Based on interview and document review, the facility failed to ensure 1 of 5 residents (R32) was reassessed for as needed (PRN) anti-anxiety medication (diazepam) every 14 days to ensure the appropriateness of continued use. Findings include: R32's 10/8/24, Significant Change Minimum Data Set (MDS) identified R32 had a diagnoses of Alzheimer's and dementia with agitation. R32 was cognitively impaired and was administered antipsychotic, antianxiety and antidepressant medication daily. R32's diazepam was ordered on 11/8/24 and started the same day, however, there was no indication the physician (MD) had limited the order for 14 days to ensure it was reviewed for continuation. R32's December 2024, Medication Administration Record (MAR) identified diazepam 5 milligram (mg) was to be given by mouth every 8 hours as needed for agitation, physical aggression, and restlessness beginning 11/08/24. The MAR lacked documentation of an end date. R32's Progress note identified on: 1) 11/26/24, the physician ordered PRN diazepam and was to be reviewed in 14 days. 2) 11/26/24, the pharmacist's (RPh) recommendation identified staff were to monitor R32's behaviors. The pharmacist identified the physician (MD) reviewed the diazepam and the order was extended to 14 days. 3) 12/10/24, the nurse practitioner (NP) reviewed R32's diazepam. R32's behaviors had improved with medication management and the NP extended the diazepam 14 days. 4) 12/28/24, the RPh recommendation identified R32's diazepam was reviewed. They had no recommendations. There was no mention the RPh had identified the MD reviewed the diazepam within 14 days by 12/24/24. R32's December 2024, Treatment Administration Record (TAR) identified a reminder for staff to notify the MD to review the diazepam prior to the end of the 14 days to justify the continuation of the need for the medication. Review of the printed December 2024, TAR given to the MD on 1/15/25 identified staff wrote FYI: Nursing orders require notification of use of R32's diazepam in the last 14 days. There was no indication staff had notified the MD prior to 1/15/25 to review the diazepam and justify the continued use and place a new order. R32's current, undated care plan identified R32 had taken diazepam for anxiety. Staff were to administer anti-anxiety medications and monitor for the effectiveness of the medication and report adverse reactions and side effects such as memory loss, slurred speech, confusion, or nausea. Staff were to monitor and record target behaviors and inappropriate responses to verbal communication and violence and/or aggression towards staff or others. There was no mention staff were to notify the MD to review the diazepam at 14 days to continue the medication. During interview and TAR review on 1/29/25 at 10:09 a.m., with licensed nurse (LPN)-A identified R32's TAR provided reminders for the nursing staff to notify the MD to review the diazepam every 14 days. LPN-A agreed there was documentation to support the provider was contacted on 12/24/24. Interview on 1/29/25 at 10:10 a.m., with LPN-B identified she agreed R32's PRN order should have been reviewed by the provider every 14 days. Interview on 1/29/25 at 11:41 a.m., with medical director identified staff should have notified the MD for R32 by day 14 to have the MD review the diazepam and document the rational to continue the order. Interview on 1/29/25 1:29 p.m., with director of nursing (DON) identified her expectation was for to staff notify the MD of the absence of a stop date on limited 14-day psychotropic medications and notify the MD if re-evaluation of the medication needed to occur for continuation. Review of October 2019, Psychotropic Medication Usage policy indicated the facility was to monitor residents receiving psychotropic medications to evaluate their effectiveness. In addition, the facility was to ensure a process for reviewing the continued need for psychotropic medications. There was no mention how the facility ensure duration of psychotropic medication use was enforced.

Based on interview and document review, the facility failed to implement a comprehensive antibiotic stewardship program with antibiotic Time Outs (ATO) (formal review of a patient's antibiotic therapy that occurs 48-72 hours after the initial dose), or evaluation of continued need for antibiotic treatment for 3 of 3 residents (R6, R15 and R28). This has the potential to affect any resident receiving antibiotic treatment. Findings include: Interview and document review identified: R6's medical record (MR) identified a 1/18/24, physician (MD) order for Macrobid (an antibiotic used to treat urinary tract infections (UTIs)), 50 milligrams (mg) by mouth (PO) every (Q) evening (PM), for UTI prevention. The medical record failed to identify any urine cultures or sensitivity (UC/US) completed following the MD order, and no ATO for continued need of the medication. The record also failed to identify any non-pharmacological interventions attempted. R15's medical record identified a 1/21/25 MD orders for Macrobid 100 mg PO x 5 days for UTI. The record failed to include any criteria implemented nor was there documentation of an ATO completed. R28's medical record identified a 12/18/24 MD orders for Macrobid 100 mg PO twice daily (BID) x 10 days. The record failed to identify any criteria identified prior to initiation of the antibiotic. R28 developed a rash, and the antibiotic was changed on 12/29/24 to Ertapenem 1 gram (GM) intramuscularly (IM) x 5 days. A UA/UC was completed, and Ertapenem 1 gm IM X 10 days was reordered. A UA/UC was again completed on 1/27/25 with negative results. R28 received antibiotics from 12/29/24 through 1/23/25 with no criteria documented prior to requesting a UA and antibiotics and ATOs were not completed during this time. Interview on 1/27/25 at 5:00 p.m. with the director of nursing (DON), reported the infection preventionist (IP) had emailed her the information to provide, reported there was not consistent documentation of criteria used for updating the provider prior to requesting an antibiotic for a UTI, nor were ATO being completed. The DON identified there had been a meeting on 1/24/25 with the DON, ADON, IP, medical director, in-house pharmacist, and a nurse practioner(NP) to discuss antibiotic stewardship, criteria to be utilized for updating the provider of a resident with a potential UTI, ATOs, and the development of individualized care plans for those residents who demonstrated S/S outside the parameters and the inclusion of that information on the Standing Order Set. There was nothing implemented prior to the survey after it was identified. Interview on 1/27/25 at 5:43 p.m., with the medical director identified he had attended the meeting on 1/24/25 with discussion of guidelines for antibiotic stewardship and what criteria was to be use in the facility. He reported they had discussed current trends, with antibiotic use, and criteria such as Loeb's, or McGeer's to include in determining the use of antibiotics. He identified his agreement for review and documentation of a resident that had orders for a prophylactic antibiotic for a UTI and it should not just be assumed that an ongoing order was sufficient. ATO should be completed. Interview on 1/29/25 at 8:45 a.m., with the IP reported she attended morning meetings which included discussion of infections, wounds, changes in resident status, laboratory tests completed. She reported she would then follow up by checking EPIC (medical record application) for any new infections, labs, then follow up for orders for UTIs and C/S. She was aware two residents were currently receiving prophylactic antibiotics. The IP stated the nursing staff was going to use Loeb's as the criteria for requesting UA/UC, and her understanding was they had the criteria posted at the nursing station. She was not aware it was not being utilized, and ATO were not currently being completed and documented according to facility policy. Review of the September 15, 2022, Antibiotic Stewardship Policy for Long Term Care Identified the need for treatment of infections with the promotion of appropriate use of antibiotics. A monthly tracking report was to include summary of data collected with review by the consulting pharmacist, and IP with reports to the Quality Assurance Committee. Areas to be identified with antibiotic orders included: Resident name, antibiotic name, indication for the medication, route, dose, length of treatment, who prescribed the order, Antibiotic time out-yes/no, the record was to be reviewed, and information recorded in the e Excel database with review by the consulting pharmacist. ATO were to be collected and reported monthly for all antibiotics ordered whether from an outside or inside facility source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to have a current, ongoing system of surveillance to identify potential outbreaks of infectious disease, ensure transmission-based precautions (TBP) were implemented timely, perform root cause analysis with contact tracking to identify patterns of illness in staff or residents, and prohibit staff from returning to work prematurely following identified symptoms. This had the potential to affect all 33 residents in the facility. In addition, the facility failed to ensure 1 of 1 whirlpool tub was appropriately disinfected between resident use according to the manufacturer's directions. This had the potential to affect 10 of 32 residents who used the whirlpool tub. Findings include: SURVEILLANCE RESIDENTS Review of the December 2024, resident infection control log identified the facility experienced a COVID-19 outbreak between (December 15, 2024, through January 20, 2025). 