**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to notify the physician when a weight gain of greater than 3 pounds (lbs) in 48 hours or a weight gain of greater than 5 lbs in a week was identified for 1 of 1 (R124) residents reviewed for edema. Findings include: R124's undated admission Record identified R124 was [AGE] years old and was admitted on [DATE]. R124 had diagnoses that included acute respiratory failure with hypoxia (low oxygen levels), hypertensive heart disease, and congestive heart failure (CHF). R124's care plan dated 5/15/25, identified R124 had an altered respiratory status and staff were directed to observe for signs of increased edema (swelling) /increased weight related to fluid retention. Document and report to medical provider as necessary R124's physician orders dated 5/15/25, directed staff to obtain daily weights: Update nurse practitioner (NP) for weight gain of 3 pounds (lbs) or greater in 48 hours or 5 lbs in a week. R124's Weights and Vitals Summary dated 5/21/25, identified the following: - On 5/17/25 at 7:51 a.m., R124 weighed 318.8 lbs. - On 5/18/25 at 11:01 a.m., R124 weighed 325.2 lbs. However, the summary failed to identify a weight increase of increase 6.7 lbs. - On 5/19/25 at 9:03 a.m., R124 weighed 326.0 lbs. However, the summary failed to identify a weight increase of 0.8 lbs in 24 hours or increase of 7.2 lbs in 48 hours. - On 5/20/25 at 3:40 p.m., R124 weighed 331.4 lbs. However, the summary failed to identify a weight increase of 5.4 lbs in 24 hours or but total increase 12.6 lbs in 72 hours. R124's nursing progress note dated 5/20/25 at 4:56 p.m., identified staff spoke with R124 regarding his pain. R124 had a hospital follow up in house with the nurse practitioner (NP) that morning. R124 had no pain then and did not need any pain medication so R124 did not ask for it from the NP when the NP was here. Now R124 was asking for morphine or codeine for leg pain from leg swelling from his water weight. R124 had 2+ edema (2+ edema is a moderate pitting edema. It is characterized by indentation that subsides rapidly. Edema is graded on a scale of 1 to 4, with 2+ being a moderate level of edema and is characterized by 3-4 millimeter (mm) of depression, rebounding in 15 seconds or less.) to his lower legs. R124 had his legs slightly elevated in bed and was refusing to move to have his legs elevated my more. R124 would not allow lower part the bed elevated either. No new orders have been received from the NP at this time from hospital follow up visit. Due to R124 having new onset of new pain, R124 would need to be evaluated in the emergency room (ER); however, R124 refused to go into the ER. R124's medical lacked evidence the provider was contacted prior to 5/20/25. During an observation on 5/20/25 at 8:29 a.m., R124 was up and dressed for the day. R124 sat in his wheelchair at the dining room table eating breakfast. R124 was wearing oxygen via a nasal cannula. R124's face, hands and legs were swollen. During an interview on 5/20/25 at 3:47 p.m., registered nurse (RN)-D reviewed R124's weights and stated R124 did have a significant weight gain because R124 had gained greater than 3 lbs in 48 hours. RN-D reviewed R124's medical record and stated she did not see where staff notified R124's NP of R124's weight gain. During an interview on 5/20/25 at 4:17 p.m., RN-B stated R124's NP had been notified of R124 earlier in the day, but RN-B hadn't had time to document it yet. However, staff should have notified the provider on 5/18/25 of R124's weight gain or the staff may have waited until 5/19/25 due to the weekend but RN-B wasn't notified until 5/20/25. During interview on 5/20/25 at 4:27 p.m., the director of nursing (DON) stated staff were expected to follow the physician orders and should have notified R124's provider on 5/18/25 when R124's weight increase was identified. During an interview on 5/21/25 at 2:00 p.m., the administrator stated staff were expected to follow physician orders to ensure residents received the care they deserved. During a phone interview on 5/22/25 at 12:35 p.m., NP-A stated she evaluated R124 on 5/20/25 and was told R124 gained 5.2 lbs over the course of 5 days. NP-A contacted R124's cardiologist for guidance and R124 was evaluated by cardiology. NP-A was unaware of R124's physician order to contact the provider if a weight gain of 3 lbs in 48 hours and would have expected nursing to contact a provider on 5/18/25 to obtain care sooner. The facility policy Edema Scale and assessment dated 5/2013, identified It is the policy of this facility to provide standardized assessment of lower leg edema and associated issues. Document any untoward results and as necessary by degree of problem, notify the Health Care Provider. The facility policy Change of Condition/Notification revised 3/25, identified Attending physician/NP, or physician on-call, is to be immediately contacted (not by voicemail) of residents change in condition/health status based on a comprehensive assessment. I. Facility must immediately inform the resident, consult with the physician, and notify representative when there is: A. An accident involving the resident which results in injury and has the potential for requiring physician intervention. B. A significant change in the resident's physical, mental, or psychosocial status. C. A need to alter treatment significantly - due to adverse consequences or new form of treatment. D. A decision to transfer or discharge the resident from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) or a clinical justification of a psychotropic medications was documented for 1 of 5 residents (R42) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], identified R42 had moderate cognitive impairment. R42 had verbal behaviors directed toward others and behaviors not direct toward others 1 to 3 days a week. R42's diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of intense highs to periods of deep lows) and anxiety. R42 received an antipsychotic medication and an antidepressant medication. The MDS identified the last gradual dose reduction (GDR) of medications was done 2/23/21, and a GDR was not documented as clinically contraindicated. R42's most recent Physician Order Report dated 5/21/25, identified haloperidol (typical antipsychotic medication) to be given twice a day related to bipolar disorder and was dated 11/22/23. R42 also received Zoloft (an antidepressant medication) given one time a day for depression related to bipolar disorder and was dated 11/29/22. R42's monthly pharmacy reviews were reviewed from 6/2024 to 5/2025, with no irregularities identified with antipsychotic medications or antidepressant medications. R42's medical record was reviewed and lacked evidence a GDR had been attempted or identified a medical justification for continued use and R42 was on the lowest effective dose, within the past calendar year for the haloperidol. During an interview on 5/21/25 at 1:13 p.m., registered nurse (RN)-H, nurse manager, stated the resident's medications were reviewed on a regular basis and discussed with nursing and pharmacy consultant (CP). RN-H stated they did not look for when a GDR was due but waited for the CP to make a recommendation for a GDR. During a telephone interview on 5/21/25 at 2:00 p.m., the CP stated GDRs on psychotropic medications were done twice a year for new medications and yearly for established medications. The CP identified the last GDR attempt was done 2/2024. During an interview on 5/21/25 at 2:37 p.m., the director of nursing (DON) stated it was the expectation nursing staff would work with pharmacy to ensure psychotropic medication GDRs were addressed for the health of the residents. The facility's Psychopharmacological Drug Use policy dated 5/2025, the resident drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in an excessive dose, for an excessive duration, or without adequate indications for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 1 of 3 residents (R24) reviewed for injectable diabetes medications. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], identified R24 had diabetes (a disorder characterized high blood sugar levels due to either insufficient insulin production or the body's inability to effectively use insulin). The MDS identified R24 received an insulin injection and was receiving hypoglycemic medication (used to lower blood sugar levels). R24's Medication Administration Record (MAR) for the month of February 2025, identified R24 received Trulicity (a medication which increased insulin release, reduced glucagon secretion; however is not insulin) for diabetes. The February 2025, MAR did not identify R24 had received any insulin during the month. During an interview on 5/21/25 at 1:45 p.m., registered nurse (RN)-B stated the MDS was coded incorrectly and should not have identified R24 had received insulin. R24 had only received Trulicity during the assessment period and not insulin. During an interview on 5/21/25 at 2:47 p.m., the director of nursing (DON) would expect the MDS to be completed correctly and stated Trulicity was not insulin. The facility's Resident Assessment policy dated December 2013, identified staff needed to utilize information found in Point Click Care (an electronic health record) to complete sections required on the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to implement interventions for edema for 1 of 1 resident (R124) reviewed for edema. Findings include: R124's undated admission Record identified R124 was [AGE] years old and was admitted on [DATE]. R124 had diagnoses that included acute respiratory failure with hypoxia (low oxygen levels), hypertensive heart disease, and congestive heart failure (CHF). R124's care plan dated 5/15/25, identified R124 had an altered respiratory status and staff were directed to observe for signs of increased edema (swelling) /increased weight related to fluid retention. Document and report to medical provider as necessary R124's physician orders dated 5/15/25, directed to obtain daily weights: Update nurse practitioner (NP) for weight gain of 3 pounds (lbs) or greater in 48 hours or 5 lbs in a week. R124's Weights and Vitals Summary dated 5/21/25, identified the following: - On 5/17/25 at 7:51 a.m., R124 weighed 318.8 lbs. - On 5/18/25 at 11:01 a.m., R124 weighed 325.2 lbs. However, the summary failed to identify a weight increase of increase 6.7 lbs. - On 5/19/25 at 9:03 a.m., R124 weighed 326.0 lbs. However, the summary failed to identify a weight increase of 0.8 lbs in 24 hours or increase of 7.2 lbs in 48 hours. - On 5/20/25 at 3:40 p.m., R124 weighed 331.4 lbs. However, the summary failed to identify a weight increase of 5.4 lbs in 24 hours or but total increase 12.6 lbs in 72 hours. R124's nursing progress note dated 5/20/25 at 4:56 p.m., identified staff spoke with resident regarding his pain. R124 had a hospital follow up in house with the nurse practitioner (NP) that morning. R124 had no pain then and did not need any pain medication so R124 did not ask for it from the NP when the NP was here. Now R124 was asking for morphine or codeine for leg pain from leg swelling from his water weight. R124 had 2+ edema (2+ edema is a moderate pitting edema. It is characterized by indentation that subsides rapidly. Edema is graded on a scale of 1 to 4, with 2+ being a moderate level of edema and is characterized by 3-4 millimeter (mm) of depression, rebounding in 15 seconds or less.) to his lower legs. R124 had his legs slightly elevated in bed and was refusing to move to have his legs elevated my more. R124 would not allow lower part the bed elevated either. No new orders have been received from the NP at this time from Hospital follow up visit. Due to R124 having new onset of new pain, R124 would need to be evaluated in the emergency room (ER). R124 refused to go into the ER. R124's medical lacked evidence if a nursing assessment was conducted and new interventions implemented. Further there was no evidence the provider was contacted prior to 5/20/25 During an observation on 5/20/25 at 8:29 a.m., R124 was up and dressed for the day. R124 sat in his wheelchair at the dining room table eating breakfast. R124 was wearing oxygen via a nasal cannula. R124's face, hands and legs were swollen. During an interview on 5/20/25 at 3:47 p.m., registered nurse (RN)-D reviewed R124's weights and stated R124 did have a significant weight gain because R124 had gained greater than 3 lbs in 48 hours. RN-D reviewed R124's medical record and stated she did not see where R124's weight gain or edema had been addressed. During an interview on 5/20/25 at 4:17 p.m., RN-B stated R124's NP had been notified of R124 earlier in the day but RN-B hadn't had time to document it yet. However, RN-B was not notified of R124's weight gain until 5/20/25. During interview on 5/20/25 at 4:27 p.m., the director of nursing (DON) stated staff were expected to monitor daily weights and ensure the appropriate actions were taken when a significant weight increase was identified. During an interview on 5/21/25 at 2:00 p.m., the administrator stated staff were expected to monitor daily weights and take appropriate action when a significant weight gain was identified. During a phone interview on 5/22/25 at 12:35 p.m., NP-A stated she evaluated R124 on 5/20/25 and was told R124 gained 5.2 lbs over the course of 5 days. NP-A contacted R124's cardiologist for guidance and R124 was evaluated by cardiology. NP-A was unaware of R124's physician order to contact the provider if a weight gain of 3 lbs in 48 hours and would have expected nursing to contact a provider on 5/18/25 to obtain care sooner. The facility policy Edema Scale and assessment dated 5/2013, identified It is the policy of this facility to provide standardized assessment of lower leg edema and associated issues. Document any untoward results and as necessary by degree of problem, notify the Health Care Provider.