Based on record review and staff interviews, the facility failed to notify the physician of missed medication administration for 1 of 2 residents reviewed for notification (Resident #2). The findings included: Resident #2 was admitted to the facility 12/1/2021 with diagnoses including diabetes and hypertension. Review of the physician orders for Resident #2 revealed an order dated 12/1/2022 for glipizide (an oral hypoglycemic) 10 milligrams (mg) daily for diabetes. Review of Resident #2's medication administration record for December 2023 revealed the following dates were documented as not given and to see the nursing notes: 12/6/2023, 12/8/2023, 12/9/2023, 12/11/2023, and 12/14/2023. Nursing notes were reviewed for Resident #2 and the following was documented: 12/6/2023 documented by Nurse #1: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: unavailable. The note did not document the physician had been notified the medication was not available. 12/8/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the physician had been notified the medication was not available. 12/9/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the physician had been notified the medication was not available. 12/11/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the physician had been notified the medication was not available. 12/14/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the physician had been notified the medication was not available. Multiple attempts were made to contact Nurse #2 for interview, but Nurse #2 did not return the calls. The former Director of Nursing (DON #1) was interviewed by phone on 7/22/2024 at 2:00 PM. DON #1 reported the facility had an automatic medication dispensing system that should have been stocked with routine medications for the residents and if the medication was not available, the physician should have been notified. The DON #1 reported she did not recall Resident #2 missing several doses of glipizide because the medication was not available and was not aware the physician was not notified. Nurse #1 was interviewed by phone on 7/22/2024 at 3:48 PM. Nurse #1 reported she was no longer employed at the facility, but she had administered medications to Resident #2 in the past. Nurse #1 explained if the facility did not have medications in stock, she would have called the pharmacy and the physician. When reviewing documentation Nurse #1 completed on 12/6/2023, Nurse #1 reported she had no memory of the incident and did not know why she had not called the physician. A phone interview was conducted with the facility physician (MD) on 7/23/2024 at 11:05 AM. The MD reported he had not been notified that glipizide 10 mg was not available for administration to Resident #2 and if he had been notified, he would have ordered a replacement medication. The MD explained that because Resident #2 was on other hypoglycemic medications, missing the 5 doses of the medication most likely had not harmed her, however, she should have received the medication, and he should have been notified she did not have 5 doses of the glipizide. The Director of Nursing (DON #2) and Assistant Director of Nursing (ADON) were interviewed on 7/23/2024 at 12:44 pm. DON #2 reported she and the ADON did not start working for the facility until 2024 and they were not in the building when Resident #2 missed her medications in December 2023. DON #2 explained the staff were educated to call the physician if a medication was not available to administer and she did not know why Nurse #1 and Nurse #2 had not contacted the MD about Resident #2's glipizide. The Regional Director of Clinical Services was interviewed on 7/23/2024 at 1:13 PM and she reported a mock survey was conducted in March 2024 and the survey discovered multiple issues with medication administration, including the physician was not notified for missed medications, and a plan of correction has been developed. The facility provided a plan of correction dated 3/28/2024 for unavailable medications. 1. During Mock Survey on 3/26/2024 it was identified Physician/Responsible Party were not notified of missed medications. 2. To identify residents that have the potential to be affected the Director of Nursing/Designee immediately reviewed 100% electronic medication administration records for the past six months to ensure all residents medications were administered as ordered. 100% of residents affected with the documentation of medications unavailable during different months during this review time. Responsible party/Guardians notified of findings. Medical Provider notified and reviewed findings and agrees no significant medication errors. A Quality Assurance Performance Improvement (QAPI) meeting was conducted on 3/27/2024 to discuss findings, develop the plan of correction, and initiate monitoring. A Root cause analysis determined the lack of notification of the Physician and Responsible Party were due to nursing staff not following the procedure to notify. 3. To prevent this from happening again on 3/28/2024, the Director of Nursing/Designee completed education with 100% of Licensed Nursing Staff, Medication Aides and Current Agency Staff on the process of notification to the DON/Nurse Manager if any issues with obtaining medications, Notifying the Responsible Party if applicable, Notifying the Physician if unable to obtain the prescribed medication and request an interchange if available in the automated medication dispensing system. Licensed Nurses and Medication Aides educated on documentation and instructed not to use medication unavailable until all the above has been exhausted and Physician has given an order to hold until medication is available. Newly hired Licensed Nursing Staff to be educated during Orientation. Agency nursing to be educated before assigned shift on Medication Administration Guidelines. 4. To Monitor and Maintain Ongoing Compliance the facility will do the following: The DON/Designee will audit the medication administration records 5x's a week for 12 weeks to ensure all medications guidelines are followed and in compliance and to ensure medical provider notified if any medication availability issues are identified. The Administrator will report the results of the audits to the QAPI committee for review and recommendations for a minimum of three months. Date of Compliance: 03/29/2024. The facility date of compliance of 3/29/2024 was validated on 7/23/2024 by review of the education provided to nursing staff and medication aides, reviewing audit forms, reviewing medication administration records and nursing notes, review of the QAPI meeting notes, and interviews with nursing staff, Physician, Director of Nursing, and Assistant Director of Nursing.

Based on record review, observation, and staff interviews, the facility failed to handle soiled linens in a manner to prevent the spread of infection for 1 of 1 laundry room observation. The findings included: The facility policy Transmission-based Precautions and Isolation Policy dated 1/2014 with a revision date of 4/15/2024 read, in part: Handle resident care .laundry . with standard precautions . The facility laundry room was observed on 7/23/2024 at 12:05 PM. The Laundry Aide #1 was interviewed at the time of the observation. The soiled linen area was observed, and no personal protective equipment (PPE) was in the room. When asked to demonstrate moving soiled linen from the soiled linen bin, the Laundry Aide #1 demonstrated removing the soiled linen from a tied plastic bag and placed the soiled linen in the washing machine. Laundry Aide #1 reported she did not apply PPE when moving the soiled linen from the plastic bags into the washing machine and she did not have PPE in the laundry room. The Infection Control Nurse was interviewed by phone on 7/23/2024 at 12:33 PM. The Infection Control Nurse reported Laundry Aide #1 should be using PPE to move soiled linen from the plastic bags into the washing machine. The Infection Control Nurse explained she had provided training to Laundry Aide #1 including the use of PPE for soiled linens and the Infection Control Nurse did not know why the Laundry Aide #1 was not using the PPE. The Director of Nursing (DON) #2 was interviewed on 7/23/2024 at 12:41 PM and she reported she was not aware Laundry Aide #1 was not using PPE when moving soiled linens from the soiled linen bin to the washing machine. DON #2 explained she expected Laundry Aide #1 to use PPE to prevent the spread of infection when in contact with any soiled laundry. The Administrator was interviewed on 7/23/2024 at 1:13 PM and he reported Laundry Aide #1 had started to work at the facility about 1 month prior and she had received training on using PPE with soiled linen and he did not know why she was not using PPE.

