**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews with staff, pharmacy consultant, pharmacy technician and the Medical Director, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 2 residents reviewed (Resident #158). The findings included: A review of the facility's policy titled Abuse Identification dated and last revised on 01/2023 revealed in part Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the residents' consent. Resident #158 was admitted to the facility on [DATE]. The resident was discharged from the facility on 7/26/24. A physician order dated 5/17/24 read oxycodone HCL (controlled pain medication used to treat moderate to severe pain) oral tablet 10mg (milligrams). Give 1 tablet by mouth every 4 hours as needed for pain. A packing slip from the pharmacy dated 6/21/24 revealed 60 Oxycodone 10 mg tablets were delivered to the facility on 6/21/24 for Resident #158 with no time noted. Nurse #5 initialed the packing slip from the pharmacy. The facility reported incident dated 7/1/24 read in part, the Director of Nursing (DON) and Administrator were notified that a count of a resident's narcotic medication revealed a discrepancy. The facility verified that the resident did not have an adequate supply of a controlled pain medication. This report was signed by the facility DON. A review of the declining narcotic count sheet in comparison with the Medication Administration Record (MAR) revealed Resident #158 received Oxycodone 10mg 25 times between the times of the delivery of the medication on 6/21/24 and the attempt to reorder on 7/1/24. The declining narcotic count sheet reflected that the resident received all 60 tablets between 6/21/24 and 7/1/24, creating a discrepancy of 35 tablets. The declining narcotic count sheet also revealed Nurse #5 signed off on 41 administrations of the oxycodone 10mg tablets including the last administration on 7/1/24. An attempt was made to reach Nurse #5 on 6/18/25 at 10:00 AM via telephone and was not successful. Her phone number was no longer valid. A progress note dated 7/1/24 at 7:28 PM by Nurse #4 revealed the Resident #158's oxycodone was discontinued. An interview with Nurse #6 was conducted on 6/18/25 at 9:47 AM. She stated she called the pharmacy on 7/1/24 to reorder the oxycodone 10mg and was told by the pharmacist that it was too early to reorder and Resident #158 should have a supply remaining at the facility. Nurse #6 then notified the DON and Administrator of the drug discrepancy. A telephone interview with Nurse #4 was conducted on 6/19/25 at 8:55 AM. She stated she did not recall the situation with Resident #158 in July 2024. An interview with the Pharmacy Consultant on 6/18/25 at 12:40 PM revealed she consulted and reviewed charts, and she referred me to the pharmacy. An interview with the Pharmacy Technician on 6/18/25 at 12:50 PM revealed the 60 tablets of the 10mg oxycodone for Resident #158 were delivered as ordered on 6/21/25. An interview with the Medical Director was conducted on 6/18/25 10:37 AM. He stated he did not recall the facility reported event as he covers many facilities. An interview was conducted with the DON on 6/18/25 at 12:43 PM. She revealed Nurse #6 called her on 7/1/24 to notify she attempted to order Oxycodone 10mg for Resident #158. The pharmacy stated there should be tablets of the Oxycodone 10mg remaining in the facility for Resident #158. The DON then notified the Administrator. The DON went to the facility and interviewed Nurse #4, Nurse #5, and Nurse #6. She then submitted the initial 24-hour report to the Department of Health Service Regulation, suspended Nurse #5 pending investigation, and completed a pain assessment with Resident #158. The DON then notified the physician and the Pinehurst Police Department. Educational in-services began with all nursing staff on 7/1/24, which included the controlled substance, abuse prohibition, abuse education, and medication administration policies and the policy and procedure for ordering and dispensing controlled substances. An interview with the Administrator on 6/18/25 at 2:18 PM revealed Resident #158 had a physician's appointment on 7/1/24. The oxycodone was discontinued on that day and an order for Norco (used to relieve moderate to severe pain) Oral Tablet 5-325 (Hydrocodone-Acetaminophen) was received after the visit. This medication was received as ordered and paid for by the facility. The facility provided a draft plan of correction for past non-compliance. The plan could not be accepted by the state agency due to there being no intervention to prevent misappropriation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to attempt alternatives prior to installing side rails for 2 of 2 residents assessed for side rails (Resident #48 and Resident #102). Findings included: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left dominant side. Resident #48's record revealed an assessment titled Device and Bed Rail Review dated 5/16/25 and completed by Nurse #1 revealed there was no question on the evaluation regarding attempts to use alternatives prior to installing side rails. A care plan with the latest review date of 5/19/25 revealed a focus of the use of quarter length side rails to enable independence with bed mobility, with increased risk for complications including entrapment and injuries. The goal stated Resident #48's risks for complications related to the use of side rails will be minimized through current interventions x 90 days. Interventions included: correct positioning, evaluate current use of side rails, observe resident for changes in condition and reassess for least restrictive device. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #48 was severely cognitively impaired. The MDS indicated Resident #48 required partial to moderate assistance with bed mobility, transfers, and ambulation. The MDS revealed Resident #48 had impairment to one side on both upper and lower extremities and side rails were not used as a restraint. An observation was conducted on 6/16/25 at 11:10 AM. Resident #48 was lying in bed with left side quarter length bed rail in the raised position. A follow up observation was conducted on 6/18/25 at 1:11 PM. Resident #48 was lying in bed with the left side quarter length bed rail in the raised position. An interview with Nurse #1 was conducted on 6/17/25 at 2:28 PM. Nurse #1 stated she completed the Device and Bed Rail Review for Resident #48 on admission. Nurse #1 revealed the facility did not try alternative interventions before installing the left quarter length side rail for Resident #48. Nurse #1 indicated she was unaware alternative interventions were required before side rails were implemented. In an interview with the Director of Nursing (DON) and Administrator on 6/17/25 at 2:54 PM, they stated alternative interventions to side rails were not tried before implementation as they were unaware that this was a requirement. 2. Resident #102 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side. Resident #102's record revealed an assessment titled Device and Bed Rail Review dated 6/4/25 and completed by Nurse #1 revealed there was no question on the evaluation regarding attempts to use alternatives prior to installing side rails. A care plan with the latest review date of 6/4/25 revealed a focus of the use of quarter length side rails to enable independence with bed mobility, with increased risk for complications including entrapment and injuries. The goal stated Resident #102's risks for complications related to the use of side rails will be minimized through current interventions x 90 days. Interventions included: correct positioning, evaluate current use of side rails, observe resident for changes in condition and reassess for least restrictive device. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #102 was severely cognitively impaired. The MDS indicated Resident #102 required substantial/maximum assistance with bed mobility and transfers. The MDS revealed Resident #102 had impairment to one side on both upper and lower extremities and that side rails were not used as a restraint. An observation was conducted on 6/16/25 at 11:50 AM. Resident #102 was lying in bed with bilateral quarter length bed rails in the raised position. A follow up observation was conducted on 6/17/25 at 1:45 PM. Resident #102 was lying in bed with bilateral quarter length bed rails in the raised position. An interview with Nurse #1 was conducted on 6/17/25 at 2:28 PM. Nurse #1 stated she completed the Device and Bed Rail Review for Resident #102 on admission. Nurse #1 revealed she did not try alternative interventions before installing bilateral quarter length side rails for Resident #102. Nurse #1 indicated she was unaware alternative interventions were required before side rails were implemented. In an interview with the Director of Nursing (DON) and Administrator on 6/17/25 at 2:54 PM, they stated alternative interventions to side rails were not tried before implementation as they were unaware that it was a requirement.

