**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and policy review, the provider failed to ensure effective pest control for flying ants for one of twenty-six sampled residents (91) who complained of flying ants in his room and ant bites on his back. Findings include: 1. Interview and observation on 4/23/25 at 10:56 a.m. with resident 91 in his room revealed he stated: *He was having a problem with flying ants in his room. *The problem was daily and he had killed 30 to 40 of the flying ants every day. *The maintenance guy thinks they are coming in from behind [the] heater that was located on the wall below the window in his room. *Every morning his bedside table was covered with them and four to five of the flying ants were in his bed. -He had bites all over his back from the flying ants. -Resident 91 lifted the back of his shirt and showed his back which appeared to have several small red marks on his mid back. *Resident 91 stated he had been having problems with the flying ants for several weeks. -He stated I can feel them [flying ants] when they bite, they grab your attention. *He stated that yesterday (4/22/25), staff had asked him if he would like to move to another room, but he liked his current room. -He was asked to vacate his room for a couple of hours, and said that three staff members had been in his room. -When he woke up this morning (4/23/25), there were around 40 flying ants on his nightstand. *There were three dead flying ants on his nightstand which he stated he had killed with a tissue. *Maintenance assistant X was outside the resident's window with a spray bottle which he used to spray at the area below the window. *A round container of ant bait was on the floor by the window next to the heater on the wall. *A liquid ant bait was on the floor by the wall at the head of resident 91's bed. 2. Observation on 4/23/25 at 11:22 a.m. revealed resident 91 walked into the hallway with his walker and stated he had a bug on his window screen. Upon entering his room, an active flying ant was observed on the window screen in his room. 3. Observation and interview on the morning of 4/24/25 with resident 91 and staff in his room revealed: *At 7:55 a.m. the resident was in his room eating his breakfast and he: -Stated that social services director (SSD) E had brought in his breakfast that morning. -Pointed to seven dead flying ants on his nightstand, and stated he had used a paper napkin to kill them. -Stated five flying ants were in his bed that morning. *At 7:58 a.m. maintenance supervisor (MS) W and SSD E entered his room and asked him about moving to another room. -SSD E offered to move him to another room so they could deal more effectively with the flying ant problem. -SSD E escorted the resident out of the room to show him the other room. -MS W stated they had been working on the flying ant problem for a few weeks: --They had offered to move the resident multiple times. --He had a bug control contractor in to service resident 91's room and he would provide those invoices. *At 8:06 a.m. SSD E stated the resident had agreed to move to the other room that day. 4. Interview on 4/24/25 at 8:15 a.m. with restorative aide Y regarding the problem with flying ants revealed she had seen flying ants in a room on the 500 hallway and a room on the 400 hallway: *In the 400 hallway's room, she had seen flying ants about a week ago, but not since then in that room. *She felt the flying ant problem in the 400 hallway's room had been taken care of. 5. Interview on 4/24/25 at 9:30 a.m. with administrator A regarding the flying ants revealed he had: *A pest control company come into the facility to service the affected room, and after several treatments, the pest control company had told him they could not do anything more regarding the flying ants. *Staff deep cleaned resident 91's room on Tuesday, 4/22/25, as they felt the snacks resident 91 kept in his room had attracted the flying ants. *They had also set out bait traps to help with the flying ants. 6. Interview on 4/24/25 at 4:33 p.m. with resident 91 in his new room revealed: *He stated he was moved into the room by 10:30 a.m. that morning. *The staff had moved his bed and recliner from his other room. *He had not seen any flying ants in his current room yet. 7. Observation on the afternoon of 4/24/25 of resident 91's previous room revealed: *At 4:39 p.m. the room was empty except for one dining room chair and an overbed table. -Two live and active flying ants were noted on the window screen in the room. -There was a sticky strip hanging from the ceiling by the window. -There were three (Product name) liquid ant baits noted on the floor by the base board. -An ant bait was by the heater unit on the floor below the window. *At 4:46 p.m. certified medication assistant/certified nursing assistant (CMA/CNA) BB entered the room and confirmed there were two flying ants on the window screen. 8. Interview on 4/25/25 at 11:00 a.m. with resident 91 in his new room revealed he stated: *He hasn't seen a bug yet and was in a good mood. *Had a good night's sleep and had slept for ten hours. 9. Interview on 4/25/25 at 11:03 a.m. with SSD E revealed she had become aware of the issue with the flying ants yesterday, 4/24/25. When she had delivered resident 91's breakfast tray into his room he had stated he was having a problem with the flying ants in his room. 10. Interview on 4/25/25 at 11:21 a.m. with MS W revealed: *He had reviewed his records. He had become aware of the flying ants in resident 91's room on 4/11/25 when a work order was entered into their electronic maintenance software system called Technology-Enabled Life Safety (TELS). *In response, they had done the following in resident 91's room: -Deep cleaned resident 91's room as they felt the snacks resident 91 kept in his room had attracted the flying ants. -Placed containers of ant bait on the floor in resident 91's room. -Sprayed ant killer on the outside of the facility by resident 91's room. *He had requested the pest control company provide treatment for the flying ants. *He confirmed the flying ants had continued to be a problem as of 4/23/25, when resident 91 had reported the problem to the surveyor. 11. Interview on 4/25/25 at 12:15 p.m. with administrator A revealed he had become aware of the flying ants problem at about the same time as MS W had on 4/11/25. 12. Review of the provider's invoices from the contracted pest control company revealed invoices for monthly contract services detailing: *Target: Spiders, Ants, Roaches. *Location: Interior Baseboards, Kitchen. *On the following dates: -1/8/25. -2/3/25. -3/5/25. -4/1/25. *There was no documentation of the pest-control company having an additional visit or involvement after 4/1/25. Review of an e-mail communication from the provider's contracted pest control company revealed a message on 4/24/25 at 8:34 a.m. stated We were there for monthly scheduled service on March 4th and April 1. We did an extra call on March 21st to spray for ants . Interview on 4/24/25 at 4:55 p.m. with administrator A revealed the provider had no invoice from the contracted pest control company for 3/21/25, but he verified they had provided service at the facility on that date. Review of the requested provider's TELS Work Orders regarding the flying ants revealed: *Work Order #3833 created on 4/11/25 at 3:43 p.m. by licensed practical nurse (LPN) Z regarding resident 91's room indicated: -Comments: Resident states that he has flying ants coming in his room by his window. -Updated Status: 4/14/25 at 10:48 a.m. Set