**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff and Nurse Practitioner (NP) interviews, the facility failed to assess whether the self-administration of medication was clinically appropriate before leaving medication at the bedside. This was for 1 of 5 residents (Resident #87) reviewed for medication administration. Findings included: Resident #87 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breath). A review of Resident #87's medical record did not reveal a self-administration of medication assessment. A review of Resident #87's physician's orders did not reveal a physician's order to self-administer any medication. A physician's order dated 8/15/24 revealed Trelegy Ellipta (a long term medication to treat COPD) blister with device; 100-62.5-25 microgram (mcg) administer one puff inhalation once daily at 9:00 AM for COPD. A review of Resident #87's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. A review of Resident #87's comprehensive care plan dated last reviewed on 2/12/25 did not reveal any evidence Resident #87 self-administered medication. On 2/24/25 at 10:42 AM Resident #87 was observed in bed. She had her Trelegy Ellipta inhaler on her bedside table. An interview with Resident #87 at that time indicated she did not usually keep the medication at her bedside. She stated this medication was for her breathing and she took one inhalation daily each morning. She reported she must have been asleep when Nurse #3 brought the medication earlier and she had not taken the inhaler yet that morning. Resident #87 was then observed to administer one inhalation from the inhaler to herself. A review of Resident #87's February 2025 Medication Administration Record (MAR) revealed documentation by Nurse #3 on 2/24/25 indicating she administered one inhalation of Resident #87's Trelegy Ellipta inhaler to her at 9:00 AM that morning. On 2/25/25 at 12:05 PM an interview with Nurse #3 indicated she was assigned to care for Resident #87 on 2/24/25 from 7:00 AM to 3:00 PM. She stated she was familiar with Resident #87 and had cared for her before. She reported Resident #87 did not self-administer any medication. Nurse #3 stated she administered one inhalation of Resident #87's Trelegy Ellipta inhaler to her on 2/24/25 at 9:00 AM and then must have inadvertently left the inhaler at Resident #87's bedside. She reported that if Resident #87 had taken another dose of the medication on 2/24/25 at 10:42 AM, this would have been a medication error. On 2/27/25 at 9:01 AM an interview with the Director of Nursing (DON) indicated Resident #87 should not have any medication left at her bedside without a self-administration of medication assessment indicating this was appropriate for Resident #87, and a physician's order to self-administer the medication. On 2/27/25 at 9:51 AM an interview with Resident #87's NP #1 indicated that while taking an additional dose of Trelegy Ellipta inhaler medication on 2/24/25 would not have caused any harm to Resident #87, the medication should not have been left at her bedside. On 2/27/25 at 11:30 AM an interview with the Administrator indicated Nurse #3 was a very experienced nurse. She stated leaving medication at a resident's bedside would be very unusual for Nurse #3. The Administrator reported she felt this was just a one-time mistake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of falls for 1 of 5 residents reviewed for accidents (Resident #87). Findings included: Resident #87 was admitted to the facility on [DATE]. A review of a nursing progress note for Resident #87 dated 1/25/25 at 4:45 PM written by Nurse #2 revealed Resident #87 had a fall from her bed. Resident #87 had no skin tears, limited range of motion or dizziness after her fall. Resident #87 was complaining of mild pain to her right hip and right knee. A review of Resident #87's quarterly MDS assessment dated [DATE] revealed she had no falls since her prior MDS assessment. On 2/26/25 at 12:46 PM an interview with Nurse #2 confirmed Resident #87 had a fall from her bed on 1/25/25. On 2/26/25 at 1:13 PM in an interview the MDS Coordinator stated she coded the falls section of Resident #87's MDS assessment dated [DATE]. She reported she normally looked at progress notes for information when coding this section. She went on to say the date of Resident #87's prior MDS assessment was 1/21/25, so the fall Resident #87 experienced on 1/25/25 should have been captured on Resident #87's 2/12/25 MDS assessment. She reported it was an oversight on her part. On 2/27/25 at 9:01 AM an interview with the Director of Nursing indicated resident's MDS assessments should accurately reflect their status. On 2/27/25 at 11:30 AM an interview with the Administrator indicated resident's MDS assessments should be coded accurately.

Based on observation, record review and staff interview, the facility failed to follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a hemodialysis catheter when Nurse Aide (NA) #1 and NA #2 provided a bed bath without wearing gowns for 2 of 20 staff observed for infection control (NA #1 and NA #2). Findings included: The facility policy titled Enhanced Barrier Precautions (EBP) dated 4/30/24 stated in part: EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gowns and gloves use during high contact resident care activities for residents with indwelling medical devices. The policy gave the example of bathing and dressing as a high contact activity. Observation of Resident #103's door on 2/26/25 at 9:03 AM revealed signage for EBP. The signage indicated that staff providing high contact care to Resident #103 were required to wear gowns and gloves. Further observation revealed a caddy outside Resident #103's room that contained Personal Protective Equipment (PPE) including gowns and gloves. An observation of NA #1 and NA #2 providing a bed bath and dressing Resident #103 was conducted on 2/26/25 at 9:05 AM. NA #1 and NA #2 were observed performing hand hygiene and donning gloves before providing the care. Resident #103 was observed to have a hemodialysis catheter (a tube with connectors) inserted in his right upper chest area. Neither NA #1 nor NA #2 donned gowns before providing high contact care to Resident #103. An interview was conducted with NA #1 and NA #2 on 2/26/25 at 9:30 AM. Both NAs stated they thought the EBP sign on the door was for Resident 103's roommate. When asked to give examples of who should be on EBP they stated residents with wounds, intravenous lines and urinary catheters. They could not recall other reasons a resident would require EBP for high contact care and did not think a hemodialysis catheter was included in reasons to require EBP. NA #1 and NA #2 both stated they had training on EBP at least one time. An interview was conducted with the Infection Preventionist on 2/26/25 at 9:34 AM. The Infection Preventionist stated all residents with an indwelling medical device, which included a hemodialysis catheter, would require EBP for high contact care such as bathing and dressing. The Director of Nursing (DON) was interviewed on 2/26/25 at 9:46 AM. The DON stated she was unaware a hemodialysis catheter required EBP for high contact care. Unit Manager (UM) #2 was interviewed on 2/26/25 at 10:05 AM. UM #2 stated a hemodialysis catheter did not require EBP for high contact care. In an interview with the Administrator on 2/26/25 at 10:38 AM she stated EBP was required for any resident with an indwelling medical device such as a hemodialysis catheter when staff were providing high contact care. She further stated staff were trained on EBP upon hire and annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and Responsible Party (RP) interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record and failed to honor the resident's wishes with regards to code status as expressed by the resident's RP on admission. This was for 1 