**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to place signage indicating oxygen was in use outside resident rooms for 2 of 3 residents reviewed for oxygen use (Resident #228 and Resident # 69). Findings included: 1. Resident #69 was admitted to the facility on [DATE], and diagnoses included congestive heart failure. Resident #69 was discharged from the facility on 1/27/2024 to the hospital and was readmitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #69 was cognitively intact, was not experiencing shortness of breath and was not receiving oxygen therapy. Physician orders dated 1/8/2024 included an order for oxygen at 2 liters per minute via nasal cannula as needed to keep oxygen saturations greater than 90%. On 2/1/2024, Resident #69's re-admission physician orders included oxygen at 2 liters per minute via nasal cannula continuously every shift for congestive heart failure and hypoxia (low oxygen in the blood). A physician note dated 2/2/2024 recorded Resident #69 was still requiring oxygen therapy, and Resident #69 was receiving oxygen via nasal cannula. On 2/5/2024 at 2:40 p.m., Resident #69 was observed wearing oxygen via nasal cannula at 2 liters per minute. There was no warning signage observed indicating oxygen was in use located outside the room or on the door frame. On 2/6/2024 at 8:28 a.m., there was no warning signage observed indicating oxygen was in use located outside the room or on the door frame. On 2/6/2023 at 2:16 p.m. in an interview with Unit Nurse Manager #1 and Unit Nurse Manager #2 (the assigned nurse on re-admission), Unit Nurse Manager #2 stated after reviewing Resident #69's electronic medical record, she could not positively say Resident #69 was using oxygen when readmitted to the facility. Unit Nurse Manager #1 explained based on the hospital's discharge summary it was reported Resident #69 was using oxygen on arrival to the facility, and Resident #69 was to continue the use of oxygen until weaned off oxygen at the facility. Unit Nurse Manager #1 stated the facility used red Oxygen in Use. No Smoking magnetic signage outside the room on the door frames to communicate oxygen was in use in the room. She stated Resident #69 was using oxygen, and nursing staff was responsible for placing and checking that the Oxygen in Use. No Smoking warning signage was outside the room on the door frame. When asked why Resident #69 did not have warning signage indicating oxygen was in use outside the room, she stated the warning signage was magnetic and could have gotten knocked off the door frame. On 2/7/2024 at 8:57 a.m. in an interview with the Director of Nursing, she stated Resident #69 should have an Oxygen in Use. No Smoking warning signage outside the room on the door frame due to receiving oxygen, and nursing staff were responsible for placing the warning signage outside the room on the door frame. She further stated checking the use of oxygen and ensuring placement of the warning signage on the door frame was a task for the nursing staff to observe for compliance when completing daily rounds on residents in the facility. She stated she did not have an explanation why a warning signage was not on Resident #69's door frame when observed on 2/5/2024 and 2/6/2024 and reported there were ambulatory confused residents on the hall where Resident #69 resided that would remove items off the walls and door frames at times. 2. Resident #228 was admitted to the facility on [DATE], and diagnoses included chronic obstructive pulmonary disease (COPD) and pneumonia. Physician orders dated 1/20/2024 included oxygen via nasal cannula at 2 liters per minute to keep oxygen saturation greater than 91% as needed due to pneumonia. Resident #228's care plan dated 1/20/2024 indicated Resident #228 was receiving oxygen therapy for a respiratory illness. Interventions included humified oxygen set at 2 liters per minute via nasal cannula continuously. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #228 was cognitively intact and was receiving oxygen therapy. Nursing documentation dated 2/5/2024 recorded Resident #228 was using oxygen. On 2/5/2024 at 10:45 a.m., Resident #228 was observed receiving oxygen at 2 liters per minute via nasal cannula. There was no warning signage that oxygen was in use observed outside Resident #228's room on the door frame. On 2/6/2024 at 8:30 a.m. there was no warning signage reporting oxygen was in use observed outside Resident #228's room on the door frame. In an interview with Unit Nurse Manager #1 on 2/7/2024, she stated after completing an interview on 2/6/2023 at 2:16 p.m. related to oxygen and the use of warning signage, she asked other unit managers to assist her in conducting rounds to check to ensure residents receiving oxygen had a warning signage, Oxygen in Use. No Smoking, outside the room on the door frame. She stated she recalled at some point Resident #228 having the warning signage, Oxygen in Use. No Smoking outside the room on the door frame and didn't know why the warning signage was not on the door frame on 2/5/2024 and 2/.6/2024. She explained unit nurse managers tried to check that the magnetic warning signage was outside the room on the door frame when completing daily rounds on the residents and explained sometimes unit nurse managers were pulled to complete other tasks which interrupted them from completing rounds on the residents. In an interview with Unit Nurse Manager #3 on 2/7/2024, she stated on 2/6/2024, after an initial interview with Unit Nurse Manager #1 on 2/6/2024 at 2:16 p.m. about oxygen warning signage, she completed rounds on Resident #228 and placed the warning signage, Oxygen in Use. No Smoking outside Resident #228's room on the door frame. On 2/7/2024 at 8:57 a.m. in an interview with the Director of Nursing, she stated Resident #228 should have an Oxygen in Use. No Smoking warning signage outside the room on the door frame due to receiving oxygen, and nursing staff were responsible for placing the warning signage outside the room on the door frame. She further stated checking the use of oxygen and ensuring placement of the warning signage on the door frame was a task for the nursing staff to observe for compliance when completing daily rounds on residents in the facility. She stated she did not have an explanation why a warning signage was not on Resident #69's door frame when observed on 2/5/2024 and 2/6/2024 and reported there were ambulatory confused residents on the hall where Resident #69 resided that would remove items off the walls and door frames at times.

