Every finding on record at Aberdeen Health and Rehab

Based on observation, interview, record review, and policy review the provider failed to ensure the staff followed standard infection control and prevention practices regarding:*Hand sanitizer dispensers that were past their expiration dates in 27 of 64 resident rooms. *One of one linen cupboard had a covering to protect against airborne infectants.*One of one resident wheelchair (26) was kept in good repair and had a cleanable surface on it.*Two of two observed residents (9 and 63) wheelchairs were clean and free from odor.*Three of three observed certified nursing assistants (CNA) (R, S, V,), one of one observed certified medication aide (CMA) (T), and one of one registered nurse (RN) (W) followed enhanced barrier precautions (EBP) (gown and glove use) when assisting one of one observed resident (34) with personal hygiene care and wound care. *One of one observed RN (W) who did not clean one of one observed resident (34)'s wound before applying a wound dressing.*One of one assistant director of nursing (ADON)/licensed practical nurse (LPN)/infection preventionist (IP) (N) and one of one RN (U) who failed to perform appropriate hand hygiene during all observed wound care, brought wound care supplies into multiple resident rooms, and did not sanitize wound care supplies between resident use while providing wound care for five of five sampled residents (5, 6, 9, 10, and 34) who had pressure ulcers. Findings include:1. Observation on 6/2/26 at 10:20 a.m. revealed Spectrum Advanced foaming hand sanitizer dispensers with expiration dates of 10/25/25, 6/20/25, 8/6/25, and 4/9/26 in 29 of 64 resident rooms. 2. Interview on 6/2/26 at 4:29 p.m. with CNA O in the Country Lane hallway regarding the hand sanitizer in the resident rooms revealed she used the hand sanitizer in the resident rooms before and after providing cares for a resident. 3. Interview on 6/2/26 at 5:15 p.m. with CNA K in the Country Lane hallway revealed that she used the hand sanitizer in the residents rooms to sanitize her hands before providing resident cares and when she left the room. 4. Interview on 6/3/26 at 1:43 p.m. with CNA Q near the nurses' station revealed she usually used the hand sanitizer in the residents' room before exiting, or she washed her hands in the sink. 5. Interview on 6/4/26 at 8:53 a.m. with director of nursing (DON) B regarding the expired hand sanitizer dispensers revealed, the provider did not have a specific policy for expired hand sanitizer products. She confirmed the hand sanitizer dispensers discovered in those 29 resident rooms were past the expiration dates. She was not sure who monitored the sanitizer dispensers for expiration dates. 6. Interview on 6/4/26 at 2:10 p.m. with executive director (ED) A regarding the expired hand sanitizer revealed that she confirmed the hand sanitizer was expired in 29 resident rooms. The staff were not assigned to check the hand sanitizer for expiration dates because it should not last that long in the resident rooms. 7. Observation on 6/2/26 at 2:41 p.m. of the linen cupboard outside the transitional care unit (TCU) dining room revealed that there were blankets, sheets, bath blankets, and gowns on the shelves. There were no doors or coverings for the closet to protect the linens from airborne infectants. 8. Interview on 6/4/26 at 11:48 a.m. with RN E revealed there were no doors on the linen cupboard across from the TCU dining room since March 2026, when she started working at the facility. She did not consider those linens in the cupboard as clean. 9. Interview on 6/4/26 at 11:49 a.m. with assistant director of nursing (ADON)/licensed practical nurse (LPN) D revealed that she would not consider the linens in the cupboard outside the TCU dining room as clean. She encouraged the staff to use the linens in the shower room in the enclosed cupboard. She had observed the staff using the linens from the cupboard outside the TCU dining room. There were no doors or covering on the linen cupboard outside the TCU dining room since October of 2025. 10. Interview and observation on 6/2/26 at 3:44 p.m. revealed that resident 26's right hand was curled under the right handle of his electric wheelchair. He explained that his hand curled outward because of a diagnosis of genetic torsion dystonia (a movement disorder causing involuntary, repetitive, sustained muscle contractions that lead to painful twisting and abnormal postures). The padding on the right handle was torn and partially missing. Scotch tape that appeared scuffed and dirty was wrapped around the padding to keep it secure. Resident 26 used his left hand to point at the torn padding and raised tape edging and stated, This is not comfortable. I have complained but they (staff) don't address my concerns. 11. Interview on 6/4/26 at 1:09 p.m. with DON B revealed that her expectation was for maintenance staff to repair or replace equipment, such as torn wheelchair padding. As the staff encountered items that needed to be repaired, they were to submit repair requests to the maintenance team, who were expected to complete the repairs pretty quickly, usually. Minimum data set (MDS) coordinator C also helped repair broken resident equipment. DON B was not aware the padding on resident 26's wheelchair handle needed to be replaced. 12. Interview on 6/4/26 at 1:36 p.m. with maintenance director M revealed that the maintenance staff were expected to work through repair requests as quickly as they could. For resident wheelchair repairs, he stated he worked with MDS coordinator C to order replacement parts, or if we have something we can put on it until we get a replacement part, I would do that. He was not aware that the padding on resident 26's wheelchair handle needed to be replaced. 13. Observation on 6/2/26 at 2:31 p.m. outside of residents 34 and 63's room revealed there was a high back reclining wheelchair that had a pressure relief cushion, and it smelled of urine. There was an EBP sign from the CDC outside of resident 34's room that indicated the staff were to wear gloves and a gown for high-contact resident care activities, which included dressing, providing personal hygiene, changing incontinence products, transferring, and providing wound care. 14. Observation and interview on 6/2/26 at 3:13 p.m. with resident 34 in her and resident 63's room revealed she was lying in bed, covered with a blanket, and stated she was using the bedpan. CNAs R and S sanitized their hands with hand sanitizer from the residents' room, put on a gown, and a pair of gloves, which were located in a bin in the residents' room. CNA R and S turned resident 34 on her side and removed the bedpan. CNA R obtained wipes from resident 34's bedside table and wiped her buttocks. CNA R obtained a new incontinence (involuntary leakage of bladder or bowel) brief from resident 34's bedside table, placed it under her, and fastened the tabs. Wearing those same gloves, CNA R assisted CNA S to pull up resident 34's pants, and then placed a sling (fabric tool that wraps around a resident's body and attaches to a mechanical lift used to lift and transfer the resident) under her. Resident 63, who was lying in her bed, started to cough up mucus. Without removing his gown and gloves, CNA S used resident 63's bed controller to elevate the head of her bed. CNA R removed her gown and gloves, discarded them in the trash can, did not perform hand hygiene (washing or sanitizing hands), and assisted resident 63 to sit up straighter in bed. CNA S removed his gown and pair of gloves, discarded them in the trash can, did not perform hand hygiene, and put on a new pair of gloves and a gown. CNA R did not perform hand hygiene, and put on a gown and a pair of gloves. CNA S hooked resident 34's sling to the full body lift (a mechanical lift and sling used to lift a person's full body), and the CNAs transferred resident 34 to her wheelchair, removed the sling from under the resident, removed their gowns and gloves, discarded them in the trash can, and washed their hands. CNAs R and S each put on a pair of gloves. CNA S brought in resident 63's high-back upholstered wheelchair from the hallway. Under the pressure relief cushion, there was old food, and it smelled like urine. CNA S used cleaning wipes to wipe off the seating surface of the wheelchair, under the pressure relief cushion. With those same gloves, CNA S used resident 63's bed control to lay resident 63 flat. CNA R removed her gloves, performed hand hygiene, and put on a new pair of gloves. CNA R opened resident 63's incontinence brief, obtained wipes that were on her bedside table, wiped her perineal (genital) area, and wiped her buttocks, opened a three-drawer bin drawer, grabbed an incontinence brief, and placed it under the resident. They turned the resident from side to side to get the incontinence brief under her, and they fastened the tabs. Resident 63 was agitated and did not want to get up into her wheelchair. With those same gloves, CNA S moved resident 34's bedside table. Both CNA R and CNA S removed their gloves, put them into the trash can, and washed their hands. 15. Review of resident 34's electronic medical record (EMR) revealed she required EBP due to having an open pressure ulcer (skin and/or underlying tissue injury from prolonged pressure). 16. Observation on 6/3/26 at 1:31 p.m. in resident 9's room revealed she had an upholstered high-back wheelchair that smelled of urine. 17. Interview on 6/3/26 at 3:51 p.m. with CNA S revealed he was to wash his hands before entering a room, after removing his gloves, and when leaving a resident's room. 18. Observation on 6/4/26 at 10:31 a.m. in resident 34's room revealed CMA T and CNA V sanitized their hands with hand sanitizer, put on a pair of gloves, and did not put on a gown. Resident 34 had an incontinent bowel movement. CMA T used wipes from resident 34's bedside table and wiped resident 34's bottom, including over the pressure ulcer on her right lower buttock. He called the nurse using his walkie to come put on a dressing. With those same gloves he obtained a paper towel, dabbed around her pressure ulcer area, and placed a brief under her. CMA T and CNA V removed their gloves, discarded them in the trash can, and did not perform hand hygiene. RN W came into the room already wearing a pair of gloves and had resident 34's pressure ulcer dressings in her hand. She did not put on a gown. She did not cleanse the wound, saying that the CNAs already did that. She leaned her arms and upper torso on the resident's bed, applied a skin prep (a moisture prep pad that is applied around a wound to protect the fragile skin) around the pressure ulcer, put a piece of collagen (a protein placed in wounds to promote healing) into the pressure ulcer, put the sliver (an antimicrobial agent) over the pressure ulcer, and then put on a foam dressing. With those same gloves, she took a black marker out of her pocket, dated the dressing, and put the marker back into her pocket. CMA T and CNA V did not perform hand hygiene, put on a pair of gloves, and pulled the resident's pants up. RN W removed her gloves and washed her hands. 19. Interview on 6/4/26 at 10:50 a.m. with RN W outside of resident 34's room revealed she did not cleanse the wound before putting the dressing on it because CMA T cleaned it with the wipes. She agreed that that was not what was on the treatment plan. She was not sure if she was supposed to wear a gown. After reviewing the Centers for Disease Control and Prevention (CDC) EBP sheet hanging by the resident's door, she said CMA T, and CNA V were to have worn gowns with personal hygiene care, and she should have worn a gown when applying the dressing. 20. Interview on 6/4/26 at 10:55 p.m. with CMA T revealed he was to wear a gown during personal hygiene care for residents who required EBP. He was to wash his hands when he entered a resident's room, left a resident's room, and when removing gloves and before putting on a new pair of gloves. He verified he did not perform hand hygiene between glove changes while providing personal hygiene care for resident 34. 21. Interview on 6/4/26 at 11:24 a.m. with ADON/LPN/infection preventionist (IP) N and RN U revealed they expected RN W to have cleaned resident 34's wound per the treatment record before applying a new dressing, staff to wear gowns when assisting residents with personal hygiene and wound care who were on EBP, and to perform hand hygiene before putting gloves on and when removing them. They verified that not following infection control processes can put the residents at risk for infection. 22. Interview on 6/4/26 at 3:05 p.m. with director of nursing (DON) B revealed she expected the overnight CNAs to clean the resident's wheelchair on the resident's shower day. If the wheelchair was upholstered, she expected the housekeeper to use an upholstery cleaner to clean them. She expected the staff to follow EBP and hand hygiene policies, and verified that not following infection control practices put the residents at risk for infection. 23. Review of the provider's 1/4/26 through 6/4/26 Infection Surveillance Report revealed 27 urinary tract/kidney infections, of which 24 were healthcare acquired infections (HAI), 13 skin and soft tissue infections, of which 11 were HAI, and 11 respiratory infections, of which nine were HAI. 24. Observation and interview on 6/3/26 at 8:06 a.m. of ADON/LPN/IP N and RN U in resident 9's room revealed RN U obtained the supplies for a wound dressing change from the treatment cart, placed a paper towel barrier on the bedside table, and placed a bottle of soap and saline (cleaning solution), gauze, and a dressing on the barrier. RN U stated she was the wound nurse. They performed wound care using appropriate infection control practices. ADON/LPN/IP removed the garbage bag from the garbage can in resident 9's room and sanitized her hands with the hand sanitizer located by resident 9's door that expired on 6/20/25. RN U washed her hands and returned the bottles of soap, saline, and the unopened package of gauze to the wound treatment cart. Review of resident 9's EMR revealed she had a stage II pressure ulcer to her left heel, and she was required to be on EBP. 25. Observation on 6/3/26 at 8:20 a.m. outside of resident 5's room revealed ADON/LPN/IP N sanitized her hands after leaving resident 9's room, which was expired. RN U got supplies out of the wound treatment cart for resident 5 and sanitized her hands. They each put on a gown and a pair of gloves and entered resident 5's room. ADON/LPN/IP N picked up the lift sling that was on the floor and put it on the resident's chair, folded a blanket, and put the blanket under resident 5's left heel. She removed resident 5's left sock, removed her gloves, discarded them in the trash can, performed hand hygiene, and put on a pair of gloves. RN U put a paper towel barrier on resident 5's bedside table, placed the same bottle of soap and saline from the wound treatment cart that was previously used in resident 9's room, a non-sterile Q-tip, gauze package, and a dressing package on the barrier. RN U removed resident 5's left heel dressing, removed her gloves, discarded them in the trash can, performed hand hygiene, put on a pair of gloves, poured soap and saline on a gauze pad, cleansed the wound, dried it with a new gauze, and applied a bordered dressing. RN U removed her gown and gloves, discarded them in the trash can, sanitized her hands, and left the room to get items from the wound treatment cart. RN U sanitized her hands, put on a gown, and a pair of gloves. RN U and ADON/LPN/IP N opened resident 5's incontinence brief and positioned her on her on her right side. Resident 5 did not have a dressing on the wound on her buttocks. RN U obtained a gauze pad that contained soap and saline from the resident's bedside table and cleansed the wound. She obtained the non-sterile Q-tip from the barrier on the bedside table, measured the depth of the wound, which was 2.5 centimeters (cm), and applied a bordered dressing. They positioned resident 5, removed their gowns and gloves, put them in the trash can, and washed their hands. Review of resident 5's EMR revealed she revealed she had a stage III pressure ulcer to her left heel, an unclassified wound to her buttocks, and was required to be on EBP. 26. Observation on 6/3/26 at 8:49 a.m. of RN U preparing for resident 6's dressing change revealed she was outside of his door with the wound treatment cart. RN U took Coban (type of wrap), kerlix (bandage roll), an opened bottle of betadine (antiseptic), soap, saline, a non-sterile Q-tip, and scissors out of the treatment cart. She entered resident 6's room and put those wound care supplies on a paper towel barrier on the resident's bedside table. RN U and ADON/LPN/IP N sanitized their hands with hand sanitizer, put on a gown, and a pair of gloves. RN U removed resident 6's left heel protective boot (a device worn on the heel to reduce pressure) and elevated his foot with a positioning device. She used the scissors to cut the tape on the dressing, and removed resident 6's dressing on his left foot. With those same gloves, she opened the gauze package, picked up the saline bottle, and poured saline on the gauze, picked up the betadine bottle, and poured it on the gauze, removed her gloves, performed hand hygiene, and put on a pair of gloves. ADON/LPN/IP N picked up the saline bottle and poured more saline on the gauze, and RN U cleansed the wound and dried it with a new gauze. RN U measured the depth of the wound with a non-sterile Q-tip, which was 0.4 cm. RN U held up resident 6's left leg while ADON/LPN/IP N took a picture of the wound using the wound documentation phone. Using those same gloves, RN U applied the betadine-soaked gauze to his wound, covered it with the abdominal pad dressing, wrapped his foot with the kerlix, and then wrapped it with Coban. Using those same gloves, she used the scissors to cut the Coban, and handed them to ADON/LPN/IP N to put on the bedside table. RN U dated the dressing with a marker and placed the marker on resident 6's bedside table. They removed their gown and gloves, discarded them in the trash can, and washed their hands. RN U picked up a packaged gauze dressing that fell on resident 6's floor and put it on the wound treatment cart. ADON/LPN/IP N picked up the scissors, marker, soap, and unused Coban from the bedside table, handed the items to RN U, and RN U put those items in the wound treatment cart in a shared resident supplies area of the cart. She did not clean the scissors, which had betadine on the cutting edge of them, or the marker. Review of resident 6's EMR revealed he had a stage II pressure ulcer to his left heel and required to be on EBP. 27. Observation on 6/3/26 at 10:06 a.m. of RN U and ADON/LPN/IP N gathering supplies outside of resident 10's room for her dressing change revealed she took out an open bottle of Hibiclens (an antiseptic), saline, and betadine from the wound treatment cart. A non-sterile Q-Tip was lying on top of the wound treatment cart, without being on a barrier. She grabbed the Q-Tip, Hibiclens, saline, betadine, and a dressing from the wound treatment cart. RN U and ADON/LPN/IP N performed hand hygiene, put on a gown, and a pair of gloves. RN U placed the Hibiclens, saline, betadine, Q-tip, gauze, and dressing on the paper towel barrier on the resident's bedside table. She poured the Hibiclens and saline on the gauze and the betadine on the gauze in a medication cup. ADON/LPN/IP N positioned resident 10 on her side. RN U removed the old dressing from her buttocks and used the non-sterile Q-tip to measure the depth of the wound, which was 2 cm. With those same gloves, she cleansed the wound with the gauze that had Hibiclens and saline on it, dried it with a new gauze, and held the resident on her side while ADON/LPN/IP N took a photo of the wound. RN U removed her gloves, performed hand hygiene, obtained the betadine gauze from the medication cup, rolled it, and packed it into the wound. She then put a bordered dressing on the wound. Wearing those same gloves, RN U helped pull up resident 10's pants and reposition her in bed. RN U removed those gloves, did not perform hand hygiene, and put on a clean pair of gloves. RN U and ADON/LPN/IP N removed their gown and gloves, disposed of them in the trash can, and washed their hands in the sink. RN U grabbed the extra gauze, the bottles of Hibiclens and saline from the resident's bedside table, and put them in the wound treatment cart. Review of resident 10's EMR revealed she had a stage IV pressure ulcer to her right buttocks and she required to be on EBP. 28. Observation on 6/3/26 at 10:31 a.m. of RN U and ADON/LPN/IP N outside of resident 34's door revealed they were gathering supplies from the wound treatment cart to complete resident 34's dressing change to her buttocks. RN U removed scissors from the cart, cleaned the cutting edge of the scissors with an alcohol pad, and set them on top of a dressing package. She took out the soap and saline bottles, gauze, dressings, non-sterile Q-tip, and set them on top of the papers on the treatment cart. RN U sanitized her hands with hand sanitizer, entered resident 34's room, placed the wound care supplies on a paper towel barrier on resident 34's bedside table, put on a gown, and a pair of gloves. ADON/LPN/IP N sanitized her hands with hand sanitizer, put on a gown and pair of gloves, put soap and saline on the gauze, and opened the bordered dressing. Using the scissors, ADON/LPN/IP N cut a piece of the collagen and silver, and placed them on top of the baggie that contained those dressings. She removed her gloves, discarded them in the trash can, sanitized her hands, and put on a pair of gloves. RN U assisted in turning the resident on her side, removed her gloves, discarded them in the trash can, and sanitized her hands. RN U put on a pair of gloves, removed the dressing to resident 34's right lower buttocks, removed her gloves, sanitized her hands, put on a pair of clean gloves, cleansed the wound with the soap and saline gauze, removed her gloves, sanitized her hands, put on pair of clean gloves, and measured the depth of the wound with the non-sterile Q-tip, which was 0.4 cm. She removed her gloves, discarded them in the trash can, sanitized her hands, put on a pair of clean gloves, put the collagen in the wound, then applied silver to the wound, and covered the wound with a foam bordered dressing. Using those same gloves, she dated the protective dressing for resident 34's sacrum with a marker. Using those same gloves, RN U opened resident 34's three-drawer plastic bin, took out an incontinence brief, and placed it under the resident. RN U handed wet wipes to ADON/LPN/IP N, and ADON/LPN/IP N wiped resident 34's perineal area, and handed the used wipes to RN U to discard in the trash can. ADON/LPN/IP N then obtained clean wipes, wiped resident 34's buttocks, handed the used wipes to RN U to discard in the trash can, attached the incontinence brief tabs, and covered resident 34 with a blanket. RN U removed her gloves, discarded them in the trash, sanitized her hands, put on a pair of clean gloves, and put the unused silver and collagen packages back into the plastic bag. She grabbed the saline and soap bottles and put them on the resident's bedside table without a barrier. They each removed their gowns and gloves, discarded them in the garbage can, and washed their hands. RN U grabbed the supplies on resident 6's bedside table and set them on top of the wound treatment cart. She put on a pair of clean gloves, wiped the cutting edge of the scissors with an alcohol pad, did not clean the handle, removed her gloves, discarded them in the trash can, did not sanitize her hands, and grabbed the keys to unlock the treatment cart. RN U opened the wound treatment cart, put the saline, soap, the baggie that contained the silver and collagen, and the unopened dressing back in the wound treatment cart. She left the unopened gauze on top of the treatment cart. 29. Interview on 6/4/26 at 11:24 a.m. with ADON/LPN/IP N and RN U revealed that they verified that the Q-tips used to measure the depth of the wounds were in a baggie with other packaged dressings, were not sterile, and should have been sterile. They verified they brought the soap bottle, saline, and betadine bottles into multiple residents' rooms, and they should not have been. They expected the scissors, including the handle, to be sanitized before use. They expected RN W to have cleaned the marker before putting it back into her pocket. They acknowledged that expired hand sanitizer might not be as effective in killing germs. They verified that not following wound care infection control processes and using expired hand sanitizer and soap put residents at risk for infection. 30. Interview on 6/4/26 at 3:05 p.m. with DON B revealed she expected the staff to follow hand hygiene policies, the Q-tips used for wound care to be from a sterile single-use package, wound care items not to be brought into multiple resident rooms, and wound care equipment to be sanitized after each use, she verified that expired hand sanitizer might not be as effective in killing germs, and verified that not following infection control practices puts the residents at risk for infection. 31. Review of the provider's 4/20/26 updated General Infection Prevention and Control-Surveillance policy revealed, Infection surveillance will be either whole house (ie. include all residents), or targeted toward high risk/high volume, whichever is in accordance with local and sate department of health requirements. a) Healthcare-associated infections (HAI) will be defined as any infection that is not present or incubating a the time of admission. It is the protocol of this facility that routine surveillance and monitoring of the workplace be conducted to determine if compliance with work practices and care of protective clothing and equipment be maintained. 32. Review of the provider's Nursing Weekly Cleaning Tasks revealed that resident individual use items, including wheelchairs, should be cleaned and disinfected weekly and PRN (as needed) when soiled. 33. Review of the provider's 4/20/26 EBP policy revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 'Enhanced barrier precautions' (EBP) refer to infection control interventions designed to reduce transmission of multidrug-resistant organisms that employ target gown and glove use during high-contact resident care activities. An order for enhanced barrier precautions will be obtained for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers). High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use., wound care: any skin opening requiring a dressing. 34. Review of the provider's 4/20/26 Hand Hygiene policy revealed proper hand washing techniques should be used to protect against the spread of infection. Cleaning your hands reduces the spread of potentially deadly germs to the residents. Handwashing should be performed by all employees, as necessary, between tasks and procedures. Alcohol based hand sanitizer should be used before touching a resident, before performing aseptic techniques, immediately before putting gloves on, when gloves are removed, and after touching a resident's environment. Hand washing with soap and water should be done before moving from a soiled body site to a clean body site on [the] same resident.