of 11 residents (Resident #94) reviewed for advanced directives. Findings included: A review of Resident #94's hospital Discharge summary dated [DATE] revealed his code status in the hospital was full code (a medical term that indicates a patient wants to receive all available measures to save their life in an emergency). It was initialed by Unit Manager #1 indicating she reviewed the document. Resident #94 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of the facility's admission document titled NC Advanced Directive for Healthcare dated [DATE] and signed by Resident #94's RP and the facility's Admissions Director revealed documentation indicating Resident #94 had previously executed an advanced directive (Living Will or Healthcare Power of Attorney) and would provide a copy to the facility. A review of the facility admission document titled DNR (Do not Resuscitate is a legal order written to respect the wishes of a patient not to undergo cardiopulmonary resuscitation (CPR) if their heart stopped or they were to stop breathing) dated [DATE] and signed by Resident #94's RP and the facility's Admissions Director revealed documentation indicating Resident #94 had a DNR order or MOST (Medical Orders for Scope of Treatment) previously executed on his behalf and a copy would be provided to the healthcare center. A review of Resident #94's physician's orders revealed a code status order for full code dated [DATE] entered by Unit Manager #2. A review of Resident #94's comprehensive care plan revealed a focus area for advanced directives initiated on [DATE] indicating Resident #94's code status was full code. The goal was for Resident #94's wishes and directives to be carried out in accordance with his advanced directives on an ongoing basis. An intervention was to discuss advanced directives with Resident #94 and/or his appointed health care representative. A review of a Social Work (SW) progress note for Resident #94 dated [DATE] at 11:35 AM written Resident #94's SW revealed Resident #94's code status was DNR. A review of Resident #94's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. A review of Resident #94's medical record did not reveal a copy of his advanced directives. On [DATE] at 1:51 PM a telephone interview with Resident #94's RP indicated she completed the admissions paperwork for Resident #94 when he was admitted to the facility as he had not been capable of doing this. She stated Resident #94 had both a living will, and a healthcare power of attorney which listed her as his RP. She reported that she expressed that he had these things when she completed Resident #94's admission paperwork and also expressed that Resident #94's wish for code status was DNR. She stated she had provided the facility with a copy of these documents. She reported no one from the facility had ever let her know they did not have them, or she would have gladly provided them again. Resident #94's RP went on to say she participated in all Resident #94's care plan meetings, but she did not recall Resident #94's code status or advanced directives being discussed there. She stated she was not aware that Resident #94's code status in the facility had been full code since his admission, and this would not be what he wanted. On [DATE] at 2:52 PM an interview with the Admissions Director indicated she completed Resident #94's admission paperwork with his RP. She stated if a resident or RP indicated a resident had advanced directives she checked that box on the admission form. She stated if Resident #94's advanced directives were not in his record, it might be that his RP had not provided it to the facility. She reported she did not follow up after the initial admission paperwork was completed to ensure that the documents were received. The Admissions Director stated for code status, if a resident or RP expressed the wish to be a DNR, she checked that box on the admission form and also put a check in the box in the residents electronic record which caused a DNR flag to appear in the electronic record on the resident's face sheet for the nurses to see. She reported it would then be the nurse's responsibility to get the DNR order. On [DATE] at 8:10 AM an interview with Unit Manager #2 indicated she entered the full code order for Resident #94 into his electronic medical record on [DATE] based on the information she obtained from his hospital discharge summary. She stated Resident #94 was not residing on her unit, so she had not looked for any advanced directive paperwork, or a DNR or MOST form. She stated Unit Manager #1 would have been responsible for this. On [DATE] at 8:16 AM an interview with Unit Manager #1 indicated she did not follow up with residents or their RP's if they indicated the resident had advanced directives such as a living will or a health care power of attorney on admission to ensure a copy was obtained for the residents record. She reported she did recall on Resident #94's admission to the facility, the banner on his electronic record face sheet said DNR, and he had a full code order in place. She went on to say at some point the SW had been doing an audit to ensure resident's face sheet banner code status matched the code status order, and Resident #94's face sheet banner had been changed to full code. She stated she had checked with the SW, and the SW told her Resident #94 was a full code. She reported if a resident's admission paperwork indicated their wish was for a DNR code status, and the physician's order was for a full code status, she did try to clarify with the resident or their RP, but she had not done this for Resident #94. On [DATE] at 8:28 AM an interview with the SW indicated she did not recall why she documented Resident #94's code status was DNR in her progress note dated [DATE]. She stated if a resident had advanced directives paperwork such as a living will or a health care power of attorney, the Admissions Director would let her know and the Admissions Director would get copies of the documents and upload them into the residents medical record. She reported she had completed the audit for ensuring that residents code status physician's order and face sheet code status banner matched and recalled that Resident #94's banner indicated a DNR code status, but the physician's order was for full code. She stated when she didn't see any advanced directive paperwork such as a living will or a healthcare power of attorney in Resident #94's record she told Unit Manager #1 that Resident #94 was a full code. She stated she had not clarified the issue with Resident #94's RP. The SW stated Resident #94's RP did attend his care plan meetings, and she did not recall Resident #94's RP ever telling her he wanted to be a DNR code status. On [DATE] at 9:27 AM an interview with the Director of Nursing indicated if a resident or their RP indicated on admission that the resident had a living will or a health care power of attorney, the Admissions Director should be ensuring there were copies of the documents in the residents medical record. She went on to say if a resident's wishes were to be a DNR code status, that's what their code status should be, and the Unit Managers should be ensuring a goldenrod DNR form or a MOST form were obtained for the resident. On [DATE] at 11:30 AM an interview with the Administrator indicated the facility had a system in place where they asked on admission whether a resident had a living will or a health care power of attorney. She stated if Resident #94's RP indicated he had these, someone should have ensured a copy was obtained and included in Resident #94's medical record. The Administrator reported if a resident or a resident's RP expressed that the resident's wishes were to be a DNR code status, then that's what it should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review the facility failed to attempt alternatives prior to installing side rails for 2 of 4 residents (Resident #18 and Resident #98) reviewed for side rails. Findings included: 1. Resident #18 was admitted to the facility on [DATE] with a diagnosis of diffuse traumatic brain injury. A review of Resident #18's record revealed an assessment titled restraint-adaptive equipment use dated 8/23/24 and completed by Unit Manager (UM) #1 indicated no answer was provided for the question have alternatives to restraint or adaptive equipment been tried in the past?. The choices were yes, no or not applicable. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #18 was moderately cognitively impaired. The MDS indicated Resident #18 required substantial to maximum assistance with bed mobility, transfers, and was non-ambulatory. The MDS revealed Resident #18 had no impairment of both upper and lower extremities. The MDS indicated Resident #18's siderails were not used as a restraint. A care plan with the latest review date of 1/17/25 revealed a problem of use of one quarter side rails for increasing or maintaining current bed mobility. The goal was Resident #18 would remain safe through the next review. The approach was for Resident #18 used one quarter side rails for turning and repositioning during incontinence care. An observation on 2/24/25 at 1:03 PM revealed Resident #18 lying in bed with bilateral one-quarter length side rails in the up position on the bed. An observation on 2/25/2025 at 12:09 PM revealed Resident #18 sitting in her bed with the head raised at a 45-degree angle. The side rails were observed to be in the raised position. An interview with Nurse #1 on 2/25/25 11:58 am revealed the Nurses completed the restraint-adaptive equipment use evaluation on admission and quarterly. Nurse #1 stated this form was used for side rail screening. She further stated she always answered no to the question Have alternatives to restraint or adaptive equipment been tried in the past?. Nurse #1 indicated side rails were on the beds on admission. She further indicated Nursing did not try alternatives to side rails before they were used, and she could not think of alternatives to try instead of using side rails. Nurse #1 was not aware alternatives needed to be tried before using side rails. In an interview with UM #1 on 2/25/25 at 12:03 PM she stated she recalled completing the restraint-adaptive equipment use evaluation for Resident #18. She further stated she was not aware of a time the facility tried alternative side rails. She was not aware alternatives to side rails needed to be attempted before using them, so she did not answer the question. In an interview with the Director of Nursing (DON) on 2/25/25 at 12:09 PM she stated Nursing completed the restraint-adaptive equipment use evaluation on admission and quarterly. She further stated they did not try interventions before using side rails as she was not aware this was a requirement. The DON revealed side rails were always on the beds. If a resident did not need them, then they were kept in the down position. In an interview with the Administrator on 2/25/25 at 12:34 PM she stated alternative interventions to siderails were not tried before implementation as she was unaware that this was a requirement. 2. Resident #98 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) of left side of body following cerebral infarction (stroke). A review of Resident #98's record revealed an assessment titled restraint-adaptive equipment use evaluation dated 10/4/24 and completed by Nurse #1 indicated no alternatives to restraint or adaptive equipment been tried in the past. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #98 was cognitively intact and was dependent on staff for bed mobility. The MDS indicated Resident #98's siderails were not used as a restraint. A care plan with the latest review date 10/21/24 revealed a problem that Resident #98 had one quarter siderails to assist with bed mobility and transfers. The goal was Resident #98 would not obtain any injury from positioning/transfers. The approach stated Resident #98 and staff would use side rails to assist with bed mobility and transfers as needed. An observation on 2/24/25 at 11:15 AM revealed Resident #98 in bed with the one quarter length side rails in the raised position. An observation on 2/25/25 at 11:45 AM revealed Resident #98 in bed with bilateral one-quarter length siderails in the up position on the bed. An interview with Nurse #1 on 2/25/25 11:58 am revealed the Nurses completed the restraint-adaptive equipment use evaluation on admission and quarterly. Nurse #1 stated this form was used for side rail screening. She further stated she recalled completing the form for Resident #98 and she always answered no to the question Have alternatives to restraint or adaptive equipment been tried in the past?. Nurse #1 indicated side rails were on the beds on admission. She further indicated Nursing did not try alternatives to side rails before they were used. Nurse #1 was not aware alternatives were required before using side rails. In an interview with UM #1 on 2/25/25 at 12:03 PM she stated she was not aware of a time the facility tried alternatives to siderails. She was not aware alternatives to side rails needed to be attempted before using them. In an interview with the Director of Nursing (DON) on 2/25/25 at 12:09 PM she stated Nursing completed the restraint-adaptive equipment use evaluation on admission and quarterly. She further stated they did not try interventions before using side rails as she was not aware this was a requirement. The DON revealed side rails were always on the beds. If a resident did not need them, then they were kept in the down position. In an interview with the Administrator on 2/25/25 at 12:34 PM she stated alternative interventions to siderails were not tried before implementation as she was unaware that this was a requirement.

Based on observation of pressure ulcer care, staff interviews and record reviews, the facility failed to perform hand hygiene after removing wound dressings, before cleaning the wound, applying the new treatments and when moving from one wound to another for 2 of 2 residents (Residents #1 and #3). Additionally, the facility failed to clean scissors before and after use for 1 of 2 residents (Residents #3) reviewed for pressure ulcer care. The findings included: The facility's policy titled, Guidelines for Cleansing and Observing a Wound, last reviewed on 07/28/2023, revealed as soon as you have finished removing the soiled dressing and cleansing the wound, remove and discard your gloves. Otherwise, everything you touch, including the faucet and handles, will be contaminated by microorganisms on your gloves. Your bandage scissors may transfer pathogens from one resident to th next, as well as to your own hands and pockets. To prevent this, wash your scissors with an alcohol product or soap and water before and after each use. Wash your hands (or use an alcohol cleanser) after removing and discarding the existing dressing. Put on clean (or sterile) gloves before applying new dressing. Be sure the soiled supplies do not come into contact with clean supplies. 