Based on observations, record review, and staff and Medical Director interviews, the facility failed to implement infection control policies when Nurse #1 did not perform hand hygiene before donning (putting on) gloves prior to assisting with wound care. The facility also failed to clean and disinfect an individually assigned glucometer stored outside the resident's room per manufacturer's recommendations. This was for 2 of 12 staff observed for infection control practices (Nurse #1 and Nurse #3). Findings included: 1. Review of the facilities updated policy titled Prevention of Infection with Wound Care dated 12/2024 stated in part: To reduce the risk of wound infections within the facility: 2. Wash hands after removal of gloves for 10 seconds with soap and friction, then rinse with running water. An observation of wound care was conducted on 6/17/25 at 3:53 PM. Nurse #1 was observed walking the length of the 400 hall, past a hand sanitizer dispenser that she did not use. Nurse #1 then donned a gown and clean gloves just inside the door of the resident's room, without first performing hand hygiene. Nurse #1 was assisting Nurse #2 with the dressing change of an open, draining, furuncle (boil) on Resident #48's left buttock. Nurse #1 assisted Nurse #2 to position the resident on her right side facing Nurse #1. While Nurse #2 was washing her hands after removing the soiled dressing, Nurse #1 was observed to reach over the resident and touch the area of the open boil several times with her gloved right hand as she was assessing a new boil developing below the open one. When the dressing change was complete and the resident repositioned, Nurse #1 removed her gown and gloves and placed them in the trash receptacle and was observed to use a wall mounted hand sanitizer dispenser in the hall, several feet from the resident's room. An interview was conducted with Nurse #1 on 6/17/25 at 4:10 PM. Nurse #1 stated she was the Nurse Supervisor and oversaw the wound care in the facility. Nurse #1 further stated she did not regularly perform wound care but would assist if needed, as she did with Resident #48 today. Nurse #1 indicated she (Nurse #1) should have performed hand hygiene before donning clean gloves and again after she removed the soiled gloves. Nurse #1 further stated that hand hygiene before and after wound care was an infection control measure to decrease the chance of spreading infection in the facility. In an interview with the Administrator and Director of Nursing (DON), who was also the Infection Preventionist on 6/17/25 at 4:22 PM, the DON stated Nurse #1 should have performed hand hygiene either by washing her hands with soap and water or using alcohol-based hand rub (AHBR) before donning clean gloves after she entered the residents room and she should have also performed hand hygiene after removing the soiled gloves before leaving the resident's room. The Administrator agreed with the DON about Nurse #1 regarding hand hygiene. An interview with the Medical Director was conducted on 6/19/25 at 9:30 AM. He stated in order to prevent the cause or spread of infection in the facility, Nurse #1 should have washed her hands with soap and water or used ABHR before putting on clean gloves at the start of wound care and after removing soiled gloves when wound care was completed. 2. The policy titled Blood Sugar Monitoring dated 12/24 stated in part: - Follow manufacturer's directions for use and care of the equipment (glucometer) used in your facility. The glucometer manufacturer's recommendations for cleaning and disinfecting the individually assigned glucometer recommended the Environmental Protection Agency (EPA)'s registered germicidal and disinfectant wipes that the facility used. The manufacturer's instructions noted, To ensure compliance, (the manufacturer) recommends that blood glucose meters be cleaned and disinfected after each use. Guidelines for cleaning and disinfecting the glucometer included: - Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One to wipe clean the glucometer and one to disinfect. - Wipe entire surface of the meter using the first wipe at least three times vertically and three times horizontally. - Repeat above steps with a new wipe to disinfect the meter. - Meter surfaces must remain wet according to contact times listed in the wipe manufacturer's instructions. Manufacturer's instructions for the EPA approved disinfectant wipe the facility used stated the surface must stay wet for two minutes and then wiped dry with a clean cloth. On 6/18/25 at 11:22 AM Nurse #3 was observed performing a blood glucose check on Resident #4. Nurse #3 obtained a glucometer from the medication cart drawer. The glucometer was stored in a clear plastic bag labeled with the resident's name. Nurse #3 gathered supplies to perform the blood glucose check, performed the blood glucose check, then returned to the cart. Nurse #3 used one EPA approved wipe to clean the glucometer for 8 to 10 seconds then set it on the top of the cart. One and one half to two minutes later, Nurse #3 put the glucometer back into the labeled clear bag and returned it to the drawer. Nurse #3 was interviewed on 6/18/25 at 1:56 PM. Nurse #3 stated she thought she had cleaned the glucometer correctly and had already received an in-service on the correct procedure at around 11:45 AM, after the blood glucose check on Resident #4. Nurse #3 indicated she should have kept the glucometer wet with the EPA approved disinfectant for two minutes and then wiped dry before returning the glucometer back to the clear plastic bag belonging to Resident #4. Nurse #3 revealed she had glucometer disinfection training within the last 6 months but wasn't sure when as they have infection prevention training on various topics monthly. Nurse #3 further stated she did not properly disinfect the glucometer during the observation because she just wasn't thinking. The Administrator and Director of Nursing (DON), who was also the Infection Preventionist, were interviewed on 6/18/25 at 2:02 PM. The Administrator stated they had reviewed the manufacturer's instructions for both the glucometer and the disinfectant wipes. The Administrator indicated Nurse #3 should have used two disinfectant wipes per the glucometer manufacturer's instructions and should have left the glucometer wet for two minutes to properly disinfect per the disinfectant wipe instructions. The DON indicated she agreed with the Administrator regarding the proper technique to disinfect a glucometer after use, which would be to follow the manufacturer's instructions.

Based on observation and staff interviews, the facility failed to label opened food items stored in 1 of 2 walk-in freezers with the date opened and use-by or expiration dates. This deficient practice had the potential to affect foods served to the residents. The findings included: On 6/16/25 at 10:45 AM an observation of the walk-in freezer was conducted with the Dietary Director. The observation revealed the following: --bag of opened chicken nuggets with no date opened, use by or expiration date labels posted on the bag that was sitting on a shelf. --carton of tilapia was opened with the inner plastic bag opened and exposing the tilapia to room air. The bag nor the carton were sealed, there was not a received on, opened or used by label in place. An interview was conducted with the Dietary Director on 6/16/25 at 10:55 AM. He stated food that was opened should have a received on, opened and used by sticker place on the package. An interview was conducted with [NAME] #1 on 6/18/25 at 9:24 AM. She revealed when a package of frozen food was taken out of the freezer and partially used it was the cook's responsibility to ensure the partial package was labeled with an open date and use by date prior to placing the remainder of the package back into the freezer. An interview with the Executive Director on 6/18/25 at 12:57 PM revealed she would expect when a staff member used a portion of an item it would be returned to the freezer with a label signifying the opened and used by dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to protect the residents ' right to be free from misappropriation of a narcotic medication (oxycodone/acetaminophen) prescribed to treat pain for Resident #250. This was for 1 of 1 residents reviewed for misappropriation. The findings included: Resident #250 was admitted to the facility on [DATE] and discharged home on [DATE]. His admitting diagnosis included cellulitis of both lower extremities, urinary tract infection due to proteus (gram-negative bacterium-type of bacteria), and lymphedema of both lower extremities. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #250 was cognitively intact. Review of Resident #250 ' s medication orders revealed the following orders: Oxycodone/acetaminophen oral tablet 5/325mg. Give 1 tablet by mouth every 6 hours as needed for pain for 5 days. Order start date was 10/25/23 with a stop date of 10/30/23. Oxycodone/acetaminophen oral tablet 5/325mg. Give 1 tablet by mouth every 6 hours as needed for pain. Start date 11/01/23. Review of the Medication Administration Record (MAR) the Oxycodone/acetaminophen oral tablet 5/325mg was given 9 times during his stay. The MAR was signed on the following dates and times: - 10/25/23 at 11:41 PM - 10/26/23 at 5:30 AM - 10/28/23 at 11:16 AM - 10/29/23 at 10:23 AM - 11/01/23 at 9:00 PM - 11/04/23 at 9:47 PM - 11/05/23 at 930 PM - 11/07/23 at 9:37 PM - 11/12/23 at 9:01 PM Nurse #2 signed the MAR for administering the oxycodone/acetaminophen 7 out of 9 times: 10/25/23 at 11:41 PM, 10/26/23 at 5:30 AM, 11/01/23 at 9:00 PM, 11/04/23 at 9:47 PM, 11/05/23 at 9;30 PM, 11/07/23 at 9:37 PM, and on 11/12/23 at 9:01 PM. A total of 9 administrations were given from a card of 20 tablets leaving 11 tablets. Record review did not reveal any evidence of uncontrolled pain. An initial report was submitted to the North Carolina Department of Health Human Services Division of Health Service Regulation on 11/17/23 by the Director of Nursing (DON). The allegation of misappropriation of property was made on 11/14/23 after a card of narcotic medication, oxycodone/acetaminophen 5/325mg tablets, and declining inventory sheet (used to record the reduction of an inventory's amount on hand) were missing from the medication cart. Resident #250 was being discharged home on [DATE] with all medications when Nurse # 1, the discharging nurse, was unable to locate his pain medication. She contacted the Director of Nursing (DON), and an investigation was initiated. The DON was unable to locate the narcotic medication or the declining inventory sheet. Review of facility investigation completed by the Director of Nursing (DON) on 11/21/23 revealed a card of 20 oxycodone/acetaminophen 5/325mg tablets were delivered to the facility on [DATE]. A review of the medication administration record (MAR) showed Resident #250 received his narcotic medication 9 times on the following dates: 10/25/23, 10/26/23, 10/28/23, 10/29/23, 11/01/23, 11/04/23, 11/05/23, 11/07/23, and 11/12/23. The MAR also revealed 7 of the 9 administrations were given by Nurse #2 which were 10/25/23, 10/26/23, 11/01/23, 11/04/23, 11/05/23, 11/07/23, and 11/12/23. Nurse #2 was interviewed on 11/14/23 and stated that she administered the last dose of the narcotic medication on 11/12/23. This 11/12/23 dose was not signed