**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure changes in medication were communicated to 1 of 1 residents (R33) reviewed for notification of change in medications. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation (irregular heartbeat), peripheral neuropathy (nerve damage), and diabetes. R33's cardiology clinic note dated 2/28/24, indicated R33 presented with family member (FM)-B for a cardiology provider visit on 2/26/24. R33 had CHF with noted congestion in lungs and reported occasional shortness of breath and lower extremity edema. R33 needed to follow up with the cardiologist in one year, or sooner as needed. On 2/26/24, the cardiologist ordered furosemide (Lasix) 20mg daily as needed (PRN) for lung congestion and/or lower extremity edema related to CHF. R33's progress note dated 3/26/24 at 3:24 p.m., indicated Pharmacist recommendation of PRN Lasix 20 mg to give for 'lung congestion or edema'. If it is to continue, please add specific parameters for when to administer Lasix 20 mg QD PRN. i.e give for 5# weight gain in a week, 3# in a day, or give for 3+ BLE (Bilateral Lower Extremity), etc. This was reviewed and agreed to by PA. However, the progress note did not indicate what the provider agreed upon. R33's medication administration record (MAR) dated March 2024, indicated R33's furosemide 20mg daily PRN for lung congestion and/or lower extremity edema was discontinued on 3/26/24. However, R33's chart lacked evidence R33's representative had been notified of the change in medication. On 12/18/24 at 9:46 a.m., FM-B stated she brought R33 to the cardiologist in February of 2024 and a PRN order for Lasix was provided for lower extremity edema related to CHF. On 12/12/24, FM-B brought R33 for a prosthetic diagnostic fitting. Because R33 experienced an increase in edema, they were unable to apply the prosthetic. Upon return to facility, FM-B inquired about the PRN Lasix. The director of nursing (DON) informed FM-B the PRN Lasix had been discontinued on 3/26/24. FM-B stated the facility had not notified her of this medication change nor would not have agreed to discontinue the Lasix On 12/20/24 at 4:18 p.m., DON confirmed progress notes failed to indicate R33's family had been notified the PRN Lasix had been discontinued. DON stated FM-B should have been made aware of the change to medications. It was important to communicate medication changes to residents and their family to ensure coordination of care. The facility's Change in a Resident's Condition or Status Policy, revised 2/2021, indicated the facility would promptly notify the resident/representative of any changes in medical care or nursing treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 24 residents (R13) reviewed for advanced directives. Findings include: R13's admission Minimum Data Set (MDS) dated [DATE], indicated R13 admission date of 10/16/2024, was moderately cognitively impaired and had the following diagnoses: hypertension (HTN) (high blood pressure), arthritis, osteoporosis (bones becomes weak and brittle), and asthma. R13's Provider Orders for Life-Sustaining Treatment (POLST) dated 10/17/24, indicated R13's resuscitation wishes were Do Not Attempt Resuscitation/DNR. The document was signed by R13's Heath care agent, and the Physician's assistant. On 12/16/24 R13's resuscitation status in the electronic medical record (EMR) banner was FULL CODE. On 12/16/24 at 12:12 p.m., the registered nurse manager (RN)-D stated upon admission the nurse would review resuscitation options with the resident or family member, fill out the paper form and have the resident or family member sign off. The physician would review and sign, then the facility would upload it to the EMR. RN-D stated in an instance where they found someone unresponsive, staff would call for help, check the banner in the EMR, and proceed with the residents wishes. RN-D reviewed R13's current code status and stated R13 was a full code, RN-D checked R13's POLST. RN-D stated the orders and the POLST did not match. RN-D got up, and left. RN-D returned shortly and stated if the instance of finding orders that do not match, they would clarify them immediately as she just had done and updated the resident's medical record. RN-D stated when checking a resuscitation status, staff would always check the banner of the EMR, and then verify with the POLST. On 12/16/24 at 1:21 p.m., the director of nursing (DON) expected resuscitation orders were reviewed by the nurse upon admission, with the resident or resident family. A POLST form was initiated and a provider signed off. The DON stated their expectation if a resident was found unresponsive, was the staff would review the code status on the EMR banner and verify with the POLST. The DON confirmed the EMR banner and POLST form did not match prior to survey start on 12/16/24. In this instance the DON's expectation was staff would verify the order and update when/if needed, and the POLST was the most current information On 12/19/24, R13's EMR indicated a physician order for Full Code dated 10/16/24 and discontinued on 12/16/24. Physician order for DNR dated 12/16/24 and care plan was revised to include DNR on 12/17/24. Changes to the EMR were noted to have been made after survey entrance. The facility's Advanced directive policy dated 2001, indicated if the resident or representative indicates the resident does not have an established advance directive, the facility will offer assistance in establishing advanced directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: Based on interview and document review, the facility failed to notify and consult provider for 2 of 2 residents (R33, R43) reviewed for heart failure monitoring. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation (irregular heartbeat), peripheral neuropathy (nerve damage), and diabetes. R33's Physician Fax Order Form dated 12/4/24, indicated an order for Lasix (a diuretic) 20mg daily as needed (PRN) for 3-pound (lb.) gain in a day or 5-lb. gain in a week. R33's weight summary and/or treatment administration record (TAR), printed 12/18/24, indicated the following daily weights from 12/5/24 to 12/18/24: 12/18 - 212 12/17 - no weight indicated 12/16 - 214.5 12/15 - 211 12/14 - 211 12/13 - 211.5 12/12 - 211 12/11 - 212 12/10 - no weight indicated 12/9 - 212 12/8 - 208 12/7 - 211 12/6 - 211 12/5 - 210.5 R33's weight summary and/or TAR, printed 12/18/24, indicated R33 had a 3.5-lbs weight gain from 12/15/24 to 12/16/24 and a 4-lbs weight gain from 12/8/24 to 12/9/24 R33's medication administration record (MAR), printed 12/18/24, indicated Lasix 20mg daily PRN had not been administered 12/16/14 or 12/9/24 as ordered for weight gain. On 12/19/24 at 2:20 p.m., registered nurse (RN)-A confirmed R33 had an order for daily weights and to give Lasix 20mg daily PRN for 3-lb gain in a day or 5-lb. gain in a week. RN-A confirmed Lasix 20mg had not been administered to R33 on 12/16/24 nor 12/9/24 as ordered. R43's quarterly minimum data set (MDS) dated [DATE] indicated R43 was admitted to facility on 8/8/23 and had the following diagnoses: acute on chronic congestive heart failure, hypertensive heart disease with heart failure, history of transient ischemic attack and cerebral infarct. The MDS further indicated R43 was cognitively intact. R43's care plan with a last review date of 6/19/24 indicated a focus area of alteration in cardiac status related to diagnosis of hypertension (high pressure in the arteries that carry blood from the heart to the rest of the body), congestive heart failure (CHF)(a progressive disease that affects pumping action of the heart muscles), angina (a condition characterized by chest pain due to insufficient oxygen-rich blood reaching the heart muscle), atrial fibrillation (an irregular and often fast heartbeat) and deep vein thrombosis (a blood clot in a deep vein). Interventions included: administer oxygen as ordered; appointments with cardiology as directed; observe for signs and symptoms of CHF exacerbation including not limited to edema, shortness of breath, weight gain, adventitious lung sounds, cough, decreased oxygen saturations, weakness, increased heart rate, distended neck veins. The care plan indicated obtain weights as directed and update MD as ordered. An order summary dated 11/20/24 indicated R43 had an order for furosemide oral tablet 20 mg twice daily related to acute on chronic congestive heart failure. The bottom of the document had a handwritten provider note indicating the following: D/C Lasix (furosemide); Bumex 1mg BID; Labs-TSH, BNP, BMP in 1.5 weeks. Weights MWF. DX: CHF. An unsigned order summary dated 12/20/24 indicated an order for Bumex 1mg tablet -give Bumex 1mg by mouth in the afternoon related to acute on chronic congestive heart failure, and Bumex 1mg tablet-give Bumex 2mg by mouth in the morning for acute on chronic congestive heart failure. The order summary lacked a documented order for weights to be obtained on Monday, Wednesday and Friday as ordered on 11/20/24. Review of R43's documented weights indicated between 8/2/2024 through 8/30/24 seven out of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 9/2/24 through 9/30/24 eight of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 10/2/24 through 10/30/24 seven of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 11/1/24 through 11/29/24 nine of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Physician progress note dated 11/18/24 indicated R43 told provider she felt like she was gaining water weight and her legs felt tighter than usual. The note went on to indicate R43's weight had increased from 261.5 on 11/1 to 265.5 on 11/11 to 268.5 on 11/18. The progress note confirmed R43's order to check weights MWF but were not getting done consistently. Physician progress note dated 11/24/24 indicated resident had a history of heart failure and had been seen a few times earlier in 2024 for the same issue. The note indicated R43's baseline weight was around 245 to 250 pounds, but she had been experiencing a gradual increase over the past few months. Review of R43's documented weights indicated between 12/2/24 through 12/16/24 three of seven opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Physician progress note dated 12/3/24 indicated R43 reported to the provider her weight was recorded once during week, despite being scheduled for weigh-in on Monday, Wednesday, and Friday. The provider indicated ongoing concerns and despite orders for weights 3 times weekly, nursing staff had only completed once weekly. During interview on 12/20/2024 at 4:11 p.m., director of nursing (DON) confirmed R43 had an order for weights three times weekly on Monday, Wednesday, and Friday. DON stated nursing staff is responsible for obtaining, documenting, and communicating any concerns for residents with an order for scheduled weights. DON stated if a scheduled weight was not performed the nursing staff should notify the physician. Further, DON confirmed R33 had not received PRN Lasix on 12/16/24 nor 12/9/24, as indicated by R33's weight gain. DON stated nurses were expected to administer the Lasix 20mg PRN if R33 had a weight gain that met the physician ordered parameters. DON further stated if a weight had been missed, nurses were expected to reach out to the provider to notify and request direction. DON stated this process was important for maintaining resident health and to avoid an acute episode of heart failure. The facility's Change in a Resident's Condition or Status Policy, revised 2/2021, indicated the facility promptly notified the resident attending physician of changes in resident's medical/mental condition and/or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide a written notice of a bed-hold at the time of transfer for two hospitalizations for 1 of 2 residents (R33) reviewed for hospitalization. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation (irregular heartbeat), peripheral neuropathy (nerve damage), and diabetes. R33's progress note dated 8/14/24 at 12:52 p.m., indicated R33 was transferred via ambulance to the hospital for increased redness and swelling in the left foot, and a verbal bed-hold was received from FM-B. R33's progress note dated 8/14/24 at 6:20 p.m., indicated R33 was admitted to the hospital for intravenous (IV) antibiotic treatment. A subsequent progress noted dated 8/20/24 at 11:57 p.m., indicated R33 returned from the hospital. R33's Bed-hold Policy form, dated 8/14/24, indicated a bed-hold telephone consent was obtained verbally from R33's family member (FM)-B. The form was signed and dated by the registered nurse (RN) on 8/14/24. However, R33's record lacked evidence a written bed-hold notice was received by the resident/representative at the time of transfer. R33's progress note dated 12/18/24 at 11:57 p.m., indicated R33 was transferred via ambulance to the hospital for increased pain and change in transfers, a verbal bed-hold from the POA (power of attorney) was noted, and orders/MAR were sent. R33's progress note dated 12/19/24 at 5:06 a.m., indicated R33 was admitted to the hospital Telemetry unit for congestive heart failure (CHF) and possible hip fracture. On 12/19/24 at 8:23 a.m., FM-B stated she gave a verbal consent for a bed-hold on 12/18/24. FM-B stated the family had questions regarding the policy and potential costs but had not received a written copy from the facility, nor was a copy sent with R33's information provided by the facility for the hospital at the time of transfer. On 12/20/24 at 10:56 a.m., social services designee (SS)-A, stated the nurses were trained to review the Bed-hold Policy with the resident/responsible party at the time of transfer, and obtain verbal consent or a signature on the form. A copy of evidence a written bed-hold notice was received by the resident/representative at the time of transfer for 8/14/24 was requested. However, SS-A only provided a copy of the telephone consent from 8/14/24. On 12/20/24 at 4:18 p.m., director of nursing (DON) verified evidence a written bed-hold notice was received by the resident/representative at the time of transfer for 8/14/24 and 12/18/24 were not stated written bed-hold information needed to be provided at the time of transfer, or with 24 hours for emergent transfers. The DON expected staff to have the Bed-hold Policy signed by the resident/representative at the time of transfer or send a copy of the Bed-hold Policy with the resident at the time of transfer. If a signature was not obtained by the resident/representative at the time of transfer, the DON expected social services (SS) or the nurse manager to follow-up until a signed form was obtained. DON stated written bed-hold information was important, so residents/representatives understood their rights and what a bed-hold entailed. On 12/23/24 at 5:18 p.m., the facility provided a copy of R33's Therapeutic Leave of Absence Day (Bed-hold Policy) form which indicated a bed-hold telephone consent was obtained from R33's family member (FM)-B. The form was signed and dated by the registered nurse (RN) on 12/18/24. However, R33's record lacked evidence a written bed-hold notice was received by the resident/representative at the time of transfer. The facility's Bed-Holds and Returns Policy, revised 10/2022, indicated residents/representatives were provided written information regarding the bed-hold policies, which addressed holding or reserving a resident's bed during periods of absence at the time of transfer or, if the transfer was an emergency, within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to complete and transmit a discharge return not anticipated Minimum Data Set (MDS) for 2 of 2 residents (R25, R48) reviewed for transmission of resident assessment. Findings include: R25's significant change MDS dated [DATE], included an admission date of 6/4/24. R25 was cognitively intact with a primary diagnosis of osteoarthritis of the right hip (the tissue of the joint breaks down over time) with joint replacement. R25's facility assessment titled Post Discharge Plan of Care dated 6/21/24, included a discharge date of 6/21/24. Assessment included R25 participated in the discharge plan. R25's medical record lacked evidence a discharge MDS was completed. R48's admission MDS dated [DATE], included an admission date of 8/2/24. R48 was cognitively intact with a primary diagnosis of hyponatremia (low sodium level). R48's progress note dated 9/5/24, included R48 left the facility and stated she would not be returning. Facility noted a Minnesota Adult Abuse Reporting Center (MAARC) report was filed. R48's progress noted dated 9/6/24, included R48 returned to the facility to collect belongings and medication. R48's medical record lacked evidence a discharge MDS was completed. During interview on 12/20/24 at 11:21 a.m., MDS registered nurse (RN)-A confirmed she completed MDS assessments for the facility. RN-A worked offsite and relied on the facility to update her when residents admitted , discharged , or had a significant change. RN-A confirmed a discharge MDS was not completed for both R25 and R48. RN-A thought this may have been due her not being updated on the discharge and noted young staff and frequent turn over of leadership. During interview on 12/20/24 at 2:23 p.m., director of nursing (DON) stated she had not had a lot to do with MDS completion and submission since she started in October. She stated there was a leadership email group that should be updated whenever someone was admitted , transferred to the hospital or discharged . The MDS nurse should have been on this email group and should have received updates. The DON stated it was important to submit complete and accurate MDS data in a timely manner to document and bill correctly. Policy for MDS submissions requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to revise the comprehensive care plan for 2 of 2 residents (R33, R43) reviewed for heart failure. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated R33 was admitted to facility on 9/15/23 and had the following diagnoses: chronic diastolic congestive heart failure (CHF), atrial fibrillation (A-Fib), chronic obstructive pulmonary disease (COPD), and diabetes. The MDS further indicated R33 was cognitively intact. R33's care plan with a last review date of 6/19/24, indicated a focus area of alteration in respiratory status related to diagnoses of COPD, sleep apnea, CHF, chronic bronchitis, and resident experienced shortness of breath (SOB) with exertion. Interventions were listed to administer medications/nebulizers as ordered and observe for effectiveness/side effects; observe for SOB, dyspnea (labored breathing), cyanosis (blue skin), change in mentation (mental function), anxiety, restlessness, air hunger, and document if these occurred; utilize CPAP per physician order. The care plan also listed an intervention of licensed nurse to observe skin weekly. Additionally, an intervention of daily weights was added on 12/12/24. R33's cardiology clinic note dated 2/28/24, indicated R33 presented with her family member (FM)-B for a cardiology provider visit on 2/26/24. R33 had CHF with noted congestion in lungs and reported occasional shortness of breath and lower extremity edema. The cardiologist ordered furosemide (Lasix - a diuretic) 20mg daily as needed (PRN) for lung congestion and/or lower extremity (LE) edema related to CHF. However, R33's record lacked evidence a nurse had contacted the cardiologist to obtain more specific parameters for the administration of a PRN diuretic. Additionally, R33's record lacked evidence measures were initiated to monitor R33 for lung congestion and LE edema. R33's order history, printed 12/18/24, indicated R33 had an order for furosemide oral tablet 20mg daily as needed for lung congestion and/or lower extremity edema was started on 2/28/24. However, R33's care plan had not been updated to include interventions to monitor for lung congestion and LE edema. R33's Hospital Orders Discharge Report dated 8/20/24, indicated R33 was hospitalized from [DATE] to 8/20/24. The discharge orders instructed facility staff to call the physician for weight gain of 3 pounds or more over night or gain 5 pounds in a week. However, R33's record lacked evidence the weight monitoring order had been transcribed and implemented. Additionally, R33's care plan had not been updated to include interventions to monitor for weight gain. R33's progress note dated 9/3/24 at 11:57 a.m., indicated R33 was seen on provider rounds and weights x 1 week was ordered. However, R33's care plan had not been updated to include interventions to monitor weights. R33's PCP progress notes for 9/3/24, dated 9/4/24 at 8:10 a.m., indicated R33's Jardiance was to be discontinued to help with R33's urinary concerns, and because CHF was a chronic concern, nursing staff would monitor weights 3 times weekly, and if weight increased the provider would consider ordering a diuretic or restart a lower dose of Jardiance. However, R33's care plan had not been updated to include interventions to monitor weights or signs/symptoms of CHF exacerbation. R43's quarterly minimum data set (MDS) dated [DATE] indicated R43 was admitted to facility on 8/8/23 and had the following diagnoses: acute on chronic congestive heart failure, hypertensive heart disease with heart failure, history of transient ischemic attack and cerebral infarct. The MDS further indicated R43 was cognitively intact. R43's care plan with a last review date of 6/19/24 indicated a focus area of alteration in cardiac status related to diagnosis of hypertension (high pressure in the arteries that carry blood from the heart to the rest of the body), congestive heart failure (CHF) (a progressive disease that affects pumping action of the heart muscles), angina (a condition characterized by chest pain due to insufficient oxygen-rich blood reaching the heart muscle), atrial fibrillation (an irregular and often fast heartbeat) and deep vein thrombosis (a blood clot in a deep vein). Interventions were listed as administer oxygen as ordered; appointments with cardiology as directed; observe for signs and symptoms of CHF exacerbation including but not limited to edema, shortness of breath, weight gain, adventitious lung sounds, cough, decreased oxygen saturations, weakness, increased heart rate, distended neck veins. The care plan also listed an intervention of obtaining weights as directed and update MD as ordered. An order summary dated 11/20/24, indicated R43 had an order for furosemide oral tablet 20 mg twice daily related to acute on chronic congestive heart failure. The bottom of the document had a handwritten provider note indicating the following: D/C Lasix(furosemide); Bumex 1mg BID; Labs-TSH, BNP, BMP in 1.5 weeks. Weights MWF. DX: CHF. R43 physician note dated 11/21/24, indicated resident had 'a history of heart failure and had been seen a few times earlier this year for the same issue. Resident baseline weight was around 245 to 250 pounds, but she has been experiencing a gradual increase over the past few months. Her most recent weight, recorded three days ago, was 268 pounds. This morning, her weight was recorded as 265.5 pounds. Resident believed her weight gain is due to fluid retention, as her legs feel tight'. R43 physician note dated 12/3/24, indicated resident reported her weight was recorded once during week, despite being scheduled for weigh-in on Monday, Wednesday, and Friday. The provider indicated ongoing concerns and despite orders for weights 3 times weekly, nursing staff had only completed once weekly and weight was up to 268. During interview on 12/20/2024, at 4:11 p.m., director of nursing (DON) confirmed R33 had a history of CHF exacerbation and expected nurses to implement interventions to monitor weights and edema. Additionally, nurses were expected to review and update resident care plans when they review orders, provider notes, and hospital discharge orders. Further, DON stated R43 had an order for weights three times weekly on Monday, Wednesday, and Friday. DON also confirmed the order was not carried over to the care plan as written. DON stated nursing staff is responsible for creating the care plan based on assessments of each resident and physician's orders. DON stated this process was important for maintaining resident health and for staff to have a clear directive and plan to prevent an acute exacerbation of heart failure. During interview on 12/20/24 at 4:18 p.m., director of nursing (DON) A policy was requested, but not provided.