to Completed by maintenance assistant X. --Notes: Housekeeping deep cleaned area, Maintenance checked area and posted Ant traps, resident offered to move and declined. *Work Order #3847 created on 4/17/25 at 7:42 a.m. by CMA AA regarding resident 91's room indicated: -Notes: Resident stated he killed about 15-20 bugs located in his bed and inside of his dresser. Resident states that the strips in the windows do not serve a purpose. -Updated Status: 4/18/25 at 2:54 p.m. Set to Completed by maintenance assistant X. -Notes: [Maintenance assistant X] 04/18 [4/18/25] Traps have been placed, sprayed for bugs, housekeeping has been notified to deep clean [that room] regularly. *Work Order #3858 created 4/22/25 at 6:55 a.m. by LPN N regarding room [ROOM NUMBER]. -Updated Status: 4/22/25 at 7:36 a.m. Set to Completed by MS W. -Notes: House keeping deep cleaned residents [resident's] room, found many food particles all over [the] ground. Maintenance silicone sealed flooring and pest control had recently been out to spray. Also Ant traps placed. Review of the provider's May 2015 Pest Control policy revealed: *Purpose: To provide an environment free of pests. *Procedure: The Center has a pest contract that provides frequent treatment of the environment for pests. It allows for additional visits when a problem is detected. -Monitoring of the environment is done by the Center's staff. Pest control problems are reported promptly.

Based on South Dakota Department of Health (SD DOH) complaint intake review, observation, interview, record review, and policy review, the provider failed to ensure proper infection control practices were followed regarding: *Hand hygiene practices by staff members BB, GG, and HH during two of two dining observations in two of three dining rooms. *Hand hygiene and personal protective equipment (PPE) use by three of three staff observed (L, M, and BB) during personal cares for one of one sampled resident (41), personal cares for one of one sampled resident (33) on contact precautions (which indicated staff should have worn gowns and gloves), and assisting with resident transportation for two of two sampled residents (33 and 85). Failure to follow infection control practices potentially contributed to a norovirus [a highly contagious virus that causes nausea, vomiting, and diarrhea] outbreak in April 2025 which included three residents (18, 40, and 76) with confirmed norovirus infections and at least forty-two additional residents (1, 2, 3, 4, 12, 13, 14, 16, 22, 23, 24, 25, 29, 30, 31, 33, 34, 35, 36, 41, 42, 43, 45, 53, 58, 60, 64, 65, 67, 68, 69, 77, 78, 79, 80, 85, 93, 99, 100, 107, 258, and 259) with identified gastrointestinal (GI) symptoms. Findings include: 1. Review of the 4/16/25 SD DOH complaint intake form revealed: *An anonymous email reported a concern that the provider had a severe outbreak of norovirus. *The anonymous reporter was concerned the provider was not monitoring hand washing, sanitation, [and] dishwashing. *The writer was fearful for their family member that resided at the facility. 2. Review of a separate SD DOH complaint intake received on 4/16/25 revealed: *The complainant reported that resident 107 was recently hospitalized and had to be admitted to the intensive care unit (ICU). Review of resident 107's electronic medical record (EMR) revealed: *On 4/9/25, she experienced vomiting, diarrhea, weakness, and confusion. She was unable to speak coherently. *On 4/9/25 around 4:45 p.m., she was sent to the local emergency room for evaluation. -She was then admitted to the ICU for a diagnosis of pneumonia. *She continued to experience diarrhea throughout her hospitalization. *She returned to the facility on 4/15/25. 3. Observation on 4/22/25 at 3:51 p.m. of certified nurse aide (CNA) M and CNA/certified medication aide (CMA) BB performing personal cares for resident 41 revealed: *Both CNAs performed proper hand hygiene before putting on clean pairs of gloves. *Resident 41 had been incontinent of bowel, and they cleaned her up and removed the soiled brief. *Without removing her gloves or performing hand hygiene, CNA/CMA BB walked over to resident 41's wardrobe and touched the door handles, rummaged around in the wardrobe, and grabbed a clean brief. *She continued to assist resident 41 with putting on the clean brief with those same soiled gloves on. *Both CNAs kept on their same pair of soiled gloves throughout the process of changing resident 41's brief, getting her cleaned up, and redressing resident 41. *Both CNAs then removed their gloves and did not perform hand hygiene. *With their unclean hands, they touched: -The resident's sling used for the full body lift. -The full body lift. -The resident's positioning pillow. -The resident's wheelchair. -The door handle to exit the room. -CNA M also touched the resident's water cup, held the straw between her right index and middle fingers, and helped resident 41 take a drink of water. *CNA/CMA BB wrapped up the trash and walked away with it down the hallway. -After she came back, she brought the full body lift out into the hallway and cleaned it. *Neither of them were observed to have performed hand hygiene after assisting the resident. 4. Interview on 4/22/25 at 4:10 p.m. with both CNA M and BB about the above observation revealed: *Neither of them realized they had missed several opportunities for hand hygiene and changing their gloves. *CNA M questioned how soon she should have performed hand hygiene after removing her gloves as she explained she came out here [the hallway] to do that, is that not soon enough? -The surveyor explained that she touched the resident's water cup and drinking straw after removing her gloves and had not yet performed hand hygiene after assisting the resident with personal care. Her contaminated hands potentially increased the risk of spreading infection. -She agreed she had done that and promptly walked away from the conversation. 5. Observation on 4/22/25 at 4:41 p.m. of CNAs L and M in resident 33's shared room revealed: *There was a sign on the door for Contact Precautions which explained what PPE each person entering the room was required to wear. -PPE was available and hanging on the door. *CNA M came out of resident 33's side of the room with no evidence that she had worn PPE while interacting with the resident. *CNA L came out of resident 33's side of the room with the full body lift and parked it in the hallway. She was not wearing any PPE. -She did not clean the lift. *She did not put on any PPE and then went back into resident 33's side of the room. *She came back out of the resident's room, wearing one glove on her left hand and was holding a small bag of trash. There did not appear to be any PPE in the small trash bag. *She was holding the bag of trash while she was pushing resident 33 in her wheelchair down the hallway. -She was touching the left wheelchair handle with the same hand that she was holding the trash with. *She wheeled the resident all the way down the 400-hallway and turned towards the rehab dining room. *By 4:56 p.m., no staff had come back to clean the lift. 6. Interview on 4/22/25 at 4:58 p.m. with licensed practical nurse (LPN) N revealed: *She confirmed that resident 33 had an order for contact precautions, but she was not sure why the resident was on contact precautions. -She wondered if it was from the gastrointestinal (GI) bug that went through the building for the past several weeks. -When reviewing resident 33's record, she confirmed that the resident had diarrhea and vomiting the previous week. *She explained that contact precautions were implemented for residents known or suspected to be infected with infectious agents transmitted [from] person-to-person. *For contact precautions, she expected staff to wear at least a gown and gloves when providing care to the resident, even for transferring. -If staff were physically touching the resident, she expected staff to wear PPE for infection control purposes. *She indicated that the contact precautions for resident 33 were no longer necessary since her GI symptoms had subsided several days ago. -She discontinued that order for contact precautions in resident 33's electronic medical record (EMR). *She did not know exactly why the contact precautions sign and the PPE were still on resident 33's door and guessed that someone may have forgotten to discontinue the precautions after she was symptom-free. *She expected staff to have followed the contact precautions signage and use the proper PPE or contact a nurse if there were any questions. 