**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure allegations of abuse were reported to the State Agency (SA) immediately (within two hours) for 1 of 3 residents (R1) reviewed for allegations of abuse. Findings include: R1's 5-day Minimum Data Set (MDS) dated [DATE] indicated R1 had moderately impaired cognition with diagnoses which included diverticulitis with recent surgery on the gastrointestinal tract. A Facility Reported Event (FRI) submitted to the SA on 6/11/25 at 4:25 p.m. indicated on the evening shift of 6/6/25 R1 told a social worker a nurse had put their hands on R1's neck, and pushed her back into bed. R1 was not sure if the nurse was going to choke her. R1 was in shock over what happened, but was not physically harmed. On 6/16/25 at 3:31 p.m., R1 stated she told nursing assistant (NA)-A, registered nurse (RN)-A had tried to choke her on the evening of 6/6/25. NA-A told her he would report it to someone higher. RN-A came back into R1's room and was questioning her. R1 stated she was afraid of RN-A that evening. On 6/16/25 at 3:57 p.m., RN-A stated she was the nurse caring for R1 on 6/6/25. She heard an alarm sounding in R1's room, and went to investigate. She found R1 with the upper part of her body face down on her bed with her feet on the floor. She assisted R1 into a sitting position on the bed by stabilizing R1's shoulders. She settled R1 into a comfortable position with the call light in reach, and left the room. Later that evening, NA-A told her that R1 had reported to him RN-A had tried to choke her. She went back to the patient room to talk to R1 about the situation. She did not report the allegation to the administrator or director of nursing (DON). On 6/16/25 at 4:21 p.m., NA-A was unavailable for interview. On 6/17/25 at 1:03 p.m., the DON stated R1 told the social worker about the event on 6/11/25. The social worker immediately told the DON who started the investigation. She confirmed this allegation should have been reported to the DON or the administrator on 6/6/25 when R1 told NA-A about the incident. The DON confirmed RN-A worked with R1 following the incident. No formal re-education was provided to staff about the importance of reporting all details immediately to the administrator or DON. The undated facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Patient Property directed any nursing home employee who becomes aware of abuse, mistreatment, neglect or misappropriation shall immediately report to the nursing home administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow residents to safely administer their own medications for 1 of 1 resident (R171) observed with medications at the bedside. Findings include: R171's Entry Tracking Record dated 11/25/24, indicated R171 was admitted to the facility on [DATE]. R171's face sheet dated 12/4/24 at 11:23 a.m., indicated the following diagnoses: reactive airway disease, closed fracture of the right humerus (upper arm), closed left hand fracture, osteoporosis (a disease that weakens bones) with pathological fracture (a fracture due to underlying disease), closed nondisplaced fracture of first metacarpal (bone near the thumb) bone of the left hand, closed displaced (out of alignment) fracture of shaft of first metacarpal bone of left hand. R171's temporary care plan (TCP) dated 11/25/24, indicated intact cognition. Additionally, the TCP indicated on 12/4/24, R171 could SAM inhalers at the bedside. R171's physician's orders indicated the following orders: • 11/25/24, fluticasone-vilanterol (Breo Ellipta) 100-25 MCG (microgram)/ACT (actuation) inhaler 1 dose daily. • 11/25/24, umeclidinium (Incruse Ellipta) 62.5 MCG/ACT inhaler 1 puff daily. • R171's physician's orders lacked information R171 could self administer inhalers. R171's admission progress note dated 11/25/24 at 3:09 p.m., indicated R171 was unable to use arms to eat, was non-weight bearing on the left wrist and had a sling to the right shoulder. R171's SAM dated 12/4/24, indicated R171 wished to self administer medications and was appropriate for R171 to self-administer the Incruse Ellipta and Breo Ellipta and medications would be stored at the bedside. During interview and observation on 12/3/24 at 8:51 a.m., and 9:02 a.m., registered nurse (RN)-A picked up the Incruse Ellipta inhaler 62.5 mcg/ACT and was looking for the Breo Ellipta that was located on R171's bedside table. RN-A provided R171 with the Breo Ellipta inhaler and some water. RN-A stated she had to check to see if R171 could have the Breo Ellipta at the bedside and stated staff looked in the summary and the medication administration record (MAR) to know if a resident could self administer their medication. RN-A viewed the computer and stated there was nothing located in the medical record that indicated R171 could self administer the medication and stated she would put the medication back in the drawer. Further, RN-A stated an assessment was completed on admission to determine whether a resident could self administer a medication. During interview on 12/4/24 at 9:40 a.m., the director of nursing (DON) stated the nurse asks residents whether they would like