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene for 2 of 4 staff observed for medication pass. Further, the facility failed to ensure 1 of 1 staff consistently followed infection control standards of practice for handling soiled clothing to reduce the risk of infection. This practice had the potential to affect all 57 residents, staff, and visitors. Findings include: During observation on 12/19/24 at 7:51 a.m., registered nurse (RN)-C was preparing and administering medications for a resident. RN-C prepared medication in medication cup, locked the medication cart, went to resident in common area and handed medication cup to the resident who took medications independently. RN-C returned to the cart, picked up a new medication cup off of a stack of medication cups, pulled up information for a new resident on computer and unlocked medication cart to retrieve medications. RN-C did not wash hands with soap and water or utilize alcohol-based hand sanitizer during this process. During interview on 12/19/24 at 7:54 a.m., RN-C stated she always utilized alcohol-based hand sanitizer when passing medications. She stated she was going to throw away the medication cups and utilize alcohol-based hand sanitizer before preparing the next resident's medications. During observation on 12/19/24 at 11:49 a.m., licensed practical nurse (LPN)-A completed a blood sugar check utilizing a glucometer stored in the resident's room. LPN-A utilized alcohol-based hand sanitizer, applied gloves, cleansed resident's finger, and completed blood sugar check appropriately. LPN-A disposed of supplies and removed gloves. LPN-A did not wash hands with soap and water or utilize alcohol-based hand sanitizer after removing gloves. LPN-A then drew up insulin, applied gloves, cleansed administration site, and gave insulin correctly. LPN-A disposed of supplies and removed gloves. LPN-A did not wash hands with soap and water or utilize alcohol-based hand sanitizer after removing gloves. LPN-A then picked up a new medication up and pulled up information to administer medication to a different resident without washing hands. During interview on 12/19/24 at 11:50 a.m., LPN-A stated she should have utilized alcohol-based hand sanitizer between residents and after completing tasks, but she forgot. During interview on 12/20/24 at 11:32 a.m., director of nursing (DON) stated she expected staff to utilize alcohol-based hand sanitizer between each resident and before and after tasks while passing medications. She stated this was important to reduce infection. Facility policy titled Medication Administration dated April 2019, included staff will follow established infection control procedures, including handwashing, for medication administration. On 12/19/24 at 8:06 a.m., nursing assistant (NA)-A was observed holding a pair of dark blue, plaid, flannel pants as she walked down the 2nd floor hallway, past the nurse station, and into the tub room. However, NA-A was observed to to be wearing gloves and the clothing was not secured in a bag. On 12/19/24 at 8:07 a.m., NA-A confirmed the soiled clothing should have been placed in a bag before the item was removed from the resident's room and brought to the tub room. NA-A did not confirm nor deny wearing gloves. On 12/20/24 at 1:25 p.m., infection preventionist (IP) stated staff were expected to have soiled items bagged and gloves on when handling soiled clothing/linens. IP stated soiled items needed to be contained, and gloves worn as a protective barrier, to prevent the spread of infection. Policy requested, but not provided by facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pneumococcal vaccine in a timely manner to 1 of 5 residents (R45) reviewed for immunizations. Findings include: R45's admission Minimum Data Set (MDS) dated [DATE], included an admission date of 11/5/24. R45's MDS indicated he was not up to date with the Pneumococcal vaccinations. Undated facility document titled Pneumococcal Vaccination Consent/Declination was marked yes next to the question asking if R45 would have been interested in receiving the recommended pneumococcal vaccination. Form was signed by R45 and uploaded to the electronic medical record (EMR) within the same week as admission. During an interview on 12/20/24 at 11:39 a.m., director of nursing (DON) stated she was unsure of the process of reviewing for and giving immunizations and would have to defer to the infection preventionist. During an interview on 12/20/24 at 1:20 p.m., infection preventionist (IP) stated she reviewed immunization status when a resident was admitted utilizing the Minnesota Immunization Information Connection (MIIC). The IP utilized an app on her phone recommended by the facility pharmacy to find out which pneumococcal vaccinations a resident was eligible for and had residents sign a consent to show if they were interested in receiving an immunization or not. The immunization would be ordered from the pharmacy after review and consent. IP stated she would follow up with the pharmacy if she had not received the immunization within a few days. IP confirmed the immunization should have been received and given by 12/20/24. Facility policy on pneumococcal vaccination requested and not received.

Based on record review and interviews the facility failed to ensure the required staffing information was posted daily. This had the potential to affect all 57 residents residing in the facility and their visitors who may wish to view the information. Findings include: On 12/16/24 upon entrance the staff posting was observed to include liscensed staff and total hours worked. On 12/17/24 the staff posting included liscensed staff and total hours worked. Staff postings dated 11/17/24 through 12/20/24, lacked evidence of accurate postinging information as evidenced by lack of information regarding how many liscensed staff were working in the facility each day, how many hours worked, and the total hours of all liscensed staff working on the days listed above. On 12/20/24 at 2:01 p.m., the director of nursing stated the information on the staff postings was incorrect and there had been miscommunication. The information had been lost. On 12/20/24 at 2:08 p.m., the director of nursing and the HR manager (O)-F stated they would run a report through their charting system and then post the posting for Monday through Friday daily and would pre-post it for the weekend. Both the DON and O-F confirmed the information on the daily staffing sheets was incorrect and/or not there. It was not updated in person on the weekends, and they had not kept the information for the time frame requested. On 12/20/24 at 2:28 p.m., the DON stated their expectation was the staff posting to be updated and posted with correct information and was important to know how many licensed staff and residents are in the building, however did not indicate daily posting as required. The facility policy was requested and none was provided.

Based on interview and record review the facility failed to conduct and document a comprehensive facility-wide assessment which included all of the necessary components to provide adequate care and services to the residents in the facility. The deficient practice had the potential to affect all 57 residents in the facility. Findings include: During the entrance conference on 12/16/24 at 9:19 a.m., the team leader requested the facility assessment to be provided within four hours of entrance. Subsequent requests were made on 12/19/24 and 12/20/24. On 12/20/24 at 6:11 p.m., the administrator sent an email to the survey team containing the document titled Facility Assessment Tool 12-2024. Review of the entire document with an assessment date of 9/5/2024, indicated the assessment lacked important components to ensure the facility identified all the resources necessary to care for and provide services to their residents. The provided document had some sections filled out and others left blank. The missing components included but were not limited to: 1) The facility's information such as name of the facility, names of current leadership and management, medical director. 2) The quality assurance teams input or participation in the facility assessment formation or update. 3) List of personal or person from whom the information was gathered, or if resident or family member input was taken into account when the assessment was created. 4) A contingency staffing plan. 5) Staff Competencies and skill sets. 6) Health information technology resources. On 12/20/24 at 5:54 p.m., the administrator confirmed they were responsible for writing and creating the facility assessment. Their expectation was its completion should have been verified while they worked on their emergency preparedness program. It was important to complete a facility assessment to help guide staffing needs, equipment, and resident care needs. A facility assessment Policy was request and none was provided.

Based on interview and document review the facility failed to maintain a Quality Assurance Assessment/ Quality Assurance and Performance Improvement (QAA/QAPI) program that was effective in identifying, assessing, performing, developing and implementing appropriate plans of action to assure clinical care, quality of care, resident rights and services were identified to maintain acceptable levels of performance. Furthermore, the facility failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 57 residents which resided in the facility. Findings include: See F552: The facility failed to ensure changes in medication were communicated to residents (R33) and or resident representative infringing on the resident's right to be informed. See F625: The facility failed to provide a written notice of a bed-hold at the time of transfer for hospitalizations as required. See F684: The facility failed to monitor and implement interventions for heart failure. This resulted in actual harm to R33 who was re-hospitalized for exacerbation of heart failure. See F838: The facility failed to conduct and document a comprehensive facility-wide assessment which included all of the necessary components to provide adequate care and services to the residents in the facility. See F880: The facility failed to ensure appropriate hand hygiene during medication pass and while handling soiled clothing to reduce the risk of infection. The facility's QAPI meeting minutes for the past 12 months were requested, however the facility only provided Quality Assurance and Assessment (QAA)/Quality Assessment and Performance Improvement meeting agenda dated October 17th, 2024. The meeting agenda did not identify previous recertification survey results. The meeting agenda identified the current performance improvement project (PIP) as meds not available on electronic medication administration record (EMAR). During interview on 12/20/24 at 4:11 p.m., the director of nursing (DON) stated she was aware of ongoing issues of quality of care and specifically concerns of staff obtaining and documenting resident weights. DON stated she had identified the issue in October 2024, however failed to provide staff education or training until two months later on 12/20/24. During interview on 12/20/24 at 5:42 p.m. the administrator stated the facility held monthly QAA meetings and quarterly QAPI meetings, however no monthly QAA meeting minutes were provided, and only one QAPI meeting agenda dated 10/17/24 was provided. The administrator stated the facilities current PIP included weights, skin audits, staffing and medication administration, however the provided QAPI agenda lacked evidence of the reported PIP projects. Undated facility policy titled Quality Assurance and Performance Improvement (QAPI) Program identified the objections of the QAPI program as: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and document review, the facility failed to contact the resident's physician of missed administration of medication for 1 of 1 resident (R2) reviewed for medication errors. The missed administration of medication resulted in a critical low potassium level of 2.4 mmol/L (millimoles per liter) (normal range 3.5 - 5.1 mmol/L). Findings include: R2's progress note dated 9/30/24 at 4:15 a.m. indicated on-call provider notified R2 had increased edema 3+ bilateral extremities (BLE) and increased pain. R2 had been admitted from hospital on 9/27/24 and discontinued diuretic Bumetanide (Bumex). Pain to BLE was 7/10 and edema 3+ from toes to knees. Ordered received administer Lasix (diuretic) 20 milligrams (mg) now and follow up with primary care provider (PCP) in morning. R2's progress note dated 10/1/24 at 1:14 p.m., seen by primary care provider (PCP) today on rounds. Add Bumex 2 milligrams (mg) daily for edema, weight daily for two week and check labs on Thursday, 10/3/24. R2's medication order start date 10/2/24 indicated Bumex oral tablet 2 mg by mouth one time a day related to edema. Order start date 10/2/24 and discontinued 10/8/24. R1's Electronic Medication Administration Record (EMAR) identified start date 10/2/24, and end date 10/8/24. Bumex oral tablet 2 mg, given by mouth one time a day related to edema was administered daily in morning on 10/2/24 through 10/8/24. R2's lab results dated 10/3/24 at 8:49 a.m. indicated potassium 2.8 mmol/L as low. The lab results were reviewed and acknowledged by physician assistant certified (PAC). R2's order dated 10/3/24 at 10:32 a.m., indicated start potassium 20 milliequivalents (mEq) twice daily, recheck basic metabolic panel (BMP) (measures calcium, carbon dioxide Chloride, Creatinine, glucose, potassium, sodium, blood urea nitrogen, to test body's kidney function) on Tuesday 10/8/24. Give 20 mEq by mouth two times a day related to hypokalemia. Order start date 10/3/24. Addressed on nursing home rounds. R2's progress note dated 10/3/24 at 8:28 p.m. indicated Orders-Administration Note: Potassium Chloride ER Oral Tablet Extended Release 20 (mEq) by mouth two times a day related to hypokalemia. Waiting on pharmacy. R1's Electronic Medication Administration Record (EMAR) identified start date 10/3/24, potassium chloride ER oral tablet 20 mEq by mouth two times a day related to hypokalemia. Potassium was signed off with a code #2 indicating not available from 10/3/24 at bedtime through 10/8/24 in the morning. R2 missed 10 doses. Potassium was signed off as given from 10/8/24, at bedtime through 10/10/24, in the morning. R2's admission Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition. R2's diagnoses included: cardiorespiratory conditions, pneumonia, and took a diuretic (removed fluid). R2's progress note dated 10/4/24 at 9:33 a.m. Orders - Administration Note: Potassium Chloride ER Oral Tablet Extended Release 20 mEq by mouth two times a day related to hypokalemia. No supply. R2's progress note dated 10/4/24 at 4:41 p.m. Orders - Administration Note: Orders: Potassium Chloride ER Oral Tablet Extended Release 20 mEq by mouth two times a day related to hypokalemia. Medication not available R2's progress note dated 10/5/24 at 6:52 p.m., Orders - Administration Note: Potassium Chloride ER Oral Tablet Extended Release 20 mEq by mouth two times a day related to hypokalemia. Medication not available - pharmacy faxed. R2's progress note dated 10/6/24 at 6:00 p.m. Administration Note: Potassium Chloride ER Oral Tablet Extended Release 20 mEq by mouth two times a day related to hypokalemia. Medication not available. R2's potassium lab results 10/8/24 at 8:23 am., potassium 2.4 mmol/L low critical. R2's progress note dated 10/8/24 at 9:24 a.m. EMS called per provider's order due to low potassium level of 2.4 mmol/L. Currently waiting for arrival. R2's progress note dated 10/8/2024 at 3:30 p.m. Incident Note: Provider and son updated on missed medication administration of Potassium doses missed on 10/3/24, evening up to today 10/8/24. During an interview on 10/10/24 at 9:10 a.m. licensed practical nurse (LPN)-A verified code number two entered in EMAR indicated medication was not available. LPN-A stated staff were expected to contact the provider after a medication error was made. During an interview on 10/10/24 at 12:30 p.m. R2's primary provider/medical doctor (MD)-A stated R2 was started on Bumex due to edema/swelling identified in lower extremities, and potassium level was to be rechecked on 10/3/24. MD-A stated R2's potassium level on 10/3/24 had dropped to 2.8 mmol/L and was started on potassium 20 mEq two times a day and recheck potassium level on Tuesday (five days later). MD-A stated he was informed on 10/8/24, R2 had not received the ordered potassium. MD-A stated would have expected staff to have contacted provider when it was discovered potassium had not been available. MD-A stated he was notified the potassium was not administered and first communication with him from staff was on 10/8/24. MD-A verified a low potassium would be concerning due the possibility of causing heart arrhythmia's (heart does not beat right, work correctly due to weak muscles and nerves caused by low potassium levels). During an interview on 10/10/24 at 1:30 p.m. floor manager/registered nurse (RN-B) stated when orders were received after rounds, they are entered into the system by medical record, then verified by the unit manager. RN-B stated R2's potassium was not received the evening on 10/3/24, and typically would wait until the next day and for what every reason it got missed. RN-B stated R2's potassium level was low at 2.4 mmol/L on 10/8/24, concerning, and should have been maintained within normal ranges to keep the body running. RN-B stated R2's trip to ER could have been prevented. RN-B stated she expected staff to have contacted the provider when a mediation error occurred and/or unable to administer the ordered mediation for further guidance/direction. During an interview on 10/10/24 at 3:34 p.m. LPN-B stated R2's potassium was low on 10/3/24 and ordered placed to start R2 on potassium. LPN-B stated R1 had not received the ordered potassium from 10/3/24, through 10/8/24, a.m. (10 doses) and was very concerning. LPN-B indicated when potassium levels were critical it would be a cardiac thing, heart does not work properly, could have resulted in a serious outcome, and provider should have been contacted regarding the medication error. During an interview on 10/10/24 at 4:15 p.m. LPN-C stated R2's potassium was not available to administer on two-day shifts (10/5/24 and 10/6/24) she had worked. LPN-C stated a fax was sent to pharmacy on 10/5/24, and they never responded. LPN-C stated the potassium was not at the facility the following day either was unaware the provider should have been contacted. LPN-C stated she had passed this information onto the oncoming shift. LPN-C stated R2's potassium level was low, and a provider should have been called for additional orders. Facility policy Adverse Consequences and Medication Errors dated 2001, identified the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. A medication error is defined as the preparation of drugs or biological which is not with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Example of a medication error: omission, a drug is ordered by not administered. A significant medication-related error was defined as hospitalization and required treatment with a prescription medication. In the event of a significant medication-related error or adverse consequence, take action as necessary, to protect the patient's safety and welfare. Provider should have been notified promptly of any significant error or adverse consequence. Communicate event to the oncoming shift as needed to alert staff for continued monitoring. Facility policy Change in Resident's Condition or Status dated 2021, identified a significant change in condition was a major decline or improvement in resident's status that without intervention by staff or implementing standard disease-related interventions (is not self-limiting) and/or ultimately based on judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Except in medical emergencies, notifications will be made within twenty-four hours of a change in the resident's medical condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure potassium was available, administered timely and administered as prescribed by the physician for 1 of 1 resident (R2). R2 missed 10 doses of potassium resulting in a critical low potassium level of 2.4 mmol/L (millimoles per liter) (normal range 3.5 - 5.1 mmol/L) requiring IV potassium. R2 was asymptomatic and stable. Findings include: R2's potassium lab results 9/27/24, potassium level 3.8 mmol/L. R2's progress note dated 9/30/24 at 4:15 a.m. indicated on-call provider notified R2 had increased edema 3+ bilateral extremities (BLE) and increased pain. R2 had been admitted from hospital on 9/27/24 and discontinued diuretic Bumetanide (Bumex). Pain to BLE was 7/10 and edema 3+ from toes to knees. Ordered received administer Lasix (diuretic) 20 milligrams (mg) now and follow up with primary care provider (PCP) in morning. R2's hospital follow-up visit dated 10/1/24, identified recently hospitalized for E. coli ((bacteria) pneumonia and septic shock that required an 11 day stay in the intensive care unit. R2 experienced pain due to fluid accumulation in legs, ankles, and believed addressing the fluid retention was necessary to alleviate her discomfort and retention of access fluid can be harmful. Due to R2's lower extremity edema most likely secondary to fluids received in hospital, she requested it be addressed. A lower dose of Bumex 2 milligrams (mg) was started and recheck kidney function on Thursday. R2's physical assessment showed lower bilateral (right /left) edema. Assessment/Plan follow-up based on lab work from Thursday as discussed. Discharge diagnosis: hypokalemia. R2's progress note dated 10/1/24 at 1:14 p.m., seen by primary care provider (PCP) today on rounds. Add Bumex 2 mg daily for edema, weight daily for two week and check labs on Thursday. R2's medication order start date 10/2/24 indicated Bumex oral tablet 2 mg by mouth, one time a day related to edema. Order start date 10/2/24 and discontinue 10/8/24. R2's Electronic Medication Administration Record (EMAR) indicated start date 10/2/24, and end date 10/8/24. Bumex oral tablet 2 mg, give 2 mg by mouth one time a day related to edema was administered daily in morning on 10/2/24, through 10/8/24. R2's potassium lab results dated 10/3/24 at 8:49 a.m. identified