**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 5 residents reviewed for unnecessary medications (Resident #1) and 1 of 1 resident (Resident #22) reviewed for anticoagulant medication. The findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. Review of Resident #1's physician orders revealed orders dated 05/15/23 for gabapentin (an anticonvulsant) 100 milligrams (mg) by mouth twice a day for diabetic neuropathy (nerve damage) and metformin (a hypoglycemic) 500 mg by mouth once a day for diabetes mellitus dated 05/09/23. Review of Resident #1's Medication Administration Record for 04/01/25 through 04/30/25 revealed the Resident received gabapentin 100 mg by mouth twice a day and metformin 500 mg by mouth once a day as ordered. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the MDS was not coded as receiving an anticonvulsant or a hypoglycemic medication. On 07/03/25 at 10:08 AM an interview was conducted with MDS Nurse #1 who reviewed Resident #1's quarterly MDS dated [DATE] and acknowledged the MDS was coded as not receiving an anticonvulsant or a hypoglycemic medication and stated she did not know why she miscoded the MDS but agreed the MDS was coded in error. On 07/03/25 at 11:00 AM an interview was conducted with the Administrator who stated she expected the MDS assessments to be completed accurately. 2. Resident #22 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation. Review of Resident #22's physician orders for 06/10/25 revealed the Resident was not prescribed an anticoagulant (blood thinner) medication. Review of Resident #22's Medication Administration Record for 06/01/25 through 06/30/25 revealed the Resident did not receive an anticoagulant medication. Review of Resident #22's quarterly MDS assessment dated [DATE] revealed the MDS was coded as receiving an anticoagulant medication. On 07/03/25 at 10:08 AM an interview was conducted with MDS Nurse #2 who reviewed Resident #22's 06/15/25 quarterly MDS and acknowledged the MDS was miscoded as receiving an anticoagulant medication and stated she coded the MDS in error. On 07/03/25 at 11:00 AM an interview was conducted with the Administrator who stated she expected the MDS assessments to be completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to submit a request for an evaluation for an updated Preadmission Screening and Resident Review (PASRR) determination for a resident who was admitted to the facility with mental health disorders for 1 of 2 residents reviewed for PASRR (Resident #33). Findings included: A PASRR Determination Notification letter dated 09/23/20 revealed Resident #33 had a Level I PASRR with no expiration date. Resident #33 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety disorder and dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident 33's electronic medical record revealed the following active physician orders: *04/28/25: Quetiapine fumarate (antipsychotic) 100 milligrams (mg) in the evening for bipolar disorder. *04/28/25: Sertraline (antidepressant) 100 mg at bedtime for bipolar/depression. *04/28/25: Trazodone (antidepressant) 100 mg at bedtime for restlessness. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #33 received antipsychotic and antidepressant medications during the MDS assessment period. A North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document provided by the facility on 07/02/25 revealed Resident #33 had a Level I PASRR effective 09/30/20. There were no requests for a PASRR reevaluation submitted or completed since 09/30/20. During an interview on 07/02/25 at 3:02 PM, the Social Worker (SW) revealed Resident #33's request for a PASRR reevaluation was overlooked. The SW explained she was not always informed when a resident admitted with mental health diagnoses and had she been aware, she would have submitted a request for a Level II PASRR reevaluation for Resident #33. During an interview on 07/03/25 at 8:07 AM, the Administrator revealed the SW was responsible for submitting PASRR reevaluation requests when needed. The Administrator stated she had completed a PASRR audit on 04/16/25 that was reviewed with the SW to determine if there were any PASRR reevaluation requests that needed to be submitted. The Administrator explained that a request for a Level II PASRR reevaluation should have been submitted for Resident #33 but hers was overlooked due to her admitting to the facility after the PASRR audit had been completed.

Based on manufacturer guidelines, observations and staff interviews, the facility failed to remove loose and unsecured pills of various shapes, sizes and colors from 2 of 6 medication carts (100 and 200 Hall) and failed to label DuoNeb solution (inhalation breathing solution) with a open date and store DuoNeb solution according to the manufacturer's guidelines for 1 of 6 medication carts (200 Hall) reviewed for medication storage. The findings included: 1a. An observation was made of the 100 hall medication cart on 07/02/25 at 10:45 AM accompanied by Medication Aide (MA) #1. The cart yielded 20 loose pills of various shapes, colors and sizes in the bottom of the medication cart drawers. An interview conducted with MA #1 on 07/02/25 at 10:45 AM. The MA explained that it was every MA's responsibility to keep the carts clean, but he did not know if it was a rule or not. b. An observation was made of the 200 hall medication cart on 07/02/25 at 10:55 AM accompanied by MA #2. The cart yielded 41 loose pills of various shapes, colors and sizes in the bottom of the medication cart drawers. An interview was conducted with MA #2 on 07/02/25 at 10:55 AM. The MA explained that it was the MA's responsibility to keep the medication carts clean and orderly, but she did it most of the time. On 07/02/25 at 12:00 PM an interview was conducted with the Unit Manager who explained that it was each MA's responsibility to keep the carts clean and orderly and at one time they had vacuums to use to clean the carts, but she did not know if they had them anymore. An interview was conducted with the Director of Nursing (DON) on 07/03/25 at 11:00 AM. The DON explained that it was the MA's responsibility to keep the medication carts clean and she had an extra nurse to work third shift on 07/01/25 with the only responsibility to clean the medication carts. The DON stated it was her expectation that the medication carts be neat, clean and orderly. 2. Review of the manufacturer's guidelines for DuoNeb solution revealed the solution should be stored in the foil pouch to protect from light. After opening the foil pouch: Individual vials of DuoNeb should be used within 7 days once removed from the foil pack. Unused vials removed from the pouch should be protected from light and used within one week. On 07/02/25 at 11:40 AM an observation was made of the 200 Nurse medication cart accompanied by Nurse #1. The cart yielded 5 DuoNeb inhalation vials loosely stored in a plastic cup. The vials were not in a foil package or dated when they were removed from the foil pack. An interview was conducted with Nurse #1 on 07/02/25 at 11:40 AM. The Nurse explained that she did not know who the DuoNeb solution belonged to, nor did she know how the solution should be stored. The Nurse stated that the solution should be dated when opened. On 07/02/25 at 12:00 PM an interview was conducted with the Unit Manager who explained that it was each nurse's responsibility to keep the carts clean and orderly. The Unit Manager stated the DuoNeb solution should be kept in the foil pouch and dated when opened. An interview was conducted with the Director of Nursing (DON) on 07/03/25 at 11:00 AM. The DON explained that it was the MA's responsibility to keep the medication carts clean and she had an extra nurse to work third shift on 07/01/25 with the only responsibility to clean the medication carts. The DON stated it was her expectation that the medication carts be neat, clean and orderly and the DuoNeb solution should be dated when open and stored in the foil pouch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, and staff interview this facility failed to identify abuse and then failed to implement and follow their abuse policy and procedures in in the areas of reporting and protection for 1 of 3 residents reviewed for accidents (Resident #17). The findings included: Review of the facility's Abuse and Neglect Protocol revised on 06/13/21 read in part, any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. A complete copy of documentation forms and written statements from witnesses, if any, must be provided to the Administrator immediately after the occurrence. If an incident of suspected abuse occurs, facility shall report immediately, but not later than 2 hours after forming the suspicion if the event that caused the suspicion resulted in serious bodily injury, or not later than 24 hours if the events that caused the suspicion do not result in serious bodily injury to designated state agency. An immediate investigation will be made and a copy of the findings of such investigation will be provided to the state agency within 5 working days or as designated by state law. Employees of this facility who have been accused of resident abuse shall be suspended from duty until the results of the investigation have been reviewed by the Director of Nursing/Designee or Administrator. Resident #17 was readmitted to the facility on [DATE] with diagnoses that included dysphagia, cognitive communication deficit, hypertension, diabetes, heart failure, and chronic obstructive pulmonary disease. Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively intact for daily decision making and had verbal behaviors 1 to 3 days, was frequently incontinent of bladder and required extensive assistance of two staff members for bed mobility. An observation and interview were conducted with Resident #17 on 05/12/24 at 11:00 AM, Resident #1 was resting in bed with his head of bed elevated and had a long sleeve flannel shirt on and was covered with a sheet. Resident #17 reported that at approximately 3:00 AM he was awakened by the Nurse Aide (later identified as NA #1) who stated she was going to change him. Resident #17 stated she grabbed my right arm while standing on the left side of the bed and was trying to turn him towards her but because of her girth he could not turn over and I kept telling her that she was hurting my arm, and she would not let go so I had to pull my arm away from her. Resident #17 pulled up the right sleeve of his flannel shirt to reveal a dime size red/purple bruise that had a small 2 x 2 bordered gauze over it. He reported that the nurse (Nurse #1) had put the dressing on this morning. Resident #17 stated that NA #1 was in his room alone that night with no other staff present. Nurse #1 was interviewed on 05/12/24 at 11:30 AM who stated that Resident #17 reported when NA #1 was changing him through the night she held his arm too tight, and he had a discolored area and a small skin tear. Nurse #1 stated she had cleaned the area and put a gauze over the area. The Administrator was interviewed on 05/13/24 at 5:45 PM. She stated that she was unaware of the incident with Resident #17 and NA #1 but stated that there should be documentation of the skin tear in his medial record. The Administrator was made aware that there was no documentation of the skin tear or incident in Resident #17's medical record. The Director of Nursing (DON) was interviewed on 05/14/24 at 5:03 PM. She stated that Unit Manager (UM) #2 went down and talked to Resident #17 and the story she got was it occurred during turning and repositioning and Resident #17 reached out and grabbed NA #1's her arm to remove her hand from his arm and that was what caused the skin tear/bruise. The DON stated she called Nurse #1 and asked her why she did not do the incident report or the change in condition and made her come back to the facility to complete them. She also stated that she spoke to NA #1 who stated she had her hand on Resident #1's shoulder and hip and that was how she rolled him and when he complained of pain, she (NA #1) reported to Nurse #3 who looked at Resident #17's arm and stated that there was nothing there except two scabbed area. The DON stated she did not feel the incident was abuse and she believed that Resident #17 caused the area when he jerked his arm away from NA #1. A follow up interview was conducted with the Administrator and DON on 05/15/24 at 10:42 AM. The Administrator stated they completed a grievance on the issues, talked to Resident #17, talked to his family, and at his request they added grab bars to Resident #17's bed to aide in turning