out on the Medication Administration Record (MAR). Nurse #2 later signed a late entry for 11/12/23 dose. This would have made the total administration 9, leaving 11 narcotic pills in the bubble pack. Nurse #2 then stated she put the declining inventory sheet in the Director of Nursing ' s (DON ' s) box (a box where staff can put documents that the DON needs to review/file). On the evening of 11/14/23 Nurse #2 sent the Director of Nursing (DON) a picture of the top portion of the narcotic card that had the resident ' s name and the name of the medication on it stating she located it in her book bag with other papers. The Administrator and DON reviewed camera footage on 11/15/23 and 11/16/23, which revealed Nurse #2 did not enter Resident #250 ' s room on 11/07/23 or 11/12/23 for several hours before or after the times the administration record (MAR) showed the narcotic had been signed as being given. Nurse #2 was interviewed again on 11/17/23 and was unable to explain the discrepancies noted. The investigation report did not indicate what time Nurse #2 had entered Resident #250 ' s room on 11/07/23 or 11/12/23. The investigation was substantiated by the DON and Administrator. Unsuccessful attempts were made to contact Resident #250. Review of a statement written by Nurse #1 dated 11/20/23 revealed on 11/14/23 she was gathering Resident #250 ' s medications and noted his narcotic medication, oxycodone/acetaminophen 5/325mg tablets, were not in the locked narcotic drawer. She also noted that the declining inventory sheet was also not on the medication cart. She notified the Director of Nursing (DON). Attempts were made to contact Nurse #1 by phone, but they were unsuccessful. Review of a statement written by Nurse #2 dated 11/14/23 indicated she worked on 11/12/23 and administered the last dose of the narcotic medication to Resident #250. She then put the declining inventory sheet, which read 0 tabs were left, in the Director of Nursing (DON) box. Multiple unsuccessful attempts were made to contact Nurse #2. An interview was conducted on 05/30/24 at 11:01 AM with the Director of Nursing (DON). She stated she was notified on 11/14/23 by Nurse #1 that Resident #250 ' s medications were supposed to be in the medication locked narcotic box, however when the nurse discharged him the narcotic pain medication was not in the drawer and the declining inventory flow sheet was missing as well. She stated she then began a full investigation. She stated nurses count the narcotics on the medication carts compared to the declining inventory sheets during shift change. The nurses did not realize the medication was missing. During the investigation copies were made of the Medication Administration Record (MAR) which revealed 8 doses of the narcotic medication were given. During the investigation Nurse #2 stated she administered the medication on 11/12/23 but she forgot to sign the MAR. This would have made the total administration 9, leaving 11 narcotic pills in the bubble pack. An interview was conducted on 05/30/24 at 12:45 PM with the Director of Nursing (DON) and the Administrator. They stated the narcotic medication or declining inventory sheets were never located. The DON stated she expected all nurses to administer medications per order and not to remove or take medications from the residents or facility for personal purposes. Nurse #2 was suspended then terminated following the completion of the investigation. The facility provided the following corrective action plan: Corrective action for the involved resident dated 11/22/23 read as follows: Resident #250 was discharged home on [DATE]. The day the card was noted missing. Resident #250 was given a prescription for oxycodone/ acetaminophen 5/325mg and his family member verified they could pick the narcotic medication up. Investigation initiated, and drug tests initiated. Drug tests were given to the 3 nurses that were working on the medication cart, all were negative. On 11/15/23 the nurse in question was suspended until investigation complete. On 11/17/23 a 24 hour report was submitted; the North Carolina Board of Nursing (NCBON) was notified, and the police department notified of open investigation. Corrective action for other potentially affected residents dated 11/22/23 read as follows: On 11/17/23, the current residents that were able to be interviewed, were interviewed using the Audit Medication Concerns/Misappropriation. This was completed by the Social Worker and Director of Nursing (DON). Results included: no concerns voiced. Additionally, pain assessments were completed by DON on current residents that were not interviewed. These residents were assessed to identify verbal or nonverbal untreated pain cues or concerns. Results included: no concerns noted. On 11/15/23 the Staff Development Coordinator and DON initiated and implemented corrective action for those residents which includes education for all nursing staff. Systemic Changes and Education initiated on 11/15/23 read as follows: On 11/15/23 the Director of Nursing (DON) initiated education for all nurses on Controlled Substance Process and Abuse policy. This education will include all current staff. DON will ensure that any of the above identified staff who do not complete the in-service training by 11/21/23 will not be allowed to work until the training is complete. Quality Assurance (QA) Plan initiated on 11/15/23 read as follows: The Director of Nursing (DON) will monitor five residents using the Medication Concerns or Misappropriation Audit weekly for 2 weeks and monthly for 3 months. Reports will be presented to the weekly Quality Assurance (QA) committee by the Administrator or DON to ensure corrective action initiated as appropriate. Compliance will be monitored, and an ongoing auditing program reviewed at the weekly QA meeting. The weekly QA meeting is attended by the Administrator, DON, Minimum Data Set (MDS) Coordinator, therapy, Health Information Manager (HIM), and the Dietary Manager. The plan alleged compliance on 11/21/23. Review of the facility plan of correction revealed evidence of 100% auditing of medication concerns or misappropriation, including pain assessments. The facility provided evidence of 100% staff education on Controlled Substance Process and Abuse policy completed on 11/21/23. Reports were presented to the QA committee by the DON to ensure corrective action was appropriate. Compliance was monitored, and the ongoing auditing program was reviewed at weekly QA meetings for the timeframe of the monitoring period. The facility ' s date of compliance was validated as 11/21/23. The facility ' s date of compliance was validated on 05/30/24.

Based on record review and staff interviews, the facility failed to submit an initial report to the state regulatory agency and to report to Law Enforcement within 24 hours of discovery of misappropriation of resident property. They further failed to notify Adult Protective Services (APS) regarding an allegation of misappropriation of resident property. This was for 1 of 1 residents (Resident #250) reviewed. The findings included: A review of the facility's Abuse policy, last revised 01/2023, revealed the facility would report a 24-hour investigation into misappropriation of resident property and the report must be completed and faxed into Healthcare Personnel Registry. All alleged violations must be reported no later than 24-hours if the alleged violation involves misappropriation of resident property and does not result in serious bodily injury. An interview with the Director of Nursing (DON) was conducted on 05/30/24 at 11:01 AM revealed she was notified on 11/14/23 by Nurse #1 that Resident #250 ' s narcotic medication was supposed to be in the medication locked narcotic box, however when the nurse was discharging him the narcotic pain medication was not in the drawer and the declining inventory flow sheet was missing as well. The DON indicated she started her investigation on 11/14/23 after being notified of the missing narcotic medication. A phone interview with the Director of Nursing (DON) and the Administrator was conducted on 06/05/24 at 9:04 AM. They both stated they did not send an initial report to the state regulatory agency or notify law enforcement within 24 hours because they were not sure if this was a diversion of facility drugs issue or not. They both clarified that they were unsure if the resident had received all the narcotic medications or if they were in fact missing. They indicated on 11/15/23 as a confirmatory measure the Administrator began reviewing camera footage but there was no evidence that implied diversion until late in the evening of 11/16/23. The DON stated she filed the 24-hour report to the state regulatory agency and reported it to Law Enforcement on 11/17/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to shave a resident who needed extensive assistance or was dependent on the staff for activities of daily living (ADL) for 1 of 2 sampled residents reviewed for ADL (Resident #9). Findings included: Resident #9 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease. The quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #9 had severe cognitive impairment, needed extensive assistance with personal hygiene and had no rejection of care. Review of Resident #9's care plan dated 2/7/23 was conducted. The care plan problems were I have an activities of daily living (ADL) self-care performance deficit related to Alzheimer's dementia and I have potential to demonstrate physical behaviors related to dementia, hitting staff, refusing daily care and perineal care. The approaches included I require staff assistance with grooming and personal hygiene. If I become resistant to care, report to nurse and attempt to determine possible cause and address, maintain safety, and approach me later and when I become agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, if response is aggressive, staff to walk calmly away and approach later. Review of the Nurse's Aide (NA) behavior documentation revealed that Resident #9 did not exhibit rejection of care from March 13 through March 23, 2023. Resident #9 was observed on 3/20/23 at 11:07 AM in bed and at 3:59 PM up in wheelchair in front nurse's station. He was observed to be unshaven. His facial hair seemed approximately 3 days growth. Resident #9 was again observed on 3/21/23 at 9:30 AM in bed and at 1:50 PM up in wheelchair in his room. He was still unshaven. Nurse Aide (NA) # 1, assigned to Resident #9, was interviewed on 3/21/23 at 1:51 PM. She stated that Resident #9 was combative, and he had beaten a staff member last week. The NA verified that Resident #9 needed to be shaved. When asked if she had tried to shave the resident, she responded no, I'm not here to get beaten up. Nurse #1 who was assigned to Resident #9 was interviewed on 3/21/23 at 1:56 PM. She stated that Resident #9 could be combative at times, but she was not notified that the resident was combative and had refused care today. The Restorative Aide (RA) was interviewed on 3/21/23 at 2:01 PM. She stated that Resident #9 could be combative at times but if you talk to him and explain what you're going to do, he will let you. The RA observed the resident and verified that the resident needed to be shaved. The RA was observed entering the resident's room and asked him if she could shave him and he agreed. The RA was observed shaving Resident #9 and he was cooperative. The Director of Nursing (DON) was interviewed on 3/23/23 at 11:20 AM. The DON expected the staff to provide care and if the resident was combative to leave and to try later.