potassium 2.8 mmol/L low critical were reviewed and acknowledged by PAC (physician assistant certified) (PAC). R2's order dated 10/3/24 at 10:32 a.m., indicated start potassium 20 mill equivalents twice daily, recheck BMP (basic metabolic panel) (measures calcium, carbon dioxide Chloride, Creatinine, glucose, potassium, sodium, blood urea nitrogen, to test body's kidney function) on Tuesday. Addressed on nursing home rounds. R2's medication order start date 10/3/24 indicated Potassium chloride extended release (ER) oral tablet 20 mEq. Give 20 mEq by mouth two times a day related to hypokalemia. Order start date 10/3/24. R2's progress note dated 10/3/24 at 8:28 p.m. indicated Orders-Administration Note: Potassium Chloride ER Oral Tablet Extended Release 20 milliequivalents (mEq) by mouth two times a day related to hypokalemia. Waiting on pharmacy. R2's medication order start date 10/3/24 indicated Potassium chloride extended release (ER) oral tablet 20 mEq. Give 20 mEq by mouth two times a day related to hypokalemia. Order start date 10/3/24. R2's Electronic Medication Administration Record (EMAR) indicated start date 10/3/24, potassium chloride ER oral tablet 20 mEq by mouth two times a day related to hypokalemia. Potassium was signed off with a code #2 (not available) on 10/3/24, HS (evening shift) through 10/8/24, a.m. (10 times). Potassium was signed off as given on 10/8/24, HS. through 10/10/24, a.m. R2's potassium lab results 10/3/24 at 8:49 a.m., potassium 2.8 mmol/L low critical. R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 was admitted from the hospital on 9/27/24. R2's had intact cognition and no behaviors noted. R2's diagnoses included: cardiorespiratory conditions, pneumonia, and took a diuretic (removed fluid). R2's progress note dated 10/4/24 at 9:33 a.m. Orders - Administration Note: Potassium Chloride ER Oral Tablet Extended Release 20 mEq by mouth two times a day related to hypokalemia. No supply. R2's progress note dated 10/4/24 at 4:41 p.m. Orders - Administration Note: Orders: Potassium Chloride ER Oral Tablet Extended Release 20 mEq by mouth two times a day related to hypokalemia. Medication not available. R2's progress note dated 10/5/24 at 6:52 p.m., Administration Note: Potassium Chloride ER Oral Tablet Extended Release 20 mEq by mouth two times a day related to hypokalemia. Med not available - pharmacy faxed. Fax dated 10/5/24, sent from facility to pharmacy identified new order 10/3/24, R2 potassium chloride 20 mEq, need supply. Fax dated 10/5/24, sent from facility to pharmacy identified R2 potassium Chloride 20 mEq. R2's progress note dated 10/6/24 at 6:00 p.m. Administration Note: Potassium Chloride ER Oral Tablet Extended Release 20 mEq by mouth two times a day related to hypokalemia. Medication not available. R2's potassium lab results 10/8/24 at 8:23 am., potassium 2.4 mmol/L low critical. R2's progress note dated 10/8/24 at 9:24 a.m. EMS called per provider's order due to low potassium level of 2.4 mmol/L. Currently waiting for arrival. R2's progress note dated 10/8/24 at 10:12 a.m. ER (emergency room) transfer note. Description of Change in Condition/Reason for Transfer: Low potassium level 2.4. Notified son and received verbal ok to send R2. Provider at facility gave order to transfer via ambulance to ER. R2's progress note dated 10/8/24 at 2:38 p.m. nurse's note: writer called the pharmacy to find out why R2 still had no potassium. Spoke with pharmacy staff and she stated she was unsure the reason why the order had not been filled. Pharmacy staff indicated would get medication sent out to facility today. Director of nursing (DON) updated. R2's Emergency Department (ED) visit dated 10/8/24 arrived at 10:39 a.m., identified [AGE] year-old woman sent in for treatment of hypokalemia, a critical lab value, potassium level of 2.4 mmol/L, after diuretics were started last week on a routine follow-up chemistry panel. R2 was recently hospitalized for sepsis (life threatening response to an infection) due to pneumonia and discharged from the hospital on 9/27/24. R2 was seen for hospital follow-up on 10/1/24 and started on Bumex. R2's labs were followed up on and the third her potassium was low at 2.8 mmol/L. R2 was started on oral potassium 20 mEq replacement twice daily. R2 was not entirely sure why she was brought by ambulance to the ED. R1's nursing home paperwork was reviewed, and the EMAR identified potassium was to be started on 10/3/24 and had not received a single dose because medication was not available. R2 was asymptomatic (no symptoms), vitally stable able to take good oral intake. R2 was given intravenous (IV) potassium total of 20 mEq and oral replacement 40 mEq. Repeat potassium level was 2.9 mmol/L. R2 remained stable and asymptomatic during her stay. R2 had a prescription sent on October 3rd, 2024, to the pharmacy. The ED nursing staff called the nursing home and was informed they had been unable to get potassium from the pharmacy and/or any other pharmacy. R2's son was contacted, discussed this logistical problem, and was recommended until potassium can be obtained R2's Bumex be stopped that was used for chronic peripheral edema and not heart failure. R2's potassium prescription was sent to an alternative pharmacy and son agreed to pick up and bring to nursing home so that a supplied would be available. R2 was to have had a follow-up potassium level lab either Thursday or Friday and message was sent to nursing home provider. Final impression: Hypokalemia. R2's progress note dated 10/9/24 at 12:00 a.m. Nurse's Note: [R2 returned from ER with Son at 6:00 p.m. New orders to stop Bumex, until potassium supplement can be obtained. Please allow family to bring in potassium tablets to use (if they can obtain from different pharmacy) . Son brought in Potassium 20 mEq tablets. Potassium administered at HS. R2's potassium lab results 10/10/24 at 8:32 a.m. potassium 3.2 mmol/L. Facility internal incident report, undated, identified potassium chloride ER (extended release) 20 mEq BID (two times a day) was ordered by provider on 10/3/24. First dose 10/3/24, evening shift. Potassium was not administered on 10/3/24, through 10/8/24, a.m. shift R2 sent to ED 10/8/24, for further evaluation. BMP (basic metabolic panel) identified potassium level 2.8 mmol/L. During an interview on 10/10/24 at 9:10 a.m. LPN-A verified code number two entered in EMAR indicated medication was not available. LPN-A stated staff should have contacted pharmacy by fax and if no response by telephone. LPN-A stated staff were expected to contact the provider after a medication error was made. During an interview on 10/10/24 at 12:00 p.m. pharmacy data entry staff (DE) verified received an e-script (electronic prescription) order for R2 on 10/3/24, potassium 20 mEq twice a day and sent to facility on 10/8/24. DE stated once the ordered was received by triage techs it was moved to a week-to-week folder and should have been placed in the day-to-day folder. DE stated R2's potassium e-script identified up in left hand corner new RX which indicated either a new script or a refill which made the process more confusing, and triage missed that mark. DE verified the triage techs would be expected to have looked back into the R1's list of medications to have determined if it was new order or existing order. DE verified no additional faxes were received from the facility regarding R2's potassium once they received initial order on 10/3/24. During an interview on 10/10/24 at 12:30 p.m. R2's primary provider/medical doctor (MD)-A stated R2 was discharged from hospital on 9/27/24 and was not prescribed Bumex or potassium. MD-A indicated R2 had a follow-up hospital visit on 10/2/24, and edema/swelling was identified in her lower extremities bilaterally possible due to fluid buildup from intravenous fluids (IV). R2 was started on Bumex, and potassium level was to be rechecked on 10/3/24. MD-A stated R1's potassium level on 10/3/24 had dropped to 2.8 mmol/L and was started on potassium 20 mEq two times a day and recheck potassium level on Tuesday (five days later). MD-A stated he was informed on 10/8/24, R2 had not received the ordered potassium. MD-A indicated he gave order and facility sent R2 to ED and received potassium replacement. MD-A verified R2's Bumex was then held, had seen R2 this morning, and potassium level was up to 3.2 mmol/L. MD-A indicted R2's edema was most likely due to lymphedema (tissue swelling caused by accumulation of fluid) and heart function showed possible decreased function with a diastolic (lower heart chambers) cardiac problem common for a [AGE] year old to have had some stiffness of the heart. MD-A stated would have expected staff to have contacted provider when it was discovered potassium had not been available. MD-A stated he was notified the potassium was not administered and first communication with him from staff was on 10/8/24. MD-A stated a potassium level of less than 3.0 mmol/L would draw out attention to address it in a stronger way and less than 2.5 mmol/L would be way too low and direct us to send to ED. MD-A verified a low potassium would be concerning due the possibility of causing heart arrhythmia's (heart does not beat right, work correctly due to weak muscles and nerves caused by low potassium levels). During an interview on 10/10/24 at 1:30 p.m. floor manager/registered nurse (RN-A) stated when orders were received after rounds, they are entered into the system by medical record, then verified by the unit manager. RN-A stated the provider sent the actual medication order to pharmacy through EPIC (electronic privacy information center) and unsure when that was done. RN-A stated would have expected to deliver on one of the two later runs (3 p.m. or between 9:00 p.m. - 10:00 p.m.). RN-A stated R2's potassium situation was a big Swiss cheese event because when stacked the holes were all in the same place and the process fell through the cracks. RN-A stated R2's potassium was not received the evening on 10/3/24, and typically would wait until the next day and for what every reason it got missed. RN-A stated facility staff sent a total of two faxes to pharmacy that requested the potassium to be sent over. The facility process has been revised our process and staff were expected to have picked up phone and call pharmacy instead. RN-A indicted R2's diuretic/Bumex deplete potassium from her body and required replacement. RN-A stated R2's potassium level was low and concerning at 2.4 mmol/L and should have been maintained within normal ranges to keep the body running. RN-A stated yes harm had been done here, R2 did not have any ill effects from it but was facility responsibility to have had the potassium on hand and administer as ordered. RN-A stated R2's trip to ER could have been prevented and caused her undue anxiety. RN-A also stated along with EMS personal had informed R2's potassium level was extremely low and had to be sent to ER to get replacement for that. RN-B stated she expected staff to have contacted the provider when a mediation error occurred and/or unable to administer the ordered mediation for further guidance/direction. RN-A stated education/coaching forms were used to educated five out of the seven staff involved in lack of R1's administration of Potassium. RN-A stated the remaining two staff will be educated prior to the next start of their shift. RN-A indicated a mandatory nursing staff meeting will be held later this month to review this education and expectations for all nursing staff. During an interview on 10/10/24 at 3:34 p.m. LPN-B stated she had faxed pharmacy potassium was delivered per R2's order. LPN-B stated pharmacy had not replied, should have followed-up and called them. LPN-B stated could have possibly taken a potassium out of the emergency kit. LPN-B stated R2's potassium was low on 10/3/24, had not received 10 doses of potassium per order and was very concerning. LPN-B indicated when potassium levels are critical it would be a cardiac thing and heart does not work properly and could have resulted in a serious outcome. LPN-B verified after R2 was discharged from the hospital ER the son picked up the prescription of potassium at another pharmacy. During an interview on 10/10/24 at 4:30 p.m. administrator stated staff would be expected to follow-up with pharmacy when R2's potassium was not available. Administrator stated would have been concerning when R2 missed 10 doses of potassium, provider should have been notified and asked what he would have liked them to do and provided direction. Administrator verified she thought most of the nurses had been provided education, unsure as to how many, DON would have kept track of that. Administrator stated planned meetings with pharmacy and completion of random audits. During an interview on 10/10/24 at 4:35 p.m. LPN-C stated R2's potassium was not delivered to the facility and was unable to administer for two shifts. LPN-C stated she had faxed pharmacy on 10/5/24 and received no response. LPN-C stated the potassium was not delivered by the 10/6/24, was unable to administer it for a second time in the a.m. LPN-C stated information was passed onto the oncoming shift. Facility policy Administering medications dated 4/2019, identified medication would be expected to be administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribed orders to enhance optimal therapeutic effect of medication. Medication errors are documented, reported, and reviewed by QAPI (quality assurance performance improvement) committee to informed process changes, or need for additional staff education. Facility policy Adverse Consequences and Medication Errors dated 2001, identified the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions and side effects. A medication error is defined as the preparation of drugs or biological which is not with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Example of a medication error: omission, a drug is ordered by not administered. A significant medication-related error was defined as hospitalization and required treatment with a prescription medication. In the event of a significant medication-related error or adverse consequence, take action as necessary, to protect the patient's safety and welfare. Provider should have been notified promptly of any significant error or adverse consequence. Communicate event to the oncoming shift as needed to alert staff for continued monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure necessary care and services were provided to 1 of 1 resident (R1), whose severe environmental allergies were not adequately addressed to ensure she was comfortable and sufficiently protected from preventable allergy reactions. Additionally, when facility renovations were started, adequate barriers to prevent debris and chemical pollution from leaving the construction area were not maintained to protect R1. Findings include: During a facility tour on 7/18/24, at 9:39 a.m., the second-floor spa room had a sign on its closed door that indicated the room underwent a complete renovation which started on 7/8/24. The spa doorway was encased by a temporary non-zippered enclosed barrier made of plastic sheeting and wooden 2x4s. The barrier's entrance was a cut in the plastic that ran from the floor to about a foot from the ceiling and was unsecured to the floor, which caused a gap in the entrance. Observations were made through the plastic sheeting into the barrier; however, there was a fine film of white powdery substance on both the inside and outside of the plastic, along with the same powder on top of the fire extinguisher box to the left of the enclosure, when fingers were swiped across the surfaces outside of the barrier. The area was free of any strong odors; however, there was a faint smell of cut wood, directly in front of the enclosure opening. On 7/18/24, at 9:52 a.m., sounds heard from the spa room were indicative of something being cut. On 7/18/24, at 10:38 a.m., the spa room was toured with the maintenance director (MD)-A. Two tile installers worked at installing tile. A commercial tile saw was present. The two air supply vents and two air return vents were all uncovered, and a box fan circulated air. Cut tile odors were smelt. R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated R1 was cognitively intact. Her significant change MDS, dated [DATE], indicated R1 experienced shortness of breath (SOB) with exertion and was free of oxygen use. Diagnoses included chronic systolic congestive heart failure (CHF) and allergic rhinitis (an inflammation of the nasal membranes that is characterized by sneezing, nasal congestion, nasal itching, and rhinorrhea, in any combination). R1's electronic medical record (EMR) allergy listing identified R1 had 11 different drug allergies, and one environmental Perfume allergy. The EMR lacked evidence to identify the perfume allergy as identified upon admission documents, which was as a severe allergy with a designation of anaphylaxis for a reaction manifestation. R1's care plan, reviewed 7/18/24, identified the following: -A self-care deficit problem, revised 5/2/23, related to impaired mobility secondary to respiratory failure with hypoxia and left below the knee amputation (BKA). -An alteration in respiratory status, revised 4/19/23, related to diagnosis of Covid-19, respiratory failure with hypoxia, and CHF where R1 experienced SOB with exertion. 4/19/23 initiated interventions included oxygen (O2) as ordered, observe for respiratory signs/symptoms (s/s), labs as ordered, provide education as needed for appropriate breathing, relaxation techniques to help normalize breathing patters, and s/s of when to rest. The care plan lacked evidence of R1's perfume and medication allergies and any associated mitigating interventions, along with R1's preferences and her concerns with other odors and chemical uses for nursing and ancillary staff to follow. In addition, the care plan lacked s/s of respiratory and/or any additional medical impact(s) R1 experienced when she was exposed to allergens to assist staff in respiratory observations. R1's Electronic Medical Record (EMR) identified the following: -On 7/10/24 at 12:22 a.m., per a progress note, R1 requested a pain medication for right leg/foot pain and a headache. -On 7/10/24, a late entry at 12:00 p.m., per a progress note, the (previous) director of nursing (DON)-A (no longer employed with the facility) met with R1 and discussed R1's concerns related to possible allergic reactions to the air from construction. Her throat was scratchy, and she wanted an EpiPen readily available, in case she worsened. She denied anaphylaxis. Environmental precautions were discussed: she was offered a room change and an N95 mask, as well as standing order O2 initiation as needed (PRN) throughout the construction period. She was pleased and declined a room change. Staff were advised to call emergency medical services (EMS) if symptoms progressed. -On 7/10/24, 1:33 p.m., per a progress note, R1 complained of allergy sensitivities due to construction smells. She was offered another room on a different floor; however, she declined and informed the nurse it is in the ventilation system, it is just as bad on third floor. PRN Benadryl was provided and ineffective. An N95 was provided, along with O2 per her request for comfort. R2 requested an increase in the PRN Benadryl. Per the DON-A, if R1 requested, staff may call EMS for hospital transport. -On 7/10/24, per R1's order listing, O2 1-2 liters via nasal canula or 5-6 liters via mask was ordered. -On 7/10/24, per R1's order listing, Benadryl 50 mg twice a day (BID) PRN for nasal rhinitis and/or allergy was increased from 25 mg per R1's request due to sensitivities with construction smells at facility. -On 7/10/24, at 4:54 p.m., per a progress note, the administrator, and the infection control preventionist (ICP) spoke with R1 to address her air quality concern. R1 wore an N95. R1 was informed the spa room demolition finished early morning on 7/9/24. R1 stated she still smelt the fumes. She was offered to visualize the spa room and its gutted status. She was also offered a room change and declined as the fumes were in the vents. Staff interviewed after the visit with R1 declined they smelt any fumes/odors. -On 7/13/24, at 4:01 p.m., per a progress note, R1 complained of SOB, and she smelt a fragrance from the vents. O2 was applied, her door was opened, and a fan was utilized. These helped her. - On 7/14/24, at 3:08 p.m., per a progress note, O2 was applied, R1 wore the N95, and the fans were on which provided R1 with relief. - On 7/15/24, at 3:00 p.m., per a progress note, R1 requested a visit with social services. R1 ' could not take it any longer' and [was] looking to move out. The note does not indicate her reasons. R1 was instructed to let social services know when she and her county worker found a location. She stated she could not live where there were communal areas due to her allergies. - On 7/18/24, per R1's order listing, Benadryl 50 mg was increased to every six hours PRN from BID. R1's [NAME] (nursing assistant care plan), reviewed 7/18/24, identified R1's perfume allergy under an allergy heading; however, the [NAME] lacked any additional information or risk mitigations related to this and/or her construction odor concerns. During observation on 7/18/24, at 11:52 a.m., R1's door lacked signage to indicate any sort of allergy and/or any additional precautions to be aware of before one entered her room. When interviewed on 7/18/24, at 11:52 a.m., R1 sat in her room with an N95 face mask on and was without supplemental O2. When the surveyor introduced herself, R1 exclaimed, You are my last resort! R1 identified a severe allergy to chemicals and provided a list of the top ones; however, she stated, Anything made with chemicals, hand sanitizer is a deadly one for me. The list identified the following: shampoo, hair conditioner, styling products, laundry products, fabric softener/scent beads, perfumes, chloride, hand sanitizer, bleach, air freshener, alcohol, body wash and lotions. Due to this, she bought her own toilet paper and bathing products, family washed her laundry, and housekeeping cleaned her room with only water. She explained that she had dealt with these concerns for the past 30 years related to an in-home chemical spill accident that burnt her nose and throat. During the interview, R1 identified that a couple months