Based on staff interview and record review, the facility Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions the committee put into place following the 04/14/2021 recertification survey. This was for a recited deficiency in the area of infection control. This deficiency was cited again on the current recertification survey. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F880 - Based on record review, observation and staff interviews, the facility failed to ensure staff followed the facility's infection control procedures by not performing hand hygiene when donning and doffing Personal Protective Equipment (gloves) during wound care for 1 of 1 resident observed for pressure ulcer wound care (Resident #60). During the recertification survey of 04/14/21, the facility was cited F880 Infection Control for failure to ensure staff wore Personal Protective Equipment (face masks) correctly while working in the facility. During an interview with the Administrator on 09/23/22 at 2:26 p.m., the Administrator indicated the QAA Committee meets on the last Friday of every month and the Director of Nursing and the Infection Control are included in attendance.

Based on record review, observation and staff interviews, the facility failed to ensure staff followed the facility's infection control procedures by not performing hand hygiene when donning and doffing Personal Protective Equipment (gloves) during wound care for 1 of 1 resident observed for pressure ulcer wound care (Resident #60). The findings included: Review of the facility's Infection Control: Hand Hygiene policy, released January 2022, read in part, Effective hand hygiene reduces the incidence of healthcare associated infections . B. Indications for Hand Hygiene Using Alcohol-based Hand Sanitizer include: #7 Before donning gloves; #8 After removing gloves . An observation of Resident #60's wound care was conducted on 09/22/22 at 9:42 a.m. Nurse #1 administered the wound care to the resident's left buttock area, assisted by Nursing Assistant (NA) #1; also in attendance was the facility's wound care medical doctor who assessed Resident #60s wound once the soiled dressing had been removed. Upon the start of the wound care, Nurse #1 washed her hands and donned gloves and set up wound care supplies on the covered overbed table. Nurse #1 removed the soiled dressing from the resident and disposed the soiled dressing. Nurse #1 then doffed her gloves and donned clean gloves. Nurse #1 then cleansed the wound. At 9:46 a.m., Nurse #1 doffed her gloves and donned clean gloves and did not wash her hands in between the glove change. Nurse #1 applied a petroleum dressing over wound. At 9:47 a.m., doffed her gloves and donned clean gloves, did not washing her hands and applied additional petroleum dressings to the wound bed. At 9:48 a.m., Nurse #1 doffed her gloves and donned clean gloves and did not wash her hands. At 9:51 a.m., Nurse #1 doffed her gloves and donned clean gloves, did not wash her hands, and cleared the overbed table of wound care supplies, sanitized her bandage scissors with an alcohol wipe, doffed her gloves and then went into the bathroom located in the resident's room and washed her hands. During an interview with Nurse #1 on 09/22/22 at 10:05 a.m., Nurse #1 was asked what she should do after doffing and before donning gloves and she did not answer. After prompting if she should have washed her hands after doffing and before donning clean gloves during the wound care procedure, Nurse #1 stated no and explained she had followed the new company's policy which she kept on a clipboard located on her treatment cart and proceeded to show this surveyor the policy. The worksheet Nurse #1 produced was a piece of paper with a check-list on it which was titled 16. Wound Dressing Change Observation. There was no author listed and no created/revised date noted on this worksheet. Nurse #1 referred to the third column on the worksheet which heading read as Hand Hygiene before and after dressing change and to the fourth column which heading read as Clean gloves donned before and doffed after dressing change. Nurse #1 further explained because of these instructions, she only had washed her hands before beginning the wound care and after the wound care was completed. A second interview with Nurse #1 was conducted on 09/22/22 at 10:20 a.m., at her request. Nurse #1 stated she knew she was supposed to wash her hands before donning and after doffing gloves and had become distracted while she provided wound care and had forgotten to do so. An interview was conducted with the Administrator on 09/22/22 at 1:27 p.m. When asked why she thought Nurse #1 did not wash her hands after doffing the soiled gloves and before donning the clean gloves, the Administrator thought Nurse #1 had become distracted during the wound care observation secondary to being observed by a surveyor, a medical doctor, a nursing assistant and the resident. The Administrator explained staff education regarding hand hygiene had already begun and stated the following week a public health nurse from the North Carolina Department of Health & Human Services, Division of Public Health, would be in the facility to monitor handwashing techniques by the staff. The Administrator stated it was her expectation the staff follow facility policy and procedure for handwashing when donning and doffing gloves.