17 of 32 residents were identified as testing positive for COVID-19 between December 15, through 31, 2024, (R1, R2, R7, R10, R13, R14, R15, R18, R19, R23, R24, R25, R32, R33, R86, R87, and R88). Review of the January 2025, infection control surveillance log identified one resident tested positive (R27). The resident surveillance logs above identified the resident name, room number, date tested positive, and off isolation date. The log failed to identify the date and type of TBP and when the precautions were implemented. STAFF Review of the staff infection control log for November 2024 identified call-ins for illness as follows: 1)Registered nurse (RN)-A reported vomiting on 11/11/24 with no additional follow up or notation of when she returned to work. She then also reported headache, fever, cough, sore throat and body aches on 11/24/24 and tested positive for COVID. 2) Nursing assistant (NA)-A reported vomiting, nausea, cough on 11/11/24. 3) Unidentified staff person-reported illness on 11/12/24 with no S/S identified. 4) Licensed practical nurse (LPN)-C -reported a sore throat on 11/18/24 with no additional S/S identified. 5) NA-B- reported illness with vomiting on 11/20/24. 6) NA-C- reported illness with vomiting, diarrhea, nausea, and cough on 11/21/24. 7) NA-D reported illness with vomiting on 11/21/24. 8) LPN-D- reported illness with vomiting and diarrhea on 11/25/24. 9) NA-E-reported illness with diarrhea on 11/25/24. 11) NA-F-reported illness with diarrhea on 11/26/24 There was no mention of any additional follow up, potential testing or identification of when staff were cleared to be able to return to work. Review of the staff infection control log for December 2024 identified 1 staff illness. NA-F-reported ill with no S/S identified and was tested positive for COVID-19. There was no mention of any additional follow up, potential testing or identification of when staff were cleared to be able to return to work. Review of the staff infection control log for January 2025 identified 3 staff illness: 1) An unidentified staff reported illness of vomiting, nausea, and headache on 1/4/25. 2) NA-E reported illness of flu symptoms on 1/9/25. 3) RN-A reported illness of vomiting and fever on 1/13/25. There was no mention of any additional follow up, potential testing or identification of when staff were cleared to be able to return to work. Interview on 1/27/25 at 5:00 p.m., with the director of nursing (DON) identified there was no documentation of the type or when TBP had been initiated on the surveillance logs. She also observed the staff illness tracking and confirmed the documentation was incomplete and should have listed staff S/S, time off work, date of return, and if they had been seen by a medical provider or had any testing for illness completed. When a staff call in was reported either she or the scheduling coordinator were to attempt to contact the employee to discover the reason for call in if it was not documented. Interview on 1/27/25 at 6:27 p.m., with LPN-E identified LPN-E worked as the charge nurse and if a staff person called in for themselves of a child, she would use the provided illness form, document the name of the staff person, S/S if they were provided and if they reported plan to see a medical provider. If they were calling in for a child, she might ask for the S/S, but reported she was not certain if she had done so. She stated the ill slip was then given to the scheduler, but she was not certain what happened after that. Interview on 1/27/25 at 6:34 p.m., with RN-B identified when a staff member called as ill, she recorded the information in the binder located at the nursing station and had spaces to record S/S, time of the call, and if the staff member was seeing a provider. She reported she recorded the information that was given, but the person calling in, did not always give the information. She stated the form was routed to infection control, but she was not aware of any follow up process. Interview on 1/29/25 at 9:08 a.m. with the infection preventionist (IP) identified she agreed employee tracking was incomplete and noted she failed to include determination of S/S, if the employee was seeing a medical provider and when it was appropriate for them to return to duty. She did receive calls from staff at times about a family member's illness, but did not perform tracking or trending or follow up about potential precautions due to contact. Interview on 1/29/25 at 11:13 a.m., with the scheduling coordinator confirmed she was only aware of one call in for a staff member in December who tested positive for COVID and three call ins for January 2025 one with flu symptoms and two with no S/S identified. She confirmed when a staff called in ill, they were supposed to give the reason for their absence, if they were seeking medical attention, and S/S of either their or family member's illness but confirmed this did not consistently occur. Following receipt of the paper slip, her job was to enter the information into the electronic employee illness log but was not aware of who/what/when reviewed further. WHIRLPOOL Interview on 1/28/25 at 10:15 a.m. with the environmental services (EVS) manager identified the whirlpool tub as a jetted [NAME] tub with water jets.The disinfectant used as CenKleen IV-Quaternary Ammonium compound disinfectant mixed at ratio of 1 ounce/gallon and filled by EVS staff for nursing staff to be used for cleaning and disinfecting the tub. Observation and interview on 1/29/25 at 3:30 p.m. with NA-G as she cleaned and disinfected the [NAME] Spa tub identified NA-G returned the bath chair to the tub and secured the door. She retrieved the quart spray bottle of Cev-Kleen IV cleaner, applied gloves placed the plug in the bottom of the tub, and using the spray bottle sprayed all surfaces of tub and chair by with the spray bottle. She then ran water into tub to above the level of the jets. While the tub was filling with water, she used a long-handled brush to bush the surfaces of the tub and chair by dipping the brush into the water and then onto the sprayed surface of the tub and chair. NA-G pushed the button labeled jet rinse and stated she held it for a few seconds. NA-G reported she allowed the solution to sit for 1-3 minutes to allow it to disinfect the surfaces and used the hand sprayer to spray off all surfaces. No clock or timer was observed in the tub room. As she waiting the solution on the sides of the tub and chair were observed to be drying. When asked how long she needed to wait, since there was no clock in the room, NA-G replied she had looked at her watch and timed it for 2 minutes. She then took the hand sprayer and rinsed off the tub sides and chair, and allowed the solution to drain from the tub and rinsed all surfaces again. NA-G released the latch on the back of the tub and reported she left the seal open, so it was able to dry. She was not aware of an instruction sheet being posted in the tub room and identified that was how she had been trained to clean and disinfect the whirlpool tub and was unaware of manufacturer's instructions requiring a specif amunt of disinfectant to be infused into the water in the base of the well and run for 10 min, keeping surfaces wet was required for appropriate disifection. Review of the [NAME] Spa Tub manufacture's guide for cleaning and disinfection of the tub following resident bath listed: 1) The tub was to be rinsed initially rinsing all surfaces with the shower sprayer, 2) Drain any water, and then refill by pressing the disinfect button which allows the properly mixed cleaning solution to run through the system. 