who were all listed as facility staff were listed as partially vaccinated and had only received one dose of a two-dose vaccine. A review on 05/22/22 of the National Healthcare Safety Network (NHSN) data for the week ending on 05/08/22 revealed the following staff vaccination information: · Recent Percentage of Staff who are Fully Vaccinated = 78.9%. An interview on 05/25/22 at 4:00 PM with Nurse Aide (NA) #3 revealed she had been sent during shift on 05/25/22 to get her 2nd dose of her vaccine and was currently working at the facility. She stated it had just slipped her mind to go back and get her 2nd dose of the vaccine. A phone interview on 05/25/22 at 8:30 PM with NA #7 revealed she had received her 2nd dose of the COVID-19 vaccine on 05/25/22. She stated she had been contacted by the facility to go get her 2nd dose of the vaccine. Phone interviews were attempted on 05/25/22 at 4:16 PM with NA #8, NA #9, and NA #10 without success. An interview on 05/25/22 at 5:34 PM with the Infection Preventionist (IP) and the Wellness Coordinator (WC) revealed the WC was responsible for COVID testing, tracking resident and staff vaccinations, weekly NHSN reporting and updating tracking reports weekly. The IP stated the WC did not realize the seriousness of the tracking of the vaccination status of the employees and stated going forward they were putting a process in place so that no one is hired and allowed to work unless they are fully vaccinated or have an exemption. The WC indicated she had reminded staff each week during testing to get their 2nd vaccine but stated she had not reported to anyone the staff that had not received the vaccinations. The WC further indicated all the NAs that were partially vaccinated were past due for their second vaccine and had been reminded to get the vaccine. The WC and IP both said the NAs that were partially vaccinated had not requested exemptions from the vaccine. An interview on 05/25/22 at 6:02 PM with the Administrator revealed the Wellness Coordinator did not realize the seriousness of tracking the staff vaccination status. He stated going forward they were putting a process improvement plan (PIP) in place so that no employee is hired to work until they are fully vaccinated, and the facility has received proof of their vaccine status.