Based on record review, observations, and staff interviews, the facility failed to provide routine medications for 1 of 3 residents reviewed for medication administration (Resident #2). The findings included: Resident #2 was admitted to the facility 12/1/2021 with diagnoses including diabetes and hypertension. The most recent quarterly Minimum Data Set assessment assessed Resident #2 to be moderately cognitively impaired. Review of the physician orders for Resident #2 revealed an order dated 12/1/2022 for glipizide (an oral hypoglycemic) 10 milligrams (mg) daily for diabetes. Additionally, physician orders for Resident #2 included the following hypoglycemic medications: Victoza 1.2 mg subcutaneous daily for diabetes ordered 11/11/2023 Metformin 1000 mg orally twice daily for diabetes ordered 12/1/2022 Sliding scale insulin as needed 3 times per day ordered 11/11/2023: give 2 units of insulin for blood sugars 200-250; give 4 units of insulin for blood sugars 251-200; give 6 units of insulin for blood sugars 301-350; give 8 units of insulin for blood sugars 351-400; give 10 units of insulin for blood sugars 401-450; give 14 units of insulin for blood sugars greater than 451 and call the physician. Review of the medication administration record for December 2023 revealed the following dates glipizide 10 mg was documented as not given and to see the nursing notes: 12/6/2023, 12/8/2023, 12/9/2023, 12/11/2023, and 12/14/2023. Nursing notes were reviewed for Resident #2 and the following was documented: 12/6/2023 documented by Nurse #1: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: unavailable. The note did not document the pharmacy had been contacted for refills. 12/8/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the pharmacy had been contacted for refills. 12/9/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the pharmacy had been contacted for refills. 12/11/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the pharmacy had been contacted for refills. 12/14/2023 documented by Nurse #2: glipizide 10 mg: give 10 mg by mouth one time a day for diabetes: none on hand. The note did not document the pharmacy had been contacted for refills. Blood glucose results for Resident #2 were reviewed with the following results: (normal results from 70-120) 12/6/2023: 5:36 AM 423 10 units of sliding scale insulin given 12/6/2023: 12:19 PM 423 10 units of sliding scale insulin given 12/6/2023: 4:35 PM 281 4 units of sliding scale insulin given 12/8/2023: 6:09 AM 231 2 units of sliding scale insulin given 12/8/2023 11:16 AM 254 4 units of sliding scale insulin given 12/8/2023 5:03 PM 225 2 units of sliding scale insulin given 12/9/202: 7:01 AM 211 2 units of sliding scale insulin given 12/9/2023: 10:37 AM 255 4 units of sliding scale insulin given 12/9/2023: 3:56 PM 236 2 units of sliding scale insulin given 12/11/2023: 5:42 AM 165 no sliding scale insulin given 12/11/2023: 11:16 AM 253 4 units of sliding scale insulin given 12/11/2023: 4:36 PM 163 no sliding scale insulin given 12/14/2023: 3:56 PM 235 2 units of sliding scale insulin given A pharmacy report of medication orders for Resident #2 in December 2023 documented glipizide 10 mg had been delivered on 12/18/2023. Multiple attempts were made to contact Nurse #2 for interview, but Nurse #2 did not return the calls. The former Director of Nursing (DON #1) was interviewed by phone on 7/22/2024 at 2:00 PM. DON #1 reported the facility had an automatic medication dispensing system that should have been stocked with routine medications for the residents. DON #1 explained staff nurses were instructed to look in the automatic medication dispensing system, then call the pharmacy and ask for the medication to be sent to the facility. DON #1 reported she did not recall Resident #2 missing several doses of glipizide because the medication was not available. Nurse #1 was interviewed by phone on 7/22/2024 at 3:48 PM. Nurse #1 reported she was no longer employed at the facility, but she had administered medications to Resident #2 in the past. Nurse #1 explained if the facility did not have medications in stock, she would have called the pharmacy and the physician. When reviewing documentation Nurse #1 completed on 12/6/2023, Nurse #1 reported she had no memory of the incident and did not know why she had not called the pharmacy. A phone interview was conducted with the facility physician (MD) on 7/23/2024 at 11:05 AM. The MD explained that because Resident #2 was on other hypoglycemic medications, missing the 5 doses of the medication most likely had not harmed her, however, she should have received the medication, and the pharmacy should have been notified the medication was not available. A Pharmacist was interviewed by phone on 7/23/2024 at 11:31 AM. The Pharmacist explained that the facility was using an automated refill system for routine medications that required completion of a form every month for the refills to be completed. The Pharmacist explained the automated refill process would not be completed if the form was incomplete, and the pharmacy records indicated the refill request for October and November 2023 were not completed and the refills were cancelled. The Pharmacist reported the automatic medication dispensing system had glipizide available as a stock medication and the facility had refilled the automatic medication dispensing system with 10 tablets of glipizide 10 mg on 12/10/2023, but they had not taken any out of the automatic medication dispensing system. The Pharmacist revealed no calls were documented from the facility from 12/6/2023 to 12/14/2023 requesting a refill of glipizide for Resident #2, and no medications were removed from the automatic medication dispensing system for her in December 2023. The Director of Nursing (DON #2) and Assistant Director of Nursing (ADON) were interviewed on 7/23/2024 at 12:44 pm. DON #2 reported she and the ADON did not start working for the facility until 2024 and they were not in the building when Resident #2 missed her medications in December 2023. DON #2 explained the ADON was completing the automated refill requests for the facility, so no refills were omitted. The ADON reported a daily report of missed medications was reviewed every morning to ensure that all residents were receiving their medications as the physician ordered. The Regional Director of Clinical Services was interviewed on 7/23/2024 at 1:13 PM and she reported a mock survey was conducted in March 2024 and the survey discovered multiple issues with medication administration, including the pharmacy was not being contacted for medications that were not in-house or stocked in the automatic medication dispensing system and a plan of correction has been developed. The facility provided a plan of correction dated 3/28/2024 for unavailable medications. 1. During Mock Survey on 3/26/2024 multiple documentations of medication unavailable in resident electronic medical records were identified. 2. To identify residents that have the potential to be affected the Director of Nursing/Designee immediately reviewed 100% electronic medication administration records for the past six months to ensure all residents medications were administered as ordered. 100% of residents affected with the documentation of medications unavailable during different months during this review time. Provider, Responsible party/Guardians (RP) were notified of findings and completed by 3/29/2024. A Quality Assurance Performance Improvement (QAPI) meeting was conducted on 3/27/2024 to discuss findings, develop the plan of correction, and initiate monitoring. A Root cause analysis determined missed medications were due to nursing staff not following the procedure to obtain medications that were not in the medication cart, the medication storage room, or in the automated medication dispensing system. 3. To prevent this from happening again, on 3/27/2024, the Director of Nursing/Designee completed education with 100% of Licensed Nursing Staff and Current Agency Staff on the process of obtaining and administering medications .The education is inclusive of the process for ordering medication when supply is low, checking the medication storage room for over stock medications, using the automated medication dispensing system, to identify if medication is available, Notifying the pharmacy for STAT delivery to the facility, Notification to the DON/Nurse Manager if any issues with obtaining medications, Notifying the RP if applicable, Notifying the Provider if unable to obtain the prescribed medication and request an interchange if available in the automated medication dispensing system. Licensed Nurses and Medication Aides were educated on documentation and instructed not to use medication unavailable until all the above has been exhausted and Provider has given an order to hold until medication is available. Newly hired Licensed Nursing Staff to be educated during Orientation. Agency nursing to be educated before assigned shift on Medication Administration Guidelines. 4. To Monitor and Maintain Ongoing Compliance the facility will do the following: The DON/Designee will audit the medication administration records 5x's a week for 12 weeks to ensure all medications guidelines are followed and in compliance. The Administrator will report the results of the audits to the QAPI committee for review and recommendations for a minimum of three months. Date of Compliance: 03/29/2024. The facility date of compliance of 3/29/2024 was validated on 7/23/2024 by observation of medication administration, review of the education provided to nursing staff, reviewing audit forms, reviewing medication administration records, nursing notes, review of the QAPI meeting notes, and interviews with nursing staff, Physician, Director of Nursing, and Assistant Director of Nursing. A medication administration observation was conducted 7/22/2024 and 7/23/2024. The facility had 0 errors out of 25 opportunities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, resident, and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents investigated for abuse from resident-to-resident sexual abuse (Resident #19). The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses to include intellectual disability and hypertension. A care plan dated 2/21/2023 addressed Resident #19's difficulty with communication related to his intellectual disability and included interventions to allow Resident #19 time to answer questions, and anticipate his needs, as he was not always able to express what he needed or wanted. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #19 to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. The MDS documented Resident #19 had no behaviors. Resident #1 was admitted to the facility on [DATE] with the most recent readmission date of 4/19/2023. Diagnoses for Resident #1 included bipolar disease, diabetes, and hypertension. A quarterly MDS dated [DATE] documented Resident #1 was cognitively intact with a BIMS of 15 out of 15. The MDS documented verbal behaviors occurred 1-3 days during the look-back period. A nursing note dated 4/14/2023 at 11:35 AM documented that Resident #1 was observed with Resident #19. Resident #19 had his pants down and Resident #1 was observed with her hands in Resident #19's genital area. The immediate intervention separated the two residents and placed both residents on 1:1 supervision. The note documented Resident #1 was anxious, upset, and agitated, and was yelling at staff. The note documented the physician, and the family member/responsible party were notified of the incident and no new orders were received. A nursing note dated 4/14/2023 at 11:40 AM documented that Resident #1 was tearful, and she refused a skin check by the nurse. The note documented the family member for Resident #1 returned the call and he reported Resident #1 liked men and liked to be sexual, and she could get upset when she cannot. The note documented Resident #1 told the nurse, Why are you trying to take my boyfriend away? A nursing progress note dated 4/14/2023 at 11:43 AM documented Resident #19 had experienced a sexual assault, and a head-to-toe assessment was completed. A facility reported incident dated 4/14/2023 at 11:45 AM documented an incident where Resident #1 was observed fondling Resident #19 inappropriately. The report documented the police department had been notified of the incident on 4/14/2023 at 12:49 PM. A nursing progress note dated 4/14/2023 at 11:45 AM documented Resident #19 had been observed with his pants down and with Resident #1's hands in his genital area. Immediate interventions included removing Resident #19 from the area and he was placed on 1:1 supervision. The note documented that Resident #19 was pleasant and cooperative and his physical assessment was within normal limits. The note documented that Resident #19's family/responsible party was notified of the occurrence and that Resident #19 was placed on 1:1 supervision. The note documented the physician was notified of the occurrence, and no new orders were received. A nursing note dated 4/14/2023 at 1:58 PM further documented Resident #1's refusal to permit a skin assessment, but she finally consented to allow an assessment of her neck, breasts, chest, and abdomen. No issues were identified. A nursing note dated 4/14/2023 at 3:57 PM documented Resident #1 continued to experience anxiety and was tearful and upset about not being able to talk to Resident #19. The note documented Resident #1 did not have an effective response to the scheduled antianxiety medication administered at 1:00 PM. A care plan dated 4/14/2023 addressed Resident #1 having inappropriate sexual behavior, with interventions included to discuss her feelings and inappropriate sexual behaviors with more appropriate options, observe for changes in mental status and reinforce unacceptability of inappropriate behaviors with other residents. A nursing note dated 4/15/2023 documented Resident #19 had no signs or symptoms of distress noted. A nursing note dated 4/16/2023 documented that Resident #19 had no signs or symptoms of distress. A psychiatry initial consultation dated 4/18/2023 documented Resident #19 was evaluated with another staff member present for inappropriate sexual behaviors. The note documented Resident #19 was alert to name, and pleasant. Resident #19 was able to answer yes/no questions. The note documented Resident #19 had no behaviors since the incident and there was no need to adjust or change medications. The facility 5-day investigative report dated 4/19/2023 documented on 4/14/2023 Resident #19 was found with his pants lowered and Resident #1 was observed removing her hands from his genital area. The report documented the police were notified of the incident, and Resident #19's responsible party was notified of the incident, and she did not want to press charges against Resident #1, but she did not want Resident #19 and Resident #1 to be around each other. Resident #19's responsible party was supportive of Resident #19 being moved to a facility that provided care for intellectually disabled adults. The report documented that an interview was conducted with Resident #19, and he reported he pulled down his pants because Resident #1 asked him. The report documented 100% staff education was provided on the abuse policy and 1:1 supervision was provided to both residents and would continue until either resident was placed (in another facility). A Quality Assessment Performance Improvement plan was developed and implemented. An interdisciplinary team meeting (IDT) note dated 4/21/2023 documented the team met to discuss the incident between Resident #19 and Resident #1. The note documented Resident #19 was on 1:1 supervision during the time Resident #1 was in the building and the plans included seeking placement for Resident #19 in an adult care home for intellectually disabled adults. A psychiatry progress note dated 4/18/2023 documented an evaluation of Resident #1 and when she was interviewed, she stated, I understand why they separated us, but I don't agree. The progress note documented Resident #1 was stable on her current medications and no changes would be made to her medications. A psychiatry progress note dated 5/16/2023 documented that no behaviors were reported for Resident #19, and he no longer required 1:1 care. Resident #19 was observed on 9/25/2023 at 3:17 PM. Resident #19 was in the dining room attending an activity. Resident #1 was in the dining room at the same time. Multiple staff members were noted supervising the activity and the residents. An observation of Resident #19 was conducted on 9/26/2023 in the activity room. Resident #19 was sitting at a table coloring pictures. Resident #1 was across the room. The activity director and the assistant activity director were supervising the residents. The Activity Director was interviewed at the time of the observation, and she reported the two residents were never to be left alone and were always supervised. The Activity Director reported she always had another staff member assist with activities to provide the supervision that was needed. Resident #19 was observed on 9/27/2023 in the dining room for an activity. Two staff members were noted to be attendance supervising the residents. Resident #19 was sitting close to the TV watching a movie and Resident #1 was noted to be seated far behind Resident #19. Resident #19 was observed on 9/28/2023 eating lunch alone at a table in the dining room. Resident #1 was not in the dining room. Several staff members were noted to be assisting residents with the lunch meal. A phone call was made to Resident #19's family member on 9/25/2023 at 3:15 PM and the family member did not return the phone call. During an attempt at an interview on 9/25/2023 at 3:17 PM, Resident #19 was unable to answer interview questions, but he did answer that yes he felt safe. An interview was conducted with the Business Office Manager (BOM) on 9/27/2023 at 10:18 AM. The BOM reported she had witnessed the incident between Resident #19 and Resident #1. The BOM described that she looked to her left into the front sitting room as she was leaving the conference room and saw Resident #19 standing in front of Resident #1. The BOM reported Resident #19's pants were pulled down to his upper thighs, and Resident #1 was removing her hands from his genital area. The BOM explained she did not see Resident #1 touching Resident #19, nor did she see his exposed genitals. The BOM described that Resident #1 was sitting in a wheelchair with her back to the door to the sitting room, and the BOM reported she saw that Resident #19's pants were pulled down to his upper thighs. The BOM reported she called Resident #19's name and he looked up at her and appeared startled and quickly pulled his pants up over his hips. The BOM reported Resident #1 turned around in her wheelchair and she had a big grin on her face. The BOM reported she had daily contact with both Resident #19 and Resident #1 and she had not witnessed any sexual behavior from either resident prior to this incident. The BOM explained that Resident #19 had no payor source, and the facility was awaiting Medicaid approval for them to make a referral to an adult care home for intellectually disabled adults. The BOM reported no facility would accept him without a payor source and the facility was providing room and board free of charge to Resident #19. Nursing assistant (NA) #1 was interviewed on 9/27/2023 at 1:20 PM. NA #1 reported she had not observed any sexual behaviors from Resident #1 or Resident #19, either before or after the incident. NA #1 reported she provided supervision to Resident #19. NA #1 reported Resident #19 was never left alone with Resident #1. An interview was conducted with NA #2 on 9/27/2023 at 1:40 PM. NA #2 reported Resident #19 and Resident #1 were always supervised and were not left alone. NA #2 explained she was on medical leave when the original incident occurred. NA #2 reported she had not observed Resident #1 exhibiting sexually inappropriate behaviors prior to the incident on 4/14/2023. The Assistant Director of Nursing (ADON) was interviewed on 9/27/2023 at 2:35 PM. The ADON reported she was working on 4/14/2023 when the incident occurred between Resident #19 and Resident #1, but she had not witnessed the incident. The ADON explained they put 1:1 supervision in place for both residents as well as 30-minute checks. The ADON reported that the staff make certain Resident #19 and Resident #1 are never alone together. An attempt was made to interview Nurse #1 who was on duty when the incident occurred, but she was not available. Resident #1 was interviewed on 9/25/2023 at 11:07 AM. Resident #1 stated, I can tell you they won't let me have a boyfriend! Resident #1 declined to answer further questions other than to state that the facility staff would not leave her and (Resident #19's name) alone, at all, ever. The Assistant Director of Nursing (ADON) was interviewed on 9/27/2023 at 2:35 PM. The ADON reported she was working on 4/14/2023 when the incident occurred between Resident #19 and Resident #1, but she had not witnessed the incident. The ADON explained they put 1:1 supervision in place for both residents as well as 30-minute checks. The ADON reported that the staff made certain Resident #19 and Resident #1 were never alone together. The ADON reported she had not observed Resident #1 exhibiting sexually inappropriate behaviors prior to the incident on 4/14/2023. Nurse #2 was interviewed on 9/28/2023 at 11:02 AM. Nurse #2 reported she had not observed Resident #1 exhibiting sexually inappropriate behaviors prior to the incident on 4/14/2023. The Director of Nursing (DON) was interviewed on 9/28/2023 at 1:38 PM. The DON reported that the BOM called out as she was witnessing the incident between Resident #19 and Resident #1. The DON explained that the residents were immediately separated, and both had assessments, the police department was notified, as well as the Department of Social Services. The DON reported the facility put both residents under 1:1 supervision to prevent any further incidents. The DON reported the psychiatrist was consulted to evaluate Resident #19 and to see Resident #1. The facility Quality Assessment and Performance Improvement Action Plan dated 4/14/2023 was reviewed. Included in the plan was immediate actions taken by the facility of separating the residents, performing head-to-toe assessments, notification of the family/responsible parties for both residents, putting both residents on 1:1 supervision, interviewing alert and oriented residents, performing 100% skin checks on all residents, auditing all care plans for residents with like care concerns or behaviors and making adjustments as needed, and interviewing family members/responsible parties for the residents with impaired cognition. The facility put into place audits to interview 10 cognitively intact residents per week for 4 weeks, then monthly for 2 months to identify any unreported incidents of abuse. Family interviews would be conducted on 7 cognitively impaired residents for 4 weeks and monthly for 2 months to identify any unreported incidents of abuse. Education was provided to all staff on 4/14/2023 and family members. The Quality Assessment and Performance Improvement Plan was reviewed, and each intervention had corresponding documentation to support the actions. Monitoring and audits were completed on 10 cognitively intact residents per week for 4 weeks, and then monthly for 2 months. Family interviews for 7 cognitively impaired residents were conducted for 4 weeks and then monthly for 2 months. Staff were interviewed and they acknowledged they had received education on 4/14/2023 regarding the residents right to be free from abuse. NA #2 reported she was on medical leave and the facility called her to provide her the education over the phone. The facility's date of compliance of 7/1/2023 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, resident and staff interviews, the facility failed to protect resident's bank debit cards, checks and credit cards from being accessed and used without resident permission for 3 of 3 residents reviewed for misappropriation of personal bank accounts (Resident #2,Resident #18, and Resident #14). The findings included: Resident # 2 was admitted to the facility on [DATE] with diagnoses that included chronic pain. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 2 had no cognitive impairment. Resident #18 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease. A quarterly MDS assessment dated [DATE] revealed Resident #18 had no cognitive impairment. Resident #14 was readmitted to the facility on [DATE] with diagnoses that included polyneuropathy and epilepsy. A review of a quarterly MDS assessment for Resident #14 revealed she had no cognitive impairment. A facility reported incident dated 05/02/23 at 1:00 PM documented the Director of Nurses (DON) was notified by a Police Detective from another city that during a police investigation in the early hours of 05/02/23 banking items were discovered in the possession of an agency nurse that previously worked at the facility with names of three persons (Resident #2, Resident #18, and Resident #14). The DON confirmed the three residents did reside at the facility and was provided a verbal record of the financial items found. The DON immediately reported the information to the Administrator and a report was filed with the local police department at 2:00 PM on 05/02/23. Resident #2, Resident #18, and Resident #14 were interviewed on 05/02/23 by the Administrator and Director of Nursing (DON) about missing bank or credit cards or other financial activity on their accounts that might have been fraudulently made. An interview was conducted with Resident #2 on 09/25/23 at 10:55 AM. Resident #2 revealed the Administrator and DON informed her the facility received a police report that revealed random numbered bank checks with Resident #2's name on them had been discovered in the possession of an unknown person that may have worked at the facility in the past. Resident #2 went through her checkbook with the DON and discovered that some random unused bank checks were missing. The Administrator notified the bank for Resident #2 to report possible fraudulent activity on her account and to ensure the bank would continue to monitor the account. Resident #2 revealed that later that day a police officer came to talk to her and asked her if she recognized a lady in a photograph. Resident #2 revealed she told him she was not sure but thought the lady looked like a nurse that had taken care of her before and the police officer reported he believed they might have a video showing the lady trying to use one of the checks, but she was not able to do so. Resident #2 revealed no money was missing from her account and she was glad the facility informed her and did a good job investigating what happened because the nurse never came back again. Resident #2 revealed she was provided a lock box for her closet for her valuable items, and she kept the key on her person at all times. Resident #2 revealed she was safe at the facility and liked living there. Resident #2 revealed she had never given anyone permission to access her private bank account. Resident #18 was interviewed on 09/25/23 at 11:23 AM. Resident #18 revealed he managed his own banking and checked his account balance almost daily. Resident #18 revealed a few days before 05/02/23, he noticed some unknown activity in his bank account but was not missing his debit card. He reported the activity to his bank , cancelled his debit card and ordered a new debit card. Resident #18 revealed there were maybe 3 or 4 charges that he did not make that totaled about $97.00 from a local grocery store and department store. Resident #18 revealed he never reported it to the facility because it was not their concern and he handled it. On 05/02/23 Resident #18 explained the DON and Administrator informed him that a police report was received by the facility, and it included store receipts with his name and bank account information on them. Resident #18 explained he had already identified the activity and informed the facility the steps he had already taken. The Administrator reimbursed him $100.00, and he was given a lockbox and key to keep his valuable items in. Resident #18 revealed that also on 05/02/23 a police officer came to his room to discuss the bank account activity information with him and was shown a photo of a young lady that he told the officer he did not recognize. Resident #18 explained that he felt safe and was appreciative of the facility and police involvement and investigations Resident #18 revealed he was private with his bank information and never shared it with anyone or gave permission to others to use his bank information. Resident #14 was interviewed on 09/25/23 at 11:47 AM. Resident # 14 revealed her banking was done by her mother who was in possession of her checks and debit card. Resident #14 revealed she had a cash app card that had no money on it that she kept it in her wallet in her purse which she always carried and at night she covered her purse with the bed linens near her feet. Resident #14 revealed that she did not know the cash app card was missing until the DON came and asked her if she was missing a debit card or checks because a bank card was reportedly found in the possession of an agency nurse that had previously worked at the facility. Resident #14 revealed she opened her purse and wallet and did not find the cash app card. The DON assisted Resident #14 to search her room and they were not able to locate the cash app card. The Administrator and DON spoke to the mother of Resident #14 and confirmed the mother was in possession of the bank debit card of Resident #14 and the cash card had no funds available on it and she would contact the bank for Resident #14 and inform them of the ongoing investigation and have them monitor the bank account for fraudulent activity. Resident #14 revealed on the same day she was given a key and a lockbox from the facility to store her purse and other valuable items. Resident #14 revealed she felt safe at the facility, the facility had been informative and handled the situation very well which was calming to her and her mother both. Resident #14 denied giving anyone permission to access her bank account or the cash app card. The facility 5-day investigation report dated 05/05/23 documented on 05/02/23 through 5/4/23. On 05/02/23 Resident #2, Resident #18, and Resident #14 were interviewed by the Administrator and Director of Nursing (DON) about missing bank, credit cards or other financial information that might have indicated fraudulent activity. The DON and Administrator interviewed 100% of cognitively intact residents and 100% of cognitively impaired residents family/RPs from 05/02/23 through 05/05/23 and educated them to monitor bank accounts, debit cards and credit card accounts for fraudulent activity, the facility offered to assist if needed making the calls or inquiries to these entities. Lockboxes with keys were offered to all residents and family/RPs by the facility and education was provided to report any suspicious or unusual behaviors observed to the Administrator, DON, or Social Worker immediately. The facility received no negative findings or concerns. 100 % of staff was re-educated on the abuse policy, types of abuse and reporting of abuse and any suspicious behaviors observed. A Quality Assessment Performance Improvement plan was implemented. On 09/27/23 at 12:52 PM an interview with the DON was conducted and she presented documents for review that included the facility timecard of the nurse involved with a recorded last date and time the agency nurse worked at the facility a from 7:00 PM on 4/22/23 until 7:00 AM on 4/23/23. Other documents reviewed included a police report from the Police Department dated 05/02/23, a copy of the North Carolina Board of Nursing nurse license verification and a copy of abuse training received from the agency of hire signed and dated by the nurse on 9/14/22. The DON revealed that when the Detective spoke to her on 05/02/23 she immediately informed the Administrator, contacted the local police department, the physician, Adult Protective Services , the North Carolina Board of Nursing (NCBON) and the agency that employed the nurse. The DON reported she and the Administrator interviewed Resident #2, Resident #18, and Resident #14 and all 3 residents denied giving their bank debit card, cash cards or checks to anyone for use. The DON and Administrator interviewed 100% of alert and oriented residents and 100% of families/RPs of cognitively impaired residents No negative outcomes were reported. All residents, families/ RPs were offered a secured lockbox to store valuable items and banking documents in. A phone interview conducted with the Police Department Detective on 09/27/23 at 1:36 PM revealed a person identified as a traveling nurse was found to be in possession of bank checks, bank debit cards and credit information that belonged to other people. The person of interest reported she had been given the items from residents with permission to use the items to make purchases requested by the residents. The Detective contacted the DON and she confirmed Resident #2, Resident #18, and Resident #14 resided at the facility and she would notify the Administrator, residents, and local police department immediately and begin a full facility investigation. The Detective confirmed he received calls from the agency that employed the nurse and a North Carolina Board of Nursing investigator for detailed information of the police investigation. The Clinical Compliance Nurse Consultant of the agency that employed the nurse was interviewed via phone on 9/27/23 at 2:24 PM and revealed a report was received from the facility on 05/02/23 about the alleged incident involving a nurse employed by the agency. The DON requested a copy of the nurse license verification and most recent abuse training dated and signed by the nurse in question on 09/14/22. The Clinical Compliance Nurse Consultant revealed the DON informed the agency that the nurse was never to return to the facility, or any facility owned by the same corporation. The DON provided the contact information of the Detective and local police and after speaking to the Detective and conducting an investigation the agency mailed a termination of employment to the agency nurse effective 05/12/23. The Clinical Compliance Nurse Consultant of the agency that employed the nurse was interviewed on 9/27/23 at 2:24 PM and revealed a report was received from the facility on 05/02/23 about the alleged incident involving a nurse employed by the agency. The DON requested a copy of the nurse license verification and most recent abuse training dated and signed by the nurse in question on 09/14/22. The Clinical Compliance Nurse Consultant revealed the DON informed the agency that the nurse was never to return to the facility, or any facility owned by the same corporation. The DON provided the contact information of the Detective and local police to the agency and after speaking to the detective and conducting an independent investigation the agency mailed a termination of employment to the nurse at the agency effective 05/12/23. The Administrator was interviewed on 09/28/23 at 1:12 PM and revealed that the facility took immediate action when the report from the Detective was received on 05/02/23.The proper reports were made to all entities required, an investigation began, interviews and audits of 100% of all cognitively intact residents and 100% of cognitively impaired residents family/RPs was initiated on 05/02/23 through 05/05/23. The QAPI (Quality Assurance and Performance Improvement) committee met, and a Performance Improvement Plan (PIP) was put into place immediately. The facility Quality Assessment and Performance Improvement Plan initiated 05/02/23 by the QAPI committee team was reviewed. The plan included immediate actions that began 05/02/23 and included actions taken by the facility of interviewing 100% of alert and oriented residents and notification of 100% of family/ RPs of cognitively impaired residents. Residents and RPs were offered and provided with secured lockboxes to store valuable items and bank information, the facility offered assistance to notify resident's banks and creditors to ensure accounts were being monitored for fraudulent activity. The facility put into place audits to interview 3 cognitively intact residents weekly for 12 week and 2 cognitively impaired resident's family/RPs weekly for 12 weeks to inquire if any fraudulent activity of their personal bank or credit card accounts was identified. Education was provided to all staff, residents, family/RPs from 05/02/23 through 05/05/23 related to abuse, neglect, exploitation and immediately reporting of abuse, or suspicious behaviors. New staff would receive training during orientation. The Quality Assessment and Performance Improvement Plan was reviewed, each intervention had corresponding documentation to support the actions. Monitoring and audit tools were completed weekly for 3 cognitively intact residents and 2 cognitively impaired residents for 12 weeks. Residents were interviewed and revealed they felt safe at the facility and had no reports of identified fraudulent bank or credit card concerns. The DON and Administrator conducted education of all staff from 05/02/23 through 05/04/23 related to the abuse policy, reporting of abuse and suspicious behaviors. Staff were interviewed and revealed they received education about abuse, types of abuse, reporting abuse and suspicious behaviors immediately to the DON or Administrator. Staff reported they were not able to work until the education was received. Residents interviewed felt safe at the facility and had no fraudulent activity identified by their banks or credit card companies. The facility's date of compliance of 07/20/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and staff interviews, the facility failed to assess injuries after an unwitnessed fall for 1 of 3 residents reviewed for accidents (Resident #6). The findings included: Resident #6 was admitted to the facility on [DATE] with traumatic brain injury and stroke. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #6 to be moderately cognitively impaired and she required total assistance of 2 people for bed mobility and transfers. The MDS did not document any falls in the past 2 months. A fall assessment dated [DATE] completed by Nurse #4 documented that Resident #6 was at high risk of falling with a score of 16. The assessment noted recent falls, need for toileting assistance, the inability to balance without assistance, and medications as having causative factors to increase fall potential of Resident #6. A nursing note written by Nurse #4 dated 7/24/2023 at 10:14 AM was marked through as being incorrect documentation. The note read, Writer was preparing medications in the hallway during morning med pass and witnessed resident scooting self onto floor mat beside bed. Writer went to stop resident but upon entering room, resident was already on the floor mat. Resident did not hit her head. Bed was in lowest position. No injuries noted. Vitals 122/272, 76, 18, 97.6, 96% on room air. Resident stated she was trying to walk. Resident Transferred into geri-chair via mechanical lift and 2 Nursing assistants. No complaints of pain noted. Resident Responsible Party (RP) called and made aware; physician made aware. A nursing note written by Nurse #4 dated 7/24/2023 at 6:23 PM documented that resident denied pain and her skin was normal, warm, and dry. A nursing note written by Nurse #4 dated 7/25/2023 at 6:35 PM documented that Resident #6 denied pain and her skin was warm and dry and normal. A skin assessment completed by Nurse #4 dated 7/25/2023 documented Resident #6 had no skin issues. A head-to-toe assessment dated [DATE] completed by Nurse #4 documented Resident #6 had a witnessed fall and her skin had normal tone and was warm and dry. A nursing note written by the Assistant Director of Nursing (ADON), dated 7/26/2023 at 9:13 PM documented that Resident #6 had a large bruise on her right shoulder that was red, purple, and yellow in color. The note documented an assessment was completed and the physician was notified, as well as the resident Responsible Party. The physician ordered x-ray for the right shoulder. A head-to-toe assessment of Resident #6 completed by the ADON dated 7/26/2023 at 9:13 PM documented the large bruise on the right shoulder that was red, purple, and yellow in color. X-ray results dated 7/27/2023 documented that there was no acute fracture or dislocation of the right shoulder. A nursing note dated 8/3/2023 at 5:10 PM documented that swelling to her right knee was noted with some yellow bruising. The condition of the knee was reported to the physician and an order was received to obtain an x-ray of the knee. The family was notified of the change in Resident #6 and the orders. A skin assessment dated [DATE] at 7:55 PM documented Resident #6 had yellow bruising to her right shoulder and right knee. A radiology report dated 8/5/2023 was reviewed and the x-ray determined there was a modest depression fracture of the right middle tibial plateau (the top of the tibia [ lower leg bone/shinbone] where it connected with the femur [long bone of the thigh]). The fracture was of undetermined age. A physician progress note dated 8/7/2023 was reviewed. The note documented that Resident #6 had an unwitnessed fall from bed on 7/24/2023 and was without pain after the fall, and on 8/3/2023 nursing noticed the right knee was swollen and bruised. The note documented that an x-ray obtained on 8/5/2023 determined there was a fracture of the right tibia plateau and Resident #6 did not report pain and did not have non-verbal expressions of pain. The note documented Resident #6's family did not want treatment for the fracture and declined to send her to the hospital or for an orthopedic referral. A Quality Assessment and Performance Improvement (QAPI) Action Plan dated 8/7/2023 documented that on 8/3/2023 Resident #6 was observed with a yellowing bruise and swelling to the right knee. The nursing staff notified the physician, and an x-ray of the right knee was ordered. The x-ray was ordered on 8/3/2023 but was not obtained until 8/5/2023 due to the radiology company not having enough staff to perform the x-ray on the date ordered, and the facility staff were not notified the x-ray would not be obtained until a later date. The facility was notified of the x-ray results on 8/5/2023, but staff did not notify the DON of the x-ray results. The DON became aware of x-ray results on 8/6/2023. The DON completed an injury of unknown origin report and notified the administrator, the regional director of clinical services, and the regional vice president of operations. An attempt was made to interview Nurse #4 on 9/27/2023 at 11:56 AM and the recording stated the number was unavailable. A text message was sent. Nurse #4 did not respond to the phone call or text. An interview was conducted with Nursing Assistant (NA) #2 on 9/27/2023 at 1:40 PM. NA #2 reported she was in the room with Resident #6 on 7/24/2023 when she fell out of bed, but NA #2's back was turned to Resident #6, and she did not see her fall. NA #2 reported Resident #6 was in bed ready to get up for the day. NA #2 was getting clothes out of the closet and when she turned around, Resident #6 was sitting on the floor beside her bed. NA #2 explained that Resident #6 had fall mats on the floor to protect her if she did fall, and the bed was low to the floor. NA #2 reported Resident #6 had not cried out or made any noise and she denied pain. NA #2 said she yelled for the other NA to go to get the nurse to come to the room to assess Resident #6. NA #2 reported Resident #6 did not appear to have any injuries after the fall, but a few days later she had a bruise on her right shoulder. During an interview on 9/27/2023 at 2:35 PM with the ADON she reported she was working on 7/24/2023 when Resident #6 fell, but she was not in the building when it happened, rather she arrived to work about 30 minutes later. The ADON explained that Nurse #4 documented that Resident #6's fall was witnessed and that she had assessed Resident #6. The ADON explained on 7/26/2023 the bruise was discovered on Resident #6's right shoulder and on 8/3/2023, a bruise on her right knee. The ADON reported that the bruise on the right knee appeared to be the same age as the right shoulder knee, and the facility felt Resident #6 obtained both bruises at the same time. The ADON reported on 8/3/2023 Resident #6's family member reported the bruise on her right knee. The ADON reported she had completed a skin assessment on Resident #6 on 7/26/2023 and she had noted the bruise on her right shoulder but had not seen the bruise on her knee. The DON was interviewed on 9/28/2023 at 1:41 PM. The DON explained that Nurse #4 had reported she had witnessed Resident #6's fall on 7/24/2023 and Nurse #4 had reported she had completed the post-fall assessment. After the bruise on her right knee was discovered on Resident #6 on 8/3/2023 and the x-ray results on 8/5/2023 determined Resident #6 had a fracture of her right tibia, the DON initiated an investigation. The DON explained she was not notified of the fracture until 8/7/2023 and she initiated her investigation on that date. The DON reported she interviewed NA #2 and discovered that NA #2 was in the room with Resident #6, but she had not seen her fall. Nurse #4 reported she had been right outside of the door, but NA #2 reported she had to send another NA to find the nurse. The DON reported the administrative staff watched video playback from the date of the initial fall on 7/24/2023 and discovered that Nurse #4 was nowhere near Resident #6's room and after questioning Nurse #4, the facility had determined she had not completed the head-to-toe assessment after the fall and had falsified her documentation. The DON reported that Nurse #4 was terminated because she had not documented the fall, had not reported the fall, and had failed to complete a full assessment of Resident #6 after the fall. The QAPI Action plan was reviewed, and the root cause was identified as staff did not follow procedures for the notification of an injury of unknown origin. The Action Plan detailed that on 8/3/2023 the physician was notified of the bruise and orders were received for an x-ray. A head-to-toe assessment was completed on Resident #6 on 8/3/2023. The x-ray was obtained on 8/5/2023 and results were called to the facility. Staff did not notify the DON until 8/7/2023, when she discovered it took 2 days for the x-ray to be taken due to issues with staffing at the radiology agency. On 8/7/2023 a full head to toe assessment was completed on Resident #6, an interview was conducted with the family member of Resident #6's family member and the plan of care was discussed. Nurse #4 and NA #2 were interviewed by the DON on 8/7/2023 and statements were obtained. A pain assessment was conducted on Resident #6 on 8/7/2023. Residents who had the potential to be affected were identified and skin assessments were completed on 8/7/2023. Current staff were educated by the DON regarding notification of the DON with x-ray results that showed fractures and documentation of incident reports after falls and education was completed by 8/8/2023. The facility instructed the radiology agency to communicate staffing issues that would affect the timeliness of x-rays directly to the DON in the future. Monitoring was put in place to conduct skin assessments on 4 residents weekly for 4 weeks, then monthly for 2 months to monitor for skin assessment documentation completed appropriately. Results of the monitoring to be taken to the QAPI committee for review and revision as needed. Additionally, the DON would review all skin documentation for 5 days per week for 12 weeks to ensure any concerns or change in condition. The facility date of completion will be 11/6/2023. The Action Plan was validated by reviewing the audits completed since 8/7/2023 and no issues were identified. Interviews were conducted with staff regarding education they received related to reporting, documentation, and procedures related to change in condition, injury of unknown origin, and falls. The ADON was interviewed on 9/27/2023 at 2:35 PM and she reported she is participating in monitoring by completing skin checks on residents and conducting audits on documentation. Nurse #6 was interviewed on 9/28/2023 at 11:02 AM and she reported she received education related to documentation of falls, reporting injuries of unknown origin and skin assessments. The facility's correction date of 8/31/2023 was validated.