3) Release the button after you see solution coming out of the jets and have 1 1/2 gallons of disinfectant solution in the foot well of the tub. 4) Scrub all surfaces of the tub and chair with the solution that remains in the well of the tub 5) Let disinfectant remain on the surface for 10 minutes or as recommended on the disinfectant container. 6) Remove the plug from the drain. 7) Rinse the soapy water away. 9) Press and hold the rinse button until water runs clear. Interview on 1/27/25 at 5:00 p.m., with the director of nursing (DON) identified she was not aware there was no longer a sign with cleansing/disinfecting instructions posted in the tub room. She stated her expectation for the tub to be cleansed and disinfected according to the manufacturer's instructions. Both the ADON and DON reported they would take immediate action to correct the procedure. Later interview on 1/29/25 at 11:20 a.m., with the DON identified she had reviewed the manufacture's guidelines for the whirlpool tub and confirmed staff were not following the manufacture's guidelines. Review of the 3/15/24, infection control plan identified the IP and committee were to develop evidence-based national guidelines in the development of the infection prevention and control program. The employee illness log was identified as available on the facility's shared drive with each department head responsible to log sick time utilized by their employees. The nursing home was identified as responsible for sending their data to the IP monthly with the information to be reviewed at the infection control meetings. The Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) surveillance methodology was to be utilized by the facility. The IP was to coordinate and review infection control issues and summarize and report to the Infection Control committee. Review of the 1/29/25 Bath- Shower/Tub - Level II policy failed to identify the procedure for cleaning and disinfecting the whirlpool tub according to manufacturer's guidelines following resident bathing.

Based on observation, interview and document review the facility failed to revise the comprehensive care plan with individualized communication intervention for 1 of 1 (R19) resident reviewed. Findings include: R19's 11/7/23, admission record identified diagnoses of hemiplegia (paralysis of one side of body) following a stroke, dysphasia (difficulty speaking) and dysphagia (difficulty swallowing). R19's 10/3/23, revised care plan identified a communication deficit as R19 was from Micronesia and only understanding simple words of English. Staff were to get R19's attention by making eye contact, and show or point in direction R19 was going to roll in bed. R19 was able to indicate yes or no by shaking her head in that gesture. R19 preferred to communicate in Micronesian. The facility was to provide a translator as necessary to communicate with resident. The translator was identified as a family member (FM)-A. Staff may call the FM-A or face time FM-A to translate. There was no mention of how the staff would communicate if they were unable to contact FM-A. There was no mention of alternate translation options if needed. R19's 1/11/23, Care Area Assessment related to communication identified R19's primary language was Micronesian. R19 understood simple English phrases and could answer yes or no. The interdisciplinary team had determined R19 had a communication problem as evidenced by hesitation and need to repeat or rephrase a statement. R19's primary language was Micronesian with FM-A providing interpretation. R19's communication difficulties could result in social isolation, depression, and/or safety concerns. Observation on 11/6/23 at 12:30 p.m., of R19 in her bed awake with television on identified when addressing R19 after saying hello, how are you?, R19 looked but had not responded. Interview on 11/6/23 at 12:51 p.m., with nursing assistant (NA)-A identified R19 knew very little English but could communicate yes or no. R19 did not have a communication board that she was aware of to assist with her communication. Interview on 11/6/23 at 12:58 p.m., with trained medication aide (TMA)-A reported R19 communicated her pain by a number system or R19 would blink if she had pain when asked. TMA-A reported that R19 had been at the facility for a long time and staff just knew her routine. She identified R19 had family members who worked at the facility, and they would translate. Interview on 11/6/23 at 2:45 p.m., with FM-A and FM-B who reported that the facility will call a family member if they could not figure out what R19 needed, and the family was okay with that. FM-B revealed it would be a good idea to have another translator as a backup though. FM-A confirmed that R19 did not have a communication board. R19's 11/2/23, progress note at 2:40 p.m. identified the facility had been unable to contact FM-A and FM-B to update about R19's new orders, the note indicated the facility would continue to attempt to contact. Additional progress notes on 11/2/23 at 4:14 p.m., facility unable to contact FM-A or FM-B facility will continue to attempt to reach. Interview on 11/7/23 at 9:25 a.m., with social service designee (SSD) identified R19 spoke minimal English but could communicate cares. The facility used family when they needed to communicate in more detail. SSD revealed there was a translation service number located in the emergency room that connected to a television for translation that she thought the facility could use if needed. The SSD then reported during the daytime hours the facility had translation covered as there were family members who worked at the facility. The SSD was unsure if R19 had ever had an assessment for a need for a translator. She reported that she had tried Google translate before, however, that does not translate from English to Chuukese or visa versa when talking as the language is very specific to certain regions in Micronesia. The SSD confirmed all translation was done by family and if the facility was unable to reach family, they could potentially use the number located in the attached hospital ER room. Interview on 11/7/23 at 9:39 a.m., with the director of nursing (DON) identified R19 spoke in Chuukese her primary language. The DON reported the facility had a staff member that had created signs of COVID and admission questions in Chuukese however, the facility still needed an interpreter to translate that information once asked. The DON revealed the clinic had a receptionist that was a paid translator for the hospital and the nursing home that the facility could use if needed. She confirmed R19's care plan lacked identification of any back up translation services the facility could use if family was unavailable, which she confirmed did occur at times. The DON confirmed that there was a real struggle to communicate with R19. She further confirmed the facility should have an alternate translator option available and identified on the care plan. There should be direction noted for staff if the facility was unable to reach the family to translate. Additional interview on 11/8/23 at 1:17 p.m., with the DON identified that the care plans were not updated like they should be. Her expectation was all residents care plans should reflect their current level of care and were individualized. Review of 11/6/23, Translation and/or Interpretation policy identified when an individual with limited English proficiency would have an initial language assessment completed. All residents with limited English would receive a written notice in their primary language of their rights to obtain an oral translation service free of charge. The interpreters and translators must be appropriately trained in medical terminology, confidentiality, and ethical issues that may arise. Family members and friends shall not be relied upon to provide translation services unless explicitly requested by the resident. If friends or family are used to interpret the resident must provide written consent for disclosure of protected health information. Review of 11/7/23, Care Plans-Comprehensive Person-Centered policy identified a resident would have a comprehensive individualized care plan developed and implemented to meet the residents needs. The care plan was to include the residents cultural and personal preference and describe specialized services needed to enhance optimal functioning of the resident. The comprehensive person-centered care plans were to be reviewed and updated to reflect the residents needs or condition changes.