and repositioning. The Administrator stated that she had spoken with Resident #17 as did the DON and explained that Resident #17 had a history of telling different stories to different people. They spoke to NA #1 and Nurse #3 and the incident report was completed as was the change in condition. The Administrator stated that NA #1 told her that she did nothing with his arm and she rolled him with his shoulder and hip, and he was fighting against her, and he jerked his arm away from her. Nurse #3 saw 2 scabbed areas. The Administrator stated she did not identify this as abuse but that she would start their investigative process which included interviewing the resident, staff, suspending NA #1, and reporting to the appropriate agencies. The DON stated that Nurse #1 did not report the issue and had not completed the incident report which was where she would have caught the potential abuse situation. A follow up interview with Nurse #1 was completed on 05/15/24 at 11:46 AM via phone. She stated she had not completed the incident report because the incident occurred on third shift, and she thought Nurse #3 had completed the required information. She confirmed that Resident #17 reported to her on Sunday 05/12/24 that the aide had held his arm too tight during incontinent care and he needed a dressing put on his forearm. She further explained that Resident #17 stated that he may have caused the area when he pulled his arm from her. Nurse #1 stated she did not think that was abuse or she would have immediately reported it to the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised and without knowledge of the staff. On 04/23/24 between the hours of 6:00 PM and 7:00 PM Resident #325 was observed by Nurse Aide (NA) #2 in the back parking lot walking away from the building approximately 30 yards away from the exit door. The findings include: Resident #325 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, hypertension, atrial fibrillation and cerebral vascular accident (CVA). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #325's cognition was severely impaired, and she ambulated independently with a walker. No wandering behaviors were noted during the observation period. On 05/12/24 at 6:30 AM during an interview with Nurse Aide (NA) #2 the NA explained that one evening of 04/23/24 he was working second shift instead of his normal third shift and was assigned to the hall that Resident #325 resided on which was the first time he had worked with the Resident. The NA described Resident #325's behavior that day as having to be redirected multiple times back to her room. He continued to explain that after he collected the supper trays, he took the meal cart back to the kitchen and on his way, he stopped at the nursing desk to inform Nurse #4 who was the Nurse on the hall that he was going to take his break. The NA reported when he came back from the store and was sitting in his car in the back parking lot, he saw Resident #325 walking away from the building toward his car approximately 30 yards from an exit door holding a plastic bag with her clothes in it with no staff following her. NA #2 stated he did not know which exit door the Resident went out of to leave the facility. The NA stated he redirected Resident #325 to the entrance door to the service hall and as they approached the door Nurse #4 and Nurse #5 were running up to them to bring the Resident back inside the facility. NA #2 reported he did not know which exit door Resident #325 left out of, but he heard that it was determined to be the exit door at the end of 400 hall which was the hall the Resident resided on. The NA stated he did not notice any cuts or bruises on Resident #325 that would indicate she had fallen while outside the facility. An observation of the back parking lot was made on 05/12/24 at 6:47 AM. The back parking lot contained a flat black top surface that was surrounded by a wooded lot. The parking lot contained several parking spaces that staff used but no other obstacles, structures, or hazards were noted. An interview was conducted with Nurse Aide #3 on 05/12/24 at 12:19 PM. The NA explained that she did not remember the day, but she was on 100 hall and looked out the exit door at the end of the hall and noticed a resident bending over to pick up something from the ground behind a truck. When the Resident stood up, she realized that she was one of the residents and went toward the nursing desk to alert the nurses when as she passed the service hall she noticed NA #2 bringing the Resident back into the building. By that time the NA stated the nurses were at the service hall and met NA #2 with the Resident. An interview was conducted with Nurse #4 on 05/12/24 at 9:51AM who confirmed she was the Nurse on the hall when Resident #325 left the building unsupervised on 04/23/24. The Nurse explained that the Resident was acting like her usual self that evening in that she was pleasantly confused and would piddle around in her room and mess in her drawers which was what she always did. The Resident ate her supper meal sitting in her chair in her room. Nurse #4 continued to explain that she and Nurse #5 were sitting at the nursing desk when NA #2 stopped by to let her know that he would be taking his break after he delivered the meal cart back to the kitchen. Approximately 10-15 minutes later Nurse Aide #3 was down on 100 hall hollered up to the desk and asked if we had a resident walking around outside. At that time Nurse #4 and Nurse #5 ran to the service hall and out the door to find Nurse Aide #2 had already gotten to Resident #325 and was bringing her back into the building. Nurse #4 reported the Resident was carrying a water pitcher and a bag of clothes and she was wearing a sweat outfit of a pink top and gray pants and shoes. The Nurse explained that they got a wheelchair and took her back to her room where she conducted a full body skin assessment to determine if she had fallen when she was outside and there were no areas like cuts or bruises noted on her skin assessment. The Nurse stated after the skin assessment Resident #325 sat in her chair in her room for a while then went to bed where she stayed for the rest of the shift (11:00 PM). Nurse #4 reported that as she assessed the Resident, Nurse #5 called the facility management to inform them of Resident #325 exiting the building. She stated the management came to the facility and a resident head count was conducted to ensure every resident was accounted for. The Nurse continued to explain that the management team investigated the incident and determined Resident #325 exited the building from the exit door at the end of 400 hall because they found the door had been left unlocked. A review of Resident #325's progress note dated 04/23/24 at 9:56 PM written by Nurse #5 read wander guard placed to left ankle at this time. Checked the device to make sure it was working properly. On 05/13/24 at 11:45 AM during an interview with Nurse #5, the Nurse explained that he was at the nursing desk with Nurse #4 when NA #3 called to the desk that a resident was outside in the parking lot. When he and Nurse #4 got to the service hall NA #2 was bringing Resident #325 back into the building. They put her in a wheelchair and took her to her room where Nurse #4 did a head-to-toe assessment to determine if there were any injuries on her and there were no injuries on the Resident. Nurse #5 continued to explain that the management team was notified of the Resident exiting the facility and soon after the management team arrived at the facility. The Nurse stated he applied a wander guard bracelet on Resident #325's left ankle and made sure the device was working properly. He reported they conducted a resident head count to make sure all the residents were accounted for, then they started an investigation to determine how Resident #325 got out of the facility. When they checked all the exit doors to ensure they were locked they found that the exit door at the end of 400 hall was unlocked therefore they determined Resident #325 left out of that door. Nurse #5 described Resident #325 as being pleasantly confused and liked to piddle around in her room or near her room but that he had not known of her having exit seeking behaviors. On 05/13/24 at 1:29 PM during an interview with the Maintenance Supervisor (MS) the Supervisor stated that on the evening of 04/23/24 he was called back to the facility because Resident #325 was discovered outside the building. He explained that he completed an investigation of all the exit doors and found that the exit door at the end of 400 hall where the Resident resided was unlocked. He continued to explain that the power to the exit door was turned off and the switch was in the off position. He continued to explain that you must have a key to unlock the door and the key was in the unlocked position as well. The MS reported that the only time the door was unlocked was for deliveries and the oxygen company delivered oxygen supplies earlier that same day and he was the one who unlocked the door for the delivery. The MS stated he stayed at the door during the delivery and made sure he locked the door after the delivery was complete. The MS continued that the door had a screamer alarm and when the cover was raised it should have made a loud sounding alarm, but no staff admitted to hearing an alarm during the evening shift. The MS explained in response to the incident he made two rounds every day on all the exit doors to ensure the doors were locked and when he was not at the facility the weekend office staff made the rounds in his place. He also added the facility was in the process of installing cameras throughout the facility as well. An interview was conducted with the Wound Nurse on 05/13/24 at 1:05 PM. She explained that the management team was called back to the facility on the evening of 04/23/34 because Resident #325 had gotten out of the facility unsupervised. It was determined that she exited the facility from the exit door at the end of 400 hall because the door was not locked. The Nurse stated she conducted a head-to-toe assessment on Resident #325 when she returned to the facility and found no indication of injuries that she could have attained through a fall or injury. Interviews were conducted with the Nurse Practitioner (NP) on 05/13/24 at 12:23 PM and 3:26 PM. The NP explained that Resident #325 had a history of a brain bleed (CVA) that left her cognition impaired, but she was physically getting stronger with her ambulation. She continued that she was notified by the facility the evening of 04/23/24 that Resident #325 exited from the building, and she visited the Resident the next day. The NP performed a thorough assessment on the Resident and found no skin tears or injuries. The facility conducted a complete resident count and checked the exit doors and wander guards. They moved Resident #325 to the locked unit shortly after that. The NP stated that because of her history and poor safety awareness Resident #325 was not cognitively safe to be outside on her own. An interview was conducted with the Medical Director (MD) on 05/14/24 at 12:23 PM. The MD explained that Resident #325 had a history of spontaneous brain hemorrhage which left her cognition compromised but she was progressing slowly physically with skilled therapies. He continued that he saw the Resident during his rounds on the Tuesday (04/23/24) and Thursday (04/18/24) prior to the incident and found her to be as her normal behavior of walking from chair to chair. The MD reported that he was notified the evening of the incident and was informed that they would be moving Resident #325 to the locked unit on 300 hall which he stated was more appropriate for her. A review of Resident #325's progress note dated 04/26/24 at 4:23 PM written by the Director of Nursing read interdisciplinary team (IDT) meeting held to discuss Resident ambulating outside. The Resident was moved to 300 hall locked unit and a wander guard bracelet was applied. The Resident has adjusted well and seems to like her new room. No further concerns at this time. An interview was conducted with the Director of Nursing (DON) on 05/13/24 at 2:18 PM. The DON explained that Resident #325 was alert but confused and mainly piddled around in her room which was nothing out of the ordinary. She was not on their radar of wandering. The DON continued that on the evening of 04/23/24 she was notified by Nurse #5 that Resident #325 was found outside of the facility in the back parking lot and was brought back inside the building. She explained that she instructed them to do a