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to ensure the low air loss mattress was set according to the resident's weight for 3 of 4 residents reviewed for pressure ulcers (Resident #21, #32, and #34). The findings include: 1. Resident #21 was admitted to the facility on [DATE]. Her diagnosis included Alzheimer ' s disease, dementia, contractures of the right and left thigh muscle, and unspecified viral infection characterized by skin and mucous membrane lesions. A review of the active physician orders included an order that read: low air loss mattress, check every shift for proper inflation, every day and night shift. Resident #21 ' s care plan revised on 11/08/22 included a focus for at risk for pressure ulcer development due to bowel and bladder incontinence, and decreased ability to assist with repositioning. The interventions included pressure reducing, low air loss mattress on bed. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #21 had severe cognitive impairment. She was at risk for Pressure Ulcers (PU) and did not have a pressure ulcer during this assessment lookback period. She had a pressure reducing device to the bed and was dependent on staff for bed mobility and all activities of daily living. The March 2023 Treatment Administration Record (TAR) revealed nursing staff had been documenting every day and night shift that the low air loss mattress was properly inflated. The order read: low air loss mattress, check every shift for proper inflation, every day and night shift. Resident #21's medical record included a weight of 81.0 pounds (lbs) on 03/06/23. On 03/20/23 at 10:23 AM Resident #21 ' s air mattress setting was observed, and the dial was set at 300 pounds (lbs). Pressure levels settings for the mattress ranged from 75 to 500 lbs. On 03/21/23 at 1:50 PM Resident #21 ' s air mattress setting was observed, and the dial was set at 300 pounds (lbs). Pressure levels for the mattress ranged from 75 to 500 lbs. An interview was conducted on 03/21/23 at 01:41 PM with the Wound Nurse. Observation of Resident #21 ' s air mattress setting on 350 pounds (lbs). The Wound Nurse indicated she would confirm Resident #21 ' s weight and correct the setting. The Wound Nurse stated that the floor nurses were responsible for checking if the air mattresses were functioning properly not to see if the weight setting was correct. She indicated she did not know who was responsible for checking the weight setting and it should coincide with the resident ' s current weight. An interview was conducted on 03/21/23 at 04:15 PM with Nurse #1. She stated she only checked to see if air mattress lights were on and functioning properly. She stated she did not check the weight parameters. Nurse #1 verified she signed the Treatment Administration Record (TAR) on day shift 03/21/23. On 03/21/23 at 04:34 PM Resident #21 ' s air mattress setting was observed to be set at approximately 100lbs. The markings on the dial read 75 then 150, the knob was closer to the 75 lb mark. An interview was conducted on 03/21/23 at 01:55 PM with Maintenance Assistant #1. He indicated that he sets the air mattresses up when the order is received. He further indicated he was unaware the dial on the box was to be turned to coincide with the weight of the resident. An interview with the Director of Nursing (DON) on 03/23/23 at 11:15 AM. She stated the air mattress should have been set according to the resident ' s weight and monitored by nursing staff every shift. She was unaware the nursing staff did not know they were to check the inflation of the air mattresses. 2. Resident #32 was admitted to the facility on [DATE]. Her diagnosis included Diabetes Mellitus and contractures of the right and left knees. A review of the active physician orders included an order for a low air loss mattress, check every shift for proper inflation, every day and night shift. Resident #32's medical record included a weight of 112.8 pounds (lbs) on 03/06/23. The March 2023 Treatment Administration Record (TAR) revealed nursing staff had been documenting every day and night shift that the low air loss mattress was properly inflated. The order read: low air loss mattress, check every shift for proper inflation, every day and night shift. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 had severe cognitive impairment. She was at risk for Pressure Ulcers and no pressure ulcers were coded on assessment. She had a pressure reducing device to the bed and was dependent on staff for bed mobility and all activities of daily living. Resident #32 ' s care plan last revised on 03/15/23 included a focus for at risk for pressure ulcer development due to decreased ability to assist with repositioning. The interventions included low air loss mattress on bed, pressure reducing mattress on bed. On 03/20/23 at 10:25 AM Resident #32 ' s air mattress setting was observed, and the dial was set at zero (0) pounds (lbs). Pressure levels for the mattress ranged from 0 lbs through 350 lbs. An interview was conducted on 03/22/23 at 9:44 AM with Nurse #3. She stated she checks if air mattresses are functioning properly and if the weight is properly set during her shift. Nurse #3 verified she signed the Treatment Administration Record (TAR) on day shift 03/20/23. She indicated she did not remember what the setting was on at that time. On 03/21/23 at 1:54 PM Resident #32 ' s air mattress setting was observed, and the dial was set at zero (0) pounds (lbs). Pressure levels for the mattress ranged from 0 lbs through 350 lbs. An interview was conducted on 03/21/23 at 04:15 PM with Nurse #1. She stated she only checked to see if air mattress lights were on and functioning properly. She stated she did not check the weight parameters. Nurse #1 verified she signed the Treatment Administration Record (TAR) on day shift 03/21/23. An interview was conducted on 03/21/23 at 01:41 PM with the Wound Nurse. The Wound Nurse stated that the floor nurses were responsible for checking if the air mattresses were functioning properly not to see if the weight setting was correct. She indicated she did not know who was responsible for checking the weight setting and it should coincide with the resident ' s current weight. An observation with Nurse # 3 was conducted on 03/22/23 at 11:48 AM. Nurse #3 confirmed Resident #32 ' s air mattress setting was set at 0 pounds (lbs), and mattress was hard to the touch. Nurse #3 set Resident # 32 ' s air mattress to approximately 120 lbs. The markings on the dial read 80 then 120, the knob was closer to the 120 lb mark. An interview was conducted on 03/21/23 at 01:55 PM with Maintenance Assistant #1. He indicated that he sets the air mattresses up when the order is received. He further indicated he was unaware the dial on the box was to be turned to coincide with the weight of the resident. An interview with the Director of Nursing (DON) on 03/23/23 at 11:15 AM. She stated the air mattress should have been set according to the resident ' s weight and monitored by nursing staff every shift. She was unaware the nursing staff did not know they were to check the inflation of the air mattresses. 3. Resident #34 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #34's active physician orders included an order dated 2/7/22 for a low air loss mattress. Check every shift for proper inflation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #34 had severely impaired cognition and had no behaviors noted. She was coded with one Stage 2 pressure ulcer over a bony prominence and had a pressure relieving device to the bed. A review of Resident #34's active care plan, last reviewed 1/16/23, included the following focus areas: - I am incontinent of bladder with increased risk for skin breakdown and infections. One of the interventions was a low loss air mattress. - I currently have a pressure ulcer to my sacrum and am at risk for development of additional pressure ulcers due to decreased ability to reposition and incontinence. The interventions included a pressure reducing, low air loss mattress. Resident #34's weight on 3/15/23 was 110.4 pounds (lbs.). A review of Resident #34's medical record revealed from 1/1/23 to 3/22/23 she received wound care every day to the sacral pressure ulcer. The March 2023 Treatment Administration Record (TAR) revealed the nursing staff had been checking for proper inflation of the low air loss mattress to Resident #34's bed every shift (twice a day) and initialed the TAR. On 3/20/23 at 9:55 AM, Resident #34 was observed sitting up in a wheelchair at her bedside. The low air loss mattress machine was set at 225 lbs. per weight setting. The machine had settings of 75 lbs., 150 lbs., 175 lbs., 225 lbs., 300 lbs., 375 lbs., 450 lbs., and 500 lbs. and indicated to set according to the resident's weight per pounds. The low air loss mattress machine had directions to set according to the resident's weight. On 3/21/23 at 9:07 AM, Resident #34 was observed sitting upright in the bed. The low air loss mattress machine was set at 225 lbs. An interview occurred with Nurse #2 on 3/21/23 at 11:07 AM. She stated she checked the functionality of the pressure reducing mattresses, making sure the connections were good, the light was on, and the mattress was inflated. Nurse #2 was unaware who set the weight on the pressure reducing mattress machine. An observation was made with the Wound Nurse on 3/21/23 at 3:21 PM, of Resident #34's low air loss mattress machine, confirming it was set at 225 lbs. and adjusted to the correct weight setting. The Wound Nurse stated the nursing staff checked the functioning of the air mattresses each shift ensuring the connections were secured and the mattress was inflated. She was unable to explain why Resident #34's mattress was set at 225 lbs. The Wound Nurse was unaware who was responsible for the weight setting on the pressure reducing mattress machine. On 3/21/23 at 11:46 AM, an interview occurred with Maintenance Assistant #1. He explained he put the pressure reducing mattresses on the beds when the order was received. He ensured the connections were tight, the machine was operating correctly and thought the mattress automatically set the weight of the resident once they laid on it. He was unaware the dial on the machine was to be turned to coincide with the resident's weight. The Physician Assistant (PA) was interviewed on 3/22/23 at 9:38 AM and indicated the air mattresses should be set according to the resident's weight if so indicated. On 3/23/23 at 10:00 AM, an interview was held with the Administrator and Director of Nursing, they stated they expected the low air loss mattress machine to be set according to the resident's weight as stated on the machine but felt it could also be set according to resident's preference for firmness or softness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff, Registered Dietitian (RD) and Physician Assistant (PA) interviews and record review, the facility failed to identify a significant weight loss for Resident #17. This was for 1 of 2 residents reviewed for nutrition. The findings included: Resident #17 was admitted on [DATE] with diagnoses of aspiration