Based on observation, interview and document review, the facility failed to comprehensively assess and obtain informed consent, prior to resident use of bed rails for 1 of 1 resident (R23) reviewed for bed rail use. Findings include: R23's 8/31/23, annual Minimum Data Set (MDS) assessment identified R23's cognition was intact, R23 required moderate to substantial assistance with personal hygiene. R23 required supervision to get from a lying to sitting position on the bed and R23 was able to stand independently from a sitting position. R23 was identified in section P of the MDS as having no bed rails used. R23's undated, care plan identified R23 used a lift chair recliner to maximize independence with repositioning. Occupational therapy has assessed R23's use of the lift chair for safety. Staff were to respect R23's right to sleep in his recliner if choosing not to sleep in the bed. There was no mention of the bilateral 1/2 side rails on R23's bed. R23's 6/1/23, Safety Risk Assessment identified history of low back pain currently controlled with spinal stimulator. R23 had urge incontinence, and a recent room change that R23 reported he liked and was adjusting well to with no issues noted. R23 had bed, side table, recliner, walker, and wheelchair. R23 had a lift chair and was able to show appropriate ability to move from a lying to sitting position. R23 was able to get from a sitting to standing position. R23 was able to ambulate the length of the hallway without difficulty. R23's walker and call light kept within reach. There were no mention of 1/2 side rails on the bed. R23's 8/31/23, Safety risk assessment identified 2 falls in past year however none in last quarter. Physical therapy orders were obtained however, R23 refused to work with therapy. R23 had a riser over the toilet with handles to help with getting on and off toilet. R23's cognition was intact and R23 kept his walker within reach. There was no mention of R23 having or using 1/2 side rails on his bed for mobility. Interview on 11/8/23 at 11:19 a.m., with R23 who reported he sleeps in his bed, and he uses the side rails to pull himself up to a sitting position and maybe he used them when he turns around in bed, but he could not remember. Interview on 11/8/23 at 12:31 p.m., with maintenance supervisor (MS) identified the nurse's let maintenance know if there was a loose side rail or something and then they would go assess and fix that. He confirmed that maintenance did not complete any type of routine checks on the bed rails for safety in the facility. The direct care staff work with the residents in their rooms daily and they would be the ones to notice if something needed to be repaired and then notify maintenance. Interview on 11/8/23 at 11:25 a.m., with director of nursing (DON) identified R23 had moved to his current room on 5/24/23, and the bed was already in the room so the 1/2 side rails must have been already on the bed when R23 moved in. The DON confirmed that the 1/2 side rails were not identified on his safety risk assessment, not on his care plan, and there was no side rail assessment completed as they were not aware R23 even had the bed rails on his bed. She reported prior to R23's move to his current room he did not have side rails on his bed and when the nurse completed his assessment, they must have missed that. Additional interview at 1:17 p.m., with the DON who identified her expectation was that any resident with a bed rail or grab bar would have an assessment completed and the care plan would reflect the assessment. Review of 1/6/21, Bed Rail policy identified goal to reduce safety risks and hazards commonly associated with bed rail use and prevent entrapment. The facility will complete regular bed maintenance to inspect all bed systems are operational and ensure they are safe. Residents using bed rails will have bed rail evaluation to determine alternatives to bed rail use. Education to resident pertaining to the risk and benefits of bed rail use will be provided. The bed rail policy was used to determine if the resident was safe and able to use the bed rail. The interdisciplinary team would use data collected from regular bed inspections and individual bed rail assessments to care plan for positive outcomes. Ther was no indication the policy had been reviewed and updated annually per the regulation.

Based on document review and interview, the facility failed to ensure 1 of 1 required member (infection preventionist) and/or their designee attended and documented the attendance at the quarterly Quality Assurance Performance Improvement (QAPI) meetings. Findings include: Review of the January 2023, through July 2023, quarterly Quality Assurance and Performance Improvement (QAPI) meeting minutes attendance record did not identify the facility infection preventionist was present at the second quarter meeting held in April 2023. Interview on 11/7/23 at 3:48 p.m., with the infection preventionist (IP) identified he was an interim IP who was to be responsible for covering the IP role until the new infection preventionist started. He confirmed he had not attended any of the QAPI meeting but he should be while covering the position. Interview on 11/8/23 at 8:25 a.m., with the director of nursing (DON) identified the IP could not make it to the April meeting. Normally, if the IP could not make it, they would delegate someone to cover the information and that was to be documented in the meeting minutes. The DON confirmed her expectation was the required QAPI members including the IP attended the quarterly meetings unless arrangements were made for someone else to cover for her. Review of the undated, QAPI plan identified all department managers, and infection control staff will be involved in the quarterly meetings. The departments will share findings with the medical staff and the board of directors. The policy had no mention of the required committee members such as the administrator or medical director that would be required to be identified and participate in the committee's quarterly meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 1 of 5 residents (R23) were appropriately vaccinated against pneumonia. Furthermore, the facility failed to have a method or system to ensure the facility offer or provided any initial or updated vaccine to residents per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE 65 years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose e) Received PCV-13 at any age AND PPSV-23 AFTER age [AGE] Years: aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. Review of 1 of 5 sampled residents for vaccinations identified: 1) R23 was over 65 and admitted to the facility September of 2019. R23 had the PCV-13 on 10/20/15 and PPSV-23 on 11/14/12. R23 should have been offered and /or administered the PCV-20 at least 5 years after prior PCV-13 in October of 2015. Interview on 11/7/23 at 2:44 p.m., with registered nurse (RN)-B identified the case manager was responsible to complete the TB screening and testing for new admissions. The case manager was responsible to review the new admission records and offer immunizations that were due or document on the immunization spreadsheet when an immunization would be next due. RN-B confirmed the facility followed CDC guidelines for recommended vaccinations. Interview on 11/7/23 at 3:48 p.m., with infection preventionist (IP) identified this was the first time he had heard about the PCV-15 and the PCV-20 vaccination. Interview on 11/8/23 at 1:17 p.m., with director of nursing (DON) identified R23 was not offered the new PCV-15 or PCV-20. The DON revealed that she was honestly unaware of the PCV-20 however when she reviewed the vaccine information statements (VIS) sheet there it was right next to the information on the PCV-15. She further reported that the nurse manager was responsible to track and offer immunizations that were due. Review of the 11/6/23, Pneumococcal policy identified residents will be offered pneumococcal vaccines to prevent pneumococcal infections. Upon admission residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated will be offered the vaccine unless medically contraindicated. The pneumococcal vaccine or re-vaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations.