1a. A pressure ulcer wound care treatment of Resident #3 was observed on 3/26/24 at 2:05 PM. Treatment Nurse #1 placed a paper barrier with clean supplies on the bedside table, donned gloves, and removed the dressing from the left and then right buttocks. The soiled dressing was placed on the bedside table next to the clean barrier. Treatment Nurse #1 proceeded to clean the left buttock with cleaner on gauze, obtained another wound cleaner saturated gauze and continued to the right buttock. Treatment Nurse #1 completed these tasks without changing gloves and performing hand hygiene. The used gauze was placed on the bedside table. Treatment Nurse #1 removed scissors from his pocket and cut the silver alginate package in half. The scissors were returned uncleaned into the pocket. The silver alginate was applied to the left buttock and covered with a clear transparent dressing. Treatment Nurse #1 then scratched his face with his left gloved hand, removed the glove, and put it on the bedside table. With the gloved right hand, Treatment Nurse #1 lifted the right buttock and with the ungloved left hand pressed the clean transparent film dressing in place with the back of his hand. Treatment Nurse #1 removed the right glove and gathered the soiled dressing and gloves in the paper barrier with his bare hands and walked out of Resident #3's room and discarded it into the trash bin on the side of the wound care treatment cart. He used hand sanitizer then pushed the cart to the next room. 1b. An observation of pressure ulcer wound care treatment for Resident #1 was conducted on 3/26/2024 at 2:14 PM. Treatment Nurse #1 placed a paper barrier on the bedside table. He placed acetic acid moistened gauze, dressing supplies, clean gloves, and a crushed metronidazole tablet in a medicine cup on the barrier. He cleansed his hands with antimicrobial foam and donned a pair of clean gloves. A new skin tear was noted on Resident #1 right shoulder. Treatment Nurse #1 removed the soiled dressing from the pressure ulcer on the sacrum and put it in the trash. Treatment Nurse #1 cleansed the right shoulder wound and applied petroleum gauze with a foam dressing to the right shoulder. Without changing gloves, Treatment Nurse #1 cleansed the wound on the buttocks with wound cleanser. The crushed metronidazole tablet was sprinkled in the wound, and the acetic acid moistened gauze was placed in the center of the wound and covered with a foam dressing. An interview on 3/26/24 at 3:10PM was conducted with Treatment Nurse #1. He stated that he was nervous, and he forgot to wash his hands and change his gloves. He indicated that he had been trained in wound care and hand hygiene. He stated that he didn't recall touching Resident #3 without gloves. He stated that he didn't think to clean his scissors from his pocket before using them to cut the calcium alginate. He stated he used scissors to cut the dressing packaging and not for patient care. He stated he was not sure why he didn't change his gloves and use hand hygiene between wounds or between the dirty dressing removal or before the clean dressing was applied. He forgot to clean his scissors. An interview on 3/26/24 at 4:00 PM with the Director of Nursing revealed that Treatment Nurse #1 was a competent nurse. She stated that all staff were trained in handwashing. She indicated nursing staff were to follow infection control procedures for wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review the facility failed to speak respectfully to a resident during an interaction (Resident #22) and failed to have a privacy cover on a resident's catheter bag (Resident #37) and for 2 of 6 resident reviewed for dignity. Findings included: 1. Resident #22 was admitted to the facility on [DATE]. A review of Resident #22's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. His hearing was adequate. He exhibited no hallucinations, psychosis, behaviors, or rejection of care during the assessment period. A review of Resident #22's comprehensive care plan revealed in part a problem area initiated on 1/26/23 of behavior symptoms related to verbal behaviors directed towards others that included Resident #22 calling staff names such as stupid and dumb. An intervention was to maintain a calm environment and approach to Resident #22. On 1/10/24 at 11:13 AM an interview with Resident #22 indicated Receptionist #1 was rude to him. He stated a few months ago, in August 2023, he was at the front desk and Receptionist #1 asked him to move away from the desk because she was talking on the phone. Resident #22 stated he didn't want to move, and she told him he was acting like a butthole. He went on to say he had not mentioned this to anyone because he didn't want to start any trouble. He stated this had made him angry and hurt his feelings at the time. On 1/10/24 at 1:23 PM an interview with Receptionist #1 indicated she recalled an instance with Resident #22 where he was sitting at the front desk while she was talking on the phone. She stated at times needed to have confidential conversations with families or funeral homes. She went on to say she had asked Resident #22 to sit somewhere else while she was on the phone, and he had gotten upset. Receptionist #1 stated Resident #22 told her she was acting like an old butthead and she told him he must have been talking about himself. She further indicated she probably should have handled the situation differently. On 1/10/24 at 1:40 PM an interview with the Administrator indicated she had not been aware of this interaction between Resident #22 and Receptionist #1. She stated Receptionist #1 should not have responded in this way to Resident #22. She went on to say if Receptionist #1 had not agreed with what Resident #22 was saying, she should have just not said anything. 2. Resident #37 was admitted to the facility on [DATE]. His active diagnoses included chronic kidney disease, autonomic neuropathy in diseases classified elsewhere, difficulty in walking, neuromuscular dysfunction of bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Resident #37's minimum data set assessment dated [DATE] revealed he was assessed as cognitively intact. He had no behaviors and used an indwelling catheter. During observation on 1/8/24 at 2:00 PM Resident #37 was observed in bed with no cover observed on his catheter bag. The catheter bag was on the side of the bed that faced the door. His roommate's bed blocked the view of the catheter bag from the hall, but Resident #37's urine was visible to anyone in the resident's room. During observation on 1/9/24 at 8:31 AM Resident #37 was observed to have no cover on his catheter bag and urine was visible to anyone in Resident #37's room. During an interview on 1/9/24 at 8:32 AM Resident #37 stated his catheter bag had a cover. When told the catheter bag did not have a cover, he stated he would like a cover on his catheter bag. During an interview on 1/9/24 at 8:36 AM Nurse Aide #1 stated Resident #37 had a catheter bag privacy cover on 1/7/24 and did not know why it was not on today and he should have a cover for his catheter bag for dignity. She did not notice this morning that he did not have a catheter cover and she would go get one now. During an interview on 1/9/24 at 8:42 AM the Director of Nursing stated they had issues with the supply company getting catheter bags with built-in covers. She stated residents should have a cover for dignity, and the facility had covers for bags that did not have built in covers and staff sometimes forget to move the catheter bag cover with the catheter bag during transfers from the wheelchair chair to bed. She concluded he should not have gone since yesterday without a catheter bag cover for dignity.

Based on observations and staff interviews the facility failed to keep medications in a locked medication cart for 1 of 4 medication carts observed (Medication Cart #1). Findings included: During observation on 1/8/24 at 2:34 PM Medication Cart #1 was found by the surveyor to be unlocked and unattended outside the nursing station. Two nurse aides were inside the nurse's station and two cognitively impaired residents were observed near the unlocked medication cart. At 2:36 PM Nurse #1 returned to the unlocked medication cart. During an interview on 1/8/24 at 2:37 PM Nurse #1 stated medication carts were to be locked when unattended and she should have locked the medication cart prior to taking medications to a resident. During an interview on 1/9/24 at 8:42 AM the Director of Nursing stated medication carts were to be locked when unattended for resident safety.