ago a newer staff entered her room after they applied hand sanitizer. This started an increase in her allergy associated s/s. She had yet to completely recoup from that episode before her health again started to go backwards after there was an odor in the air the prior week on the second and third units that reminded her of bug spray. This odor lasted all afternoon on 7/10/24 and some on 7/11/24. She thought this came from the vents. On 7/13/24 and 7/14/24, there was a completely different odor: a powdery fragrance. She pondered the 7/10/24 odor was from the wood utilized during the construction but did not know what other supplies were utilized by the workers. She stated she was not updated on the construction specifics or any associated risks to her health before it began, only that there would be construction and a new tub. R1 acknowledged she was offered a different room after her initial complaints on 7/10/24 but declined, as she felt the odors came from the vents, no matter where she went, she would smell them. Since the construction started, her speech was choppy, and she required supplemental O2 which she had not utilized since last summer. She attributed this to the construction odors, not the dust. Additionally, R1 stated, I cannot continue to live like this. I try to handle things myself but this last issue with my allergies, I just cannot take it anymore. She explained everyone knew, or should know, about her allergies, and other odor sensitivities. She was able to make her providers understand at times; however, nothing work[ed] on the nurses. Facility management talked with her the previous week, after her complaints, and informed her there was nothing in the air or coming from the vents. As staff often told her they did not smell what she smelt, she felt staff did not believe her. R1 additionally vented her frustrations related to staff, especially management, who failed to take her seriously. She questioned, Why would I ask for a mask and oxygen when I would not need it. I do not need their attention. She felt staff likely disbelieved how bad her allergies were, or they did not understand, or they did not care, adding did not fit the norm when it came to allergies. Immediately after R1's interview, a sign was observed on her closet door: located just inside her room door. The sign identified no chemicals, scents, and perfumes due to severe allergy. Surveyor had not noted this walking into the room, or while in the room for an extended period of time, only while exiting. On 7/18/24, at 12:38 p.m., a sign was observed on a unit restroom door, adjacent to R1's room, that identified No Sprays, Scents, or Perfumes in this bathroom. This is a scent sensitive hallway. On 7/18/24, at 12:40 p.m., the spa door was wide open, and the room was free of construction workers. A fan was positioned in the room and air was felt coming from the room. The plastic barrier sheeting doorway moved on its own. A fainter chemical/wet tile/grout like odor was smelt in the hallway. Shortly after, two construction workers entered the room and shut the door. When interviewed on 7/18/24, at 2:58 p.m., RN-A, who identified herself as the nurse manager, stated she was made aware of R1's construction concerns on 7/10/24; however, she did not get involved, nor performed any follow-up with R1, nor setup any respiratory monitoring for her. RN-A stated R1 was very sensitive to any smell(s): hand sanitizer will set her off sometimes. At times, R1 overexaggerated and she felt R1 experienced more of a mental reaction versus a physical reaction to odors. RN-A explained R1's allergies and sensitivities were just passed on from person to person and if there were new staff, they went a little more in-depth with training related to things such as R1. In addition, staff obtained resident information via the care plan and the [NAME]. RN-A reviewed R1's [NAME] and care plan and acknowledged they lacked information related to R1's allergy concerns and risk mitigation. This information was expected to be there as it was very important information, even if some of R1's concerns were preferences and not true allergies. RN-A identified she would add this information to these items on 7/19/24. During an interview on 7/18/24, at 3:38 p.m. nursing assistant (NA)-A stated that on 7/8/24 R1 complained of a headache and queasy feeling related to odors within the facility. R1 was super sensitive to smells: just about to anything. She however was unaware of R1's hand sanitizer sensitivity. She was expected to not wear fragrances, which she attempted to do. She identified the facility hired agency staff at times and explained information about residents was obtained from the [NAME], or care plan, and they were expected to review this information to ensure appropriate care. When interviewed on 7/18/24, at 3:45 p.m., NA-B stated R1 had allergies to fragrances and strong smells, especially hand sanitizer, and that R1 kicked staff out of her room if she smelt them in any way. On 7/8/24, R1 complained of chemical smells in the air. Since then, R1 reported someone told her there were chemicals in the vents. R1 currently utilized an N95 mask, kept her door open, windows open at times, and fans on to help mitigate odors being smelt. She identified R1 provided staff a list of specific information related to things that upset her allergies; however, it was some time since she saw that and could not remember specific details. NA-B felt this information was on R1's [NAME] but was not 100 percent sure. She expected any specific [resident] information to be on the [NAME] for staff awareness. If not present, there was potential for R1's allergies to flareup, cause mental stress to R1, and/or cause R1 frustration and agitation. During an interview on 7/19/24, at 9:31 a.m., housekeeper (HSK)-A stated she entered R1's room to clean on 7/16/24 and R1 brought up perfume concerns. She reminded HSK-A to keep smells away from her. After she reiterated her knowledge of this to R1, R1 informed her someone that day entered her room with perfume on. HSK-A did not ask her for any additional details. When interviewed on 7/19/24, at 10:35 a.m., the ICP stated she followed up with R1 on 7/10/24, 7/11/24, and 7/12/24 after R1 was observed with an N95. R1 was very sensitive to fragrances and smells and could not handle them, and thus staff were highly encouraged to not wear fragrances. She explained R1 reported potential anaphylaxis concerns related to this; however, RN-B was not aware of such a reaction since her admission. She identified, a lot of staff education on wearing perfumes was provided as this [was] healthcare. If staff failed to follow risk mitigation for R1, risks to R1 would potentially be anxiety and panic. Staff needed to be proactive related to the potential anaphylaxis and resident safety was above everything else. Due to this, she expected this was on R1's care plan/[NAME] to ensure all staff who worked with R1 were knowledgeable. If not there, she expected this to be immediately added. During an interview on 7/19/24, at 11:06 a.m., the interim director of nursing (DON) stated in situations such as R1's, she expected to see a notice on the resident's door and staff education. She also hoped this information was on the care plan for it to trigger the [NAME]. However, she did not feel there were any real risks to R1 if this information was not on the care plan as there was a sign on her room door, and this was enough, as staff saw this when they entered R1's room. The DON stated she was not overall familiar with the current spa construction and was unsure if there was any resident harm, or concerns, other than one lady who complained of odors and dust. She followed up with the statement, Maybe mental harm, I do not know. When asked to clarify her statement, she identified R1 filed a police report; however, she was unsure as to what the report stated. She was informed R1 called the police often and staff were not surprised when the police walked in. She denied she spoke with R1 after, or since, the police exited. On 7/19/24, at 11:21 a.m., an observation of R1's room door identified a lack of any precaution identification(s). During a follow-up interview with R1 on 7/19/24, at 11:22 a.m., R1 stated she experienced another episode when staff came into her room the prior evening. She did not initially react; however, right after the staff exited, she smelt an odor that caused her mouth to burn and needed the oxygen to clear her lungs. This delayed reaction occasionally occurred. R1 identified she often experienced a flight or fight response when she smelt odors that may cause breathing concerns because of how staff react to her and their unwillingness to protect her life. She does not feel safe here as there was nowhere for her to go to get away from the odors and she did not have enough strength to go outside when her symptoms occurred, and even if she did, she was required to pass by the essential oil staff. In addition, when she experienced increased breathing concerns, staff just told her to call 911. Overall, she expressed concerns if staff entered her room and had something on that triggered her anaphylaxis, she would die, as staff did not understand how significant her allergies to odors were. When interviewed on 7/19/24, at 11:49 a.m., for follow-up, RN-A stated, since 7/18/24, there were no conversations with other staff related to R1 and she had yet to update R1's care plan related to allergies and preferences. When interviewed on 7/19/24, at 12:08 p.m., NA-C stated awareness of R1's allergies to perfumes and such. She identified that at one point in time the facility painted R1's unit and she moved to another. After R1 returned to her current unit, she stopped coming out of her room as she had previously. She felt R1 currently came out even less now compared to before the construction. R1's [NAME] identified allergies; however, she was unaware of any details. Due to R1 allergies, she did not wear perfumes or other similar items at work. She identified, when she switched hair shampoo, R1 questioned her about it. Recently, R1 appeared more sniffly, was more upset, had headaches, watery eyes, and stated she was itchy when she had reactions: You can tell she is going through it. During a telephone interview on 7/19/24, at 1:44 p.m., R1's family member (FM)-A stated R1's concerns increased when [management] stopped listening to [R1] in November . after there was a management change. She explained R1 felt her life was in danger as no one took R1's allergies seriously as they had prior to November. She explained R1's allergy history, history of medical neglect, and how she struggled with her many allergies and sensitivity fluctuations. She and R1 spoke daily. R1 updated her today of an incident that occurred later in the day prior (last evening). The encounter did not burn her mouth right away, but she was impacted shortly after. On 7/9/24, R1 contacted her and continued to call about every 10 minutes until she finally calmed down. She cried and was hysterical as she stated staff were going to kill her, nobody cared about the odors she smelt, and staff made her feel stupid when they stated they smelt nothing and how they communicated with her at the time. FM-A thought R1's allergies and mitigations were on her care plan; however, had never fully verified this. She wanted this information added, especially since they all know about R1's condition. During a telephone interview on 7/22/24, at 9:48 a.m., the director of social services (DSS) stated R1 could not be around perfumes and currently pursued a different living situation in relation to her concerns. Staff attempted very hard to keep other staff out of R1's room who wore body sprays, but despite staff reminders, that does not always connect with staff. She stated R1 now ate in her room as her throat closed-up when she went to the dining room. During recent conversations with R1, R1 was very fearful, she did not like the N95 but continued to wear it, and she did not trust anyone anymore. She was concerned none of her concerns were being addressed. Due to this, R1 called the ombudsman and the police. Her mood then was defensive and angry, but she calmed by the end of the conversation. DSS was unaware if R1's allergy concerns, and risk mitigation, were on the care plan; however, even if on the care plan, she felt nothing would change as staff failed to listen. During a telephone interview on 7/22/24, at 3:01 p.m., R1's medical provider (MD) identified R1's clinic record contained an extensive list of adverse reactions/allergies, which included a perfume allergy initially documented in 2012. He lacked remembrance of any recent conversations with R1, or staff, related to odors and reactions, nor any conversations about the construction and any potential impacts on R1, but recently she requested Benadryl increases due to smells. With R1's provider visit on 7/18/24, R1 did not mention construction concerns and her respiratory exam was negative. MD explained, based on R1's perfume allergy, anyone who went into her room with perfume on was a concern due to her anaphylaxis risks. He expected staff with perfume to remain out of R1's room and commented the facility should be fragrance free. In addition, if he were in R1's shoes, and sincerely afraid of something happening when someone came into her room with perfume on, he would have a placard placed on her door to visible warn and/or remind others. Care plans were great, but realistically everyone who went into her room may not have access to her care plan. A Care Plans, Comprehensive Person-Centered policy, dated March 2022, identified a comprehensive, person-centered care plan, that included measurable, objectives and timetables, to meet the resident's physical, psychosocial and functional needs, was developed and implemented for each resident. The care plan was expected to be reviewed at routine intervals and when desired outcomes are not met and then revised as information about the resident and their condition(s) changed. An Abuse Prevention and Vulnerable Adult Procedure policy, dated 2/13/24, identified its purpose was to provide a safe living environment to all residents of the facility and indicated the following Mission Statement: We are a community of concerned professionals working together to provide the best quality of life for those entrusted to us. We accomplish this Mission by maintaining a high standard of care for all, in a home-like atmosphere, which addresses their physical, emotional, and spiritual needs.

Based on observation, interview, and document review, the facility failed to ensure infection control mitigation processes were timely and effectively implemented prior to, and during, facility demolition and renovations. In addition, the facility failed to hire a licensed, and certified contractor, to oversee the construction. This had the potential to impact all 51 residents within the facility. Findings include: Between 7/12/24 and 7/15/24, five Common Entry Point (CEP) complaints were submitted to the State Agency (SA) from multiple residents. Concerns centered mainly around a construction project not being properly overseen by a licensed contractor and failure to adhere to Centers for Disease Control and Prevention (CDC) Long Term Care (LTC) construction guidelines for infection control (IC) and resident respiratory and safety protections. As a result, construction odors and dust traveled into resident areas and a potential black mold discovery was not properly remediated and removed. A CDC website, Part ll. Recommendations for Environmental Infection Control in Health-Care Facilities, dated 1/11/24, identified the recommendations were part of the Guidelines for Environmental Infection Control in Health-Care Facilities (2003), which reflected a consensus of expert opinions and extensive consultation with agencies of the U.S. Department of Health and Human Services, and derived from empiric IC or engineering principles, theoretic rationale, scientific data, applicability, experience and/or evidence based practice. A section, C. II. Construction, Renovation, Remediation, Repair, and Demolition, identified the following recommendations: · It is strongly recommended, and/or required by state or federal regulation(s), the facility initially establishes a multidisciplinary team that includes IC staff to coordinate demolition and construction and to consider proactive preventive measures. · It is strongly recommended education be provided to the construction team and staff in immunocompromised resident areas regarding airborne infection risks associated with the project, fungal spores' dispersal during such activities, and methods to control it. · It is required by state or federal regulation(s) the facility incorporates mandatory adherence agreements for IC into construction contracts. · It is strongly recommended the facility establishes and maintains airborne environmental disease surveillance (e.g., fungus) as appropriate during project activities to ensure the health and safety of immunocompromised residents. · It is strongly recommended, and/or required by state or federal regulation(s), the facility implement IC measures relevant to the project. Before project implementation, perform an ICRA (Infection Control Risk Assessment) to define the scope of the project and the need for barrier measures. Determine if immunocompromised residents may be at risk of fungal spore exposure due to dust generation and develop an exposure contingency plan. For internal construction activities construct barrier(s) for resident area dust prevention which are impermeable to fungal spores and compliant with local fire codes. Block and seal off return air vents if rigid barriers are used for containment. Implement dust control measures on surfaces and divert pedestrian traffic away from work zones. Relocate residents who are adjacent to work zones, depending on immune status. · It is strongly recommended, and/or required by state or federal regulation(s) to perform engineering and work-site related IC measures as needed for internal projects. Ensure proper operation of air-handling system after erection of barriers and before the room or area is set to negative pressure. Create and maintain negative air pressure in work zones adjacent to resident areas. Monitor negative air flow inside rigid barriers and to ensure barrier integrity; repair gaps or breaks in barrier joints. Wet-wiping tools and tool carts before their removal from the work zone. Placing mats with tacky surfaces inside the entrance; and covering debris and securing this covering before removing debris from the work zone. For ceiling tile removal, in resident care areas, use plastic sheets or prefabricated plastic units to contain dust; use negative pressure system within the enclosure to remove dust; and either pass air through an industrial grade, portable HEPA filter, or exhaust air directly to the outside. A facility provided list of immunocompromised residents, identified 41 residents were mildly to severely immunocompromised. A picture (screenshot) was anonymously provided. The picture was time stamped Albany July 8 3:23 PM and identified the spa room hallway. The picture lacked a barrier outside of the spa room door and the hallway floor showed a light dusting of a whiter colored substance. The substance was visualized about half-way down the hallway; however, was heavier by the spa area. Footprints were present throughout the substance. Facility provided email strings identified the following: -7/8/24, 12:12 p.m., the previous director of nursing (DON)-A (no longer employed at facility) updated the foundation director (FD) and the nurse manager (RN)-A with the CDC information website link to Part ll. Recommendations for Environmental Infection Control in Health-Care Facilities. This email asked if the contractors would ensure plastic barriers was put up to reduce dust to protect residents from dust and respiratory irritants. -7/8/24, at 4:06 p.m., the DON-A updated the maintenance director (MD)-A and the housekeeping supervisor (HS) with the CDC information website link and asked for assist to facilitate increased air exchange, increased air filter changes, and other environmental measures to prevent airborne fungal particles from affecting residents. DON-A provided email strings identified the following: -7/9/24, 8:54 a.m., the DON updated the administrator, the FD, and MD-A the contractor spoke to her that morning and confirmed that there was quite a bit of exposed mold in that bathroom. She explained during construction projects, mold spores became airborne and thus they needed to protect their community from respiratory infections and any exacerbations of respiratory conditions. Given that risk, she again asked to purchase an approved air filtration system to clean mold spores from the air. She identified the construction workers wore N-95 masks during the renovation; however, she was concerned staff and residents were already affected and potentially needed additional assessments to recognize early signs of respiratory failure. Today, the Construction team is building a barrier of wood and plastic to help contain the air to the workspace. As we noticed yesterday, the air travels throughout that wing of the facility. -7/9/24, at 9:04 a.m., the DON-A asked the Infection Control preventionist (ICP) to provide her with guidance on protections to be taken during construction given there is exposed mold. -7/9/24, at 7:33 p.m., the ICP responded and identified the DON-A could find this information in the policy book. If the DON-A was unable to locate, she would find it in the morning. The email identified no other information. A mold removal statement, dated 7/16/24, identified the maintenance director (MD)-A discovered some mold in the spa room, by the tub and shower, on 7/8/24. They cut out a section behind the tub about two-feet up and about four-feet wide, and two-feet all the way around the shower. The removed sheetrock was bagged up and brought to the dumpster. During a facility tour on 7/18/24, at 9:39 a.m., the second-floor spa room had a sign on its closed door that indicated the room underwent a complete renovation which started on 7/8/24, and thus was unavailable for use for three to four weeks. The following additional information was observed: -The spa doorway was encased