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified the need for a gradual dose reduction (GDR) or medical justification of use for 1 of 5 residents (R42) reviewed for unnecessary medication and were taking psychotropic medications. Findings include: R42's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment with verbal behaviors directed toward others and behaviors not direct toward others 1 to 3 days a week. R42's diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings, ranging from periods of intense highs to periods of deep lows) and anxiety. R42 received an antipsychotic medication and an antidepressant medication. The MDS identified the last gradual dose reduction (GDR) of medications was done 2/23/21, and a GDR was not documented as clinically contraindicated. R42's most recent Physician Order Report dated undated, identified haloperidol (typical antipsychotic medication) to be given twice a day related to bipolar disorder and was dated 11/22/23. R42 also received Zoloft (an antidepressant medication) given one time a day for depression related to bipolar disorder and was dated 11/29/22. R42's monthly pharmacy reviews were reviewed from 6/2024 to 5/2025, with no irregularities identified with antipsychotic medications or antidepressant medications. R42's medical record was reviewed and lacked evidence a GDR had been attempted or identified a medical justification for continued use within the past calendar year for antipsychotic or antidepressant medications. During an interview on 5/21/25 at 1:13 p.m., registered nurse (RN)-H stated the consulting pharmacist (CP) reviewed the residents' medication lists and identified if any residents were due to a GDR, and that is how she was flagged if a resident was due for one. RN-H stated R42's medical record lacked any evidence a GDR had be attempted or a clinical justification for continued use. During a telephone interview on 5/21/25 at 2:00 p.m., the CP stated a resident's medication lists were reviewed monthly and medications were monitored, this included reviewing psychotropic medications (drugs that affect mental processes and behavior, often used to treat mental health conditions like anxiety, depression, and psychosis) for adverse reactions, monitor GDR or clinical contraindication for medication reduction. GDR's are to be attempted yearly. The CP stated the last documented GDR was from 2/2024, and a GDR or clinical contraindication should of be documented and was not. During an interview on 5/21/25 at 2:37 p.m., the director of nursing (DON) she would expect GDR's to be attempted or documented contraindication to be done yearly. The facility's Psychopharmacological Drug Use policy dated 5/2025, identified the CP would review resident medication records on a monthly basis for documentation/justification for the drug use and will recommend dosage reductions or modifications as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure conflicting notes and orders transmission based precautions were clarified to ensure an accurate medical record was maintained for 1 of 1 resident (R127) whose medical record was found to lack admission notes. Findings include: R127's entry Minimum Data Set (MDS) dated [DATE], identified R127 was [AGE] years old and was admitted to the facility on [DATE]. R127's Diagnosis Report dated 5/21/25, identified R127 had diagnoses that included enterocolitis due to Clostridium difficile (C. diff, or costridioides difficile, is a bacterium that can cause severe diarrhea and colitis (inflammation of the colon). It is often associated with antibiotic use, which can disrupt the normal gut flora, allowing C. diff to proliferate. Symptoms of a C. diff infection can range from mild diarrhea to severe, life-threatening conditions. Treatment typically involves specific antibiotics to target the infection.) R127's History and Physical dated 5/7/25, identified R127 had been diagnosed with C. diff, completed a 10-day course of oral vancomycin (an antibiotic used to treat C. diff) and R127's diarrhea had resolved. R127's admission Screening dated 5/9/25, was a handwritten paper form that identified R127 had C. diff 4/22. R127's Nursing Home Visit progress note dated 5/12/25, identified R127's C. diff was resolved. R127's nursing progress notes dated 5/9/25 through 5/21/25, failed to identify an admission note or a nurse-to-nurse communication (nurse-to-nurse communication refers to the exchange of information, opinions, and ideas between nurses, either face-to-face, through written reports, or electronically) regarding R127's hospital discharging condition. During an interview on 5/20/25 10:33 a.m., RN-B stated the admission nurse completed R127's admission screening. The admission nurse completed the nurse-to-nurse communication and entered an admission note. During an interview on 5/20/25 at 10:40 a.m., RN-F stated the hospital usually sent a referral packet for any potential resident: history and physical, notes, etc. RN-F reviewed everything from medications to therapy notes to ensure the facility could meet the resident's needs. If the resident was accepted, that information was loaded into the electronic medical record. R127's C. diff diagnoses was on 4/22/25 and RN-F entered that on R127's screening form. R127's C. diff may have been resolved but that was the cue for the admission nurse to talk to the hospital nurse regarding R127's stool. That information should be entered into an admission note, however, RN-F was unable to find an admission note in R127's medical record. During an interview on 5/20/25 at 11:13 a.m., RN-C stated he did R127's admission, however, could not recall a nurse-to-nurse communication about R127 because he completed 3 admissions that day. RN-E did not enter an admission note because all that information was on the admission nurse's screening form. RN-C may have hand written notes of the conversation on that paper form, however, that form was sent to the shred box for destruction. Yea, I guess if I don't enter a note and don't scan that form, it's not documented. RN-C stated days were rapid fire and staff got through what we needed to get done to get people settled. It was staff's responsibility to be aware of what residents needed. The IP nurse did send out a list every morning in an email and RN-C thought the cart nurses did get that email but who had time to read their emails. Really, staff just did what they had to do to get through it. During an interview on 5/20/25 at 4:27 p.m., the director of nursing (DON) stated staff were expected to either enter an admission note or scan handwritten notes in the medical record to ensure the resident's medical record was complete and to document what condition the resident was in on admission. During an interview on 5/21/25 at 2:04 p.m., the administrator stated staff were expected to ensure a resident has a complete medical record to ensure the resident receives the quality of care they deserve. The facility policy Documentation Standards Policy dated 10/24, identified the following: a. All documentation must reflect the resident's condition, care provided, and any status changes. b. Documentation must be completed at the time of care or as soon as possible after care is provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene was completed during personal cares for 1 of 3 residents (R121) whose cares were observed. Findings include: R121's 5-day Minimum Data Set (MDS) dated [DATE], identified R121 required set up to touching assistance for most care areas including toileting. R121's care plan revised 5/19/25, identified R121 required assist of one staff for toileting, dressing and grooming. During an observation on 5/20/25 at 3:02 p.m., nursing assistant (NA)-A assisted R121 to the bathroom for toileting. NA-A failed to use hand sanitizer and put on a pair of gloves R121 stood up from the toilet and NA-A stated R121 had a medium bowel movement (BM) and used a disposable wipe to clean feces from R121's buttocks. NA-A with the contaminated gloves assisted R121 to sit down on the toilet. NA-A then assisted R121 to put on a clean pull-up brief and pajama pants without completing hand hygiene or changing gloves.NA-A flushed the toilet, continued to wear the same soiled gloves and assisted R121 back to his bed. NA-A hung R121's gait belt on R121's door and picked up R121's urinal off his overbed table and dumped it in the toilet. NA-A gave R121 the call light and removed her soiled gloves. During an interview on 5/20/25 at 3:19 p.m., NA-A stated she was always told you wear the same gloves from the start of a care until the care was finished. During an interview on 5/20/25 at 3:22 p.m., licensed practical nurse (LPN)-A stated staff were expected to change gloves after wiping BM because you don't want to cross contaminate anything with feces. During an interview on 5/20/25 at 3:27 p.m., registered nurse (RN)-A stated staff were expected to remove their soiled gloves after doing BM cares, before touching clean items to prevent cross contamination of clean items. During an interview on 5/20/25 at 4:27 p.m., the director of nursing (DON) stated staff were expected to immediately removed gloves soiled with feces and to put on clean gloves before completing cares to prevent cross contamination of clean items. During an interview on 5/21/25 at 2:00 p.m., the administrator stated staff were expected to change gloves whenever going from dirty to clean to prevent transferring feces or bacteria on the resident's clothing. The facility policy Hand Hygiene revised 4/24, identified staff were expected to change gloves during patient care if the hand would move from a contaminated body site (e.g., perineal area) to a clean body site. Staff were directed to perform hand hygiene when removing gloves and before putting on a new pair of gloves.