Based on the observation, interview, and record review, the provider failed to ensure the staff responded promptly to 11 of 16 sampled residents (6, 22, 30, 34, 36, 40, 41, 62, 64, 68, and 73) call lights. Findings include:1. Interview on 6/2/26 at 9:54 a.m. with resident 6 in his room revealed that after he turned his call light on it took the staff 15 minutes to two hours to answer his call light. 2. Review of resident 6's call light log (a report that states how long it takes for staff to answer a resident call light) from 5/3/26 through 6/2/26 revealed he had to wait for over 20 minutes three times, over 30 minutes four times, and over forty minutes one time for the staff to answer his call light. 3. Review of resident 6's electronic medical record (EMR) revealed his 3/31/26 brief interview for mental status (BIMS) assessment score was 15, which indicated his cognition was intact. His 4/30/26 care plan indicated he required one staff member to assist him with getting in and out of bed, repositioning, dressing, using the bathroom, and personal hygiene care. 4. Interview on 6/2/26 at 10:15 a.m. with resident 30 in her room revealed that she sometimes had to wait a long time for the staff to answer her call light. 5. Review of resident 30's call light log from 5/3/26 through 6/2/26 revealed she had to wait for over 20 minutes ten times, and over 30 minutes three times for the staff to answer her call light. 6. Review of resident 30's EMR revealed her 3/31/26 BIMS assessment score was 13, which indicated her cognition was intact. Resident 30's 3/31/26 MDS assessment (used to document resident care needs) indicated she was dependent on staff for assisting her with bathroom needs, personal hygiene care, dressing, and moving in bed. 7. Interview on 6/2/26 at 10:25 a.m. with resident 64 in her room revealed that she had to wait a long time when she turned her call light on, and the staff was in a rush when they took care of her. She had to wait two hours when the staff changed shifts. When she had to wait a long time for the staff to respond to her call light, she was incontinent of urine. She stated that this made her feel upset because she could not do things herself, and she required the staff's assistance. 8. Review of resident 64's EMR revealed her 5/12/26 BIMS assessment score was 13, which indicated her cognition was intact. Her 5/12/26 MDS assessment indicated she required staff assistance with bathroom needs, personal hygiene care, dressing, moving in bed, and ambulation. 9. Review of resident 64's call light log from 5/3/26 through 6/2/26 revealed she had to wait for over 20 minutes five times and over 30 minutes four times for the staff to answer her call light. 10. Review of resident 30 and 64's bathroom call light log from 5/3/26 through 6/2/26 revealed that one of them had to wait 25 minutes once and 152 minutes and 57seconds once. 11. Interview on 6/2/26 at 11:04 a.m. with resident 34 in her room revealed that she had to wait a long time for the staff to answer her call light, and then she was incontinent of urine. She stated, Maybe they do not take care of me because they do not like me. I am hard work. She had turned her call light on a while ago and no one had come to assist her. Sometimes the staff did not give her the call light device, and she had to bang on something to get their attention. 12. Review of resident 34's call light log from 5/3/26 through 6/2/26 revealed she had to wait for over 20 minutes four times, over 30 minutes five times, and over 40 minutes once for the staff to answer her call light. 13. Review of resident 34's EMR revealed her 5/4/26 BIMS assessment score was 14, which indicated her cognition was intact. Her 5/19/26 care plan indicated she required two staff to assist her with bathroom needs, moving in bed, getting in and out of bed, and dressing. 14. Observation and interview on 6/2/26 at 11:29 a.m. with resident 68 in her room revealed she was sitting in her wheelchair, and her call light device was on her bed, within arm's reach of her wheelchair. She stated the call light doesn't seem to work all the time, so if 15 minutes have passed, I'll go (by wheelchair) up to the main nurse's area and wait there. 15. Review of resident 68's electronic medical record (EMR) revealed her 4/10/26 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated her cognition was intact. Her 5/9/26 care plan indicated she required one staff member to assist her to and from the bathroom.16. Interview on 6/2/26 at 2:20 p.m. with resident 41in her room revealed she waited an hour sometimes for the staff to answer her call light. The staff did not answer her call light between 1:30 p.m. and 2:00 p.m. sometimes because of the shift change, and the staff would wait for the oncoming shift to answer her call light. 17. Review of resident 41's 4/30/26 BIMS assessment score was 14, which indicated her cognition was intact. 18. Review of resident 41's call light log from 5/2/26 to 6/2/26 revealed she had twelve call light response times over 20 minutes long, and of those call light response times three were over 30 minutes long. 19. Interview on 6/2/26 at 3:29 p.m. with resident 36 in his room revealed that his call light took quite a while to be answered by the staff. He had a sore on his buttock, and he did not like having to wait 20 to 45 minutes to get help from the staff. 20. Review of resident 36's 3/12/26 BIMS assessment score was 15, which indicated his cognition was intact. 21. Review of resident 36's call light log from 5/2/26 to 6/2/26 revealed he had 29 call light response times over 20 minutes long, and of those 29 call light response times, eleven were over 30 minutes long. 22. Interview on 6/3/26 at 9:30 a.m. with resident 40 and her family member in the activity room revealed that she sometimes lost control of her bladder while waiting to be assisted to the bathroom. We don't have enough lifts (a mechanical device used to lift a person's full body). Half the time the aides come in, turn the light off, say they'll be back in a few minutes because they have to find a lift, and they may not come back. Resident 40's family member stated, We were told that after five minutes if they (staff) don't come back, pull the call light again.23. Review of resident 40's EMR revealed her 5/11/26 BIMS assessment score was 15, which indicated her cognition was intact. Her 5/26/26 care plan indicated that she used a sit-to-stand lift (a mechanical lift used to assist a person from a seated to a standing position) with two staff members to assist her to and from the bathroom.24. Review of resident 40's call light log from 5/4/26 through 6/3/26 revealed that she had to wait over 20 minutes seven times, over 30 minutes three times, and over 50 minutes one time. 25. Observation and interview 6/4/26 at 10:20 a.m. in resident 34's room revealed that she could not reach her call light. It was lying on the bedside table, which was on the resident's left side. She had a sling on her left arm and the full body lift sling (a supportive fabric that attaches to a mechanical lift [a device used to lift a persons fully body]) under her. She stated that the staff were supposed to come back and had not yet, and stated, They are probably in the breakroom, that is where they sit. 26. Observation and interview on 6/4/26 at 10:31 a.m. in resident 34's room revealed that CMA T and CNA V came into the room to get her up. Resident 34 told CMA T and CNA V that she could not reach her call light device. CMA T verified that she could not reach her call light and stated that residents' call lights were to be left within their reach when the staff left the room. 27. Interview during the Resident Council Meeting on 6/4/26 at 1:30 p.m. revealed that the residents 6, 22, 41, 62, and 73 had concerns about long call light wait times, around 15 minutes to 2.5 hours, and call lights being left where they could reach them. They expressed concern that there was no staff on the floor to answer their call lights because they all went out to smoke together or sat in the breakroom. One resident stated that she was incontinent of urine when she had to wait to long for the staff to assist her to the bathroom, and this made her feel terrible, and they try to make you feel bad by telling me I am not the only one here. The residents discussed their call light concerns in the Resident Council meetings before. One resident stated that her call light was left out of reach, so she had to yell for assistance, and then the staff member told her not to yell. 28. Review of resident 22's 4/27/26 BIMS assessment score was 15, which indicated her cognition was intact. 29. Review of resident 62's 5/12/26 BIMS assessment score was 15, which indicated her cognition was intact. 30. Review of resident 73's 4/29/26 BIMS assessment score was 15, which indicated her cognition was intact. 31. Interview on 6/2/26 at 11:15 a.m. with RN P and ADON/LPN/IP N at the nurses' station revealed that there were no resident call lights turned on at that time. The surveyor reported to them that resident 34 stated that her call light was on for a while. RN P went to check on resident 34's call light device and stated that the call light was disconnected from the call light extender that plugged into the wall, so that was why the call light did not turn on when she pushed her call light device. 32. Interview on 6/3/26 at 1:42 p.m. with CMA T revealed he noticed several times when he came in in the morning for his scheduled shift that the residents did not have their call light devices within their reach. When he saw this, he reported it to the nurse. 33. Interview on 6/3/26 at 2:11 p.m. with RN P and ADON/LPN/IP N revealed that they would occasionally find a resident's call light device that was not within their reach. 34. Interview on 6/4/26 at 9:17 a.m. with certified medication assistant (CMA) I revealed that when call lights were activated, the room numbers were displayed on a digital screen in each hallway and announced on the staff's radios. He stated, It's not our practice to go into the room and shut off the light and then return - we just take care of their needs right away. 35. Interview on 6/4/26 at 9:24 a.m. with assistant director of nursing (ADON)/licensed practical nurse (LPN)/infection preventionist (IP) N revealed that until the call light was deactivated in the resident's room, the staff were unable to talk over their radio. It's good incentive to get the aides to the rooms quickly so they can use their radios again. She stated that the provider's protocol was to shut the resident's call light off and then assist the resident, but some staff assist a resident to the bathroom before deactivating the light, which could extend response time on the call light log.She expected a timely response to a resident's call light would be between five and ten minutes at the most, but I know sometimes we're challenged on the floor. If the staff turned the resident's call light off and left to locate a lift, she said the residents were expected to turn the light on if the staff did not return within a few minutes. She was not aware of the extended response times for resident 40's room but stated that some residents experienced bladder urgency or could not verbally tell the staff when they needed to use the bathroom, so accidents may happen. 36. Interview on 6/4/26 at 11:11 a.m. with certified nursing assistant (CNA) J revealed that she thought the resident's call lights should be answered within ten minutes. The call lights would sound over the staff's radio system to alert the staff that a resident had activated their call light and needed staff's assistance. 37. Interview on 6/4/26 at 11:24 a.m. with registered nurse (RN) E revealed she expected the resident's call lights to be answered within two minutes. She stated, We use the walkie system, and call light alerts to go right over that system to alert staff. 38. Interview on 6/4/26 at 11:49 a.m. with ADON/LPN D revealed she considered five to seven minutes to be a reasonable time for resident call lights to be answered by the staff. 39. Interview on 6/4/26 at 1:09 p.m. with director of nursing (DON) B revealed that she expected the resident's room call lights to be answered within 15 minutes and their bathroom call lights to be answered within five minutes. Executive director A would pull random call light logs throughout the month and more frequently if residents had shared concerns about longer response times. Call light audits were also posted in the staff breakroom for the staff to review.DON B was aware of resident 40's call light response times. I think there's only one bariatric lift (a mechanical lift use to help transfer overweight residents to the bathroom), so her response time gets delayed. She agreed that some aides turned off the resident's call lights and told residents to push it again if the staff did not return within five minutes. It's usually something they only do if (the staff have) to wait for a lift to be available, sometimes if they're in the middle of assisting someone else. She expected the resident's call lights to always be in working order and said that most days, the maintenance staff or MDS coordinator C repaired or replaced any non-working call lights before the leadership staff arrived at 8 a.m.40. Interview on 6/4/26 at 1:22 p.m. with executive director A revealed that she expected the resident's room call lights to be answered within 15 minutes and their bathroom call lights to be answered within five minutes. Unfortunately, that's not the way it always goes. She asked residents to tell her when staff turned their call lights off without addressing their needs. In addition to auditing call light logs two or three times per month, she stated she had audited call light frequencies, such as when a resident's call light was repeatedly activated within a 30- or 60-minute timeframe. When lengthy response times or repeated call lights were observed, she expected DON B to address it with unit managers and the nursing staff.41. A call light policy was requested, and the provider did not have a call light policy.

Based on record review, interview, and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual version 1.20.1 October 2025 review, the provider failed to ensure accurate MDS (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment coding for two of three sampled residents (4 and 59) dialysis (a medical treatment that performs the essential functions of the kidneys when they fail) medications. Findings include:1. Review of resident 4's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 3/23/26 Brief Interview for Mental Status (BIMS) assessment score was 13 which indicated his cognition was intact. He had diagnoses of type 2 diabetes mellitus (a chronic condition that occurs when your body cannot properly produce or use insulin) without complications, end stage renal disease, and dependence on renal dialysis. He had a 1/24/26 physician's order for Ozempic (0.25 or 0.5 milligrams (mg)/dose) subcutaneous solution pen-injector 2 mg/1.5 milliliter (mL) (Semaglutide) (a GLP-1 receptor agonist that mimics gut hormones to suppress appetite, slow digestion, and regulate blood sugar), inject 0.25 mg subcutaneously one time a day every Saturday for diabetes. Resident 4's 3/24/26 annual MDS assessment section N0350 insulin injections in the last seven days was marked yes. Section N0415 High-Risk Drug classes: use and indications section J Hypoglycemic (including insulin) was marked yes. 2. Review of resident 59's EMR revealed she admitted to the facility on [DATE]. Her 6/1/26 BIMS assessment score was 15 which indicated her cognition was intact. She had diagnoses of chronic kidney disease and type 2 diabetes mellitus without complications. Resident 59 had a 2/6/26 physician's order for Mounjaro subcutaneous solution auto-injector 2.6 mg/0.5 mL (Tirzepatide) (a dual GIP and GLP-1 receptor agonist that mimics gut hormones to stimulate insulin production when blood sugar rises and decreases the amount of sugar produced by the liver), inject 2.5 mg subcutaneously once weekly Friday for diabetes. Resident 59's 3/11/26 quarterly MDS assessment section N0350 insulin injections indicated she received one insulin injection during the last seven days. Section N0415 high-risk drug classes: use and indications section J hypoglycemic (including insulin) was marked yes. 3. Interview on 6/3/26 at 4:20 p.m. with Minimum Data Set (MDS) coordinator C revealed she was aware that Ozempic and Mounjaro were coded inaccurately as insulin. She learned about the inaccuracy on 4/24/26 but did not updated the MDS assessments for residents 4 and 59. 4. Interview with executive director A on 6/4/26 at 1:22 p.m. revealed she expected MDS updates to be completed within 24 to 48 hours, or a few business days. 5. Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed Section N, page 3, Coding Instructions for N0350A: Enter.the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. Section N, page N8 for N0415J1 and N0415J2, revealed, Hypoglycemic (including insulin): Check if a hypoglycemic medication was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days).

Based on observation, interview, and record review, the provider failed to ensure call lights (a communication tool that enabled residents to alert staff for assistance) were functioning for three of three sampled residents (34, 41 and 73) whose call lights were not functioning. Findings include: 1. Observation and interview on 6/2/26 at 11:04 a.m. with resident 34 in her room revealed she was lying in bed. She had to wait a long time for the staff to answer her call light, and then she would be incontinent of urine. She stated, Maybe they do not take care of me because they do not like me. I am hard work. She stated that she turned her call light on a while ago and no one had come. 2. Interview on 6/2/26 at 11:15 a.m. with registered nurse (RN) P and assistant director of nursing (ADON)/licensed practical nurse (LPN)/infection preventionist (IP) N at the nurses' station revealed that there were no resident call lights turned on at that time. The surveyor reported to them that resident 34 stated that her call light was on for a while. RN P went to check on resident 34's call light and stated that the call light was disconnected from the call light extender that plugged into the wall, so that is why it did not turn on when she pushed her call light. 3. Review of resident 34's electronic medical record (EMR) revealed her 5/4/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact. 4. Interview on 6/2/26 at 4:44 p.m. with resident 73 in the dining room revealed she had issues with her call light being unplugged from the wall, and she had to yell to her friend who lived across the hall to turn on his call light to get the staff's help. 5. Review of resident 73's EMR revealed her 4/29/26 BIMS assessment score was 15, which indicated her cognition was intact. 6. Observation on 6/3/26 at 10:31 a.m. in resident 34's rooms revealed ADON/LPN/IP N turned on resident 34's call light, and it turned back off on its own. ADON/LPN/IP N stated that resident 34's call light does that sometimes, and she would notify maintenance. 7. Interview on 6/3/26 at 4:00 p.m. with RN P revealed that the call lights sometimes get hooked under the resident's bed and get pulled out of the connector, then the call light does not work. 8. Interview on 6/4/26 at 1:09 p.m. with DON B revealed she expected call lights to always be in working order. She stated that most days, maintenance staff or Minimum Data Set (MDS) coordinator C have already repaired or replaced any non-working resident call lights before leadership staff arrived at 8 a.m. 9. Interview during the Resident Council Meeting on 6/4/26 at 1:30 p.m. revealed that resident 41's call light has not worked numerous times, and resident 73 had issues with her call light not working. 10. Review of resident 41's EMR revealed her 4/30/26 BIMS assessment score was 14, which indicated her cognition was intact. 11. The provider's call light policy was requested, and they did not have a call light policy.

Based on observation, record review, interview, and policy review, the provider failed to ensure infection control practices were followed regarding the storage of oxygen equipment for two of two sampled residents (5 and 6). Findings include:1. Observation on 6/2/26 at 9:54 a.m. in resident 6's room revealed he had an oxygen concentrator (a device that filters room air into purified oxygen) in his room. His nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) was on the floor, and it was not dated. His pre-filled humidifier (a plastic bottle that attaches to the oxygen machine to add moisture to the oxygen) was not dated. 2. Observation on 6/3/26 at 1:29 p.m. in resident 6's room revealed his nasal cannula oxygen tubing was on the floor. His nasal cannula oxygen tubing and the pre-filled humidifier were not dated. 3. Review of resident 6's electronic medical record (EMR) revealed he admitted to the facility on [DATE] and had a diagnoses of obstructive sleep apnea (where your throat muscles relax too much and block your airway while you sleep). He had an 8/17/25 physician's order for oxygen to be administered at 3 liters (L) by a nasal cannula at bedtime while sleeping and as needed. His June 2026 treatment administration record (TAR) did not indicate when the nurse was to change the oxygen tubing. 4. Observation on 6/2/26 at 2:36 p.m. in resident 5's room revealed she had an oxygen concentrator in her room, the nasal cannula tubing was dated 6/1, and the pre-filled humidifier was empty and not dated. Her continuous positive airway pressure (CPAP) machine (a bedside device used to pump a steady, gentle stream of pressurized air through a tube and a face mask) was on her nightstand, and the mask was on the floor between her bed and nightstand. 5. Review of resident 5's EMR revealed she admitted to the facility on [DATE] and had a diagnoses of Chronic Obstructive Pulmonary Disease (COPD) (progressive lung disease that makes it hard to breathe). She had a 7/16/24 physician's order to wear her CPAP nightly and when napping, and an 11/18/24 physician's order for continuous oxygen at 2 L. Her June 2026 TAR indicated the nurse was to change the oxygen tubing and set it up weekly every Friday night, and to date it. 6. Observation and interview on 6/3/26 at 3:51 p.m. with certified nursing assistant (CNA) S in resident 5's room revealed that resident 5's nasal cannula oxygen tubing was on the floor. He picked the tubing up off the floor and stated that the resident's oxygen tubing was supposed to be in the bedside table drawer or hung up so it did not touch the floor. He verified that resident 5's CPAP mask was on the floor between her bed and nightstand, picked it up, and stated it should not be on the floor, and he would clean it. The nurse was responsible for changing and dating the oxygen tubing and pre-filled humidifier. 7. Interview on 6/3/26 at 4:00 p.m. with registered nurse (RN P) revealed the CPAP masks should be stored on the CPAP machine, the nasal cannulas should be stored in a bag, and the nasal cannula and pre-filled humidifier should be dated when changed by the nurse weekly. 8. Interview on 6/4/26 at 11:24 a.m. with assistant director of nursing (ADON)/licensed practical nurse (LPN)/infection preventionist (IP) N revealed that she expected oxygen tubing to not to be on the floor, and to be in a bag on the resident's concentrator when not in use. The oxygen tubing and the pre-filled humidifier were to be changed weekly, and the tubing and the pre-filled humidifier should be dated when they were opened to be used. 9. Interview on 6/4/26 at 3:05 p.m. with DON B revealed she expected oxygen tubing to not be on the floor but to be stored in a bag when not in use, and the oxygen tubing and the pre-filled humidifier should be dated when they were opened to be used. 10. Review of the provider's 4/20/26 Respiratory Equipment Cleaning Procedure policy revealed O2 [oxygen] tubing, nasal cannula/mask will be changed weekly. O2 tubing will, also, be changed when tubing (nasal prong area) is noted lying on the floor. The pre-filled Humidifier bottle needs to be replaced weekly & [and] prn [as needed] (date and initial). This policy did not include information regarding cleaning or storage of the CPAP mask. 11. The provider's 11/18/25 CPAP and BiPAP policy did not include information regarding cleaning or storing the CPAP mask.

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices for one of one observed cook (Y) who did not remove her gloves and washed her hands after touching a garbage can lid before handling resident food, and when she changed her gloves. Findings include:1. Observation on 6/2/26 at 10:32 a.m. of cook Y in the kitchen revealed she was wearing a pair of gloves and was peeling cucumbers on a cutting board with a knife. She walked over to the garbage can, lifted the garbage can lid, and discarded the cucumber peelings in the garbage can. With those same gloved hands, she put the peeled cucumbers in a bowl, rinsed them with water, removed her gloves, and did not wash her hands. She put a bag of shredded cheese in the walk-in cooler, used pot holders to take a peach cobbler pan out of the oven, and placed it on a metal tray. She took off the pot holders, took a dirty knife to the dirty dish area, obtained a clean knife, put on a pair of gloves, and cut the cucumbers on a cutting board. With those gloved hands, she picked up the cut cucumbers and put them in a bowl, brought the dirty knife and cutting board to the dirty dish area, obtained a washcloth with sanitizer on it, and wiped the counter where she cut the cucumbers. She removed her gloves, discarded her gloves in the trash can, and washed her hands with soap and water. 2. Interview on 6/3/26 at 2:31 p.m. with cook Y revealed she was to wash her hands with soap and water when she came into the kitchen, before putting on gloves, and after taking gloves off. She should have removed her gloves and washed her hands after touching the garbage can lid. 3. Interview on 6/3/26 at 4:15 p.m. with dietary manager (DM) X revealed she expected cook Y to remove her gloves after touching the garbage can lid and wash her hands after removing her gloves. 4. Review of the provider's 4/20/26 Hand Hygiene policy revealed, proper hand washing techniques should be used to protect against the spread of infection. It indicated that hand hygiene with hand sanitizer should be completed immediately before putting on gloves and after glove removal. 5. A policy regarding hand hygiene in the kitchen was requested, and the provider did not have a policy regarding hand hygiene specifically for the kitchen.