by a temporary non-zippered barrier made of plastic sheeting and wooden 2x4s. The barrier's entrance was a cut in the plastic that ran from the floor to about a foot from the ceiling and was unsecured and opened approximately an inch. The edges of the barrier were attached to the hallway wall by green colored tape. The sides were secured to the ceiling and floor via wood boards. The entire front of the barrier was unsecured to the floor. The barrier failed to maintain a negative pressure status. -Visualization through the plastic sheeting was able to be conducted; however, there was a fine film of white powdery substance on both the inside and outside of the plastic, along with the same powder on top of the fire extinguisher box to the left of the enclosure, when fingers were swiped across the surfaces outside of the barrier. -The area was free of any strong odors; however, there was a faint smell, possibly of cut wood, when directly in front of the enclosure opening. -The barrier lacked a sticky mat to collect dust/debris when exiting the spa/enclosure and the barrier lacked any sort of air-filtration system and/or process. -Inside the barrier were three five-gallon buckets. One, located just to the left of the spa door, up against the wall, contained an unknown murky liquid. Another bucket, closer to the unsecured barrier entrance, in front of the first bucket, contained an opened bag of powdered floor leveler. The third bucket, located just to the right of the spa door, contained unknown cloudy liquid. -A white piece of towel/blanket was haphazardly folded up and located between the barrier entrance and the spa door. -One resident room, who's door was wide open, was adjacent on the right side of the spa room and another resident room was across the hall from the adjacent room. On 7/18/24, at 9:52 a.m., sounds heard from the spa room were indicative of something being cut. On 7/18/24, at 10:34 a.m., a box fan circulated air from the direction of a centrally located unit nurse's station toward the unit that was adjacent to the spa housed unit. On 7/18/24, at 10:38 a.m., the spa room was toured with MA-D. Two tile installers worked at installing tile. A commercial tile saw was present. The two air supply vents and two air return vents were all uncovered, and a box fan circulated air. The ceiling lacked tiles. An odor of cut tile was smelt. The room entryway lacked a sticky mat to collect dust/debris when exiting the room and the room lacked any sort of air-filtration system and/or process in addition to the air supply/return vents. The room was windowless. Upon exit of the spa room, MD-A confirmed one bucket contained floor leveler; however, was unsure about the contents of the other two buckets. During an interview on 7/18/24, at 10:44 a.m. MD-A stated the spa remodel project was planned by the administrator and the FD, and overseen by volunteers, despite a previous lobby renovation project completed by hired contractors approximately a years ago. He was unaware of the volunteers (VOL)-A and VOL-B's qualifications, credentials, and/or licensure and he identified VOL-A oversaw the project. Prior to initiation, he knew the project was needed and when it started; however, he was not involved in any decision making, IC risk mitigation conversations, or in the volunteer recruitment process(es). He recommended, on multiple occasions, to hire a qualified contractor to ensure project steps were completed, and completed correctly, especially as there were risks volunteers were not knowledgeable and thus performed steps incorrectly. In addition, the volunteers may not know how to manage concerns that arose during the project. He participated in the initial demolition process but was unsure if there were any steps taken to identify possible mold, lead, and/or asbestos risks associated with the project. If found, a qualified company was required to assist with removal and remediation. On 7/8/24 during demolition, potential mold was discovered on an approximate two foot by four-foot front section of sheetrock behind the free-standing tub. This section of sheetrock looked wet; however, he did not verify. There were non-odorous black spots that resembled wet dust bunnies. Additional sheetrock was removed from behind the shower due to similar findings, but he did not visualize that area. After, the only actions taken were removal of the potential moldy sheetrock from these two areas, the sheetrock was placed in standard plastic bags, and the bags were transported through the facility to the dumpster. MD-A indicated VOL-A updated DON-A and the FD. The project was not stopped and there were no remediation's completed, despite thoughts they should have sprayed the room to deter the spores from going all over. He was unaware of any facility construction related policies. Nor was he aware of requirements for IC risk mitigation, as the nurses and nurse managers were responsible for that. He identified the spa room vents were shut when they removed the blackened and wet sheetrock, and the workers wore N95 masks. A barrier was constructed after the demolition started which was free of any modifications. The barrier and/or the spa room lacked a negative pressure status and the HVAC system sucked up any air in the spa room and carried it outside. He denied the use of any additional air filtration processes. He last changed the air filters at the end of June and had not checked them since. He denied knowledge of any monitoring or surveillance to ensure air, odors, and/or particles remained in the spa room and did not migrate to resident areas. During a telephone interview on 7/18/24, at 1:52 p.m., the previous DON-A stated she initially was informed the construction would occur and its timelines to assist with resident, family, and staff notifications, and to prepare for adjustment in bathing locations, along with staff were expected to help clean up and haul debris to the dumpster. No conversations occurred for assist with decision making and/or IC risk mitigation prior to construction. She was unfamiliar with VOL-A or VOL-B's names and/or their qualifications. On 7/8/24, the demolition process started around 9:00 a.m. Around noon, staff reported dust was everywhere. After, no construction workers were present in the spa room, and thus staff cleaned up the area. She updated FD and requested a barrier to protect everyone from the dust. On 7/9/24, in the morning, either VOL-A or VOL-B approached her to discuss her dust concerns. He identified there was a lot of mold and they needed help to clean it up. She explained to him there was a professional process required for mold remediation. He responded, 'We are a low budge project.' After she brought this to the attention of FD, MD-A, and the administrator, and provided them with information related to the above CDC guidelines and mold management, she was instructed to perform resident assessments but to leave the construction processes to the administrator, VOL-A, and VOL-B. She did not enter the spa room after she was updated on the mold. She instructed the workers to keep the door shut and reiterated the need for the barrier. She brought N95 masks to the unit and encouraged staff and residents to wear them, especially as no interventions for air purification were put into place. She emailed the IC preventionist (ICP) to inquire about construction policies as she was unable to find any. She denied resident respiratory monitoring/assessments were initiated. When interviewed on 7/18/24, at 2:58 p.m., RN-A stated she was only updated about the spa renovation date and the need to adjust bath locations for the unit two residents for about three to four weeks. She was not involved in any renovation details or conversations related to IC risk mitigation. The demolition started the morning of 7/8/24, by non-professional volunteers, and continued through Tuesday. On 7/8/24, she brought dust concerns to the DON-A as there was dust being drug throughout the unit. No dust mitigation was done that day. After a morning meeting on 7/9/24, the DON-A brought up black mold concerns and a plastic barrier started to be erected around midday. She heard only a little bit of mold was found and it was bagged as required; however, she did not witness any garbage bags hauled to the dumpster; only witnessed uncovered debris being hauled through the unit in wheelbarrows. Prior to the barrier completion, demolition again restarted, and was not completed until staff questioned them on its completion timeframe. The barrier remained unchanged since. No dust and/or odor mitigation was evident prior to the barrier's placement, and/or since. She visualized the spa room after demolition and observed all the sheetrock from about half the wall down was removed. She acknowledged immunocompromised residents on that unit; however, did not initiate any respiratory monitoring /assessments. Due to lack of respiratory monitoring, residents were susceptible to anaphylactic reasons, decreased respiratory status, and respiratory condition exacerbations, especially those already on oxygen. During an interview on 7/18/24, at 3:38 p.m., nursing assistant (NA)-A stated she was not involved in any resident discussions related to the construction. She was just informed it would occur and when. She worked on 7/8/24, during the evening shift, and noted dust on the unit, especially by the spa room, as a bunch of guys were going in and out of the room. Due to the dust and the noise, staff attempted to keep resident doors shut as much as possible. NA-A was unsure when the barrier went up but indicated it was not installed on 7/8/24. She was unaware of any potential concerns discovered during demolition. When interviewed on 7/18/24, at 3:45 p.m. NA-B stated she worked the evening shift on 7/8/24 and visualized dust tracked all down the unit. She assisted DON-A to mop up the dust. During an interview on 7/19/24, at 9:15 a.m., maintenance assistance (MA)-B stated he assisted the construction volunteers with demolition. He was unsure who the general contractor of the project was and/or the volunteers ' qualifications; however, VOL-B appeared to know what he was doing. During demolition a little tiny bit of mold was discovered by the shower and tub areas. This little black area was removed by VOL-A and VOL-B. He was unable to provide further details as there were so many of us in there doing [demolition], and mold scared him so he did not dig into it. The black areas were just cut out and disposed of. MA-B explained there were initially no mitigation interventions put into place for dust and/or mold control, but after a little bit of dust escaped the room, in which footprints could be seen in the film on the floor, a barrier was placed. He was unsure if this occurred the first or second day of the demolition. He thought when he opened the spa door, air pushed into the room and was sucked out of the vents. When interviewed on 7/19/24, at 9:31 a.m., the HS stated staff attempted their best to clean up after the dusty footprints which came from the spa room. This required mopping versus sweeping at least twice on 7/8/24. She denied involvement in conversations related to construction housekeeping processes. She just paid more attention to the details such as the extra dust. She stated MD-A updated her about the mold finding; however, no further conversations were had, and no precautions were taken for cleaning since. During an interview on 7/19/24, at 10:35 a.m., the ICP stated her role related to construction ensured residents and staffs' safety was monitored, they were not exposed to any contaminants, PPE (personal protective equipment) was available and utilized, and construction was performed in a safe manner. She denied the facility discussed IC risk mitigations, or performed an ICRA, prior to initiation. She was unaware of VOL-A or VOL-B's qualifications and/or IC knowledge. She was not within the facility when the demotion started but she discussed construction expectations in a morning standup which included PPE use and demolition safety such as no supplies or equipment in the hallways. She also updated staff there was a binder in her office related to construction policies and encouraged staff to contact her if concerns arose. She denied she setup resident respiratory/IC monitoring documentation; however, she spoke to DON-A and floor staff to remind them of the need for such monitoring. Initially the ICP denied there were concerns discovered during the demolition process and identified it was monitored very well. When she returned to work, she made sure nothing was missed. She stated maintenance monitored the air filters and they did not need to be switched out. When the ICP was questioned on potential mold during the demolition, she identified staff told her there was a dime/quarter size amount of a black colored mold found on the sheetrock on Monday (7/8/24). This was immediately removed, and the lower parts of the walls were also removed and inspected. There was no further mold found. She denied she spoke to VOL-A or VOL-B after she was updated on this. If mold was found, she expected this to be taken care of immediately; however, was not 100 percent sure of the process. Despite this, she stated the mold concern was properly taken care of. She denied the spa room or barrier maintained a negative pressure; however, she deferred these types of questions to MD-A. She denied she set up resident respiratory monitoring despite an explanation that mold could potentially be very harmful to residents' respiratory systems, especially those already with respiratory concerns as this could cause a flare-up or respiratory illness. When interviewed on 7/19/24, at 11:06 a.m., the interim director of nursing (DON)-B stated most of the heavy spa construction was completed prior to her start date. She stated an overall lack of knowledge related to the construction but was updated there was a small area of mold which was safely removed. She denied involvement in any ongoing construction discussions to mitigate IC risk. During an interview on 7/19/24, at 12:42 p.m., the FD stated VOL-A and VOL-B were brought onto the project to try to save as much money as possible, to be frugal, and to get the project done as quick as possible for decreased disruptions. She was unsure how construction processes occurred without shutting the whole facility down. VOL-A was affiliated with the facility and VOL-B was recommended by VOL-A due to VOL-B's construction background. No contracts were signed with VOL-A or VOL-B. She was unaware of either VOL-A or VOL-B's qualifications and/or IC knowledge. Before demolition, the administrator reached out to Leading Age (long term care (LTC) member-led association) to inquire about construction requirements. The administrator was informed they did not need to worry about anything as they only replaced tile, flooring, and the tub; however, VOL-A and VOL-B were responsible to ensure construction requirements were completed. Despite this, neither provided any guidance other than the need to keep the spa door closed. FD explained she conversed with DON-A related to the construction and assumed she would have taken care of any IC risk mitigation. By the end of 7/8/24, the tiles were torn out and a very concerning problem was discovered. They cleaned it up and put up a barrier. She explained a little bit of mold was found; however, no one knows if it was truly mold. She was told the insulation behind the tub was a darker discoloration. They got it out within five minutes and disposed of it. Once the DON-A was informed, she sent out emails that identified CDC guidelines as you do not want it traveling through the air . But it already did not seem like it was any different from the mold we would find in the kitchen sink if you pulled the sink out. VOL-B was not concerned about the mold as it was such a very little amount and thus neither was she. The mold was already removed before she was updated on its finding. The FD was unsure of the ICP role and/or actions related to the project and/or the mold but they took the input the DON-A provided to make sure there were no concerns after the mold was discovered. When interviewed via telephone on 7/19/24, at 1:53 p.m., VOL-A identified he knew construction based on his experience and building his own homes; however, he was not a licensed contractor. He assisted with the demolition and followed the directions of VOL-B, who was a licensed contractor. He reported he was unaware of LTC construction and/or IC regulations, or requirements for mold remediation and removal. VOL-A denied previous management of black mold but he has seen lots of mold which had always grown on things, was soft, and was furry-like. What he saw in the spa room was not mold-like. It was darker in color just black, but not real dark, and nothing grew on it. It was noted on the back of the sheetrock, within the walls, when wet, soft, sheetrock was found by the tub and shower. These areas were removed, along with some additional areas where the sheetrock was also wet and darker in color. When this was discovered, they just removed it. He was unsure what was done for IC mitigation before, during, or after the mold was found, other than they wore N95 masks, kept the door closed, placed towels on the floor to decrease dust on their feet when they exited the spa room, and put up a barrier. In addition, he updated DON-A. When he updated her, he identified he mentioned the word mold; however, he should not have used that word. During a telephone interview on 7/22/24, at 12:15 p.m. VOL-B stated he was only a volunteer in the project where he just did the demo work and got it ready. He denied he was a licensed contractor; however, he owned a construction company which mainly did residential trimming and framing. He identified his knowledge for LTC/IC construction came from past employment and four pages of printed information that the FD provided to him. He read about a page and a half of this information but not all of it. He did not remember what the information he read pertained to other than keeping the dust and noise down. During demolition they plugged the vents with a bath towel to mitigate dust from escaping the spa room and put up a barrier outside the spa; however, no additional interventions were utilized to mitigate the spread of dust and/or odors. VOL-B denied any construction concerns. This interview was the first he heard of potential mold. He denied any conversations with DON-A during demolition and/or anyone else about mold. He stated the sheetrock by the shower and tub was discolored a little bit, probably due to getting wet at one point and drying out. In addition, it was full of holes, thus the reason why it was cut out and replaced. When interviewed via telephone on 7/22/24, at 3:01 p.m., a medical provider (MD), who saw numerous facility residents, denied any IC risk mitigation discussions related to his patients prior to, or after the construction started. During an interview on 7/19/24, at 4:16 p.m., the administrator stated she contacted Leading Age and inquired into construction requirements. She was instructed, as they were not changing the footprint of the spa room, and just doing a face lift, they were not required to contact the State of MN or obtain any permits - just to make sure they installed slip resistant tiles, all the vents were closed, and a barrier was installed to prevent dust entering resident areas. In addition, she was informed they did not need specific, additional, air purification as they had a fresh air exchange. She was unfamiliar with VOL-A and VOL-B and/or their qualifications. She thought VOL-A owned his own construction company, but she stated they probably should have checked into their credentials to ensure they were legitimate and that they were knowledgeable about construction and IC requirements. In addition, she lacked knowledge of LTC/IC construction requirements. She indicated the ICP did not provide any policies on construction IC. In addition, she was unaware of any overall facility construction policies. On 7/8/24, after the demolition started, the construction workers told her a small amount of black mold was found, which was something that was common to see. They told her it was nothing to worry about and as they were construction workers, she did not question this. They cut it out, wrapped it up in plastic, and took it to the dumpster per compliance requirements. It sounds as if they handled it perfectly. This was removed before she visualized it. DON-A sent out communications that identified requirements; however, she told the DON-A there was a fresh air exchange, the vents were tapped off, and there was no risk to anyone when they removed things. She indicated this was confirmed by the construction workers. She explained the information provided by DON-A only applied to hospitals, and not them. A barrier went up on 7/8/24; however, this was after the demolition started. There was minimal dust in the hallways which only required a sweeping, and which did not even fill up a dustpan. She denied there were meetings prior to the demolition to discuss IC risk mitigation or to perform any sort of risk assessments, or that she conducted, or instructed others to conduct, any construction risk audits. She was unfamiliar with ICRA. She denied the demolition was placed on hold after the finding of mold for remediation, as the amount found was so small. On 7/10/24, she and the ICP rounded in the facility to identify any concerns with residents and their respiratory statuses; however, there was no documentation of this. She identified, We should have done better with the construction process. A Construction and Renovation - Role of the Administrator or Designee(s) policy, dated 12/2006, the administrator or designee was to plan, implement, and supervise IC practices during construction, renovation, remediation, repair, and/or demolition of the facility in accordance with recommendations of the CDC, the Healthcare Infection Control Practices Advisory Committee (HICPAC), and state or local requirements to reduce resident and employee exposure of potentially infectious agents released into the environment due to such activities. The policy outlined the following administrative or designee responsibilities: review all plans prior to initiation and perform an ICRA for dust control and barrier measures, monitor such measures and other IC measures in accordance to recommendations, establish a multidisciplinary team that included IC staff and maintain a log of their activity, provide construction workers and staff educational information related to airborne infection risk to immunocompromised residents, dispersal of fungal spores and other dust-borne or airborne infection agents with methods to control such agents, review construction contracts and incorporate mandatory adherence agreements for IC, establish and maintain surveillance for airborne and waterborne environmental disease to protect immunocompromised residents, and monitor projects until completion to ensure adherence to CDC/HICPAC guidelines and state or local requirements. A Construction & Renovation policy, dated 2023, identified the ICP, or designee, was to be involved in all aspects of construction or renovation to reduce potential infection or contamination risks and will perform a review and risk assessment to determine measures necessary for safety and