7. Interview on 4/22/25 at 5:05 p.m. with CNA L revealed: *She could not remember how long she had been working at that facility. *When asked if she knew which resident in the shared room from the above observation was on contact precautions, she indicated that she did not know how to tell which resident in that room was on contact precautions. *She confirmed that neither she nor CNA M wore gowns while interacting with resident 33, they only wore gloves. *When asked if she knew what contact precautions meant, she said that they were supposed to wear gowns, gloves, and sometimes a face shield when interacting with the resident. *She said she also caught the GI bug that was going around the facility recently. *When asked why she did not follow the contact precautions as posted on the door and in the resident's orders, she said, I don't know, that's what I was trained to do, to just follow the other CNA. *When asked how often she was to clean the lift, she indicated that it was supposed to have been cleaned after each resident's use. -She still did not clean the lift after being informed that she had not cleaned the lift after taking it out of the resident's room. 8. Observation on 4/22/25 at 5:11 p.m. revealed LPN N was removing the contact precautions sign and PPE off resident 33's door. 9. Observation on 4/22/25 from 5:34 p.m. to 5:40 p.m. in the rehab dining room revealed: *CNA/CMA BB was sitting between two residents (41 and 56) to help them eat supper. *With her bare hands, she touched her hair braids to push them back behind her shoulders. *Without performing hand hygiene, she continued to help the two residents eat their meals. -She was taking straws out of their wrappers and placing the straws into the residents' beverages, touching the resident's silverware handles, squeezing condiments out of packets, and wiping the residents' mouths with their napkins. 10. Observation on 4/22/25 at 5:49 p.m. of the evening meal on the memory care unit (MCU) revealed: *Residents were not assisted with cleaning their hands before their meal. *CNA HH did not sanitize her hands before she passed the residents' meal trays. *She was observed coughing into her hand, she did not sanitize her hands after coughing, then she delivered the resident's meal tray. *There was a potentially contaminated rehabilitation cone device on the table. -A resident grabbed the cone and appeared to have been trying to take a drink from the cone as he picked it up and brought it to his mouth. -CNA HH noticed this and gently removed the potentially contaminated cone from his hands. She continued serving meal trays without performing hand hygiene. *She served nine residents their meal trays and did not sanitize her hands. 11. Observation on 4/23/25 at 9:29 a.m. of the morning meal service on MCU revealed: *Some residents were sitting at the table prior to meal service. *CNA GG did not perform hand hygiene before assisting residents with eating. *CNA GG was observed assisting a resident to eat after the resident had coughed. -The resident was not offered hand sanitizer or a hand wipe. *CNA GG then moved to another table without sanitizing her hands and assisted a different resident with eating. 12. Observation on 4/23/25 at 10:09 a.m. near the 400-hallway nurse's station revealed: *CNA M had a glove on her right hand and was holding a bag of trash. *At the same time, she was touching resident 85's wheelchair handle as she pushed him down the hallway. 13. Interview on 4/24/25 at 8:43 a.m. with resident 33 revealed: *She confirmed: -She had the GI bug earlier that month. -Staff did not put on gowns when they helped her with personal cares. *She was no longer experiencing GI symptoms like vomiting or diarrhea. Review of resident 33's electronic medical record revealed: *Her quarterly Minimum Data Set (MDS) assessment completed on 4/4/25 revealed a Brief Interview for Mental Status assessment score of 14, which indicated she was cognitively intact. *A nursing progress note from 4/8/25 that read, Contact precautions and isolation to room implemented per protocol for GI illness. *She experienced diarrhea on 4/8/25, 4/9/25, 4/10/25, and 4/11/25. *A physician's order started on 4/8/25 for Contact precautions as recommended for residents known or suspected to be infected with infectious agents transmitted person to person via the direct/indirect contact route (e.g. VRE [Vancomycin-resistant Enterococcus], Clostridium Difficile, MRSA [Methicillin-resistant Staphylococcus aureus] etc.). 14. Interview on 4/24/25 at 11:32 a.m. with LPN FF regarding resident and staff hand hygiene during meal service revealed: *There was usually hand sanitizer on the tables for residents to use before meals. *Residents were given a hand wipe to clean their hands with their meals. *It was her expectation that staff assisting residents with eating would sanitize their hands before assisting a resident, and before assisting the next resident. 15. Interview on 4/24/25 at 1:50 p.m. with CMA II revealed: *She was aware of a GI outbreak in the facility the past couple weeks. *She reported the outbreak was facility-wide and included many residents and staff members. *She reported if she were assisting residents to eat, she would sanitize her hands before assisting residents, then after assisting them before she assisted another resident. 16. Interview on 4/25/25 at 10:15 a.m. with resident care manager registered nurse (RN) G revealed: *She was a the provider's infection preventionist. *There was an outbreak of norovirus in the facility during April 2025. *They tested three residents, each from different wings of the facility, all were positive for norovirus. *After that initial testing, all residents with GI symptoms (nausea, vomiting, diarrhea) were assumed to have norovirus and were tracked for infection control purposes. *Residents with symptoms were placed on contact precautions to prevent further spread of the virus. *Residents remained on contact precautions for 24 hours after symptoms stopped. 17. Interview on 4/25/25 at 10:51 a.m. with director of nursing services (DNS) B and division director of clinical services (DDCO) C revealed: *DNS B recently started her position at the facility on 4/7/25. *Since the resident GI symptoms started on 4/8/25, she was fully aware of the GI outbreak. -In her time at that facility, she noted concerns in infection control such as hand hygiene. *On 4/8/25, residents who were experiencing diarrhea and vomiting were placed on contact precautions. *The staff collected and sent stool cultures to the laboratory for testing from three residents that had GI symptoms (residents 18, 40, and 76). Those residents resided in different areas of the facility. On 4/12/25, those stool culture results came back positive for norovirus. *Both DNS B and DDCO C appeared disappointed when they were informed about the above observations. -They expected staff to have followed the provider's policies on hand hygiene, glove use, and contact precautions. *A total of 45 residents were affected. -The census at the time of the survey was 104. 