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, document review, record review, and policy review, the facility failed to ensure the safety for one of one sampled resident (1) who was identified at risk for elopement (leaving the facility without staff knowledge) and left the building unsupervised on 2/13/26. Immediate Jeopardy (IJ) at F 689, severity K, began on 2/13/26 at 4:10 a.m. when the provider failed to ensure the safety of resident 1 who eloped through his bedroom window and was found at 4:38 a.m. outside when outdoor temperatures were approximately 25 degrees Fahrenheit (F), for an unknown amount of time, and the safety of any other residents identified at risk for elopement (total of 11). The facility failed to implement appropriate safety measures to ensure all residents identified at risk for elopement could not exit the facility unsupervised and without staff knowledge. Executive director A was notified of the IJ on 2/24/26 at 6:03 p.m. and a removal plan was requested. The removal plan was received on 2/25/26 at 1:37 p.m., and it was accepted on 2/25/26 at 2:00 p.m. The IJ was removed on 2/25/26 at 3:25 p.m. as confirmed by onsite verification by the survey team. After the IJ removal, the severity of the non-compliance remained at an E. The current census was 73. Findings include:1. Review of the provider's 2/13/26 SD DOH FRI revealed that certified nursing assistant (CNA) R and CNA S notified registered nurse (RN) J on 2/13/26 at 4:10 a.m. that resident 1 was not in his room, and his window was open with the screen pushed out of it. They checked the rooms on resident 1's wing and had the other facility staff members check the rest of the building. When resident 1 was not found, they searched outside, and CNA R found him lying in the grass at about 4:38 a.m. He did not have any major injuries, and his vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were normal. He was wearing a long-sleeved shirt, pants, socks, shoes, and two jackets. The temperature outside was around 25 degrees Fahrenheit (F). Staff secured his window, started 15-minute safety checks for 72-hours, changed his clothes, and helped him to bed. The facility management team, the resident's physician, and the resident's family were notified of the incident. The management team had a meeting that morning of 2/13/26 about resident 1's elopement and determined that his window did not have a safety stopper in place to prevent it from sliding open all the way. Maintenance staff placed a stopper and a window alarm on resident 1's window on 2/13/26 at 10:10 a.m. The management team interviewed the staff who were working at the time of the elopement and determined the last time resident 1 was seen was around midnight. At about 10:30 a.m., director of nursing (DON) B instructed maintenance staff to check every window in the building to ensure that they were unable to be opened far enough for someone to go through. Maintenance staff was placing stoppers on all of the sliding windows to prevent them from being opened more than a few inches. Minimum Data Set (MDS) coordinator/licensed practical nurse (LPN) H reviewed all resident care plans and pocket care plans (personalized plan that addresses a resident's care needs, goals, and interventions) to ensure they were up to date. The WanderGuards (a wearable door alarming device) were checked for placement and functionality for all residents who wore them and at risk for elopement. Executive director A ensured the elopement binders (a binder that contained a picture and description of the residents who were at risk for elopement) were current and that the elopement drills had been completed. DON B was completing all staff education regarding elopement, residents who were at risk for elopement, two-hour rounding (checking on residents' status and assistance needs) for all residents, and immediate notification of reportable incidents. The provider's five-day final investigation FRI report stated that resident 1 had not tried to elope since the 2/13/26 incident, and his physician started him on a medication for dementia (a group of symptoms affecting memory, thinking, and social abilities). Other interventions included checking that all the WanderGuard devices on the doors were functioning, and indicated that all of the other interventions were completed. 2. Observation on 2/24/26 at 8:52 a.m. of resident 1's window in his room revealed it had metal stoppers on the window so it could not be opened further than a few inches but there was no alarm on his window. 3. Observation on 2/24/26 at 9:15 a.m. of the sliding window in the tv room revealed that it did not have a metal stopper and it could be slid open far enough for a person to climb out of it. 4. Observation on 2/24/26 at 9:28 a.m. of the sliding windows in the restorative room revealed there were three windows in that room. Two of them did not have the metal stoppers and were able to be opened far enough for a person to climb out of. The window that had the stoppers on it had a sign on it that stated do not open windows. There were two doors to access the restorative room from the resident hallway that did not lock. The restorative aide left the room unattended when bringing a resident back to their room. 5. Observation on 2/24/26 at 9:34 a.m. of the sliding windows in the therapy room revealed they had three windows that had the metal stoppers. One window did not have the metal stoppers and was able to be opened far enough for a person to climb out of. 6. Observation on 2/24/26 at 9:55 a.m. of the sliding windows in the chapel revealed there were two windows that did not have the metal stoppers and were able to be opened far enough for a person to climb out of. There were two doors to access the chapel from the hallway that did not lock. 7. Observation on 2/24/26 at 1:45 p.m. of the sliding window in resident 2's room revealed that her window had a stopper on the left side of her window and did not have one on the right side. The right window was able to be opened far enough for a person to climb out of. 8. Observation on 2/24/26 at 1:47 p.m. of the surveyors' facility map that indicated resident rooms who were at risk for elopement revealed that there were four residents who were at risk for elopement whose rooms were located near the restorative room. 9. Interview and observation on 2/24/26 at 2:08 p.m. with CNA K in the nurses station revealed she had worked at the facility for about two and a half years. She was able to state the process for what to do if a resident eloped. There was an elopement binder at each nurse's station with resident's identification information who were at risk for eloping. She knew that resident 1 had the metal stoppers on his room window because he eloped recently. She verified that resident 1 did not have an alarm on his window and was not aware that he was to have one. She was able to see the residents' Kardex (a report of the resident's care needs and interventions), but not their care plans. She carried a pocket care plan, which indicated the residents who wore WanderGuards, but it did not indicate that resident 1 was to have an alarm on his window. Resident 1's Kardex did not indicate that he needed to have an alarm on his window. CNA K reported that resident 1 had exit-seeking and wandering behaviors at times, that increased in the evenings. He would put on his jacket, grab some belongings, and stand by the exit door at the end of his hallway and at the therapy room exit door. He appeared anxious at times but was easily redirected to a different area. After his family left after a visit, he would get more upset. She documented his behaviors in the CNA charting on the computer, and she notified the nurse. CNA K reported that the door at the end of the hallway on both Arbor wings, resident 1's wing and the adjacent wing, had a magnet alarm that alarmed at the door alarm panel when the door was opened and needed to be reset by staff to turn it off. She recalled receiving mandatory education about elopements and two-hour rounding one to two weeks ago. 10. Observation on 2/24/26 at 2:36 p.m. of the restorative room revealed that there was no one in the room, the sliding windows did not have stoppers, and the doors to enter the room from the hallway were unlocked. 11. Interview on 2/24/26 at 3:40 p.m. with CNA P revealed they were still doing 15-minute safety checks for resident 1, but she could not find the documentation sheets. She asked another staff member and was told the office staff had taken those sheets. 12. Observation 2/24/25 at 3:55 p.m. of the sliding windows in resident 4 and resident 5's rooms revealed that they did not have stoppers on the windows, and they were able to be opened far enough for a person to climb out of. 13. Observation on 2/24/26 at 4:01 p.m. revealed that unoccupied room [ROOM NUMBER] was used for equipment and not for residents. There was a keypad lock on the door, but it was not locked. It was close to resident 1's room, and the sliding window did not have metal stoppers on it. 14. Observation and interview on 2/24/26 at 4:04 p.m. of resident 3's window revealed that it did not have metal stoppers, it did not close tight enough for it to be locked, and it opened far enough for a person to climb out of. Resident 3 stated she had an air conditioner in that window over the summer, which caused it to not lock properly. 15. Observation on 2/24/26 at 4:13 p.m. of resident 6 and resident 7's sliding windows revealed they did not have the metal stoppers, and they had a magnet alarm on them. 16. Interview on 2/24/26 at 4:13 p.m. with CNA K revealed there were two stoppers in place on resident 1's windows, but there was no window alarm. 17. Interview on 2/24/26 at 4:30 p.m. with CNA L and CNA M revealed that residents always had access to the television lounge, restorative therapy room, and the chapel. 18. Interview on 2/24/26 at 4:36 p.m. with business office assistant (BOA) N revealed that the interior double doors to the therapy room were always open. No one could enter the therapy room through the outside door after 5:00 p.m., and the residents had access to that room at any time of day. 19. Observation and interview on 2/24/26 at 4:43 p.m. with executive director A and maintenance director G in resident 1's room revealed that there was no alarm on resident 1's window. There were metal stoppers placed on the window. Executive director A stated she picked up a window alarm at a local store on 2/13/26. Maintenance director G tried to place it on resident 1's window, but it did not fit correctly. Another one needed to be ordered online. It had not yet been ordered. The metal window stoppers were purchased on 2/13/26, they arrived on 2/19/26, and maintenance director G had been installing them in the residents' rooms when he had a chance. Maintenance director G did not tell executive director A that the window alarm did not fit resident 1's window. Executive director A was aware that resident 1's care plan indicated he had the alarm on his window, and it was reported to the SD DOH as being completed. Executive director A was not aware that not all of the resident-occupied rooms had the metal stoppers on them, which included a resident who was identified as at risk for elopement. She stated, he [maintenance director G] will do that today. They did not have a date set for placing the metal stoppers on non-resident care rooms, and executive director A stated, they all [windows] need to be done [have stoppers installed]. 20. On 2/24/26 at 6:03 p.m. executive director A was notified of IJ at F689, regarding a resident who eloped through his bedroom window and failing to implement appropriate safety measures to ensure all residents identified at risk for elopement could not exit the facility unsupervised and without staff knowledge. A removal plan was requested. On 2/25/26 at 1:37 p.m. the removal plan was received. The removal plan was reviewed and accepted on 2/25/26 at 2:00 p.m. REMOVAL PLAN: On 2/24/2026, Administrator, Director of Nursing and maintenance director were educated on the process of submitting a final report and the action plan in a final investigation report. They were also educated on the importance of elopement mitigation and ensuring the safety of all residents at risk for elopement. All windows were locked. On 2/24/2026 at 5:38 pm, Maintenance Director placed sliding window clamp locks on sliding windows including resident 2's room, the tv room window on TCU dining, the activity/restorative room, the therapy room and the chapel. Resident 1's room was safety secured with a sliding window clamp lock and found unnecessary to apply a window alarm at this time. Audit: All sliding windows in the facility were audited by Administrator and Director of Nursing at 6:38pm on 2/24/2026 and all sliding windows in the facility were found to have safety mechanisms consisting of sliding window clamps locks. All door alarms were checked and verified by [name redacted] Administrator at 7:30 pm on 2/24/2026 that they were in working order. Maintenance assistant [name redacted] completed the weekly door check on all doors on 2/23/2026 resulting in all doors passing alarm testing. On 2/25/2026, [name redacted], MDSC was educated on completing care plan and pocket care plans timely and/or updated as changes occur. Resident 1's care plan was updated on 2/25/2026 and all like residents care plans were updated on 2/25/2026 that require sliding window clamp locks determined by elopement risk. As per final state report all staff were educated 2/13/2026-2/18/2026 on the following topics: Elopement Process/Policy, 2 hour rounding, notification expectations of reportable events to the Administrator, Director of Nursing, Physician, and family members, and who our current wander guard residents are and how we identify them. On 2/25/2026, [name redacted], Director of Nursing contacted staff that received the mandatory education information in their work mailbox have received the training information. On 2/25/2026, [name redacted], MDSC completed elopement risk assessments for all current residents in the building. No new residents were identified as being an elopement risk. On 2/16/2026, [name redacted], Administrator reviewed the current Emergency Plan for [provider]. This review included the Elopement policy and procedure for the facility. The Emergency Operation Plan, including elopement policy was reviewed by [name redacted], Administrator on 2/25/2026 and found no changes needed to be made. Any concerns will be reported to the administrator immediately and addressed in the facility QA [quality assurance committee]. 21. Observation and interview on 2/25/26 at 2:04 p.m. with executive director A and maintenance director G while observing the facility's windows that were not previously secured, revealed that resident 5's window did not have the metal stoppers on it. They stated they did not think they needed to be on it because it slid upward and not sideways, and they verified it opened far enough for someone to climb out of. 22. Interview on 2/25/26 at 2:40 p.m. with BOA N revealed that she received education after resident 1's elopement on 2/13/26. It included the elopement policy, who needs to be notified when there is an elopement, and submitting the information to the DOH. 23. Interview on 2/25/26 at 2:42 p.m. with RN O revealed he received education after resident 1's elopement. It included the elopement policy, who needed to be notified of the elopement and when, and included follow-up interventions when an elopement occurs. 24. Observation on 2/25/26 at 2:45 p.m. with executive director A and maintenance director G of the facility's windows that were not previously secured, revealed that they all had the metal stoppers and were now secured. 25. Interview on 2/25/26 at 2:48 p.m. with CNA P revealed she received education on 2/13/26 after resident 1's elopement. It included a review of the elopement policy, rounding every two hours on all residents, and information on interventions if an elopement occurs. 26. Interview on 2/25/26 at 3:00 p.m. with DON B revealed that the staff who had not yet completed the elopement education would complete it prior to their next shift worked. 27. Record review revealed that ten random residents who were not previously identified as at risk for elopement had elopement risk assessments completed on 2/25/26. The eleven residents that were previously identified as being at risk for elopement had current elopement risk assessments completed, their care plans were up to date, their pocket care plans were up to date, their WanderGuards were documented as being checked for placement and functionality, and elopement drills were completed. The survey team verified onsite, through observations, interviews, and record reviews, that the provider followed their IJ removal plan and the immediacy was removed. The scope and severity level of the noncompliance remained at an E. 28. On 2/25/26 at 3:25 p.m. executive director A was notified that the IJ had been removed. 29. Observation and interview on 2/26/26 at 9:03 a.m. with maintenance director G checking the door alarms throughout the facility revealed the door in the activity room had a magnet alarm that alarmed when it was opened, but the alarm turned off immediately after it was closed. It did not need to be reset by staff to turn the alarm off. The exit door by the laundry room and employee break room had a red alarm box with a keyhole on it, which did not alarm when it was opened. The door alarm was not activated, and he had not checked this door since he started working at the facility. Maintenance director G activated it, and it was functioning. He was unaware if anyone else had keys to turn that alarm off. There were two black doors in the dining room that opened to the courtyard that were unlocked and not alarmed. They were unable to be opened more than a few inches at this time due to snow that was packed behind them. He did not check these doors because he thought they were always locked. He started working at the facility at the end of January, and the previous maintenance director resigned before that. Executive director A and regional maintenance director Q completed his orientation. He went over the easement doors exit doors with regional maintenance director Q during his orientation, but not all of the exit doors. 30. Interview on 2/26/26 at 9:21 a.m. with activities director I revealed that the two doors that accessed the activity room from the hallway were always kept unlocked. She was not aware if the exit door in that room could be locked. 31. Interview on 2/26/26 at 9:55 a.m. with executive director A revealed she had problems with her previous maintenance director completing his duties. He was no longer working there when maintenance director G's employment there started. She and regional maintenance director Q completed maintenance director G's orientation, and he planned for him to have more education completed after three months of employment. She expected that all exit doors would be secured and checked routinely. She acknowledged that the immediate jeopardy (IJ) removal plan indicated she verified that all exit door alarms were in working order on 2/24/26 at 7:30 p.m. She stated that she must have missed checking the activity room door, the exit door by the laundry room, and the two black doors in the dining room. 32. Interview, observation, and document review on 2/26/26 at 11:30 a.m. with executive director A and maintenance director G revealed that the once unsecured doors were now secured, and they were now added to the weekly door check audit. 33. Interview on 2/26/26 at 8:17 a.m. with DON B revealed that CNAs did not complete behavior documentation on resident 1 because the nurses were completing it. She was unaware that resident 1 had any exit-seeking behaviors. She was aware that he was sometimes up during the night. His doctor started him on medication for dementia symptoms last week. 34. Interview on 2/26/26 at 8:36 a.m. with RN J revealed resident 1 was usually awake around midnight to 3:00 a.m., he usually wanted his room door closed, and he would sometimes go sit in the dining room for a snack. He explained resident 1's elopement incident with no discrepancies to the information included in the FRI report. He stated he did not witness resident 1 attempt to go outside or open his window before that incident occurred. 35. Interview on 2/26/26 at 9:00 a.m. with CNA R revealed that when she began to work on 2/12/26 at 10:00 p.m. resident 1's door was closed, and it was usually left open a crack. She did not open his door because she did not want to wake him up, because then he would be more confused and wander. She last saw him around midnight. When she entered his room to empty his catheter at 4:10 a.m., he was not in his room. She notified RN J. Herself, RN J, and another CNA saw that his window was open, so they climbed out of his window to look for him. They could not find him immediately, so they went back inside to search for him. They could not find him inside, so they went back outside with flashlights and found him lying on the ground behind the garbage dumpsters at the back of the building in the brush. She never saw him try to get out of his window or the doors before that incident. She stated that when he wandered, he was easily redirected. 36. Interview on 2/26/26 at 12:25 p.m. with executive director A revealed she expected all the facility doors and windows to be secured. She expected the maintenance department to have monitored all of the exit doors. She was responsible for making sure the maintenance director completed his duties. 37. Review of maintenance director G's training record revealed he received training regarding how to complete and document monthly door inspections on 1/27/26 and 1/28/26 by regional maintenance director Q. 38. Review of the providers 2/24/24 Director of Maintenance Job Description revealed the primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standard, guidelines, and regulations governing the facility, and as may be directed by the Executive Director, to assure that the facility is maintained in a safe and comfortable manner. 39. Review of resident 1's medical record revealed he was admitted to the facility on [DATE]. He had diagnoses of dementia without behavioral disturbances and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). His 1/23/26 brief interview for mental status (BIMS) assessment score was 3, which indicated he had severe cognitive impairment. His 2/4/26 care plan indicated he used a walker to ambulate, he had impaired thought processes and decision-making abilities, and the staff was to report to his physician any changes in cognitive function. His elopement risk assessment score on 1/20/26 was 5, and on 2/13/26 was 6, which both indicated that he was at risk for eloping. He was identified as a wander risk and the staff were to check his wander guard for proper placement, observe his behavior and attempt to determine a pattern, frequency, intensity, and triggers. It indicated a window alarm was placed on his window on 2/13/26. He had a 1/20/26 admission note written by RN F that indicated he had a history of wandering and elopement. On 1/21/26 he received physician orders for the use of a WanderGuard. His skilled nursing notes from 1/23/26 through 2/13/26 at 3:11 a.m. indicated he was confused and did not exhibit behaviors. On 2/13/26 at 9:39 a.m., his skilled nursing note, written by assistant DON (ADON),LPN D, indicated he was confused and had mood and behavior changes, but it did not state what those changes were. On 2/13/26 at 1:13 p.m. a nursing progress note written by ADON, LPN D indicated a fax was received from resident 1's physician to monitor his scratches and abrasions he received when he eloped for signs of infection. His skilled nursing notes from 2/14/26 at 4:12 a.m. through 2/24/26 at 9:00 a.m. indicated he was confused and did not have mood or behavior changes. A 2/15/26 at 5:27 a.m. adverse event follow-up note written by RN J stated he continued on 15-minute checks, he slept until 10:30 p.m., was awake and up in his room until 12:30 a.m., and he went out in the hallway once. A 2/16/26 at 5:30 a.m. adverse event follow-up note by RN J indicated he continued on 15-minute checks, was up at 12:30 a.m. for a sandwich, and fell back to sleep at 2:00 a.m. A 2/17/26 at 1:45 p.m. progress note by RN O indicated that physician orders were received for dementia medication. On 2/22/26 at 12:34 a.m. a behavior note by LPN N indicated that he was up at 12:10 a.m. for a snack, and he was watching the therapy room exit doors. On 2/22/26 at 12:51 a.m. a behavior note by LPN N stated he had his coat on and collected some of his belongings and was watching the therapy doors, but was able to be redirected back to bed. 40. Review of the providers 10/29/24 Missing Resident/Elopement Process policy revealed that an elopement risk assessment would be done on admission, readmission, quarterly, annually, and with any significant change. The care plan would be updated as needed based on the risk assessment. Missing resident identification forms would be completed on admission and annually for resident's who were identified as moderate or high risk for elopement. If a resident was identified as moderate or high risk for elopement they could wear a wander guard, they would keep a current photo of the resident, staff were to respond to exit alarms immediately, staff were to encourage resident activities to distract them, and the resident's care plan would address behaviors to include resident specific goals. When a resident was missing staff would notify the charge nurse, and all staff would search the facility. If not located, staff would then search the grounds. If not found then the executive director, DON, family or legal representative, attending physician, and police would be notified. When the resident was located they would have a head to toe assessment completed to identify injuries, and the physician would be notified of the assessment results. The resident's family would be notified of the resident's condition and the residents condition would be monitored every shift for 72 hours. An incident and investigation report would be completed. The incident report would be reviewed at the monthly safety committee and quality assurance meeting. All staff would be educated during orientation and annually on the proper identification, assessment, and treatment of residents who were identified as at risk for exit seeking. Missing resident drills will be completed on all shift every month.

Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to thoroughly investigate resident-to-resident incidents of potential abuse by one of one sampled resident (1) who used acts of physical aggression toward two of two sampled residents (2 and 3) on separate occasions. Failure to thoroughly investigate those incidents may have placed all residents at risk for potential resident-to-resident abuse.Findings include:1. Review of the South Dakota Department of Health (SD DOH) complaint received on 8/5/25 regarding resident 1 revealed:*Resident 1 was identified by first name only.*It was reported that resident 1 would walk in the halls, enter other residents' rooms, and take items that did not belong to her from other residents' rooms.*The complainant was told that resident 1 had gone into another resident's room, and choked that resident.*The resident who had been choked reported the incident to the provider and she [resident 2] was told the incident was documented and reported.-The provider had not completed a facility reported incident (FRI) related to the choking incident.*The complainant reported that resident 1 continued to walk in the hallways and some residents were fearful of resident 1.2. Review of resident 1's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She was discharged from the facility on 8/16/25.*Her 5/27/25 Minimum Data Set (MDS) indicated she was rarely understood or able to understand others and was severely cognitively impaired.*Her diagnoses included Alzheimer's (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), major depressive disorder, personality disorder (a group of mental health conditions characterized by inflexible and unhealthy patterns of behavior and thinking that differ from cultural norms), a traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), and behavioral disturbances.*A 6/24/25 progress note stated, Another resident addressed [resident 1] patting at [a] chair next to her offering her to sit by her. [resident 1] rushed over to her & [and] stated, ‘I'll kill you!'. Nurse intervened &walked [resident 1] to her room & offered her a snack which she refused.*A 6/26/25 progress note stated, Resident [resident 1] went into another residents [resident 3's] room and attempted to take [that] resident's remote. [The] Resident [3] stated, ‘That is my remote can I have it back?' Resident [1] said ‘No' and slapped [the other] resident in the head twice before exiting her room. Reported to resident's nurse.*A 7/6/25 progress note stated, resident [1] was in [the] dining room yelling at another resident she was redirected by staff and removed from [the] dining room, will continue to monitor.*A 7/9/25 progress note stated, Resident [1] [is] verbally aggressive toward staff members and other residents at this time.*A 7/10/25 progress note stated, resident [1] [is] agitated [and] going into other resident rooms.*A 7/16/25 progress note stated, resident [1] [is] agitated [and] going into other residents' rooms.*A 7/19/25 progress note stated, resident [1] [is] being reported to have aggressive behaviors towards another resident during bingo and patted her shoulder, will continue to monitor.*A 7/20/25 progress note stated, resident 2 said that [resident 1] came into her room around 515 pm [5:15 p.m.] while [resident 2] had company. [Resident 1] went and sat on the residents [resident's] bed then got up and went to [resident 2]'s hand towels and grabbed one, when [resident 2] told her that they were her towels [resident 1] stated that they were her's then walked over to [resident 2] and put her hands around residents [resident 2's] neck, however [resident 2] said that she did not squeeze or apply pressure [resident 1] just pressed her hand around her [resident 2's] throat.*Resident 1's 7/28/25 progress notes stated,- [resident 1 is] Extremely agitated and yelling at residents [and] staff and attempting to grab them.- resident [1] was yelling out no and swearing at staff, residents, and some visitors, was trying to grab at other residents and when staff would redirect [resident 1] would yell or grab at them.3. Interview on 8/27/25 at 3:40 p.m. with resident 2 regarding the 7/20/25 incident involving resident 1 revealed:*Resident 2 stated she was talking with her visitor when resident 1 entered her room.*Resident 1 had gone over and picked up resident 2's towels.*Resident 2 told her No then resident 1 walked over to resident 2 and placed her hands on resident 2's neck.*Resident 2 stated resident 1 did not squeeze her neck.*Resident 2 denied having felt fearful of resident 1.*She stated that after that incident (on 7/20/25), if resident 1 was agitated and walking in the hallways, she would close her door.4. Review of the provider's investigation related to the incident on 7/20/25 between resident 1 and resident 2 revealed:*Administrator A spoke with resident 2 on 7/21/25 at 10:30 a.m.*Resident 2 told administrator A resident 1, came into her room and wanted her wash cloths [washcloths]- told her No- then came over and put [her] hands on front of her by neck- no squeezing or pushing.*Resident 2 denied feeling threatened and stated she felt safe.*Resident 2 stated it had only happened the one time and she had no other concerns or issues.*On 7/25/25 administrator A followed up with resident 2 and she continued to deny concerns at that time.*There was no documentation that the staff had been interviewed related to the reported incident on 7/20/25.*There was no documentation that other residents had been interviewed.*There was no documentation that a skin assessment for resident 2 had been completed after the incident.5. Interview on 8/28/25 at 10:55 a.m. with administrator A revealed, there was no investigation completed regarding the 6/26/25 resident to resident incident involving resident 1 and resident 3, because she had not been informed of the incident.6. Interview on 8/28/25 at 11:30 a.m. with licensed practical nurse (LPN) C revealed:*She worked on 6/26/25 and had taken care of resident 3.*She did not witness resident 1 slap resident 3.*Resident 3 told her that resident 1 wanted her remote and when resident 3 told resident 1 No, resident 1 slapped her.*LPN C stated she documented the incident, and then reported it to the other nurse on duty.-She was not sure who she had reported the incident to but recalled it was a male nurse.7. Interview on 8/28/25 at 11:35 with registered nurse (RN) D revealed:*He had worked on 6/26/25.*He did not recall being informed that resident 1 had slapped resident 3.8. Interview on 8/28/25 at 11:45 a.m. with administrator A and director of nursing (DON) B revealed:*They were aware resident 1 had displayed verbal and physical aggression towards other residents.*Administrator A had completed an investigation on 7/21/25 related to the 7/20/25 incident when resident 1 had placed her hands on resident 2's neck.-She had not interviewed staff or other residents at that time to determine if there had been other residents who had been affected or felt unsafe from resident 1.*Administrator A nor Interim DON B had not been notified that resident 1 had slapped resident 3 on 6/26/25.*Administrator A stated she would have investigated the incident if she had been notified.9. Review of the provider's 10/19/22 Vulnerable Adult policy revealed:* Resident to resident altercations; including physical, mental, or verbal abuse are reportable to the state agency. The facility should have a system in place to identify resident's whose personal history render them at risk for abusing other residents.* Not all incidents or events sustained by a vulnerable adult are required to be reported, even if they appear to meet the technical definition of maltreatment. These events must be reported internally to the immediate supervisor who will notify the Administrator and the Director of Nursing Services.* The Supervisor, Director of Nursing or Administrator will immediately institute an internal investigation of the reported allegation or incident. The investigation may include:-1) Interview of staff-2) Resident interviews-3) Witness interviews-4) Environmental review-5) Resident health status-6) Behavior review-7) Medication review.* All incidents will be investigated thoroughly by administration.* Further, the facility shall ensure that all alleged violations involving abuse, neglect, mistreatment, misappropriation of resident property including injuries of unknown source are reported immediately to the Administrator and to other agencies in accordance with state law through established procedures. [The provider] shall have evidence that all alleged violations are thoroughly investigated and shall prevent further potential abuse while the investigation is in progress.-Written Report--a) Who was interviewed--b) Content of interview--c) Resident Diagnosis--d) ADL [activities of daily living] capabilities and a determination if the resident is interview-able--e) Resident reactions--f) Circumstances pertaining to the incident.