Based on interview and document review the facility failed to report an allegation of abuse timely (with in two hours) to the State Agency for 1 of 1 resident (R2) reviewed for allegations of physical abuse. Findings include: During an interview on 1/22/24 at 4:20 p.m., R2 stated a black girl came into her room about a week ago and hit her on the back and that she got smart with her. R2 further stated she had not told any of the staff because she didn't know what the girl's name was. On 1/22/24 at 4:25 p.m., the director of nursing (DON) was notified of R2's allegation of abuse. During an interview on 1/22/24 at 5:40 p.m., the DON stated she had interviewed R2 and had enough information to determine who the alleged perpetrator (AP) probably was. Further stated she notified the administrator, and the next step was to interview the AP. During an interview on 1/22/24 at 5:45 p.m., the administrator stated she was aware of the alleged abuse by R2 and would work through their process. During an interview on 1/23/24 at 10:35 a.m., the DON indicated they were continuing to investigate. The DON stated they had not reported the alleged abuse to the State Agency. During an interview on 1/23/24 at 10:40 a.m., the administrator stated their process is to make sure the resident is safe, look for injury, and do an investigation. The administrator verified they had not reported the alleged abuse to the State Agency because she didn't think it was a reportable incident. The undated, facility Abuse Prevention and Vulnerable Adult Procedure Program Policy indicated, the facility was to report all alleged violations and substantiated incidents to the state agency and to all other agencies as required within 24 hours for any reportable incident and two hours for those involving a significant injury and take all necessary corrective actions depending on the results of the investigation. The facility policy included direction and language that did not reflect the current regulatory guidance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the faciilty failed to notify the resident's physician of omitted medications, reason for medication omissions, and abnormal blood sugars for 1 of 2 residents (R44) reviewed for insulin. Findings include: R44's admission Minimum Data Set (MDS) dated [DATE], indicated R44 admitted to the facility on [DATE], and had severe cognitive impairment. R44's diagnoses included diabetes mellitus (DM) and Alzheimer's Disease. R44 received daily insulin injections. R44's Medication Review Report dated 10/26/23, indicated R44 was prescribed scheduled mealtime and sliding scale Humalog insulin (fast-acting insulin), and scheduled Lantus insulin (long-acting insulin). The orders lacked parameters to hold the scheduled mealtime insulin. R44's Medication Administration Record (MAR) dated 10/1/23 through 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/9/23 at 12:00 p.m. (Humalog 10 units). R44's progress note dated 10/9/23 at 12:58 p.m., the lunchtime dose of Humalog 10 units indicated R44's blood sugars (BS) prior to lunch was 55 and while resident did consume lunch, BS is not coming up very quickly. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. R44's Medication Administration Record (MAR) dated 10/1 through 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/10/23 at 12:00 p.m. (Humalog 10 units). R44's progress note dated 10/10/23 at 12:40 p.m., the lunchtime dose of Humalog 10 units indicated R44's BS prior to lunch was 67 and was slow to come up. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. R44's Medication Administration Record (MAR) dated 10/1 through 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/12/23 at 12:00 p.m. (Humalog 10 units). R44's progress note dated 10/12/23 at 1:00 p.m., the lunchtime dose of Humalog 10 units indicated R44's BS prior to lunch was 70 and was slow to come up. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. R44's Medication Administration Record (MAR) dated 10/1 through 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/16/23 at 5:00 p.m. (Humalog 8 units). R44's progress note dated 10/16/23 at 6:06 p.m., indicated R44's suppertime dose of Humalog 8 units was held due to B/P [BS] of 53 before supper, ate well at supper. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. R44's Medication Administration Record (MAR) dated 10/1 through 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/17/23 at 12:00 p.m. (Humalog 10 units). R44's progress note dated 10/17/23 at 12:56 p.m., the lunchtime dose of Humalog 10 units indicated R44's BS before lunch was 94 and R44 did not eat 50% of meal. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. R44's Medication Administration Record (MAR) dated 10/1 through 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/19/23 at 12:00 p.m. (Humalog 8 units). R44's progress note dated 10/19/23 at 1:27 p.m., the lunchtime dose of Humalog 8 units indicated R44's BS was 117 and R44 did not consume much lunch. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. R44's Medication Administration Record (MAR) dated 10/1 through 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/21/23 at 5:00 p.m. (Humalog 6 units). R44's progress note dated 10/21/23 at 3:23 p.m., indicated R44's BS at 3:00 p.m. was 52, with no signs or symptoms of hypoglycemia (low blood sugar). R44 was given a banana split sunae. R44's BS was 56 at 3:25 p.m. Note indicated nurse would continue to monitor. Subsequent progress notes on 10/21/23 did not indicate R44's provider was notified R44's Humalog 6 units was held at 5:00 p.m. R44's Medication Administration Record (MAR) dated 10/1 to 10/31/23, indicated R44's scheduled mealtime insulin was held on10/23/23 at 5:00 p.m. (Humalog 6 units). R44's progress note dated 10/23/23 at 5:42 p.m., regarding the suppertime dose of Humalog 6 units indicated R44 did not eat enough carbohydrates for low BS from 60-82 prior to supper. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. Review of R44's Medication Administration Record (MAR) dated 10/1 to 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/24/23 at 5:00 p.m. (Humalog 6 units). R44's progress note dated 10/24/23 at 6:30 p.m. indicated R44's BS lowered to 82 at 3:40 p.m., 72 at 4:32 p.m., and 70 at 5:08 p.m. R44's BS after supper was 127. No insulin was administered for supper. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. R44's Medication Administration Record (MAR) dated 10/1 through 10/31/23, indicated R44's scheduled mealtime insulin was held on 10/25/23 at 5:00 p.m. (Humalog 6 units). R44's progress note dated 10/25/23 at 6:17 p.m., regarding the evening dose of Humalog 6 units indicated R44 did not eat supper. The progress note did not indicate R44's provider was notified the scheduled mealtime dose of Humalog was held. R44's Provider Visit Progress Note dated 10/19/23, indicated nursing staff described R44 had a hypoglycemic event 10/18/23 around suppertime, was very sweaty, blood sugar was around 50, emergency glucagon was administered, and R44 responded well. R44 had tendency to have lower blood sugar readings in the early evenings, high readings during nighttime, and was relatively consistent with eating her meals. Provider decreased mealtime insulin dosing and slightly increased R44's basal insulin doseing. Nursing staff were instructed to monitor R44 closely, encourage regular meals, not miss meals, and limit snacking. Provider planned to follow up in about two weeks to review blood sugars. Provider visit progress note did not indicate staff had notified the provider scheduled mealtime insulins had been held. Parameters to hold the scheduled insulins were not addressed in the provider visit note. R44's Consulting Pharmacist summary of pharmacist identified irregularities dated 10/24/23, indicated R44's 5:00 p.m. dose of Humalog had been held twice in the past five days and the 12:00 p.m. Humalog had been held twice in the past six days. Standing orders for hypoglycemia (low blood sugar) that staff were expected to follow included administration of glucose, hypoglycimia symptoms present, BS checks every 15 minutes until BS >70 mg/dL, and contacting the physician. All of these steps should have been documented in a progress note. Consulting Pharmacist review of R44's records revealed these expectations were not done consistently for R44. The Consulting Pharmacist summary did not address the absence of parameters to hold the scheduled mealtime insulins. On 10/25/23 at 8:33 a.m. Licensed Practical Nurse (LPN)-B stated R44's blood sugars had been very low and LPN-B had held R44's lunchtime dose of Humalog if R44 had not eaten very much or if R44 had been walking around a lot. LPN-B stated the orders did not have parameters for when insulin should be held, and had not contacted the provider prior to holding the insulin. LPN-B stated, Okay, I've been doing it wrong then. On 10/25/23 at 2:20 p.m. the Registered Nurse Unit Manager (RN)-A stated R44 admitted to facility because R44's family could no longer manager her diabetes. RN-A stated staff should have notified the provider at the time they made the judgement to hold the scheduled mealtime insulins, it would be important because nurses are only licensed to follow provider orders, and nurses cannot write orders as it would be beyond our scope of practice. The facility's Insulin Administration policy, approved 10/2023, indicated insulin would be administered as ordered by the provider, and any refusals would be documented and the provider would be notified.

Based on interview and document review the facility failed to have 8 hours of consecutive registered nursing coverage on a daily basis. This had the potential to affect all 54 residents residing in the facility. Findings include: The Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report identified during the third quarter of 2023 (4/1/23 through 6/30/23) the facility failed to have registered nurse (RN) coverage for the entire quarter. The facility provided schedules for the third quarter of 2023 indicated a lack of RN coverage for 8 consecutive hours for the following dates: 4/16, 4/30, 5/7, 5/14, 5/28, 6/3, and 6/11. The facility provided schedules for week of the survey period (10/22/23 through 10/28/23) and month preceding (9/23/23 through10/23/23) indicated a lack of RN coverage for 8 consecutive hours for the following dates: 9/23, 9/24, and 10/1. During an interview on 10/25/23 at 9:40 a.m., staff scheduler (SS-E) stated that when creating the schedule, she made sure to have 24 hours of licensed nursing coverage, and 8 hours of that should be for an RN. SS-A continued that she was not aware that the eight hours of RN coverage meant the RN needed to be in the building. SS-A stated, I thought the RN could be on call for the eight hour of weekend coverage. During an interview on 10/25/23 at 10:40 p.m., director of nursing (DON) stated there needed to be 8 hours of continuous RN coverage. She was aware of the issue on the weekends with RN coverage. Facility staff scheduling policy requested, none provided.

Based on observation, interview and record review, the facility failed to maintain temperature logs for refrigerators and food served. This had the potential to affect all 54 residents residing in the facility. Finding includes: During observation on 10/24/23 at 2:47 p.m., the 2nd floor kitchenette refrigerator temperature log indicated multiple missing entries. 1st and 3rd floor kitchenette refrigerator temperature logs indicated missing multiple entries as well. Facility document for refrigerator logs indicated 25 missing temperatures for 1st floor kitchenette refrigerator, 45 missing temperatures for 2nd floor kitchenette refrigerator, and 43 missing temperatures for 3rd floor refrigerator. During observation on 10/25/23 at 11:57 a.m., dietary cook (DC-A) and DC-B finished noon meal prep in the kitchen. However, did not record temperatures from meal preparation on temperature logs located on cabinets above preparation station in main kitchen. During observation on 10/25/23 at 12:08 p.m., DC-A recorded food temperatures prior to serving food for 2nd floor kitchenette. During interview on 10/25/23 at 12:08 p.m., DC-A stated she took the temps, but often forgets to record the temps in the logbooks. DC-A stated refrigerator temperatures for 2nd floor should have been done but wasn't sure why only 1 entry had been recorded. During observation on 10/25/23 at 12:13 p.m., DC-B recorded food temperatures prior to serving food for 1st floor kitchenette. During interview on 10/25/23 at 12:15 p.m., DC-B stated awareness of the requirement to take temperatures and to record but forgets in haste at times. DC-B stated it was important to take temperatures to prevent under cooked food from being served. DC-B stated he usually took the refrigerator temperatures for 1st floor AM's but wasn't sure why PM's wasn't done. During observation on 10/25/23 at 12:20p p.m., DC-C recorded food temperatures prior to serving food for 3rd floor kitchenette. During interview on 10/25/23 at 12:18 p.m., DC-C stated she always took the temperatures for the foods, and recorded them. They were to be done before leaving the main kitchen. DC-C stated it was important to temp and record, because we don't want to get anybody sick. DC-C stated she should have recorded the temperatures for the refrigerator on 3rd floor, and noted the log was missing entries. During interview on 10/25/23 at 1:38 p.m., registered dietician (RD) stated it was important for staff to be utilizing temperature logs and recording the temperatures of foods and refrigerators. RD stated it was an important practice and helped to avoid any food borne illness. During interview on 10/25/23 at 1:48 p.m., certified dietary manager (CDM) stated he expected staff to check and record food temperatures in the food logbook and on the refrigerator temperature logs. CDM stated it was important to know the food was cooked appropriately and equipment was functioning appropriately. During interview on 10/25/23 at 3:32 p.m., director of nursing (DON) stated she became aware staff had not been recording food and refridgerator temperatures after she had reviewed the logs. DON stated that she had spoken with the CDM about this issue and would expect staff to record temperatures as it could lead to illness or other potential infection issues, if not done. Facility document, titled 1st, 2nd, and 3rd choice temperature log noted for month of October 2023 indicated 5 missing entries for 1st choice meal, 43 missing entries for 2nd choice, and 10 missing temperatures for puree. Kitchenette logs also indicating similar amounts of missing information. Facility document, titled, temperature checks, dated 10/23, indicated that food service staff document hot food temperatures on the appropriate form in temperature books, and initial form.

Based on interview and document review, the facility failed to submit the payroll-based journal system (PB&J) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 54 residents residing in the facility. Findings included: The Centers for Medicare and Medicaid Services' (CMS) Payroll Based Journal (PBJ) Staffing Data Report identified during the third quarter of 2023 (4/1/23 - 6/30/23) the facility failed to have registered nurse (RN) coverage and licensed nursing coverage for 24 hours a day for the entire quarter for the following dates: 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30, 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18, 5/19, 5/20, 5/21, 5/22, 5/23, 5/24, 5/25, 5/26, 5/27, 5/28, 5/29. 5/30, 5/31, 6/1, 6/2, 6/3, 6/4, 6/5, 6/6, 6/7, 6/8, 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/25, 6/26, 6/27, 6/28, 6/29, and 6/30. During an interview on 10/25/23 at 10:40 a.m., director of nursing (DON) stated the PBJ report was submitted by the payroll submitter (PS-F). During interview on 10/25/23 at 1:04 p.m., PS-F stated that she was responsible to report the PBJ reports and submits them by exporting the data directly to CMS. PS-F stated the 2023 third quarter data missing in the PBJ was because she had missed the submission window due to a vacation. During interview on 10/25/34 at 1:06 p.m., DON stated that we should be submitting the PBJ data, and we need to have a better plan in place to that if someone PS-F goes on vacation, another person is able to submit the PBJ report. Facility document, titled, Payroll Based Journal (PBJ) Reporting, dated 10/23, indicated the facility will submit direct care staffing information on the schedule specified by CMS, but at a minimum a quarterly basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify a resident representative timely of bruising for 1 of 3 residents (R4) reviewed for injury of unknown source. Findings include: R4's Diagnoses List indicated R4's diagnoses included dementia and diabetes. R4's Face Sheet listed family member (FM)-A as the emergency contact, responsible party, financial and health care power of attorney. R4's significant change Minimum Data Set (MDS) dated [DATE], indicated R4's cognitive status was not assessed. The MDS further indicated R4 had frequent physical and verbal behaviors that interfered with her care and were disruptive to the care/living environment. R4 frequently rejected care. R4's Skin Evaluation dated 8/9/23 indicated R4 had numerous bruises, several small bruises on all extremities and abdomen. R4's medical record lacked indication FM-A was notified of these bruises. R4's Skin Evaluation dated 8/15/23 indicated R4 had numerous bruises, several small bruises on all extremities and abdomen. R4's medical record lacked indication FM-A was notified of these bruises. R4's Skin Evaluation dated 8/22/23 indicated R4 had numerous bruises, several small bruises on all extremities and abdomen. R4's medical record lacked indication FM-A was notified of these bruises. On 8/22/23, at 1:14 p.m., FM-A stated she was not informed of R4's bruises. On 8/23/23, at 10:51 a.m., registered nurse (RN)-A stated residents representatives should be notified upon discovery of an unexplained bruise. On 8/23/23, at 12:46 p.m., RN-B (regional resource nurse) stated family should be notified of bruises. The facility Accidents and Incidents policy dated 11/21 directed the date/time the family was notified and by whom shall be included on the Report of Incident/Accident form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain wheelchairs in good repair for 2 of 2 residents (R5 and R29) reviewed for wheelchair utilization. Findings include: R5 R5's face sheet indicated diagnoses of dementia, depression, and peripheral vascular disease (causes reduced blood flow to the limbs). R5's annual Minimum Data Set (MDS) dated [DATE], indicated usually able to make herself understood and usually able to understand others. R5's cognition was severely impaired. R5 was dependent on physical assistance from staff for dressing, transfers and mobility. R5's care plan last reviewed 12/7/22, indicated R5 was independent in her wheelchair in her room. R29 R29's face sheet indicated diagnoses of dementia, hypertension and muscle weakness. R29's quarterly Minimum Data Set (MDS) dated [DATE], indicated R29 could communicate needs and cognition was moderately impaired. R29 required physical assistance from staff for dressing and transfers. R29's care plan last reviewed 2/8/23, indicated R29 required assistance from staff for mobility in wheelchair. On 2/13/23, at 2:03 p.m. R5 was seated in her wheelchair. Both right and left arm rests were noted to be cracked with areas of missing vinyl. R5 rubbed her hand across the right arm rest and stated, Oh, that's rough. On 2/13/23, at 2:47 p.m. R29 was seated in his wheelchair. Both right and left arm rests were noted to be cracked with areas of missing vinyl. R29 stated the cracks were uncomfortable when they rub on his arms. On 2/17/23, at 8:53 a.m. occupational therapist (OT) stated therapy and maintenance departments worked together to ensure wheelchairs were well maintained. OT was not aware of any wheelchairs that needed repair or arm rests that were cracked and peeling. OT stated it was important for the arm rests to be free from cracks for skin integrity and infection control. On 2/17/23, at 9:04 a.m. maintenance director (MD) indicated wheelchair repair, including arm rests was done by maintenance. Repair may depend on if the wheelchair belonged to the resident or the facility. If the wheelchair belonged to the resident, the facility would contact the resident's family for direction. MD was not aware of any wheelchairs currently in need of repair. MD confirmed R5's and R29's right and left wheelchair armrests needed repair. A facility policy on wheelchair repair was requested but was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure physician orders were followed for 1 of 5 residents (R43) reviewed for unnecessary medications. Findings include: R43's admission Minimum Data Set (MDS) dated [DATE], indicated R43 had moderate cognitive impairment, heart failure, and chronic kidney disease. R43's Order Summary Report included the following orders: 1) Order dated 1/17/23, for daily weight in the morning for medication monitoring. 2) Order dated 1/18/23, for furosemide (a diuretic) oral tablet 40 mg. Give 20 mg by mouth in the afternoon related to heart failure. If weight less than 158, then take 40 mg daily. If weight 159-162 then 40 mg in AM and 20 mg in PM. If weight 163 or higher then take 40 mg twice daily. 