Based on interview and document review, the facility failed to act on a positive tuberculosis (TB) test result for 1 of 5 staff (housekeeping (HSK)-A) tested for active TB upon hire. Furthermore, the facility failed to ensure any person or persons with a positive history of TB was added to surveillance to mitigate potential risks for spread of possible active TB. This had the potential to affect all 43 residents, other staff, and visitors. Findings include: Review of housekeep (H)-A's employee file identified on 3/15/23, H-A's baseline TB Screening and questionnaire identified H-A had no symptoms of active TB however, it was identified that H-A had lived in Micronesia, and it was unknown if Micronesia had a high TB rate. Review of the National Library of Medicine (NIH) website, located at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000724, identified the Federated States of Micronesia is a US-affiliated jurisdiction that comprises more than 600 islands dotted across 1 million square miles in the western Pacific Ocean. Micronesia is a low-income country where 27% of the people live below the US poverty line. While TB incidence in the United States continues to drop (4.4 reported cases per 100 000 population in 2007), Micronesia has sustained some of the highest rates of TB among the US-affiliated Pacific Islands (169 reported cases per 100 000 in 2008). Further review of H-A's Baseline TB Screening Tool for Healthcare Workers, identified H-A's hire date was 3/27/23. The form identified questions related to symptoms of active TB which were to be circled if present. The answer was listed as none. The screening form noted if TB symptoms were present staff would promptly be referred for a chest X-ray and medical evaluation prior to working. The screening form further had questions about staff's personal history such as if the employee had ever had a positive test result, which was answered no on H-A's form. There was also a question asking if the staff had been a temporary or permanent residence in a country with a high TB rate for a month or longer (any country other than the United States, Canada, Australia, New Zealand, and those in Northern Europe or Western Europe). The answer was yes, with a note next to the answer if Micronesia counts. All other questions on the screening form to determine if active TB or symptoms of TB were present were answered as no. Review of H-A's QuantiFERON-TB Gold Result identified as abnormal. The QuantiFERON-TB Gold test was completed on 3/17/23, with the results verified on 3/19/23 as positive. Interferon-gamma response to M. tuberculosis antigens detected, suggesting infection with M. tuberculosis. Positive results in staff at low risk for tuberculosis should be interpreted with caution and repeat testing should be considered as recommended. There was no indication test results were repeated for accuracy. Review of March through November 2023, resident infection and illness surveillance log had no evidence of residents with signs or symptoms of active TB and the staff infection and illness surveillance log had no evidence that H-A had ever called in to report any illness. The surveillance lacked identification of increased surveillance for H-A who had a known positive TB test result for signs or symptoms of active TB, that would have put all 43 residents at risk. Interview on 11/7/23 at 3:48 p.m., with infection preventionist (IP) identified that he was not aware of H-A's positive TB test result until H-A's information was requested as part of the sample of staff to be reviewed for TB screening and testing. He reported the minute he reviewed the test results and saw H-A's positive result, he immediately sent H-A for a medical exam and chest X-ray. He was unsure why the previous IP had not acted upon the positive results. He confirmed he reviewed all the resident surveillance and found no residents to have had signs or symptoms of active TB since H-A started working. He further confirmed staff were not to start employment until a TB negative result was obtained per the facility policy and was the facility policy to not hire any staff with an active TB test. Review of H-A's 11/7/23, Chest X-ray result were negative. There was no physician progress note to review related to the medical examination portion. Interview on 11/8/23 at 1:17 p.m., with director on nursing (DON) identified she was unaware H-A had a positive TB test result on 3/19/23. The DON reported the IP was responsible for ensuring new hires were screened and had laboratory testing for active TB and found positive, they were to be sent for a medical exam and/or chest X-ray with a physician. The IP was responsible to act on any positive TB results and file the results in the staff personnel file. The previous IP ended her employment on 8/1/23. H-A was employed full time and had never called in for work since starting her employment. Staff were not allowed to work at the facility if a staff was shown positive until they had a repeat test showing it was truly negative. Review of January 2023, the facilities Tuberculosis (TB) risk assessment identified the facility had no resident suspected or confirmed with TB disease. The assessment identified the facility to be at a low risk for TB. The assessment identified the facility had no staff with a test conversion rate for TB infections that exceeded the health-care setting's annual average. There was no indication in the assessment that the facility identified they employed a staff with a positive TB test result. Review of 11/6/23, Tuberculosis-Employee Screening policy identified all staff will be screened for Tuberculosis (TB) infection and disease through a blood assay for Mycobacterium tuberculosis (BAMT) or two-step tuberculin skin test (TST) prior to working. If the results return as negative the staff will not be given another test prior to working. If the test results are positive or unavailable, the staff must have additional verification of absence of active TB. The policy furthermore identified staff who had a positive reaction to the TB test would be referred for a chest X-ray and symptom screening, which must be completed prior to working. If the staff chest X-ray results are negative and the staff has no symptoms of active TB, the staff will be considered free of active tuberculosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to report an allegation of abuse timely to the State Agency for 1 of 1 resident (R1) reviewed for allegations of abuse. Findings include: An anonymous Vulnerable Adult Maltreatment Report submitted to the State Agency on 10/25/23, alleged staff to resident sexual abuse when it was reported a caregiver touched R1's genitals. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of dementia and Parkinson's disease. R1 had severe cognitive impairment, no hallucinations, and did not reject cares. The MDS also noted R1was dependent on staff for toileting hygiene, dressing, and transfers. During an interview on 11/1/23 at 10:10 a.m., R1 indicated he had an issue with one staff but the staff person did not work with him anymore. R1 stated had already answered alot of questions and didn't want to answer anymore. During an interview on 11/1/23 at 11:10 a.m., family member (FM)-A indicated on 10//21/23, R1 reported he was having an issue with a NA that was touching him inappropriately at night, further explaining the staff person reached between his legs touched his privates [gentitals]. FM-A described R1 as being more alert and more clear than he had been on previous visits. FM-A further stated that although R1 has some confusion, R1 repeated the same allegation three (3) different times throughout the day. On 10/21/23, FM-A could not find a nurse to report the allegation to but, did report the allegation to a charge nurse (could not recall name of charge nurse) on 10/22/23. At that time FM-A was told they were already aware of the allegation. FM-A indicated the social worker (SW) called on 10/25/23 and told her that she was just made aware of the allegation of abuse and had moved R1 to a different room and team [of caregivers]. During an interview on 11/1/23 at 12:35 p.m., FM-B indicated she was aware of R1's allegation of inappropriate touching of the genitals and reported it to registered nurse (RN)-A on 10/21/23 and again on 10/22/23. During an interview on 11/1/23 