Based on South Dakota Department of Health (SD DOH) complaint, record review, interview, and policy review, the provider failed to follow professional nursing standards to ensure:*One of one sampled resident's (1) pain was assessed according to the provider's policy.*The indication for administration of an as needed anxiety medication administered to one of one sampled resident (1) was documented.*The effectiveness and any adverse reactions were documented for the use of a newly ordered mood-altering medication (Depakote) for one of one sampled resident (1).Findings include: 1. Review of the South Dakota Department of Health (SD DOH) complaint received on 8/5/25 regarding resident 1 revealed:*Resident 1 was identified by first name only.*It was reported that resident 1 would walk in the halls, enter other residents' rooms, and take items that did not belong to her from other residents' rooms.*The complainant was told that resident 1 had gone into another resident's room, and choked that resident.*The resident who had been choked reported the incident to the provider and she [resident 2] was told the incident was documented and reported.-The provider had not completed a facility reported incident (FRI) related to the choking incident.*The complainant reported that resident 1 continued to walk in the hallways and some residents were fearful of resident 1.2. Review of resident 1's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She was discharged from the facility on 8/16/25.*Her 5/27/25 Minimum Data Set (MDS) indicated she was rarely understood or able to understand others and was severely cognitively impaired.*Her diagnoses included Alzheimer's (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), major depressive disorder, personality disorder (a group of mental health conditions characterized by inflexible and unhealthy patterns of behavior and thinking that differ from cultural norms), a traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), and behavioral disturbances.*Review of her July medication administration report (MAR) revealed she did not have a physician's order for regularly scheduled or as needed pain medication until she was prescribed morphine as part of her comfort care plan.*Resident 1's 8/27/25 care plan revealed she had a focus area of has potential for pain with need for medication management R/T [related to] general discomfort with an intervention of report pain or requests for analgesics [medication to relieve pain] to nurse.3. Review of resident 1's history falling documentation from July through August 2025 revealed:*In July she fell on the 5th, the 8th, the 20th, the 28th, and the 29th.*In August she fell on the 3rd and the 4th.*As a result of her fall on 7/29/25 she sustained an indentation on her forehead. She was very agitated and her pain level was assessed to be a six on a zero to ten scale with the use of the PAINAD (a tool to assess pain assessment for people with advanced dementia) assessment scale which meant she had moderate pain.*On 8/3/25 resident 1 fell and sustained a three centimeter laceration (cut or torn skin) to her forehead and her pain level was assessed to be a four with the use of the PAINAD assessment scale, which meant she had moderate.*Review of resident 1's pain assessment revealed:-There were no documented pain assessments completed in June 2025.-On 7/15/25 resident 1's pain assessment was documented at a level four.-On 7/29/25 resident 1's pain assessment was documented at a level six.*There was no documentation of staff having contacted the physician to consider giving orders to for pain medications prior to resident 1 being placed on comfort cares (a type of medical care that focuses on providing relief from symptoms and improving the quality of life for people with serious or life-threatening illnesses) on 8/4/25.*Review of her August MAR revealed she had 8/4/25 physician's order for Morphine Sulfate [narcotic pain medication] (Concentrate) 20 MG/ML [milligrams/milliliter] Give 0.25 ml by mouth every 4 hours as needed for Pain.4. Further review of resident 1's EMR revealed she had a 6/26/25 physician's order for LORazepam [an anti-anxiety medication] Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 12 hours as needed for severe anxiety/agitation.*Resident 1's MAR documentation indicated she was administered the as needed lorazepam 47 times in July 2025.-Of those 47 documented lorazepam administrations, 28 did not indicate what the medication was administered for.*Resident 1 had a 7/22/25 physician's order for Depakote Oral Tablet [a medication used to treat seizures and bipolar disorder] Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for mood stabilization.*An 8/1/25 communication with psychiatric mental health nurse practitioner J revealed she had spoken with licensed practical nurse (LPN)/Minimum Data Set (MDS) coordinator H, who reported resident 1 continued anger/irritability and aggression at times.*On 8/1/25 a physician's order was received to change resident 1's Depakote order to Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) Give 1 tablet by mouth in the morning for mood stabilization and Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for anger/irritability/aggression.*There was no documentation regarding the effectiveness or adverse effects of the newly ordered Depakote in resident 1's EMR.*There was no documentation regarding the effectiveness or adverse effects of the Depakote after the dose was increased on 8/1/25.5. Interview on 8/28/25 at 11:40 a.m. with registered nurse (RN) I revealed:*It was the expectation that a reason for the administration of an as needed medication was to be documented at the time the medication was administered.*If there was no documented reason for that medication administration, the staff would not be able to follow-up to determine if the medication was effective.6. Interview on 8/28/25 at 11:45 a.m. with administrator A and director of nursing (DON) B revealed:*Administrator A stated the provider used [NAME] and [NAME] as a resource for professional standards.*In February or March of 2025, the staff had noticed resident 1's gait began to change, and she became more anxious.*She was given physician ordered acetaminophen 500 mg two tables three times per day from 4/28/25 through 5/23/25.*DON B stated that beginning in May 2025 resident 1 began to further decline in her physical and cognitive abilities.*DON B was not sure why the scheduled acetaminophen was discontinued.*She stated pain could be difficult to evaluate with residents who had dementia and for some residents their pain could be expressed through behaviors.*DON B stated pain assessments were to be completed and documented by the staff with the administration of a pain medication, anytime a resident fell, if a resident had skin concerns, if there was a change in a resident's condition, or there was a change in the resident's cognition.*DON B verified there were no pain assessments documented in June 2025.*She would have expected there had been a pain assessment completed in June but since the resident did not have any skin issues or documented falls the staff were not prompted to complete a pain assessment.*DON B verified resident 1 had no physician's orders for pain medication in July 2025.*She stated the provider had standing orders for acetaminophen as needed but verified there was no documentation of acetaminophen having been administered until 8/12/25, after resident 1 was placed on comfort cares.*DON B stated she expected that the staff would document a reason for administration of an as needed medication at the time of administration.*DON B expected the effectiveness and any adverse effects from a mood altering medication, such as Depakote, to be documented every shift for the first 14 days after the first administration of the medication.*The staff had a hot charting form at the nurses' stations that instructed them to complete that charting for residents with those types of new medications.*She verified there was no documentation related to the effectiveness or any adverse reactions related to resident 1's use of the Depakote medication that was started on 7/22/25, and had a physician's ordered dose increase on 8/1/25.Review of the provider's April 2025 Pain Management policy revealed:* The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.* The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain.* Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: .-c) Fidgeting, increased or recurring restlessness-d) Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw)-e) Behaviors such as: resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities.-g) Weight loss-h) Difficulty sleeping (insomnia)-i) Negative vocalizations (e.g. groaning, crying, whimpering, or screaming)* The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain.A medication administration policy was requested on 8/28/25 at 9:30 a.m. and was not received by the end of the survey.

Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to have reviewed and revised the care plan for one of one sampled resident (1) needs and how to manage those needs.Findings include:1. Review of the South Dakota Department of Health (SD DOH) complaint received on 8/5/25 regarding resident 1 revealed:*Resident 1 was identified by first name only.*It was reported that resident 1 would walk in the halls, enter other residents' rooms, and take items that did not belong to her from other residents' rooms.*The complainant was told that resident 1 had gone into another resident's room, and choked that resident.*The resident who had been choked reported the incident to the provider and she [resident 2] was told the incident was documented and reported.-The provider had not completed a facility reported incident (FRI) related to the choking incident.*The complainant reported that resident 1 continued to walk in the hallways and some residents were fearful of resident 1.2. Review of resident 1's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She was discharged from the facility on 8/16/25.*Her 5/27/25 Minimum Data Set (MDS) indicated she was rarely understood or able to understand others and was severely cognitively impaired.*Her diagnoses included Alzheimer's (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), major depressive disorder, personality disorder (a group of mental health conditions characterized by inflexible and unhealthy patterns of behavior and thinking that differ from cultural norms), a traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), and behavioral disturbances.*She had a 6/26/25 physician's order for LORazepam [an anti-anxiety medication] Oral Tablet 0.5 MG [milligrams] (Lorazepam) Give 1 tablet by mouth every 12 hours as needed for severe anxiety/agitation.*Resident 1 was being seen by a mental health practitioner for management of her behaviors and mental health medications.*A 6/24/25 progress note stated, Another resident addressed [resident 1] patting at chair next to her offering her to sit by her. [resident 1] rushed over to her & [and] stated, ‘I'll kill you!'. Nurse intervened &walked [resident 1] to her room & offered her a snack which she refused.*A 6/26/25 progress note stated, Resident [resident 1] went into another residents [resident's] room and attempted to take resident's remote. Resident stated, ‘That is my remote can I have it back?' Resident said ‘No' and slapped resident in the head twice before exiting her room. Reported to resident's nurse.*A 7/6/25 progress note stated, resident was in [the] dining room yelling at another resident she was redirected by staff and removed from [the] dining room, will continue to monitor.*A 7/9/25 progress note stated, Resident verbally aggressive toward staff members and other residents at this time.*A 7/10/25 progress note stated, resident agitated going into other resident rooms.*A 7/16/25 progress note stated, resident agitated going into other residents' rooms.*A 7/19/25 progress note stated, resident being reported to have aggressive behaviors towards another resident during bingo and patted her shoulder, will continue to monitor.*A 7/20/25 progress note stated, resident 2 said that [resident 1] came into her room around 515 pm [5:15 p.m.] while [resident 2] had company. [Resident 1] went and sat on the residents [resident's] bed then got up and went to [resident 2]'s hand towels and grabbed one, when [resident 2] told her that they were her towels [resident 1] stated that they were her's then walked over to [resident 2] and put her hands around residents neck, however [resident 2] said that she did not squeeze or apply pressure just pressed her hand around her throat.*7/28/25 progress notes stated,- Extremely agitated and yelling at residents [and] staff and attempting to grab them.- resident was yelling out no and swearing at staff, residents, and some visitors, was trying to grab at other residents and when staff would redirect [resident 1] would yell or grab at them.3. Review of resident 1's 8/27/25 care plan revealed:*An identified focus area that indicated she had an Elopement [leaving the facility without staff knowledge]/wander Risk.-Interventions for that focus area included staff were to Maintain familiar items in environment, with well-lit room. Observe behavior and attempt to determine pattern, frequency, intensity and triggers. Offer/encourage activities for distraction.-Her care plan did not include her tendency to wander into other resident rooms and take items, or any identified triggers or interventions to attempt to prevent that behavior.*Her care plan did not address her agitation, verbal and physical aggression towards staff and other residents, potential triggers, or interventions related to her agitation and verbal and physical aggression.*Resident 1's care plan did not indicate she was being seen by a mental health practitioner.4. Interview on 8/27/25 at 3:40 p.m. with resident 2 revealed she had been told by staff that telling resident 1 No was a trigger for resident 1's agitation and aggression.5. Interview on 8/27/25 at 3:45 p.m. with certified nursing assistant (CNA)/certified medication aide (CMA) F revealed:*When resident 1 was initially admitted she was pleasant and easy to redirect. In the past year her dementia had progressed, and she could become aggressive and difficult to redirect.*He stated that resident 1 would become more agitated when staff attempted to redirect her.*Resident 1 wandered into other resident rooms.*He had witnessed times when resident 1 had become physically aggressive with staff without staff having interacted with her prior to the aggression.*Resident 1 would grab other residents by their arms if they told her No or if staff were attempting to redirect her.*Other residents had expressed to him that they were fearful of resident 1.*Staff encouraged other residents to close the doors to their rooms when resident 1 was agitated because resident 1 did not usually go into rooms with closed doors.*He used resident care plans as a resource to provide care for the residents.*He did not recall resident 1's care plan having addressed her verbal and physical behaviors, interventions or triggers.6. Interview on 8/27/25 at 3:55 p.m. with registered nurse (RN) G revealed:*When resident 1 was wandering into other resident rooms, staff would watch her more closely.*Resident 1 would not sit long enough to participate in activities.*She recalled that resident 1's care plan included that she wandered, but she did not recall if there were any identified behaviors or interventions for her behaviors identified in her care plan.7. Interview on 8/27/25 at 4:28 p.m. with licensed practical nurse (LPN)/Minimum Data Set (MDS) coordinator H revealed:*Care plans were to be updated by the interdisciplinary team (activities, nursing, social services, administration, and dietary).*She had been told resident 1 had episodes of verbal and physical aggression with staff and residents, but she had not witnessed that.*Resident 1 would become more agitated if someone repeatedly said her name.*Resident 1's care plan indicated she was a risk for elopement related to her wandering.*LPN/MDS coordinator H stated that staff were to turn the [NAME] show on resident 1's television as an intervention for resident 1's wandering.*Upon review of resident 1's care plan, she confirmed resident 1's care plan indicated she had a preference of watching the [NAME] show, but it was not listed as an intervention for her wandering.*She verified resident 1's care plan did not address her verbal and physical aggression.*She did not know if there were any interventions put into place related to resident 1 wandering into other residents' rooms.*She agreed it may have been helpful for staff to care for resident 1's wandering and behaviors if there were interventions addressed in her care plan.8. Interview on 8/28/25 at 8:10 a.m. with administrator A revealed all interventions that were attempted with resident 1 related to her aggressive verbal and physical behaviors would have been documented in her care plan.9. Interview on 8/28/25 at 11:45 a.m. with administrator A and director of nursing (DON) B revealed:*When resident 1 was admitted she did not display any aggressive behaviors.*In the beginning of 2025 resident 1's dementia progressed, and she began to display increased wandering as well as verbal and physical behaviors.*Due to resident 1's increased behaviors a mental health practitioner was consulted for her care.*Staff would provide one to one observation of resident 1 whenever they were able to prevent her from wandering into other resident rooms and avoid altercations between resident 1 and other residents.*Staff would also ask and encourage residents to have their doors closed when resident 1 had episodes of increased agitation.*Resident 1 ate her meals with a staff member instead of in the dining room to decrease the stimulus in an attempt to get resident 1 to eat her meal.*Administrator A and DON B expected the interventions in place for resident 1's wandering and aggressive behaviors to have been included in her care plan.*Administrator A and DON B verified resident 1's care plan had not been updated to include interventions for her aggressive behaviors or wandering into other residents' rooms.*LPN/MDS coordinator H was primarily responsible for updating the nursing portion of residents' care plans but anyone on the interdisciplinary team (IDT) team could update the residents' care plans.*Administrator A and DON B expected that the residents' care plans would be updated with each quarterly and annual MDS as well as with any changes in the residents' care needs.10. Review of the provider's April 2025 Comprehensive Care Plan policy revealed:* It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.* The comprehensive care plan will describe, at minimum, the following:-a) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.-f) Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated.* The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, and policy review, the provider failed to ensure one of one sampled resident's (1) wheelchair was secure in the facilities transport vehicle according to manufacturer's guidelines resulting in the resident's wheelchair tipping backwards and the resident sustained a spinal fracture.Findings include:1. Review of SD DOH FRI that was submitted on 7/15/25 revealed:*At approximately 11:15 a.m. on 7/15/25, resident 1 was being transported from an appointment back to the facility in the facility's transport van by certified nursing assistants (CNA)s G and H and his wheelchair tipped backwards while the van was driving.*It was suspected that the front wheelchair locking mechanisms failed, allowing resident 1's wheelchair to tip backwards.*Resident 1 complained of pain in his back to the staff in the van.*CNAs G and H assisted resident 1 back into his wheelchair after it tipped and transported the resident back the facility.*At the facility, resident 1 was assessed by registered nurse (RN) I and was sent to the Emergency Department (ED) for further evaluation related to his back pain.*On 7/15/25, resident 1 returned to the facility from the ED with a diagnosis of a closed nondisplaced fracture of the sixth cervical vertebra (a break in one of the bones in his neck).*The provider's investigation concluded that lap belt connectors malfunctioned and did not tighten correctly which caused the resident's wheelchair to tip backwards.*The lap belt connectors suspected of malfunctioning were removed from the transport van and replaced with new parts.*CNA G was educated on correctly locking and tightening wheelchair straps in the transport van. 2. Interview on 7/22/25 at 10:55 a.m. with resident 1 revealed:*He recalled the accident that happened on 7/15/25 in the facility's transport van.*He was able to describe the injury he sustained due to the accident.*He stated he had been to several medical appointments in the past while CNA G was driving and had never had any accidents.*He could not recall if CNA G had any changes in her normal routine of securing his wheelchair that day. 3. Interview on 7/22/25 at 1:02 p.m. with CNA H revealed:*She had accompanied resident 1 to his medical appointment on 7/15/25 and rode along in the facility's transport van.*She did not assist with securing his wheelchair in the transport van.*She could not recall watching CNA G securing resident 1's wheelchair in the transport van that day. 4. Interview on 7/22/25 at 2:50 p.m. with administrator A revealed:*After resident 1's 7/15/25 incident in the facility's transport van, she had CNA G demonstrate to her what happened during the transport.*Administrator A checked the wheelchair securing straps and was not able to duplicate the malfunction that happened during the incident that day.*CNA G had been the transport van driver for the past two years and had not encountered an accident like that before.*The wheelchair securing straps were replaced with new ones.*After the incident, there had been a new section added to the van's daily checklist that would have the driver physically check the tension on the wheelchair securing straps for safety.*She felt it was an unfortunate event caused by faulty equipment. 5. Interview and demonstration on 7/23/25 at 10:45 a.m. with CNA G and administrator A in the facility's transport van related to resident 1's incident revealed:*CNA G reported on the day of the incident she loaded resident 1 into the van from the rear wheelchair ramp.*Once resident 1 was in place in the van, she locked his wheelchair brakes, then she attached two hooks to the rear of the wheelchair. She then attached two hooks to the front of the wheelchair. She then fastened resident 1's seat belt.*She then reported leaving the medical provider's parking lot.*After driving for about a block, she heard a loud noise and when she looked back she found resident 1 had tipped backwards in his wheelchair inside the van.*She reported that after pulling over the van, the two hooks attached to the rear wheelchair wheels were still attached. The hooks attached to the front of the wheelchair were no longer attached. It did not appear that the front straps had pulled out of the locking device.*She and CNA H then assisted resident 1 back into his wheelchair.*Resident 1 was taken back to the facility to be assessed by as nurse. 6. Interview on 7/23/25 at 3:30 p.m. with regional nurse consultant/acting director of nursing B revealed that she did not do the staff training for the facility van operation. 7. Interview on 7/23/25 at 4:00 p.m. with administrator A revealed:*Business Office Assistant (BOA) J does the competency testing for staff that drove and operated the facility van.*The current van driver (CNA G) provided training for new van drivers. The new driver would ride with the current driver for a couple days to learn the process.*BOA J used the Driver's Road Test Examination to verify the driver's ability to safely operate the van. 8. Interview on 7/23/25 at 4:47 p.m. with BOA J revealed:*She did not use a specific curriculum for testing a driver's ability to safely operate the van.*She used the facility's Driver's Road Test Examination, which contained a checklist of observed steps.*When asked if she had a checklist for what was specifically observed during the Observed and has competency in securing a wheelchair in the vehicle. step, she stated No, I've just done it so many times. I did it for two years. 9. Record review of education provided to facility van drivers on 7/15/25 revealed:*All safety belts will be checked with each resident transport daily to ensure all locks are secure and lap belts are placed for resident safety. Van Driver will note this on the van log with each transport.*The van driver will notify the resident's nurse of any injury that occurs in the van during transport or loading/unloading resident for appointments. The resident will not be moved until assessment has been made by the nurse or EMS [emergency medical services]. 911 will also be called if the injury assessment is deemed appropriate.*CNA G was educated by administrator A.*Administrator A was educated by nurse consultant B.*BOA J was educated by administrator A. 10. Review of the AMF [NAME] America (wheelchair tie down manufacturer) user manual revealed:*Section 2, A. Daily Inspection Checklist, 1. Check the retractors by quickly pulling out the webbing to ensure proper locking.*Section 3, Wheelchair and Securement Instructions, Step 6. Once you have all four straps attached, release the brakes on the wheelchair and check for movement. Once secured, the wheelchair should not move more than two (2) inches front-to-back or side-to-side. Reapply the brakes. 11. Interview on 7/24/25 at 8:35 a.m. with administrator A revealed:*She was not aware that the manufacturer's instructions were to release the wheelchair brakes to check for movement before driving the vehicle.*She was not sure if following that step could have prevented resident 1's accident because she was not there during the accident.*She felt it was an equipment malfunction that caused resident 1's wheelchair to tip in the van that day.