18. Review of the provider's Line listings for infections by resident tracking sheet revealed: *Between 4/6/25 and 4/14/25, a total of 45 residents (1, 2, 3, 4, 12, 13, 14, 16, 18, 22, 23, 24, 25, 29, 30, 31, 33, 34, 35, 36, 40, 41, 42, 43, 45, 53, 58, 60, 64, 65, 67, 68, 69, 76, 77, 78, 79, 80, 85, 93, 99, 100, 107, 258, and 259) had been identified to have GI symptoms. 19. Review of the provider's March 2018 handwashing/hand hygiene policy revealed: *Policy statement: This Center considers hand hygiene the primary means to prevent the spread of infections. *Procedure: -1. Personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -2. Personnel follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 20. Review of the provider's May 2015 Initiating Transmission-Based Precautions policy revealed: *Policy Statement: Transmission-Based Precautions are initiated when there is reason to believe that a resident has a communicable infectious disease. -Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. *Procedure: -1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor notified the Infection Preventionist and the resident's Attending Physician for appropriate Transmission-Based Precautions. - .4. Transmission-Based Precautions remain in effect until the Attending Physician or Infection Preventionist discontinues them, which occur after pertinent criteria for discontinuation are met. -5. When Transmission-Based Precautions are implemented, the Infection Preventionist or designee: --a. Validates protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need; --b. Posts the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. This Center's process for notification is signage . -6. In an emergency, the Infection Preventionist, [Executive Director], and/or Medical Director have the administrative authority, accountability, and responsibility to: --a. Institute actions necessary to control or prevent infections within the Center; --b. Notify the health department of reportable diseases, as appropriate; --c. Initiate isolation precautions; --d. Obtain laboratory specimens; --e. Restrict or ban admissions; --f. Restrict or ban visitations; --g. Implement other measures as necessary to prevent and control infections within the Center. 21. Review of the provider's March 2025 Transmission-Based Precautions (Isolation) policy revealed: *Policy Statement: Transmission-Based Precautions (previously referred to as isolation precautions) are implemented for residents known to be, or suspected of being, infected with infectious agents. *Procedure: -1. Use Transmission-Based Precautions in addition to Standard Precautions. -2. The four types of Transmission-Based Precautions may be used alone, or in combination for diseases that have multiple routes of transmission. Determination of use is based on how the infectious agent is transmitted. --Contact precautions. --Droplet precautions. --Airborne precautions. --Enhanced barrier precautions. -3. The need to implement Transmission-Based Precautions is determined by the [facility's] Infection Preventionist (IP), Director of Nursing and/or consultation with the local health department. Precautions are based on CDC [Centers for Disease Control and Prevention] guidelines. Precautions are the least restrictive possible for the resident. -4. The facility documents in the resident's medical record the rationale for the type of transmission-based precautions selected as well as the length of time the precautions is maintained. -5. Communication of Transmission-Based Precautions is accomplished with the pertinent signage and verbal reports to personnel and visitors. -6. Residents on TBP [Transmission-Based Precautions], apart from EBP [Enhanced Barrier Precautions], should remain in their room for the duration of precautions, except for medically necessary care or resident choice. -7. Indirect transmission of infectious agents can occur through contact with resident care equipment. Whenever possible, personal care items such as thermometers, stethoscopes, blood pressure cuffs and gait belts will be dedicated for use by the resident needing contact, droplet, or airborne precautions. All reusable items, including glucometers and other point-of-care devices are cleaned using appropriate disinfectant after using the devices with individual residents. *Contact Isolation Precautions: -Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Contact transmission can occur by directly touching the resident, through contact with the resident's environment, or by using contaminated gloves or equipment. -Personnel having contact with the infected resident should wear gloves and a gown. -Prior to leaving the resident's room, gown and gloves are removed and hand hygiene performed. -Options for residents on contact precautions may include a private room, cohorting with another infected or colonized resident or sharing a room with a resident with limited risk factors (no immunosuppression, IVs, indwelling catheters or open skin lesions). -Residents with wound drainage, fecal incontinence, or diarrhea, that cannot be contained, should be placed on contact precautions until a specific organism for the origin of the medical issue is identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, interview, and policy review, the provider failed to administer physician-ordered antibiotic treatment and monitoring for one of one resident (1) who had an infection and was readmitted to the hospital. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 1 revealed: *His Brief Interview for Mental Status (BIMS) assessment score was 7 which indicated he had moderate cognitive impairment. *He had been hospitalized and returned to the facility on [DATE] with a diagnosis of clostridium difficile (an infection that causes inflammation of the colon and diarrhea). *He had an order for Vancomycin HCI Oral Suspension 50 milligrams (mg)/milliliter (ml) give 2.5ml by mouth four times a day (antibiotic to treat infection) for clostridium difficile. *Upon his re-admission the admitting team incorrectly entered his antibiotic order into the electronic medical record (EMR) system as unsupervised medication administration (which indicated a resident gave themself the medication unsupervised). *On 11/19/24 the Minimum Data Set (MDS) coordinator registered nurse (RN) F had found the incorrect transcription error. *Resident 1 had not received any of the physician-ordered doses of Vancomycin. *Physician ordered to start vancomycin doses as originally prescribed until all doses were given. *He was re-admitted to the hospital on [DATE] for hyponatremia (low sodium) and hyperglycemia (high blood sugar) and loose stools. *Audits were completed on all residents to ensure no one else had a medication order in their EMR for unsupervised medication administration. 