head-to-toe assessment on the Resident and do a resident head count to ensure all the residents were accounted for. The DON stated that by the time she arrived at the facility Nurse #4 or Nurse #5 had discovered that the exit door at the end of 400 hall was unlocked and locked it back. She reported that by that time most of the management team was at the facility, and she instructed the Wound Nurse to conduct another head-to-toe skin assessment on Resident #325 and found nothing. The DON explained at that time they conducted a reenactment of the situation and had NA #2 and both Nurses #4 and #5 walk them through the entire situation and it was determined that Resident #325 left the facility out of the unlocked exit door at the end of 400 hall since that was the only exit door found unlocked. The DON reported the last time the 400 hall exit door was known to be used was earlier in the day when the Maintenance Supervisor unlocked it for the oxygen company to deliver the oxygen. She stated the Maintenance Supervisor insisted that he locked the door back but there was no other explanation as to why the door was unlocked since the door required a key and a code to unlock the door. The DON stated she had Nurse #5 place a wander guard bracelet on Resident #325, and she called the Resident's family member and explained the situation to them. She informed the family member of the situation and that they had placed a wander guard bracelet on the Resident and that they wanted to move her to the locked unit for her protection which they did move the Resident to the unlocked unit. The DON reported that she notified the Nurse Practitioner that evening. The DON added that the facility was in the process of installing cameras facility wide for surveillance. During an interview with the Administrator on 05/13/24 at 2:50 PM. The Administrator explained that she was notified of Resident #325's elopement by the DON on the evening of 04/23/24 and had the management team return to the facility for the investigation. She continued to explain that through a reenactment with the staff involved they determined the Resident left the building through the exit door at the end of 400 hall which was found unlocked at the time of the incident. She reported at that time the only time the exit door was used was when the oxygen company delivered oxygen once a week and they happened to deliver oxygen earlier that same day as the elopement. She stated the only explanation was that the door had mistakenly been left unlocked. The Administrator reported to ensure Resident #325's safety they placed a wander guard bracelet on her and moved her to the locked unit. The Administrator continued to explain that the facility developed a plan of correction that included the exit door at the end of 400 hall was not used for anything including the oxygen company delivery and that all deliveries had to go through the front main entrance. The facility provided the following corrective action plan with the completion date of 04/25/24. All items listed on this self-imposed action plan were complete and implemented on 04/23/24 with ongoing monitoring to ensure compliance. This includes the action plan and any potential citation associated with this action plan should be considered past noncompliance as of 04/25/24. The facility identified concerns regarding Resident #325 exited side door and observed in the parking lot by staff and returned to the facility without issue on 04/23/24. CORRECTIVE ACTION THAT WILL BE ACCOMPLISHED: On 04/23/24 Resident #325 was assisted into the facility by CNA and assessed by licensed nurse with no injury noted. On 04/23/24 licensed nurse notified responsible party and medical provider of incident. On 04/23/24 Resident #325's elopement assessment was updated by licensed nurse to reflect current wandering behaviors. On 04/23/24 an order for wander guard device obtained from provider by licensed nurse and applied to the Resident. On 04/23/24 the Resident's photograph was placed in the Elopement risk book at the front desk and nurses' station. On 04/23/24 the Resident's care plan was updated by licensed nurse to reflect new orders and new behaviors. On 04/23/24 all exit doors were checked by the Maintenance Director to validate that doors were functioning/locked/alarming properly with any unlocked / non alarmed door reset to ensure proper locking and alarming. On 04/23/24 Administrator educated the Maintenance Director on assurance of locking/alarming doors after any vendor enters the facility. IDENTIFICATION OF OTHER RESIDENTS: On 04/23/24 licensed nurses conducted a 100% audit of current residents to validate all residents were accounted for. All residents were present and accounted for. On 04/23/24 licensed nurses reviewed wandering assessments for all current residents to ensure appropriate interventions are in place for those residents identified as a wandering risk. No one was out of compliance, but we did identify a resident who had a change of status, and we placed a wander guard bracelet on her. On 04/23/24 the licensed nurses conducted an audit of residents identified with wander guard bracelets to validate that the bracelets were in place and functioning. MEASURES FOR SYSTEMIC CHANGE: The process to address residents identified with new behavior of wandering or exit seeking was updated to include Educated all staff to notify management if a resident begins to have new behaviors of wandering or exit seeking. When management is notified, a new assessment will be completed to determine if a wander guard needed to be initiated. Process to address all doors checked whenever vendor enters/exits to ensure locked, and alarm activated: Maintenance Director was educated by the Nursing Home Administrator on 04/23/24 regarding validation of exit door lock and alarm after use and routine checks twice daily on all exit door locks and alarms. The Administrator will appoint another Department Head if the Maintenance Director is absent/vacation and the weekend receptionist responsible for doing checks on weekends. Director and/or Administrator completed education for all staff on or before 04/24/24 regarding identification of and response to residents with exit seeking behaviors, missing residents and process to check that doors are properly secured. Education will be provided for all new hires in orientation. HOW CORRECTIVE ACTION WILL BE MONITORED: The decision to formulate how the corrective action will be monitored was made on 04/23/24. The Director of Nursing and or the Administrator will review progress, wandering assessments and 24-hour reports 5 days a week times 4 then 3 times a week for 2 months to identify residents with wandering or exit seeking behaviors and validate that appropriate interventions are initiated. The Administrator will audit the exit door securement logs five days a week for four weeks and then weekly for eight weeks to ensure twice daily checks completed. The Administrator and or Director of Nursing will review the audit to identify patterns and trends and will adjust the plan to maintain compliance. The Administrator and or Director of Nursing and interdisciplinary team inclusive of Medial Director and or the Nurse Practitioner held an ad hoc QAPI to review incident and root cause analysis in its entirety with proposed plan of correction interventions. The Administrator or Director of Nursing will review the plan during the monthly QAPI meeting, and the audits will continue at the direction of the QAPI committee. Validation Statement: During the recertification and complaint survey investigation the facility provided information through observations and interviews from staff to support the facility conducted a 100 % audit of resident census on 04/23/24 after Resident #325 was discovered outside the building in the back parking lot. The facility also provided information such as exit door audits twice a day, 100% facility wide education to current employees and new hires on the new process, the elopement risk assessments and the updated elopement notebook and the clinical morning meeting of discussion of the information and audits conducted. The completion date of 04/25/24 was validated.

Based on observations, record reviews and staff interviews, the facility failed to remove expired medications available for use from a medication refrigerator in 1 of 1 medication room reviewed for medication storage. The findings included: A review of the manufacturer's recommendation for Purified Protein Derivative (PPD) storage, PPD vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. On 05/14/24 at 11:25 AM during an observation of the medication room refrigerator with Nurse #2 and Unit Manager (UM) #1 the observation yielded 2 open vials of PPD solutions. One vial was in a box with an open date of 04/01/24 printed on the box and one vial was in a box in a plastic pouch with an open date of 04/03/24 printed on the box. During interviews with both the Unit Manager and Nurse #2 on 05/14/24 at 11:25 AM neither nurse knew how long the PPD solution could be used after opening. The UM explained that she inspected the refrigerator the previous evening and there was one PPD vial in the refrigerator, but the solution was not out-of-date. The UM stated she could not remember the date on the vial or if the vial was in a box or plastic pouch. The UM left the medication room and returned at 11:28 AM and reported the PPD solution was good for 30 days after opening. An interview was conducted with the Director of Nursing (DON) on 05/14/24 at 11:31 AM. The DON was informed of the findings in the medication room refrigerator and the DON stated the Unit Manager had looked in the refrigerator the prior evening and did not find any out-of-date PPD solution.

Based on observations, record reviews and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the Recerfification and Compliant Survey on 03/01/23. This failure was for 2 deficiencies that were originally cited in the areas of (F600) Free from Abuse and Neglect and (F880) Infection Control that were subsequently recited on the current Recertification and Complaint Survey on 05/15/24. The repeat deficiencies during the 2 surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. The findings include: This tag is cross referenced to: F-600: Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #17 asked Nurse Aide (NA) #1 multiple times to let go of his right arm during incontinent care and when she did not Resident #17 pulled his right arm away from NA #1 and during the interaction received a small skin tear with a red/purple bruise that was approximately the size of a half dollar on his right forearm. The deficient practice occurred for 1 of 3 residents reviewed for accidents. During the recertification and compliant survey on 03/01/23 the facility failed to provide supervision to prevent a cognitively impaired resident from attacking another cognitively impaired resident in their shared bathroom which resulted in a resident having a bloody right lower lip, left nostril and left cheek. Her wrist was swollen, bruised and painful and required evaluation and treatment at the emergency room. F-880: Based on observations, record reviews and interviews the facility failed to follow their infection control policy when the Wound Nurse failed to change her gloves after removing a soiled dressing, that contained a moderate amount of brown drainage, and before cleansing a sacral wound on 1 of 4 residents (Resident #18) reviewed for pressure ulcers. The facility also failed to follow their hand hygiene policy when the Unit Manager failed to change her gloves and preform hand washing hygiene after she provided incontinent care and before she applied a moisture barrier cream and touched other environmental surfaces for 1 of 3 residents (Resident #54) reviewed for incontinence care. During the recertification and compliant survey on 03/01/23 the Nurse failed to perform hand hygiene and change gloves after removing a dirty dressing, after cleansing a wound, and before applying a clean dressing to a wound. An interview was conducted with the Administrator on 05/15/24 at 3:30 PM who explained she was not the Administrator at the time of the last recertification when the previous citations were given but she felt as if the current citations were isolated issues and not a result of facility failures. The Administrator indicated that through the plan of corrections for the citations the staff will be educated, audits will be conducted and monitored through the quality assurance committee. Hopefully the citations will not be repeated.