Based on record review, interview, and policy review, the provider failed to ensure professional nursing standards of practice regarding timely and accurate documentation of narcotic medications for two of two sampled residents (1 and 2) to ensure accountability of high risk medications.Finding include: 1. Review of the narcotic sign-out sheet and resident 1's medication administration record (MAR) revealed:*On 7/17/25 at 9:30 a.m., one Hydrocodone-Acetaminophen 5-325 milligrams (mg) tablet was signed out on the narcotic sign-out sheet by registered nurse (RN) C, but it was not documented as administered in the MAR.*On 7/21/25 at 8:45 a.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was signed out on the narcotic sign-out sheet by RN C, but it was not documented as administered in the MAR.*On 7/22/25 at 8:00 a.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was signed out on the narcotic sign-out sheet by RN C, but it was not documented as administered in the MAR.*On 7/22/25 at 3:00 p.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was signed out of the narcotic sign-out sheet by RN C, but it was not documented as administered in the MAR until 6:10 p.m. that day.*On 7/22/25 at 9:00 p.m., one Hydrocodone-Acetaminophen 5/325 mg tablet was signed out on the narcotic sign-out sheet by RN D, but it was not documented as administered in the MAR.*On 7/23/25 at 5:29 p.m., one Hydrocodone-Acetaminophen 5-325 mg tablet was signed out on the narcotic sign-out sheet by RN E, but it was not documented as administered in the MAR.*On 7/24/25 at 8:54 a.m., one Hydrocodone-Acetaminophen 5-325 mg tablet had been removed by RN C with no time of removal noted, RN D documented in the MAR that the tablet was administered at 7:50 a.m. that day2. Review of resident 2's the narcotic sign-out sheet revealed that on 7/21/25 at 4:00 p.m., RN C placed a line through the removed tablet and wrote dropped, but she did not have a second nurse's signature to verify the wasted narcotic medication.3. Interview on 7/23/25 at 3:30 p.m. with RN F revealed:*When narcotic medications were signed out, they should be documented as administered in the MAR at that same time.*If a narcotic medication was dropped or needed to be destroyed for any reason, it should have been signed by two nurses to document the destruction of it.4. Interview on 7/24/25 at 10:35 a.m. with director of nursing (DON) B revealed.*It was her expectation that if a narcotic medication was signed out on the narcotic sign-out sheet, it should have been documented in the MAR at that same time.5. Review of the provider's Controlled Substances policy (updated 4/25/24) revealed:*Purpose, B. To assure controlled drugs are handled, stored, and disposed of properly.*Purpose, C. To assure proper record keeping for controlled drugs.*Administration of Controlled Substances, B. Administering a controlled substance to a resident: it must be signed out on the individualized controlled substance sheet and documented on the eMAR.*Administration of Controlled Substances, C. The controlled substance sheet and eMAR [electronic medication administration record] must match.

Based on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to protect the resident's right to be free from neglect related to assessing and providing skin care to prevent skin necrosis (death of cells or tissue through disease or injury) of both the residents feet and implementing monitoring to potentially prevent a significant weight loss for one of one sampled discharged resident (51) who required hospitalization related to those conditions. Findings include: 1. Review of the 1/9/25 SD DOH complaint intake revealed: *The complainant had a concern regarding the quality of care and treatment for resident 51. *The reported the resident was admitted to the hospital on 1/7/25. *The resident's left foot great toe, three other toes, and 3 last toes and part of his foot was necrotic. *The resident's right foot necrosis was between his great toe and the next toe. *The resident had been previously hospitalized in October 2024 and had no skin issues at that time. *The first time the facility had reached out to the doctor about the necrosis on his feet was on 1/1/25 *The resident had dementia (impaired memory and cognition) and thought his foot was broken. *The resident's wife lived at a different facility and his durable power of attorney (DPOA) was his daughter who did not live close by. 2. Review of the 1/16/25 SD DOH complaint intake revealed: *The complainant wanted to remain anonymous. *They reported the resident was admitted to the facility late fall 2024. *The complainant reported the resident's family had not been invited to his care plan meetings to review his current status and allow them to be a part of any changes in his plan of care. *His family had been notified of a fall and skin tear but had not been notified about his toes until 1/1/25. *The resident's family had been informed by the unit manager, licensed practical nurse (LPN) C regarding the necrosis of his toes. *They reported the family had been informed the resident's toes had started to turn black related to his diabetes diagnosis. *They felt the resident should have been sent to the emergency room (ER) but it was decided he would be seen by a podiatrist (foot doctor) instead. *On 1/7/25 the hospital podiatry department informed the family the resident had gangrene (dead tissue caused by an infection or lack of blood flow) in both of his feet related to an untreated infection. *The family had been told his condition Was brewing for months: and could not have been a recent onset. *The complainant reported the hospital staff informed the family that when they took off the resident socks, they had been afraid his toes would peel off with the socks due to the advanced state of the gangrene. *They were aware the resident had been hospitalized in December of 2024 due to Coronavirus disease (COVID -19) and had returned to the facility on [DATE]. *The hospital's podiatry department also informed the family the resident was malnourished (had a nutritional deficiency). *He had lost 23 pounds (lbs.) from 10/23/24 through 1/7/25. *The facility had not informed the resident's family of his extreme weight loss and when discussed with the facility they were informed he had been refusing his medications also. *The complainant reported the family felt like no one was paying attention to the resident and they had been concerned he was being neglected. *The hospital informed the family the only options for him was a double amputation of his legs or Hospice Care (end-of-life care). *The family made the difficult decision for the resident to start Hospice Care and admitted him to a different long term care facility (LTC) for Hospice Care. 3. Review of resident 51's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included: -Chronic Obstructive Pulmonary Disease (a disease that makes it hard to breathe). -Type 2 Diabetes Mellitus without complications. -Type 2 Diabetes Mellitus with Diabetic Neuropathy (decreased sensation in the feet, legs, hands, and arms). -Chronic Kidney Disease Stage 3 (moderate damage to the kidneys, where they are not filtering waste effectively). -Dependence on Renal Dialysis (medical treatment that removes waste products and excess fluid) 3 times per week. -Dementia. -He had been affected by COVID-19 from 12/16/24-1/1/25. *His Brief Interview for Mental Status (BIMS) score was 11 which indicated he had moderate cognitive impairment. *On admit on 10/29/24 he had a skin tear on his left 2nd toe which measured 0.3 centimeters (cm) x 0.3 cm, and it had healed on 11/19/24. *There was a note in his Dialysis report dated 12/20/24 which indicated: -Dialysis education additional information: Nursing Home staff: Please check bilateral feet as they are red. *There was no documentation, progress note, or a Non-Ulcer Skin Assessment form in his EMR to indicate his feet were checked for that redness. *He had an order dated 11/12/24 for daily weights to be checked. -Upon admission on 10/29/24 he had weighed 158.6 lbs. and by 1/7/25 he had weighed 128.2 lbs. -He had lost 30.4 lbs. within 69 days. *There was no documentation that indicated the weight loss was reported to his doctor or his family to ensure further guidance was provided. 4. Interview on 2/5/25 at 9:20 a.m. with director of nursing (DON) B regarding skin assessments for residents who were in isolation related to COVID-19- revealed: *She would have designated a tub room for residents on isolation to use, the resident could have worn a mask in the hallway when staff transported them to the tub room, or they resident could have received a bed bath in their room. *CNAs would do skin checks on residents when they bathed or showered them. *If a CNA noted a skin concern for a resident, they would have been reported that to the nurse or unit manager *The nurse, unit manager, or wound nurse would have completed the Non-Ulcer Skin Assessment form in the residents' EMR and added the resident and skin concern to their weekly wound rounds for follow up. 5. Interview on 2/6/25 at 11:50 a.m. with wound nurse N regarding resident 51's necrotic skin revealed: *She had been wound nurse since employed at the facility. *She had not received any special training related to wounds. -no special training *She completed the resident's Non-ulcer Skin Assessment on 10/29/24 for weekly wound rounds and had notified the family that the area of concern had been healed by 11/19/24. *The resident had COVID-19 from 12/16/24 through 1/1/25 and had remained isolated to his room, and had not received a shower during that time. -He had a shower after the COVID-19 had been resolved on 1/1/25. -The skin concerns on his feet had been discovered at that time. *The CNA identified the concerns during the resident's shower and had let the nurse know about the new skin issue. *She knew the nurse working that day had called for an appointment to get his foot looked at and he had gone later that week to a podiatry appointment. *She did not do regular diabetic skin checks and was not sure if that had been completed by the nurses. *She expected the CNA's and nurses to let her know when they identified a new skin concern for her to follow up on it. 6. Interview on 2/6/25 at 12:57 p.m. with certified medication aid (CMA)/CNA O revealed: *She had been doing residents' baths for [AGE] years at the facility. *She stated if she found a skin tear, an open area, an abrasion, a bruise or anything she had not seen before on a resident during their bath she would let the nurse know about it. If it was new to her, she would have reported it even if nurse had seen it. -The nurse would have come in to assess that resident's area, get measurements, and fill out their documentation for wounds if one had not been started. -The nurse would take that information to the wound nurse so she could add it to their list and follow up on their weekly rounds. *She did not know anything about resident 51's feet or skin concerns. *If there was COVID-19 in the building she would have given those not on precautions baths first. -She would take residents on isolation one by one to the bathing room at the far end of the hall that was for those on isolation. 7. Interview on 2/6/25 at 12:04 p.m. with assistant director of nursing (ADON) C revealed: *She had been notified by the nurse on Wednesday 1/1/25 about resident 51's feet by text message. *She read the text that had asked her, Were you aware of pinky toe and next two toes are black? *They had set up an appointment for the resident right away because his toes on both his feet were blackened. *On 1/1/25 they received an antibiotic order from the doctor, and he was given his first dose that day. *The resident was scheduled to see podiatry on 1/7/25 at 3:00 p.m. *He went to his podiatry appointment and was admitted to the hospital from there. She stated, I am assuming because of the feet. *She completed weekly wound rounds on her area of the building with wound nurse N every Wednesday. *On 12/31/24 she had done wound rounds with the wound nurse and resident 51 was not on their list to monitor at that time. *She would not have expected the resident to be on the list that day because he did not have an identified skin issue at that time. *She stated they would have measured a new wound, documented in the resident's EMR and notified the resident's doctor, family, administrator, and DON of the skin concern. *The next step in the process or follow up would depend on what the doctor ordered. *Nurses did not complete or perform regular diabetic skin or foot checks. -The bath aid would let her know if they saw anything. -She would check their feet when she cut their nails if the resident was Diabetic. -Nurses do not complete skin assessments for residents until there is an issue. *Resident 51: -Did not return to the facility. -tested positive on 12/16/24 for COVID-19 and after he moved over from the rehab unit, she stated he didn't feel good. *She had not received a report from the rehab unit manager prior to his admit to long term care on 12/5/24 but she had done a chart review and had not seen skin issues to monitor for him. *He had been refusing most cares and would not eat much of anything while he was sick with COVID 19. *She was not sure if he had gotten a bath during his COVID-19 isolation, He had been refusing cares and did not want to do much. *She stated his necrotic toes had come on kind of quick and then he was hospitalized on [DATE] and did not return to the facility. 8. Interview on 2/6/25 at 2:25 p.m. with RN E regarding resident 51 revealed: *She had been called to the tub room by the CNA on 1/1/25 to look at his skin. *She recalled his left foot had redness and dark spots on it. *She called the doctor and received orders to start him on an antibiotic and to make him a podiatry appointment instead of going to the emergency room . *She had contacted the resident's family to inform them of this skin concern. *He had been started on an antibiotic for his foot infection. *She did not do skin assessments and had not assessed his skin when he moved over from the rehab unit on 12/5/24. *Bath CNAs checked residents' skin when they gave them a bath and would have let her know if they discovered a skin concern to be checked. *Residents cannot come out of their room for showers when they were on COVID-19 isolation, but they could have gotten a bed bath. *She thought 1/1/25 was the first shower resident 51 had since he had COVID-19 starting on 12/16/24. *Daily weights had not been done while resident 51 was on COVID-19 isolation. *She thought Covid isolation was for 7-10 days. *The resident did not have any treatments for his feet prior to the blackened toes being identified on 1/1/25. *There was no documentation in his EMR for wound care had been provided to his feet between 1/1/25 and when he had gone to the podiatry appointment on 1/7/25. 9. Interview on 2/6/25 at 3:49 p.m. with DON B revealed: *CNA's gave residents their showers and would have performed a head-to-toe skin check and would notify the nurse if skin issues were discovered. *Residents with wounds were added to the weekly wound rounds with the nurse to monitor. *Nurses did not complete or perform regular diabetic foot checks but did check (or trim) their nails weekly or every other week and checked their feet at that time. *The last COVID-19 outbreak had been from 12/16/24 through 1/7/25 and there had been confusion about resident's bed baths. *Residents could have had showers if they wore a mask in the hallway or they could choose a bed bath if they refused to wear a mask. *Resident 51 admitted in October 2024 with a skin tear on his left foot that had healed November 2024. -All he wanted to do was to lay in bed and not receive cares while he had COVID-19. -He refused care and would not go to dialysis while he was sick with COVID-19 *He could have come out of isolation and his room if he had worn a mask for certain activities. 10. Interview on 2/6/25 at 3:49 p.m. with nurse consultant P revealed, he had poor vascular circulation and was frail and fragile when he admitted here. 11. Review of resident 51's care plan dated 10/29/24 revealed: *He had a diagnosis of Diabetes Mellitus and nursing would check his body for breaks in skin and treat promptly as ordered by medical practitioner. *He had potential for impairment to his skin integrity and nursing would observe skin during cares and report changes to the nurse. -Weekly skin inspections and as needed. *Discharge plan was undetermined but resident 51 wished to return home after rehab, staff to assist the resident and family in decision making process based on home situation and resident's needs. *He had the potential for nutritional problems related to type 2 diabetes, kidney dialysis. -His weight would remain stable during the review date with targeted date 1/17/25. -Registered Dietician would evaluate and make diet change recommendations as needed. Provide/serve modified renal diet 1500 milliliter (ml.) fluid restriction as ordered. *He was independent with eating after setting up and preferred meals in his room. A house supplement was ordered. *There was no focus area that indicated he had been refusing to eat and what further interventions had been put in place to promote nutritional health. *There was no focus area that indicated they were aware of his significant weight loss and the interventions put in place to support nutritional health. 12. Review of the provider's January 2024 Person-Centered Care Plan policy revealed: *'Guideline, Person centered care planning is an on-going process which actively encourages the resident and/or the resident's representative to be an active participant in the care planning process and addresses the development and implementation of individualized person care . -2. The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: -(ii) A summary of the resident's medications and dietary instructions. -(iv) Any updated information based on the details of the comprehensive care plan, as necessary. 13. Review of the provider's 10/19/22 Vulnerable Adults policy revealed: *Purpose; Accura Health Care supports Zero Tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of resident property. -Identifying Maltreatment: g) Neglect 1) Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 14. Review of the provider's 1/20/23 Weekly Skin Assessment and Documentation Process revealed: *Skin ulcers and Non-Ulcers will be assessed and documented weekly by the facility wound nurse. -Assessment and Documentation Process, b) Identifying a Skin Ulcer or Non-Ulcer Assessment; 1) the nurse who initially identifies the Skin Ulcer or Non-Ulcer ulcer will complete the appropriate Skin Assessment (Non-Ulcer or Ulcer Assessment). 15. Review of the provider's 11/13/24 Process for Resident Activity Restrictions During an Outbreak revealed: *a) During an infectious disease outbreak, we may limit resident group activities to prevent the spread of communicable disease within the facility. When a significant number of resident's are exhibiting signs and symptoms of potentially infectious illness, the supervisor will restrict resident activity, after discussion with the IPN [infection prevention nurse] and/or the on-call representative of administration. If the supervisor is unable to reach either of the above, she or he will make a decision about restrictions based on information available. *1. Restrictions may include: -i) Restriction of residents to their units. -ii) Restriction of residents to their rooms. *b) All other restrictions deemed appropriate by the supervisor or the IPN [infection prevention nurse]. *Bathing and skin checks were not listed as resident restricted activities.

Based on observation, interview, record review, and policy review, the provider failed to ensure the dishwasher temperatures and chemical sanitizer concentration were monitored and recorded for one of one mechanical dishwasher used for the cleaning and sanitization of dishes and items used to prepare and serve residents' food. Finding include: 1. Observation on 2/4/25 at 8:11 a.m. during the initial tour of the provider's main kitchen revealed a mechanical dishwasher was used to clean and sanitize dishes. 2. Interview and observation on 2/5/25 at 4:34 p.m. with dining services manager (DSM) F in the kitchen revealed: *She had worked at the facility for [AGE] years and was a certified dietary manager. *The new low temperature mechanical dishwasher used chemical sanitization and had been in use since 11/25/24. *The dishwasher was connected by a service line to a five gallon bucket of Low Temp Machine Sanitizer which listed sodium hypochlorite, commonly known as bleach. *No logs or documentation was observed in the dish machine area ensuring the temperature and sanitizing solution were at the appropriate levels for the dishwasher. *DSM F used a test strip to test the chemical sanitizing solution in the mechanical dishwasher and it indicated it was at 200 parts per million (ppm) which was above the required 50 ppm. Interview and record review on 2/6/25 at 8:30 a.m. with DSM F revealed: *The previous mechanical dishwasher had used heat sanitization with high temperatures. *The Dishwasher Temperatures logs that were used for the old dishwasher from November 2023 through November 2024 were reviewed that indicated: -Temperatures were logged at each meal: Breakfast, Lunch, and Supper. -The wash cycle temperatures recorded were at the required minimum temperature of 150 degrees Fahrenheit (F) or higher. -The final rinse temperatures recorded were at the required minimum temperature of 180 degrees F or higher. -The last temperatures were recorded on 11/20/24 at the Supper mealtime with a handwritten note on the form Switched to chemical sanitizer. *DSM F stated they had used paper products from 11/21/24 through the morning of 11/25/24 when the chemical sanitizer was hooked up to the new dishwasher and the chemical sanitizer level was tested to ensure it was sanitizing appropriately, but no documentation was left regarding that visit. *When asked why the logs did not continue with the new low temperature mechanical dishwasher, DSM F stated the new mechanical dishwasher did not use heat sanitization that required monitoring of the high temperatures to ensure sanitization. *The dietary staff were not currently using a form to document the new mechanical dishwasher's wash temperature and sanitization level. *She agreed that if they were not regularly checking the mechanical dishwasher's wash temperature and sanitization levels there could have been a risk it was not sanitizing the dishes properly. On 2/6/25 at 8:45 a.m. record review and interview with DSM F regarding the October 2022 Centers for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Survey Pathway's Form CMS-20055 Kitchen/Food Service Observation which included the following recommendations according to the U.S. Department of Health and Human Services, Public Health Services, Food and Drug Administration Food Code: *Low Temperature Dishwasher (chemical sanitization): -Wash - [temperature of] 120 degrees F; and -Final Rinse - 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. -The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. *After review of the recommendations, DSM F agreed that she should have been using a form to document the mechanical dishwasher's wash temperature and chemical sanitization level. Observation on 2/6/25 at 9:02 a.m. of the low temperature (chemical sanitization) dishwasher with DSM F revealed the wash cycle reached 145 degrees F and the chemical test strip indicated a sanitization level of 200 ppm which were in the acceptable ranges. Interview on 2/6/25 at 12:18 p.m. with administrator A regarding the kitchen's mechanical dishwasher revealed she: *Provided the mechanical dishwasher's manufacturer's manual and confirmed the new low temperature mechanical dishwasher that used chemical sanitization was put into service on 11/25/24. *Agreed the 2013 Dish Machine Temperature Log policy was their current policy and that its procedure should have been followed which included: - .a log to be posted near the dish machine. - .train dishwashing staff to monitor [the] dish machine . *Agreed the dietary staff should have been logging the temperature and sanitizer levels at each meal according to their policy. Review of the provider's 2013 Dish Machine Temperature Log policy revealed: *Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. -The food service manager will provide the dishwashing staff with a log to be posted near the dish machine. -The food service manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. -Staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. Review of the 10/7/13 mechanical dishwasher's manufacturer's manual provided by administrator A on 2/6/25 at 12:18 p.m. revealed: *Chemical Sanitizing: -Final rinse minimum temperature: 120 degrees Fahrenheit. -Sanitizer required: 50 ppm available chlorine. *Questions to Evaluate Operation of Conveyor Machines. -When the machine fills with water, what is the incoming water temperature? It should be 120 [degrees] F for Chemical Sanitizing. -Is the final rinse water at the correct temperature? 120 [degrees] F min. [minimum] for Chemical.

Based on observation, interview, resident council meeting, and policy review, the provider failed to ensure a clean and homelike environment had been maintained for 25 of 25 residents (2, 6, 8, 11, 12,14, 15, 16, 19, 21, 23, 24, 26, 33, 36, 38, 41, 44, 45,52, 53, 55, 59, 60, 61) of the C wings. Findings include: 1. Observation on 2/4/25 of the two C wing hallways of revealed a buildup of gray dust and debris along the edges where the carpet met the wall. Observation on 2/4/25 at 8:30 a.m. of the room shared by resident 55 and resident 2 revealed: *A large quantity of items on the dresser tops and end tables, leaving no room for either resident to set additional things down. -The residents were out of the room and both beds were unmade. *At 9:55 a.m. the bathroom shared by resident 24 and resident 33 had: -A toilet riser on the toilet with yellow spots. -The exposed toilet rim had yellow spots. -No toilet paper dowel in the holder leaving the toilet paper sitting on the grab bar. -A wallpaper border above the tile that was peeling off along the entire top edge. -A buildup of crumbs and dirt along the edges of the floor. *At 9:58 a.m. the room shared by resident 53 and resident 44 had: -Large amounts of clutter with the dresser tops piled full of items. -The edges of the floor contained crumbs and dirt. -Resident 44 was not in the room and the bed was unmade. *At 10:00 a.m. of the room shared by resident 41 and resident 38 revealed: -Both residents were dressed and sitting in their room. -Both beds were unmade. *At 10:01 a.m. the room shared by resident 21 and resident 61 had: -An upholstered chair that was full of blankets and stuffed animals stacked on the seat and above the back chair. *At 10:01 a.m. the bathroom shared by resident 21 and resident 61 had: -An unpleasant odor. -A buildup of crumbs and dirt along edges of floor. * At 10:44 a.m. the room shared by resident 12 and resident 59 revealed: -Resident 12 dressed in day clothes and asleep on his bare mattress that had been stripped of bedding. -room [ROOM NUMBER] on 2/4/25 at 4:39 p.m. revealed a three inch by six inch piece of linoleum flooring was missing from the center of the room in front of the recliner with three other gouges and numerous cracks in the flooring. 2. Interview on 2/5/25 at 8:40 a.m. in resident 6's room revealed: *He had lived at the facility for one year. *He stated the missing piece of linoleum, the gouges, and the cracks in the flooring was from the use of the mechanical lift. *He stated an unidentified staff person had said the provider was going to repair the flooring but the flooring had been in disrepair since March 2024. Observation and interview at 2:30 p.m. observation and interview with resident 15 in the room she shared with resident 14 revealed: -The double room was cluttered with items on end tables and bathroom vanity. -The chair for resident 14 had clothing in it. -The chair for resident 15 was completely filled with a stack of clothing on hangers. *She was seated in her recliner with her oxygen cannula in place. She had been recently hospitalized for pneumonia and cellulitis and used the oxygen at night when sleeping and sometimes when napping if she feels short of breath. -She was not aware of the provider's process for the care of the oxygen and nebulizer equipment and supplies. -She had not seen staff clean or change the tubing. *Her clothing was frequently lost when it was in the laundry. When items had not been returned, she would tell someone with the Activities Department and they would look for it. -She did not always get the lost item back. -The facility had not replaced lost laundry items. -She felt the housekeeping service wasn't very good and it should happen more often. Observation and interview on 2/4/25 at 3:19 p.m. of resident 23 in his room revealed: *The resident's bed had not been made and there were several brown smears approximately two inches by four inches visible on the lower front edge of the bottom sheet. *The resident indicated he had turned on his call light to request the bed to be made prior to the surveyor's entrance to the room. -He stated the bed will frequently remain unmade throughout the day and he will turn on his light and ask for it to be done. -The sheets were not always changed on his bath day or when they were dirty. *At 3:29 p.m. certified nursing assistant (CNA) I answered the call light and made the bed without changing the sheets. *There was food crumbs, dirt, and candy pieces along the edges of the wall on the floor. *The overbed light went on and off several times during the interview. The resident stated the light had been like that for several months and the CNAs were aware of it. Observation and interview with resident 60 on 2/5/25 at 10:30 a.m. in his room revealed: *Resident 60 was the sole occupant of the room. *One section of the three-part window had a stiff opaque torn plastic hanging loose over it with dried duct tape around the edges. -The visible portion of the window screen below the plastic was filled with unidentifiable seeds, grass, and leaves. -He mentioned the plastic had been there since he arrived in March of 2024. -He did not know the purpose of the plastic covering but expressed that it looked trashy. *The floor appeared clean in the center but there were crumbs and dirt along the edges. *He was unhappy with the housekeeping of his room. -He had been told upon admission that there would be daily housekeeping. -Housekeeping did not happen daily and it was poorly done because they just mopped without sweeping or moving things. *Hand towels and washcloths were replaced infrequently or not at all. -His relative did his laundry and had offered to purchase him his own towels and washcloths due to not having them. *Bed linens were changed only if he requested them to be changed and they were not changed regularly or on his bath days. *The noise level from the closets and drawers in the next room was at a level that the surveyor and resident had to pause their conversation while they were being opened and closed. -The resident expressed irritation of the noise happening multiple times per day. 3. Interview on 2/4/25 at 4:29 p.m. with CNA I revealed: *If a resident's sheets were soiled, she would change them when she made the bed. -She had not seen that resident 23's sheets were soiled when answering his call light and making the bed at 3:29 p.m. that day. *The daily bed-making was to be completed by CNAs when getting residents up for the day, but that there were days like today where they were short of staff and a lot of beds did not get made. *Residents were supposed to get clean sheets on their bath day but they don't always get that done when they are short of staff. Interview on 2/4/25 at 4:00 p.m. with Activities Director J revealed: *Residents were to bring new clothing items to the Activities department for labeling. *Activities staff looked for items that were reported as missing. *Missing items were often found in the wrong resident's room. *They did not replace resident's missing laundry. *She thought the missing laundry issue was improving. Interview on 2/5/24 at 9:00 a.m. with assistant director of nursing (ADON) and licensed practical nurse (LPN) C revealed: *CNAs were responsible for making the residents' beds and changing sheets if they were soiled and on the resident's bath day. *They confirmed it had been a problem getting it done. 4. Resident council was conducted on 2/5/24 from 3:00 p.m. to 4:00 p.m. with 14 residents and revealed: *Resident 21 reported she her own washcloths and towels that were purchased and laundered by a relative since the ones provided by the facility were only enough for her roommate. *Resident 21 reported that garbage was not removed from her room regularly. *Resident 36 reported that he and his wife shared a room and they frequently did not have clean towels, they were always short of washcloths, and that they had to ask for their bedding to be changed. *Resident 36 indicated that the garbage was frequently overflowing. -If the garbage was removed by staff, the liner was often not replaced. *Resident 52 reported that she retrieved clean sheets from the linen closet herself and changed her own bedding as the sheets do not get changed. -She made her own bed in the mornings. *Her garbage did not get removed from her room regularly. *Resident 19 reported that their beds did not get made without asking staff and clean sheets were not provided regularly. *Resident 26 indicated that she had to ask staff to have her bed made and did not have clean hand towels or washcloths regularly. *Resident 15 stated they were always short of washcloths for their rooms. *Resident 6 reported that laundry frequently gets lost and it is not consistently found. *Residents 15, 52, 45, 26, 36, and 19 reported that laundry was frequently returned to the wrong resident's room and they had laundry that had been lost. *Review of the 11/26/24 resident council minutes revealed: *Old business included garbage cans/bags still needed improvement. *Hand towels and washcloths in rooms still needed improvement. *Residents were not satisfied with cleaning services, particularly sweeping. *A feedback form to Administrator A had been completed by Activities Director J regarding residents' grievance that housekeeping was not cleaning thoroughly enough and not sweeping before mopping. *A feedback action plan form marked resolved described a walk-through with housekeeping manager who stated they were to sweep before mopping and she would review with staff and add to the training. Review of the 12/23/24 resident council minutes revealed: *Old business included housekeeping not sweeping before mopping, marked resolved. *Old business included towels and washcloths not being passed, marked not resolved, action needed. *A feedback form to Administrator A stating resident complaint that towels and washcloths were not being passed stated by multiple residents. *A feedback action plan form noted resolved, stating that staff working on nights were filling in and not typically on night shift. *DON B, Minimum Data Set (MDS) assessment coordinator M, and the unit managers were given reeducation from 12/24/24 through 12/27/24 so all staff are aware, per DON B. Review of the 1/22/25 resident council minutes revealed old business included towels and washcloths not being passed, the staff had been educated, and it was marked resolved. Review of the provider's undated Routine Cares of a Certified Nursing Assistant: 6 a.m.-2 p.m. shift instructions revealed that upon resident rising the: *CNA was to make bed. -Complete bed change if the resident was to have a shower. *Make sure the resident's room was neat and tidy. *Take out the resident's trash and dirty linen/clothing.