2. Review of resident 1's EMR revealed: *He was re-admitted to the facility on [DATE] at 12:46 p.m. following a hospitalization for a syncope episode (sudden loss of consciousness), pancolitis (a type of inflammatory bowel disease), and clostridium difficile. *He missed 16 scheduled doses of his physician-ordered vancomycin which were marked as U-SA for unsupervised self-administration (indicating he gave himself the vancomycin) on his medication administration record (MAR). *Nurses charted that he did not have any adverse side effects from the vancomycin medication on 11/15/24, 11/17/24 (three times), and on 11/18/24 (two times). *He received scheduled daily glycolax powder (used for constipation) on 11/16/24, 11/17/24, 11/18/24, and on 11/19/24. *He had bowel movements on 11/16/24, 11/17/24, 11/18/24, 11/19/24, and on 11/20/24. *A nursing progress note indicated he complained of frequent loose stools on 11/18/24 at 9:44 p.m. *He received his first dose of vancomycin on 11/19/24 at 3:16 p.m. when RN B was notified of the error and corrected the order on resident 1's MAR. *On 11/20/24 he had a basic metabolic panel (BMP) lab test completed which indicated hyponatremia and hyperglycemia and he was re-admitted to the hospital. 3. Interview on 11/25/24 at 3:39 p.m. with RN B revealed: *She received education on 11/22/24 about medication administration and if they have concerns to check with the nurse manager. *She stated she was unaware of any concerns of wrong resident medication orders. 4. Interview on 11/26/24 at 8:23 a.m. with licensed practical nurse (LPN) I revealed: *An unsupervised medication administration is care planned and staff must ensure it is safe for residents to have that medication in their room and be able to administer it themselves appropriately. *If a medication is labeled as unsupervised medication administration on a resident's MAR then it would be shown as a green box. *The green box would indicate a medication had already been given during that medication pass time. *Medications shown as a red box would indicate they need to be administered. *The medication aides (CMAs) would give the residents their medications which included any antibiotics. *She stated the nurses were to chart the resident's signs and symptoms of adverse effects of antibiotics use: -They would go into the resident's room to ask the resident how they were feeling. -The nurse would not know if they had received that medication or not. 5. Interview on 11/26/24 at 08:36 a.m. with staff development RN C and resident care manager (RCM) E revealed: *They were on the admission team and would participate in the process for admitting residents to the facility. *On admission, one person would transcribe the resident's medication orders and another person would double-check they were correct. *On 11/15/24 RCM J entered the vancomycin order into resident 1's EMR as unsupervised instead of clinician by accident. *RCM J had put the vancomycin in the medication refrigerator and said the nurses were aware that it was in there. *Resident 1's discharge order from the hospital included the glycolax powder, give 17 grams by mouth one time a day for constipation (in liquid). *They changed their order entry process of the double-check for medication orders to ensure that this type of incident would not happen again. *Admit orders would be reviewed against a printed MAR to visualize any errors. *They were not aware of anyone having questioned why they were not giving a resident on clostridium difficile precautions antibiotics. 6. Interview on 11/26/24 at 9:32 a.m. with certified medication aide (CMA) H revealed: *If a resident had orders for a scheduled constipation medication, she would administer it even if they had a bowel movement. *She stated if a resident were on precautions for an infection such as clostridium difficile and they still wanted the constipation medication she would administer it. 7. Interview on 11/26/24 at 10:55 a.m. with director of nursing services (DNS) A revealed: *She stated communication among the CMAs and nurses only happened if there was an issue such as when a medication was not given. *She felt the nurse should not need to verify with the CMA that a medication had been given in order for them to complete their medication assessment on a resident because the medication should be labeled on the residents MAR as given or not given. *She agreed that the CMAs should have questioned the green box which indicated resident 1's vancomycin was already given. *She confirmed that resident 1 had not received his doses of vancomycin as ordered. *She agreed resident 1 should not have been given glycolax powder while he was on precautions for clostridium difficile and was having loose bowel movements. *Education was provided to staff to report any time a medication was shown on a resident's EMR as an unsupervised medication administration green box which would indicate the medication was already given. 8. Review of providers Certified Medication Assistant Job Description policy updated April 2019 revealed: *Administers prescribed medications to residents and maintains related medical records under supervision of Nurse. *1. Verifies identify of resident receiving medication and records name of drug, dosage, and time of administration on specified forms or records. *2. Presents medication to resident and observes ingestion or other application, or administers medication, using specified processes. *3. Takes vital signs or observes resident to detect response to specified types of medications and prepares report or notifies designated personnel of unexpected reactions. *4. Documents reasons prescribed drugs are not administered. Review of providers Medication Administration policy updated June 2017 revealed there was no indication of how nurses were to oversee medications administered by CMAs to ensure proper documentation and follow-up nursing assessments were completed appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, policy review, and interview the provider failed to ensure the safety of one of one sampled resident (1) who had a fall from the full mechanical lift and required hospitalization for injuries the following day. The citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. Review of provider's 10/4/24 DOH FRI resident 1 revealed: *On 10/4/24 at 11:30 a.m. resident fell from the full mechanical lift -Resident 1 was interviewed by staff and stated, it happened so fast I am not sure what happened. -Resident interview also indicated her legs went up in the air and head went down causing her to slide onto the floor on her back. -Her vital signs were taken and were within normal limits. -She complained of upper back pain. -She refused further evaluation. -Neuro checks (the assessment of mental status, coordination, and reflexes) were performed and were within normal limits. -She requested PRN (as needed) acetaminophen (pain medication) and to get up for lunch. -Her family and physician were notified of the fall. *Resident 1 was hospitalized on [DATE] for: -Increased hip pain as well as atrial fibrillation (AFIB), urinary tract infection (UTI), right ventricular response (RVR). -Her x-ray report showed a right hip fracture. -Non-surgical conservative treatment was recommended by an orthopedic doctor. *On 10/8/24 resident 1 was re-admitted to facility 2.Review of resident 1's record revealed: *She had diagnosis including cardiomyopathy, gastro-esophageal reflux disease, constipation, hypertension, glaucoma, atrial fibrillation, major depressive disorder, and anxiety disorder. *She had a Brief Interview for Mental Status score of 13 meaning cognitively intact. *Her care plan has been updated to include use of EZ lift with assist of 2. *Care plan has been updated to include the correct sling size of medium. *72 hour neurological checks were completed following the fall. *An updated device evaluation was completed on 10/8/24. 