to keep any medications at the bedside and stated the assessment is completed and placed in an orange book at the nursing stations and then a tag line located at the top of the electronic medical record (EMR) is placed if a resident can SAM. The DON reviewed R171's record and stated she did not locate anything and stated she did not recall R171 having a SAM and stated if they don't want to SAM, medications were not left at the bedside until they were reassessed. A policy, Self-Administration of Drugs, dated September 2024, indicated patients who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. As part of their overall evaluation, the staff and practitioner will assess each patient's mental and physical abilities, to determine whether a patient is capable of self-administering medications. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including ability to read and understand medication labels, comprehension of the purpose and proper dosage and administration time for his or her medications, ability to remove medications from a container and to ingest and swallow them, and ability to recognize risks and major adverse consequences of his or her medications. If the staff or IDT determines that a patient cannot safely self-administer medications, the nursing staff will administer the patient's medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure that an opened medication was labeled and contained the correct expiration date for one of one resident (R126), and failed to ensure an expiration date was documented on an opened medication for one of one resident (R176) reviewed. Further, staff were not aware of the correct expiration date of an insulin medication once opened. Findings include: The Admelog website, products.sanofi.us/admelog/admelog.pdf indicated opened Admelog insulin vials must be used within 28 days or be discarded, even if they still contained Admelog. R126: R126's face sheet form dated [DATE] at 11:32 a.m., indicated R126 had a diagnosis of type two diabetes. R126's physician's orders form indicated the following order: • [DATE], insulin lispro (Humalog, Admelog) injection vial, inject 10 units three times a day with meals. During interview and observation on [DATE] between 8:10 a.m., and 8:45 a.m., registered nurse (RN)-B pulled a multi-dose vial of Admelog insulin 100 units/milliliter (ML) out of the medication cart. The insulin did not contain a label that identified who the insulin belonged to. Further, the insulin was not in a bag. RN-B stated at 8:29 a.m., the insulin was not labeled, but stated she knew it was R126's insulin because R126 was there the day prior and stated she could go into the refrigerator and waste the bottle, however stated there was none in the refrigerator. At 8:43 a.m., RN-B opened a new multi-dose vial of Admelog insulin and stated she assumed the insulin expired after one month and added an expiration date of [DATE], and administered the insulin to R126 at 8:45 a.m. During interview on [DATE] at 12:34 p.m., RN-D stated all insulins were discarded 28 days after opening. During interview on [DATE] at 11:24 a.m., the pharmacist consultant (PC) stated insulin bottles stored in drawers with multiple residents should contain identifiable information on who the insulin belonged to. R176: R176's face sheet form dated [DATE] at 11:15 a.m., indicated R176 had type two diabetes mellitus without complication, with long-term current use of insulin. R176's physician's orders form indicated the following order: • [DATE], insulin lispro (Humalog, Admelog) injection vial 4 units three times a day with meals. During interview and observation on [DATE] between 10:19 a.m., and 10:29 a.m., licensed practical nurse (LPN)-A explained the process of dispensing medications from the Pyxis medication cart. LPN-A stated when administering medications, opens the chart and reviews medications. LPN-A stated all insulin bottles were multi-use vials and were dated when opened, and expired after 30 days. Further, LPN-A verified R176 had a multi-dose vial of Admelog that was opened on [DATE], but did not contain an expiration on the bottle. During interview on [DATE] at 10:56 a.m., LPN-A stated she clarified the expiration date for Admelog was actually 28 days with RN-D. During interview on [DATE] at 9:40 a.m., the director of nursing (DON) stated their policy indicated insulins were labeled with the patient name and date of birth , physician, and medical record number and were dated when opened and further, the vial was scanned and the order showed up for staff to be certain they had the correct medication. The DON stated it was important to have a label in order to know who the medication belonged to. During interview on [DATE] at 11:01 a.m., the DON stated they were looking at the open date and have not always written the expiration date but the rule was 28 days. A policy, Labeling of Medication Containers, dated [DATE], indicated all medications maintained in the facility shall be properly labeled in accordance with current state and Federal regulations. Labels for individual drug containers shall include all necessary information such as