Based on observations and staff interviews the facility failed to label and date resident's personal food items stored in a nursing unit nourishment refrigerator. This was for 1 of 2 nursing unit nourishment refrigerators (First-Floor) observed. Findings included: On 1/10/24 at 11:24 AM an observation of the First-Floor nursing unit nourishment refrigerator with Nurse #2 revealed the following: a. two unlabeled and undated cardboard pizza boxes containing pizza. b. an unlabeled and undated brown paper bag containing tortilla chips and an unlabeled and undated cup of red liquid. c. an unlabeled and undated plastic food storage container of fried chicken, collard greens, and macaroni and cheese. d. an unlabeled and undated plastic food storage container containing corn bread and black-eyed peas. e. an unlabeled and undated plastic food storage container of green beans and black-eyed peas. In an interview at the time of the observation, Nurse #2 stated she was sure the unlabeled and undated food items in the refrigerator belonged to residents. She stated she had not placed the food items in the refrigerator, and she did not know who had. She went on to say she was not sure how long the items had been in there. She further indicated residents and family members were unable to place items in this refrigerator as it was behind the nurses station. Nurse #2 stated food items had to be given to a staff member. Nurse #2 stated staff were supposed to label items with the resident's name or room number and the date when items were placed in the refrigerator. Nurse #2 stated everyone tried to keep up with this. She went on to say she would need to discard the items because they were not labeled, she was not sure who they belonged to, and she did not know how long they had been in there. On 1/10/24 at 2:46 PM an interview with the Director of Nursing indicated Nurse Aide (NA) #2 was responsible for checking this refrigerator daily Monday through Friday and discarding any items that were not labeled and dated. She stated any staff member who placed an item in this refrigerator should be labeling the item with the resident's name and the date the item was put in the refrigerator. On 1/10/24 at 2:51 PM an interview with NA #2 indicated she was responsible for checking the First-Floor nursing unit nourishment refrigerator daily Monday through Friday to be sure all food items were labeled and dated. She stated she normally checked the refrigerator in the morning when she came in and, in the evening, before she left for the day. She went on to say she had checked the refrigerator on 1/9/24. She further indicated any item that was not labeled and dated was to be discarded. NA #2 stated she had not checked the refrigerator yet on 1/10/24, as she had been out of the facility on a transportation appointment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Nurse Practitioner, and Pharmacist interviews, the facility failed to obtain a pain medication from the pharmacy for 1 of 1 resident (Resident #1) reviewed for medications. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus and dementia. Nurse Practitioner (NP) order dated 8/29/23 read Dilaudid (hydromorphone) (an opioid pain medication) 2 milligram (mg) tablet every 4 hours for terminal pain. The start date was 8/29/23. The order was discontinued 10/26/23 and the end date was 10/26/23. Review of the October 2023 Medication Administration Record (MAR) revealed the Dilaudid 2 mg tablet was documented as not administered as follows: - 10/19/23 2:00 AM - Not Administered: Drug/Item Unavailable - 10/19/23 6:00 AM - Not Administered: Drug/Item Unavailable - 10/25/23 6:00 AM - Not Administered: Drug/Item Unavailable Further review of the October 2023 MAR revealed no order for Dilaudid liquid until October 26, 2023. The Controlled Drug Record date received 8/10/23 for Resident #1's Hydromorphone liquid 1 mg/milliliter (ml) revealed Nurse #1 signed out 3 ml on 10/19/23 at 2:00 AM and 10/19/23 at 6:00 AM. There was no dose signed for 10/25/23 at 6:00 AM. An interview on 11/1623 at 12:14 PM with Nurse #1 revealed the facility had run out of Resident #1's Dilaudid 2 mg tablets and she had given him Dilaudid liquid instead. She stated she had done this on 10/19/23 for both his 2:00 AM and 6:00 AM doses and again on 10/25/23 at 6:00 AM. She stated she put a paper notice in the NP's box to notify her about the medication form change. She was unable to explain why she gave Dilaudid 3 mg dose instead of the ordered 2 mg dose. She was unable to explain why she had not signed on the Controlled Drug Record for the 10/25/23 6:00 AM dose. An interview on 11/16/23 at 2:38 PM with the NP revealed she remembered being notified of the Dilaudid form change. She stated that Resident #1 had previously been on Dilaudid 3 mg dose in August 2023 and felt the resident had no adverse effects from the dose given. An interview on 11/16/23 at 3:01 PM with the Pharmacist revealed that a new prescription for Resident #1's Dilaudid 2 mg tablet had been requested on 10/19/23 and received at the pharmacy on 11/01/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interviews, the facility failed to place a resident's call light within reach to allow for the resident to request staff assistance if needed for 2 of 2 residents (Resident #72 and Resident #12) reviewed for accommodation of needs. Findings included: 1. Resident #72 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired. Resident #72 was observed and interviewed on 12-4-22 at 10:30am. The observation revealed Resident #72 was lying in his bed and his call light was laying on the floor behind the bed. Resident #72 stated he if he needed something from staff he was yelling for help. He explained he used to have a flat button he could push if he needed help but stated he did not know where the flat button was. Another observation occurred with Resident #72 on 12-4-22 at 3:05pm. The observation revealed the resident's call light remained on the floor behind his bed. An interview with Nursing Assistant (NA) #1 occurred on 12-4-22 at 3:30pm. The NA explained she had been working with Resident #72 since 7:00am on 12-4-22. NA #1 said she checked for call light placement each morning when she started her shift and each time, she entered Resident #72's room. The NA stated she had not checked call light placement today (12-4-22) on any of her assigned residents because she forgot. She discussed the capabilities of Resident #72 and stated he was able to use his call light to request assistance from staff. NA #1 verified Resident #72's call light was on the floor behind his bed and the resident would not have been able to reach the call light. The NA was observed to place the call light around Resident #72's side rail. During an interview with Nurse #1 on 12-4-22 at 3:35pm, the nurse explained she sometimes checked for call light placement in resident rooms when she entered their room but stated she had not checked any of her assigned residents today (12-4-22) for call light placement. Nurse #1 discussed it was the NAs' responsibility to ensure each resident had their call light in place. She stated Resident #72 was able to use his call light to obtain assistance from staff and was unaware the resident did not have his call light available. Nurse #1 said she guessed Resident #72 would have had to yell if he had needed assistance. The Director of Nursing (DON) was interviewed on 12-5-22 at 9:00am. The DON discussed call light placement being every staff members' responsibility. She stated Resident #72 was able to use his call light to obtain assistance from staff and had not been aware the resident did not have his call light available on 12-4-22. The DON said she expected every staff member who entered a resident room to ensure the resident had access to their call light. The Administrator was interviewed on 12-8-22 at 9:50am. The Administrator discussed daily rounds by the department heads and that they were supposed to be checking for call light placement during their rounds. She said she did not know what had happened and it was not common practice for a resident not to have their call light available. The Administrator stated she expected all residents to always have their call light available. 