3.Reviw of providers fall policy, dated March 2018 review revealed: *An interdisciplinary progress note, including a summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's current condition will be completed. *Nurse will complete nursing evaluation, notify necessary parties, and review resident's condition following a resident fall. *Resident's Morse scale will be updated for the resident following a fall. *The resident's family and physician will be notified following a fall. *Residents care plan will be updated to include newly identified interventions, as needed. *Nurse will complete neurological checks for 72 hours following the fall and resident's condition will be documented in nurse's notes in resident's chart. 4. Interview on 10/16/24 at 2:15 pm with CNA D and CNA E revealed: * CNA E states that she has been a CNA for 15 years * She reports that she has working this facility 2-3 months -She works on 400 and 500 wings -She reports that there are 2 sit to stand lifts and 2 full mechanical lifts available to use for 400 and 500 wings *CNA D states that he thinks the sling used for resident 1 at the time of the fall was too large for her. -He states that when resident 1 was lifted from her bed, she became unbalanced and slid out of the sling and onto the floor. -He states that audits are being completed regarding lifts and transfers -He reports that prior to resident 1's fall, the sling that was with the lift was the one used for the resident, regardless of size. *CNA D and CNA E both state that they were immediately educated regarding lifts and transfers 5. Interview on 10/17/24 at 7:56 am with registered nurse (RN) C revealed: *She was the nurse on duty at the time of resident 1's fall -She states that she entered resident 1's room following the fall and observed her on the floor still strapped in the sling -She states that she observed that the sling had been placed on resident 1 incorrectly. -She states that the shoulder straps were longer than needed for the resident *She states that she completed an assessment and neuro checks on resident 1 *She states that staff education regarding lift procedure and correct sling size has been completed since resident 1's fall. 6. Interview on 10/17/24 at 11:35 am with director of nursing (DON) B revealed: *Mechanical lift and sling size education was completed for all care staff including CNA D and CNA E dated 10/7/24 *Mechanical lift competency was complete with CNA E on 10/4/24 *Facility assessments are completed annually and as needed *All resident care plans requiring lifts have been updated verifying the correct sling size for resident use *Audits have been completed for staff since the date of the incident -Audits were to be reviewed at the next scheduled quality assurance and performance improvement meeting on 11/8/24 The provider implemented action on 10/4/24 to ensure the deficient practice does not recur and was confirmed on 10/17/24 after record review revealed the facility had followed their quality assurance process, education was provided to all direct care staff regarding mechanical lift safety and following residents' care plans, observations and interviews revealed staff understood how to correctly operate mechanical lifts according to each resident's individualized care plan, review of the appropriate sling sizes for each resident's mechanical lift needs, care plans were updated to include the resident's correct sling size, and verification certified nurse aide (CNA) competencies and audits were being performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and resident rights review, the provider failed to ensure staff were available to promptly respond to call lights for seven of seven sampled residents (1, 2, 3, 4, 5, 8, and 9) who used call lights to alert staff of their assistance needs. Findings include: 1. Observation on 9/16/24 at 3:45 p.m. throughout the facility revealed there was: *A sit-to-stand lift (mechanical lift used to assist to a standing position for transfers) and total lift (a mechanical lift with a body sling used for transfers) located in the hallway between rooms [ROOM NUMBERS]. *A sit-to-stand lift located in the 400 hallway outside of room [ROOM NUMBER]. -The lift had two safety slings stacked on top of it. *Two sit-to-stand lifts and two total lifts located in the 200 hallway. *A sit-to-stand lift located in the 100 hallway. Interview on 9/16/24 at 3:50 p.m. with certified nursing assistant (CNA) C revealed: *She worked as a bath aide in the 400 and 500 hallways. *She would have completed eight to ten baths during an 8-hour shift. *She estimated ten residents who resided in those hallways required a sit-to-stand lift for all transfers. -Some residents required one staff to assist them with that lift, some required two staff to assist with that lift. *She estimated five residents who resided in those hallways required a total lift for all transfers. -Residents always required two staff to assist them with a total lift. *She reported that they had two sit-to-stand lifts and two total lifts. *She stated, Residents sometimes have to wait for a lift to be available. *Residents who required two staff to assist with the transfer sometimes have to wait longer for two staff to be available. Interview on 9/16/24 at 3:54 p.m. with resident 1's daughter revealed: *She visited every day. *Her mother required a total lift for transfers. *It sometimes took 30 to 45 minutes or longer for one person to come to answer the call light and It's even longer if you have to wait for a second person. -She stated, They will come and shut off the call light while they wait for a second person to come to assist with transfers. *She did not feel the long wait times were not limited to a certain time of day or a certain day of the week. It varies. Review of resident 1's call light audit report from 8/29/24 to 9/3/24 revealed: *There were two call light response wait times over 25 minutes. *On 9/3/24 at 6:47 p.m. the wait time was 30 minutes. Interview on 9/16/24 at 4:12 p.m. with resident 2 revealed: *She required the sit-to-stand lift for transfers. -Sometimes one staff assisted her and sometimes they needed two staff to assist. *Sometimes they don't come for a very long time. I pull the string and they just don't come. -She clarified she felt a long time to wait was over 15 minutes. -She became visibly upset when she discussed how long she had waited for someone to answer her call light. *She preferred her bathroom door to be open just a little. If they close it [the door], I get scared because I have to wait so long. Interview on 9/16/24 at 4:19 p.m. with resident 3 revealed: *She shared a room and bathroom with resident 2. *She could walk to the bathroom, But I am supposed to wait for help. -I just can't wait that long. *She stated she fell next to her bed last week. -After putting my light on I waited 25 minutes [for staff assistance] then, I got up and went by myself. -She reported that was when she fell. Review of resident 3's electronic medical record (EMR) revealed: *She had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. *A 9/14/24 progress note indicated Resident was self-transferring from bed to recliner and lost her balance. Resident call light was on prior to the fall. Review of residents 2 and 3's room call light audit report from 8/23/24 to 9/17/24 revealed: *There were 88 call light response wait