pneumonia, dysphagia and dementia. Resident #17's admission Physician orders dated 11/18/22 included the following: *Regular diet soft and bite sized texture with liquids of thin consistency *Weekly weights x four weeks then monthly and as needed (prn). Resident #17's electronic medical record (EMR) read her admission weight of 131.6 lbs. on 11/21/22. Resident #17's diet orders were changed on 11/21/22 to easy to chew texture and fluids of mildly thickened consistence. There was no documentation in the EMR as to why her diet order was changed. Review of a Speech Therapy evaluation only dated 11/28/22 indicated a recommendation of a fiberoptic endoscopic evaluation of swallowing (FEES)study and supervision for all oral intake. A FEES study was to determine how well Resident #17 was able to swallow. Review of a Dietitian Nutritional assessment dated [DATE] read Resident #17's weight was 131.6 lbs. The assessment read to continue the regular easy to chew diet with mildly thicken liquids and her average oral intake was between 50-75%. There were no new nutritional recommendations. Resident #17's EMR read she weighed 125.2 lbs. on 12/2/22. There was no documented evidence of weekly weights as ordered for the week ending 12/10/22 or the week ending 12/17/22. Review of the FEES test dated 12/9/22 read no change in diet or liquid consistency but recommended Resident #17 to sit upright with all intake for at least 20-30 minutes. There were no new Physician orders based on the results of her FEES study. Resident #17's EMR read she weighed 123.8 lbs. on 1/4/23, a 5.93% weight loss since admission. Review of Resident #17's nutritional care plan initiated 11/21/22 and revised on 1/4/23 read she had a potential for a problem with her nutrition due to difficulty chewing and swallowing, eating too fast and not completely chewing her food. Interventions included encouraging Resident #17 to slow down eating, take time to chew food her completely. Review of the Speech Therapy re-screen on Resident #17 dated 1/5/23 following the FEES study. There was no skilled justification for speech therapy due to the time since the onset of her dysphagia and her baseline cognitive impairment, but it was recommended restorative dining for safety. There was a Physician order dated 1/5/23 for mighty shakes (dietary supplement) three times per day. There was no documentation in the EMR as to the reason Resident #17 was placed on the supplement. Review of Resident #17's care plan included a new focus dated 1/6/23 for restorative dining for safe swallowing strategies. Review of Resident #17's January 2023 food intake ranged from zero to 100% with the monthly average of 50%. There was no documented evidence that the facility obtained Resident #17's weight for the month of February 2023. Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] indicated she had severe cognitive Impairment, required extensive assistance with eating, intact skin and her weight of 123 lbs. The MDS nurse was interviewed on 3/22/23 at 1:30 PM. She stated she used the weight in the EMR for 1/4/23 when completing Resident #17's MDS dated [DATE]. Review of Resident #17's February 2023 food intake ranged from zero to 100% with 25% or less documented intake for all meals and supplements on 2/4/23, 2/10/23, 2/13/23, 2/14/23, 2/17/23, 2/18/23, 2/19/23, 2/22/23, 2/23/23 and 2/25/23. There next documented evidence of a weight obtained on Resident #17 was on 3/15/23 when she weighed 119.2 lbs. which was a 9.42% weight loss in 4 months. A lunch meal observation was completed on 3/20/23 at 1:02 PM of the lunch meal in the dining area designated for restorative dining and there were several episodes of Resident #17 coughing during the meal. There were 10 residents observed with 2 aides at one table feeding/assisting the residents at that table. The table where Resident #17 sat did not have any staff present observing her eat, drink or swallow. It appeared that she ate approximately 50% and she drank all of her dietary supplement. The EMR included a Dietary Review completed by the DM on 3/15/23. The review was modified on 3/21/23. The original Dietary Review dated 3/15/23 did not include any documentation in the following areas: *supplement orders *swallowing issues *relevant conditions and diagnosis *feeding assistance/meal location *patient preferences *dietary summary The revised Dietary Review dated 3/15/23 included the following documentation: *supplement orders-nutritional shake and multivitamin *swallowing issues-coughing or choke during meals or when swallowing medications *relevant conditions and diagnosis-Vitamin D deficiency and dysphagia *feeding assistance/meal location-supervised eating *patient preferences-see tray card *dietary summary-patient is on a regular diet with soft and bite sized textures, intake is 50/75%, Vitamin D, dysphagia, supplemented with nutritional shake and multivitamin The DM was interviewed on 3/22/23 at 8:55 AM. He validated he completed the Dietary Review dated 3/15/23 but he locked the review in the EMR on 3/21/23 when he noticed he had not done it. He stated the facility held a weekly weight meeting which he attended. He stated the weekly weight meetings were held every Thursday and if the RD was unable to attend, he would communicate any identified concerns with her. He stated he did not recall if Resident #17 was discussed in last week meeting, but the support nurse would know. The support nurse was interviewed on 3/22/23 at 9:43 AM. She confirmed she had oversight of resident weights. She recalled Resident #17 triggered on the EMR dashboard as have loss weight last week. She stated it was discussed that there was no February weight recorded in the EMR, and she was going to investigate why the RA did not enter a February weight. The support nurse stated she forgot to follow up with the RA about the missing weight and the RD was unable to attend with weight meeting Thursday. She stated she planned to let the RD know if the February weight showed continued weight loss, but she forgot to pursue anything about Resident #17's weight loss or missing February weight. An observation was completed on 3/21/23 at 8:23 AM. Resident #17 was sitting up in her bed feeding herself. There was no staff in her room to observe or encourage her. She ate approximately 25% and drank only a few slips of her dietary supplement. There were no observed coughing episodes. Another observation was completed on 3/21/23 at 12:25 PM of the lunch meal in the dining area designated for restorative dining. There were 2 aides at one table feeding/assisting the residents at that table. There was 2 observed occasions of Resident #17 coughing during the meal. She ate approximately 25% and she only took a few slips of her dietary supplement. The restorative aide (RA) was interviewed on 3/21/23 at 12:30 PM. She stated Resident #17 would only eat small amounts and she often coughed with her liquids. She stated Resident #17 was only in restorative dining for lunch and for other meals, she ate in her room. She stated staff did not sit with Resident #17 while she ate her lunch but rather she was to intervene as needed for her swallowing difficulty with coughing. The RA stated the MDS was over the restorative program. The MDS Nurse was interviewed on 3/22/23 at 2:54 PM. She confirmed she was over the RA who obtained the weights as ordered. She stated she informed the RA if any resident was ordered a weight other than monthly. The MDS Nurse confirmed the RA was often pulled to the floor. She stated she was not a part of the weekly weight meetings and only updated the care plans from the email she would receive from the DON. The MDS Nurse stated Resident #17 was in restorative dining for closer observation while eating. An interview was completed on 3/22/23 at 3:40 PM with nursing assistant (NA) #3. She stated Resident #17 ate breakfast in bed with the head of her bed raised to prevent choking, ate lunch in restorative dining area and ate dinner in her room usually sitting up in her wheelchair. NA #3 stated Resident #17 was a picky eater, often coughed while eating but she was able to clear her throat in order swallow. She said Resident #17 was a poor eater and ate around 25% of her breakfast and dinner. The Director of Nursing (DON) was interviewed on 3/22/22 at 8:35 AM. She confirmed there was a weekly weight meeting held every Thursday but stated she did not attend the meetings. She stated the treatment nurse, restorative aide, the Staff Development Coordinator, the DM and the support nurse all attended the meeting. She stated the support nurse had oversight of the weight meetings and resident weights. The DON stated the DM communicated with the RD if she was not able to attend the meeting. She stated after the meetings, any changes she emailed the MDS Nurse to update the care plans. The DON stated she was unaware of the significant weight loss. The RA was interviewed again on 3/22/23 at 1:25 PM. She stated she had been doing restorative nursing a few months and she was responsible for monthly, weekly weights and restorative dining. The RA stated there were occasions where she was pulled to work the floor and the aides would have to get their own weights for any residents that required it. She stated she entered the weights into the EMR and that she nor the MDS Nurse were part of the weekly weight meetings. The RA provided Resident #17's February 2023 weight she had documented on her undated written February weight list, but she stated she must have forgotten to enter it into the EMR. She stated the support nurse or anyone else requested Resident #17's February weight so she was unaware that it was not in the EMR until surveyor requested it. The February 2023 weight was 118.6 lbs. with was a 9.88% weight loss in 3 months. The he RA monthly were normally obtained the first week of every month. Review of Resident #17's March 1 to March 22, 2023, food intake ranged from zero to 100% with 25% or less documented intake for all meals and supplements on 3/14/23, 3/17/23, and 3/21/23 with the average of 50%. Review of the EMR included a weight of 120 lbs. obtained 3/22/23 for Resident #17. Review of a Dietitian nutritional Review dated 3/22/23 completed by the RD read as follows: Referral for review request related to 3% weight loss-not significant with Resident #17's weight on 3/22/23 was 120 lbs. Nutritional supplements were ordered on 1/5/23. Current oral intake was 54.7% in last 13 days, no skin issues and recommended dietary to reevaluate Resident #17's food preferences and offer snacks in addition to regular meals. A telephone interview was completed on 3/23/23 at 9:43 AM with the RD. She stated she started at the facility in February 2023 and attended the weekly weight meeting remotely. She also stated if there were any concerns that came up prior to the next meeting, the DM would email or call her the let her know. She stated she had not received any request to reassess Resident #17 until 3/22/23. She stated she was not able to attend the weight meeting held last Thursday. She stated there was no documented weight in the EMR for the month of February 2023 so Resident #17 was weighed yesterday. When the February weight of 118.6 lbs. was provided to the RD by the surveyor, she stated in relation to Resident #17's admission weight of 131.6, that it was a significant weight loss and had she