Based on observations, record reviews and interviews the facility failed to follow their infection control policy when the Wound Nurse failed to change her gloves after removing a soiled dressing that contained a moderate amount of brown drainage and before cleansing a sacral wound on 1 of 4 residents (Resident #18) reviewed for pressure ulcers. The facility also failed to follow their hand hygiene policy when the Unit Manager failed to change her gloves and preform hand washing hygiene after she provided incontinent care of stool and before she applied a moisture barrier cream and touched other environmental surfaces for 1 of 3 residents (Resident #54) reviewed for incontinence care. The findings include: 1. A review of the facility's policy on Dry Clean Dressing dated 09/2013 revealed steps in the procedure, 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull gloves over dressing and discard them into plastic or biohazard bag. 8. Wash and dry hands thoroughly. On 05/14/24 at 2:02 PM an observation of wound care was made by the Wound Nurse. The Nurse washed her hands and donned clean gloves to remove the old, soiled dressing which was saturated with brown drainage from Resident #18's sacrum. With the same gloved hands, the Wound Nurse proceeded to cleanse the stage 3 sacral wound with a gauze saturated with wound cleanser then removed the gloves and washed her hands before she donned a clean pair of gloves to apply the ordered treatment to the sacral wound and secured the wound with a border dressing. An interview was conducted with the Wound Nurse on 05/14/24 at 5:08 PM who explained she did not realize that she did not remove her gloves and wash her hands after she removed the soiled dressing from Resident #18's stage 3 pressure ulcer. She stated that it was her normal routine to remove her gloves and wash her hands after she removed the old dressing but that she was nervous being watched during the procedure. An interview was conducted with the Wound Nurse Practitioner on 05/15/24 at 10:50 AM. The Nurse Practitioner explained that Resident #18's stage 3 sacral pressure ulcer was being closely monitored for signs and symptoms of osteomyelitis because of the near bone exposure. She continued to explain that she had not observed the Wound Nurse's dressing change technique as being bad but stated she normally documented her wound assessments while the Wound Nurse redressed the wounds on rounds. During an interview with the Director of Nursing on 05/15/24 at 12:15 PM she explained that the Wound Nurse had already informed her of the wound treatment and stated that she would have to be more careful being sure to remove her gloves when she removed the old dressings. 2. A review of the facility's hand washing/hand hygiene policy revised on October 2023 read; Hand hygiene is indicated: immediately before touching a resident, before performing a aspect task, after contact with blood, body fluids, or contaminated surfaces, after touching a resident, after touching the residents environment, before moving from work on a soiled body site to a clean body site. A continuous observation was made on 05/12/24 from 9:14 AM to 9:47 AM. Resident #54 was resting in his bed and was covered with a sheet. He reported he was wet with urine and needed to be changed. He explained that the last time the staff had provided care to him was around 3:00 AM to 3:15 AM and he was pretty wet. Resident #54 was able to turn himself onto his right side using the grab bar. When he turned himself over it was noted that his brief was saturated to the very edge of the absorbent part of the incontinent product, the draw sheet under him was not wet. At 9:29 AM Resident #54 turned on his call light and stated, they should have done been in here. At 9:31 AM a staff member entered the room and Resident #54 stated that he needed to be changed, the staff member stated she would let his Nurse Aide (NA) know and left the room. At 9:35 AM Unit Manager (UM) #2 entered Resident #54's room and Resident #54 told her he needed to be changed. UM #2 turned off the call light and stated she was going to get some gloves and would be right back. UM #2 returned to Resident #54's room with supplies and with NA #4 to assist. UM #2 obtained a rag with warm water and placed soap on the rag and proceeded to wash Resident #54's peri area, once she had rinsed and dried his peri area, Resident #54 grabbed his right grab bar and turned himself to his right side. Once Resident #54 was on his right side, using a different rag that was wet with soap and water UM #2 was observed to wash Resident #54's buttock that were noted to be soiled with stool. It took several attempts from UM #2 wiping and cleaning Resident #54's buttock to get all the stool off of his buttocks. Once clean and without changing her gloves UM #2 was observed to grab her name tag and put inside her scrub top, then grab a tube of cream from Resident #54's table and open the tube and apply a generous amount to both buttocks. Once she had applied the cream without changing her gloves, UM #2 and NA #4 applied a new brief and covered him with a sheet before removing their gloves using hand sanitizer and exiting Resident #54's room at 9:47 AM. UM #2 was interviewed on 05/14/24 at 9:29 AM, she explained that Resident #54 had been incontinent since he was admitted to the facility and at times, he would ring his call bell for assistance. UM #2 confirmed that she had provided incontinent care to Resident #54 on 05/12/24 and stated, to be honest I forgot to change my gloves between clean and dirty and I knew immediately when I came out of the room I had messed up. She added that she should have removed her gloves used hand sanitizer and applied new gloves before applying the cream to Resident #54's buttocks and again before applying his clean brief. The Infection Preventionist (IP) was interviewed on 05/14/24 at 3:47 PM who stated that during incontinent care staff were expected to perform hand hygiene before starting the procedure and again after cleaning the resident up and removing the soiled brief or incontinent product but before applying a clean incontinent product. The IP explained this was to ensure that the staff did not contaminate the environment with dirty gloves. The Director of Nursing (DON) was interviewed on 05/14/24 at 5:24 PM. The DON stated that UM #2 was nervous during the incontinence change that was observed on 05/12/24. She stated that as soon as UM #2 came out of Resident #54's room she came and stated that she had messed up and had not taken her gloves off nor completed hand hygiene like she was supposed to. The DON stated she immediately reeducated UM #2 on the hand hygiene policy and also started a reeducation for all staff as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to honor a resident's bathing preference for 1 of 6 residents reviewed for choices (Resident #15). The findings included: Resident #15 was readmitted to the facility on [DATE] with diagnoses that included a heart failure, pneumonia, and diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 was cognitively intact and displayed no rejection of care. The MDS further revealed Resident #15 required extensive assistance with activities of daily living and bathing was coded as did not occur. Further review of the MDS revealed it was very important to Resident #15 to be able to choose between a tub bath, shower, bed bath, or sponge bath. Review of the undated facility shower book revealed Resident #15 was to receive a shower on Tuesdays and Friday on first shift. Review of Resident #15's ADL sheet documented she last received a bed bath on 02/18/23. There was no documentation of Resident #15 receiving a shower. An observation of Resident #15 on 02/26/23 at 05:07 PM revealed she did not look dirty and had no body odor. Her hair was pulled back and did not appear greasy. In an interview on 02/26/23 at 5:07 PM with Resident #15, she stated has not had a shower since she returned from the hospital on [DATE]. She stated she had her face and hands washed a few times and a few bed baths but would like a shower so she could feel clean. During a follow up interview on 03/01/23 at 8:31 AM with Resident #15, she stated she told the staff several times that she would like to have a shower but had not received a shower or a bath since she was re-admitted to the facility. She stated she refused a bed bath one time because she did not feel comfortable with a male bathing her. In an interview on 03/01/23 09:26 AM with Nurse Aide (NA) #3, she stated she cared for Resident #15 regularly on second shift and had not assisted Resident #15 with a shower because she was a 2-person assistance, and they did not have the staff to give Resident #15 a shower. An interview on 03/01/23 at 11:37 AM with NA #4, revealed he attempted to give Resident #15 a bed bath on 01/25/23, but she refused because he was a male. He stated he was not aware of Resident #15's preference for a shower. In an interview on 03/01/23 at 3:10 PM with NA #5, he stated he cared for Resident #15 regularly was not surprised that Resident #15 had not received a bath or shower since her re-admission because they did not have enough help to give showers. He stated he had not ever given her a shower. He stated in the shower book, Resident #15 was scheduled for a shower on Tuesdays and Fridays during the day shift. An interview was conducted on 03/01/23 at 3:12 PM with Nurse #1, she stated the reason that Resident #15 didn't get her showers was because there were not enough staff members to give showers. She stated they had to prioritize resident safety and with limited staff, they couldn't send the NAs to the shower room and not have them on the floor caring for the residents and keeping them safe. She stated the NAs knew who was supposed to receive a shower by looking in the shower book. She further stated, if their name was in the shower book, that meant they were supposed to get a shower and not a bath. In an interview on 03/01/23 at 12:02 PM with NA #6 she stated she had never given Resident #15 a shower, only a bed bath. She stated Resident #15 was a 2-person assist and they didn't have enough staff to give her a shower. In an Interview on 03/01/23 at 3:53 with the Administrator, she stated if residents are scheduled and they want a shower then staff should give the shower as scheduled. If the resident does not to receive shower, then washing their face and hands would be appropriate. The lack of shower should be reported to the nurses to document.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Resident and staff interviews the facility failed to provide incontinent care when requested by the resident for 1 of 6 residents reviewed for activities of daily living (Resident #22). The finding included: Resident #22 was admitted to the facility on [DATE] with diagnoses of heart disease, diabetes, and weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #22 was cognitively intact for daily decision making, required extensive assistance with toileting, and was frequently incontinent of bladder and occasionally incontinent of bowel. No refusal of care was noted during the assessment reference period. A care plan created on 01/27/23 read in part, Resident #22 had a history of urinary tract infections. The interventions included: check with care rounds and as needed for incontinence. Wash, rinse, and dry soiled area. Resident #22 was interviewed in her room on 02/28/23 at 1:33 PM. Resident #22 stated on 02/04/23 in the early evening hours (could not recall the exact time) she turned her call light on and when Nurse Aide (NA) #1 responded she made her aware she needed incontinent care and needed to be changed. NA #1 stated that she would be back, but she did not return. Resident #22 stated that after the change of shift Medication Aide (MA) #1 came in and provided care to her, she stated she was saturated with urine, and MA #1 had to take her to the shower to get her cleaned up. Resident #22 further stated that on 02/05/23 at approximately 4:30 PM she began turning her call light on because the brief she had on was wet. She stated that NA #1 was working again that day and had been providing care to her throughout the day. Resident #22 stated that NA #1 kept coming in (at least twice) and turning her call light off and would say she would be back to change her, but she never returned to change her. Resident #22 stated that at change of shift another NA who she could not recall her name came into her room to provide care to her sometime after 7:00 PM. Resident #22 explained that she took Lasix (diuretic) every day and she urinated a lot, she explained on 02/04/23 and 02/05/23 by the time the oncoming shift provided care to her she was saturated with urine that required an entire bed change. NA #2 was interviewed via phone on 02/28/23 at 2:43 PM and confirmed that she worked the weekend of 02/04/23 and 02/05/23. She stated that on 02/05/23 she reported to work at 7:00 PM and was preparing to complete a walking round with NA #1 who had worked the previous shift. NA #2 stated NA #1 disappeared from the unit by the time she had sat her belongings down and was gathering her assignment information, she stated, she just disappeared and NA #2 did not receive any report that day. NA #2 stated she responded to Resident #22's call bell at approximately 7:00 PM to 7:15 PM and was made aware that she was wet and needed to be changed. NA #2 stated that she told Resident #22 she had just arrived to work and was gathering supplies and she would be right back to get her cleaned up. NA #2 stated that she went and gathered her supplies and immediately returned to Resident #22's room at around 7:30 PM room to provide care to her. She stated Resident #22 was in the bed and was soaking wet with urine. She stated that she was so wet, Resident #22 required an entire bed change. She confirmed that she had removed the soiled brief and sheets, washed Resident #22's peri area and applied a clean brief and clean bed linens. She stated that Resident #22's buttocks were not red, and she had no sores on her buttock. NA #2 further stated that Resident #22 was able to turn from side to side and she was able to provide care to her by herself. The Weekend Supervisor was interviewed via phone on 02/28/23 at 3:55 PM. She confirmed that she was working on the weekend of 02/04/23 