Based on observation, interview and document review, the facility failed ensure beard coverings were worn when preparing resident meals, to prevent the spread of food born illness. This had the potential to affect 68 out of 68 residents that received food out of the kitchen or kitchenette. Findings included: During initial kitchen tour on 5/19/25 at 11:19 a.m., cook-A was observed in the kitchen not wearing a beard covering. Cook-A stated he had just finished making lunch. On 5/20/25 at 8:27 a.m., cook-B was observed in a unit kitchenette serving food to residents without a beard net. Cook-B's facial hair went from below the ears to the top of the neck and under the chin, and was approximately 1.5 inches long and shaggy in areas. Cook-B stood over an open loaf of bread with one slice of bread on the countertop and putting a plate of food into the microwave. After several seconds cook-B removed the plate of food from the microwave, walked to the counter and handed the plate to another staff member who brought the plate to a resident. Cook-B stated his facial hair was long and needed to be trimmed. Cook-B stated beard coverings should be worn prior to the start of work although had not put on a beard covering because he was uncertain where to locate them. Cook-B stated the potential risks of not covering facial hair was that hair could fall into the food. On 5/20/25 09:02 a.m., dietary manager (DM) stated staff were instructed to always wear hair/beard coverings, including when prepping, cooking, serving foods, and anytime they are working with food. DM stated she was aware cook-B was not wearing a beard covering and stated she just hadn't had time to tell him to put one on. DM stated the potential risks of staff not wearing a hair/beard covering was hair could fall into the residents food and cause bacteria to grow. The Employee Sanitary Practices policy revised 7/19, identified staff were to wear hair restraints to prevent hair from contacting exposed food, including a beard net, when an employee had a beard. According to section 2-402.11 of the FDA Food code: A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. This is crucial to prevent cross-contamination. Staphylococcus aureus is an example of a common pathogen that is found on skin and hair. If enough of the bacteria is ingested, it could cause illness. Common symptoms of this illness include vomiting, nausea, and stomach cramps.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to perform an assessment delaying care for 1 of 3 residents (R1) reviewed for a change of condition. R1 had right arm/hand weakness on 3/23/25, was not assessed, and was sent to the hospital on 3/24/25 diagnosed with a stroke. Findings include: R1's admission Record indicated an initial admission date of 4/25/24. Diagnosis included multiple sclerosis (MS), paraplegia and a diagnosis added 3/24/25, of cerebral infarction (also known as an ischemic stroke which occurs when the blood supply to part of the brain is blocked or reduced. Symptoms include Trouble speaking and understanding what others are saying. A person having a stroke may be confused, slur words or may not be able to understand speech. Numbness, weakness or paralysis in the face, arm, or leg. This often affects just one side of the body. The person can try to raise both arms over the head. If one arm begins to fall, it may be a sign of a stroke). R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition. The MDS indicated R1 had upper extremity impairment on one side, lower extremity impairments on both sides and required substantial/maximal assistance for toileting hygiene, showering and upper body dressing. R1's care plan dated 1/23/25, identified a self-care deficit related to activity intolerance, fatigue, impaired balance, MS, and paraplegia. The care plan was updated 3/26/25, to include acute stroke affecting right side. The care plan directed staff to provide assistance of two staff for bed mobility and toilet use. If R1 did not wish to get out of bed at night, offer use of bed pan and approach/attempt to check and change every four hours. R1's Progress Note dated 3/24/25 indicated writer was summoned to assess R1 at 7:20 a.m. for upper right sided weakness. Upon assessment R1 was unable to squeeze or lift right upper extremity. Extremity appeared limp. R1 requested to be sent to the ED for evaluation. Progress Note dated 3/24/25 at 3:40 p.m., indicated ED nurse called to update facility R1 was admitted to the hospital for an acute infarction. R1's hospital History and Physical (H and P) dated 3/24/25, indicated she presented to the emergency département (ED) on 3/24/25, due to a reported history of right arm weakness and that her arm was posturing straight beginning on 3/23/25, at around 3:00 p.m. R1 was right handed and informed staff she could not move her arm at all. R1 was admitted for further evaluation and monitoring and diagnosed with acute cerebrovascular accident (CVA) with right arm weakness. Found to have frontal/parietal embolic appearing CVA's. Neurology evaluated and recommended continuing Apixaban (an anticoagulant medication used to treat and prevent blood clots and to prevent stroke). Progress Note dated 3/26/25, indicated maintenance was notified that R1 would need controls on her wheelchair switched to the left side. R1 was unable to lift her right arm. During observation and interview on 4/10/25 at 1:07 p.m., R1 was seated in a power wheelchair in her room with family member (FM)-A. FM-A stated R1 lucked out, she was totally gone with her right arm. The nursing assistants (NA)'s kept reporting it and the nurse never came in. FM-A said starting the morning of 3/23/25, R1 was up and about and had to eat with her left hand which was unusual. R1 spoke with NA-A during the day and later it was getting worse and was reported to NA-B and another aide at 4:30 p.m. FM-A said the next incident occurred at 9:45 p.m. when R1 spilled everything on her bedside table. NA-B and another staff cleaned up the spill, asked R1 a lot of questions and reported concern to the nurse. FM-A stated he had turned in a grievance form because no one had come in to assess R1 the whole day, then at 6:10 a.m. the next day (3/24/25), NA-D came in to get R1 ready for the day, looked at R1 and went out to report to the nurse. The NA's had to power R1 out to the dining room because R1's arm was hanging, and she could not use the control on her chair. FM-A said he called the building charge nurse who came to the unit and said she thought R1 had a stroke. At 1:26 p.m. R1 said on 3/23/24, her arm had started tingling, then went to numbness. R1 said she could not really use it as far as picking something up and her motor skills were gone. A Formal Grievance/Concern dated 3/29/25, written by FM-A on behalf of R1 indicated the following: -3/23/25 at 10:30 a.m. R1 told NA's of right-hand numbness, had to use left hand. -3/23/25 at 4:30 p.m., R1 reported right arm was very weak to the NA's. -3/23/25 at 9:45 p.m., R1 spilled everything on her bedside table and her right arm and hand were numb. NA-B reported. -3/24/25 at 6:10 a.m. R1's right hand and arm were unusable. NA-D reported to licensed practical nurse (LPN)-A. R1 was assisted to dress and staff powered the chair to the dining room. FM-A called the charge nurse at 7:30 a.m. All this time, no nurse had checked on R1. An untitled, undated facility documented indicated FM-A reported R1 had been having trouble with her right arm since 3/23/25 at 10:30 a.m., nurses were made aware several times and did nothing. NA-A was interviewed and denied any complaints from R1 during day shift on 3/23/25. NA-B was interviewed and said R1 had no complaints until just before 10:00 p.m., when her light was on because she had spilled her water. NA-B stated R1 reported being weak and he reported it to the nurses. LPN-B was interviewed and denied any concerns until NA's reported at the end of the PM shift that R1 spilled her water because she had been weak. LPN-B did not take it as a concern, just a resident who was tired and spilled her water. The overnight nurse, LPN-C stated no concerns were brought to her during her shift until the morning when the NA reported to the oncoming nurse R1 was having a problem with her right arm. LPN-A was interviewed and said on 3/24/25, NA-D came to her and reported R1 was unable to move her right arm. LPN-A called the charge nurse and left a message as she believed assessing for a stroke was outside her scope. During interview on 4/10/25 at 2:03 p.m., NA-B stated he went in to check on R1 just before 10:00 p.m. on 3/23/25. R1 had dropped her cup, and she was kind of out of it. NA-B said not tired but groggy and her fingers were stuck in the mug, and she could not feel them. NA-B asked R1 if that had ever happened before, and she said no. NA-B said he had been working with NA-E and they had reported everything to LPN-B who made a comment how strange it was but did not do anything or go see R1. During interview on 4/10/25 at 3:27 p.m., NA-D said at shift change on 3/23 she noticed R1 could not grip and thought it was weird. NA-D told both the P.M. shift, LPN-B, and overnight nurse LPN-C that R1 had dropped her water and was having trouble grabbing stuff with her hand which was unusual for her. NA-D said R1 sometimes dropped things but could grip with her hand and that night she could not. NA-D remembered NA-B being there and both talking about it to the nurses. During interview on 4/10/25 at 3:37 p.m., the administrator said she and the director of nursing (DON) had spoken to FM-A who had reported everything as it had been written on the grievance form. The administrator said she had not spoken to R1 about the reported events. The administrator stated the expectation would have been that the nurses would have gone in and assessed R1. During interview on 4/10/25 at 3:53 p.m. the DON stated she heard through the rumor mill that FM-A had been having concerns for a day. The DON said she asked some staff and NA-B reported just before 10:00 p.m., that R1 said she was weak, and it was reported to the nurses. The DON said LPN-B reported the NA's had told her R1 was weak during shift report. NA-D reported the next morning R1 could not move her right arm and reported it to LPN-A. LPN-A told the DON she could not assess for a stroke, so she called the charge nurse who was doing a training with staff. The DON stated the overnight nurse should have assessed R1 and LPN-A could have gone in and assessed R1 instead of waiting for the charge nurse. During interview on 4/11/25 at 8:41 a.m., NA-D said on 3/24/25, she walked into R1's room and asked how she was doing. R1 said I don't know and said I can't move my right arm. NA-D said when she looked, she could tell something was different and asked R1 if she had reported it. R1 said the previous night she told the NA's, but no one had come to see her. NA-D reported the concern to LPN-A and LPN-C who said it was the first time she had heard of it. NA-D stated she went to complete cares for R1 and FM-A which took approximately 45 minutes. During that time, no nurses came to assess R1. NA-D had to drive R1's wheelchair to the dining room because she could not operate the controls. NA-D said R1 had been in the dining room for a half hour to an hour before the charge nurse came to assess R1. During interview on 4/11/25 at 8:49 a.m., the nurse practitioner (NP) stated R1 had already been taking Apixaban due to a blood clot. The NP said it was hard to know for sure but if R1 had gone in earlier the ED may have tried tPA (Tissue plasminogen activator, a drug given through a vein to help break up a blood clot so that blood flow can return to normal. It is used for the emergency treatment of ischemic stroke, which occurs when a blood clot interrupts blood flow to a region of the brain) which was used if they could catch the symptoms within three hours. The NP said staff should have contacted the nurse manager, assessed R1 and sent her in right away. During interview on 4/11/25 at 10:33 a.m. registered nurse (RN)-A stated she had been the charge nurse on 3/24/25. RN-A said she arrived at the facility at 6:00 a.m. to complete training with the night shift. RN-A got a phone call around 7:20 a.m. from FM-A who was concerned about R1's right arm and that she could not move it. R1 was in the dining room when RN-A assessed her and R1's right arm was completely limp, there was nothing there, she could not move it or squeeze. RN-A said there was no record of LPN-A attempting to contact her. R3's admission Record indicated an initial admit date of 2/20/25. Diagnosis included heart failure, contusion of left thigh and left artificial knee joint. R3's 5-day MDS dated [DATE], identified intact cognition. R3's care plan dated 3/23/25, identified a self-care deficit related to activity intolerance, fatigue, impaired balance, and infected traumatic left thigh hematoma. The care plan identified altered skin integrity and directed staff to observe for signs and symptoms of infection and report to physician. A Formal Grievance/Concern dated 4/1/25, indicated during care conference, R3 voiced concern that the previous day, 3/31/25, he asked multiple times to go to the ED to have his leg