3) Order dated 1/18/23, for furosemide oral tablet 40 mg. Give 40 mg by mouth in the morning related to heart failure. R43's Weights and Vitals Summary indicated the following weights: On 1/19/23, 161.2 lbs. On 1/29/23, 157 lbs. On 1/30/23, no weight documented On 2/2/23, 160.2 lbs. R43's Medication Administration Record (MAR) dated 1/1/23 to 1/31/23, indicated the following: On 1/19/23, furosemide 40 mg was administered at 8:00 a.m. and furosemide 40 mg was administered at 2:00 p.m. On 1/29/23, furosemide 40 mg was administered at 8:00 a.m. and furosemide 20 mg was administered at 2:00 p.m. On 1/30/23, furosemide 40 mg was administered at 8:00 a.m. and furosemide was not administered at 2:00 p.m. R43's Medication Administration Record (MAR) dated 2/1/23 to 2/28/23, indicated the following: On 2/2/23, furosemide 40 mg was administered at 8:00 a.m. and furosemide 40 mg was administered at 2:00 p.m. R43's progress note dated 1/30/23, at 3:03 p.m. indicated R43's 2:00 p.m. furosemide was not given because R43's weight was not taken that morning. Evidence the physician was notified was not found in R43's record. On 2/17/23, at 10:20 a.m. director of nursing (DON) confirmed R43 did not receive furosemide as ordered at 2 p.m. on 1/19, 1/29, 1/30, and 2/2/23. DON confirmed furosemide was held on 1/30/23, at 2:00 p.m. because the weight was not taken that morning, and she would have expected the staff to obtain a weight at that point and update the provider for further instruction. On 1/19/23, R43's weight was between 159 and 162 lbs, 20 mg of furosemide should have been administered. On 1/29/23, R43's weight was less than 158 lbs, R43 should not have been administered furosemide at 2:00 p.m. On 2/2/23, R43's weight was 160.2 lbs, R43 should have received 20 mg of furosemide at 2:00 p.m. R43 did not receive the correct doses and the provider should have been notified. DON was aware the order was complicated and did not know what errors had been made. DON had instructed RN-A to address the order with the provider, and the provider wanted to keep the parameters as written. A second request for clarification was sent via fax to the provider on 1/30/23, and the provider wanted to keep the order as written. DON stated after the second request for clarification was unsuccessful, she probably should have called him myself. Because the order was confusing, she would have expected the nurse manager to monitor to ensure the medication was administered appropriately, but she had not instructed the nurse manager to monitor the administration. DON stated receipt of the correct dosage of furosemide was important for cardiac and kidney function, and R43 could have adverse effects if he did not receive the correct dose of furosemide. On 2/17/23, at 11:56 a.m. registered nurse (RN)-A stated she was instructed by the DON to get the order clarified, and the previous primary provider sent back the same order. RN-A planned to notify the provider that staff did not know what to do when R43's weight fell between the ordered parameters. RN-A stated she was not supposed to enter the parameters into the system so they were clearer and had to input parameters exactly as written by the provider. The facility's Medication Guidelines policy, last approved 11/2021, indicated the provider would be contacted for any necessary order clarifications, and clarifications would be documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 1 or 4 residents (R30) admitted during the 2022/2023 influenza season (October 1 through March 31) received the influenza vaccination in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R30's face sheet indicated diagnoses included diabetes mellitus, anemia, and heart failure. R30's admission Minimum Data Set (MDS) dated [DATE], indicated cognitively intact. Additionally, the MDS indicated R30 did not receive the influenza vaccine while at the facility because she was not in the facility during the influenza vaccination season. R30's Influenza Vaccination Consent/Declination form, signed by R30 on 1/23/23, indicated R30 had consented to receive the influenza vaccine for the 2022/2023 influenza season. R30's admission summary progress note dated 1/23/23, at 3:30 p.m. indicated resident declined COVID and Flu vaccines. R30's Immunization Report printed 2/17/23, indicated R30 did not receive the influenza vaccine while at the facility. On 2/17/23, at 10:48 a.m. director of nursing (DON) confirmed an influenza vaccination consent was signed by R30 on 1/23/23. Additionally, DON confirmed R30's medical records lacked evidence of the influenza vaccine being administered. The DON stated she considered this to be a failure in following facility process, and she expected residents who consented to the influenza vaccine received it within 7 days of admission. The facility's Influenza Vaccination Policy last revised 11/2021, indicated between October 1 through March 31, all residents would be offered, and when indicated, provided the influenza vaccination according to CDC recommendation, unless medically contraindicated, already immunized, or the resident and/or the resident representative declined the vaccine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to identify medical symptom for use of seatbelt, provide least restrictive restraint for least time possible, and provide ongoing monitoring of seatbelt use for 4 of 4 residents (R1, R47, R53, R159) reviewed for restraints. Findings include: R1 R1's face sheet indicated diagnoses included persistent vegetative state, pneumonia, and quadriplegia. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was not able to communicate with staff and fully dependent for physical assistance from two staff for all activities of daily living (ADLs) including repositioning, bed mobility, transfers and wheelchair mobility. MDS lacked evidence of restraints. R1's physician orders signed 11/8/22, included use seatbelt when in wheelchair as safety device related to positioning every shift. However, lacked evidence of medical symptoms treated. R1's care plan last reviewed 1/26/23, failed to provide direction on use of seat belt. Progress note dated 1/20/23, indicated R1 did not use restraints. R1 was in a persistent vegetative state with quadriplegia and contractures, totally dependent with ADLs and mobility. R1 was unable to move or reposition independently. A seat belt was used while in wheelchair to ensure safety and placement. R1 was not able to make purposeful movements independently. R1's Physical Device Evaluation dated 1/6/23, indicated the facility failed to identify the powered wheelchair (PWC) seatbelt as a restraint, alternative interventions attempted, ongoing monitoring for use, and ability to release the seatbelt independently. On 2/16/23, at 8:52 a.m. R1 was observed seated in wheelchair, reclined back approximately forty-five degrees, with the seat belt secured across the abdomen. On 2/16/23, at 9:37 a.m. trained medication aid (TMA)-A confirmed placement of the seat belt. TMA-A stated R1 had always used the seat belt and was not be able to remove it independently. R47 R47's face sheet indicated diagnoses included stroke, quadriplegia, and epilepsy. R47's MDS dated [DATE], indicated R47 had unclear speech, usually understood others, severe cognitive impairment and required extensive to total physical assistance of two staff for bed mobility, transfers, dressing, eating, toilet use, bathing, and personal hygiene. However, the MDS did not indicate the use of restraints. R47's physician orders signed 1/26/23, included an order effective 9/17/22, to apply seatbelt when seated in PWC to provide safety, proper position, and mobility every shift. However, lacked evidence of medical symptoms treated. R47's care plan last revised 11/21/22, lacked evidence of seatbelt interventions or tasks. R47's progress note dated 11/18/22, indicated R47 had no use of restraints. However, had a PWC seatbelt for safety. R47's Restraint/Adaptive Equipment Use assessment dated [DATE], indicated the facility failed to identify the use of a PWC seatbelt as a restraint, but as an adaptive device. Additionally, the assessment lacked evidence alternatives were tried, failed to identify medical symptom treated, ongoing monitoring, and ability to release the seatbelt independently. R47's Physical Device Evaluation dated 2/3/23, failed to identify the PWC seatbelt as a restraint, alternative interventions attempted, ongoing monitoring for use, and ability to release the seatbelt independently. On 2/14/23, at 8:32 a.m. R47 was observed in the dining room seated upright in PWC with seatbelt secured around abdomen. On 2/14/23, at 4:24 p.m. nursing assistant (NA)-B stated R47 used a PWC with seatbelt, and all residents with PWC had seatbelts. R47 was not able to unbuckle the belt independently. NA-B was not aware why the seatbelt was needed. On 2/15/23, at 10:24 a.m. NA-A stated R47 used a seatbelt to protect her from falling or getting hurt while seated in the PWC. R47 was not able to unbuckle it herself, and therefore, it was a restraint. Further, NA-A stated it was not safe for residents to use a PWC without a seatbelt. On 2/15/23, at 10:36 a.m. R47 was observed alone in room, seated in PWC, reclined back approximately thirty-degrees, with the seatbelt secured around abdomen. On 2/15/23, at 10:45 a.m. TMA-B stated R47 was not able to move her arms and did not have the ability to release the PWC seatbelt independently. All residents with a PWC used a seatbelt, and technically the seatbelts were restraints. On 2/15/23, at 1:05 p.m. R47 was observed in PWC with seatbelt secured around abdomen. TMA-B confirmed placement of the seat belt. R47 shook her head from side-to-side when asked if she was able to remove the seatbelt. R53 R53's face sheet indicated diagnoses included amyotrophic lateral sclerosis (a nervous system disease that weakens muscles), epileptic seizures, and Parkinson's disease. R53's significant change MDS dated [DATE], indicated R53 had unclear speech, usually understood others, intact cognition and required extensive to total physical assistance of two staff for bed mobility, transfers, dressing, eating, toilet use, bathing, and personal hygiene. However, the MDS did not indicate the use of restraints. R53's physician orders signed 1/3/23, included an order effective 9/18/22, to apply seatbelt when seated in PWC to provide safe and adequate seating and mobility every shift. However, lacked evidence of medical symptoms treated. R53's care plan last revised 12/20/22, failed to provide seatbelt interventions or tasks. Progress note dated 12/20/22, indicated R53 had no use of restraints. However, had a seatbelt for PWC for safety. R53's Restraint/Adaptive Equipment Use assessment dated [DATE], indicated the facility did not identify the PWC seatbelt as a restraint, but as an adaptive device. Additionally, the assessment lacked evidence alternatives were tried, failed to identify medical symptom treated, ongoing monitoring, and ability to release the seatbelt independently. R53's Physical Device Evaluation dated 12/8/22, failed to identify the PWC seatbelt as a restraint. The assessment lacked evidence alternatives were tried, failed to identify an appropriate medical symptom for use, on going monitoring, and ability to release the seatbelt independently. On 2/14/23, at 9:31 a.m. R53 was observed in the hallway, seated in PWC with a seatbelt secured around abdomen. On 2/14/23, at 4:24 p.m. R53 was observed in PWC with seatbelt secured around abdomen. NA-B confirmed placement of the seat belt. R53 was unable to unbuckle the seatbelt. NA-B stated R53 needed the seatbelt for safety because R53 kind of leans in the chair. On 2/15/23, at 10:24 a.m. NA-A stated R53 had a PWC seatbelt for safety because she drives herself around. She had reduced hand strength and was not able to release the seatbelt independently. On 2/15/23, at 10:45 a.m. TMA-B stated R53 had a PWC seatbelt because she leaned to one side and liked to tilt back. R53 was not able to release the seatbelt independently, and the seatbelt could be a restraint. R159 R159's face sheet indicated diagnoses included dementia, bilateral artificial knee replacements, and Parkinson's disease. R159's admission MDS dated [DATE], indicated moderate cognitive impairment, and required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and bathing. However, the MDS did not indicate the use of restraints. R159's care plan last revised 2/15/23, failed to provide seatbelt interventions or tasks. Physician Fax Order form, signed 2/10/23, indicated seatbelt while in PWC for safety, and turn off controls of power wheelchair when in room alone. However, lacked evidence of medical symptoms treated. R159's progress note dated 2/15/23, indicated R159 had no use of restraints. Progress note dated 2/16/23, indicated R159 was found to have unbuckled his seatbelt while in his PWC. It was reattached. R159 did not comprehend why seatbelt was needed, and education on safety was provided. R159's Physical Device Evaluation dated 2/2/23, failed to identify the PWC seatbelt. The assessment lacked evidence alternatives were tried, failed to identify an appropriate medical symptom for use, ongoing monitoring, and ability to release the seatbelt independently. On 2/13/23, at 7:22 p.m. R159 was observed alone in room, seated in a PWC with a seatbelt secured around abdomen. Licensed practical nurse (LPN)-A entered R159's room to administer medications. After LPN-A administered eye drops, R159 asked LPN-A to remove the seatbelt. LPN-A told R159 he needed it for safety. After LPN-A administered R159's inhaler, R159 asked LPN-A to remove his seatbelt. LPN-A told R159 he needed to keep the seatbelt on while he was in the PWC for his safety. On 2/14/23, at 4:24 p.m. NA-B stated R159 had a PWC seatbelt as a fall prevention because he attempted to self-transfer. However, R159 had not fallen in the facility. R159 had a manual wheelchair when he was admitted to the facility, and use of the seatbelt was initiated once the PWC arrived. NA-B found R159 seated in his PWC once without the seatbelt secured, but she did not know if R159 released it himself. On 2/15/23, at 10:45 a.m. TMA-B stated R159 had a PWC seatbelt, did not know why the seatbelt was used, and had not observed R159 attempt to self-transfer. On 2/13/23, R159 tried to release the seatbelt, was unable to, and requested a knife so he could cut the seatbelt off. On 2/15/23, at 11:40 a.m. registered nurse (RN)-A stated seatbelts were used for residents with PWCs for safety, and that R1, R47, and R53 would not be able to unbuckle the seatbelt independently. RN-A stated R159 probably would have been able to unbuckle the seatbelt, but the facility had not assessed R159's ability. RN-A stated seatbelts were not used prior to September 2022, when she was instructed by the previous DON to implement use of the seatbelts as a fall prevention, to get physician orders for use, and to note the use of a seatbelt on the quarterly Physical Devices Evaluations. RN-A stated the seatbelt was a restraint if the resident was not able to open it independently, and was not aware of seatbelt use on the residents' Plan of Care. On 2/15/23, at 2:21 p.m. director of nursing (DON) stated use of the seatbelt as a restraint depended on the purpose and how the facility used them. She was not aware which residents used them or if the facility had a system or policy in place when residents were not able to release them independently. DON stated she became aware of the use of seatbelts with PWCs the week prior when R159 was admitted to the facility and RN-A stated R159 needed an order for the PWC seatbelt. DON stated the seatbelt was a safety thing and R159's responsible party requested the seatbelt. RN-A was instructed to refer to the facility policy because she was not used to people using seatbelts, and she did not know if R159 had been assessed for a restraint. The seatbelt would be a restraint if it was used to prevent a resident from getting out of the PWC independently and if they were not able to verbalize they wanted the seatbelt released or release it on their own. On 2/17/23, at 11:22 a.m. the DON confirmed R47's Physical Device Evaluation indicated use of a seatbelt with use of PWC per physician order, and the device was used as a therapeutic intervention for positioning and balance. DON stated R47's device assessment did not contain a good note that explained the use or whether R47 was able to release the seatbelt. The DON confirmed R53's Physical Device Evaluation indicated a physician order for a PWC seatbelt, and did not indicate R53 had the ability to release the seatbelt. DON confirmed R159 did not have Physical Device Evaluation completed for the PWC seatbelt or documentation that indicated R159 was assessed for independent seatbelt removal. On 2/17/23, at 11:35 a.m. DON stated at the morning meeting on 2/10/23, RN-A informed her an order for a PWC seatbelt for R159 was requested. She had not looked for a policy on 2/10/23, had not ensured that a process for the use of restraints had been followed, but planned to follow-up on Monday [2/13/23]. She was not aware the facility did not have a restraint policy until 2/13/23. The DON confirmed R1, R47, R53, and R159's records lacked the documented purpose and medical symptom for use, assessment of the medical symptoms that warrant the restraint, documented alternatives attempted, documented consent with risks/benefits, and the time/frequency of use. This should have been completed prior to use of the seatbelts. Documented re-evaluation for continued restraint use and effectiveness in treating the identified medical symptoms, documented monitoring, care planned interventions to prevent risks related to use, and documented interventions for reducing the use of the seatbelts were required for use of any restraint. The facility's Physical Device Assessment policy, effective 2/2023, defined a physical restraint as any method that is attached or adjacent to the resident's body, cannot be removed easily by the resident, restricts the resident's freedom of movement or normal access to his/her body, and has the potential of many negative side effects and risks that outweigh any benefit from their use. In the rare and infrequent instances in which the medical symptoms warrant the use of a physical restraint, a physical device assessment would be completed, need/request would be reviewed with the DON, and provider orders would be obtained. Additionally, the identification, care planning and communication of the following would be completed: medical symptoms which warranted the use of the restraint; the less restrictive alternatives attempted; risks, benefits, and alternatives reviewed with resident/resident representative; identification, development and implementation of interventions to prevent/reduce the potential for risks; length of time restraint was anticipated to be used; who would apply the restraint; when and how the restraint would be used; time and frequency the restraint would be released; type of monitoring and supervision provided during use; and when on-going reassessment would be completed to determine the effectiveness and continued need.

Based on interview and document review, the facility failed to ensure the quality assessment and assurance committee (QAA) developed and/or maintained an appropriate systemic action plan for provider recommendations, as previously cited in survey exited 11/18/21. Additionally, the facility failed to develop and implement appropriate action plans to correct quality deficiencies identified during the survey related to restraints. This deficient practice had the potential to affect all 53 residents currently residing in the facility. Findings include: On 2/16/23, at 2:13 p.m. nurse manager (NM)-C stated she knew she needed to read provider notes, including Associated Clinic of Psychology (ACP) notes and document the visit in a progress note. However, NM-C was not aware she needed to follow up on provider recommendations indicated in the provider notes. On 2/17/23, at 9:17 a.m. director of nursing (DON) stated she expected the nurse manager to review ACP progress notes and follow up on provider recommendations. AND On 2/15/23, at 2:21 p.m. director of nursing (DON) stated use of a power wheelchair (PWC) seatbelt as a restraint depended on the purpose and how the facility used them. She was not aware which residents used seatbelts, and if the facility had a system or policy in place to release the seatbelts if residents were not able to release them independently. DON stated the week prior, she became aware of the use of seatbelts with PWCs. She instructed staff to refer to the facility policy because she was not used to people using seatbelts, and she did not know if residents had been assessed for a restraint. The seatbelt was a restraint if it was used to prevent a resident from getting out of the PWC independently and if they were not able to verbalize they wanted the seatbelt released or release it on their own. On 2/17/23, at 11:22 a.m. the DON stated four residents (R1, R47, R53, R159) had physician orders for use of a seatbelt with PWC. DON confirmed physical device assessments did not contain the needed information to warrant use, nor if residents were able to release the seatbelt on their own. She became aware the facility did not have a policy for restraints on 2/13/23. On 2/17/23, at 1:55 p.m. administrator stated facility staff were not familiar with the purpose and processes of Quality Assurance and Performance Improvement Plan (QAPI) and QAA prior to him assuming his position as administrator. The QAA committee started putting Performance Improvement Projects (PIPS) in place, and started with some of the easy things so the committee representatives saw how the process worked. Committee members were instructed to propose PIP recommendations this week. QAA committee representatives will learn to develop, implement and maintain systems to address quality deficiencies. The facility's Quality Assurance Performance Improvement policy, last approved 8/2022, indicated QAA focus areas included all systems that affected resident and family satisfaction, quality of care and services provided, and all areas that affected quality of life.