and 02/05/23. She stated she was not aware of the specific incident with Resident #22 but stated she had performance issues with NA #1 and had reports of residents being left wet. She stated that NA #1 was a new NA and she had requested additional orientation for her and had asked the staff to perform walking rounds with NA #1 so that any issues could be brought to her attention before she left after her shift. NA #1 was interviewed via phone on 02/28/23 at 5:21 PM. NA #1 stated she had just started working at the facility one month ago (01/25/23). She confirmed that she was working the weekend of 02/04/23 and 02/05/23. She added that she was still in orientation but was working by herself that day due to staff call outs. NA #1 stated she was familiar with Resident #22 and had provided care to her both days that weekend. She stated that Resident #22 turned on her call light anytime she needed something including when she needed incontinent care. If Resident #22 was up in her wheelchair NA #1 stated that she would take her to the bathroom and provide care but if Resident #22 was in bed she would provide care to her in the bed. NA #1 did not recall the times that she provided care to Resident #22 on either 02/04/23 or 02/05/23 because she would just do so at the time Resident #22 turned her call light on and requested care. NA #1 denied that she had turned Resident #22's call light off and denied that she had not provided care when requested. NA #1 stated that she did not do a round or report with NA #2 when she came on shift but could not recall why she had not done so. NA #1 stated no had one spoken to her about the weekend of 02/04/23 and 02/05/23 and was unaware of any issues that occurred during that time. MA #1 was interviewed via phone on 03/01/23 at 9:21 AM. MA #1 confirmed she had worked the weekend of 02/04/23 and 02/05/23. She further explained that on 02/04/23 she took over Resident #22's unit at 11:00 PM, she indicated that she was not sure who had worked the previous shift as she did not get any report when she arrived for her shift. MA #1 explained that Resident #22 wore a pull up during the day or anytime she was out of bed but if she was in bed, she preferred to wear a brief due to how much she urinated because of her medications that she took. MA #1 recalled on 02/04/23 after shift change around 11:30 PM, she responded to Resident #22's call light. Resident #22 stated she was soiled and needed to be changed. MA #1 stated that when she pulled back the covers to provide care she found that Resident #22 was soaking wet with a dried brown ring of urine on her bottom sheet. She stated that she told Resident #22 that she was going to get her up and take her to the shower so she could wipe down her mattress and let it air dry while they were in the shower. MA #1 stated she asked Resident #22 what happened and why she was so wet, she stated that NA #1 had left without providing care to her. MA #1 stated she assisted Resident #22 to her wheelchair stripped her bed of the soiled linens, wiped her mattress with Clorox wipes and let it air dry while she took Resident #22 to the shower. After the shower she remade Resident #22's bed and then assisted her back to bed. MA #1 stated that Resident #22 peri area was not red and was intact during that shower. The Administrator and Director of Nursing (DON) were interviewed on 03/01/23 at 11:41 AM. The Administrator stated that NA #1 was a new employee and had been going through a lot of orientation. She stated NA #1 had requested additional orientation and the staff had come to her with performance issues. The staff had reported to the Administrator that NA #1 lacked the confidence to jump in and get things done, she required a lot of prompting and someone to help NA #1 stay on task. She further explained they were trying to foster NA #1 as much as possible. The Administrator and DON confirmed they were not aware of the incidents with Resident #22 that occurred on 02/04/23 and 02/05/23. The DON stated the staff should be rounding for incontinent care every two to three hours. She added that incontinent care should be completed when requested by Resident #22 before her call light was turned off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and staff and Wound Nurse Practitioner interviews, the facility failed to implement a new treatment order prescribed by the Wound Nurse Practitioner for a pressure ulcer for 1 of 1 resident (Resident #86) reviewed for pressure ulcers. The finding included: Resident #86 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, chronic kidney disease, peripheral vascular disease, and neuropathy. Review of Resident #86's weekly skin assessment dated [DATE] revealed purplish/black areas on bilateral buttocks. The care plan dated 02/19/23 revealed Resident #86 had actual skin impairment with interventions to monitor the site for infection and to ensure the dressing was intact. A review of Resident #86's Wound Nurse Practitioner (NP) wound evaluation dated 02/22/23 revealed the Resident's right buttock was unstageable and the treatment would be cleansing with wound cleanser and applying a medical grade honey and cover with a gauze border dressing every day. A review of Resident #86's physician orders revealed an order dated 02/24/23 to cleanse right buttock with wound cleanser and apply medical grade honey and cover with a gauze border dressing every day. A review of Resident #86's Wound Nurse Practitioner wound evaluation dated 02/27/23 revealed the Wound NP utilized sharp debridement to the unstageable pressure ulcer and the treatment was changed to cleansing with wound cleanser and apply Santyl ointment (a debriding agent) and cover with a gauze border dressing every day. A review of the Wound Nurse Practitioner wound log dated 02/28/23 revealed the order for cleansing the pressure ulcer with wound cleanser and applying Santyl ointment and cover with a gauze border dressing every day. A review of Resident #86's Treatment Administration Record (TAR) for 02/2023 revealed the order to cleanse right buttock with wound cleanser and apply medical grade honey and cover with a gauze border every day was initiated on 02/24/23. Further review of the Treatment Administration Record (TAR) for 02/2023 revealed the order for cleansing the pressure ulcer with wound cleanser and applying Santyl ointment and cover with a gauze border dressing every day was not added to the TAR on 02/28/23. An observation of the pressure ulcer treatment was conducted on 02/28/23 at 1:35 PM by Nurse #2. The Nurse cleansed the pressure ulcer with a wound cleanser and applied medical grade honey ointment then covered the pressure ulcer with a gauze border dressing every day. Review of Resident #86's TAR for 03/2023 revealed an order to cleanse right buttock with wound cleanser and apply medical grade honey and cover with a gauze border every day. The treatment was signed off for 03/01/23 indicating the treatment had been completed. An interview was conducted with the Unit Manager (UM) #2 on 03/01/23 at 12:05 PM who explained that the Wound Nurse Practitioner sent her wound log to the facility via email and there was no one person responsible to look at the log and pick up on writing new orders that might need to be initiated. The UM stated she tried to look at the log for order changes for the residents she was responsible for, but she had not looked at it yet. The UM pulled up the wound log that was sent to the facility on [DATE] and located the order change of Santyl for Resident #86 and stated she had not had time to look at it yet. The UM stated in her opinion the Santyl ointment should have been obtained from the pharmacy by now and the new treatment should have been applied to the pressure ulcer. An interview was conducted with the Wound Nurse Practitioner on 03/01/23 at 11:26 AM who explained that Resident #86 was admitted with a deep tissue injury over his right buttock, and she initially started the medical grade honey ointment to get the debridement process started. When she evaluated the pressure ulcer on Monday 02/27/23 she debrided the pressure ulcer and changed the order from the medical grade honey to Santyl ointment because the pressure ulcer needed a more aggressive debriding agent to speed up the debridement process. The Wound NP continued to explain that she sent the wound log to the facility via email within 24 hours of her visit which was on 02/27/23 and her expectation was for the facility to initiate new orders as soon as they obtained the treatment from their pharmacy. The Wound NP stated Santyl should have been started before now (03/01/23 at 11:26 AM). On 03/01/23 at 12:24 PM during an interview with the Director of Nursing she stated it was the Unit Managers responsibility to follow up with writing the new treatment orders provided by the Wound Nurse Practitioner and it was her expectation that it should have been done when they received the new orders on 02/28/23. On 03/01/23 at 12:50 PM an interview was conducted with the Administrator who indicated her expectation was that the new treatment for Resident #86's pressure ulcer should have been started on 02/28/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff and Resident interviews the facility failed to have ongoing communication to ensure a newly admitted resident received a meal tray during meal service for 1 of 13 residents (Resident #88) reviewed for dining. The finding included: Resident #88 was admitted to the facility on [DATE]. Review of Resident #88's medical record dated 02/24/23 revealed she was on a regular diet with regular texture and consistency. Review of Resident #88's admission nursing assessment dated [DATE] revealed the Resident was alert and oriented to person, place, and time. On 02/26/23 at 6:00 PM an observation was made of multiple staff passing out supper trays from the meal cart on 400 hall. An observation and interview were conducted with Resident #88 on 02/26/23 at 6:04 PM. The Resident was lying in bed and explained that they had not brought her supper tray to her yet. On 02/26/23 at 6:31 PM an observation was made of the meal cart not being on the 400 hall. An interview and observation of Resident #88 on 02/26/23 at 6:32 revealed she still had not received a supper tray. The Resident explained that a man stopped by and asked her for her tray, and she told him that she didn't have a tray. On 02/26/23 at 6:32 PM an interview with the Weekend Supervisor revealed she did not know why Resident #88 did not receive her supper tray and she would speak with Nurse Aide (NA) #4 to find out why she did not receive her meal tray. On 02/26/23 at 6:40 PM during an observation and interview of Nurse Aide #4, the NA was coming out of Resident #88's room and explained that he stopped by the Resident's room earlier and asked her if she had her tray and she told him that she did not have a tray. The NA stated that he misunderstood her because she was telling him that she did not receive her supper tray at all. The NA stated he thought her tray had already been picked up from the Resident's room by one of the other people helping him pass out the meal trays. The NA continued to explain that he normally did not have help passing out the meal trays and that day he had other people helping him, so he did not realize Resident #88 did not receive her supper tray. The NA stated he would go to the kitchen and get Resident #88 something to eat. During an interview with Resident #88 on 02/26/23 at 6:46 PM the Resident still did not have a supper tray. The Resident explained that NA #4 apologized to her for not getting her supper tray and told her that he normally did not get help passing out the meal trays therefore, he did not realize she did not get her supper tray. The NA was going to get her a supper tray. At 6:51 PM on 02/26/23 Nurse Aide #4 took Resident #88 her supper tray of chicken tenders, macaroni and cheese, green beans and a cookie for dessert which was what was served to the rest of the residents. An interview was conducted with Resident #88 on 02/28/23 at 10:24 AM. The Resident explained that she was disappointed when she did not get her supper tray on Sunday night (02/26/23) and stated, when you are sick already it just did not make me feel good being forgotten. On 02/28/23 at 10:31 AM during an interview with the Marketing Director she explained that she only passed out one supper tray on 400 hall on 02/26/23 because she arrived at the facility late that evening. She stated she did ask if there were anymore trays to pass out and was told no. On 02/28/23 at 10:42 AM during an interview with the Admissions Director (AD) she confirmed that she helped pass out the supper meal trays on 400 hall on 02/26/23. The AD explained that there were two supper trays left on the cart that were not passed out because she put them back on the cart because the residents refused the trays. The AD stated she was not aware that Resident #88 did not receive her supper tray until later Sunday night. An interview with the Certified Dietary Manager (CDM) on 02/28/23 at 4:50 PM revealed she assisted with plating the food for the supper meal on 02/26/23 and was made aware that Resident #88 did not receive her supper tray after they had finished the serving line in the kitchen. The CDM explained that she investigated the situation and found that the Resident was admitted on Friday 02/24/23 and all weekend her meal tickets had to be handwritten until her information could be entered into the system before the system could print out a meal ticket for her. She continued to explain that she interviewed the dietary aide that wrote Resident #88 meal ticket for the supper meal that day so she could not determine why the Resident did not get her tray other than it was possible that the meal ticket was stuck to another meal ticket, or it was even possible that Resident #88's supper meal was put on a different cart but she could not be 100 % sure that happened either. An interview was conducted with the Administrator with the Director of Nursing (DON) in attendance on 03/01/23 at 12:24 PM. The DON explained that she was not made aware that Resident #88 had not received her supper tray until it was brought to her attention on the night of 02/26/23. The DON indicated there should be a double check system to ensure the all the residents received their meal trays.