the expiration date when applicable. Further, labels for small multi-dose containers will include all necessary information: the patient's name, the patient's MRN (medical record number), attending physician, and the date opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure medications were passed without an error rate greater than 5 percent (%) by failing to follow administration instructions for 1 of 6 residents (R74) observed for medication administration. There were 30 opportunities for medication administration with two errors. This resulted in an error rate of 6.67%. Findings include: R74's admission Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairment with diagnoses including pneumonia, acute (short-term) respiratory failure, heart failure and atrial fibrillation (an irregular heart rhythm). R74's physician orders observed for morning medication pass included the following: - potassium chloride (Klor-Con M) extended release 20 milliequivalents (mEq) oral tablet once daily, should be swallowed whole, for treatment of low potassium levels, dated 1/23/24. - furosemide (Lasix) tablet 40 milligrams (mg) oral tablet once daily for treatment of heart failure, dated 1/17/24. - metoprolol tartrate (Lopressor) oral tablet 25mg twice daily, to be taken with food, for treatment of atrial fibrillation, dated 1/16/24. - metronidazole (Flagyl) oral tablet 500mg twice daily for treatment of pneumonia, dated 1/16/24. - levofloxacin (Levaquin) oral tablet 750mg once daily, do not give within 2 hours of calcium, iron, magnesium supplements or antacids, for treatment of bacterial pneumonia, dated 1/17/24. - ferrous sulfate enteric coated (EC) oral tablet 325mg once daily on Mondays and Thursdays for treatment of low iron levels, dated 1/18/24. - clopidogrel (Plavix) 75mg oral tablet once daily for treatment of heart disease, dated 1/09/24. During observation of medication administration on 2/01/24 at 8:20 a.m., registered nurse (RN)-B was preparing R74's morning medications. She scanned each individual medication package and verified the medication, the dose, the route, time and expiration date on the packaging against R74's medication administration record (MAR). RN-B scanned one levofloxacin (antibiotic) tablet with administration instructions that advised, do not give within 2 hours of calcium, iron, magnesium supplements or antacids, and put the tablet into the medication cup. RN-B then scanned one ferrous sulfate tablet (type of iron supplement) and put that tablet into the medication cup. RN-B scanned one potassium chloride tablet with administration instructions that advised it, should be swallowed whole, and put the tablet into the medication cup. RN-B gave the medication cup to R74, who requested the bigger tablets be split in half so she could swallow them. RN-B performed hand hygiene, applied gloves, and retrieved each large tablet and used a pill splitter to split each tablet, including the potassium chloride tablet. RN-B gave the cup back to R74 and monitored while she took her medications. During interview on 2/01/24 at 9:59 a.m., RN-B reviewed R74's MAR and verified potassium chloride had administration instructions advising not to split the tablet and acknowledged splitting the tablet during morning medication pass. RN-B reviewed administration instructions for levofloxacin and verified the instructions advised not to administer with iron, which RN-B acknowledged doing. RN-B reported being unaware of any potential adverse effects of administering the antibiotic with iron. RN-B stated R74's provider would be updated on the medication errors and a request for a different form of potassium would be made. During interview on 2/01/24 at 10:46 a.m., the pharmacist stated potassium chloride tablets are coated for extended release and by not swallowing them whole, they could lose their effectiveness. If a resident was unable to tolerate swallowing the tablet whole, the pharmacist recommended contacting the provider for either a liquid or effervescent form of potassium. The pharmacist stated levofloxacin is less effective when taken with iron because there is decreased absorption, which could lead to decreased effectiveness of the antibiotic The pharmacist recommended if a nurse came across these two medications being scheduled at the same time, the nurse could contact the pharmacist by message or phone call to adjust the timing to ensure administration instructions were followed. During interview on 2/01/24 at 1:05 p.m., the director of nursing (DON) stated if a medication's administration instructions advised the nurse not to split the medication, the nurse could offer the resident to take the medication whole with applesauce. The DON stated the expectation was not to split the tablet and contact pharmacy for recommendations as there could be negative outcomes related to splitting potassium tablets. The DON stated the expectation of nurse who encountered administration instructions for levofloxacin to not administer with iron, which had the same scheduled administration time, would be to stop the process and determine which medication could be held. The DON