looked at but no one did anything until 10:00 p.m. The timeline completed by LPN-D indicated: -At 9:00 a.m., R3 asked to LPN's to look at his leg. -At 11:00 a.m., RN-B back in office and was told about R3's leg and that he may want to be seen. -At 1:00 - 2:00 p.m., RN-B went to look at R3. -At 5:30 p.m. R3 started to complain of pain in his leg. R3's Progress Notes dated 3/31/25, indicated: -At 12:19 p.m., staff wrote R3's left upper leg was swollen and warm to touch. -At 8:50 p.m., staff wrote incision had healed over but area under thigh had swollen dramatically. R3 agreed to go to the ED. Previous nurse gave pain medication but R3 was still very concerned about the swelling. -At 11:33 p.m., staff wrote R3 had increased swelling to left upper thigh, no drainage from area. R3 requested to go to the ED for evaluation. During interview on 4/11/25 at 8:49 a.m., the nurse practitioner stated no one had reported to her that R3 had requested to go to the ED. During interview on 4/11/25 at 9:47 a.m., RN-C stated she had taken the grievance but had not been at the facility on 3/31/25. RN-B was present and said LPN-D had talked to her about R3 and she went and looked at his leg. R3's leg was swollen about the size of a football, and he said it had not been draining. RN-B said she told R3 she would let the NP know, and said R3 replied I suppose she will want me to go in. She said she asked the NP if there was anything she needed to do before she left, and the NP said no. RN-B said she left early that day and said she had not documented an assessment of R3's leg. During interview on 4/11/25 at 11:51 a.m., the DON stated she thought R3 had been thinking in his mind that he wanted to be seen but did not say it to anyone. Job Description Licensed Practical Nurse dated March 2017 indicated essential job responsibilities that included assists registered nurse with completion of assessments, documentation, and data collection within scope of practice and acting timely on findings. Facility policy Change of Condition/Notification dated March 2025, indicated a change in condition may include but not limited to: Injury, abnormal lab values, acute symptoms, change in vital signs and other conditions as deemed necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide the opportunity for an admission care conference for 1 of 3 residents (R49) reviewed for care planning. Findings include: R49's admission Minimum Data Set (MDS) assessment dated [DATE], identified R49 was cognitively intact. Diagnoses included renal insufficiency, diabetes, and arthritis. Review of R49's electronic medical record (EMR) lacked documentation of a care conference since admission to the facility. During an interview on 8/26/24 at 7:09 p.m. R49 stated he had not been invited to, or attended any care conference to discuss the plan of care (POC) since admission to the facility on 7/30/24. During an interview on 8/28/24 at 2:29 p.m. registered nurse (RN)-B stated the facility would rarely have an admission care conference. They would build the care plan and just let the resident review it after completion. Staff usually never met with the resident until closer to discharge, to discuss the discharge planning. Turn around times on the rehab unit did not allow to meet with each resident at admission to discuss the POC with them. During an interview on 8/29/24 at 10:28 a.m., the social services designee (SSD) stated care conferences would be scheduled by her and social services, nursing, therapies, and other departments would attend them with the resident and family members. The SSD reviewed R49's EMR and confirmed there was no documentation related to a care conference. The SSD also confirmed R49 had not had a care conference since admission. During an interview on 8/29/24 at 10:49 a.m., the director of nursing stated an expectation that all care conferences would be done within 7-12 days of admission, as stated in the policy and the resident admission handbook. Facility Welcome to Grand Village resident handbook last revised 4/11/24 indicated 7-12 days after admission an interdisciplinary team (IDT) meeting called a resident care conference would be held to discuss the residents care at the facility. The meeting would include several staff at the facility, the resident, and the resident family. Facility policy Individualized Care Plan last revised 6/24, indicated the IDT would meet with the resident and family related to the POC. The policy lacked documentation of when the care conference should take place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R2) reviewed and observed for self-administration of medications. Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. During observation on 8/27/24 at 10:46 a.m., R2 was sitting in her recliner with the nebulizer mask on her face. Nebulizer cup contained a clear solution and nebulizer machine was running with no staff present in room. Nurse walked from the medication cart into R2's room, stated to R2 that the treatment was all done and shut the nebulizer machine off. Nurse washed nebulizer mask and cup and left it to air dry. During record review on 8/26/24, the self-administration of medications assessment that was completed on 7/11/24, identified R2 required frequent prompting, cues and reminders, and was not safe to self-administer own medications. Assessment also indicated that R2 did not wish to self-administer any medications. During interview on 8/29/24 at 8:34 a.m., licensed nursing staff (LPN)-A stated there were no residents on this unit that were able to self-administer medications. LPN-A stated if a resident was able to self-administer medications, it would be displayed in the resident's banner in the electronic health record (EHR). LPN-A confirmed that R2 did not have an order to self-administer medications which included nebulizer treatments. LPN-A stated an assessment would need to be completed before a resident was able to self-administer medications. LPN-A stated the assessment was important to ensure that the mask was properly place on resident's face and that the resident was able to keep mask on during treatment as nebulizer could be running with the resident not receiving any solution making the treatment ineffective. During interview on 8/29/24 at 10:17 a.m., registered nurse (RN)-C stated an assessment would need to be completed by the RN prior to a resident being able to self-administer medications. RN-C confirmed R2 did not have an order for self-administration of medications. RN-C stated it was important to complete the assessment to ensure that the resident was cognitively able to use the nebulizer without monitoring and to ensure the resident could remove nebulizer mask from face if resident was experiencing adverse side effects such an increased heart rate with palpitations during nebulizer treatment. During interview on 8/29/24 at 10:38 a.m., director of nursing (DON) stated self-administration of medications assessments are completed by the nurse manager or the MDS nurse. DON stated assessments are completed at time of admission, annually, or with a significant change in status. DON confirmed that nebulizer treatments, when nurse leaves the room, needed to be assessed and a self-administer order would need to be obtained from the provider. It was important for the resident to be assessed for self-administration of medications to ensure that the resident was safe to be left alone with the nebulizer treatment running. The facility Self-Administration of Medications policy, dated 4/23, identified a self-administration of medications assessment would be completed for any resident requesting to administer any medication without the direct supervision of a nurse. Residents who have nebulizer treatments may only self-administer if assessed for self-administration of nebulizer assessment and a physician order is received to self-administer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure proper wheelchair equipment was used to prevent potential complications for 1 of 1 resident (R55). Findings include: R55's significant change Minimum Data Set (MDS) dated [DATE], identified R55 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R55's diagnoses included progressive neurological conditions, degenerative disease of nervous system, non-Alzheimer's Dementia, and unspecified abnormalities of gait and mobility. During observation on 8/26/24 at 1:28 p.m., R55 left the unit with staff to go to activities. Staff assisted R55 with propelling down hallway in his wheelchair that did not have foot pedals. R55 was experiencing difficulty with holding his feet up while staff pushed wheelchair. R55's feet dropped on floor and bounces. R55's foot pedals were laying on top of dresser in room. During observation on 8/29/24 at 9:13 a.m., R55 left the unit with staff to go down to therapy. Staff assisted R55 with propelling down hallway in his wheelchair that did not have foot pedals. R55 was experiencing difficulty with holding his feet up while staff pushed wheelchair. R55's feet dropped on floor and bounced. R55's foot pedals were laying on top of dresser in room. During record review on 8/28/24, R55's care plan indicated staff were to ensure bilateral foot pedals were on wheelchair when assisting resident to and from destinations due to limited physical mobility related to weakness. During interview on 8/29/24 at 8:36 a.m., licensed practical nurse (LPN)-A stated if R55 was going a long distance or off unit, staff assisted R55 with propelling wheelchair down hallway. LPN-A stated R55 does not have foot pedals for his wheelchair. During interview on 8/29/24 at 8:40 a.m., nursing assistant (NA)-A stated if R55 was going off unit, staff assisted R55 with propelling wheelchair down hallway. NA-A stated R55 does not use foot pedals on his wheelchair. During interview on 8/29/24 at 10:11 a.m., registered nurse manager (RN)-A confirmed R55 was to have foot pedals on his wheelchair when been propelled for longer distances. RN-A stated it was important for foot pedals to be used on wheelchair, so the resident does not fall forward out of wheelchair and/or sustain injuries. During interview on 8/29/24 at 10:31 a.m., director of nursing (DON) stated nursing evaluated whether or not foot pedals needed to be used for the resident and if foot pedals were needed it would be added to the care plan. DON stated that if a resident was not able to hold their legs up that foot pedals should be used. DON stated it was important for foot pedals to be used per care plan to ensure resident safety. A wheelchair/foot pedal policy was requested but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide timely assistance with repositioning to minimize the development of pressure ulcer risk for 1 of 2 residents (R50) reviewed for wound care. Findings include: R50's quarterly Minimum Data Set (MDS) dated [DATE], identified R50 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R50's diagnoses included hypertension, renal failure, non-Alzheimer's dementia, anxiety disorder and other symptoms and signs involving the musculoskeletal system. MDS also identified that R50 was at risk for developing pressure ulcers/injuries and is on turning and repositioning program. R50's care plan undated, identified R50 had altered skin integrity related to fragile skin due to closed lumbar fracture and was at risk for the development of pressure ulcers. R50's care plan directed staff to reposition R50 every two hours while in bed and/or wheelchair. During continuous observations on 8/27/24 from 1:12 p.m. to 3:37 p.m. R50 was lying on his back in his bed. At 1:12 p.m., R50 was observed to be lying on his back in bed. At 2:30 p.m., R50 remained in same position in bed. At 2:54 p.m., nurse went into R50's room and obtained vitals but did not reposition R50 and R50 remained in same position in bed. At 3:01 p.m., staff brought in new water pitcher into room and did not reposition R50. At 3:32 p.m., R50 remained in same position in bed. At 3:37 p.m., staff went into R50's room and assisted R50 with repositioning. During interview on 8/27/24 at 3:29 p.m., nursing assistant (NA)-B stated R50 was unable to reposition himself in his bed and needs staff to assist with repositioning. NA-B stated R50 was to receive assistance with repositioning every two hours. During interview on 