Based on observations, record reviews, 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 the complaint survey conducted on 07/27/20. This failure was for one deficiency that was originally cited in the areas of Infection Control (F880) and was subsequently recited on the current recertification and complaint survey of 03/02/23. The repeat deficiency during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This tag is cross referred to: F880: Based on observation, record review, and staff interviews, Nurse #2 failed to perform hand hygiene and change gloves after removing a dirty dressing, after cleansing a wound and before applying a clean dressing to a wound for 1 of 1 staff member that completed wound care (Nurse #2). During the Covid-19 Focused Infection Control and complaint investigation survey completed on 7/27/20 the facility failed to implement protocols when staff did not don and doff Personal Protective Equipment (PPE) when they entered and exited the rooms of residents who were on Droplet Precautions for 2 of 2 nursing staff observed working on the facility's quarantine hallway. The facility failed develop a policy that addressed when laundry staff were to perform hand hygiene and what Personal Protective Equipment (PPE) they were to wear. Additionally, a laundry aide was observed not wearing any PPE while handling clean and dirty laundry nor perform hand hygiene after touching soiled linen laundry for 1 of 1 staff observed processing laundry. Staff disposed of isolation gowns, that were used on the facility's quarantine unit, in a bag that was attached to a blood pressure machine. Staff failed to disinfect a mattress that was removed from a resident's room who was on droplet precautions, and failed to wear PPE, to prevent contact with skin and clothing, when the mattress was removed from the quarantine unit. These failures in proper infection control practices occurred during a COVID-19 pandemic and had the potential to affect all residents and staff in the facility through the transmission of COVID-19. The Administrator was interviewed on 03/01/23 at 4:01 PM who stated that the facility Quality Assurance (QA) committee met monthly and included all the department heads and the Medical Director, and a smaller group met monthly to go over antibiotic stewardship, residents with weight loss, trends, grievances, etc. They had monthly staff meetings to share QAPI information with the floor staff. Some recent PIP (performance improvement projects) they were working on were around staff retention and Point of Care (POC - point in time when care is given) documentation. The Administrator stated that they would incorporate the current survey results into their meeting and discuss way to achieve substantial compliance.

Based on observation, record review, and staff interviews, Nurse #2 failed to perform hand hygiene and change gloves after removing a dirty dressing, after cleansing a wound and before applying a clean dressing to a wound for 1 of 1 staff member that completed wound care (Nurse #2). The finding included: Review of a facility policy titled Infection Control Guidelines for all Nursing Procedures dated 12/29/20 under General Guidelines the policy indicated: 3. Employees must wash their hands for a minimum of 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions, c. After contact with secretions or non-intact skin; e. After handling items potentially contaminated with blood, bodily fluids, or secretions. 4. e. Before handling clean dressing, gauze pads and etc; h. After handling used dressings. On 02/28/23 at 1:35 PM an observation was made of Nurse #2 performing a dressing change on Resident #86's pressure ulcers. The Nurse sanitized her hands and applied clean gloves then brought wound care supplies (gauze soaked with wound cleanser, ointment in a medicine cup, and 2 border dressings) into the Resident's room. Resident #86 was positioned on his left side with his buttocks exposed where he had an unstageable wound on his coccyx (without a dressing present) and an open wound on his right buttocks (with a dressing present). The Nurse proceeded to cleanse the coccyx wound with the soaked gauze then removed the dirty dressing from his right buttock and cleansed that wound. She then used her index finger to apply the medicated ointment to the two wounds then covered the two wounds with border dressings. After Nurse #2 applied the two border dressings she removed her gloves and sanitized her hands. An interview was conducted with Nurse #2 on 02/28/23 at 1:45 PM who explained that she realized she did not change her gloves and wash her hands during the dressing change. The Nurse continued to explain that she should have removed the dirty dressing from the Resident's right buttock first then remove her gloves and sanitized her hands before she cleansed the wounds. She stated she also should have removed her gloves and sanitized her hands before she applied the medicated ointment and applied the clean border dressings. The Nurse verbalized that she clearly contaminated the Resident's wounds. An interview was conducted with Unit Manager (UM) #2 and the Administrator on 02/28/23 at 2:00 PM. The observation of Nurse #2's performance was explained in step-by-step detail to the UM and the Administrator. The UM verbalized the Nurse should have removed her gloves and sanitized her hands after she removed the dirty dressing and after she cleansed the dirty wounds to prevent recontamination of the wounds. The Administrator acknowledged the situation and agreed with the Unit Manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 15 was readmitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #15 was cognitively intact. Review of Resident #15's Activities of Daily Living (ADL) sheet revealed the last documented bed bath was on 02/18/23. There was no documentation of Resident #15 receiving a shower. Resident #15 was scheduled to receive a shower on Tuesdays and Fridays on first shift. An interview and observation were conducted on 02/26/23 at 5:07 PM with Resident #15. She stated has not had a shower since she returned from the hospital on [DATE]. She stated she had her face and hands washed a few times and a few bed baths but would like a shower so she could feel clean. Resident #15 stated she wanted a shower or at least a tub bath so she could just feel clean. She stated she just didn't know why the staff didn't want to clean her. Observations revealed Resident #15 did not look dirty, had no body odor, and her hair was pulled back and did not appear greasy. The highlighted sentences contradict each other. During a follow up interview on 03/01/23 at 8:31 AM with Resident #15, she stated she told the staff several times that she would like to have a shower but had still not received a shower or a tub bath since she was re-admitted to the facility. Resident #15 stated she felt nasty and just wanted to feel clean. In an interview on 03/01/23 09:26 AM with Nurse Aide (NA) #3, she stated she cared for Resident #15 regularly on second shift and had not assisted Resident #15 with a shower because she was a 2-person assistance, and they did not have the staff to give Resident #15 a shower. In an interview on 03/01/23 at 3:10 PM with NA # 5, he stated he cared for Resident #15 regularly was not surprised that Resident #15 had not received a bath or shower since her re-admission because they did not have enough help to give showers. He stated he had not ever given her a shower. An interview was conducted on 03/01/23 at 3:12 PM with Nurse #1, she stated the reason that Resident #15 didn't get her showers was because there were not enough staff members to give showers. In an interview on 03/01/23 at 12:02 PM with NA #6 she stated she had never given Resident #15 a shower, only a bed bath. She stated Resident #15 was a 2-person assist and they didn't have enough staff to give her a shower. The Director of Nursing (DON) was interviewed on 03/01/23 at 11:41 AM and stated that she believed in treating everyone with the upmost respect and dignity and care should be provided as requested. Based on record review, Resident, and Staff interview the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested (Resident #22) and for not providing showers as the resident preferred (Resident #15) for 2 of 3 residents reviewed for dignity. The Finding included: 1. Resident #22 was admitted to the facility on [DATE] with diagnoses of heart disease, diabetes, and weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #22 was cognitively intact for daily decision making, required extensive assistance with toileting, and was frequently incontinent of bladder and occasionally incontinent of bowel. No refusal of care was noted during the assessment reference period. Resident #22 was interviewed in her room on 02/28/23 at 1:33 PM. Resident #22 stated that on 02/04/23 in the early evening hours she turned her call light on and when Nurse Aide (NA) #1 responded she made her aware she needed incontinent care and needed to be changed. NA #1 stated that she would be back, but she did not return to change her. Resident #22 stated that after the change of shift Medication Aide (MA) #1 came in and provided care to her, she stated she was saturated with urine, and MA #1 had to take her to the shower to get her cleaned up. Resident #22 further stated that on 02/05/23 at approximately 4:30 PM she began turning her call light on because the brief she had on was wet. Resident #22 stated that NA #1 kept coming in (at least twice) and turning her call light off and would say she would be back to change her, but she never returned to change her. Resident #22 stated that at change of shift another NA who she could not recall her name came into her room to provide care to her sometime after 7:00 PM. Resident #22 explained on 02/04/23 and 02/05/23 by the time the oncoming shift provided care to her she was saturated with urine that required an entire bed change. Resident #22 stated she did not like the fact that she sat soiled for so long, it doesn't make me feel good, but what else can I do? I have no choice but to sit and wait for the staff to come and help me. NA #2 was interviewed via phone on 02/28/23 at 2:43 PM and confirmed that she worked the weekend of 02/04/23 and 02/05/23. She stated that on 02/05/23 she reported to work at 7:00 PM. NA #2 stated that she responded to Resident #22's call bell at approximately 7:00 PM to 7:15 PM and was made aware that she was wet and needed to be changed. NA #2 stated that she told Resident #22 she had just arrived to work and was gathering supplies and she would be right back to get her cleaned up. NA #2 stated that she went and gathered her supplies and immediately returned to Resident #22's room at around 7:30 PM room to provide care to her. She stated Resident #22 was in the bed and was soaking wet with urine. She stated that she was so wet, Resident #22 required an entire bed linen change. NA #1 was interviewed via phone on 02/28/23 at 5:21 PM. NA #1 stated that she had just started working at the facility one month ago (01/25/23). NA #1 stated that she was familiar with Resident #22 and had provided care to her both days the weekend of 02/04/23 and 02/05/23. She stated that Resident #22 turned on her call light anytime she needed something including when she needed incontinent care. If Resident #22 was up in her wheelchair NA #1 stated that she would take her to the bathroom and provide care but if Resident #22 was in bed she would provide care to her in the bed. NA #1 did not recall the times that she provided care to Resident #22 on either 02/04/23 or 02/05/23 because she would just do so at the time Resident #22 turned her call light on and requested care. NA #1 denied that she had turned