at 11:45 a.m., the SW indicated R1's daughter reported the allegation of abuse on 10/25/23 at 11:50 a.m The SW further indicated R1 was interviewed by the facility but he declined to dicuss the allegation and only provided concerns related to another staff he did not care to work with. As a result of the ongoing concerns with that staff and the allegation they immediately moved R1 to a different room which meant a different team of caregivers and implemented two staff for all personal cares. The SW stated she did not report the allegation to the SA because everything she was hearing was second hand and R1 did not tell her anything firsthand. Further stated she did not feel the allegation was reportable [to the SA]. During an interview on 11/1/23 at 12:00 p.m., the director of nursing (DON) indicated she had been on medical leave and returned on 10/31/23. She was made aware of the allegation on 10/31/23 but did not think it was reportable [to the SA]. During an interview on 11/1/23 at 12:25 p.m., the administrator indicated the SW reported the allegation of abuse to her on 10/25/23. Further indicated she wasn't aware that it was reportable but planned to report it immediately now that she was aware of the regulatory requirements. The Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy last revised 1/7/21, indicates it is the policy of the facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse are reported immediately, but not later than 2 (two) hours after the allegations is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure comprehensive fall assessments, identification of casual factors and probable root cause, and development and implementation of interventions that would prevent/or mitigate the risk or re-current falls and injury for 2 out of 3 (R2 and R3) residents evaluated for falls. Finding include: EZ lift = (Hoyer) full body mechanical lift. EZ stand=mechanical lift that residents are able to bear weight and assist to stand with R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2's diagnoses included heart failure, diabetes, and seizure disorder. R2 had moderate cognitive impairment. R2 required extensive assist of 2 staff for bed mobility, transfers, and toileting. R2 required human assistance with balancing while moving from a seated to standing position, walking, moving on and off the toilet and surface-to-surface transfers. R2 used a wheelchair and a walker for mobility. R2 had two falls without injury since the last MDS. R2's fall care plan dated 12/21/22, identified R2 was at risk for falls related to multiple health problems including weakness evidence by low tolerance to activity. Interventions included: -gripper strips on floor in front of bed to prevent slipping, start date 5/4/23, -Assist of two staff, walker, and gait belt, to walk a few steps in room, revised date 6/22/23, -R2 Required wheelchair and assist of one staff with locomotion outside of room, revised date 6/22/23, -R2 required assist of two staff with transfer to and from commode next to the bed for bowel movements, one staff to wipe after bowel movements and adjust and change brief. R2 used call light to request assist, start date 6/22/23, -the resident is able to come to standing potion from bed by raising bed height before standing and with staff assist, gait belt and walker, revised date 6/22/23 R2's safety risk assessment dated [DATE], indicated a risk for falls secondary to multiple comorbidities and generalized weakness. R2 was non-compliant with most treatments and orders. R2 had been educated on risk for falls with independent transfers and ambulation but desired to be left alone despite the risk for injury or death. R2's care sheet (abbreviated care plan used by direct care staff), dated 6/22/23, did not identify R2 as a fall risk and did not list any fall interventions. R2's fall records were reviewed between 2/21/23 thru 6/22/23, the record identified R2 had six unwitnessed falls and one witnessed fall. Although R2's record identified predisposing risk factors, the record consistently lacked a comprehensive fall assessment to determine root cause for appropriate interventions or failed to include appropriate interventions when the root cause was identified. Fall 1 R2's progress note dated 2/21/23, indicated R2 had a witnessed fall, R2 lost his balance while stepping off the portable scale and nursing assistant (NA) lowered R2 to the floor. R2 was sitting on his bottom with legs/feet folded to the left side of his body. No injuries denied pain. R2 was not wearing any footwear or stocking per his preference. Assisted off the floor after assessment and vital signs (VS) obtained. Oxygen saturations were low at 84%, (normal is above 90%) on room air, oxygen reapplied as R2 removed the oxygen for his transfer. Corresponding incident report identified the fall occurred at 9:20 a.m. with predisposing factors included gait imbalance during transfer. R2's post fall interdisciplinary team (IDT) notes dated 2/23/23, identified R2 refused to allow staff to place gait belt or provide contact guarded assist (CGA) or allow assistance for all transfers. R2 removed his oxygen prior to being weighed and saturations dropped to 84%. R2 refused physician required rounding visit on 2/22/23. Encouraged staff to be more aware during collection of weight, R2 refuses multiple staff in room at once. R2's follow up IDT note for 3/2/23, indicated no injury from fall. NA stated that R2 had already stepped off the scale and was standing with walker when he lost his balance. Portable scale used as R2 refused to leave room. Will initiate standby by assist (SBA) of one staff when resident weighed to minimize risk of falls. R2's care plan did not reflect revisions. Fall 2 R2's progress note dated 4/15/23, indicated R2 had an unwitnessed fall with no injuries. Corresponding incident report identified the fall occurred at 3:00 p.m. R2 stated that his bathroom was too small and slipped. Denied injuries and denied hitting his head but neuros were started due to unwitnessed fall. Immediate action was noted to be VS obtained and neuros started, transferred from floor to bed via Hoyer lift assisted by three staff. Predisposing factors listed wet floor, R2 was incontinent, ambulating without proper footwear, ambulating without assist and using walker. R2 was offered gripper socks but refused. R2 post fall IDT notes dated 4/20/23 Reviewed. Offered gripper socks, resident refused. R2's follow up IDT was not completed until 4/27/23; that note indicated R2 had a status change and was no longer using bathroom without help and was using his call light for assistance now. Although, R2's fall record identified potential causal factors, the record lacked full comprehensive analysis to determine probable root cause and was not evident immediate interventions were developed and implemented to mitigate modifiable risk factors to prevent recurrent falls or the risk. Fall 3 R2's progress notes dated 4/19/23, indicated R2 had an unwitnessed fall. R2 was noted to by lying on his right side. R2 was not able to say what he was doing prior to fall. Denies injuries. [NAME] noted near foot of bed, R2 was barefoot. Assisted off floor with two staff and EZ-Lift into bed. Seizure like activity noted for about 20 seconds during assessment and occurred two more times at 7:30 a.m. and 7:45 a.m. After episode R2 was able to answer questions and was alert, pupils no longer fixed. Corresponding incident report identified the fall happened at 7:15 a.m. Immediate interventions were to start neurological checks and vital signs (VS) as R2 allowed, and housekeeping to mop floor. Predisposing factors included decrease in ornamentation over the past week, confusion, incontinent, wet floor-floor sticky with jello particles, gait imbalance, recent change in medications/new- increase Ativan (anti-anxiety medication) over weekend, recent change in condition and weakness/fainted. R2's post fall IDT notes dated 4/27/23, referred to IDT note second fall for 4/19/23. Which was R2 had a status change and was no longer using bathroom without help and was using his call light for assistance now. Although R2's record identified a new medication was started, the record did not address interventions to prevent and/or mitigate R2's risk for falls related to seizure activity. Fall 4 R2's progress note dated 4/19/23, indicated