8/27/24 at 3:40 p.m., licensed practical nurse (LPN)-B stated R50 was to receive assistance with repositioning every two hours when in bed or wheelchair. LPN-B stated R50 was not able to reposition himself in his bed. During interview on 8/29/24 at 8:36 a.m., LPN-A stated R50 had a wound on his spine that was not open at this time. LPN-A stated R50 had a protective bandage, placed along his spine, due to him having thin skin. LPN-A stated R50 was to receive assistance with repositioning every two hours as it was important to ensure that R50's skin on back/spine does not break down. During interview on 8/29/24 at 8:40 a.m., registered nurse clinical manger (RN)-A stated R50 currently does not have any open wounds as the pressure ulcers that he had has resolved. RN-A stated R50 had a preventive protective dressing that was placed on his spine for a bulge that staff has been monitoring closely. RN-A stated R50's skin was very thin and the bulge on his spine was protruding with the area being blanchable. RN-A stated R50 was to receive assistance with repositioning every two hours as it was important due to R50's skin being so vulnerable and his history of pressure ulcers. During interview on 8/29/24 at 10:35 a.m., the director of nursing (DON) stated the staff were to provide assistance with repositioning in accordance with the care plan. DON stated repositioning a resident was important to prevent skin breakdown. The facility Positioning the Resident policy dated 6/24, indicated that it was the policy of the facility that staff reposition identified residents to relieve pressure, prevent skin breakdown, pain, and promote proper body alignment. The facility Individualized Care Plan policy dated 6/24, indicated the facility would develop a comprehensive care plan using the comprehensive assessments, will individualize the plan of care to accurately reflect resident's functional capacity and medical, nursing, psychosocial, activity and other identified needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to facility policy and failed to ensure nebulizer tubing/cannister was cleaned and allowed to air dry after each use for 1 of 1 resident (R38) reviewed for oxygen therapy. Findings include: R38's admission Minimum Data Set (MDS) dated [DATE], identified R38 was cognitively intact and had continuous oxygen therapy since admission to the facility. R38's provider order dated 8/13/24, identified oxygen at 2 liters/minute by nasal cannula (NC) continuously and budesonide inhalation suspension 0.5 milligrams/2 milliters inhaled via nebulizer two times a day. R38's care plan dated 8/7/24, identified R38 needed continuous oxygen therapy and to administer oxygen and respiratory medications as per orders. The care plan lacked documentation when to change oxygen tubing and when/how to clean nebulizer tubing/cannister. R38's treatment administration record for 8/24 indicated oxygen tubing and nasal cannula had been changed on 8/11/24, 8/18/24, and 8/25/24. On 8/26/24 at 3:09 p.m., R38 was observed wearing continuous oxygen via NC. The date on the green extension tubing and the NC was 8/18/24. A nebulizer canister and tubing was observed sitting on the bedside table and was also dated 8/18/24. The cannister was noted to be closed and had visible liquid in the cannister along with condensation along the inner walls of the cannister. During interview on 8/26/24 at 3:09 p.m., R38 stated the staff very rarely change the oxygen tubing the way they were supposed to. The staff will never clean out the nebulizer cannister after my treatment. They start out the day by bringing me the vials of nebulizer liquid for all treatments that day and R38 would set up and self-administer the nebulizer treatments when scheduled. The staff never came back to clean the nebulizer cannisters after each use. On 8/27/24 at 1:29 p.m., all the oxygen tubing in R38's room was observed to be dated 8/18/24 along with the nebulizer tubing and cannister. The nebulizer cannister was again noted to have liquid and condensation built up inside the cannister. During interview on 8/27/24 at 1:34 p.m., licensed practical nurse (LPN)-A stated all oxygen tubing and nebulizer tubing/cannisters would be changed every 7 days based on when the resident was admitted . Documentation of the change would be done in the TAR and the tubing would be labeled with tape and the current date on the tape. LPN-A stated nebulizer cannisters needed to be cleaned after each use and allowed to air dry before the next treatment was given. Cleaning should occur immediately after the medication in the nebulizer was administered. LPN-A entered R38's room and confirmed the date on all oxygen tubing was 8/18/24. Based on that date the tubing should have been changed on 8/25/24. LPN-A also confirmed the nebulizer had not been cleaned out since the last treatment that day which had been at 8:00 a.m. During interview on 8/29/24 at 10:38 a.m. registered nurse (RN)-A stated all oxygen tubing and nebulizer tubing/canisters should be changed every 7 days, on Sunday evening shft. RN-A stated nebulizer cannisters should be cleaned immediately after each use to prevent bacteria growth that can occur in left over moisture in the cannister. During interview on 8/29/24 at 10:48 a.m. the director of nursing (DON) stated an expectation all staff would follow the facility policy related to oxygen tubing changes and nebulizer cleaning schedules. Facility policy Nebulizer Treatment last revised 12/23, identified after each use the nebulizer would have all excess fluid removed from the nebulizer and placed on a paper towel to air dry completely. Nebulizer pieces would be changed weekly, which included tubing. A facility policy for oxygen tubing changes was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to assure the use of PRN (as needed) psychotropic medications (a drug which affects mood/behavior) were limited to 14 days, or had a physician specified, time limited order and failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 1 of 1 residents (R4) reviewed for hospice. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 had moderate cognitive impairment and required assistance with all activities of daily living (ADL)'s. R4's diagnoses included non-Alzheimer's dementia, anxiety disorder, nutritional deficiency, and chronic pain. R4's physician orders included orders for lorazepam 0.5 milligram (mg) every four hours as needed. This order was initiated on 3/8/24 and was open-ended. Orders also included risperidone (antipsychotic) 0.25 mg by mouth two times daily for obsessive itching/picking related to generalized anxiety disorder. R4's medical record was reviewed and lacked any evidence orthostatic blood pressures had been obtained for R4. During interview on 8/28/24 at 1:43 p.m , registered nurse case manager (RN)-A stated for psychotropic medications monitoring needed to be completed for behaviors. RN-A confirmed that R4's lorazepam was ordered on 3/8/24 and has no end date. RN-A stated R4 did not have any behaviors and probably does not need the lorazepam order at this time. RN-A stated antipsychotic medications are monitored for adverse effects and orthostatic blood pressures are obtained monthly. RN-A confirmed R4 has not had orthostatic blood pressures obtained. DON stated orthostatic blood pressures are important as antipsychotic medications can cause dizziness and cause blood pressure to drop, which could lead them to fall. During interview on 8/29/24 at 10:26 a.m., director of nursing (DON) stated target behaviors and adverse effects are monitored for PRN psychotropic medications. DON stated PRN psychotropics need to be evaluated every 14 days with the provider to ensure medication was still needed with the rationale of why it is needed. It was important to re-evaluate to ensure that resident was not receiving the medication that was not needed and are on the lowest dose possible. During interview on 8/29/24 at 11:40 a.m., consultant pharmacist (CP) stated Lorazepam was to be re-evaluated after 14 days. Provider was expected to document rationale and specify duration of medication. CP stated it was important to re-evaluate medication to make sure the resident was benefiting from it and to ensure the resident was not having any adverse effects from the medication. CP stated any resident on an antipsychotic medication should have orthostatic blood pressures obtained monthly. Pharmacist stated orthostatic blood pressures consist of obtaining a blood pressure when resident is lying, sitting, and then standing within the same timeframe. Pharmacist stated orthostatic blood pressures were important to monitor due to postural hypotension being one of the major side effects, especially in an older person, and would put the resident at a higher risk for falls when taking these medications. The facility Psychopharmacologic Drug Use policy, dated 7/8/2024, identified residents are free from the use of any psychotropic medication for purposes of discipline or convenience and from mediations not required to treat medical symptoms. Psychopharmacologic drugs include antianxiety agents, antidepressants, sedatives, hypnotics, antipsychotics, and other drugs that affect behavior. As needed (PRN) orders must include an indication for use. PRN orders for psychotropic drugs are limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The attending physician or prescribing practitioner directly examines the resident's current condition and progress to determine if the PRN antipsychotic medication is still needed. The facility Blood Pressure - Orthostatic policy, dated 1/2022, identified orthostatic blood pressures are to be obtained to assess effectiveness of medication, assess potential side effects of medications and to assess risk for falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure 1 of 3 residents (R1) reviewed for medication errors received physician ordered medications. In addition, the facility failed to notify the physician of the missed medications. Findings include: R1's admission Record indicated she admitted to the facility on [DATE]. Diagnosis included atrial fibrillation, chronic kidney disease and hypertension. R1's care plan dated 7/9/24, identified an alteration in health status and directed staff administer medications per physicians order. R1's Order Summary Report printed 7/31/24, identified the following order dated 7/9/24: Slow Magnesium/Calcium oral tablet delayed release 70-117 milligram, give two tablets one time a day for hypomagnesemia. R1's Medication Administration Record for July 2024, indicated she received the medicaion on 7/10/24, 7/15/24 and 7/29/24. All other days staff indicated she did not receive the medication. R1's Hospitalist Discharge summary dated [DATE], indicated she admitted to the hospital on [DATE] and discharged on 7/28/24. Discharge diagnosis included atrial fibrillation with ventricular response. The discharge summary indicated during R1's hospital stay she required ongoing magnesium replacement. During interview on 7/31/24 at 10:33 a.m., licensed practical nurse (LPN)-A stated if a medication was not available they could either call the pharmacy or fill out a reorder form and send via fax. LPN-A stated usually she just notified the charge nurse. During interview on 7/31/24 at 10:10 p.m., registered nurse (RN)-A, nurse manager, stated when a medication was not available the nurses were supposed to notify her so she could call the pharmacy. RN-A stated she had not been aware R1's magnesium had never been delivered to the facility. During interview on 7/31/24 at 11:59 p.m., nurse practioner (NP)-A stated she had written the order for the Slow Magnesium because when she last saw R1, her magnesium levels were low which could cause an electrolyte imbalance. NP-A stated the facility had not notified her that R1 never received the prescribed medication. During interview on 7/31/24 at 1:01 p.m. pharmacy technician (PT)-A stated the pharmacy had never delivered R1's magnesium to the facility. PT-A stated the medication was back ordered from their supplier. PT-A stated typically the pharmacy would have either called or sent a fax to the facility to let them know when a medication could not be delivered. During interview on 7/31/24 at 2:05 p.m. the director of nursing (DON) stated she had not been