Resident #22's call light off and denied that she had not provided care when requested. MA #1 was interviewed via phone on 03/01/23 at 9:21 AM. MA #1 confirmed that she had worked the weekend of 02/04/23 and 02/05/23. She further explained that on 02/04/23 she took over Resident #22's unit at 11:00 PM. MA #1 recalled on 02/04/23 after shift change around 11:30 PM, she responded to Resident #22's call light. Resident #22 stated she was soiled and needed to be changed. MA #1 stated that when she pulled back the covers to provide care, she found that Resident #22 was soaking wet with a dried brown ring of urine on her bottom sheet. She stated that she told Resident #22 that she was going to get her up and take her to the shower so she could wipe down her mattress and let it air dry while they were in the shower. MA #1 stated she asked Resident #22 what happened and why she was so wet, she stated that NA #1 had left without providing care to her. MA #1 stated she assisted Resident #22 to her wheelchair stripped her bed of the soiled linens, wiped her mattress with Clorox wipes and let it air dry while she took Resident #22 to the shower. The Administrator and Director of Nursing (DON) were interview on 03/01/23 at 11:41 AM. The Administrator and DON confirmed that they were not aware of the incidents with Resident #22 that occurred on 02/04/23 and 02/05/23. She added that incontinent care should be completed when requested by Resident #22 before her call light was turned off. The DON added that she had a conversation with Resident #22 in the past about her wearing briefs when in the bed, she stated that Resident #22 toileted during the day while up and she did not think there was any reason why she could not toilet during the night to avoid wearing a brief. The DON stated she offered Resident #22 a bedside commode which she declined because she was afraid it would not get empty and would smell bad in her room. The DON stated she believed Resident #22 was being untruthful and exaggerating the time she was left soiled and about the staff turning her call light off. The DON further stated, I believe in treating everyone with the upmost respect and dignity and I have tired to promote her dignity and she refused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews the facility failed to ensure code status information was available for use for Resident #68 and Resident #14 and failed to ensure the code status information was accurate throughout the medical record for Resident #35. This affected 3 of 3 residents (Resident #68, #35 and #14) reviewed for advanced directives. The findings include 1. Resident #68 was admitted to the facility on [DATE]. A review of Resident #68's electronic medical record revealed a physician order for a Full Code dated 11/06/22. A review of the Code Status notebook kept at the nursing station revealed there was no advanced directive in the notebook for Resident #68. An interview was conducted with the Admissions Director (AD) on 02/28/23 at 11:08 AM. The AD explained that she addressed the residents' advanced directive, do not resuscitate or full code while in the admission meeting with the resident and or responsible party and put the paperwork in the big red code status notebook at the nursing station. The AD continued to explain that she had only been responsible for doing it for about 2 weeks, so she did not know anything about why Resident #68's code status was not in the notebook. During an interview with the Unit Manager (UM) #1 on 02/28/23 at 12:20 PM the UM explained that the admission Director (AD) informed her of the residents' code status, and she was responsible for writing the order for it and the AD was responsible for putting the proper paperwork in the code status notebook. The UM indicated she did not know why Resident #68 did not have a designated advanced directive in the notebook. An interview was conducted with the Director of Nursing (DON) on 02/28/23 at 11:28 AM who stated that it was her expectation that the residents' advanced directives be in the code status notebook at the nursing station, and they should match the residents' electronic medical record. 2. Resident #35 was admitted to the facility on [DATE]. Review of Resident #35's electronic health record revealed a physician order dated 12/09/22 for Do Not Resuscitate (DNR). A review of Resident #35's care plan dated 12/21/22 revealed the Resident was a Full Code status with the goal to initiate all life sustaining technology as agreed upon. An interview was conducted with the Minimum Data Set (MDS) Nurse #1 on 02/28/23 at 11:19 AM who explained that she was responsible for care planning Resident #35's advanced directive and remembered the day of the care plan meeting with the Resident and her family. The Nurse continued to explain that when she reviewed her advanced directive with the Resident, she voiced that she did not want to be a DNR but that she wanted to be a Full Code, so she wrote the care plan for a Full Code status. She stated she sent a message to Unit Manager #2 about the change in the advanced directive. An interview was conducted with Unit Manager (UM) #2 on 02/28/23 at 12:20 PM. The UM explained that she was responsible for the residents on the hall that Resident #35 resided and stated she was not aware of being notified of the Resident's advanced directive needing to be changed. During an interview with the Director of Nursing (DON) on 02/28/23 at 11:28 AM she explained that the MDS Nurse should have care planned Resident #35's advanced directive for what it was at the time of the care plan meeting (DNR) and notified the UM about the Resident's wishes for the advanced directive to be changed to a Full Code. The DON stated when the order for the Full Code was obtained then the MDS Nurse should have updated the care plan to reflect a Full Code. 3. Resident #14 was readmitted on [DATE]. Review of Resident #14's electronic medical record revealed a physician order dated 01/31/23 that read, Full Code. A review of the Code Status notebook kept at the nursing station where all residents in the faciltiy code status inforamtion was kept revealed there was no advanced directive in the notebook for Resident #14. An interview was conducted with the Admissions Director (AD) on 02/28/23 at 11:08 AM. The AD explained that she addressed the residents' advanced directive, do not resuscitate or full code while in the admission meeting with the resident and or responsible party and put the paperwork in the big red code status notebook at the nursing station. The AD continued to explain that she had only been responsible for doing it for about 2 weeks, so she did not know anything about why Resident #14's code status was not in the notebook. During an interview with the Unit Manager (UM) #1 on 02/28/23 at 12:20 PM the UM explained that the admission Director (AD) informed her of the residents' code status, and she was responsible for writing the order for it and the AD was responsible for putting the proper paperwork in the code status notebook. The UM indicated she did not know why Resident #14 did not have a designated advanced directive in the notebook. An interview was conducted with the Director of Nursing (DON) on 02/28/23 at 11:28 AM who stated that it was her expectation that the residents' advanced directives be in the code status notebook at the nursing station. The DON stated that they implemented the notebook at the nursing station for the nursing staff to have a quick reference of code status during an emergency and a place to keep the original document so they could make copies if the resident was transferred to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility activity calendar, resident and staff interviews, the facility failed to ensure group activities were planned in the evenings on weekdays and on weekends to meet the needs of residents who expressed that it was important to them to attend group activities for 4 of 4 residents reviewed for activities (Resident #65, Resident #14, Resident #22 and Resident #62). The findings included: A review of the February 2023 activity calendar revealed morning breakfast daily and dining with music Monday through Friday (lunch). An activity titled Social Time listed Monday through Friday at 4:30 PM, but was not listed on the weekends. There were no activities listed after 4:30 PM on the calendar on weekdays. On weekends, the following activities were listed: Saturday- 10:30 AM Snack social and 2:30 PM Bingo and Sunday- Spiritual in rooms (Channel 32) and at 2:30 Bible Chat. The calendar revealed there were no other activities available on the weekends. a. Resident #65 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #65 felt that it was very important to have activities that included music, books, newspaper, going outside, and doing things in a group setting. The assessment further indicated Resident #65 was cognitively intact. A review of the comprehensive careplan for Resident #65 revealed no care plan for activity interest or involvement. An observation and interview with Resident #65 was conducted on 2/26/23 at 3:24 PM. Resident #65 was in her room lying in bed and indicated staff did not ask her if she wanted to go to the few activities offered because they were short staffed. Resident #65 also stated life here is boring. Resident #65 had various art hangings in her room and she said she used to be able to participate in art activities, but the facility did not provide them anymore. b. Resident #14 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #14 felt that it was very important to do activities that included receiving the newspaper, listening to music, and doing things in a group setting. The assessment further indicated Resident #14 was cognitively intact. An observation and interview with Resident #14 was conducted on 2/26/23 at 5:09 PM. Resident #14 was in her room sitting in her wheelchair with the roommate's television on; however, Resident #14 was not watching it. She indicated she got bored often due to the lack of activities in the evening and on the weekends. A review of the comprehensive care plan for Resident #14 revealed no care plan for activity interest or involvement. c. Resident #22 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #22 felt that it was very important to do activities that included listening to music, pets, religious activities, and doing things in a group setting. The assessment further indicated Resident #22 was cognitively intact. An observation and interview with Resident #22 was conducted on 2/26/23 at 3:51 PM. Resident #22 indicated the facility did not have a lot to do for activities and she stated, we are so bored we cannot see straight. The activity calendar looks full, but it has our meals as three activities each day. Resident #22 was conversing with her roommate (Resident #62) during the interview, and Resident #22 stated the activity at 4:30 PM on weekdays titled Social Time was strictly where snacks were brought to each of their rooms and not an activity or a group activity to socialize. A review of the comprehensive care plan for Resident #22 revealed no care plan for activity interest or involvement. d. Resident #62 was admitted to the facility on [DATE]. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #62 felt that it was important to do activities that included watching the news, listening to music, playing with pets, attending religious activities, and doing things in a group setting. The assessment further indicated Resident #62 was cognitively intact. An observation and interview with Resident #62 was conducted on 2/26/23 at 3:51 PM. Resident #62 indicated that the facility did not have many activities to do and indicated their activity calendar may look full, but it actually was very limited in structured activities and it included meals. Resident #62 explained we simply get bored because there's nothing to do. Resident #62 was conversing with her roommate (Resident #22) during the interview. Resident #62 agreed with Resident #22 (her roommate) that the activity at 4:30 PM on weekdays titled Social Time was strictly where snacks are brought to each of our rooms and not an activity or a group activity to socialize. A review of the comprehensive care plan for Resident #62 revealed no care plan for activity interest or involvement. An interview with the Activity Director was conducted on 2/27/23 at 11:45 AM which revealed she was in charge of developing the activity calendar each month. She acknowledged that the meals were included in the activity calendar and she had been trying to provide activities for the facility alone until an assistant was recently hired to help. She stated that an activity that was scheduled every Monday only benefited one resident in the facility, but remained on the calendar. She explained that this was a spiritual activity entitled Jehovah's Witness and this was not applicable to most resident's in the facility. The Activity Director explained that she added an extra day of bingo to the calendar but was not aware meals could not be counted as an activity and would try to modify the calendar beginning in April. The activity director acknowledged there were no activities in the evenings and on the weekends there was bingo on Saturday and on Sunday there was a worship service, but this activity was where residents were able to watch church on television and not a live in person service. During an interview with the Administrator on 03/01/23 at 3:24 PM she revealed she was aware that the residents had requested more bingo activities and that an extra day of bingo was added to the calendar in recent months. The Administrator stated that she was not aware of ongoing concerns with the lack of activities in the evenings and on the weekends.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and resident and staff interviews, the facility failing to clean oxygen filters for 2 of 3 residents (Resident #3 and Resident #13) reviewed for oxygen usage. 1. Resident #3 was re-admitted to the facility on [DATE] with diagnoses that included asthma. A care plan dated 1/3/23 indicated Resident #3 requires oxygen usage with interventions to include may titrate oxygen rate to ensure oxygen saturations are greater than 92% and position for body alignment to facilitate optimal breathing patterns. A hospital Discharge summary dated [DATE] indicated Resident #3 was to receive oxygen via nasal cannula at 2L (liters) continuously. Review of the Treatment Administration Record (TAR) dated February 2023 revealed the following: Change oxygen tubing when visibly soiled every Sunday night. The TAR further revealed that Nurse #4 initialed the oxygen tubing change on 02/26/23. Multiple attempts were made to contact Nurse #4 without success. An observation on 2/26/23 at 2:51 PM revealed Resident #3's oxygen concentrator contained a black filter which had a visible grayish-white fuzzy substance on the surface. An observation on 2/27/23 at 8:57 AM revealed Resident #3's oxygen concentrator contained a black filter which had a visible grayish white fuzzy substance on the surface. An interview with Nurse #3 on 3/1/23 at 2:24 PM revealed she is a night shift nurse (11 PM to 7 AM shift) and stated all residents who use concentrators should have their filter cleaned weekly on Sunday night when the nasal cannulas were replaced. An interview with the Director of Nursing and Administrator on 3/123 at 3:53 PM revealed the filters attached to the oxygen concentrator to be cleaned weekly on Sunday by the nursing staff on night shift. The DON indicated the nurses cleaned external filters and maintenance staff would clean internal filters. 2. Resident #13 was readmitted to the facility on [DATE] with diagnoses that included respiratory failure and asthma. A physician order dated 10/27/22 read Oxygen at 2 liters per minute via nasal canula. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #13 was moderately impaired for daily decision making, had shortness of breath with exertion, and required the use of oxygen during the assessment reference period. Review of the Treatment Administration Record (TAR) dated February 2023 revealed the following: Change oxygen tubing when visibly soiled every Sunday night. The TAR further revealed that Nurse #3 initialed the oxygen tubing change on 02/05/23 and 02/19/23 and Nurse #4 initialed the oxygen tubing change on 02/12/23 and 02/26/23. An observation of Resident #13 was made on 02/26/23 at 4:13 PM. Resident #13 was sitting in her wheelchair at the foot of her bed. She was wearing oxygen via nasal canula that was connected to an oxygen concentrator sitting next to her. The concentrator was noted to have no external oxygen filter and the space where the filter was to be placed was full of grey/white dust particles. An observation of Resident #13 was made on 02/27/23 at 10:18 AM. Resident #13 was resting in bed. She was wearing oxygen via nasal canula that was connected to an oxygen concentrator sitting next to her bed. The concentrator was noted to have no external oxygen filter and the space where the filter was to be placed was full of grey/white dust particles. An observation of Resident #13 was made on 02/28/23 at 4:46 PM. Resident #13 was sitting in her wheelchair at the foot of her bed. She was wearing oxygen via nasal canula that was connected to an oxygen concentrator sitting next to her. The concentrator was noted to have no external oxygen filter and the space where the filter was to be placed was full of grey/white dust particles. An observation of Resident #13 was made on 03/01/23 at 10:08 AM. Resident #13 was being assisted to her recliner by the Physical Therapist (PT). The PT was observed to replace Resident #13's portable oxygen with the oxygen concentrator that sat next to her bed. The oxygen concentrator was noted to have no external oxygen filter and the space where the filter was to be placed was full of grey/white dust particles. Nurse #5 was interviewed on 03/01/23 at 10:21 AM who confirmed that she was caring for Resident #13. She stated that the third shift nurses were responsible for changing the oxygen tubing once a week. Nurse #5 was unsure of who was responsible for cleaning/replacing oxygen filters. She stated that in other facility's she had worked the maintenance department took care of them but could not say who was responsible in this facility. Nurse #5 stated she had not cleaned or checked the filter on Resident #13's oxygen concentrator because she did not know she needed to. The Maintenance Director was interviewed on 03/01/23 at 10:31 AM who stated that he cleaned/replaced the oxygen concentrator filers as needed. He was asked to observe Resident #13's oxygen concentrator and confirmed that there was no filter where it should be and that the dust needed to be removed from the empty space in the back of the concentrator. The Central Supply Clerk was interviewed on 03/01/23 at 10:44 AM who stated the third shift nursing staff were responsible for cleaning/replacing the oxygen filters. Multiple attempts to speak to Nurse #4 were made on 03/01/23. The Director of Nursing (DON) was interviewed on 03/01/23 at 12:02 PM who stated that on Sunday nights the nurses were responsible for changing oxygen tubing as well and checking/cleaning and/or replacing the oxygen concentrator filters. She stated that the nurses would do the external filters and the Maintenance department would do the internal filters. Nurse #3 was interviewed via phone on 03/01/23 at 2:24 PM who confirmed that she worked night shift at the facility on Sunday nights and was responsible for changing oxygen tubing and cleaning or replacing oxygen filters. Nurse #3 stated that she did not recall specifically checking or cleaning Resident #13's oxygen filter because she did so many. She further stated that it was her general practice to check and clean each oxygen filters for the residents on her unit on Sunday nights and if she documented that she did it then that would indicate it had been done.

Based on observations, record reviews, staff, and Resident interviews the facility failed to provide sufficient nursing staff resulting in residents not being treated in a dignified manner and missed showers for 2 of 6 sampled residents (Resident #22 and Resident #15). The findings include: This tag is crossed referenced to F 550: Based on record review, Resident, and Staff interview the facility failed to treat a resident in a dignified manner by not providing incontinent care when requested (Resident #22) and for not providing showers as the resident preferred (Resident #15) for 2 of 3 residents reviewed for dignity. This tag is crossed referenced to F 561: Based on observations, record review, resident and staff interviews the facility failed to honor a resident's bathing preference for 1 of 6 residents reviewed for choices (Resident #15). This tag is crossed referenced to F 677: Based on record review, Resident and staff interviews the facility failed to provide incontinent care when requested by the resident for 1 of 6 residents reviewed for activities of daily living (Resident #22). An interview was conducted with the Weekend Supervisor via phone on 02/28/23 at 3:55 PM who explained that she worked every weekend from 7:00 AM to 11:00 PM on the medication cart, helping the Nurse Aides (NAs), and navigating whatever other issues came her way. She stated that nine times out of ten on the weekend the facility was short staffed, and residents had to wait longer than use for care. The Weekend Supervisor stated that showers were not being provided because they were too short staffed, these residents deserve better than what they get. She explained that on the weekends there were generally one NA on each floor then the Nurses were expected to help pass meal trays, answer call lights, and provide care as needed, no matter how much we asked for help we were just left to deal with it. The Scheduling Coordinator was interviewed via phone on 03/01/23 at 9:46 AM who confirmed that she had been at the facility since December 2022 and at that time staffing was terrible, they did not have a lot of staff, and the staff that they had were upset because they had to work every other weekend so a lot of employees quite or went as needed and then would not come in when we needed them. The Scheduling Coordinator stated that she asked and begged for the facility to allow agency staff to come in and help fill the staffing shortages and finally about two weeks they agreed. She stated that the agency staff has eased some of the burden but she still had openings on second shift and the weekends. She added she was very flexible with the facility staff that they had in regard to their hours, she stated some come in at 7, some come in at 8 but she remained flexible in attempt to retain the employees that they had. The Scheduling Coordinator stated that she liked to have 8 NA on first and second shift and 5 on the night shift and one nurse on each unit or 2 nurses and a medication aide this included the weekends. She stated with the help of agency they are able to do this more often then they were two weeks ago. The Director of Nursing (DON) was interviewed on 03/01/23 at 4:01 PM who stated that the last month she has been hanging on by a fingernail due to staffing shortages. She stated she was getting pulled to assist with the staffing shortages and everything that she needed to be monitoring was not getting monitored like it should because she was busy with other things.