Based on record reviews and staff interviews, the facility failed to protect residents and staff from COVID-19 exposure and infection after a medication aide (MA#1) reported to work with signs and symptoms of COVID-19 and worked her shift before testing positive for COVID-19. MA #1 failed to notify the facility administration of the positive test result. 11 out of 21 residents were reviewed for COVID (Resident #4, Resident #9, Resident #18, Resident #13, Resident #3, Resident #2, Resident #15, Resident #17, Resident #123, Resident #124, and Resident #19) and 6 out of 35 staff (MA #2, Nursing Assistant #3, Nursing Assistant #4, Assistant Director of Nursing, MA #3, and Maintenance Director) tested positive for COVID-19. The findings included: A review of the facility immunization report revealed that 84% of the census of 21 had been vaccinated for COVID-19 (3 resident refusals for the vaccine). A review of the staff immunization report revealed the 32 out of 35 staff members had been vaccinated for COVID-19 (3 staff approved exemptions for the vaccine). The facility Performance Improvement Plan dated 3/4/2023 identified that on 3/3/2023 MA #1 entered the facility with signs and symptoms of COVID. The root cause analysis documented MA #1 did not notify administration of her symptoms and did not wear a mask during her shift. The root cause analysis documented MA #1 tested herself for COVID approximately 4:30 AM on 3/4/2023 and she tested positive, but she did not notify the Director of Nursing (DON), Assistant Director of Nursing (ADON), or the Administrator of the positive test. Resident #4 tested positive for COVID on 3/8/2023. Review of her medical record indicated Resident #4 was fully vaccinated and had a mild illness and did not require hospitalization. Resident #9 tested positive for COVID on 3/8/2023. Review of her medical record indicated Resident #9 was fully vaccinated and had a mild illness and did not require hospitalization. Resident #18 tested positive for COVID on 3/8/2023. Review of his medical record indicated Resident #18 was fully vaccinated and had a mild illness and did not require hospitalization. MA #2 tested positive to COVID on 3/8/2023. MA #2 was not available for interview. The Administrator reported that no staff were severely ill with COVID, and no staff had been hospitalized . Resident #13 tested positive for COVID on 3/11/2023. Review of her medical record indicated Resident #13 was fully vaccinated and had a mild illness and did not require hospitalization. Resident #3 tested positive for COVID on 3/11/2023. Review of her medical record indicated Resident #3 was fully vaccinated and had a mild illness and did not require hospitalization. Nursing Assistant (NA) #3 tested positive for COVID on 3/15/2023. NA #2 was not available for interview. The Administrator reported that no staff were severely ill with COVID, and no staff had been hospitalized . Nursing Assistant (NA) #4 tested positive for COVID on 3/15/2023. NA #2 was not available for interview. The Administrator reported that no staff were severely ill with COVID, and no staff had been hospitalized . Resident #2 tested positive for COVID on 3/16/2023. Review of her medical record indicated Resident #2 was fully vaccinated and had a mild illness and did not require hospitalization. Resident #15 tested positive for COVID on 3/15/2023. Review of his medical record indicated Resident #15 declined the COVID vaccine and had a mild illness and did not require hospitalization. Resident #17 tested positive for COVID on 3/15/2023. Review of his medical record indicated Resident #17 was fully vaccinated and had a mild illness and did not require hospitalization. Resident #123 tested positive for COVID on 3/17/2023. Review of his medical record indicated Resident #123 was fully vaccinated and had a mild illness and did not require hospitalization. Resident #124 tested positive for COVID on 3/17/2023. Review of his medical record indicated Resident #124 was fully vaccinated and had a mild illness and did not require hospitalization. Resident #19 tested positive for COVID on 3/17/2023. Review of his medical record indicated Resident #19 was fully vaccinated and had a mild illness and did not require hospitalization. The Assistant Director of Nursing (ADON) tested positive for COVID on 3/19/2023. MA #3 tested positive for COVID on 3/20/2023. MA #3 was not available for interview. The Administrator reported that no staff were severely ill with COVID, and no staff had been hospitalized . The Maintenance Director tested positive for COVID on 3/22/2023. The Maintenance Director was interviewed on 9/28/2023 at 8:34 AM and he reported he was fully vaccinated against COVID, but he tested positive in March of 2023. The Maintenance Director explained he had very mild symptoms and recovered without incident. The Maintenance Director reported he had been provided with education related to testing after COVID exposure and the signs and symptoms of COVID to report to the administration staff. An interview was conducted by phone with MA #1 on 9/28/2023 at 10:15 AM. MA #1 reported she came to work on 3/3/2023 with a cough and she reported she felt like she couldn't stop coughing. MA #1 explained she had COVID in the past, but it wasn't that bad. MA #1 reported she wore a blue surgical mask during her shift, and she was fully vaccinated for COVID. MA #1 explained she felt like she had a cold, but about 4:00 AM it occurred to her that she should test for COVID. MA #1 expressed that when the test resulted positive for COVID she didn't believe that the test was right. MA #1 reported she went out to complete her medication administration to the residents and after she was finished, she retested for COVID, and the results were again positive. MA #1 explained she stayed in the medication room until the change of shift at 7:00 AM and her relief MA #2 showed up. MA #1 stated she and MA #2 counted narcotics and then she called MA #2 into the medication room and showed her the positive COVID tests. MA #1 reported she went home and was sick for almost 10 days. MA #1 stated she had not called the DON, ADON, or Administrator to report the positive COVID test and her symptoms because she thought MA #2 would report to the DON for her. During an interview on 9/28/2023 at 11:02 AM, the ADON reported she had COVID in March 2023, but she was not hospitalized . Resident #18 was interviewed on 9/29/2023 at 11:54 AM. Resident #18 reported he had COVID in 2023 but did not remember the exact dates. Resident #18 reported he had a mild illness, It was nothing. An interview was conducted with the DON on 9/28/2023 at 1:38 PM. The DON reported that MA #1 had not called her to report her symptoms or the positive COVID test and later in the day on 3/4/2023 the DON had been notified by MA #2 that MA #1 had gone home at 7:00 AM after testing positive for COVID. The DON explained she called MA #1 and took a statement regarding the positive COVID test, her symptoms, and the residents and staff she was in contact with on 3/3/-3/4/2023. The DON explained they initiated contact tracing and tested anyone who had worked with MA #1 and residents she provided care to during her shift. The DON reported all residents tested negative on 3/4/2023, but on 3/10/2023 MA #2 started having symptoms of COVID and tested positive. The DON reported on 3/4/2023 they initiated a plan of correction to prevent any further incidents or risk resident exposure to COVID by a staff member with signs and symptoms of the infection. The facility Performance Improvement Plan dated 3/4/2023 was reviewed. The facility identified MA #1 reported for work on 3/3/2023 with signs and symptoms of COVID and did not report her symptoms to the administrative staff. MA #1 worked until 4:00 AM and then took a COVID test, which was positive. MA #1 continued to work her shift and passed medications before taking another COVID test, which was positive. MA #1 did not wear a mask during her shift, and she did not notify the DON, ADON, or the Administrator of the positive COVID test. The facility contacted MA #1 on 3/4/2023 to obtain a list of her close contacts and testing was performed on those residents and staff on day 1, day 3, and day 5 after exposure. The facility identified that all residents had the potential to be affected by the deficient practice. The facility conducted education to 100% of the staff on the signs and symptoms of COVID, the COVID policy, and the testing requirements after exposure. The facility put a monitoring plan in place to maintain ongoing compliance that included daily audits on mask compliance, and monitoring all callouts for signs and symptoms of COVID to ensure testing for COVID was completed per the guidelines. The facility continued this monitoring 5 days per week for 12 weeks. The results of the audits were reported to the Quality Assurance Performance Improvement committee for review and recommendations during the monitoring period and the results were reviewed for 3 months. The facility Performance Improvement Plan was validated by reviewing the education provided to the staff and interviews with staff to validate the education. NA #1 was interviewed on 9/27/2023 at 1:20 PM. NA #1 reported she had received education related to COVID, mask use, testing, and signs and symptoms to report. An interview was conducted with NA #2 on 9/27/2023 at 1:40 PM. NA #2 reported she had received education related to COVID, mask use, testing, and signs and symptoms to report. Nurse #3 was interviewed on 9/27/2023 at 2:14 PM and she reported she was newly hired and in orientation. Nurse #3 reported she had received COVID education in orientation, including signs and symptoms to report and testing requirements. The Maintenance Director was interviewed on 9/28/2023 at 8:34 AM. The Maintenance Director reported he had been provided with education related to testing after COVID exposure and the signs and symptoms of COVID to report to the administration staff. The ADON was interviewed on 9/28/2023 at 11:02 AM, and she reported she provided education and monitoring of mask and personal protective equipment by the staff on all nursing units. The facility correction date of 6/14/2023 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, observation, and record review, the facility failed to accurately code the quarterly Minimum Data Set in the area of restraints (Resident #s 9, and 13) and failed to accurately code the comprehensive Minimum Data Set in the area of restraints (Resident #s ). Findings included: 4. Resident #9 was admitted to the facility on [DATE] with the diagnosis of stroke. A review of Resident #9's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident required assistance to transfer out of the bed and Section P A100 Restraint was coded 2 with bed rail used daily. The corresponding care plan dated 6/14/23 documented Resident #9 had a quarter side rail for bed mobility as an enabler for self-movement in her bed. On 9/26/23 at 2:30 pm the MDS Coordinator was interviewed. She stated that Resident #9's quarterly MDS dated [DATE] Section P A100 Restraint was coded for bed side rail as a restraint. She further stated that the Director of Nursing (DON) informed her to code the side rails as a restraint. On 9/26/23 at 3:50 pm the DON was interviewed. The DON stated there were no restraints in the facility. The quarter side rails on the resident beds were for mobility only, they were not a restraint. The MDS Coordinator coded all residents with quarter side rails for their last MDS assessment in Section P as restraints in error. The quarter side rails were evaluated for each resident individually and used as an enabler for bed mobility. The DON further stated the staff used an informed consent form for side rail use. The resident or resident representative would be educated on the safe use and potential hazards and sign for consent of side rail use. None of the quarter side rails restrained a resident that can get out of bed to not be able to get out of bed. The DON further stated she was aware of the difference between a restraint and an enabler. 