Based on observation, record review, interview, and policy review, the provider failed to ensure respiratory needs of one of one sampled resident (15) had been met for changing of oxygen tubing and nebulizer tubing weekly according to the provider's policy. Findings include: 1. Observation and interview with resident 15 on 2/4/25 at 11:00 a.m. in her room revealed: *An oxygen concentrator was near her recliner. *The oxygen tubing and nasal cannula (nosepiece) was draped on top of the concentrator. *There was no visible dating or tag on the oxygen tubing. *The resident indicated she had been using the oxygen since her January 2025 hospitalization . *She used it when she was short of breath and when sleeping. *She was concerned that no one had changed the oxygen tubing yet. *She did three or more nebulizer treatments per day. *She did not think her nebulizer tubing or mask supplies had been changed. Observation of resident 15 on 2/5/25 at 4:00 p.m. revealed the resident was asleep in her recliner with the oxygen cannula under her nose and the oxygen concentrator running. 2. Review of Resident 15's (EMR) revealed: *Resident had a Brief Interview for Mental Status assessment score of 15, indicating that her cognition was intact. *She had diagnoses of Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, and Chronic Respiratory Disease *A physician's order for use of oxygen was not located. *Her physician had been notified by fax on 1/17/25 that she was using oxygen. *The response from the physician did not acknowledge the oxygen use or provide a flow rate for the oxygen. *Use of oxygen or a flow rate of use was not listed on her Interagency Transfer Orders (discharge orders) from her hospital stay from 1/21/25 through 1/24/25. *Her care plan had been updated on 1/24/25 to include requires oxygen therapy. *There was no task noted in the Medical Administration Record (MAR) or Task Administration Record (TAR) addressing the changing of oxygen concentrator tubing. *The TAR indicated that her nebulizer tubing had been changed weekly. 3. Interview with assistant director of nursing (ADON) and licensed practical nurse (LPN) C revealed: *Residents would have an order for oxygen use. *She had told the nursing staff that they needed to get an as needed order for resident 15's oxygen. *She did not realize that fax to the resident's physician on 1/17/25 had not acknowledged or ordered oxygen usage for her. *The physician's order would be how the staff knew the correct oxygen setting for rate of flow. *Resident 15 had been given oxygen based on her shortness of breath prior to being hospitalized in January 2025. *The oxygen tubing and nasal cannula was to be dated, initialed, and changed weekly by the night shift nurse and documented in the resident's TAR. *Her expectation was for that to be done. *Tubing would be changed by the night nurse. *She would not be able to verify the change of the tubing or cannula without TAR documentation or tape with initials on tubing and cannula. Interview with registered nurse (RN) G on 2/5/25 at 2:01 p.m. revealed: *All oxygen and nebulizer tubing was to be changed one time per week or more often if it had buildup or had been kinked. *Would be changed on night shift and would have a tape tag near the machine with date changed and initials of who changed it. Interview with Director of Nursing (DON) B on 2/6/24 at 3:00 p.m. revealed: *She was unable to locate an order for resident 15 to receive oxygen in the EMR (electronic medical record). *She provided a Nursing Home Standing Order Protocol signed by the medical director on 2/29/24 that indicated to use oxygen at 4 L (liters) per nasal cannula as needed for oxygen saturation levels below 92%. *Notify physician any time 02 has been started on a resident. Review of the provider's updated 11/13/24 Respiratory Cleaning Procedure policy revealed: *Oxygen tubing and the nasal cannula/mask should have been changed weekly. *Nebulizer mouthpieces, tubing, and the medication receptacle should have been changed weekly. Review of provider's 2/29/24 Nursing Home Standing Orders Policy revealed: *Standing order for use of oxygen at 4 L (liters) per nasal cannula as need for oxygen saturation levels below 92%. *Notify the physician any time oxygen has been started on a resident.

Based on observation, record review, interview, and policy review, the provider failed to effectively implement, monitor, and document a walk to meals restorative program for one of one sampled resident (54) to help maintain her mobility. Findings include: 1. Observation on 2/4/25 at 10:22 a.m. of resident 54 revealed: *She used her feet to propel her wheelchair independently to move up and down the hallway on Arbor Lane. *She did not respond to questions asked by this surveyor. 2. Observation and interview on 2/5/25 at 3:40 p.m. of resident 54 with registered nurse (RN) E revealed: *The resident had wheeled herself via her wheelchair to Country Lane hallway from her living area on Arbor Lane on the rehab unit. *RN E stated resident 54 wheeled herself everywhere in the building in her wheelchair. 3. Record review of resident 54's electronic medical record (EMR) revealed: *She had a Brief Interview for Mental Status (BIMS) score of 8 which indicated she had moderate cognition impairment. *She had limited physical mobility and used of a four wheeled walker and wheelchair due to her risk of falls. *Her last fall was on 7/13/24. *He comprehensive care plan indicated she was to participate in the restorative therapy program of walking-ambulate to meals every day. -That intervention was initiated on 3/1/24 by Minimum Data Set (MDS) coordinator M. 4. Interview on 2/5/25 at 2:30 p.m. with certified nursing assistant (CNA) Q revealed resident 54 had not walked to meals for a long time. She indicated, it had been months and months ago. 5. Interview on 2/5/25 at 2:45 p.m. with certified occupational therapist assistant (COTA) K regarding resident 54 revealed: *She had worked with resident 54 and had discharged her from occupational therapy to continue on a restorative therapy on 10/30/24. *When a resident was discharged from occupational therapy to a restorative therapy program she would have told the nurse that day. *MDS coordinator M would know who would update residents'' care plans. *She was not sure why resident 54 had not been walking to meals according to her restorative program. 6. Interview on 2/5/25 at 2:49 p.m. with assistant director of nursing (ADON), RN L regarding resident 54 revealed: *She was the unit manager of the rehab unit that resident 54 resided on. *She was not sure about resident 54's walking-ambulate to meals restorative program. -She stated, that would be something to ask MDS coordinator M about, but to her knowledge the resident had not participated in that restorative program. 7. Interview on 2/5/25 at 2:58 p.m. with MDS coordinator M regarding resident 54's restorative program revealed. *The residents walking-ambulate to meals restorative program had been missed. *She stated the resident could walk by herself in her room a little bit. *She indicated she would like therapy to work with the resident again before starting the resident's restorative program to evaluate her current mobility and needs. *She stated a resident's care plan could be updated by anyone, but typically staff brought her information to update the care plans. 8. Review of the provider's 10/26/21 Restorative Program Process revealed: *Purpose: To ensure our resident (s) achieve and maintain their highest level of function. *Process: -a) Upon admission, quarterly, and with significant change the resident's level of function will be assessed by the licensed nurse or in collaboration with therapy. -b) Based on the results of the assessment the licensed nurse will develop a care plan showing the resident's individual problems, determine approaches/interventions and set goals. -c) The licensed nurse will develop a restorative nursing program with individualized interventions and goals which may include recommendations for strategy and adaptive equipment from therapy. -d) The licensed nurse will educate all direct are staff assigned to the resident(s) on their restorative nursing program. -e) The licensed nurse will monitor the daily restorative nursing program documentation in POC and follow-up with staff as needed. -h) The licensed nurse will update the care plan and the restorative nursing program to reflect the resident (s) specific goals and interventions as needed. -i) The licensed nurse will make referrals to therapy as needed. -j) The licensed nurse will develop a discharge plan for the resident (s) who no longer need a restorative nursing program. 9. Review of the provider's Person-Centered Care Plan policy dated 1/2024 revealed: *Person centered care planning is an on-going process which actively encourages the resident and/or the resident's representative to be an active participant in the care planning process and addresses the development and implementation of individualized person care . -2. Contain measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessments. The comprehensive care plan must describe the following: (i) the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -4. The overall person-centered care plan should be oriented towards: (i) Preventing avoidable declines, (ii) managing risk factors, (iii) Preserving and building on the resident's strength's.

Based on observation, record review, interview, and policy review the provider failed to implement prescribed, and care-planned preventative pressure injury interventions for one of one (50) sampled resident with a history of skin breakdown on his feet. Findings include: 1. Observation on 2/4/25 at 2:28 p.m. revealed resident 50 was lying in his bed in his room. He had a floor mat on the floor next to the bed and had no heel-lift boots on his feet while he was taking his nap. Observation on 2/4/25 at 4:02 p.m. of resident 50 revealed he was lying on the right side of his bed, had a body pillow behind him, and had no heel lift boots on his feet. Observation on 2/5/25 at 2:07 p.m. of resident 50 revealed he was lying in his bed on his left side with no heel lift boots on his feet. 2. Review of resident 50's electronic medical record (EMR) revealed: *A care plan intervention of float/offload heels with heel lift boots when resident was in bed was initiated on 11/7/23. *A doctor's order for heel protection boots to be worn while the resident was in bed was dated 1/24/24. *Treatment administration record (TAR) documentation had been signed off by the nurse that the resident's heel lift boots were on for 2/4/25 and 2/5/25. 3. Interview on 2/5/25 at 10:07 a.m. with certified nursing assistant (CNA) D regarding resident 50 revealed: *The resident did not have heel-lift boots on that morning before she got him up from his bed. She did not think he was supposed to wear them. Interview on 2/5/25 at 10:09 a.m. with registered nurse (RN) E regarding resident 50 revealed: *CNAs and nurses would heel lift boots for residents if those were ordered or care planned for them. *It was the nurse's responsibility to verify that heel boots were in place for a resident according to the orders before signing them off on the TAR. Interview on 2/5/25 at 3:38 p.m. with the assistant director of nursing (ADON)/ licensed practical nurse (LPN) C revealed: *Resident 50 had an open area on the outer bony aspect of his R) ankle bone on 1/24/24. *They implemented the heel lift boots as a preventative measure for resident 50 at that time to prevent further skin breakdown. *She agreed whenever resident 50 was in his bed he should have had the heel lift boots in place per his care plan and the doctor's order. *She could not find heel lift boots in resident 50's room when she looked on 2/5/25 following interview. Interview on 2/6/25 10:27 a.m. with director of nursing (DON) B revealed: *It would be her expectation for the doctor's order for heel lift boots to be followed. *She expected resident's care plans to be followed for any interventions listed. *Resident 50 should have been wearing his heel-lift boots whenever in bed for prevention of skin breakdown. *The CNAs had pocket care plans and those were updated with that information also. 4. Review of the provider's updated 1/20/23 Weekly skin assessment and documentation process policy revealed: *The treatment orders for all Skin Ulcer or Non-Ulcer will be implemented per the Accura's Skin Management Protocol. *The Nurse leader will fax the appropriate wound treatment order per Accura Skin/Wound Protocol for approval by the physician. *The Care plan will be updated and reviewed to ensure that the skin/wound alteration and appropriate interventions have been identified on the Care plan.

Based on observation, interview, and policy review, the provider failed to ensure three of three mechanical stand aid lifts were cleaned after each resident's use. Findings include: 1. Observation and interview on 1/22/24 at 3:05 p.m. with certified nurse assistant (CNA) C on the Arbor Avenue resident living unit revealed: *There was one stand lift on that unit but staff had not used it for a few weeks. -There was a rolled-up towel at the front of the footplate to keep resident from pinching their toes when using the lift. -Dust, dirt and unidentified solid particles were seen along the back perimeter of the footplate. -There was a leather pouch with Clorox bleach wipes in a pouch attached to the lift. Observation on 1/22/24 at 3:30 p.m. on the Country Lane resident living unit revealed: *Two mechanical stand aide lifts were against a wall in the TV/lounge room. -Both lifts had attached leather pouches with Clorox bleach wipes in them. *The footplates on both stand aide lifts had dust, dirt, and unidentified solid particles against and along the entire perimeter of the footplates. Observation on 1/22/24 at 3:41 p.m. of CNAs D and E revealed: *They used one of the mechanical stand aide lifts from Country Lane to assist resident 1 into and out of her bathroom. *CNA D removed the lift from resident 1's room after it was used then cleaned the upper grab bars, the padded knee support and the front of the stand aide lift with Chlorox bleach wipes. -The support belt and the footplate were not cleaned. Observation on 1/22/24 at 3:59 p.m. of unlicensed medication aide (UMA) F cleaning the second stand lift on Country Lane after resident use revealed she: *Used the Clorox bleach wipes to wipe down the upper grab bars, padded knee support, and the front of the stand aide lift. *Had not cleaned the safety belt or the footplate on the stand aide lift. Interview on 1/22/24 at 4:25 p.m. with CNA D regarding her process for cleaning the mechanical stand aide lifts following resident use revealed she: *Used Clorox bleach wipes to wipe the lift unless it needed more in-depth cleaning. -She used a cleaning/disinfectant spray that remained on the surface of the lift for five minutes then she wiped down the stand aide lift. *Cleaned the footplate with a Clorox bleach wipe. Follow-up interview on 1/22/24 at 4:33 p.m. with UMA F regarding her process for cleaning the mechanical stand aide lift observed above revealed she: *Had not cleaned the footplate because she was nervous during the surveyor's observation. *Later she had gotten a spray bottle and a washcloth out of a storage closet and cleaned the footplate. *Felt the unidentified solid particles were food that fell from the residents' clothes when the aides used the stand aide lift to take them to the bathroom after a meal. Observation on 1/22/24 at 4:40 p.m. revealed that the footplates on both mechanical stand aide lifts had the dust, dirt and the unidentified solid particles still present and were pushed to the right side and the back perimeter. Interview on 1/23/24 at 1:11 p.m. with administrator A and director of nursing (DON) B revealed they: *Agreed the mechanical stand aide lifts should have been cleaned after each residents' use and that included the footplates. *Agreed the unidentified solid particles could have been food that fell from the residents' clothes when the aides use the stand aide lift to toilet residents after meals. Review of their Updated 10/5/23 Nursing Weekly Cleaning Task policy: * Multiple use items will be cleaned and disinfected between each resident use: d) Mechanical Lifts.