aware R1 had never received her prescribed magnesium and said staff should have notified the physician. Facility Medication Error Management Policy dated 3/31/23, identified medication errors to include medication not available for administration. The policy indicated all medication errors must be reported immediately to the nursing supervisor and DON. The policy further indicated the residents physician or NP must be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to honor resident's right for privacy for 1 of 1 resident (R10) reviewed for resident privacy. Findings included: R10's annual Minimum Data Set (MDS) dated [DATE], identified no cognitive impairment and a diagnosis of COVID-19. R10's progress note dated 9/25/23 at 4:42 p.m., identified R10 returned following a hospitalization for acute respiratory failure due to COVID-19 and was to remain in isolation until 9/28/23, at 11:59 p.m. During an observation on 9/25/23 at 5:17 p.m., a visitor and seven other residents were in the dining room. The visitor asked if R10 would be coming to the dining room to join for the meal. Nursing assistant (NA)-E stated residents had to maintain a 6 foot distance between each other because R10 was positive for COVID-19. Other residents began asking NA-E questions about how long they had to do that, etc. NA-E wasn't up-to-date with COVID requirements, but NA-E thought it was 10 days. NA-E told the residents they needed to stay 6 feet apart at least for a few more days. During an interview on 9/25/23 at 5:34 p.m., NA-E stated the residents already knew R10 had COVID-19 because R10 told them, but, no, we're not supposed to tell people that. During an interview on 9/25/23 at 6:67 p.m., R10 stated he valued his privacy and did not want the other residents in the facility to know he was hospitalized with COVID-19; and didn't want the other resident spreading rumors around about him. During an interview on 9/27/23 at 9:19 a.m., NA-A stated you never discuss a resident's health status or illnesses with other residents. During an interview on 9/27/23 at 1:25 p.m., the director of nursing (DON) stated staff should not talk with residents about the health status or illness of another resident. It was an expected right for R10 to have privacy. The facility's Health Insurance Portability and Accountability Act (HIPAA) Privacy Policy and Procedure dated 9/2016, identified the facility was responsible for ensuring the employees were trained to adhere to HIPAA privacy policy and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R5, R26, R19, R58, R61) reviewed for immunizations. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 admitted to the facility on [DATE], was [AGE] years old, at had diagnoses including hypertension, atrial fibrillation, and history of pancreatic cancer. The facility Immunization Report dated 9/27/23, identified R5 received the pneumococcal polysaccharide vaccine (PPSV23) on 12/2/08 and the pneumococcal conjugate vaccine (PCV13) on 10/30/15. R5's electronic health record did not include evidence R5 or R5's representative received education regarding pneumococcal vaccine booster and there was no indication R5 was offered the pneumococcal vaccine per CDC guidance. R26's quarterly MDS dated [DATE], identified R26 was admitted to the facility on [DATE], was [AGE] years old and had diagnoses including hypertension and stage 3 chronic kidney disease. The facility Immunization Report dated 9/27/23, identified R5 received the PPSV23 on 11/3/05, and the PCV13 on 6/9/16. R26's electronic health record did not include evidence R26 or R26's representative received education regarding pneumococcal vaccine booster and there was no indication R26 was offered the pneumococcal vaccine per CDC guidance. R19's quarterly MDS dated [DATE], identified R19 was admitted to the facility on [DATE], was [AGE] years old and had diagnoses including diabetes mellitus type 2 and hypertension. The facility Immunization Report dated 9/27/23, identified R19 received the PPSV23 on 9/22/10. R19's electronic health record did not include evidence R19 or R19's representative received education regarding pneumococcal vaccine booster and there was no indication R19 was offered the pneumococcal vaccine per CDC guidance. R58's significant change MDS dated [DATE], identified R58 was re-admitted to the facility on [DATE], was [AGE] years old and had diagnoses including coronary artery disease, hypertension, and ischemic cardiomyopathy. The facility Immunization Report dated 9/27/23, identified R58 received the PPSV23 on 10/2/09, and the PCV13 on 2/1/16. R58's electronic health record did not include evidence R58 or R58's representative received education regarding pneumococcal vaccine booster and there was no indication R58 was offered the pneumococcal vaccine per CDC guidance. R61's admission MDS dated [DATE], identified R61 was admitted to the facility on [DATE], was [AGE] years old and had diagnoses including coronary artery disease, hypertension, and rheumatoid arthritis. The facility Immunization Report dated 9/27/23, identified R61 received the PPSV23 on 1/4/12, and the PCV13 on 5/2/17. R61's electronic health record did not include evidence R61 or R61's representative received education regarding pneumococcal vaccine booster and there was no indication R61 was offered the pneumococcal vaccine per CDC guidance. During interview on 9/27/23 at 2:30 p.m., the director of nursing (DON) stated upon admission the nursing staff review the residents medical record as well as the Minnesota Immunization Information Connection (MIIC) database for immunizations and enter the data into the facility immunization assessment. The assessment would identify what immunizations the resident was due for, then staff would offer the immunizations to the resident and/or family representative. The DON was aware the guidance for pneumococcal vaccines had recently changed, and their assessment was updated accordingly. During interview on 9/27/23 at 2:47 p.m., registered nurse (RN)-A, stated they were looking at pneumococcal vaccines with new admission, quarterly, and significant change assessments. The electronic assessment was recently updated but was not updated according to the newest CDC guidance. When there was a new admission, the staff would assess the residents needs and then offer the pneumococcal vaccine, if indicated. They did not have a plan in place to offer or administer pneumococcal vaccinations for current residents. The facility Pneumococcal Vaccine policy version 2.2 (H5MAPL0650), identified upon admission, residents would be assessed for eligibility to receive pneumococcal vaccines and when indicated, would be offered on of the pneumococcal vaccines within thirty days of admission unless medically contraindicated. Before receiving a pneumococcal vaccine, the resident or legal representative would receive education regarding the benefits and potential side effects of the pneumococcal vaccine according to the current vaccine information statements. Provisions of such education would be documented in the resident's medical record. The policy did not address the updated CDC guidance. The facility copy of the currently used Pneumococcal Vaccine Information Sheet was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, failed to implement timely transmission-based precautions (TBP) and testing according to the Centers for Disease Control (CDC) for 1 of 1 residents (R10) who were displaying COVID-19 symptoms; and the facility failed to conduct COVID-19 outbreak testing was conducted according to CDC guidance for 4 of 4 residents (R21, R26, R21, R41) who were exposed to COVID-19 and 1 of 1 staff ( NA-D) who worked without participating in outbreak testing; and failed to ensure surveillance tracking of infections was completed for 6 of 6 residents (R118, R1, R14, R49, R15, R45) who displayed signs and symptoms of potential infection. This had the potential to affect all residents and staff. In addition, the facility failed to ensure catheter care was done to prevent transmission of organisms for 1 of 1 residents (R121). Findings include: COVID: The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 5/8/23, identified when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. - A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. - The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. - Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. - In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction ' s public authority recommends these and additional precautions. - If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. - If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. The CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 updated 9/23/22, identified HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays. When testing a person with symptoms of COVID-19, negative results from at least one viral test indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected. If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. For HCP who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. R10's annual Minimum Data Set, dated [DATE], identified no cognitive impairment and diagnoses included atrial fibrillation, hypertension, renal insufficiency, and diabetes. The Easy Reporting testing log dated 9/26/23, identified R10 tested positive for COVID-19 on 9/20/23, and 9/21/23. R10's nursing progress notes identified the following: - 9/21/23 at 3:12 a.m., R10 put on his call light and complained of not feeling well. R10 sounded congested/nasal congestion. R10's temperature was 97.5 degrees Fahrenheit (F). No coughing noted. R10 stated he felt achy all over and requested to be COVID tested which was negative. The note lacked to identify if R10 was placed in transmission-based precautions. - 9/21/23 at 5:16 p.m., staff approached R10 at approximately 4:00 p.m. in the commons area to complete an informed consent for use of escitalopram. R10 had a congested cough, moderate amounts of bright green mucous at the edge of his nose, and face was flush. R10 stated he was feeling under the weather and that it was worsening throughout the day. R10 was chilled. R10's skin was warm and clammy to touch. R10 was rapid tested earlier and was negative. R10 was retested which was positive. R10 was assisted to his room, updated on status, and R10 would like to take an antiviral if he was eligible. Director of nursing (DON), medical director, administrator, and infection control nurse were updated. An isolation cart was placed outside R10's room and immediate contract tracing was completed with shift staff on at that time and residents who R10 had contact with greater than 15 minutes of high-risk exposure. These residents were scheduled for Covid testing on days 1, 3, and 5. - 9/22/23 at 1:33 a.m., R10 was admitted to the hospital due to COVID-19. - 9/22/23 at 1:47 a.m., late entry for 9/21/23: unidentified trained medication assistant (TMA) reported to writer R10 was not doing well and wanted to go to the ER. The TMA stated R10's oxygen saturations were 77% on 2 liters per minute (lpm) per nasal cannula (nc). R10 had yellow mucus from his nose, lung sounds were adventitious (abnormal lung sounds heard over the lungs and airways) bilaterally. Called the provider on call and received order to send R10 to ER for evaluation and treatment. R10's blood pressure was 139/29, pulse 99, temperature 103.2 degrees F, and oxygen saturations were 77% on 2 lpm via nc. R10 was transported to the hospital via ambulance at 6:55 p.m. R21's significant change MDS dated [DATE], identified R21 had no cognitive impairment and diagnoses included atrial fibrillation, heart failure, hypertension, renal insufficiency, and diabetes. The Easy Reporting testing log dated 9/26/23, identified R21 tested negative for COVID-19 on 9/21/23, 9/22/23 and 9/23/23. During an interview on 9/27/23 at 9:06 a.m., RN-B stated R21's COVID-19 testing was initiated by RN-C during contact tracing from R10's positive COVID-19 test. R21 should have been tested on day 1, day 3 and day 5. R21 tested on day 0, day 1 and day 3. This did not meet the facility's testing plan. R26's significant change MDS dated [DATE], identified R26 had a severe cognitive impairment and diagnoses included Alzheimer's disease, renal insufficiency, and hypertension. The Easy