5. Resident #13 was admitted to the facility on [DATE] with the diagnosis of degeneration of the nervous system. The 8/29/23 quarterly Minimum Data Set (MDS) for Resident #13 documented the resident required assistance to transfer out of the bed and Section P A100 Restraint was coded 2 with bed rail used daily. The corresponding care plan dated 8/29/23 documented Resident #13 had a quarter side rail for bed mobility as an enabler for self-movement in her bed. On 9/26/23 at 2:30 pm the MDS Coordinator was interviewed. She stated that Resident #13's quarterly MDS dated [DATE] Section P A100 Restraint was coded for bed side rail as a restraint. She further stated that the Director of Nursing (DON) informed her to code the side rails as a restraint. Interview of the DON 9/26/23 at 3:50 pm. The DON stated that there were no restraints in the facility. The quarter side rails were for mobility only, they were not a restraint. The resident would be evaluated for side rail use and then the resident or resident representative were educated and signed an informed consent form for use of bed rails. The care plan was for quarter side rails used as an enabler for mobility. None of the rails restrained a resident that can get out of bed to not be able to get out of bed. The DON stated and explained she was aware of the difference between a restraint and an enabler. The MDS was incorrectly coded as side rails were used as a restraint. There was a miscommunication with the MDS Coordinator. The DON further stated that the MDS coded and care plan do not match, one as a restrain and one as an enabler. 6. Resident #1 was readmitted to the facility on [DATE] with diagnoses to include diabetes and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 was cognitively intact, and she required extensive assistance for bed mobility and to transfer out of the bed. The MDS documented that bed rails were used daily as a restraint. Resident #1 was observed on 9/25/2023 at 11:07 AM. Resident #1 was in bed with both upper side rails in the up position. Resident #1 reported she used the side rails to assist her to move back and forth in the bed and it gave her something to hold on to when she transferred out of the bed. Resident #1 reported she required someone to stand by and supervise when she transferred in or out of the bed. The Director of Rehabilitation was interviewed on 9/27/2023 at 11:00 AM. The Director of Rehabilitation reported that Resident #1 was able turn herself in bed and was able to transfer out of bed with supervision. The Director of Rehabilitation explained that Resident #1 was discharged from therapy last month and she improved her activity level. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded. 7. Resident #6 was admitted to the facility on [DATE] with diagnoses to include stroke and traumatic brain injury. The significant change MDS dated [DATE] assessed Resident #6 to be moderately cognitively impaired. The MDS documented Resident #6 required extensive assistance for bed mobility and she had transferred once or twice in the past 7 days. The MDS documented that bed rails were used daily as a restraint. Resident #6 was observed on 9/25/2023 at 3:04 PM in bed. Resident #6 was grasping the side rail and turned her body towards the door. Resident #6 was not able to answer interview questions, but she did nod yes when asked if she used the side rails to move in bed. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded. Based on observations, record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessments for 7 of 14 residents reviewed for MDS accuracy. Resident #14 was not coded for Level II Preadmission Screening and Resident Review (PASRR) and inaccurately coded for daily restraint use. Residents #8, #5, #9, #13, #1 and Resident #6 were also inaccurately coded for daily restraint use. Findings included: 1a.Resident #14 was readmitted to the facility on [DATE] with diagnoses that included epilepsy. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #14 had no cognitive impairment and was noted as not coded for PASRR Level II at section A 1500 for Level II PASRR screening and Resident #14 was not coded at section A 1510 for Level II PASRR conditions as required by the RAI manual (Resident Assessment Instrument). A review of a PASRR Level II history detail report from the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services revealed Resident #14 had been determined to require a Level II PASSR since 12/18/21. A letter dated 5/31/22 from the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services to the facility revealed Resident #14 had been determined to require a Level II PASRR. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she never saw Level II PASRR documents in Resident #14's medical record and did not know Resident #14 had been determined to be a PASRR Level II. The MDS Nurse revealed she believed the Social Worker coded the section related PASRR Level II on the comprehensive MDS assessments. The Social Worker was interviewed on 9/27/23 at 10:31 AM. The SW revealed she was not responsible to complete any part of Section A on any MDS assessment and she believed the MDS Nurse reviewed the medical record and coded section A based on Level II PASRR status located in the medical record. The Regional Clinical Reimbursement Specialist was interviewed on 9/27/23 at 2:06 PM and revealed the PASRR status of Resident #14 should have been coded on the comprehensive MDS assessment by the MDS Nurse and the missed coding was likely an oversite by the MDS Nurse. 1.b.Resident #14 was readmitted to the facility on [DATE] with diagnoses that included epilepsy, muscle weakness and right above the knee amputation. Review of a comprehensive MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident #14 had no cognitive impairment and was coded at section P 0100. Physical Restraints. Section P 0100. A was coded that Resident #14 required bed rails daily. An observation of Resident #14's bed conducted on 09/25/23 at 12:50 PM revealed there were no bed rails on Resident #14's bed. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The MDS Nurse revealed she was not aware that Resident #14 did not have bed rails on her bed and likely coded the bed rails on both MDS assessments in error. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded. 2.Resident #8 was admitted to the facility on [DATE] with diagnoses that included anxiety and dementia. A review of an annual MDS assessment dated [DATE] revealed Resident #8 had short term and long-term memory deficits. Resident #8 was coded at section P 0100. Physical Restraints. Section P 0100 A was coded that Resident #8 required bed rails daily. An observation conducted on 9/25/23 at 9:56 AM of Resident #8's bed revealed one grab bar in place to the left side of her bed. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The MDS Nurse revealed she was not aware that Resident #8 did not have bed rails on her bed and likely coded the bed rails on both MDS assessments in error. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded. 3.Resident #5 was admitted to the facility on [DATE] with diagnoses that included anxiety. A review of a quarterly MDS assessment dated [DATE] revealed Resident #5 had no cognitive impairment and was coded at section P 0100. Physical Restraints. Section P 0100. A was coded that Resident #5 required bed rails daily. An observation of Resident #5 conducted on 9/25/23 at 10:29 AM revealed she had a quarter side rail in place on one side of her bed. A phone interview conducted with the MDS Nurse on 09/26/23 at 1:21 PM revealed she had been instructed by the Director of Nurses (DON) to code all bed rails as restraints. The MDS Nurse revealed she was not aware that Resident #14 did not have bed rails on her bed and likely coded the bed rails on both MDS assessments in error. The DON was interviewed on 9/26/23 at 3:23 PM. The DON revealed the facility had no restraints and bed rails were used to enable residents with mobility. The DON revealed she never instructed the MDS Nurse to code any bed rails as restraints on the MDS assessments and could not explain why restraints had been coded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a family interview, staff interviews, and record review, the facility failed to invite the responsible party of a cognitively impaired resident to participate in the planning of the residents' care for 11 months. This occurred for 1 of 3 sampled residents reviewed for care plan meetings (Resident #9). The findings included: Resident #9 was re-admitted to the facility 11/11/19. Diagnoses included dementia with behaviors, psychosis, major depressive disorder, and anxiety, among others. Medical record review revealed the responsible party (RP) for Resident #9 was last invited and attended an interdisciplinary care plan conference on 06/02/21 to discuss the Resident's care. Medical record review revealed Resident #9's cognition was assessed as severely impaired on quarterly Minimum Data Set (MDS) assessments dated 8/17/21, 11/8/21, 1/31/22 and on an annual MDS assessment dated [DATE]. There was no record that the RP was invited to discuss the care for Resident #9 during these assessments. A family interview occurred on 06/07/22 at 1:46 PM and revealed the RP had not been invited to participate in a care plan meeting regarding Resident #9's care in several months. The RP stated he did not recall being invited to participate in a care plan meeting either in person or by phone and he wanted to discuss concerns he had regarding the Resident's recent weight gain. On 06/09/22 at 09:48 AM a phone interview with the MDS Nurse revealed she retired in July 2021, and then returned back to work on a part-time basis about 4 weeks ago. The MDS Nurse stated she was responsible to invite residents and their RP to care plan meetings which occurred in conjunction with the MDS assessment. She stated she mailed a letter to the RP and gave a copy of the invitation to the resident. The MDS Nurse further stated that before she retired in July 2021, she invited the RP for Resident #9 to attend care plan meetings, but he did not respond to the letter and he did not attend. The MDS Nurse could not recall the specific month when this occurred. She also stated that when the RP had questions about Resident #9, he called the facility to get his questions answered. An interview with the Regional Nurse Consultant/Director of Nursing (RNC/DON) on 06/09/22 at 10:00 AM revealed she had no further documentation to support that the RP for Resident #9 was invited to participate in care plan conferences in the last year. The RNC/DON stated that the last care plan meeting that the RP was invited to was 06/02/21. The RNC/DON stated that when the MDS Nurse retired about 1 year ago, the facility experienced a lot of staffing changes, the RNC/DON took on multiple responsibilities at the facility and although she was a prior MDS Nurse, her focus during this time was on the clinical needs of the residents. The RNC/DON stated she contacted the RP for Resident #9 to advise him of changes in the Resident's condition, but she could not explain why the RP was not invited to care plan meetings during each MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to store medications that required refrigeration in accordance with the manufacturer's instructions and to monitor refrigerator temperatures in 2 of 2 medication refrigerators (east hall and west hall). The facility also failed to date a multiple use medication vial when opened in 1 of 1 medication storage room (west hall). Findings included: The facility's temperature logs indicated the medication refrigerator temperature should be kept at 36-46 degrees (°) Fahrenheit (F). The facility's 'Administering Medication' policy dated [DATE] indicated a multi-dose medication should be dated and recorded on the container when opened. 