Based on observation, interview, record review, and policy review, the provider failed to ensure:*Preventative interventions and approaches were implemented prior to the development of pressure ulcers for two of two sampled residents (59 and 60). *Interventions and approaches were consistently implemented for three of three sampled residents (25, 59, and 60) who currently had pressure ulcers. Findings include: 1. Observation on 10/17/23 at 10:35 a.m. of resident 59 revealed: *He was seated in his wheelchair outside of the small dining room area near the rehabilitation unit. *He had gripper socks on his feet and both feet were placed on the foot-pedals of his wheelchair. *There was a cushioned footboard placed on the top of the wheelchair foot-pedals that extended up behind his heels and legs. *Heel boot protectors were not on his feet. Observation and interview on 10/17/23 at 11:00 a.m. with resident 59 in his room revealed: *He had been seated in his wheelchair with gripper socks on his feet. *His wife had been with him and talking to him. *She visited him on a daily basis. *He had an area on his left heel that had developed a week after his admission. *The area had been healing but she stated she had not seen it recently because it had been covered with a dressing. *The nurses monitored it daily. *He had heel protectors for his feet. *She had not seen the nursing staff put heel protectors on his feet lately. *She was not sure what had happened to them. *He used to fiddle with the boots and would attempt to remove them. *When he rested in bed, the nursing staff would place pillows under his ankles to relieve the pressure off of his heels. Observation on 10/19/23 at 9:11 a.m. of resident 59 revealed: *He was seated in his wheelchair with the footboard cushion in place at the bottom of his wheelchair. *He had been wearing gripper socks. *There were no heel protector boots on his feet. Review of resident 59's 12/27/22 Comprehensive Skin and Repositioning Evaluations revealed: *His Braden score was 12, that indicated he was at high risk for developing pressure ulcers. -- [Resident] has no pressure areas, does have potential for altered skin integrity r/t [related to] his impaired sensory r/t his diabetes, dementia, moisture r/t his incontinence and perspiration, impaired activity/mobility r/t his use of w/c [wheelchair] and shearing/friction r/t his scooting to [the] edge of [the] bed/chair and general repositioning, pressure reducing mattress on bed and pressure reducing cushion in w/c, skin inspected weekly, does participate in therapy. Review of resident 59's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *A Brief Interview for Mental Status (BIMS) score of zero that indicated he had severe cognitive impairment. *He had diagnoses of the following: congestive heart failure, post Covid-19 condition, atherosclerotic heart disease, atrial fibrillation, type 2 diabetes, and dementia. *A left heel unstageable pressure ulcer that had been discovered after his admission on 1/4/23. -It had been a fluid filled blister when it was first identified that measured 4.5 centimeters (cm) by 5 cm. -It currently measured 0.8 cm by 0.8 cm on 10/11/23. Review of resident 59's current Kardex interventions for CNAs to have followed revealed: *There were no interventions to float his heels by positioning pillows under his ankles while he was in bed. *There were no interventions for staff to follow when he refused or had combative behaviors. Review of resident 59's revised 9/27/23 care plan revealed: *There was no information that his feet were to have been floated and positioned with pillows under his ankles while he was in bed. *His heel boot protectors were still on the care plan and had not been discontinued as an intervention. *Focus: [Resident] has Pressure injury to left heel: Date initiated: 1/14/23 -Goal: Pressure injury will show signs of healing and remain free from infection by/through review date: Date initiated: 1/14/23 -Interventions/Tasks: --Administer treatments as ordered and observe for effectiveness. Date initiated: 1/14/23. --Dakins wet to dry to left heel daily. Date initiated: 10/1/23. --Glucerna 8 oz with meals BID. Date initiated: 1/13/23. --Heel lift boots when in bed. Date initiated: 1/14/23. --Notify family and medical practitioner of any new area of skin breakdown or worsening in status of current area. Date initiated: 1/14/23. --Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration, noted during bath or daily care. Observe skin daily with cares. Date initiated: 1/14/23. --Obtain lab/diagnostic work as ordered. Report results to medical practitioner and follow up as indicated. Date initiated: 1/14/23. --Pumpless air mattress on bed and pressure reducing cushion in w/c. Date initiated: 1/14/23. *The above interventions were added to the care plan after he had acquired the pressure ulcer to his left heel on 1/4/23. *Preventative measures were not put into place even though he had been identified through the Braden scale for being at high risk for developing pressure ulcers. *No information was documented that his feet were to have been floated by positioning a pillow under his ankles when he was in bed. *His heel protector boots had not been discontinued according to the information on the care plan. Interview on 10/19/23 at 9:13 a.m. with certified nursing assistant (CNA) P and CNA Q regarding resident 59 revealed: *The pressure ulcer on his heel was there since he was admitted and had started as a blister from his heel rubbing on the wheelchair pedal. *They used two pillows positioned under his ankles to float his heels when he was rested in the bed. *When he was in his wheelchair he had a footboard cushion that was placed on top of the foot-pedals to cushion his heels and the back of his legs. *His wife visited every day to help him with his needs and to spend time with him. *When he laid down for a nap after lunch staff floated his heels off the bed with positioning pillows under his ankles. *He had used boot protectors for a short time but had not liked them and would take them off. *They no longer put the heel boot protectors on the resident. *He had been resistive of care and at times struck out at staff, but they knew him well and were able to reapproach him when his mood improved. *They used pocket care plans to know what care to provide to the residents. *Interventions were documented on the computer Kardex system when they had been completed by the CNAs. Interview on 10/19/23 at 9:38 a.m. with RN K revealed: *She had been the nurse that completed wound care for the residents. *The wound was discovered on 1/4/23 and caused by his left heel rubbing against his wheelchair that caused a blister to form. *The area was unstageable (the wound is covered by a layer of dead tissue that might be yellow, grey, green, brown, or black. The base of the wound is not visible and therefore cannot be staged) and had been healing. *The wound was monitored daily by nursing staff. *She completed weekly wound assessments. *He had a pressure reducing mattress. *For anyone with skin concerns it would have been her expectation to have interventions in place to prevent resident skin integrity issues from developing. *He hated the heel protector boots, so they got rid of them and got a cushioned insert for the wheelchair to cover the back and the foot-pedals. *They now placed a footboard cushion on his wheelchair to protect his heels. *His heels were to have been floated with positioning pillows under his ankles while he was in bed. *CNAs were to reposition residents every two to three hours or as the physician had ordered. *The CNAs carried a pocket care plan to follow for the appropriate care to complete with each of the residents. -The CNAs also documented completion of assigned tasks in the computerized Kardex system. *The care plan was to be updated with resident changes that reflected the resident's current needs. -Interventions were driven from the care plan into the computerized Kardex system. *When an intervention or a condition would change with the resident's care, the Minimum Data Set (MDS) coordinator L would update the care plan and the pocket care plan. *Staff used a computerized Kardex program with interventions for CNAs to document when the care was completed for the resident. *All the interventions should have been the same in the resident's current care plan, the Kardex, and the pocket care plan. 2. Observation on 10/17/23 at 1:58 p.m. of resident 60 revealed: *He was lying in his bed on his right side facing the wall. *He had not been wearing heel protector boots. *His body pillow was placed on top of his recliner. *His bed was in the lowest position. *There was a Geri wheelchair next to his closet. *His electric recliner was in the upright position and had a padded cushion in the seat. Observation on 10/18 23 at 2:11 p.m. of resident 60 and his unoccupied room revealed: *He was seated in a Geri wheelchair chair wheeling himself down the hallway. *He had not been wearing the heel protective boots. *His bed was made and he had a pressure reducing mattress. Review of resident 60's 2/3/23 Comprehensive Skin and Repositioning Evaluation revealed: *His Braden score of 17, that indicated he was at risk for developing pressure ulcers. -- [Resident] does have pressure areas to his buttocks, does have cream that is applied to the buttock area, does have potential for altered skin integrity r/t [related to]his impaired sensory r/t his dementia, moisture related to his perspiration, impaired activity/mobility r/t his weakness and use of FWW [front wheeled walker] and general shearing /friction r/t his scooting to edge of bed/chair and general repositioning, pressure reducing mattress on bed, skin inspected weekly. Review of resident 60's EMR revealed: *The resident admitted on [DATE]. *He had been admitted with pressure ulcers on his buttocks that were healed. *His BIMS score was 99 and that indicated he chose not to answer, or had given responses that had not made sense. *He was not able to be interviewed. *His diagnoses included: dementia, benign prostatic hyperplasia, high cholesterol, spinal stenosis, heart disease, and major depressive disorder. *A stage II (an open wound, the skin opens and wears away or forms an ulcer, it is usually an abrasion, blister, or a shallow crater in the skin) pressure ulcer on his right buttock area that was discovered on 3/2/23 that measured 1.5 centimeters (cm) by 0.5 cm. -It currently measured 1.5 cm by 0.8 cm. *A stage II pressure ulcer on his left buttock area that was discovered on 5/30/23 that measured 0.5 cm by 0.5 cm. -It currently measured 1.0 cm by 0.5 cm. *He was placed on hospice care on 7/12/23 for advanced dementia symptoms and increased weakness. Review of resident 60's revised 10/6/23 care plan revealed the following interventions: *Daily wound monitoring in place. Date initiated: 2/19/23. *Float/offload heels. Date initiated: 2/19/23. *Give anti-pruritic medication as ordered by medical practitioner. Observe and document side effects/effectiveness. Date initiated: 2/19/23. *Keep linens dry, wrinkle-free. Date initiated: 2/3/23. *Keep skin clean and dry. Date initiated 2/19/23. Revision on: 10/11/23. *Observe for side effects of antibiotics and over the counter medications: gastric distress, rash, allergic reactions which could exacerbate skin injury. Report changes to nurse/medical practitioner. Date initiated: 2/19/23. *Observe skin during cares. Report changes to nurse. Date initiated: 2/19/23. *Pressure reducing mattress on bed and pressure reducing cushion in wheelchair. Date initiated: 2/19/23. Revision on 10/17/23. -The last two interventions were added to his care plan on 10/17/23 which was during the time of the survey. *Weekly skin inspection and prn (as needed). Date initiated: 2/19/23. Revision on 10/17/23. *The following had been added in the care plan on 10/17/23, which was during the time of the survey: -Focus: [Resident] has potential impairment to skin integrity r/t [related to] impaired sensory r/t his dementia, moisture r/t his incontinence, impaired mobility/activity/r/t his use of w/c [wheelchair] and general shearing/friction r/t his scooting in bed/chair and general repositioning. Date initiated: 10/17/23. -Goal: Will have no complications through the review date. Date initiated: 10/17/23. -Interventions/Tasks: --Encourage reposition/position changes during Rounds and every 2-3 hours. Date initiated: 10/17/23. --Keep linens dry, wrinkle free. Date initiated: 10/17/23. --Keep skin clean and dry. Date initiated: 10/17/23. --Observe skin during cares. Report any changes to nurse. Date initiated: 10/17/23. --Pressure reducing mattress on bed and pressure reducing cushion in w/c. Date initiated: 10/17/23. --Weekly skin inspection and prn (as needed). Date initiated: 10/17/23. Review of resident 60's undated pocket care plan revealed: *The pocket care plan had been received by nurse manager D on 10/19/23 at 2:40 p.m. *He had a wound to his coccyx. *He was on hospice. *He had heel lift boots. -Heel lift boots had not been seen in his room or placed on the resident during the above previously noted observations. Interview on 10/18/23 at 2:17 p.m. with the nurse manager D and certified medication aide (CMA) R regarding resident 60 revealed: *Family members came for daily visits. *His daughter had been a nurse practitioner and was very involved with his care. *He used a Geri chair and was able to wheel himself around the area. *On admission he had used a four wheeled walker to ambulate. *His dementia had worsened and he had been placed on hospice care. *Hospice staff came on a weekly basis to provide him care. *When he needed to use the restroom he would let staff know. *His days and nights were mixed up. *He had a body pillow that they used to position him when he was in bed. Interview on 10/19/23 at 9:59 a.m. with RN K regarding resident 60 revealed: *He had a history of breakdown in that area prior to and at the time of his admission. *The area had healed and redeveloped again on 3/2/23 on the right buttock and on 5/30/23 on the left buttock. *She completed wound assessments on those areas weekly and documented the results on a weekly wound assessment form. *The dressings were changed daily. *She thought those areas had not healed due to his advancing dementia and health decline. *Any resident who had been at risk for skin breakdown should have had interventions in place prior to prevent any breakdown of the skin. *The CNAs had pocket care plans to follow and the Kardex for interventions to follow. -Those interventions should have all been the same from what was on the resident's care plan. Interview on 10/19/23 at 12:43 p.m. with director of nursing (DON) C regarding residents with current pressure ulcers revealed: *She thought the pressure ulcers they currently had were due to the residents health declines. *They had not had a good process in place to prevent pressure ulcers. *They recognized that the current process was not working. *They added two nurse manager positions recently to attempt to correct the issues with pressure ulcer prevention. *She confirmed there had been a lack of communication and consistency in writing care plans, Kardex interventions, and pocket care plans and their oversite of those processes had been lacking. *She agreed there had not been a clear policy and procedure in place for pressure ulcer prevention interventions. piece. *They used nursing care standards and the American Healthcare Association for reference and guidance. 49395 3. Observation on 10/16/23 at 4:03 p.m. revealed resident 25 was lying on her back and sleeping in her bed. Her heel protector boots were lying beside her but were not on her feet. A pressure relieving cushion was in the wheelchair. Observation on 10/17/23 at 1:39 p.m. revealed resident 25 was again lying on her back in her bed after lunch without her heel protector boots on her feet. Observation on 10/17/23 at 1:54 p.m. with RN K providing wound care to resident 25 revealed: *The right (R) heel wound measured 1 centimeter (cm) in length and 1 cm in width. *The R ankle wound measured 1.2 cm in length and 1.8 cm in width. *The R heel and the R ankle were treated with Betadine and then covered with foam dressings. *The sacral pressure ulcer measured 2.5 cm in length, 0.6 cm in width, and 0.5 cm deep and was treated with Betadine and a wet-to-dry dressing. *When asked what other interventions were being done for the resident's pressure ulcers. RN K stated that the resident should have been wearing the heel protector boots while she was lying in bed. Observation on 10/18/2023 at 8:58 a.m. revealed resident 25 was lying on her back in bed without her heel protector boots on. Interview on 10/18/23 at 9:02 a.m. with CNA E revealed resident 25's heel protector boots should have been worn while the resident was lying in bed. Interview on 10/18/2023 at 1:15 p.m. with CNA H and CNA J revealed: *Pocket care plans were used by the CNAs to determine what care needs were required for the residents. *When the pocket care plan was reviewed, the CNAs stated that those pocket care plans were not currently updated with the resident's current pressure ulcer interventions. That included both repositioning and the heel protector boots. The pocket care plan provided no specifics as to when those heel protector boots should have been worn or any repositioning information. CNA H verbalized that resident 25's heel protector boots were to have been worn while the resident was in bed. *Review of the Kardex on 10/18/23 at 1:30 p.m. with the CNA J revealed: *The Kardex had not listed the heel protector boots as an intervention and was not included on the resident's current care plan interventions for impaired skin integrity regarding repositioning. The Kardex stated that the resident should have been repositioned every 4 to 5 hours. CNA J stated that the repositioning every 4 to 5 hours was not correct. *CNA J. stated that pocket care plans and Kardex's were updated by the MDS nurse. Interview on 10/18/2023 at 2:57 p.m. with nurse manager D regarding the monitoring of resident interventions revealed the monitoring of CNAs completing care plan interventions was completed by a visual inspection with eyes on the resident and was done randomly. Interview on 10/18/23 at 3:35 p.m. with RN K revealed: *RN K was responsible for documenting interventions in the care plan regarding the current pressure ulcer interventions for resident 25. *A blister that measured 2.5 cm x 2.3 cm was identified on the R heel on 8/17/2023. *A physician order was received to change Adaptic Touch dressing weekly until healed. Review of resident 25's 9/19/23 physician's orders included the following: *Betadine wet to dry dressing daily. *Low air loss mattress *Frequent repositioning every 2-3 hours *R heel - paint with Betadine, cover with foam dressing *Continue the heel protector boots, change foam dressing every 3 days. *R ankle - paint with Betadine, cover with foam dressing, and change every 3 days. *When asked how resident 25's pressure ulcers had developed, she stated, Probably from lying in bed. She does not see well and would run into things with her ankle while in her wheelchair. Wearing her boots probably would have helped. Interview on 10/19/23 at 12:13 p.m. with director of nursing (DON) C and Minimum Data Set (MDS) coordinator L regarding resident pressure ulcers revealed: *DON C. was unable to provide a policy for the prevention of resident pressure ulcers. *She was able to verbalize in detail how the facility prevents pressure ulcers. *She was able to provide a Skin Management Protocol updated on 5/16/23, which included steps for wound notification when a skin alteration or skin ulcer was identified but there was no documentation on how to prevent pressure ulcers from occurring. * She provided a Leadership's Admission checklist updated on 6/9/23 the facility used when admitting a new resident that included a comprehensive skin assessment and a Braden scale. *She stated that the interdisciplinary team (IDT) met daily and reviewed any concerns of those residents with pressure ulcers and those residents that were at risk for developing pressure ulcers. *When asked about the discrepancy with the resident care plans, the pocket care plans, and the Kardex, she stated that she would communicate changes with her nursing supervisors, and it was their responsibility to update the direct care staff on those changes. *DON C stated that she has had issues with RN K updating resident care plans. *When asked how nurses monitor to ensure interventions were being completed, she stated the CNAs document using the task tab in Point Click Care. Repositioning and the heel protector boots were not included in those tasks for resident 25. *MDS Coordinator L. admitted that she had at times missed putting interventions in the task tab and that she has had issues with Point Click Care and entering interventions into the resident care plans. Review of resident 25's 10/11/23 care plan revealed the following: *The care plan had not mentioned a R heel pressure ulcer. *The care plan did list interventions related to the residents non-healing chronic Stage II pressure ulcer to the sacrum. *Interventions included: - Encourage resident to reposition/position changes during rounds. -Attempt to turn and reposition off the area every 2-3 hours and as needed and/or not position on that area, when possible. -Float and off-load heels with pillows or offloading boots. *The care plan intervention had not specified when the heel protector boots were to have been used. Review of resident 25's 6/23/23 Quarterly Comprehensive Skin and Positioning Evaluation revealed: *The Braden score was 14 indicating the resident was at moderate risk for altered skin integrity. *Interventions included: -Pressure reducing device in the chair. -Pressure reducing device in bed. -Pressure ulcer/injury care, application of non-surgical dressings (with or without topical medication) other than the feet. -Application of ointments/medications other than the feet, keep the linens dry and wrinkle-free. *Summary included, [Name of the resident] does have a non-healing pressure area on her coccyx, treatment as ordered from MD (medical doctor), does have potential for altered skin integrity r/t her impaired sensory r/t diagnosis of depression, dementia, and diabetes, moisture r/t (related to) her perspiration, has Foley indwelling catheter, impaired activity/mobility r/t use of full mechanical lift and w/c (wheelchair) and general shearing/friction with repositioning and scooting down in bed, air mattress on bed and pressure reducing cushion in w/c, skin inspected weekly. Review of the provider's revised 10/20/17 Care Plan policy revealed: *The resident care plans were reviewed and revised annually, quarterly, with significant change in status and as needed. *The resident care plan should have been consistent with the CNAs pocket care plans.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (124) received preventative skin care to prevent acquiring two pressure injuries. Findings include: 1. Observation on 10/25/22 at 12:43 p.m. of resident 124 before and after certified nursing assistants (CNA) E and F had provided personal care revealed: *She required total assistance with a full body lift to transfer from her wheelchair to her bed. *She required total assistance to be repositioned from side-to-side. *Had an incontinent bowel movement (BM) and required her brief to be changed. *The BM was up to her waist in the back and the edges were dried. *No protective ointment was applied after she had been cleansed. *She was positioned on her back and her heels were not elevated. *There were no extra pillows or heel protectors in the room. *She did not have a special cushion in her wheelchair. *Did not have a special mattress on her bed. Review of resident 124's 10/14/22 at 4:45 p.m. admission nursing assessment included: *She was incontinent of bowel and bladder and was to have had a barrier cream or protective ointment applied after each incontinent episode. *Her skin was to have been observed with personal cares and any concerns were to have been reported to the nurse. *She had bruising to her right inner elbow, left elbow, the right side of her back, and a stage two pressure injury to her right third toe. Review of resident 124's 10/18/22 at 11:01 a.m. comprehensive skin and positioning evaluation included: *A Braden (skin risk assessment) score of 14 which indicated she was at moderate risk for skin breakdown. *A nursing summary statement [Resident name] does have pressure area to her toe, does have potential for altered skin integrity r/t [related to] her weakness and use of w/c [wheelchair] and general shearing/friction r/t her scooting in w/c and bed and general repositioning, pressure reducing mattress on bed and pressure reducing cushion in w/c, skin inspected weekly. Review of resident 124's skin ulcer assessments revealed: *On 10/26/22 at 4:16 p.m. a nursing progress note Right heel has fluid filled blister 4.0 x 2.0 cm [physician] updated. *On 10/26/22 at 8:22 p.m. an acquired unstageable pressure injury to her sacrum. It measured 1.5 centimeters (cm) by 1 cm by 0.5 cm. *On 10/26/22 at 8:30 p.m. a stage 2 pressure injury to the bottom of her left third toe. It measured 0.6 cm by 0.5 cm. This had been noted in her admission assessment and a skin ulcer assessment had not been completed until this date. *On 10/26/22 at 8:32 p.m. a stage 2 pressure injury to the top of her second toe on her left foot. It measured 0.7 cm by 0.8 cm. There was no documentation of this area in her admission assessment. Review of a 10/26/22 at 8:22 p.m. nursing progress note regarding resident 124's sacral pressure injury revealed: Documentation is of a new area that is a pressure wound. Wound base has slough [dead skin tissue] present. A scant amount of drainage noted. No odor is present. Drainage is serosanguinous [thin and watery with a light red or pink hue]. Wound edges are intact. Wound edges are pink. MD [medical doctor] notified of new area on Wound is new. Review of resident 124's baseline care plan revealed it had been initiated on 10/14/22. Areas related to skin integrity had been added on 10/26/22 and included: heel protectors/elevate heels, and wound locations. Written on the bottom border of the document was -Repo [reposition] as needed. Interview on 10/27/22 at 11:30 a.m. with clinical coordinator C regarding resident 124's newly acquired pressure injuries to her right heel and sacrum revealed no other inventions were put in place based on a residents risk at admission or during their stay. The interventions were put in place if they developed any areas of concern. Interview on 10/27/22 at 2:30 p.m. with administrator A revealed they had started a skin process improvement plan for pressure areas. They were monitoring to ensure skin audits were forwarded to the wound nurse so they could be monitored and followed up on timely. The bath aides were responsible for the completion of a skin audit for each resident with each bath/shower they received. Those audits were then to have been reviewed by the charge nurse for any interventions needed. The completed bath audits were scanned and attached in the residents electronic medical record (EMR). No bath audits were found for resident 124 in her EMR. Bath audits for resident 124 had been requested on 10/27/22 at 11:30 a.m. from clinical coordinator C. They had not been received by the end of the survey on 10/17/22 at 5:30 p.m. Review of the provider's updated 10/14/22 Skin Management Protocol revealed: *Notify DON (director of nursing) and wound nurse of the new skin alteration or skin ulcer. *Procedures for stage 2, 3, 4, or unstageable pressure injuries had no interventions other than treatment types.