R2 has an unwitnessed fall. R2 was found with right leg bent under him and left leg out in front of him. R2's back was against the bed. R2 was able to move right leg and denied pain. Assisted off of floor with EZ-Lift and assist of four staff. Video monitoring initiated with family consent. Corresponding incident report identified the fall occurred at 3:22 p.m., predisposing factors included second fall of the day, weakness, confusion, recent illness. Resident able to say that he slipped off the bed. Recent history seizure like activity of freezing and holding unusual body positions. Immediate actions were to assist off of floor. IDT determined best action would be for video monitoring as a alarm would irritate R2. Hospice requested increasing pain medication. R2's post fall IDT note dated 4/20/23, indicated seizure activity, start Keppra and video monitoring. R2 was medicated as needed. R2's care plan did not include video monitoring as an intervention. Fall 5 R2's progress notes dated 4/21/23, indicated R2 had an unwitnessed fall. R2 was heard calling out for help and was found on floor next to bed, feet tucked under bottom and head and left shoulder resting on walker near foot of bed. Bedding and gown noted to be on floor saturated with urine, water, or soup from meal. Resident denied pain. R2 refused to allow staff to do proper assessment but did allow them to assist him with the EZ-Lift . Once in bed noted to be having visual hallucinations. Staff provided one on one and R2 seemed to have seizure like activity, lasting approximately 30 seconds. R2 was alert after episode but continued to refuse neuro's and VS. Corresponding incident report indicated the fall happened at 12:15 p.m. and R2 received a bruise to his right hip measuring 3-centimeters (cm) x 3 cm. Predisposing factors included wet floor, furniture, confusion, R2 was incontinent, recent change in condition, and recent medication change/new- started Keppra, increase Morphine. R2's post fall IDT note dated 4/27/23 stated to see risk notes. (Asked for and not received). Although, R2's fall record identified potential causal factors, the record lacked full comprehensive analysis to determine probable root cause and was not evident immediate interventions were developed and implemented to mitigate modifiable risk factors to prevent recurrent falls or the risk. Fall 6 R2's progress note dated 4/23/23, indicated R2 was found on floor calling for help by hospital staff. R2 was lying on floor mat with food noted on floor, bowel movement was on floor, underwear and on bedding. R2 refused VS and assessment but did allow staff to assist off the floor with Hoyer lift and two staff. Hematoma noted on R2's right bottom, skin tear on back of right hand, R2 refused measurements of but did allow staff to apply dressing. Corresponding incident report dated 4/22/23, indicted an unwitnessed fall at 6:40 p.m. Predisposing factors include confusion, gait imbalance, impaired memory, ambulating without assist. R2's post fall IDT note dated R2 could have been having seizures and refusing Keppra. R2 was restless and having hallucination, was medicated with Morphine (narcotic pain medication) and Haldol (antipsychotic medication). Mat attempted on floor beside bed but bed table not able to be by beside which upset R2. Gripper strips were applied to floor on 4/27/23. R2 now taking Keppra with no seizure activity, improved mood, and less confusion. R2 using call light for assist. R2's follow up IDT note dated 5/11/23, started on Keppra, more alert, no recent seizure activity and more cooperative. R2's record identified R2's grip strips were not implemented until 5 days after fall on 4/22/23. Fall 7 R2's progress note dated 4/23/23, noted that on 4/22/23 at 7:30 p.m. R2 was found lying on floor mat with bowel movement noted on floor, food on floor. R2 stated he was looking for his remote. R2 was transferred from floor to bed and refused VS and neuro checks. R2 was medicated with lorazepam (anti-anxiety medication) by mouth. There was no corresponding incident report. R2's fall record lacked a comprehensive analysis that identified root cause and was not evident immediate interventions were developed and implemented to prevent and/or mitigate risk of recurrent falls. R3 R3's quarterly MDS dated [DATE], identified R2's diagnoses included Alzheimer's disease, dementia, anxiety, psychotic disorder other than schizophrenia, visual and auditory hallucinations. R3 had severe cognitive impairment. R3 was totally dependent on two staff for transfers, locomotion on and off unit. R3 had range of motion impairment to one side upper and lower extremities. R3 had no fall since previous significant change MDS dated [DATE], which R3 had one fall. R3's revised care plan, dated 5/2/23, indicated R3 had limited physical mobility related to history of cardiovascular accident (CVA), with right sided weakness, syncopal episodes. Physically unable to bear weight, walk or stand without assist of EZ-Stand. R3 was at high risk for falls related to history of and falls since admit to facility. R3 did not remember her limitations. Interventions included -Ensure R3 is wearing proper footwear; gripper socks or her slip-on tennis shoes when transferring with mechanical stand (revised date 9/5/19.) -Anticipate and meet R3 needs. If restless or agitated, assess for sign and symptoms of pain, or need to use bathroom. Staff assist R3 as soon as possible if she is awake, be aware R3 attempts self-transfers, does not wait for assist (revised date 10/04/19.) -Place books of interest with large print in resident's room to enable staff to offer to resident (revised date 11/7/19.) -IDT to review R3's falls, discuss causal factors, relationship to agitation and/or pain (revised date 12/16/19.) -R3 uses TABS chair/bed alarms. Ensure device is in place and functioning with every care contact and nurse to follow up with nursing assistants, document in treatment record (revised date 12/18/20.) -Be sure call light within reach and encourage use during periods of alertness. R3 needs prompt response to all requests for assistance and to TABs alarm sounding. Use mat on floor during night and day especially when agitated to decrease risk of injury with falls (revised date 4/4/20.) -When R3 is attempting to go into her room, she wants to lay down. Assist R3 into bed at these times. Start date 10/29/21. -When restless or agitated, attempting to self-transfer, may try warm blankets or weighted blanket. Sleeps/rests better with lights off and door only slightly open allowing visual checks (revised date 12/21/21.) -Needs a safe environment with even floors free from spills and/or clutter; adequate glare-free lighting; a working and reachable call light, the bed in lowest position at night; grab bar as ordered, personal items within reach. Revised date 12/22/22. -Has grab rails on bed to allow resident to assist if able if/when her status allows. Bed in low position with mat on floor, noodle under outside mattress edge (revised date 12/22/22.) -Allow resident to rest in recliner if desires, use EZ-Lift and assist of 3 staff for transfers. Staff to run the lift chair and lift chair control to be kept out of resident's reach (revised date 5/2/23) R3's current care sheet indicated fall risk with the fall interventions of low bed, floor mat, alarms in bed and while in broda chair. Keep recliner unplugged and to monitor frequently (monitoring frequency was not identified). R3's safety risk assessment dated [DATE], indicated at risk for falls, continue current care plan with high low bed in lowest position when in bed, mat on floor by bed when in bed, TABs alarms on bed and wheelchair, and staff assist resident to lay in bed when tired. Fall 1 R3's progress note dated 4/20/23, indicated R3 had an unwitnessed fall. R3 was noted to be hollering out and was found on floor mat next to bed and attempting to get back into bed. R3 was assisted with two staff to get back into bed. VS obtained. R3 was anxious and restless most of the shift and required one-on-one. Did receive as needed Ativan, had multiple snacks, fluids, repositioning, wheeled in wheelchair up and down the halls. Air mattress overlay was placed earlier; staff thought the mattress caused the fall and encouraged night shift to remove if R3 seemed uncomfortable during the night. Corresponding incident report