2. Resident #12 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was severely cognitively impaired. Resident #12 was observed and interviewed on 12-4-22 at 11:35am. The resident was observed sitting up in bed and her call light was on the floor behind her bed and privacy curtain. Resident #12 stated she did not know where her call light was, but she would use it if she had it. The resident said she received help from staff by using my mouth and yelling. Another observation of Resident #12 was made on 12-4-22 at 3:15pm. The resident's call light remained in the same position behind her bed and privacy curtain. An interview with Nursing Assistant (NA) #1 occurred on 12-4-22 at 3:30pm. The NA explained she had been working with Resident #12 since 7:00am on 12-4-22. NA #1 said she checked for call light placement each morning when she started her shift and each time, she entered Resident #12's room. The NA stated she had not checked call light placement today (12-4-22) on any of her assigned residents because she forgot. She discussed the capabilities of Resident #12 and stated she was able to use her call light to request assistance from staff. NA #1 verified Resident #12's call light was on the floor behind her bed and privacy curtain. She also verified the resident would not have been able to reach the call light. The NA was observed to place the call light over the head of the bed down to Resident #12's right hand. During an interview with Nurse #1 on 12-4-22 at 3:35pm, the nurse explained she sometimes checked for call light placement in resident rooms when she entered their room but stated she had not checked any of her assigned residents today (12-4-22) for call light placement. Nurse #1 discussed it was the NAs' responsibility to ensure each resident had their call light in place. She stated Resident #12 was able to use her call light to obtain assistance from staff and was unaware the resident did not have her call light available. Nurse #1 said she guessed Resident #12 would have had to yell if she had needed assistance. The Director of Nursing (DON) was interviewed on 12-5-22 at 9:00am. The DON discussed call light placement being every staff members' responsibility. She stated Resident #12 was able to use her call light to obtain assistance from staff and had not been aware the resident did not have her call light available on 12-4-22. The DON said she expected every staff member who entered a resident room to ensure the resident had access to their call light. The Administrator was interviewed on 12-8-22 at 9:50am. The Administrator discussed daily rounds by the department heads and that they were supposed to be checking for call light placement during their rounds. She said she did not know what had happened and it was not common practice for a resident not to have their call light available. The Administrator stated she expected all residents to always have their call light available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame for 1 of 3 residents reviewed for resident assessments (Resident #63). Findings included: Resident #63 was admitted to the facility on [DATE]. Record review revealed Resident #63's last comprehensive minimum data set assessment was dated 5/20/22 and last quarterly Minimum Data Set (MDS) assessment was dated 7/22/22. 90 days from that date was 10/20/22. During an interview on 12/5/22 at 1:21 PM the MDS Coordinator stated Resident #63's quarterly minimum data set assessments slipped through the cracks and was not completed on or prior to 10/20/22. During an interview on 12/5/22 at 1:39 PM the Administrator stated Minimum Data Set assessments should be completed timely.

**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) before the expiration date for 2 of 3 residents with a Level II PASRR (Residents #44 and #45). Findings included: 1. Resident #44 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. Review of a PASRR Level II Determination Notification letter dated [DATE] noted Resident #44 was evaluated and assigned a time-limited Level II PASRR with an expiration date of [DATE]. Further review revealed in part, a placement determination of nursing facility placement is appropriate for limited nursing facility stay lasting no more than 30 calendar days. It continued to read if the resident is expected to extend beyond the end date, further approval and screening must be obtained through N. C. Medicaid Uniform Screening Program. The admitting facility is responsible for initiating further screening through a Level II evaluation process within 5 calendar days of the PASRR expiration date. An interview on [DATE] at 8:37 AM with the Social Worker (SW) confirmed she was responsible for initiating and coordinating Level II PASRR reviews. The SW stated she had not known Resident #44's PASRR expired and had not initiated a follow up. She stated she had not initiated further PASRR screening through the evaluation process. An interview on [DATE] at 10:43 AM with the Administrator confirmed that SW was responsible for keeping track of PASRRs and requesting screening when needed before the expiration date. She did not know why it had not been done. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia. Review of the N. C. Medicaid Uniform Screening Program PASRR detail history revealed Resident #45 had a PASRR Level II Determination with start date of [DATE] and an expiration date of [DATE]. An interview on [DATE] at 8:37 AM with the Social Worker (SW) confirmed she was responsible for initiating and coordinating Level II PASRR reviews. The SW stated she had not known Resident #45's PASRR expired and had not initiated a follow up evaluation until [DATE]. An interview on [DATE] at 10:43 AM with the Administrator confirmed that SW was responsible for keeping track of PASRRs and requesting screening when needed before the expiration date. She did not know why it had not been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop and implement an individualized person-centered care plan for 2 of 5 residents (Resident #72 and Resident #34) who were routinely receiving an antidepressant and an antipsychotic medication reviewed for unnecessary medications. Findings included: 1. Resident #72 was admitted to the facility on [DATE] with multiple diagnoses that included dementia and schizoaffective disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #72 was severely cognitively impaired and received antipsychotic medication 7 out of 7 days and an antidepressant 7 out of 7 days. Resident #72's care plan dated 9-12-22 revealed no goals or interventions related to Resident #72's antidepressant or antipsychotic medications. The MDS Coordinator was interviewed on 12-6-22 at 2:19pm. The MDS Coordinator explained she would typically develop a care plan for an antidepressant medication and a separate care plan for the use of an antipsychotic medication. After reviewing Resident #72's care plan and medications the MDS Coordinator stated she had made an oversite on not having a care plan for Resident #72's antidepressant and antipsychotic medication use. The Director of Nursing (DON) was interviewed on 12-6-22 at 2:49pm. The DON stated she thought there had been something wrong with the facility's computer system not saving goals and interventions to Resident #72's care plan as the reason he was not care planned for his antidepressant and antipsychotic medications. She explained she did not know if the facility had contacted their corporate office to have the computer system issues investigated. The DON also said she expected each resident's care plan to reflect the resident's needs and any high-risk medications. 2. Resident #34 was admitted to the facility on [DATE] with multiple diagnoses that included Tourette's disorder. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #34 was severely cognitively impaired and received an antipsychotic medication 7 out of 7 days. Resident #34's care plan dated 12-4-22 revealed no goals or interventions related to his antipsychotic medications. The MDS Coordinator was interviewed on 12-6-22 at 2:19pm. The MDS Coordinator stated when she developed a care plan for antipsychotic medications, she typically would not include interventions other than for the resident to receive the smallest dose possible. After reviewing Resident #34's care plan and medications, the MDS Coordinator stated she had overlooked the resident receiving an antipsychotic medication, so she had not developed any goals or interventions. The Director of Nursing (DON) was interviewed on 12-6-22 at 2:49pm. The DON stated she thought there had been something wrong with the facility's computer system not saving goals and interventions to Resident #34's care plan as the reason he was not care planned for his antipsychotic medications. The DON also said she expected each resident's care plan to reflect the resident's needs and any high-risk medications. The Administrator was interviewed on 12-8-22 at 9:50am. The Administrator stated she had been aware of the issues with the resident care plans and explained it was the MDS Coordinator's responsibility to assure care plans were up to date and accurate. She explained the facility had hired an assistant for the MDS Coordinator. She also said she expected care plans to be accurate and individualized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for Preadmission Screening and Resident Review (Residents #5, #44 and #45) oxygen use (Resident #83) and vision (Resident #2) for 6 of 30 resident records reviewed for MDS accuracy. Findings included: 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia. Resident #5's Preadmission Screening and Resident Review (PASRR) Level II determination letter dated 10/26/22 revealed he had a Level II determination with no expiration date. The annual Minimum Data Set, dated [DATE] revealed Resident #5 was coded as no in the Level II PASRR determination section. An interview on 12/05/22 at 3:10 PM with the MDS Coordinator confirmed she was responsible for coding the PASRR section of the MDS. She confirmed that Resident #5 should have been coded as a Level II PASRR on the MDS and had not done so. She stated she had simply missed it. An interview on 12/06/22 at 10:43 AM with the Administrator confirmed that MDS Coordinator was responsible for ensuring that the MDS was coded accurately, and she did not know why it had not been done. 2. Resident #44 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. Resident 44's Preadmission Screening and Resident Review (PASRR) Level II determination letter dated 6/16/22 revealed he had a Level II determination with an expiration date of 7/16/22. The admission Minimum Data Set, dated [DATE] was coded as no in the Level II PASRR determination section. An interview on 12/05/22 at 3:10 PM with the MDS Coordinator confirmed she was responsible for coding the PASRR section of the MDS. She confirmed that Resident #44 should have been coded as a Level II PASRR on the MDS and had not done so. She stated she had simply missed it. An interview on 12/06/22 at 10:43 AM with the Administrator confirmed that MDS Coordinator was responsible for ensuring that the MDS was coded accurately, and she did not know why it had not been done. 3. Resident #45 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia. Resident #45's Preadmission Screening and Resident Review (PASRR) Level II determination letter was not available for review but based on the applicant lookup information in the North Carolina Medicaid Uniform Screening Program PASRR history detail, starting on 8/23/22 he was given a Level II determination with an expiration date of 11/21/22. The admission Minimum Data Set, dated [DATE] was coded as no in the Level II PASRR determination section. An interview on 12/05/22 at 3:10 PM with the MDS Coordinator confirmed she was responsible for coding the PASRR section of the MDS. She confirmed that Resident #45 should have been coded as a Level II PASRR on the MDS and had not done so. She stated she had simply missed it. An interview on 12/06/22 at 10:43 AM with the Administrator confirmed that MDS Coordinator was responsible for ensuring that the MDS was coded accurately, and she did not know why it had not been done. 4. Resident #83 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and acute and chronic respiratory failure. Review of physician's orders revealed an order dated 10/29/22 for oxygen at 2 liters per minute via nasal cannula continuous. The admission Minimum Data Set, dated [DATE] was not checked as receiving oxygen therapy while a resident section. Review of physician's orders revealed an order dated 10/29/22 for oxygen at 2 liters per minute via nasal cannula continuous. An interview on 12/05/22 at 3:10 PM with the MDS Coordinator confirmed she was responsible for coding the oxygen section of the MDS. She confirmed that Resident #83 should have been coded as using oxygen on the MDS. She stated she had simply missed it. An interview on 12/06/22 at 10:43 AM with the Administrator confirmed that MDS Coordinator was responsible for ensuring that the MDS was coded accurately, and she did not know why it had not been done. 5. Resident #76 was admitted to the facility on [DATE]. Her active diagnoses included cerebral infarction due to embolism of left middle cerebral artery and diabetes mellitus. Resident #76's minimum data set assessment dated [DATE] revealed she was assessed to have received insulin injections 7 days of the 7 day lookback period. Resident #76's medication administration record for 10/13/22 through 10/20/22 revealed Resident #76 did not receive any insulin injections. During an interview on 12/5/22 at 1:28 the MDS Coordinator stated Resident #76 did not receive insulin during the lookback period of the minimum data set assessment dated [DATE] and it was marked in error. During an interview on 12/5/22 at 1:39 PM the Administrator stated the minimum data set assessments should accurately reflect the resident's use of insulin. 6) Resident #2 was admitted to the facility on [DATE]. Her diagnoses included degenerative myopia bilaterally, macular degeneration and corneal scar and opacity. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was coded as having adequate vision. She was coded as severely cognitively impaired (BIMS score of 04). Resident #2 care plan most recently revised on 11/06/22 by the MDS Coordinator revealed a problem of visual function noting she has side vision problems (decreased peripheral vision) related to degenerative myopia bilateral. On 12/5/22 at 11:43 AM Resident #2 was observed turning pages in a book which was on her over the bed table. The book was noted to be upside down. Resident #2 was not aware the book was upside down. On 12/7/22 at 2:30 PM Nurse #4 said there were times during medication pass when Resident #2 would attempt to reach for the cup of water she was offering but would not reach in the correct direction and would reach toward the nurse's voice instead of toward the cup. During an interview on 12/08/22 at 9:11 AM, the MDS Coordinator said she conducted the vision assessment for Resident #2. She said she asked her questions about items in the room such as the sink, the clock on the wall or the dresser. She said she was unsure if Resident #2 used glasses but had noted she had adequate vision. The MDS Coordinator explained she asked other MDS nurses how they completed the assessments and did not consult the RAI (Resident Assessment Instrument -manual with MDS instructions). The MDS Coordinator explained she may need to do more or different testing and should have asked her about seeing fine details.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #37 was admitted to the facility on [DATE] with multiple diagnoses that included dementia and unsteadiness on feet. Resident #37's active care plan dated 10-29-22 revealed a problem of the resident having a history of falling due to muscle weakness. The goal documented was Resident #37 would remain free from injury. The interventions were for Resident #37 to wear non-skid socks during the night while in bed and remind the resident to wear both shoes when ambulating. A second goal was added on 12-5-22 for the resident to meet therapy goals. The interventions for the goal were to monitor Resident #37's progress and response to therapy. Review of Resident #37's event report dated 11-7-22 revealed Resident #37 had a fall in the facility's dining room while trying to ambulate. The fall was documented as unwitnessed, and Resident #37 complained of mild pain to his left hip. The event report documented staff assisted resident back into his wheelchair. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #37 was severely cognitively impaired. The MDS also documented the resident needed a wheelchair for ambulation and was documented as having falls, one with a major injury. Nurse #2 was interviewed on 12-7-22 at 12:37pm. Nurse #2 stated she was familiar and usually was assigned to Resident #37. She explained she had not seen any updated interventions on Resident #37's care plan since his fall on 11-7-22 but stated typically the interventions for a resident who falls was for their call bell to be in reach, make sure the resident wears non-skid socks, keep their bed in a low position and increase frequency of rounds. Nurse #2 stated since Resident #37's fall he had not been out of bed, but she had made sure his bed was in a low position and his call light was within reach. The Director of Nursing (DON) was interviewed on 12-7-22 at 1:03pm. The DON explained the management team met every morning and discussed any falls that had taken place the previous day. She said the discussion included making any fall intervention revisions or updates to the resident's care plan. The DON reviewed Resident #37's care plan and stated the only update was made on 12-5-22 for therapy. She further stated Resident #37 should have had revisions or an update made for fall prevention. During an interview with the MDS Coordinator on 12-7-22 at 1:08pm, the MDS Coordinator explained the nurses were responsible for updating the care plan after a resident fall. She further explained she tried to review the care plan during morning meetings to ensure the care plan had been updated but she had not reviewed Resident #37's care plan and was not aware the care plan had not been updated from his fall on 11-7-22. The Administrator was interviewed on 12-8-22 at 9:50am. The Administrator stated she had been aware of the care plan issues and that Resident #37's care plan had not been updated to reflect his fall on 11-7-22. She further stated she expected care plans to be completed timely, be accurate and individualized. Based on record review and staff interviews the facility failed to hold a quarterly care plan meeting and failed to update the care plan for 2 of 2 residents reviewed for care planning (Resident #84 and Resident #37). Findings included: 1. Resident #84 was admitted to the facility on [DATE]. Resident #84's Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and had no behaviors. A review of Resident #84's chart revealed Resident #84's last care plan meeting was on 5/31/22. During an interview on 12/4/22 at 11:01 AM Resident #84 stated she had not attended a care plan meeting since the end of spring or early summer. During an interview on 12/6/22 at 12:04 PM the MDS Coordinator stated the Social Worker sent out an invitation a week before care plan meeting to invite residents and families. Care plan meetings were to be done every 90 days. She concluded the Social Worker might have more information on if Resident #84 had a care plan meeting since 5/31/22. During an interview on 12/7/22 at 11:31 AM the Social Worker stated the last care plan meeting for Resident #84 was 5/31/22 and Resident #84's next care plan meeting was set for 12/13/22. She concluded she should have had one prior to 12/13/22 but the Social Worker was behind on care plan meetings. During an interview on 12/7/22 at 11:37 AM the Administrator stated care plan meetings should be held quarterly.

Based on observations and staff interviews the facility administration failed to provide oversight and leadership to ensure the facility maintained the walk-in freezer in proper working condition to prevent structural damage of the freezer door and the accumulation of ice in the freezer for 8 months. The findings included: This tag is cross referenced to: F 908: Based on observations and interviews with facility staff the facility failed to maintain the walk-in freezer in proper working condition when the exterior door malfunctioned and created the accumulation of ice and ice crystals inside the walk-in freezer for the last eight months for 1 of 1 walk-in freezer. On 12/06/22 at 4:30 PM the Administrator provided a copy of the email verification dated 12/06/22 from the Maintenance Director via the computerized maintenance log system of the approved authorization for repair of the walk-in freezer door separating at the bottom. She was unable to state why it had taken 8 months to receive the authorization to repair the walk-in freezer door.

Based on record review, and staff interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 11/3/21 recertification/complaint survey. This was for 3 deficiencies cited on the current recertification/complaint survey of 12/8/22: 3 deficiencies were cited on the 11/3/21 recertification/complaint survey in the areas of F641 Accuracy of Assessments, F644 Pre-admission Screening Resident Review (PASSR) and F656 Develop/Implement Comprehensive Care plan. The continued failure of the facility during 2 federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Findings included: This tag is cross referenced to: F 641 Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for Preadmission Screening and Resident Review (Residents #5, #44 and #45) oxygen use (Resident #83) and vision (Resident #2) for 6 of 30 resident records reviewed for MDS accuracy. During the 11/3/21 recertification/complaint survey the facility was cited for failing to accurately code the MDS. F 644 Based on record review and staff interviews, the facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date for 2 of 3 residents with a Level II PASRR (Residents #44 and #45). During the 11/13/21 recertification/complaint survey the facility was cited for failing to provide follow-up psychiatric services in accordance with the recommendations and failing to incorporate the recommendations into the comprehensive plan of care. F 656 Based on record review and staff interviews the facility failed to develop and implement an individualized person-centered care plan for 2 of 5 residents (Resident #72 and Resident #34) who were routinely receiving an antidepressant and an antipsychotic medication reviewed for unnecessary medications. During the 11/13/21 recertification/complain survey the facility was cited for failure to develop comprehensive individualized plans of care. In an interview on 12/8/22 at 11:56 AM the Administrator indicated she felt the continued inaccuracy of assessments was due to the fact the facility had only 1 person completing these. She stated she planned to have an additional person assist now. She went on to say she felt the repeat failures in the areas of PASSR and comprehensive care plans were due to inconsistencies in the way they were being completed. The Administrator stated the facility would review its process and put corrective actions in place to address these issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews with facility staff the facility failed to maintain the walk-in freezer in proper working condition when the exterior door malfunctioned and created the accumulation of ice and ice crystals inside the walk-in freezer for the last eight months for 1 of 1 walk-in freezer. The findings included: On 12/04/22 at 10:30 AM the Certified Dietary Manager (CDM) removed a 3-foot-long metal pole which was positioned under the door latch to keep the door to the walk-in freezer closed tightly. Upon entrance to the walk-in freezer an accumulation of ice crystals was observed along the left interior of the freezer. There was also an accumulation of solid ice observed on the left side of the freezer along the outside of the boxes and shelves. There was broken ice on the freezer floor. During the observation on 12/04/22 at 10:30 AM the CDM said she worked on Sundays to remove the ice build up inside the freezer so she could complete the inventory check in preparation for placing the food order on Mondays. She said she used a [NAME] style hammer to break the ice and then she swept it up for disposal. Upon exiting the walk-in freezer on 12/04/22 at 10:35 AM an observation of the freezer door revealed the metal covering of the door was separated away from the interior structure of the door along the interior lower right side (when facing the door from the interior of the freezer) of the door. Facing the door from the exterior of the freezer revealed both the left and right sides of the lower portions of the door were separated revealing the interior structure of the door. On 12/06/22 at 11:34 AM the Administrator reported she was aware of the need to have the walk-in freezer door replaced and the proposal was completed on 11/03/22 but had not followed up on proposal. She said a new thermostat was installed on 11/17/22. The Administrator said she was able to approve facility expenditures but any expenditure over $500.00 required approval from the regional vice president. She said she would request approval for replacement of the walk-in freezer door. On 12/08/22 at 9:30 AM the CDM said she had used a [NAME] to remove the ice for the last 8 months. She said she had requested to have the walk-in freezer and walk-in cooler problems corrected by completing a proposal for replacement a few months back but had not received any information back.