expected the nurse to contact the pharmacist for further advisement. The DON stated if a nurse made a medication error, the nurse was expected to report the error to the DON and they would work together to correct it. An undated facility policy titled MED31 - Administering Oral Medications advised following medication administration guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** HAND HYGIENE during incontinence cares: R6's admission minimum data set (MDS) dated [DATE], indicated R6 was cognitively intact and did not refuse cares. R6 required assistance with toileting hygiene, dressing, mobility, and transfers. R6's care sheet dated 1/30/24, indicated R6 was on contact isolation for extended-spectrum beta-lactamases (ESBL; a bacteria which cannot be killed by many antibiotics used to treat infections) in urine, incontinent of bladder and continent of bowel, and transferred using a mechanical lift with two to three staff. During observation on 1/31/24 at 8:55 a.m., NA-B assisted R6 with activities of daily living with personal protective equipment (PPE) which included a gown and gloves. NA-B removed R6's incontinence product and wiped R6's bottom with gloved hands while R6 was laying on their side. Bowel movement was noted on the wipe and NA-B grabbed a clean incontinent product and tucked the product under R6 without performing hand hygiene or changing their gloves. NA-B assisted R6 to lay on their back and wiped R6's perineal area with different wipes and the same gloves. NA-B turned R6 on to their other side and R6's brief was secured. NA-B removed their gloves, did not perform hand hygiene, and placed new gloves on their hands. NA-B assisted R6 to dress with pants and a shirt, and NA-B assisted R6 to transfer from their bed to wheelchair using a mechanical lift. During interview on 1/31/24 at 9:27 a.m., NA-B stated staff should perform hand hygiene between glove changes and change their gloves and perform hand hygiene after cleaning bowel movement and before touching a clean incontinent brief. NA-B stated they perform peri-cares from bottom and up and start with the bottom or peri-area depending on where bowel movement is if there is so. When interviewed on 2/1/24 at 2:31 p.m., the Director of Nursing (DON) expected staff to follow the signage posted outside of the residents' room and wear the appropriate PPE for any task inside the room. All used PPE should be removed and disposed of inside the residents' room and appropriate handwashing to occur. Used items or supplies should remain inside the room, and should be disposed of in the room. Resident items should not be going in and out of the room of resident's room who require TBP. Furthermore, DON expected staff to remove gloves and perform hand hygiene when moving from soiled or dirty areas to clean areas during resident care as well as after glove removal. A facility policy titled Infection Control Guidelines for All Nursing Procedures no date, directed staff to wash hands after removing gloves, and staff must wash hands with soap and water when likely exposure to C. Diff. A facility policy titled Isolation- Categories of Transmission Based Precautions no date, directed staff to use TBP when caring for residents who have suspected or confirmed communicable diseases or infections that can be transmitted to others. The facility's policy Standard Precautions undated, directed staff to wash hands after removing gloves and remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. Based on observation, interview and document review, the facility failed to follow nationally recognized best practices regarding isolation precaution for communicable diseases for 1 of 4 residents (R7) this had the potential to affect 8 residents who resided on the unit. Additionally, the facility failed to ensure hand hygiene was performed during incontinent cares for 1 of 1 resident (R6) reviewed for infection control practices. Findings include: R7's admission minimum data set (MDS) dated [DATE], indicated R7 was cognitively intact, did not refuse cares, and incontinent of bladder and bowel. R7 had impairment to both upper extremities. R7 required substantial/maximal assistance for dressing and toileting hygiene, partial/moderate assistance for toilet transfers, and supervision or touching assistance for eating. Diagnoses included end stage renal disease, urinary tract infection in the last 30 days, diabetes mellitus, and hemiplegia (loss of ability to move one side of the body) or hemiparesis (partial muscular weakness to one side of the body). R7 was on isolation for active infectious disease. R7's order included Vancomycin 250 mg four times a day orally for Clostridioides difficile (C. diff; a germ which causes diarrhea and inflammation of the colon) with start date of 1/24/24 and enteric isolation for c. diff with start date of 1/29/24. An observation and interview on 1/29/24 at 1:29 p.m., RN-A indicated R7 had C. diff. R7's door had a sign which indicated contact precautions and directed staff to use alcohol-based hand rub, gloves, gowns, and dedicated or disposable equipment. A magnet located on the side of the door directed