indicated fall happened at 6:25 p.m. Immediate interventions taken was to assist R3 off the floor via two staff as R3 was partially on the bed. No injuries noted. Predisposing factors included fall alarm, impaired memory, recent change in condition, recent medication change/new. Resident noted to be more anxious and received PRN Ativan and nonpharmacological interventions used with minimal effect noted. R3's post fall IDT note dated 4/27/23, new air mattress overlay thought to be the reason along with increased confusion that day. Evaluated the use of toilet as resident gets restless when needs to have a BM. Attempt to toilet the resident when stating need. R3's fall record did not mention if the TAB alarm had been functioning at the time of the fall. R3's record did not identify when/if mattress was removed and/or revision to the care plan. Fall 2 R3's progress note dated 6/19/23, indicated an unwitnessed fall at 4:15 p.m. R3 stated pain when asked but not able to tell where pain was located. R3 also stated that she did not feel well. VS taken and R3 had an elevated diastolic blood pressure (blood pressure not identified). Recheck of blood pressure 15 minutes later was 127/86. Corresponding incident report indicated the R3 slid out of bed and was found on her mat with TABS alarm going off. R3 had no injuries. Immediate interventions were R3 was assessed for injuries; no injuries were identified, however, R3 reported pain, and stated I don't feel well. Predisposing factors included confusion, memory impairment. Although R3's fall record identified potential causal factors, it was not evident a comprehensive analysis was completed that identified root cause and not evident interventions were developed and implemented to prevent and/or mitigate risk for recurrent falls. During an interview on 6/22/23 at 3:33 p.m., nursing assistant (NA)-L indicated that R2 had been waxing and waning with his level of care and his cognition since his admission. R2 went through a period where R2 he was falling a lot but NA-L could not remember if the falls resulted in injury. NA-L stated staff had to anticipate R3's needs, NA-L was not aware if R3 had any falls. NA-L would refer to the current care sheet to look for residents at fall risk for falls and what their fall interventions were. During an interview on 6/22/23 at 3:47 p.m., NA-A indicated R2 was assist of two staff with transfers and could not remember any recent falls for R2 . R2 wore a TABs alarm at all times and had a fall mat beside her bed. NA-A stated R3 was a hoyer lift with assist of two staff. NA-A indicated R3 liked to crawl out of bed at times. NA-A was able to articulate the steps involved when there was a fall per facility protocol. make sure resident is safe, call for nurse and stay with resident until nurse comes to assess resident, and then help get resident off the floor. During an interview on 6/23/23 at 8:27 a.m., NA-N indicated R2 was a two person pivot transfer from bed to commode and back again, and was able to turn self in bed. R2 had a history of falls, could not remember how long ago R2 last fell, and was not sure of his fall interventions however would check the care sheet. NA-N stated R3 was a EZ-Lift with assist of 2 for most transfers, EZ-Stand for transfers to and from commode only after breakfast. NA-A could not remember R3' s last fall. NA-N was able to articulate the steps involved with falls per facility protocol. During an interview on 6/22/23 at 2:10 p.m., director of nursing (DON) indicated when there was a fall the NAs would contact the nurse to come and do assessment and then staff would assist resident off the floor with the EZ-Lift The nurse would document the incident, note any injuries, and who they contacted. Every Thursday the IDT risk management meeting was held. IDT reviews the incidents from the previous week; notes were made on the incident report during the meetings. On 6/23/23 at 12:00 p.m., DON explained nurses were supposed to complete the Post Fall RCA (root cause analysis) questionnaire with each fall. DON reviewed R2 and R3's fall records; stated she was unable to completed RCA's for R2 and R3's falls. DON stated nurses were supposed to follow and complete the Fall Checklist. DON stated expectation nursing staff followed the facility's fall program policies. Review of revised facility's policies Fall-Clinical Protocol and Assessing Falls and Their Causes, both dated 6/22/23, indicated identifying causes of a fall within 24 hours. Currently IDT meets weekly to discuss falls. Performing post fall evaluation 4) .complete of falls risk assessment and put in appropriate interventions taken to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately report an allegation of abuse within the required 2 hours to the State Agency for one of one residents (R11) when R11 reported staff to resident verbal abuse. Findings Include: R11's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition based on Brief Interview for Mental Status (BIMS) score of 13/15. R11 was frequently incontinent of bowel and bladder and required assist of two staff for bed mobility, transfers, dressing, bathroom needs, and personal hygiene. R11's care plan indicated resident's vulnerability potential due to her physical status, complex medical condition, and dependence on two staff for activities of daily living (ADLs). It stated resident will receive needed care in manner that provides her safety and dignity for her over all well-being. During an interview on 1/23/23, at 5:15 p.m. R11 stated nursing assistant (NA-A) refused to help her that morning because she didn't say please. R11 stated she'd to take it higher. NA-A provided cares, however, stated I can walk out of here any time I want to. R11 did not report this to the facility, however, stated it made her feel very inferior. On 1/23/23, at 7:45 p.m. allegation of verbal threat to deny cares was reported by surveyor to the director of nursing (DON) and administrator. During an interview on 1/24/23, at 10:48 a.m. DON stated suspected abuse, was reported to OHFC (office for health facility complaints) and suspected abuser was removed until investigation was complete. However, there was no evidence this incident had been reported to the SA. During an interview on 1/25/23, at 2:03 p.m. DON and administrator stated after an internal investigation, the facility removed the NA-A from the schedule and planned to make a report to the state agency. Further, they acknowledged the report was late and should have been reported within two hours of initial report from R11. NA-A's employee file indicated EduCare training modules titled Abuse Prevention, and Abuse Prevention and Resident Rights were completed on 7/1/20. NA-As Minnesota Nursing Assistant Registry verified. Expires12/9/23. Background clearance completed for NA-A on 1/29/22. Review of Abuse, Neglect, Mistreatment and Misappropriation of Property policy, last revised 1/7/2021, indicated allegations of abuse were to be reported to the SA within 2 hours.

Based on observation, interview and document review, the facility failed to ensure infection control practices were followed during handling of soiled laundry. This had the potential to affect all residents whose laundry was completed at the facility. Findings include: During observation on 1/26/23, at 8:27 a.m. laundry aide (LA)-A did not have on proper PPE when sorting soiled laundry. During interview on 1/26/23, at 8:27 a.m. LA-A stated gowns were not worn over clothing to sort soiled laundry items, unless the bag was a different color. However, gloves were worn at all times when sorting laundry. LA-A stated she was not aware of the need to wear a gown while sorting soiled laundry. An interview on 1/26/23, at 10:14 a.m. infection preventionist (IP) stated staff were expected to wear gowns and gloves when sorting laundry. However, I cannot confirm the laundry staff are wearing gowns downstairs when sorting laundry. Further, nurse aides likely did not wear a gown when they sorted laundry items either. The facility policy Departmental (Environmental Services)-Laundry and Linen approve date 1/26/23, indicated employees sorting or washing line must wear a gown and gloves. A mask may be worn if aerosolization is expected. Use heavy duty rubber gloves for sorting laundry. Always wash hands after completing the task and removing gloves.