Reporting testing log dated 9/26/23, identified R26 tested negative for COVID-19 on 9/22/23 and 9/24/23. During an interview on 9/27/23 at 9:06 a.m., RN-B stated R26's COVID-19 testing was initiated by RN-C during contact tracing from R10's positive COVID-19 test. R26 should have been tested on day 1, day 3 and day 5. R21 tested on day 1 and day 3, but the log did not identify R26 was tested on day 5. This did not meet the facility's testing plan. R27's quarterly MDS dated [DATE], identified R27 had severe cognitive impairment and diagnoses included Alzheimer's disease, hypertension, renal insufficiency, and diabetes. The Easy Reporting testing log dated 9/26/23, identified R27 tested negative for COVID-19 on 9/22/23 and 9/24/23. During an interview on 9/27/23 at 9:20 a.m., RN-B stated R27's COVID-19 testing was also initiated because of her exposure to R10. R10 should have completed testing according to the facility's testing plan. R41's quarterly MDS dated [DATE], identified R41 had a severe cognitive impairment and diagnoses included Alzheimer's disease. The Easy Reporting testing log dated 9/26/23, identified R41 tested negative for COVID-19 on 9/22/23 and 9/24/23. During an interview on 9/27/23 at 9:25 a.m., RN-B stated R41 was also exposed to R10. R10 should have completed testing according to the facility's testing plan. R41 tested the morning of 9/27/23, due to exhibiting possible symptoms of COVID-19. NA-D's Sample Risk Assessment for Healthcare Workers Potentially Exposed to COVID-19 in Minnesota dated 9/21/23, identified NA-D was within 6 ft of a person with confirmed COVID-19 for greater than 15 minutes without personal protective equipment (PPE). NA-D was determined to be high-risk due to NA-D had prolonged close contact with R10 and was not wearing a surgical mask or respirator. The Easy Reporting testing log dated 9/26/23, identified NA-D tested negative on 9/22/23 and 9/24/23. The log did not identify if NA-D tested for COVID-19 on 9/26/23. During an interview on 9/27/23 at 7:16 a.m., NA-B stated staff really didn't have to do anything with R10. R10 did his own cares, staff picked up his trash and his dirty clothes. That was about it. The day R10 became ill, R10 was in the dining room, the common area, he was all over. No one was wearing PPE. The next day, NA-B tested and threw the test away. It was negative. NA-B did not know if the facility had to track any testing results. NA-B did not write it down anywhere. During an interview on 9/27/23 at 7:48 a.m., LPN-B was observed unmasked and stated she worked the day R10 became sick. R10 was saying he had a little tickle but did not have a fever. Later that day, he became sick. LPN-B didn't think anything of it. R10 was independent with supervision to make sure he's clean and his bathroom was clean. R10 was about and about. He ate at the corner table in the common area. His tablemate, most of the time, ate his meals in his room. LPN-B could not say if R10 ate alone that day. All staff tested for COVID-19, the results were written down on the sign in sheet and staff with close contact masked for 10 days. Staff would know if they had close contact because you knew what you've done with the resident every day. For LPN-B, close contact meant if you had to assist the resident to eat or if you had to help with daily cares. LPN-B passed medications to R10 but R10 thought he was the boss, so you don't like to hang around. It really depended on how much care a resident required. Staff tested that day, you can't lie, staff reported to the nurse manager and RN-B. RN-B took care of all that for staff. During an interview on 9/27/23 at 8:00 a.m., NA-F was observed unmasked and stated she worked until 5:00 p.m. the day R10 became ill. R10 was sitting in his recliner in the common area like he always did, and he sounded horrible. Coughing, congested. NA-F told the nurse but could not remember who the nurse was. R10 was tested after NA-F left for the day and was sent to the hospital. The next day, NA-F had to test. Staff collected their own swab in the nurses' station and the nurse put the swab in the card. The nurse took care of it after that. Afterwards, NA-F was instructed to wear a mask for 10 days. NA-F stated 9/27/23, was day 6. NA-F was off and when she came to the facility that morning the sign in sheet did not say she needed to mask or not. So, NA-F did not need to. During an interview on 9/27/23 at 9:06 a.m., RN-B stated she was responsible for the facility's infection control program for a little less than three months. If a resident was feeling ill, the cart nurse should update the nurse manager and, if there were any concerns, the nurse manager would let RN-B know. RN-B was also available during off hours by phone and email. There was always a RN on-call, and they should call her for guidance as well. RN-B was informed of R10's positive COVID-19 test on Monday, 9/25/23, because she was on vacation. R10 wasn't feeling good, the nurse manager tested him that morning and R10 was negative. Then, the nurse went to get a consent form that afternoon, R10 was clammy and didn't feel good. R10 was tested again, and it was positive. Test results are entered in the assessment tab in R10's electronic health record (EHR) and the result automatically populated on the Easy Reporting testing log. In R10's progress notes, it showed R10 was tested at 3:12 a.m. on 9/21/23, but nursing did not enter the test in the assessment. R10 complained of nasal congestion and achy all over. On rounding notes, it just said R10 wasn't feeling well, and no monitoring was initiated. Ideally, monitoring should have been implemented in R10's EHR. Because R10's COVID-19 antigen test was negative and there was no known exposure, R10 was not placed in transmission-based precautions prior to his COVID-19 antigen test was positive. RN-B did not know the CDC guidance regarding using antigen tests for residents or staff that were symptomatic for COVID-19. The facility policy one test confirmed a resident was negative. RN- B stated it would make sense to place R10 in transmission-based precautions because he was symptomatic. Symptoms could mean he was contagious to other staff and residents. RN-C and the director of nursing (DON) did contact tracing the day R10 tested positive. For residents, they determine who was exposed for greater than 15 minutes in 24 hours. Staff did not observe every resident at all times because it just was not possible. RN-C and the DON filled out the contract tracing sheets and found only two staff that needed to test: NA-D and NA-E. RN-B was unaware of any other staff that needed testing. Staff were to notify RN-B when a test was completed for tracking of the information. When RN-B was in the facility and was notified of a staff's exposure, RN-B would put in a note prior to the shift to make sure the staff tested. The result was entered into Easy Reporting. RN-B stated there are antigen tests on the units, so the nurses have them for residents. Staff used them though and didn't communicate that. If RN-B did not know of a test, she was unable to document it and track it properly. RN-B has spoken to the DON about that because, according to the contact tracing forms, only NA-D was supposed to test for COVID-19. During an interivew on 9/27/23 at 10:25 a.m., RN-C stated when a resident exhibited signs or symptoms of COVID-19, nursing assessed them depending on the symptoms and the resident's medical history. It really didn't matter what symptoms, a COVID-19 antigen test was done because it either rule it out or clarified the problem. R10 was tested at approximately 3:00 a.m. on 9/21/23, with an antigen test with a negative result. That's what was reported off to day shift. R10 was not placed into transmission-based precautions but was greater than 6 feet away from residents and staff. Contact tracing was done. There were four residents and two staff that needed to be tested. Initially two staff tested right away because they had direct contact, but with further evaluation no one had more than 15 minutes with R10. R10 usually sat by himself and talks to others but sits so most are more than 6 feet away from him. Basically, we're told if a resident is acting abnormal to test. The nurse practitioner always asked if we tested a resident when we call her. RN-C was unaware of CDC guidance for use of antigen tests with symptomatic residents and stated, in her experience, one COVID-19 antigen test with a negative result ruled out COVID-19. Typically, nursing looked for a persistent cough, fever, burning in the chest, loss of taste or smell. During an interview on 9/27/23 at 10:45 a.m., the DON stated the unit nurse managers were responsible for infection control on their unit, implementing transmission-based precautions and tracking/trending of infections during the month. Staff should update the nurse manager or charge nurse with symptoms so they can be assessed and tested. All testing should be documented. I know we were doing it wrong. During an interview on 9/27/23 at 12:53 p.m., the DON stated the staff figured out where problems began. Prior to June, the facility was using a quantative real-time PCR or q test which only required one test. After June, the staff began using the antigen tests and did not realize they needed to change the testing process. The facility policy COVID-19 Community Testing Plan dated 8/6/21, identified the purpose of the policy was to identify COVID-19 positive residents and staff through viral testing; testing was a priority to help inform clinical care and infection prevention and control practices in the facility's setting. A negative RT-PCR test only indicated that an individual did not have detectable virus material present at the time of testing, and repeat testing might be needed. Widespread community transmission as well as movement of staff and residents in and out of a facility result in continuous introduction. Testing complimented existing infection control interventions but did not replace good infection control. However, the policy did not address the use of antigen tests. The facility policy COVID-19 policy undated, identified residents and team members with suspected/confirmed COVID-19 or exposures would be quarantined/isolated based on the most up-to-date CDC guidance. Residents and team members with symptoms of COVID-19 would be tested unless an alternate diagnosis was provided by a healthcare provider with the appropriate scope of practice. admission testing, outbreak testing, and exposure-related testing of residents and team members would be based on the most up-to-date CDC guidelines. Residents would be placed under enhanced respiratory precautions until symptoms could be ruled-out as COVID (via testing or alternate diagnosis). However, the policy did not address the use of antigen tests. Surveillance R118's admission Record dated 9/27/23, identified R118 was admitted to the facility on [DATE]. R118 had diagnoses that included chronic obstructive pulmonary disease (COPD) and diabetes. R118's progress notes identified the following: - 9/8/23 at 4:35 p.m., R118 admitted to the facility with a primary diagnosis of left femur fracture and UTI. Resident is alert and oriented to person, place, and time, pleasant and cooperative upon assessment. Faint crackles in lower lobes. Resident reports a dry cough. COVID test was negative. Does report having issues with dizziness and vertigo. Educated R118 to change positions slowly and not to get up without staff present until cleared by therapy to do so. Educated on the use of the call light and was able to verbalize understanding of its use. No further questions or concerns at this time. - 9/10/23 at 3:32 p.m., identified R118 complained of nausea and general gastrointestinal distress. R118 had her morning medication sitting on bedside table and stated, I'm just not going to take them with me being nauseated, I was going to earlier but decided not to as won't keep them down. Resident sat at bedside, alert and orientated, complained of nausea, pneumand was given Maalox. R118's COVID test negative. R118 just could not give specific symptoms of not feeling right; just nauseated. R118 had large normal bowel movement, denied shortness of breath or respiratory distress, chest pain or discomfort. Vital signs were within normal range