known the weight in February 2023, should have added another supplement or other recommendations. A telephone interview was completed with the PA on 3/23/23 at 10:00 AM. He stated he was not aware of the significant weight loss on Resident #17. He stated he would assess Resident #17 the following day to see what other interventions could be implemented to address her weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, staff and Physician Assistant (PA) interviews and record review, the facility failed to change the oxygen tubing weekly as ordered and failed to obtain oxygen saturation parameters for an order to titrate oxygen as tolerated. This was for 1 (Resident #250) 1 residents reviewed for respiratory care. The finding included: Resident #250 was admitted on [DATE] with diagnoses of respiratory failure and Congestive Heart Failure (CHF). Review of Resident #250's admission orders dated 3/10/23 included the following orders related to his oxygen usage: - Oxygen at 3 L/M continuous via nasal cannula - Change oxygen tubing every week on Sunday nights - Titrate oxygen as tolerated His admission Minimum Data Set was in progress and indicated he was cognitively intact. Review of Resident #250's oxygen care initiated on 3/10/23 read that he required continuous oxygen therapy due to CHF and ineffective gas exchange. Interventions included oxygen at 3 liters per minute (L/M-a measurement of the velocity in which oxygen flows to the resident) continuously and an intervention dated 3/13/23 to titrate oxygen as tolerated. Review of Resident #250's Medication Administration Record (MAR) for March 2023 indicated Nurse #4 initialed she changed Resident #250's oxygen tubing on 3/19/23. An interview and observation was completed on 3/20/23 at 10:41 AM. Resident #250 stated he did not use oxygen at home but was discharged from the hospital with the oxygen. He stated he wore the oxygen all the time since being admitted to the facility. Observation of the oxygen concentrator revealed it running at the ordered rate of 2.5 L/M. Observation of his oxygen tubing had a label dated 3/13/23. Observation of Resident #250's oxygen tubing on 3/21/23 at 9:25 AM still had a label indicating last changed on 3/13/23. The oxygen was running at 2 L/M. Observation of Resident #250's oxygen tubing on 3/22/23 at 9:40 AM had a label indicating last changed on 3/13/23. The oxygen was running at 2.5 L/M. A telephone interview was completed on 3/22/23 at 11:49 AM with Nurse #5. She confirmed she worked night shift on 3/19/23 and initialed off that she changed Resident #250's tubing. She stated she got distracted with something else and forgot to actually replace Resident #250's oxygen tubing and she should not have initialed off that she completed it until she actually replaced the old tubing. An interview was conducted on 3/22/23 at 9:30 AM with Nurse #2. She stated Resident #250's oxygen was ordered for 3 L/M but there was also orders to titrate his oxygen as tolerated. She stated it was her understanding that therapy was titrating Residents #250's his oxygen to see if he could be discharged home without it. An interview was completed with the Therapy Director on 3/22/23 at 1015 AM. She stated titrating a resident's oxygen rate was not a therapy function but rather was done by the nursing staff with titration parameters ordered by the Physician. An interview was completed on 3/22/23 at 3:20 PM with the Director of Nursing (DON). She reviewed March 2023 MAR and noted Nurse #5 initialed that she changed the oxygen tubing but was not aware that Nurse #5 forgot to change his oxygen tubing. The DON agreed there should be a Physician order indicating Resident #250's oxygen saturation parameters in order to titrate Resident #250's continuous oxygen. A telephone interview was completed on 3/23/23 at 10:00 AM with the PA. He stated in order to titrate a resident off of continuous oxygen, there needed to be parameters for the resident's oxygen saturation to ensure the resident tolerated the decrease in the oxygen flow rate. He stated for a resident without the diagnosis of Chronic Obstructive Pulmonary Disease, the oxygen saturation percent should be maintained at 92% or above. Review of Resident #250's oxygen saturation rate in his electronic medical record never dropped below 92% with the average of 97%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and resident, staff and Physician interviews, the facility failed to assess for level of pain and treat a resident with complaints of pain during wound care (Resident #21). This was for 1 of 4 residents reviewed for wound care. The findings included: Resident #21 was admitted to the facility on [DATE]. Her diagnosis included Alzheimer ' s disease, dementia, contractures of the right and left thigh muscle, and unspecified viral infection characterized by skin and mucous membrane lesions. Resident #21 ' s care plan reviewed on 11/08/22 included the following: 1. I have recurrent bullous skin disease to my chest and left buttock. · Give anti-pruritic medication as ordered by MD. Monitor/document side effects and effectiveness. · Monitor skin bullous skin disease for increased spread or signs of infection. · Seek medical attention if skin becomes bloody or infected. 2. I have episodes of displaying the following inappropriate behaviors: refusing care, yelling out, especially during bathing. · Approach in a calm manner. · Explain all procedures to me before starting and allow me adequate time to adjust to changes. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had severe cognitive impairment and displayed no behaviors. She required extensive assistance of one person for bed mobility. The MDS indicated pain was present occasionally and was rated a 04 out of 10 for severity. As needed pain medication was given for reports of pain. She was coded for the application of dressings with ointments and/or medications to skin. A review of the active physician orders from February 2023 through March 2023 revealed Resident #21 was not ordered anything for pain on a routine basis. She did however have an order for acetaminophen 325 Milligrams (MG), give 1 tablet by mouth every 6 hours as needed for Pain/fever. Documentation on Resident #21 ' s March 2023 Medication Administration Record (MAR) indicated acetaminophen 325mg, 1 tablet by mouth was administered on 03/04/23 with a 07 out of 10 for severity pain rating, 03/19/23 with a 08 out of 10 for severity, and 03/21/23 at 3:00 PM, post wound care, with effective results. There was an order for Doxycycline Monohydrate Capsule 100 MG, give 1 capsule by mouth two times a day for wound infection for 14 Days started on 03/20/23. An order that read pain assessment every shift, ask patient if they are in pain according to a 0-10 scale. Pain level documented for March 2023 ranged from 0-2 out of 10 for severity pain rating. Review of Resident #21 ' s Treatment Administration Record (TAR) and the active physician orders from February 2023 through March 2023 were completed. An order with a start date of 03/13/2023 and a discontinue date of 03/17/2023 to please paint chest wound area or back side of abdominal pad with Vaseline (petroleum-based ointment) to prevent sticking, current abdominal pad needs to be well saturated to remove. An order with a start date of 03/18/2023 that read ALERT: Cleanse chest wound with normal saline, apply Medi honey cover with 4x4 dressing every day shift. Being followed by Physician Assistant (PA) PLEASE DO NOT CHANGE TREATMENT. The nursing progress notes from 09/14/23 to 03/22/23 were reviewed and indicated Resident #21 had no episodes of refusals of wound care. The Physician Assistant (PA) notes for Resident #21 from 2/27/23 to 03/22/23 were reviewed. A note dated 02/27/2023 that upon assessment Resident #21 had a large chest wound, skin excoriation like thermal or chemical burn. Most likely from extremely adhesive bandages. A note dated 03/10/23 stating follow-up to evaluate ongoing large superficial chest epidermal injury. Instructions given to apply very light coating of Vaseline (petroleum-based lubricant) to wound/abdominal pad, prefer painting abdominal pad and then applying. Porosity of abdominal pad is causing issues with proteins leaking out to heal and being dried by abdominal pad to the point of sticking/gluing to wound surface so that removal damages healing portions. A note dated 03/17/23 included instructions given to apply very light coating of Vaseline to wound/abdominal pad, prefer painting abdominal pad and then applying. Issue with overly aggressive adhesive bandages being applied which is sticking/gluing to wound surface so that removal damages healing portions, and tears new skin. On 03/21/23 at 1:41 PM wound care observation was completed with the Wound Nurse. The Social Worker (SW) assisted with the dressing change by holding Resident #21 ' s hands and talking to her in a calm voice. The Wound Nurse started to remove the old dressing andResident #21 was observed pushing the Wound Nurses hands away and yelling out it hurts, stop. At that time the Wound Nurse was asked if she gave pain medication before the wound care to Resident #21 and she stated yes that she had given her something for pain prior to the dressing change. The Wound Nurse stopped touching the area and Resident #21 stopped yelling. After a brief 30 second to 1 minute pause the Wound Nurse then saturated the old bandage with normal saline to aid in an easier removal. Resident #21 started moaning and yelling when the Wound Nurse removed the old dressing and she stated, I ' ll be done in just a minute. During the removal of dressing a piece of skin approximately 1-1.5 inches was observed coming off with old bandage. Resident #21 was yelling out continuously while the dressing was being removed and the wound was being cleaned and then was observed Medi honey was applied to a new abdominal pad and then placed on top of chest wound. Wound care lasted approximately 10 minutes total. Review of Medication Administration Record (MAR) revealed that no pain medication was administered prior to the dressing change. An interview was conducted on 03/22/23 at 9:44 AM with the Wound Nurse. She stated she did not administer pain medication prior to wound care on Resident #21 on 03/21/23 like she had previously stated. She then stated she administered the pain medication after the dressing change was completed on 03/21/23. She did not stop yesterday when the resident asked her because she thought by saturating the dressing and taking breaks the resident would be able to tolerate the dressing change better. The Wound Nurse explained the floor nurses normallyperformed wound care on Resident #21. She indicated that she was familiar with Resident #21 but had not asked other staff if the resident voiced or showed signs/symptoms of pain when her dressing was changed. An interview was conducted on 03/21/23 at 2:00 PM with the Social Worker (SW). She stated Resident #21 yells out at times when her treatment was being performed, during incontinence care, and during bathing. She further stated at times she comes in and attempts to distract her and comfort her. An interview was conducted on 03/21/23 at 4:15 PM with Nurse #1. She stated she did not give Resident #21 pain medication prior to her dressing change on 03/21/23. Nurse #1 did not perform wound care on Resident #21 on 03/21/23 