times over 15 minutes. -21 of those were over 30 minutes. -6 of those were over 45 minutes. -On 9/5/24 at 4:44 a.m. the wait time was 64 minutes. *On 9/14/24 the call light was activated at: -4:53 p.m. -6:55 p.m. -9:00 p.m. -9:15 p.m. -9:37 p.m. -10:17 p.m. Interview on 9/16/24 at 4:26 p.m. with resident 4 revealed she said: *They get mad at me for pushing my call light. They think I am playing with it. *She knew when she needed to use the bathroom, But when they don't come I just go in my pants. *I can't hold it as long as it takes them to get here. *She could not state how long it took staff to answer her call light in minutes. *They don't have enough people working here. Review of resident 4's EMR revealed: *She had a Brief Interview for Mental Status (BIMS) score of 8 which indicated she was moderately cognitively impaired. *From 8/27/24 through 9/17/24 she was incontinent of urine 34 times. -She had been continent 24 times in that same period. * From 8/27/24 through 9/17/24 she was incontinent of bowel two times. -She had been continent 11 times in that same period. Review of residents 4's room call light audit report from 8/26/24 to 9/17/24 revealed: *There were 45 call light response wait times over 15 minutes. -Six of those were over 30 minutes. -Two of those were over 45 minutes. -On 9/13/24 at 7:08 p.m. the wait time was 88 minutes. Interview on 9/16/24 at 5:08 p.m. with resident 8 and resident 9 revealed: *Resident 8 and resident 9 shared a room and a bathroom. *They said staff could take a long time to respond to their call lights. -Resident 9 felt a long time was over 20 minutes. *They both acknowledged the staff was trying hard but there isn't enough of them. Review of residents 8 and resident 9's shared room call light audit report from 8/26/24 to 9/17/24 revealed: *There were 38 call light wait times over 15 minutes. -12 of those were over 30 minutes. -6 of those were over 45 minutes. *On 9/11/24 at 7:11 p.m. the wait time was 57 minutes Interview on 9/16/24 at 5:40 p.m. with CNA D revealed: *There were 40 residents who resided between the 400 and 500 hallways. *There were two CNAs assigned to care for the residents on the 400 and 500 hallways. -There was a third CNA there that day, but that was not always the case. *Ten residents required the use of a sit-to-stand lift, and five residents required the use of a total lift. -They had two sit-to-stand lifts and two total lifts available for use that day. *There were not enough lifts or staff to assist the residents. *Residents got frustrated because they had to wait to be assisted with a lift or for two staff to help them. Interview on 9/16/24 at 5:54 p.m. with resident 5 revealed: *She required the sit-to-stand lift for assistance with all of her transfers. *There were only two CNAs assigned to the 400 and 500 hallways over the weekend *She had to wait over 30 minutes for staff to respond to her call light. -They know I only call when I need to use the bathroom. -There are not enough lifts or staff. *Two weeks ago, I had to wait so long that I was incontinent of BM [bowel] while sitting in my wheelchair and it leaked on the floor. -It's so embarrassing. *She had not filed a grievance about the long wait times but was aware of the process. *She did not attend the resident council. She stated, All we do is complain and nothing gets done. Review of resident 5's EMR revealed she had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Review of resident 5's room call light audit report from 8/23/24 to 9/17/24 revealed: *There were 35 call light response wait times over 15 minutes. -Five of those were over 30 minutes. *On 9/14/24 at 4:54 p.m. the wait time was 38 minutes. Interview on 9/16/24 at 4:34 p.m. director of nursing (DON) B revealed: *They do not have a lift policy or a call light policy. *She confirmed that the call lights are not visible outside the resident rooms when the call lights are activated. -Staff carried a walkie-talkie that announced when a call light was on. *There was a monitor that CNAs could look at that indicated which call light was active and for how many minutes it had been waiting for staff response. Interviews on 9/17/24 between 8:00 a.m. and 4:00 p.m. with staff members E, F, G, H, and I who requested anonymity for fear of retaliation revealed: *Issues with insufficient staff have impacted residents' having to wait to be toileted, dressed, repositioned, and changed. *At times one CNA may be responsible for the care of up to 20-33 residents. *At night when a CNA needs to leave their assigned area to help another staff member there was no staff available to assist residents in that area for over 15 minutes. -We are doing the best we can with what we have. *A bath aide was assigned 12 baths in an 8-hour shift. *We are always rushed. *Some of the residents require two [staff to] assist [them] and there is only two of us on the hallway so they have to wait while we help the others. *Sometimes we have to tell the resident we will come back as soon as we can, but then two more people need help. Interview on 9/17/24 at 3:15 p.m. with activities director K revealed: *Resident council meetings are held monthly. *Residents raised concerns about food and call lights at almost all resident council meetings. *She assisted residents individually to complete a grievance when needed. -The resident group did not complete a grievance form when they had concerns during the resident council meetings. Interview on 9/17/24 at 3:36 p.m. with resident 6 and resident 7 about the resident council meetings revealed: *Resident 6 became the president of the resident council last month but had attended those meetings regularly before that. *Resident 7 attended all of the resident council meetings. -She confirmed the resident council met monthly. *Residents are unhappy about the food and long call wait times. *Executive director (ED) A had attended resident council meetings. -Resident 6 stated, We tell him about the food and call lights -Resident 7 stated, .but [it] doesn't do any good. Interview on 9/17/24 at 5:00 p.m. with ED A and DON B revealed: *Two additional sit-to-stand lifts had been ordered and were expected to be received the following week. *Nurse staffing is based on the facility assessment. -They considered the facility adequately staffed. *They conducted call light audits for Quality Assurance (QA) and had not identified a problem with extended call light times. *ED A stated he was not aware of resident concerns about long call light wait times. *ED A stated there had been a problem with the call light system activating lights when residents were not in the room and staff were not able to turn those lights off. *There was no time range provided to staff on how quickly call lights were expected to be answered. -Don stated, As quickly as we can. -DON B would not confirm that 15 minutes was a reasonable time for a call light to be answered, but confirmed that 30 minutes was a long time. *They did not have a call light policy or a lift policy. Review of the provider's updated November 2016 Notice of Resident Rights under Federal Law handout revealed: *The Resident has the right to a dignified existence and self-determination. *The Resident has the right to be treated with respect and dignity. *The Resident has the right to reside and receive services in the Center, with reasonable accommodation of Resident needs, except when doing so endangers the health and safety of other Residents. Review of the provider's The 4 R's of Resident Satisfaction Employee Acknowledgement form revealed: * .the 4R's of resident satisfaction that ALL employees adhere to and implement. *Relieve- We want to relieve any and all pain! *Reposition - We want our residents comfortable! *Restroom- We want our residents dry! Assist the resident to the restroom, if needed or as scheduled. *Reach- We want our residents to have what they need!