for R118's baseline. Staff encouraged resident to be up and see if that helped. During an interview on 9/27/23 at 9:06 a.m., RN-B stated she was unaware of R118's cough or symptoms. R1's significant change MDS dated [DATE], identified R1 had a moderate cognitive impairment and diagnoses that included dementia, pneumonia, and respiratory failure. R1's progress note dated 9/10/23 at 5:53 a.m., identified R1 was awake this shift since 01 :30 and was irritable. R1 had a non-productive cough since 1 :30 a.m. which was unaided by an Albuterol nebulizer but responded somewhat to Tussin cough syrup. COVID swab administered at 3:30 a.m. and was negative. R1's progress note dated 9/10/23 at 5:44 a.m., identified at 1:00 R1 started having an infrequent nonproductive cough. At 3:00 a.m., R1's cough had increased in frequency but remained non-productive. Vitals were within normal limits. R1's lung sounds were wheezy on left and mildly congested on right in all lobes. R1 was given an Albuterol nebulizer treatment and was somewhat effective. Cough decreased in frequency and respirations came down to 20. At 3:28 a.m., Tussin cough syrup was offered and accepted for cough (medication was effective). At 3:30 a.m., COVID swab administered with negative results. During an interview on 9/27/23 at 9:06 a.m., RN-B stated R1 had repetitive aspiration pneumonia. R1 was not added to the Monthly Infection log. R14 annual MDS dated [DATE], identified R14 had a severe cognitivie impairment and had diagnoses that included Alzheimer's disease. R14's progress note dated 9/10/23 at 5:52 a.m., identified at 3 :30 a.m. a COVID swab was administered to R14 with negative results. R14 had a frequent, non-productive cough from 03:30 - 05:00 with a temperature of 97.5 degrees F. R14's EHR failed to identify further documentation related to R14's cough. During an interview on 9/27/23 at 9:06 a.m., RN-B stated R14 did not have a repeat test. RN-B read the progress note and was aware of R14's symptoms but did not add R14 to the Monthly Infection log. R49's admission MDS dated [DATE], identified R49 had no cognitive impairment and had diagnoses that included atrial fibrillation, hypertension, and diabetes. R49's progress notes identified the following: - 9/17/23 at 8:19 p.m., R49 was out of the facility, returned with upper wheeze vocal sounds with breathing. Only happened when breathing through his nose. Denied any allergies. COVID test was done, lungs assessed, clear throughout. Denied shortness of breath. Denied wanting to go to ER. Fell asleep during the assessment. Noted short periods of apnea, and then R49 coughed and took a deep breath. -9/17/23 at 11:09 p.m., identified R49 was of the facility for a birthday party. R49 came back very fatigued and went straight to bed. He did not get up for supper so R10's insulin was held and continued to monitor his blood sugar. Later, R49 was complaining of a cough and phlegm in his throat. His lungs were clear. Blood pressure was 111/73, oxygen saturations were 93%, pulse was 77, temperature 98 degrees F and respirations 14. R49 continued to state that he was not feeling well, he thought this may be because of taking the suboxone. This was his third dose, but R49 stated his symptoms started shortly after. Nursing continued to check in on the R49 multiple times throughout the remainder of the shift. R49 was having longer periods of apnea and staff reminded him to breathe. R49 was still refusing to go into the ER. During an interview on 9/27/23 at 9:06 a.m., RN-B stated the charge nurse stated in her note R49 said it was a side effect of his meds, but R49 had signs of COVID-19. RN-B was unaware of R49's symptoms. R15's significant change MDS dated [DATE], identified R15 had no cognitive impairment and had diagnoses that included atrial fibrillation, renal insufficiency, and cancer. R15's progress notes identified the following: - 9/17/23 at 8:27 a.m., identified the nursing assistant summoned nursing to R15's room and stated she thought R15 was sick. R15 was lying in bed with blankets and all clothes stripped away, a flushed complexion, and covered in yellow vomit. R15 stated I feel like horseshit. R15's rapid COVID test was negative. R15 was taking chemotherapy. Charge nurse was updated. - 9/17/23 at 11:00 a.m., identified staff stopped and spoke with R15. R15 reported he was not feeling well all over. Rapid COVID test was negative. R15 was in bed resting. - 9/17/23 at 1:27 p.m., identified R15 was in bed since 9:30 a.m., stating I feel sick. Supervisor updated. During an interview on 9/27/23 at 9:06 a.m., RN-B stated, yes, R15 was showing signs and symptoms of COVID-19. RN-B was unaware of his symptoms. R45's significant change MDS dated [DATE], identified R45 had a mild cognitive impairment and had diagnoses that included hypertension, pneumonia, and diabetes. R45's progress note dated 9/23/23 at 4:25 p.m., identified R45 told staff she had been sneezing and coughing and had a burning throat. A COVID-19 test was administered and was negative. R45's EHR lacked to identify further information regarding R45's symptoms. During an interview on 9/27/23 at 9:06 a.m., RN-B stated she was unaware of R45's symptoms but R45 had previously been positive for COVID-19 less than 30 days prior. The facility Monthly Infection log dated September 2023, identified room number, resident name, site, criteria met, date of admit, date of symptoms, signs/symptoms, antibiotic treatment, antibiotics entered in antibiotic tracker, 72-hour hold completed in antibiotic tracker and resolved date. The log identified five UTI, one sepsis, one right ankle repair and one cellulitis. The log lacked to identify any infection not requiring antibiotic treatment, including R10's COVID-19 infection; and R118, R1, R14, R49 or R15 potential infection symptoms. During an interview on 9/27/23 at 9:06 a.m., RN-B stated she would need to speak with the DON because she was unsure what was requested when asked for the surveillance logs. RN-B provided a large green binder and stated the facility conducted infection prevention rounds weekly. A map of the facility was color coded by infection type to determine if there were any common factors such as room location. The log identified any resident who required antibiotic treatment for an infection. RN-B reviewed nursing progress notes daily and ensured monitoring was entered into the resident's EHR. On the units, nursing also had a log where they entered information, but this was also for residents treated with an antibiotic. RN-B reviewed the unit logs at the end of the month and entered them onto the log in the binder. Because R118, R1, R14, R49 or R15 were not prescribed an antibiotic, they would not be entered into the log for trending and/or tracking. During an interview on 9/27/23 at 10:45 a.m., the DON stated RN-B was in the infection prevention role for approximately three months. In the beginning, the DON was pretty involved, but RN-B seemed to catch on quickly. General surveillance logs should be reviewed by the nurse managers consistently and then given to RN-B at the end of the month to review them. The nurse managers were responsible for infection prevention on their units, were responsible to implement transmission-based precautions, and tracking and/or trending of infections during the month. The nursing staff should update the nurse managers with any signs/symptoms of infection and enter the information on the log. During an interview on 9/27/23 at 12:54 p.m., RN-B stated she was aware of the missing months of Monthly Infection Control Reporting Logs from the units and the Lodge unit never completed them. [NAME] verified there are months missing from the Monthly Infection Control Reporting Log and The Lodge unit never completed them. They should have and the unit managers were educated about that. The facility policy Surveillance for Infections revised September 2017, identified the Infection Preventionist would conduct ongoing surveillance for healthcare acquired infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Infections that will be included in routine surveillance include those with: a. Evidence of transmissibility in a healthcare environment; b. Available processes and procedures that prevent or reduce the spread of infection; c. Clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTIs, C. diff); and d. Pathogens associated with serious outbreaks. (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza). In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted; for example, focused surveillance data may be gathered for residents with a high-risk for infection or those with a recent hospital stay. Catheter Care: R121's admission MDS dated [DATE], identified R121 had no cognitive impairment and R121 used an indwelling urinary catheter. R121's Order Summary Report dated 9/26/23, identified the following: 1. Staff were to provide education regarding catheter care every shift. 2. Change foley catheter as needed based on clinical indications such as infection, obstruction or when the system is compromised. During an observation on 9/26/23 at 10:23 a.m., LPN-C emptied R121's catheter leg bag. LPN-C applied gloves and obtained R121's graduate from his bathroom. LPN-C placed the graduate on the floor under the R121's catheter leg bag port, opened the port and drained the bag. LPN-C cleaned the catheter bag port with an alcohol swab and closed the port. LPN-C then poured the urine into the toilet and rinsed the graduate with water. During an interview on 9/26/23 at 10:32 a.m., LPN-C stated you needed to make sure to wipe the port with alcohol before opening the catheter bag port. Normally, she would have placed a barrier between the graduate and the floor. She just didn't today. LPN-C believed she cleaned the port before opening. During an interview on 9/27/23 at 1:05 p.m., RN-D stated she expected staff to follow the facility's procedure for catheter care by placing a barrier between the graduate and the floor and cleaning the port before and after opening. During an interview on 9/27/23 at 1:14 p.m., the DON stated she expected staff to perform catheter care per procedure by placing a barrier between the floor and the graduate as well as cleaning the port prior to opening to prevent the spread of possible bacteria. The facility's catheter care policy was requested but not received.

Based on observation, interview and document review the facility failed to implement a process for conducting routine maintenance of rehabilitation equipment. This had the potential to affect all residents in the facility who received rehabilitation services. Findings include: On 9/12/23, at 1:07 p.m. A standing frame in the facility wellness center was observed. The standing frame had a sign on it that indicated out of service, do not use. During interview on 9/12/23, at 1:11 p.m. the physical therapy assistant (PTA) program manager stated the maintenance department had taken the standing frame out of commission. The PTA stated there was supposed to be a back support on the frame and said the facility was unable to locate it and was unable to purchase one. The PTA stated he had worked at the facility three years prior and did not believe he had ever seen the back support. The PTA stated the missing back support would not have contributed to the injury that prompted the inspection of the standing frame. During interview on 9/12/23, at 1:17 p.m. the restorative aide, nursing assistant (NA)-A stated the sign was placed on the standing frame following an incident in which a resident was injured. On 9/12/23, at 2:34 p.m. the maintenance director stated he had reached out to the company who made the standing frame and said no parts were available so it was taken out of commission. The maintenance director stated he did not have any maintenance records on the rehabilitation equipment in the wellness center. He said maintenance made sure nuts and bolts were tights and nothing broken but said for the most part, nothing. The maintenance director said he was not aware the standing frame was missing a part and said an outside company inspected the therapy equipment annually but said the inspector had missed the standing frame and had last looked at it in 2022. A policy related to maintenance of rehabilitation equipment was requested but not received.