but she was her nurse. She also stated Resident #21 would sometimes verbalize pain according to the 0-10 severity pain scale and other times she would evaluate her pain by looking at non-verbal signs such as facial grimacing and/or moaning. She further stated Resident #21 would often yell out during incontinent care and showers. An interview was conducted on 03/21/23 at 3:48 PM with Resident #21. She stated the area to her chest hurts when her dressing was changed. A phone interview was conducted on 03/21/23 at 3:55 PM with Nurse #5. He stated he does the treatments on Resident #21 ' s chest wound when he works day shift. Nurse #5 worked on March 15th, 16th, 18th, and 19th and confirmed he completed the treatment. He also stated he always medicated her prior to the dressing change because the treatment was very painful to her. Resident #21 was able to verbalize pain according to the 0-10 severity pain scale but other times he would assess her nonverbal behaviors. He stated the acetaminophen helped but she still had pain when the dressing was changed. He further stated Resident #21 would moan or yell out at times during the dressing change, but she did not ask him to stop. When she would moan or yell, he would pause and give breaks which helped her with pain. He would saturate the dressing prior to removing it and explained what he was doing prior to doing it, which helped for easy removal. Nurse #5 stated he did administer acetaminophen on March 15th, 16th, and 18th but he forgot to sign the Medication Administration Record (MAR). An interview was conducted on 03/22/23 at 9:52 AM with Physician Assistant (PA) related to Resident #21 ' s chest wound. He stated Resident #21 should receive pain medication prior to the dressing change to her chest because the area was very painful. He also stated he told nursing to administer the pain medication prior to the dressing change but he had not written an order to do so. He then stated if the acetaminophen was administered prior to the dressing change but was ineffective he would expect to be notified. He further stated she had acetaminophen ordered for pain, but he would add a different pain medication to her orders to be administered prior to wound changes. An interview with the Director of Nursing (DON) on 03/23/23 at 11:15 AM. She indicated she was unaware Resident #21 was in pain during her dressing change and that she was not given pain medication prior to the dressing change. She also indicated if a resident had a painful wound change, she would expect pain medication to be given 30 minutes prior to the wound care. She further indicated if a resident exhibited pain during the treatment the nurse should stop and administer pain medication and return later to complete the wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of wound care (Resident #34) and weights (Resident #17 and Resident #41). This was for 3 of 13 resident records reviewed. The findings included: 1. Resident #34 was admitted to the facility on [DATE] with diagnoses that included dementia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #34 had severe cognitive impairment, displayed no behaviors or rejection of care, and was coded with one stage 2 pressure ulcer over a bony prominence. A review of Resident #34's active physician orders included an order dated 1/17/23, to cleanse the sacrum with normal saline, pat dry, apply skin prep, calcium alginate (a dressing that absorbs wound fluid) with Medihoney (an antibacterial gel) to the wound bed and cover with a dry dressing every day. The January 2023, February 2023 and March 2023 Treatment Administration Records (TARs) were reviewed and revealed the sacral wound care had not been documented as completed or refused by the resident on 1/20/23, 1/25/23, 1/29/23, 2/11/23, 2/25/23, 2/26/23, 3/2/23 and 3/7/23. Review of the nursing progress notes from 1/17/23 to 3/22/23 did not reveal any refusals of wound care by Resident #34. On 3/21/23 at 11:05 AM, an interview occurred with Nurse #1, who was assigned to care for Resident #34 on the day shift of 1/25/23, 2/25/23 and 2/26/23. She reviewed the TARs showing no initial as completing the wound care or refusal by Resident #34 and stated that she completed the wound care as ordered but got busy and forgot to sign the treatments off as completed. Nurse #2 was interviewed on 3/21/23 at 11:10 AM. She was assigned to care for Resident #34 on the day shift of 1/20/23, 1/29/23, 2/11/23 and 3/7/23. Nurse #2 reviewed the TARs showing no initials as completing the wound care or refusal by Resident #34 and stated she had completed the wound care as ordered but had forgotten to sign the TAR. The Director of Nursing was interviewed on 3/23/23 at 10:00 AM and indicated it was her expectation for the nursing staff to complete wound care as ordered as well as to document that it was completed or refused by the resident. 2. Resident #17 was admitted on [DATE]. There was no documented evidence that the facility obtained Resident #17's weight for the month of February 2023. The support nurse was interviewed on 3/22/23 at 9:43 AM. She confirmed she had oversight of the resident weights. She recalled Resident #17 triggered on the Electronic Medical Record (EMR) dashboard as having lost weight last week. She stated it was discussed that there was no February weight, and she was going to investigate why the Restorative Aide (RA) did not enter a February weight into the EMR. The RA was interviewed on 3/22/23 at 1:25 PM. She stated she obtained and entered the weights into the EMR and provided Resident #17's February weight of 118.6 lbs. she had documented on her undated handwritten February weight list, but she must have forgot to enter it into the EMR. The Director of Nursing (DON) was interviewed on 3/22/22 at 8:35 AM. She reviewed the EMR for Resident #17 and stated she was not aware there were missing February weight on Resident #17's in the EMR. A telephone interview was completed on 3/23/23 at 10:00 AM with the Physician Assistant (PA). He stated it was important to have accurate and complete weights in the EMR to rule out and intervene weight loses or gains. 3. Resident #41 was admitted on [DATE]. Review of Resident #41's admission orders dated 12/16/22 included an order for weekly weights for four weeks. Review of Resident #41's electronic medical record (EMR) include her weight of 214 pounds (lbs.) on 12/16/22. This was the only documented weight in the EMR for Resident #41. Review of the admission Minimum Data Set, dated [DATE] indicated Resident #41 was cognitively intact with her admission weight of 214 lbs. Review of Resident #41's medication administration record (MAR) for December 2022 did not include documented evidence of her weight on 12/16/22 but rather on 12/23/22. There was no weekly weight due on 12/30/22 or 1/6/23. Review of Resident #41's MAR and EMR did not include evidence of a monthly weight for February or March 2023 as of 3/20/23. There was new newly documented weight dated 3/20/23 of 214 lbs. in the EMR. The Restorative Aide (RA) was interviewed on 3/22/23 at 1:25 PM. She stated she obtained and entered the weights into the EMR for all the residents. She did not provide evidence of Resident #41's weight for January or February 2023. An interview was completed on 3/22/23 at 3:25 PM with Nurse #1. She confirmed she documented the weight of 214 lbs. for Resident #41 in the EMR dated 3/20/23. She stated someone asked her yesterday told her to obtain her weight, but she just used the weight of 214 lbs.in the EMR. Nurse #1 confirmed there was no other weight in the computer other than her admission weight of 214 lbs. on 12/16/22. The Director of Nursing (DON) was interviewed on 3/22/22 at 8:35 AM. She stated she was not aware there were missing weights in Resident #41's EMR and not aware the documented weight on 3/20/23 was inaccurate. Review of the EMR on 3/23/23 indicated a weight of 217.4 lbs. had been entered for 2/8/23 and 216 lbs. on 3/8/23. A telephone interview was completed on 3/23/23 at 10:00 AM with the Physician Assistant (PA). He stated it was important to have accurate and complete weights in the EMR to rule out and intervene weight loses or gains.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interview the facility failed to disinfect multi use medical equipment between residents for 1 of 1 Nursing Assistant (NA) observed for infection control practices. (NA #4) The findings included: The facility provided a copy of the policy and procedure for cleaning of non-critical, reusable patient care equipment. The policy was dated October 2022 and read in part, facility will implement and maintain processes to ensure all non-critical, reusable patient care equipment is cleaned before and after reuse. A continuous observation on 03/20/23 from 10:58 AM until 11:09 AM was conducted. NA #4 was observed retrieving multi-use patient care medical equipment from the hall to obtain blood pressure, temperature, and oxygenation and entering room [ROOM NUMBER]. She did not disinfect the equipment prior to using it on resident in room [ROOM NUMBER]. She proceeded to room [ROOM NUMBER] and used the device on resident in A bed. She did not clean the device between residents. She then rolled the monitor into the hall, leaving it against the wall. NA #4 then entered room [ROOM NUMBER] to provide care. She did not disinfect the equipment after use. A continuous observation on 03/21/23 from 10:15 AM until 10:30 AM was conducted. NA #4 was observed retrieving multi-use patient care medical equipment from the hall to obtain blood pressure, temperature, and oxygenation and entering room [ROOM NUMBER]. She did not disinfect the equipment prior to using it on resident in room [ROOM NUMBER]. She proceeded to room [ROOM NUMBER] and used the device on resident in A bed then on resident in B bed. She did not clean the device between residents. No cleaning wipes located on device. An interview was conducted on 03/21/23 at 10:30 AM with Nurse Aide (NA) #4. She stated she did not clean the multi-use patient care medical equipment between the 3 residents, and she will get cleaning wipes to clean the machine before using it again. She stated she should have disinfected the medical equipment prior to using it on a different resident and before leaving it for someone else to use. An interview was conducted on 03/23/23 at 11:15 AM with the Director of Nursing (DON). The DON indicated staff should follow the facility's policy on cleaning multi-use patient care medical equipment.

Based on record review and staff interviews, the facility failed to provide annual dementia training and mandatory twelve hours of annual in-servicing for 1 of 5 nursing assistants (NA) #2 reviewed for competent nursing staff. The findings included: NA #2 date of hire was 12/7/21. Review of NA #2's educational record did not include any dementia training for 2022 and did not include 12 hours of the annual mandatory in-servicing for 2022. The Staff Development Coordinator was interviewed on 3/22/23 at 10:00 AM. She stated the facility utilized an online in-servicing program that should have identified NA #2's missed training, but she was unable to explain how NA #2's training requirements were missed. The Director of Nursing (DON) provided documentation on 3/23/23 at 9:42 AM of NA #2's completed dementia and annual mandatory in-servicing on 3/22/23.