1. On [DATE] at 9:15 AM the west hall medication refrigerator was checked with Nurse #1 in attendance. The medication room refrigerator temperature was checked and noted to be within normal range of 36-46 °F. Review of the May and [DATE] refrigerator temperature logs revealed no temperatures were documented for [DATE], 4, 5, 9, 10, 11, 12, 16, 17, 18, 19, 23, 24, 25, 26, 30, 31 and [DATE] and 2. The instructions at the bottom of the Refrigerator temperature log read: 'drug room [ROOM NUMBER]-46°F.' An interview was completed on [DATE] at 9:16 AM with Nurse #1 and she stated night shift was responsible for checking the temperatures in the medication refrigerator. She noted several dates in [DATE] and the two dates in [DATE] that temperatures were not recorded. Medications that were stored in the west hall refrigerator included in part: - Tuberculin (TB) purified protein tuberculin unit (tu)/0.1ml, 5 milliliters (ml) vial which was opened, dispensed on [DATE] and expired on [DATE]. This was facility stock for tuberculin skin tests. Instructions indicated it was to be stored between 35-46°, dated when opened and discarded after 30 days. An interview was done on [DATE] at 9:18 AM with Nurse #1 regarding the opened and undated medication vial. She stated she was not aware when the TB test vial was opened, and she would have to check on how long the medication was good for once it had been opened. She acknowledged there was no date on the bottle, or the box and it was to be stored between 35-46 °F. The following additional medications were in the refrigerator on the west hall and required a storage temperature of 36-46 °F: - Procrit 20,000 ml-1 vial - Novalog prefilled pen-1 - Levemir insulin 100 units (u)/ml-1 On [DATE] a phone interview was attempted with Nurse #3 that worked nights [DATE], [DATE], [DATE] and [DATE], and had not recorded temperatures. She was unable to be contacted after two attempts on [DATE] at 9:32 AM and 4:36 PM. An interview was conducted on [DATE] at 9:41 AM with the Nurse #4 that worked nights usually on the west hall. She noted she checked the medication refrigerator each night. The Director of Nursing (DON) was interviewed on [DATE] at 4:58 PM regarding medication storage. She stated she would expect the medications to be stored within the manufacturer's recommended temperature range, medications that were opened were to be dated and that staff followed the manufacture guidelines for dating the vial or label the multi-dose vial. The DON added the temperature logs were to be completed each night and staff were to ensure that the temperatures were within range and signed. She noted maintenance should be notified with any temperature concerns. An interview with Administrator #1 was done on [DATE] at 5:17 PM in reference to the medication refrigerator on west hall. She was informed of concerns with the refrigerator log not being completed on several dates for May and [DATE], and the opened and undated multidose vial of Tubersol (TB) test solution. She stated she would expect temperatures in the medication refrigerator to be checked daily, monitored that they were in range and the TB vaccine solution would be dated when opened and discarded per manufacturer's guidelines or the facility policy. 2. The Temperature logs for May and [DATE] were reviewed for the east hall and revealed no temperatures were documented on [DATE] or [DATE]. Temperatures were documented below the required range of 36-46 degrees Fahrenheit (°F) on all dates in [DATE] except [DATE], [DATE] and [DATE]. These dates and temperatures were as follows: - [DATE]: 30°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 30°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 30°F - [DATE]: 30°F - [DATE]: no temperature documented - [DATE]: no temperature documented - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 34°F - [DATE]: 34°F - [DATE]: 31°F - [DATE]: 31°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 32°F - [DATE]: 30°F - [DATE]: 30°F East hall medication refrigerator temperature logs were reviewed for [DATE] temperatures and noted to be below the required range on [DATE] (32°F), [DATE] (32°F), and [DATE] (31°F). These 3 dates had been checked by Medication Aide #1. No comments were listed of actions taken for the temperatures that were out of range. The instructions at the bottom of the Refrigerator log read: 'the drug room refrigerator temperature should be 36-46°F. On [DATE] at 4:15 PM a review of the east side medication refrigerator was conducted with Medication Aide #3 in attendance from 4:15-4:30 PM, and Nurse #5 in attendance from 4:30-4:40 PM. Medications that were stored in the east hall refrigerator that required a storage temperature of 36-46 °F per the medication packaging included in part: - Levemir flextouch pen-1 - NovoLog injection flex pen -10 - Lantus solution injection pen -2 - Insulin glargine pens -2 - Latanoprost sol 0.005% eye drops - Trulicity pens 4.5/0.5 milliliter (ml) solution-4 - Repatha injection 140 milligram (mg)/ml syringe -1 An interview was conducted with Nurse #5 on [DATE] at 4:15 PM regarding the medication refrigerator temperature logs. She stated the night shift checked the medication refrigerator temperatures and Nurse #5 verified several of the medications in the refrigerator required the storage temperature of 36-46°F. Medication Aide (MA) #1 was interviewed via phone on [DATE] at 2:32 PM that worked nights and covered the east hall. The MA stated she checked the refrigerator in the morning when it had not been opened for a while, and thought the temperature range should be 33-46°F. She was asked when she recorded the temperature of 31°F on [DATE] night shift what actions were taken. The MA stated she meant to tell maintenance before she left and forgot. She was asked if she had the option to have submitted a written request and she said yes. She revealed she had not completed a written request. She was also asked about the [DATE] date when she had signed the log, but no temperature was logged and MA #1 stated she must have overlooked it. Medication Aide #1 was asked about the dates in May that she documented temperatures below range ([DATE], 4, 9,10, 11, 12, 16, 17, 18, 23, 24, 25, 30, and 31). She stated she should have had maintenance check them and completed a request, but she had not done so. The Director of Nursing (DON) was interviewed on [DATE] at 3:20 PM. She stated she had just been made aware of the medication refrigerator temperature logs being out of range and too cold for the east hall. She noted the staff should have adjusted the temperature independently and rechecked the temperature. The DON also indicated staff should have notified maintenance immediately if it was not corrected. An interview with the Director of Maintenance was done on [DATE] at 3:15 PM regarding the medication refrigerator temperatures. He said there were no requests for the refrigerator temperatures being out of range in the medication rooms. He also noted that staff had a mailbox on each hall they could put the maintenance requests in, but they did not use it. The Maintenance Director stated he was at the facility before night shift left in the morning, made rounds each day and was not told of any issues. An interview was done on [DATE] at 4:42 PM with Administrator #2 regarding the east side medication refrigerator temperatures. He stated the temperatures should have been reported to maintenance when temperatures were logging below the appropriate level. He noted some reeducation should be done to ensure staff know what the appropriate actions should be.

Based on an observation of the lunch meal tray line, interviews with staff and record review, the facility failed to serve a 4-ounce portion of fried rice and a 3-ounce portion of mechanical soft pineapple chicken per the menu. This failure had the potential to affect 21 of 23 residents. The findings included: An observation of the lunch meal tray line in progress occurred on 06/09/22 at 12:08 PM. The lunch menu included pineapple chicken and fried rice. Dietary Staff (DS) #1 (AM cook) was observed to plate both fried rice and mechanical soft pineapple chicken with a 2-ounce serving utensil for each item. Review of the menu, approved and signed by the Registered Dietitian (RD), revealed residents should receive a 4-ounce portion of fried rice and residents with a physician order for a mechanical soft diet should receive a 3-ounce portion of mechanical soft pineapple chicken. DS #1 was interviewed on 06/09/22 at 12:10 PM and stated that she worked at the facility for the past 19 years and currently worked 4 days one week and 3 days the next week. DS #1 stated she referred to the menu when serving food and that she knew that the menu recorded to serve a 4-ounce portion of fried rice and a 3-ounce portion of mechanical soft pineapple chicken, but that she chose to use a 2-ounce serving utensil for each because the portions on the menu was too much for the residents. DS #1 stated that she watched how much food came back uneaten by the residents and when she noticed that residents were not eating all of their food, she started cutting back on the portions. The Certified Dietary Manager (CDM) was interviewed on 06/09/22 at 12:15 PM and stated that DS #1 had been a cook for 19 years, so the CDM stated she did not check behind her that often because DS #1 knew what to do and she knew to serve the portions as recorded on the menu. The CDM stated she was unaware that DS #1 served smaller portions because she was usually in the dining room during meals when DS #1 plated the foods. The CDM was observed to provide DS #1 with the correct size serving utensils and advised her that she was required to serve residents foods in the portions recorded on the menu. A telephone interview with the RD occurred on 06/09/22 at 1:20 PM and revealed she reviewed/approved each cycle menu and expected the menus to be followed. The RD stated that if a resident requested smaller/larger portions, the facility should obtain a physicians order for that and that plate waste was not an appropriate reason to serve smaller portions to residents. The RD stated that she expected dietary staff to let her know if they felt that residents did not eat the portions of foods provided for further discussion, otherwise, residents should receive the portions according to the menu. An interview with the Regional Nurse Consultant/Director of Nursing 06/09/22 at 4:00 PM revealed she expected residents to be served portions of food according to the menu that was reviewed/approved by the RD.