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) complaint report review, record review, and interview, the provider failed to correctly administer medications as ordered for one of one sampled resident (1) who required hospitalization. Failure to administer medications as ordered may have contributed to resident 1's health condition and need for hospitalization. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of SD DOH complaint revealed resident 1 had not received his medications as ordered after his 1/10/24 admission to the facility and he required another hospitalization on 1/14/24 . Review of resident 1's electronic medical record (EMR) revealed: *He was hospitalized on [DATE] for the evaluation and treatment of hypokalemia (low potassium), falls, rib fractures, acute kidney injury, and dehydration. *On 1/10/24 he was admitted to the facility following the hospital stay. His diagnosis included hypopotassemia (low potassium), anemia, acute kidney injury, chronic kidney disease stage III, hypertension, and malignant neoplasm (cancer) of the bladder. *His potassium level at the time of his discharge from the hospital on 1/10/24 was 2.8. (normal range is 3.5-5.1). *His 1/10/24 hospital discharge orders included new orders for four medications including: -One Folic acid 1 milligram (mg) tablet daily for anemia due to folic acid deficiency. -Two Potassium chloride 20 milliequivalents (mEq) extended-release tablets twice daily for Hypopotassemia. -Two Sodium bicarbonate 650 mg tablets three times daily for acute kidney injury. -Urea-lactic acid 10-4% cream topically twice daily for sebaceous cyst. Review of resident 1's January 2024 medication administration record (MAR) revealed he had not received his ordered: *Folic Acid 1 mg to be given once daily on 1/11/24 and 1/12/24. *Potassium Chloride ER Give 40 mEq to be given twice daily on: -1/10/24 at 8 p.m. -1/11/24 at 8 a.m. -1/11/24 at 8 p.m. -1/12/24 at 8 a.m. -1/12/24 at 8 p.m. Review of resident 1's progress notes revealed: *On 1/11/24 at 10:41 a.m. a pharmacy note regarding the review of resident 1's admitting orders indicated remote review per facility request, no recommendations . *Registered nurse (RN) E documented on 1/13/24 at 1:40 p.m. Family made aware of not receiving Potassium and 40 MEQ taken from E-kit [emergency medication supply] (4- 10 meq tabs) earlier this AM and given to resident. *Licensed practical nurse (LPN) G documented on 1/14/24 at 8:21 a.m. Received lab report; abnormal results as follows: -Potassium: 2.6 L -Chloride: 114 H -CO2: 15 L -Calcium: 8.4 L -BUN: 42 H -Creatine: 4.9 H -BUN/Create Ratio: 8.6 L -GFR (MDRD) 12 L -GFR (CKD-EPI) 12 L *LPN G documented on 1/14/24 at 8:30 a.m. Called PCP [primary care provider] with lab results, send to ED [Emergency Department] for IV therapy per PCP verbal order. Called [family] notified about resident getting transferred to ED. *LPN G documented on 1/14/24 at 1:21 p.m. Hospital called stated they admitted resident to ICU [Intensive Care Unit] for low potassium and were going to administer potassium via IV [intravenously] . Interview on 5/29/24 at 2:06 p.m. with executive director (ED) A revealed: *They did not have policies regarding physician orders or medication administration. *They would follow the medication administration quick reference guide updated in June 2017. Further interview on 5/29/24 at 2:31 p.m. with ED A regarding the admission process for medication orders revealed: *Medication orders upon admission should be entered into the EMR by the admission nurse manager. *The orders should be double-checked by another nurse for accuracy. *Medication orders should be faxed to the pharmacy for review and dispensing to the facility. *Medications should be delivered on the same day they were ordered. -There are two scheduled medication deliveries daily, one mid-afternoon and one late evening. *In addition, the pharmacy would deliver stat (rush) medications if needed. *There were medications available in the E-kit also. Interview on 5/30/24 at 10:03 a.m. with LPN F revealed: *The admissions team nurse enters all orders into the EMR system. *If medications are not delivered, an RN should be notified. *Medications should be taken from the E-kit for administration if available. Interview on 5/30/24 at 10:12 a.m. with the resident case manager (RCM)/RN D revealed: *The admissions team nurse inputs the orders into the EMR system. *Orders should then be faxed to the pharmacy. *Another nurse should double-check the orders for accuracy. *Pharmacy reviews the orders. *Orders will indicate pending confirmation in the EMR and are not activated to prompt for administration until they have been double-checked and marked as confirmed. *Medications must be confirmed before the pharmacy would send the medications to the facility. *The pharmacy would call or fax the provider if they had questions about medication orders the facility had input into the system. *She was unsure if the pharmacy called or faxed anything regarding resident 1's medication orders. *She agreed resident 1's potassium level of 2.8 at the time of his 1/10/24 hospital discharge was low. *She confirmed resident 1 did not receive two doses of folic acid and five doses of potassium chloride as ordered while he was at the facility from 1/10/24 through 1/14/24. *Potassium chloride ER 10 mEq tablets were available in the E-kit. Interview on 5/30/24 at 11:30 a.m. with director of nursing (DON) B and minimum data set (MDS) coordinator C revealed: *DON B confirmed blanks on the MAR indicate the medication was not administered. -They confirmed resident 1 had not received medications as ordered following his 1/10/24 admission to the facility as indicated above. *An EMR integration was completed in January 2024. *The pending confirmation notice for new orders was new following the integration. *On 1/13/24 at 8:09 a.m. a medication error form was completed for resident 1's missed doses of potassium. -The reason for the error was listed as pending confirmation. *On 1/13/24 the resident's PCP had been updated on the medication error. *They had recognized the concern with the pending confirmation notice and implemented corrective action. *The facility had an E-kit available for certain medications. That E-kit could be used if medications were not available from the pharmacy. *Education was provided to staff on 1/25/24 that orders pending confirmation, need to be addressed by a nurse to activate the orders for the resident. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 5/30/24 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding medication orders processing, pharmacy notification, E-kit medication availability and administration of medications as ordered, interviews revealed staff understood the education provided regarding those topics, observation of the E-kit contained medications, as listed on its content sheet were available for resident use, and a review of recently admitted residents revealed no omissions on medication administration records. Based on the above information, non-compliance at F760 occurred on 1/10/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 5/30/24, the non-compliance is considered past non-compliance.