Based on observation, record review and staff and resident interviews, the facility failed to resolve repeat grievances related to dietary services which were reported in the Resident Council meetings for 7 out of 9 months reviewed (June 2022, July 2022, August 2022, October 2022, December 2022, January 2023, and February 2023). The findings included: Review of the Resident Council minutes dated 06/24/22 indicated a resident was concerned because her Sunday meal was not enough to help her with her blood sugar through the night. Residents discussed recent patterns of not being offered evening snack items. In addition, a resident stated her recent chicken entrée was blackened and burnt. Review of the Resident Council minutes dated 07/29/22 indicated one resident stated it appeared that meat was being cooked ahead of time and sauce was being put on afterwards. Breakfast trays were occasionally missing items such as coffee and sugar. Another resident expressed concerns regarding the bread being hard. The Dietary Manager was present and discussed the concerns. Review of the Resident Council minutes dated 08/26/22 indicated residents stated at night there had been some skim on the top of the soup similar to when soup had been sitting out. Review of the Resident Council minutes dated 10/03/22 expressed concerns regarding the menu being difficult to understand because they did not know what some of the items were. A resident shared a concern regarding ordering fried eggs and she received scrambled. She was told only items on the menu were available. A grievance form dated 10/04/22 was completed on behalf of the Resident Council. The concern indicated the food and coffee were cold during breakfast and dinner. Review of the Resident Council minutes dated 10/28/22 expressed concerns regarding food being cold and residents were wondering if warming plates were being used. Review of the Resident Council minutes dated 12/30/22 expressed concerns with food not being consistently warm and the plate warmers did not seem to be as warm. The coffee was not hot. A resident expressed the desire for more country food. Several residents would like more meat and potato type foods. There were concerns regarding missing utensils. The dessert that was offered on 12/30/22 did not taste good. Review of the Resident Council minutes dated 01/27/23 stated residents were receiving plastic utensils. They stated it was difficult to cut steak and meats with plastic utensils. Review of the Resident Council minutes dated 02/24/23 indicated vegetables were not tender and were difficult to cut with a knife. Residents felt like more attention needed to be paid to the tenderness of meats and vegetables. Observation of a Resident Council meeting was conducted on 03/21/23 at 2:00 PM with 4 alert and oriented members of the Resident Council revealed an issue with resolution of repeat grievances regarding multiple concerns regarding the dietary department. The residents reported having expressed concerns about the lack of variety on the menu; meat and vegetables being difficult to cut and chew; and the menus being difficult to understand. The President of the Resident Council (Resident #3) stated many residents here have difficulty chewing the meat because it's so tough. She indicated the Dietary Manager has attended Resident Council meetings but she felt like concerns were not being addressed and resolved. Resident #17 indicated we would like more variety in menu like having chicken salad, potato salad, or tuna salad. Resident #30 indicated when she went to pick items on the menu, she did not know what she was ordering because the names were confusing. Residents also stated the concern with food being cold had improved some, but not by much. The residents stated they had discussed their concerns with the dietary department several times during Resident Council meetings but felt like an appropriate resolution had not been made. An interview with the Activities Director on 03/22/23 at 8:55 AM revealed she met monthly with the Resident Council to discuss concerns. She stated for every grievance expressed in Resident Council meetings, she identified the type of grievance and then provided it to the relevant department head. The Dietary Manager was verbally made aware of the Resident Council's concerns regarding the dietary department. She stated the Social Worker completed the grievances. The Social Worker was interviewed on 03/22/23 at 1:06 PM. She stated the Activities Director informed her of Resident Council concerns and informed all the department heads depending on the type of concern. She stated she could not remember if she completed a grievance for every concern expressed in Resident Council. The Administrator was interviewed on 02/23/23 at 12:45 PM. She stated she was aware of Resident Council's repeat grievances regarding the dietary department and felt like the facility had addressed the concerns regarding the dietary department. She stated the menu had been changed due to Resident Council's request and she did not know why the Resident Council continued to express this concern. She stated she held a Lunch with Admin lunch monthly with the residents so they could express their concerns regarding anything they found important to them. She did not know why Resident Council kept bringing up previous concerns.

Based on record reviews, observations, Physician Assistant, residents and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following a focused infection control and complaint survey completed on 10/5/20. This was for two deficiencies that were cited in the areas of Respiratory Care and Infection Control. In addition, four additional deficiencies were cited during the annual recertification and complaint survey on 8/25/21 in the areas of Resident/Family Group and Response, Accuracy of Assessments, Treatment/Services to Prevent/Heal Pressure Ulcers and Resident Records. The duplicate citations during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F695- Based on observations, resident, staff, and Physician Assistant (PA) interviews and record review, the facility failed to change the oxygen tubing weekly as ordered and failed to obtain oxygen saturation parameters for an order to titrate oxygen as tolerated. This was for 1 (Resident #250) 1 residents reviewed for respiratory care. The finding included: During the facility's focused infection control and complaint survey of 10/5/20, the facility failed to initiate the physician ' s treatment plan for incentive spirometry (device utilized for breathing exercises) for 1 of 3 residents reviewed for respiratory care. In an interview with the Administrator and Director of Nursing on 3/23/23 at 10:00 AM, they indicated the oxygen concentrators could be bumped, adjusted by the resident or if the nurse was looking over the machine rather than at eye level could cause the oxygen setting to not be the ordered rate. 2. F880- Based on record review, observations and staff interview the facility failed to disinfect multi use medical equipment between residents for 1 of 1 Nursing Assistant (NA) observed for infection control practices. (NA #4) During the facility's focused infection control and complaint survey of 10/5/20, the facility failed to implement the Centers for Disease Control (CDC) guidelines and the facility's COVID-19 Preparation and Response policy in the facility's COVID positive unit in 4 of 4 residents reviewed for enhanced droplet/contact precautions when staff, who were assigned to care for both COVID positive residents and residents in the general population, did not wear the required Personal Protective Equipment (PPE), failed to perform hand hygiene when entering/exiting resident rooms, and failed to store used isolation gowns in a manner that would reduce the chance of spreading COVID-19. These failures occurred during a COVID19 pandemic. In an interview with the Administrator and Director of Nursing on 3/23/23 at 10:00 AM, they stated at the time of the observation the basket on the blood pressure machine was out of sanitizing wipes and were replaced. They stated that all the staff were familiar with the need to sanitize multi-use equipment between residents. 3. F565- Based on observation, record review and staff and resident interviews, the facility failed to resolve repeat grievances related to dietary services which were reported in the Resident Council meetings for 7 out of 9 months reviewed (June 2022, July 2022, August 2022, October 2022, December 2022, January 2023, and February 2023). During the facility's recertification survey of 8/25/21, the facility failed to implement the facility's grievance policy for continued unresolved resident council (RC) complaints about getting the incorrect items and missing items on their meal trays for the last 3 months. In an interview with the Administrator on 3/23/23 at 10:00 AM, she felt the grievances had been resolved at each occurrence. 4. F641- Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Resident #25), hospice and prognosis (Resident #53) for 2 of 20 sampled residents whose MDS were reviewed. During the facility's recertification survey of 8/25/21, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of falls and discharge disposition. This affected 2 of 15 residents reviewed. In an interview with the Administrator on 3/23/23 at 10:00 AM, she felt the repeat citation in MDS accuracy was related to human error. She explained the MDS Nurse was fairly new to the role and had no prior experience. 5. F686- Based on record review, observations, and staff interviews, the facility failed to ensure the low air loss mattress was set according to the resident's weight for 3 of 4 residents reviewed for pressure ulcers (Resident #21, #32, and #34). During the facility's recertification survey of 8/25/21, the facility failed to provide pressure ulcer treatment as ordered for 1 of 4 sampled residents reviewed for pressure ulcers. In an interview with the Administrator and Director of Nursing on 3/23/23 at 10:00 AM, they both acknowledged the alternating pressure mattress machines indicated to set according to the resident's weight but also felt the machines could be adjusted for comfort. 6. F842- Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of wound care (Resident #34) and weights (Resident #17 and Resident #41). This was for 3 of 13 resident records reviewed. During the facility's recertification survey of 8/25/21, the facility failed to maintain complete medical records in the areas of wound consultant progress notes for 3 of 3 medical records reviewed for wound care. In an interview with the Administrator and Director of Nursing on 3/23/23 at 10:00 AM, they indicated the facility was utilizing agency staff and felt the repeat citation could be a result of human error.

Based on observation and staff interviews the facility failed to date leftover food in 1 of 2 walk-in refrigerators; failed to maintain a clean kitchen floor; failed to store clean and dirty knives separately; and failed to thaw meat in sanitary conditions to prevent the potential for cross contamination. The failures had the potential to affect food served to residents. The findings included: 1. An initial observation of 1 of 2 walk-in coolers on 03/20/23 at 9:38 AM revealed an open, undated package of parmesan cheese. During an interview with the Dietary Manager (DM) on 03/20/23 at 9:39 AM, he stated the parmesan cheese was probably opened during the weekend and it should have been dated when it was opened. 2. An initial observation of the kitchen floor on 03/20/23 at 9:45 AM revealed there were crumbs in various sizes across the entire kitchen floor including under and behind appliances. Another observation of the kitchen floor on 03/20/23 at 2:10 PM revealed very small to nickel sized crumbs across the entire kitchen floor including under and behind appliances. An additional observation on 03/21/23 at 8:30 AM revealed crumbs of various sizes throughout the kitchen including the prep area and tray line area. Crumbs were also observed under and behind appliances. An observation and interview with the DM on 03/22/23 at 10:45 AM revealed there were crumbs throughout the entire kitchen including under and behind appliances. He stated it was his expectation that the floors needed to be clean to ensure pest infestations do not occur. He stated the Utility Worker was responsible for cleaning the kitchen floor. The Utility Worker was interviewed on 03/22/23 at 10:50 AM which revealed he swept and mopped every day. He stated the floors were old and it's difficult to get them clean. He stated he had swept and scrubbed the floors during the survey. 3. An observation of the 1-compartment sink in the prep area on 03/20/23 at 2:10 PM revealed a large package of ground turkey meat three-forth submerged in an 8-quart plastic container thawing under cool running water in a clogged sink with food debris. Additionally, on the shelf attached to the 1-compartment sink there were clean knives stored in a dishwasher basket and dirty knives were observed to be stored outside and touching the basket. During the observation on 03/20/23 at 2:10 the DM acknowledged the food particles in the sink. He stated the building was old and had issues with sink draining. He stated the ground turkey should not have been thawing in a clogged sink with food particles. Additionally, the clean knives were stored at the sink because that's the safest place for them. He stated the facility did have a magnetic knife holder; however, the knives fall off it. He further stated the dirty knives and clean knives were stored together because they were all going to get cleaned at the same time. An interview with the Administrator on 03/22/23 at 2:14 PM revealed she expected food to be label and dated when opened, kitchen floors should be kept clean, meat should be thawed properly to avoid potential contamination, and clean and dirty dishes should be kept separate.