Based on interview and document review, the facility failed to develop antibiotic stewardship program which included implementation of protocols and a system to monitor antibiotic use to ensure appropriate antibiotics were utilized. In addition, the facility failed to ensure prescribed antibiotics met criteria for antibiotic use and that the reassessment for continued need of the antibiotics was completed. This deficient practice had the potential to affect all 53 residents who resided in the facility. Findings include: A facility form, untitled, from November 2022 through February 2023, tracked actual infections and antibiotic us. The form was organized with 35 columns which included the following data: resident name, room number, infection type, symptoms, onset date, use of a device, if diagnostic testing was performed, test date, identified pathogen, date/type/duration of antibiotic treatment, provider, if the infection met criteria and if reassessment of the antibiotic was performed. The December 2022 log identified 12 antibiotics were prescribed. Seven infections were identified as an UTI, two infections were identified as pneumonia, one was identified as an URI and one was identified as paranychia (infection in the skin surrounding the nail). One sinus infection, one pneumonia and the paranychia infection failed to include diagnostic testing. All 12 infections lacked evidence of meeting criteria. The antibiotics for each of the infections was not reassessed for appropriate use or continued need. The December 2022 log identified eight antibiotics were prescribed. Seven infections were identified as an UTI and one infection was identified as a sinus infection. All seven infections lacked evidence of meeting criteria. The antibiotics for each of the infections was not reassessed for appropriate use or continued need. The January 2023 log identified three antibiotics were prescribed. Two infections were identified as an UTI and one was identified as an URI. All three infections lacked evidence of meeting criteria. The antibiotics for each of the infections were not reassessed for appropriate use or continued need. The February 2023 log identified five antibiotics were prescribed. Four infections were identified as a UTI, one of the UTI's did not include diagnostic testing. One infection identified was a sinus infection. All four infections lacked evidence of meeting criteria. The antibiotics for each of the four infections were not reassessed for appropriate use or continued need. Facility documents: Minimum Criteria for Initiation of Antibiotics in LTC (long term care) Residents with Suspected Lower Respiratory Tract Infection, Minimum Criteria for Initiation of Antibiotics in LTC Residents with Suspected Skin and Soft-Tissue Infection, Minimum Criteria for Initiation of Antibiotics in LOTC Residents with Fever or Unknown Focus of Infection and Minimum Criteria for Initiation of Antibiotics in LTC Residents with Suspected UTI each included spaces to include resident name, physician and concern. Instructions on the forms guided staff to indicate what symptoms the resident was experiencing. Space was provided on each form for the doctor to respond and provide further direction. On 2/16/23, at 12:54 p.m. infection preventionist (RN-A) stated there were forms on each unit for the nurses to complete when they had a concern about a resident having a possible infection. The form guided the nurse for next steps which included indicating signs and symptoms the resident was experiencing and updating the provider. RN-A expected these forms were completed, then faxed to the doctor to update. RN-A expected a copy of the form was also given to her for tracking and surveillance. RN-A stated the forms were not completed consistently resulting in antibiotics being prescribed without meeting criteria. RN-A reviewed logs dated November 2022-February 2023 and confirmed the logs failed to indicate in the antibiotics prescribed during that time met criteria and the logs indicated reassessment of prescribed antibiotics were not completed. RN-A stated it was important to ensure criteria was met and to reassess prescribed antibiotics to ensure antibiotics were not overly used and to prevent resistance. RN-A stated she did not have sufficient time to follow up on antibiotics prescribed to ensure they met criteria and reassessed for continued use and need. On 2/16/23, at 1:24 p.m. RN-B confirmed she was aware of the forms to complete when a resident was showing signs of a possible infection but stated she did not always use the form. On 2/17/23, at 9:09 a.m. director of nursing (DON) stated she expected nurses to complete the minimum criteria forms when there were concerns about possible infection. DON expected the forms were used to update the providers and to give the provider all possible information before antibiotics were prescribed. DON expected RN-A to review prescribed antibiotics and report concerns to the unit managers if the forms were not being completed or criteria was not being met. DON expected reassessment of prescribed antibiotics happened 72 hours after they were started. Appropriate use of antibiotics was important to prevent future resistance to antibiotics. Facility policy, Antibiotic Stewardship Program, reviewed 11/2021, instructed the program would review new antibiotic starts to determine whether the clinical assessment and prescription documentation is in accordance with the facility policy and antibiotic use protocol. Also, to perform a review 48-72 hours after initiation of antibiotics to determine the resident's clinical response to treatment and the antibiotic choice based on test/culture results when available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to develop interventions to reduce the risk for falls for 1 of 3 residents (R2) reviewed for accidents. Findings include: R2's quarterly Minimum Data Set, dated [DATE], identified moderate cognitive impairment, indicated he required supervision for transfers, ambulation and toileting and was continent of bowel and bladder. R2's fall care plan dated 11/7/22, identified a risk for falls related to weakness, incontinence, impaired cognition and a history of falls. The care plan directed staff to encourage appropriate footwear, observe for adverse effects of medications and refer to therapy as indicated. The care plan was revised on 1/10/23, and indicated R2 required assist of one staff with wheel chair for locomotion. A facility incident report dated 12/17/22, at 1:33 p.m. indicated staff went to R2's room around 5:50 a.m. and saw him on the floor in front of the bathroom door. R2's wife stated he was checking on her and lost his balance. Investigation summary indicated R2 had a fall that was not suspicious in nature. R2 was impulsive and had poor safety awareness. After thorough review it was likely R2 was self transferring and fell. A facility incident report dated 12/18/22, at 10:55 a.m. indicated R2's wife utilized the call light and reported R2 had been sleeping in bed, rolled to the edge then slid onto the floor. An investigative summary indicated R2 fell out of bed. Fall not suspicious in nature. R2 was independent with transfers and bed mobility. A facility incident report dated 12/18/22, at 5:45 p.m. indicated staff found R2 on the floor after hearing him yell out. R2 was not wearing non-skid socks or shoes and was unable to give a description of what happened. A facility incident report dated 12/22/22, indicated R2 fell and landed on his left side. Fall was not suspicious in nature. R2 self-transferred and had poor safety awareness. Thorough review indicated R2 self transferred and fell. A Post-Fall Investigation dated 12/22/22, indicated on 12/21/22, at 10:30 p.m. R2 fell near his bed and was found seated on the floor between his bed and recliner. The report indicated R2 self-transferred and did not use his call light. Staff educate and monitor for safety every hour due to impulsive behavior and failure to utilize call light. The report indicated R2 displayed a drop in blood pressure upon standing which caused dizziness and unstable transfers. A physician visit note dated 12/22/22, indicated R2 was seen for increased weakness and falls and lift side rib pain. No physician recommendations were identified. A facility incident report dated 12/26/22, indicated R2 self transferred to the bathroom and was found on the floor in the bathroom. Investigation summary indicated R2 had a fall, not suspicious in nature. R2 was impulsive and displayed poor safety awareness. After thorough review, R2 was self-transferring and fell. A Post-Fall Investigation dated 12/26/22, indicated the fall was reviewed on 12/28/22, but lacked evidence of assessment of interventions. R2's Progress Note dated 12/28/22, indicated the physician directed staff to monitor R2's sleep habits and review in one week. The medical record lacked evidence of a review. A facility incident report dated 1/7/23, indicated R2 was found on the floor between beds, face down with his left arm under his body. He had some emesis present. R2 was sent to the hospital due to left side weakness and head injury resulting in a skin tear and hematoma formation. A Post-Fall Investigation dated 1/7/23, was blank. A facility incident report dated 1/11/23, indicated upon entering R2's room to check on him, he was seen sliding to the floor from his recliner. R2 was unable to describe what happened. Review of R2's medical record lacked evidence falls were assessed to determine a root cause and lacked evidence of interventions specific to R2's falls. During interview on 1/25/23, at 8:38 a.m. registered nurse (RN)-A stated R2 used to come out to the dining room for meals and was able to ambulate by himself using a cane. RN-A stated R2 spent most of the day sleeping and would take himself to the bathroom independently. RN-A stated R2 began having falls in the bathroom or in his room on the way to the bathroom. In regard to interventions, RN-A stated she would look on the care plan but did not know who developed the fall interventions. RN-A stated when a fall occurred the nurse on duty would document the details in an incident report. RN-A state she was not involved the review process. During interview on 1/26/23, at 6:51 a.m. RN-B stated R2 had been declining in his abilities the past few months and said the past month or so, assistance from staff was definitely needed. RN-B stated R2 had a bed alarm and stated he would forget he couldn't walk. RN-B stated staff checked on him often and tried to anticipate his needs. RN-B stated if she was present when a resident fell she completed the initial fall report and the unit manager and director of nursing (DON) completed the post fall report. During interview on 1/27/23, the DON stated falls were discussed in morning meetings to discuss each fall and allow the team to give input. The DON stated it looked like documentation was not being completed after the falls were reviewed. The DON said, I think things were done but not documented. A facility policy Assessing Falls and Their Causes dated 07/2022, directed staff to complete and incident report no later than 24 hours after a fall and submit the form to the DON. The policy indicated after a fall occurred staff were to document details of the fall to include when the fall occurred and what the resident was trying to do at the time and begin to try to identify possible or likely causes of the incident. The policy directed staff to continue to collect and evaluate information until the cause of the fall was identified or it was determined the cause could not be found. The policy further directed staff to document appropriate interventions taken to prevent further falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the assistant administrator (AA) was certified as a nursing assistant (NA) or had demonstrated competency prior to assisting residents with transfers and incontinence cares for 3 of 3 residents (R4, R5 and R6). In addition, the facility failed to ensure nursing staff received and demonstrated competency related to the use of mechanical lifts and other transfer aids for 5 of 5 NA's NA-A, NA-B, NA-C, NA-D and NA-E, and 1 of 1 trained medication aid (TMA)-A. This deficient practice had the potential to affect all 50 residents who resided in the facility who required the use or had the potential to require the use of a mechanical lifts, transfer aids or required assistance with personal cares. Findings include: R4 R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had diagnoses which included multiple myeloma of the lung (cancer), respiratory failure, diabetes, and anxiety. The MDS identified R4 had moderate cognitive impairment and was dependent on staff for transfers and required extensive assistance of two staff with activities of daily living (ADL's) of bed mobility, toileting, personal hygiene, and dressing. The MDS indicated R4 was incontinent of bowel. Review of R4's undated care plan, revealed R4 had a self-care deficit and required the use of a mechanical Hoyer lift (full body lift) with two staff for transfers. The care plan revealed R4 required assistance of two with toileting and required assistance with peri cares. R5 R5's quarterly MDS dated [DATE], identified R5 had diagnoses which included Alzheimer's disease, dementia, anxiety, and chronic obstructive pulmonary disease (COPD.) The MDS identified R5 had severe cognitive impairment, was totally dependent with ADLs of bed mobility, transfers, and toileting and required assistance of two staff. Review of R5's undated care plan, revealed R5 had a self-care deficit related to dementia and impaired cognition. The care plan indicated R5 required the assistance of two staff and a Hoyer lift for transfers. R6 R6's quarterly MDS dated [DATE], identified R6 had diagnoses which included dementia, post-traumatic stress disorder (PTSD), anxiety and diabetes. The MDS indicated R6 had severe cognitive impairment, was totally dependent with ADLs of bed mobility, transfers, and toileting and required assistance of two staff. Review of R6's undated care plan, revealed R6 had a self-care deficit related to dementia, PTSD and Bipolar disorder. The care plan identified R6 required the assistance of two staff and a Hoyer lift for transfers. Review of email chain correspondence dated 10/28/22, at 4:48 p.m. to 10/29/22, at 7:48 a.m. revealed the director of nursing (DON) sent out an email to the facility's registered nurses and director of staff development and administration. The email identified the DON had provided mechanical lift training to the assistant administrator (AA) and another staff member as of that day. The email revealed the AA was very active on the floor with patient care. The email revealed the DON identified the goal was to complete competencies on all nursing staff as time allowed. During an interview on 11/1/22, at 11:20 a.m. NA-C indicated she had been working at the facility on 10/17/22, providing cares to residents who required assistance, when she was approached by the facility's AA who had offered to help her transfer residents, such as R4, with a mechanical lift. NA-C indicated she had asked AA if he was okay to assist with resident transfers and indicated AA had responded he could. NA-C stated she had not been comfortable as she was unsure of his competency level and declined his assistance. NA-C indicated she had been working at the facility for several months and had not had any formal competency or skills training for use of the facility's mechanical lifts and transfer aids since she had been hired. During an interview on 11/1/22, at 1:33 p.m. registered nurse (RN)-B stated she had been made aware from several staff over the last few weeks AA had been assisting NAs with resident cares and transferring residents with mechanical lifts, which included R5. RN-B indicated she had been informed by the facility's leadership AA was able to answer call lights and assist residents with non-care needs, such as handing resident's items. RN-B stated she was not aware if the AA had any formal training in using the mechanical lifts previously. RN-B indicated she had significant concerns for resident safety and had been informed on 10/28/22, AA had received skills training of the use of mechanical lifts. RN-B stated she was not aware if AA had any prior training or certifications which allowed him to provide personal cares or assistance with transfers. RN-B indicated the facility has had several changes in leadership and management in the last years and felt staff training and competencies had not been offered or completed as needed. During an interview on 11/1/22, at 2:19 p.m. NA-B indicated she had been working at the facility for several years and could not recall the last time she had received any skills training or competency assessments with the use of mechanical lifts/transfer aids. NA-B stated AA had been assisting with answering call lights and with transferring residents for the last few weeks off and on. NA-B indicated she was not aware if AA had any training to assist with transfers or resident cares, had questioned the AA and he had informed her he was able to as he was a paramedic. NA-B indicated she could not recall specific residents AA had assisted her with, though had no concerns. NA-B stated the facility has had several changes in leadership and management in the last years and felt staff training and competencies had not been offered or completed as needed. During an interview on 11/1/22, at 2:30 p.m. trained medication aid (TMA)-A indicated she had been working at the facility for several years and had not received any skills training or competency assessments for use of the mechanical lifts within the past few years. TMA-A indicated in the past, a few years ago, the facility would have annual skills training, where she was shown and had to return demonstrate the use of mechanical lifts, Hoyer (full body) sit to stand lift and transfer aid device. TMA-A indicated the facility has had several changes in leadership and management in the last years and felt staff training and competencies had not been offered or completed as needed. During an interview on 11/1/22, at 3:05 p.m. the facility administrator stated there had been a blow up at the facility when the AA had come to the facility over the weekend of 10/22/22, and 10/23/22, to answer call lights and assist with non-direct cares, when one of the nurses got her panties in a bunch. The administrator indicated one of the nurses had informed him AA had assisted with resident transfers and personal cares. However, he indicated the AA had denied assisting with any type of direct cares. The administrator stated he felt the AA had seen there were a few holes in the schedule over the weekend, and wanted to come and see if he could help answer call lights, opening/shutting blinds and passing meal trays. The administrator stated staff were expected to be trained on the use of mechanical lifts prior to use. He indicated the AA was a paramedic and he was not aware of any plans for AA to obtain his nurse aid certification. During an interview on 11/1/22, at 3:49 p.m. AA indicated he had been at the facility for a little over a month and had recently received training for using mechanical lifts to assist with resident transfers. AA stated he had been at the facility on 10/17/22, and had entered one of the nursing units to introduce himself to the staff, and assist with non-direct cares. AA indicated he answered a few call lights and had taken a lift into a resident's room. The AA stated he had been present in the room with a NA and a resident, though could not recall who the staff or resident were, and had stood to the side while the NA used a Hoyer lift (two-person full body lift) to transfer the unnamed resident. The AA stated he did not assist with the transfer in any way and had not touched the resident. The AA indicated he had come to the facility on Sunday, 10/23/22, for a few hours to introduce himself to staff and to assist with non-direct cares. AA stated he had not provided any cares or assisted any residents with transferring. The AA indicated he currently had his paramedics certification and had had his NA certification back in 2007, however confirmed he did not have a current certification to practice as a NA nor was he enrolled in a NA certification class to obtain certification. The AA stated he had never practiced as a NA in the past. The AA indicated he had requested to be trained in the use of mechanical lift transfers and had received training on 10/28/22, by the DON. During an interview on 11/1/22, at 4:00 p.m. NA-A stated she had been working at the facility for several months and had come from another long-term care facility. NA-A indicated since her hire, she had not received any formal training to use the facility's mechanical lifts or had her competency evaluated. During an interview on 11/1/22, at 4:12 p.m. RN-A stated on 10/23/22, she was informed on that day and throughout the previous week, the facility AA had assisted NA's with resident transfers and incontinence cares, such as R4 and assisted transferring R5 and R6, both of which required the use of a Hoyer lift. RN-A indicated she had asked other staff and the DON if the AA had been trained or certified as a NA and had been able to assist with resident transfers and cares. RN-A indicated she had been told the AA would receive training on the use of mechanical lifts and was able to assist with non-direct cares. RN-A indicated on that day, she had texted AA and asked him to stop assisting with resident transfers as he was not currently certified as a NA or trained to transfer residents. Review of text message dated 10/23/22, revealed RN-A sent AA a text message which indicated she had heard he he had been assisting residents with transfers that day, requested him to stop transferring residents as he was not certified as a NA or trained on the use of lifts. The message thread revealed AA responded he was sorry and would update the DON. During an interview on 11/2/22, at 10:02 a.m. NA-D indicated on 10/23/22, the AA had been on the first floor when R5's wife asked to lay him down. NA-D indicated she had placed R5's call light one, the AA responded and had offered to help her with transferring R5 as he required the use of a Hoyer lift and two staff. NA-D stated she had assumed the AA was a nurse as she had not met him prior to that time. NA-D indicated R5 was assisted to bed with the use of a Hoyer lift. NA-D indicated she had clipped the lift sling straps to the lift bar, ran the controls while the AA guided R5's body over the bed and into position while she lowered him to the bed. NA-D stated following R5's transfer into bed, the AA assisted to roll R5 to remove the lift sling and exited the room. NA-D indicated she worked for a pool agency and had been working at the facility since approximately January 2022. NA-D stated she had not received any type of training or competency assessment for the use of the facility's mechanical lifts. During an interview on 11/2/22, at 9:51 a.m. the facility's director of staff development indicated she had started at the facility approximately four months ago and had not started any education programs. She stated it appeared the facility used to provide skills training and competency assessments for NA and licensed nursing staff for a variety of areas, which included using a mechanical lift and transfer aids. The director indicated it appeared the facility had not provided skills training or competency assessments for nursing staff within the last couple of years. During a telephone interview on 11/2/22, at 11:31 a.m. NA-F indicated she had worked at the facility for a couple of years and had received formal training on using mechanical lifts by the previous director of nursing and had not had any competency assessments since. NA-F indicated she had worked on 10/23/22, and had assisted R4 with cares during her shift. She stated she had been in with another resident when the AA approached her and notified her R4 had to use the bathroom. NA-F stated she had entered R4's room with AA and proceeded to assist R4 out of her recliner and into her bed with a Hoyer lift. NA-F stated AA assisted to guide R4 while she was in the sling over her bed and assisted to position her in bed. She indicated R4 had been incontinent of bowel and proceeded to assist R4 with incontinence cares while AA held R4 onto her side. NA-F stated she had assumed AA was an NA or had some type of training since he offered to help to her transfer and provide incontinence cares to R4. NA-F stated she had felt uncomfortable following R4's cares and contacted her charge nurse to ask if AA was allowed to assist with resident cares as it didn't seem right to her. During an interview on 11/2/22, at 11:50 a.m. the DON indicated she was not aware AA had provided direct cares to residents during his time spent on the resident care units. The DON confirmed AA was not currently certified as a NA and was not scheduled for any NA training classes in the future. The DON confirmed AA had not been trained or had a competency assessed prior to 10/28/22, when he had requested to be trained in order to assist the nursing staff. The DON stated she had completed mechanical lift training with AA on 10/28/22. She indicated AA had previously had his NA certificate, though was not active since 2009. The DON confirmed the facility had no processes in place to provide training on the use of mechanical lifts or to ensure staff were competent to use them prior to the survey. Personnel records were reviewed with the DON and the following was confirmed: -NA-A, was hired on 9/8/22, and had received no training on the use of mechanical lifts or competency assessment of lift use upon hire and prior to using the mechanical lifts. -NA-E was hired on 8/25/22, and had received no training on the use of mechanical lifts or competency assessment of lift use upon hire and prior to using the mechanical lifts. -NA-C was hired on 6/23/22, and had received no training on the use of mechanical lifts or competency assessment of lift use upon hire and prior to using the mechanical lifts. -NA-D was a pool agency staff who started 1/10/22, had received no training on the use of mechanical lifts or competency assessment of lift use upon hire and prior to using the mechanical lifts. -NA-B was hired on 8/9/18, and had received no training on the use of mechanical lifts or competency assessment of lift use since 2018. -TMA-A was hired on 5/6/02, and had received no training on the use of mechanical lifts or competency assessment of lift use since 2014. Review of a facility policy titled, Mechanical Lift - Full Mechanical Lift - Long Term Care revised 11/2021, identified it was the purpose of the policy to facilitate the safe transfer of a resident using the full mechanical lift, including but not limited to residents unable to bear weight during transfers, assisting resident who have fallen, and residents unable or unwilling to participate in transfers. The policy identified all personnel using a mechanical lift to assist residents with transfers, will be educated on how to safely utilize the mechanical lifts and will complete competency checklist. The policy identified two trained personnel would assist with all transfers using the full mechanical lift. Review of a facility policy titled, Mechanical Lift - Standing Lift - Long Term Care revised 6/2021, identified it was the purpose of the policy to facilitate the safe transfer of a resident using the mechanical standing lift. The policy identified all personnel using a mechanical lift to assist residents with transfers, will be educated on how to safely utilize the mechanical lifts and will complete competency checklist. Review of a facility policy titled Nursing Department Staff Competency dated 4/27/18, identified it was the purpose of the policy to ensure all care providers were competent to perform responsibilities in their specific areas of clinical practice.