staff to wash hands with soap and water, gown, and glove. An observation on 1/30/24, at 9:03 a.m., nursing assistant (NA)-A walked to the doorway of R7's room and was handed a clear plastic water mug with a cover and straw. NA-A took the mug into the nurse's station, removed the cover and placed it on the counter. NA-A then filled the mug with ice and water from the ice machine. The mug was placed on the counter and the cover placed back on. The mug was then returned to R7's doorway and handed off to staff inside. When interviewed on 1/30/24 at 9:07 a.m., NA-A stated R7 was on TBP for C-Diff. NA-A verified R7's mug was just refilled with ice water and further stated they were not sure if the mug could come out of R7's room to fill. NA-A then asked licensed practical nurse (LPN)-A. LPN-A verified residents on TBP should have a new mug filled and brought into the room. Used mugs needed to be sent to wash and bringing items in and out was an infection risk. NA-A then acknowledged a clean mug should have been filled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 5 of 5 (R7, R6, R74, R4) residents reviewed for vaccinations. Findings include: R7's admission MDS dated [DATE], indicated R7 was cognitively intact and had diagnoses of diabetes and chronic kidney failure. Furthermore, R7's MDS indicated R7 was up to date with the pneumococcal vaccine. R7's facility immunization record dated 12/26/23, indicated R7's PPV status was up to date and was received 10/9/17. R72's immunization record lacked what PPV dose(s) had previously been given. R7's Minnesota Immunization Information Connection (MIIC) report printed 2/5/24, indicated R7 had recieved PCV13 on 10/19/17. Review of the current CDC recommendations 03/15/23, indicated one dose of the PCV20 given at least one year after the PCV13 would complete R7's pneumococcal vaccinations. R6's admission Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact and had diagnoses of stroke. Furthermore, R6's MDS indicated R6 was up to date with the pneumococcal vaccine. R6's facility immunization record dated 11/22/23, indicated R6's PPV status was up to date and was received 8/3/21. R6's immunization record lacked what PPV dose(s) had previously been given. R6's MIIC printed 2/5/24, indicated R6 had recieved PSV23 on 8/3/21. Review of the current CDC recommendations 03/15/23, indicated one dose of the pneumococcal conjugate vaccine (PVC)15 or PCV20 given at least one year after the PSV23 would complete R6's pneumococcal vaccinations. R74's admission MDS dated [DATE], indicated R74 was cognitively intact and had diagnoses of pneumonia and stroke. Furthermore, R74's MDS indicated R74 was up to date with the pneumococcal vaccine. R74's immunization record dated 1/8/24, indicated R74's PPV status was up to date and was received 4/13/16. R74's immunization record lacked what PPV dose(s) had previously been given. R74's MIIC printed 2/5/24, indicated R74 had recieved the PSV23 on 12/18/14 and the PVC13 on 4/16/16. Review of the current CDC recommendations 03/15/23, indicated shared clinical decision making was needed to determine if a dose of the PCV20 should be given. R4's admission MDS dated [DATE], indicated R4 was cognitively intact and had diagnoses of high blood pressure and impaired mobility. Furthermore, R4's MDS indicated R74 was up to date with the pneumococcal vaccine. R4's immunization record dated 1/9/24, indicated R4's PPV status was up to date and was received 12/8/09, 11/30/15, and 3/11/22. R4's immunization record lacked what PPV dose(s) had previously been given. R4's MIIC printed 2/5/24, indicated R4 had recieved the PSV23 on 3/11/22 and the PVC13 on 1/30/15 Review of the current CDC recommendations 03/15/23, indicated shared clinical decision making was needed to determine if a dose of the PCV20 should be given. When interviewed on 2/1/24 at 9:07 a.m., registered nurse (RN)-A stated when a resident was admitted , the admission nurse either asks the resident about their vaccination status and if they are up to date. This was documented on the paper immunization record. RN-A further stated staff could also look up the immunizations in the electronic medical record (EMR) to determine when the vaccines were received. When interviewed on 2/1/24, at 2:31 p.m., the Director of Nursing (DON) stated nurses screened residents and identified if they were up to date with the pneumococcal vaccination. If residents were up to date, that was documented. If residents were due, the vaccination was offered. DON acknowledged work was recently started to streamline the process and help staff identify if a resident was up to date or not per the CDC recommendations. DON acknowledged there was work to be completed to ensure nurses understood what up to date meant and how to determine the resident's up to date status. This was important to do to protect residents from the risks of being unvaccinated. A facility policy Pneumococcal Vaccine dated directed staff to assess the pneumococcal vaccination status upon admission. Furthermore, administrations will be made in accordance with current CDC recommendations at the time of the vaccination.