Based on observation, interview, record review, policy review, and anonymous complaint report received by the South Dakota Department of Health (SD DOH), the provider failed to ensure residents received treatment and care in accordance with professional standards of practice for ensuring: *Six of Six residents (1, 2, 3, 4, 5, and 6) had received toileting, bathing, and services from staff in a timely manner. -There was a call system that would notify all direct care staff if any of the 57 residents in the building were in need of assistance. *One of one resident (7) had received toileting and services from staff in a timely manner, according to their representative interview. *Six of Six (1, 2, 3, 4, 5, and 6) residents who had been waiting for staff assistance had not had falls or accidents. *Three of six residents (1, 2, and 5) were transferred safely and appropriately with the use of a mechanical lift. Findings include: 1. Review of an anonymous complaint received by the SD DOH revealed residents were: *Waiting for a long time to have their call lights answered and not receiving appropriate care. *Being transferred with lifts with only one person instead of the two people that had been required. 2. Observation and interview on 12/8/21 at 8:10 a.m. with resident 3 revealed she: *Often had to take herself to the bathroom because the staff took so long to answer her call light. *Had been unable to tell surveyor how long she would have to wait but she felt it had been over a half-hour. *Should have staff assistance to use the bathroom but would have to take herself without staff assistance to order to avoid having an accident. -She felt unsafe. *Had experienced accidents waiting for staff. *Had open areas on her skin. Review of resident 3's electronic medical records (EMR) revealed she had: *A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *Blisters to her lower legs that had foul-smelling drainage. *An area to her perineal area with purulent (liquid) drainage and odor. *Required the assistance one staff person for toileting. Review of resident 3's toileting records for December 2021 revealed: *On: -12/1/21 she had gone 15 hours without toileting. -12/2/21 she had 12 hours and 50 minutes without toileting. -12/3/21 she had 21 hours without being toileted. -12/4/21 she had almost 9 hours without toileting. -12/5/21 she had a period of 6 hours and 10 hours without toileting. -12/6/21 she had almost 13 hours without toileting. -12/7/21 she had 14 hours without toileting. -12/8/21 she had a time of 10 hours and 12 hours without being toileted. Review of call light logs that inlcuded resident 3, revealed on 12/1/21 she had a call light on for 1 hour and 39 minutes. 3. Observation and interview on 12/8/21 at 8:15 a.m. with a resident 5 who wished to remain anonymous revealed: *Dependent on staff for help and transitioning. *There were many times that they must wait for an hour for staff assistance. *At night they can hear other residents crying out for help. *They have had accidents because they had to wait for staff assistance. *Since they had accidents, they were worried they wound develop open sores again. *Staff used the Hoyer to reposition and transfer them, and it is often only one staff operating the lift. -They were afraid they would fall out of the Hoyer lift. Review of December 2021's task care records that included resident 5 revealed: *There had been one day in December when they had not received dressing assistance. *They had the following time gaps in toileting: -22 hours. -15 hours. -13 hours on two different days. -12 hours. Review of call light logs from 12/1/21 through 12/7/21 that included resident 5 revealed: *In seven days, they had the following periods they had to wait for staff assistance. -One hour and thirty-one minutes. -One hour and six minutes. Surveyor: 4. Observation and interview on 12/8/21 at 8:50 a.m. with resident 6 regarding the care she received in the facility revealed: *She used a wheelchair to move around the facility. *She required assistance with toileting, hygiene, dressing, and mobility. *When she was questioned about staff answering her call light, she stated: -Sometimes it took a long time for staff to answer her call light. -She has had to wait more than 30 minutes for staff to toilet her . -She got upset when she had to wait to use the toilet. -She had episodes when she soiled her brief waiting for help. -Sometimes she would take herself to the bathroom so she would not soil herself. --The staff did not like it when she took herself to the toilet. -She had falls while attempting to transfer herself onto the toilet. Review of resident 6's medical record revealed: *Her most recent (10/15/21) Significant Change Minimum Data Set (MDS) assessment had indicated: -Her Brief Interview for Mental Status (BIMS) score was 14, indicating she was cognitively intact. -She required extensive assistance of one staff member for: --Bed mobility. --Transfers. --Dressing. --Toileting. --Hygiene. --Bathing. -She had physical impairment to both sides of her upper and lower extremities. -She used a wheelchair with the assistance of one staff member for locomotion off the unit. -She had not walked during the MDS look-back period. -She had occasional urinary incontinence. *Review of resident 6's most recent documented toileting assistance from 11/9/21 through 12/7/21 had revealed she had been assisted with toileting in those 29 days: -Three times per day for six days. -Two times per day for twenty days. -One time per day for three days. Review of resident 6's 10/11/21 at 3:00 p.m. fall report revealed she was found sitting on the floor in her bathroom between the toilet and the wall. *The form stated, Resident description: 'I had to go to the bathroom.' *The fall was not witnessed. *No injury was identified at the time of her assessment. *Predisposing environmental factors: None. *Predisposing situation factors: Ambulating without assistance. Review of resident 6's 10/26/21 at 4:36 p.m. fall report revealed: *The nursing description indicated the resident was found sitting on the floor in front of her wheelchair near a paper towel holder with an active nose bleed. *Staff had documented that fall had been unwitnessed. *The resident description indicated the resident had not wanted to get blood on her clothing. *Predisposing factors had been an active nose bleed prior to the fall. *The documentation had not reflected that she had pressed her call light at 4:13 p.m. Review of the provider's call light log for 10/26/21 at 4:13 p.m. revealed resident 6's bedside call light had remained on for 74 minutes and 24 seconds. Surveyor: 5. Observation and interview on 12/8/21 at 9:45 a.m. with resident 4 revealed he: *Was upset because he had just been at the nurses station for over five minutes and staff acted as if he was not there. *Has had falls. *Stated he had not ever used his call light *Surveyor observed resident was sitting in his recliner, his call light was out of reach behind him on the wall. Review of the provider's 9/1/21 through 12/5/21 fall records revealed resident 4 had experienced 16 falls within that time. 6. Observation and interview on 12/8/21 at 9:55 a.m. with a resident 1 who had wished to remain anonymous revealed: *There had been a strong smell of urine in the resident's room. -There was only one resident who resided in the room. *The resident's brief appeared to be soaked with urine. *They had not been taken to the bathroom or had staff come in to get them ready for the day. -They pointed out to the surveyor that they had their call light on for the past 15 minutes or so. *The surveyor had been unable to see a light or hear an audible sound from outside the resident's room. *They had experienced an instance where they had been left on the toilet for an hour and a half. -They believed this happened a couple of months ago. *Staff had not been answering the resident's call lights. -They would come in and turn off the call light and not address the resident's needs. *They often used one staff member when using a lift to take them to the bathroom, which scared them to death. Review of call light logs that included resident 1 revealed they had a bathroom call light that was 1 hour and 21 minutes in September 2021. Review of task care records that included resident 1 revealed: *In December 2021 there had been the following gaps in their toileting documentation: -10 hours. -11 hours. -12 hours. -14 hours. -15 hours. -19 hours. -22 hours. Review of bathing records that included resident 1 revealed they had received two baths in 30 days, other entries had been marked as not applicable. Review of resident 1's October 2021 care plan revealed they required the assistance of two staff members for toileting and bathing. 7. Observation and interview on 12/8/21 at 10:15 a.m. with a resident 2 who wished to remain anonymous revealed: *Staff took a long time to answer their call lights. -A long time was defined as over twenty minutes. *That morning they had to wait 45 minutes to receive help for toileting. *They had experienced accidents due to waiting for staff assistance. *Staff used the lift to toilet them with only one person. Review of call light logs that inlcuded resident 2's confirmed: *They had to wait 32 minutes to receive staff assistance on 12/8/21. *The longest call light they had from September 2021 through December 2021 was 1 hour and 35 minutes. Observation on 12/8/21 at 10:05 a.m. revealed certified nursing aide (CNA) I had transferred resident 2 using only one person. Review of December 2021's toileting logs that included resident 2 revealed: *They had gone the following periods without being toileted by staff: -7 hours. -9 hours and 7 hours in one day. -9 hours and 11 hours in one day. -12 hours and 10 hours in one day. -12 hours. -13 hours. -15 hours. -21 hours. 8. Phone interview on 12/8/21 at 10:45 a.m. with resident 7's daughter revealed: *She had placed a camera in the resident's room due to staff not providing care for her mom. *It takes a long time for staff to answer her mom's call light, sometimes 30 to 45 minutes. *She had called the nurses station when staff were not answering the call lights. -She would not receive an answer at the nurses station either. *She had tried to talk to the executive director (ED) A regarding this. -ED A never returned her phone call. -They receive no resolutions for their concerns. *They went through human resources for approval for the camera. Surveyor: 9. Observation and interview on 12/8/21 at 11:20 a.m. on the Country Lane unit with registered nurse (RN) Q and certified nursing assistants (CNAs) F, G, H, and I regarding the call system revealed: *RN Q stated the call light lamps above each residents' doors would light up if a resident pushed the call button. *CNAs F, G, H, and I revealed: -The call system screen was on the computer in the nurses' station. -If a resident pushed the call light for help their name came up on the computer screen. *The CNAs also used cell phones to view who had their call lights on. -If a resident pushed the call light for help their name came up on the call phone screen. *The call light lamps above each residents' doors had been disconnected from the call system because the provider had purchased a new system. -RN Q confirmed she had not known the lamps above resident doors had been disconnected. *The new system used call phones to identify who needed assistance. *There were only four phones in the building for the CNAs to use. -There were currently four CNAs working on the Country Lane unit and two CNAs working on the Arbor unit. -The CNAs without phones were required to enter the doors of the nurses' stations to check the computer screen to identify who needed assistance. *This surveyor could see the residents' names on the computer screen, but had not heard any audible bell from the computer or the phones to notify staff that a call light was on. *Interview at that time with CNA I regarding the call light system revealed: -Not every CNA had a call phone to monitor the call system. -Several phones had disappeared. -She had not known why there were not enough phones. -She had worked at the facility for [AGE] years. -The call light system was capable of being audible on the computers and the phones. -It was up to the CNA that was working whether they used the audible bell with the call light or just used the vibrate option on the phone. *CNA I: -Left her phone on vibrate without audible alerts. -Placed the phone in the pocket of her scrub shirt. -The phone was not contacting her body. 10. Observation and interview on 12/8/21 at 1:35 p.m. on the Arbor unit nurses' station with RN D, and CNAs E and J regarding the call system revealed: *The call system screen was in the nurses' station. *There were names on the screen but no audible bell was heard. *When asked why there was no audible bell heard, RN D stated she did not know why there was no noise. When RN D turned the volume up the call system was audibly heard. *At the same time CNAs E and J were inside the nurses' station. -When questioned if the CNAs used the volume on their phones to hear the call system, both CNAs stated they did use the audible volume. -No audible bell was heard from either phone. Further interview at that time with RN D revealed the leadership team had pagers to monitor if lights were being answered. Staff educator/RN C walked out of her office with a pager with the volume up. She stated the leadership team was to attend to the call system if it was not being answered. Surveyor: 11. Observation and interview on 12/8/21 at 2:00 p.m. revealed: *RN Q and certified medication aide (CMA) L were standing at the nurse's station, at their medication carts. *Neither one had a call light phone on them, nor could see when a resident needed help. *They were unsure if there were any residents who currently were needing assistance. *They have a couple of phones, but they do not have enough for all the staff. *Two of the staff have a call light phone on their unit. -They were not sure where those staff were. Further interview on 12/8/21 at 2:10 p.m. with CMA L revealed: *Nights and weekends were usually worse. *They had a lot of call-ins. *They did not have enough staff to complete the tasks that they needed to complete. Observation and interview on 12/8/21 at 2:15 p.m. with two CNAs who had wished to remain anonymous revealed: *They did not have enough staff to care for the residents. *They were unable to use two staff while using the lifts to transfer residents. *They had been unable to toilet residents and bath all of the residents. *Surveyor observed that the call phone that had been being used by one staff member was lying on the desk. -Only one staff member had a call phone in their possession who had been working on that wing. On 12/8/21 at 2:30 p.m. surveyors had requested the following policies: -Call light policy. -Lift policy. -Bathing policy. -Activities of Daily Living policy. *ED A stated they had none of the above policies. Interview on 12/8/21 at 5:32 p.m. with director of nursing services (DNS) B, ED A, MDS Coordinator K, and RN consultant R revealed: *The process improvement plans (PIPS) they have had in place were related to their July 2021 survey. *They were to implement marquees so staff could visualize when residents needed assistance. *They were also supposed to have leadership carry call phones to answer any calls that went over 10 minutes. -The leadership rounds started in November. *The marquee had not been installed as of 12/8/21. -There had been issues with the company. -Their boss had called the marquee company's boss and it has been scheduled for January 2022. -They verified it had been rescheduled multiple months. *They had goals of staff answering call lights within five minutes. *ED A had not been aware that not all staff were carrying a call phone. -They had not always been told when staff did not have access to a call phone. *Two years ago they had ordered 50 call phones. *They had ordered 10 more call phones at the end of August 2021. -By the end of November 2021 that one wing of the facility had five phones and the other wing had three. *They had expected all direct care staff to carry call phones. *They agreed staff would be unable to answer call lights when they are not aware when a resident needs assistance. *They had expect residents to be toileted every two to three hours. *Staff were always supposed to use two staff members while using lifts. Review of the provider's revised January 2020 Abuse and Neglect policy revealed: *The provider had a zero-tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of funds. *Neglect was the failure of the facility, the employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the provider's revised June 2021 facility assessment revealed: *The provider would adjust daily staffing according to census and acuity. The ED had the discretion to adjust staffing to respond to census, acuity, emergency or other extenuating circumstances. *Toileting programs, incontinence prevention and care, responding to requests for assistance to the bathroom/toilet promptly to order to maintain continence and promote resident dignity. *Bathing, showers, oral/denture care, and dressing were routinely provided by the provider.

Based on observation, interview, record review, and guideline review, the provider failed to ensure a system was in place for one of two sampled residents (27) who was at risk for skin breakdown and was dependent upon staff to assist her with all of her activities of daily living (ADL) to: *Prevent pressure injuries from occurring or worsening. *Provide appropriate treatment, monitoring, and documentation of pressure injuries. Findings include: 1. Interview on 10/28/19 at 4:00 p.m. with registered nurse (RN) I regarding residents with skin issues revealed: *Resident 27 had a pinpoint area to her left foot that had a scab on it but had been resolved. *She stated they were still putting a dressing on the area every three days for protection. Observation and interview with RN I on 10/29/19 at 10:06 a.m. during resident 27's left foot dressing change revealed: *Resident 27 was in her bed laying on her side. *Her knees were bent and was unable to move her legs independently. *She did not respond to surveyor's questions. *She had a pair of Rooke boots on her bare feet. *RN I removed the Rooke boot and the dressing from the inner side of her left foot by her great toe. -A dark black and purple colored approximately a quarter sized wound was observed. -There was no crusting, drainage or swelling. *She applied a new [MEDICATION NAME] dressing over the area. *According to RN I the wound had not changed from the previous day. *RN I stated: -The wound was considered resolved by the wound nurse. -The dressing they were doing was for protection only. *She did not consider the appearance of the wound concerning. Review of resident 27's medical record revealed: *She was admitted on [DATE]. *[DIAGNOSES REDACTED]. *She was not interviewable and had problems with short and long term memory recall. *She had been dependent upon the staff to assist her with all ADLs. -That had included bed mobility, transfers, dressing, incontinence care, and repositioning from side-to-side. *Her Braden Scale for Predicting Pressure injuries scores from 3/27/19, 6/17/19, and 9/12/19 ranged from six to ten indicating she was very high risk for skin breakdown. *She was dependent upon the staff to anticipate her needs and develop a plan of care to ensure no skin breakdown had occurred. *She had: -Limited range-of-motion to her lower extremities and was not able to walk. -Required the use of a wheelchair (w/c) to meet all of her mobility needs. -A history of a stage two facility-acquired pressure injury to her left buttock. *Her 9/27/19 comprehensive skin and positioning evaluation revealed: -She had a pressure injury on her left foot that was a stage 1 or greater. -Interventions to the left foot were listed as inspect skin weekly and apply dressings to legs. *Interventions on her comprehensive care plan matched the above evaluation and included the Rooke boots and heel lift boots. Continued review of resident 27's medical record and wound history documentation revealed: *She had a facility-acquired left foot stage two pressure injury that was identified on 1/15/19. -It had worsened to necrotic tissue on 1/30/19, but was documented as a stage two. -On 2/20/19 it was still a stage two with fifty percent necrotic tissue and fifty percent pink/red tissue. -The length, width, and depth measurements had not changed from 1/15/19. -On 2/27/19 it was now an unstageable necrotic wound with drainage. -The measurement was now slightly different. *On 6/26/19 they had documented the wound as closed. -On 7/2/19, only six days later it was again an unstageable wound. *The unstageable wound to her left foot remained until it was documented as healed on 9/18/19. -There were no further notes about the status of the wound after 9/25/19 that listed it as healed. *For the left foot pressure injury she was seen at the wound clinic three times in (MONTH) 2019. -According to the last documentation from that clinic the area was considered resolved and the facility was to call if the area reopened. -There was no further documented contact with the wound clinic regarding the pressure injury. *The documentation and assessments overall were inconsistent and unclear to support the status of the wound. Interview on 10/29/19 at 11:03 a.m. with the assistant director of nursing (ADON) regarding resident 27's pressure injury revealed: *The ADON was the primary nurse that assessed pressure injuries and surgical wounds. -She did not do the skin assessments for other skin concerns. *She had started that role in (MONTH) 2019. *She was aware the resident had a history of [REDACTED]. -She had considered it resolved the prior week due to it being a white calloused area. *She had not been made aware of any changes to that area since she resolved it. *Nurses should have informed her when there was a new or change to pressure injuries. *There were two different documentation systems used for charting skin concerns. -She primarily used one system and the charge nurses used the other. -Those systems were not integrated. *Her focus was solely on the pressure injuries and surgical wounds. *She assessed pressure injuries weekly until they were resolved. *She considered pressure injuries resolved when the wound was closed, and there was no change. Continued interview and observation with the ADON of resident 27's left foot revealed: *The resident was sitting in her wheelchair with the Rooke boots on. *The ADON removed the left boot and dressing from the area. *She said what she was observing was a change in the area, and it should have been reported to her by nursing. *The left foot area would have been considered an unstageable pressure injury at that time. *The nurses should have charted that change in the record. *The interventions that should have been used were either heel lift boots or the Rooke boots. *She stated the resident should have been wearing the heel lift boots now instead of the Rooke boots because of the change in the wound. -She was unable to locate the heel lift boots in the resident's room and said they were probably in the laundry. Interview on 10/29/19 at 1:49 p.m. with certified nursing assistant J regarding resident 27's pressure ulcer revealed: *She had seen the resident's left foot while doing her shower a couple of weeks ago. *There were no skin issues at that time. *If she had identified a change in a resident's skin she would have informed the nurse. *After speaking with the nurse she would have documented the injury depending on what the nurse told her to do. Further interview on 10/30/19 at 10:06 a.m. with the ADON and the nurse consultant revealed: *A weekly skin assessment was to have been completed by the nurse when the resident was being showered. *The DON would be expected to monitor and ensure the assessments were being completed. *The ADON had training on how to use the wound rounds software program. *She had not been given any specific wound assessment training. -The ADON completed those weekly assessments of pressure injuries to ensure consistency occurred. *The staff often called the ADON the wound nurse at the facility. *There was no job description for the wound nurse position, because it was a task that was assigned to the ADON. Observation on 10/30/19 at 10:58 a.m. of resident 27 revealed: *She was sitting in her wheelchair (w/c) in the television room. *She had Rooke boots on her feet. *The front of her feet were out of the front of the boots. *Her feet were turned inward resting on each other at the area of the pressure injury. *She did not have any foot pedals on her w/c. *At that time the surveyor asked RN I if she had been informed to use the heel boots instead of the Rooke boots. -She said she had not been informed of any changes for the resident. -When asked to find the boots she stated she would when she was done putting orders away. -After waiting several minutes the nurse was again asked to assist with the boots. The nurse indicated she was busy. *The ADON was then approached about the resident's heel lift boots and she obtained a set of boots from the supply closet. -She went and applied those boots to the resident's feet and removed the Rooke boots. The DON was not available for interviews throughout the survey from 10/28/19 through 10/31/19. Review of the provider's (MONTH) 2019 Skin Management Program guidelines revealed: *The purpose was: Promote the prevention of alterations in skin integrity: promote healing of current skin alteration and to prevent further loss of skin integrity. *Body audits should have been completed weekly. *The skin and wound monitoring form was to be completed daily when there was a skin integrity issue. *Assessment guidelines were: -Establish individual interventions needed to promote and/or prevent alteration in skin integrity. -Monitor for healing process of alterations in skin.

Based on record review, interview, policy review, and job description review, the provider failed to ensure: *All licensed nurses were educated and followed the physician's orders [REDACTED]. *Medications were received from the pharmacy in a timely manner for administration for one of one sampled resident (1). *The physician and family were notified of a significant change of condition in a timely manner for one of one sampled resident (1). *Pain was assessed and managed for one of one sampled resident (1) by the administration of pain medications in a timely manner. NOTICE: Notice of immediate jeopardy was given verbally to the director of nursing (DON) and the assistant DON on 11/5/14 at 2:40 p.m. The administrator was on medical leave and notified by phone by the DON. They were asked for a plan of correction to be given to the surveyors on 11/6/14 at 9:00 a.m. The provider informed the surveyors the plan of correction might not be completed until later on 11/6/14 pending the meeting with the pharmacy. They were asked that the plan of correction include: *The education of all licensed nurses regarding any residents' skilled nursing procedures. *How medications were going to be received to enable they were administered in a timely manner according to the physicians' orders. PLAN: A plan of correction for the education of all licensed nurses regarding any skilled nursing procedure and obtaining medications from the pharmacy in a timely manner was accepted on 11/6/14 at 4:00 p.m. The plan of correction also included education to all the licensed nurses on pharmacy guidelines and procedures and care of residents with impaired skin integrity. *All licensed personnel will be re-educated prior to their next scheduled shift on the following guidelines: -Medication administration. -Physician/practitioner notification. -Significant change of condition. *All licensed personnel will be re-educated on the following skills prior to performing: -Care of drainage tubes. -Intravenous therapy. -Gastrostomy (tube in the stomach) tube sites and medication administration. -Peripherally inserted central catheter care. -[DEVICE] assisted closure. -Any other skilled nursing procedure resident specific. *Licensed staff will be trained prior to their next scheduled shift on the following pharmacy guidelines and procedures: -Pharmacy related general grievances or complaints. -Pharmacy related occurrence reporting. -Medications ordered too soon. -Backorders. -Medication shortages/unavailable medications. -Emergency medication supplies. -General dose preparation and medication administration. -Delivery and receipt of medication and pharmacy documents from the facility to the pharmacy. -Delivery and receipt of routine deliveries. -Receipt of interim/stat/emergency deliveries. -New orders for schedule II controlled substances (medications). -New orders for schedule III-IV controlled substances. -New orders for non-controlled substances. -Reordering, changing, and discontinuing orders. -Physician/prescriber authorization and communication of orders to pharmacy. -Providing pharmacy products and services. *Consulting pharmacy nurse will provide an inservice by 11/20/14 regarding medication availability. *Skin care for residents with impaired skin integrity (intactness) would be reviewed with all licensed staff. *Seventy-five percent of the licensed nursing staff had been provided the above at the time of the acceptance and removal of the immediate jeopardy on 11/6/14 at 4:00 p.m. Findings include: 1. Review of resident 1's medical record revealed: *A 10/22/14 admitted at 5:30 p.m. *[DIAGNOSES REDACTED]. -Hypertension (high blood pressure). -Diabetes mellitus (varying up and down blood sugars). -[MEDICAL CONDITION]. -[MEDICAL CONDITIONS]. -Oxygen dependent. -Asthma. -Cholelithiasis (hard deposits called gallstones in the gallbladder.) Biliary drain (drainage tube from the liver) was placed on 10/19/14 in the hospital. Review of resident 1's 10/22/14 admission orders [REDACTED] *Respiratory therapy (RT) evaluation and treatment as indicated once. *Interdry AG (moisture-wicking fabric with antimicrobial silver to keep skin dry and helps eliminate skin-on-skin friction). Use to abdominal folds for prevention or treatment of [REDACTED]. Leave a two inch tail outside of each end of affected area to wick away the moisture. *Observe the site for signs of infection: increased pain, redness, foul odor or drainage, swelling, or fever above 100 degrees Fahrenheit orally. *If you observe signs of infection please call the physician or go to the nearest emergency room . *Flush tube with [MEDICATION NAME] 0.9 percent (%) sodium chloride (NaCl) twice daily as ordered. *Record the output from the drainage tube every shift. *Weigh yourself at the same time of the day and with the same amount of clothing. *Contact the doctor if a sudden weight gain of two to three pounds in a day or five pounds in a week. That a sign of fluid build-up. *If you were on an antibiotic take as instructed. *Medications as follows: -[MEDICATION NAME] 325 milligrams (mg) every four hours as needed (PRN) for pain. -[MEDICATION NAME] 0.083% nebulizer four times a day. -[MEDICATION NAME] (gout) 100 mg one tablet daily (qd). -[MEDICATION NAME] 300 mg one tablet qd. -[MEDICATION NAME] clavulanate potassium (antibiotic) one tablet twice a day (BID). -[MEDICATION NAME] (fluid retention) one tablet BID. -[MEDICATION NAME] sulfate (iron) 325 mg one tablet qd. -[MEDICATION NAME] (asthma) two sprays into each nostril qd. -[MEDICATION NAME] 500-50 micrograms (mcg) one puff orally BID. -[MEDICATION NAME] (anticonvulsant) 300 mg three capsules, four times a day (QID). -[MEDICATION NAME]4 to15 units subcutaneously (under the skin) four times a day with meals and bedtime. Use sliding scale (units per blood sugar test results). -[MEDICATION NAME] ([MEDICAL CONDITION]) 0.06% nasal spray, two sprays into each nostril three times a day (TID). -[MEDICATION NAME] 20 units subcutaneously qd. -[MEDICATION NAME] (seasonal allergy) 5 mg one tablet qd in the evening. -[MEDICATION NAME] (blood pressure) 5 mg one tablet BID. -Magnesium oxide (supplement) 400 mg one tablet BID. -[MEDICATION NAME] (blood pressure) 25 mg one tablet BID. -[MEDICATION NAME] 2% powder (skin rash) apply topically BID. -Montelukast (asthma) 10 mg one tablet qd at bedtime. -[MEDICATION NAME] (stomach) 20 mg one tablet qd in the morning. -[MEDICATION NAME] (narcotic for pain) 15 mg one tablet TID PRN as needed for moderate pain. -[MEDICATION NAME] 20 mg one tablet TID. -[MEDICATION NAME] (steroid) 10 mg one tablet qd. -Roflumilast 500 mcg one tablet qd. -Senna-[MEDICATION NAME] (stool softner) 8.6-50 mg two tablets BID. -[MEDICATION NAME] (stomach) one gram QID. -[MEDICATION NAME] ([MEDICAL CONDITION]) 300 mg one tablet BID. -[MEDICATION NAME] ([MEDICAL CONDITION]) 18 mcg two inhalations qd per capsule. Review of resident 1's 10/22/14 at 12:30 a.m. physician's orders [REDACTED]. Review of resident 1's 10/23/14 physician's orders [REDACTED]. *[MEDICATION NAME] (nausea medication) every six hours PRN. *Discontinue [MEDICATION NAME] ([MEDICATION NAME]). Hospital transfer sheet listed [MEDICATION NAME] as an allergy. *Triple antibiotic to toe PRN. Review of resident 1's 10/22/14 through 10/27/14 progress notes by the following nurses revealed: *10/22/14 at 11:22 p.m. admission note by RN E "Pain at the time of admission was rated as 7 on a scale of 0-10 (1 being no pain and 10 being severe pain). Is oriented (alert) to person, place, and time. Oxygen is in use at 2 liters per minute per nasal cannula. A nebulizer treatment has been ordered. [MEDICAL CONDITION] (swelling) is present." *10/23/14 at 1:19 p.m. by RN D "Short of breath (SOB) with exertion. Oxygen at 2 liters. Has drain to right abdomen that drains bile from gall bladder. Have emptied 420 milliliters (ml) since 6:00 a.m. Has mid abdominal pain. Received [MEDICATION NAME] sulfate 5 mg IM this a.m. Upset this a.m. because medications not delivered from pharmacy. Has not received [MEDICATION NAME], magnesium oxide, [MEDICATION NAME] at 6:00 a.m. and 2:00 p.m., [MEDICATION NAME], rofumilist, and [MEDICATION NAME] medication related to them not being here." *10/23/14 at 1:38 p.m. by RN D "Doctor here for rounds. Received order for [MEDICATION NAME], discontinue [MEDICATION NAME], and triple antibiotic ointment to end of 3rd toe PRN." *10/24/14 at 12:40 a.m. by LPN G "Alert and oriented. PRN and scheduled pain medications arrived during the first run from pharmacy. PRN [MEDICATION NAME] for pain relief administered at 9:45 p.m. and then scheduled [MEDICATION NAME] 40 mg tablet administered at 10:00 p.m. Does have right upper quadrant pain from surgical procedure with gall bladder." 10/25/14 at 3:54 p.m. by RN H "Has request PRN [MEDICATION NAME] for nausea. Has a drain in her abdomen which she says the area around it is tender at times. It is bright red around the insertion site. Was a small amount of tan drainage on the dressing when it was changed. Has been complaining of discomfort to her abdomen. Has scheduled pain medications." *10/26/14 at 12:28 a.m. by RN E "Has a tube from gallbladder emptied several times a shift with dark green bile. [MEDICATION NAME] 40 mg TID and prn [MEDICATION NAME] for joint and abdominal pain." *10/26/14 at 3:11 p.m. by RN H "Has been complaining of nausea and has taken [MEDICATION NAME] for the same with relief. Has drain in her right abdomen. It is red around the insertion site. She is complaining of discomfort to that area." *10/26/14 at 10:54 p.m. by RN E "Sleepy this p.m. Gets [MEDICATION NAME] 40 mg TID and [MEDICATION NAME] 15 mg PRN for abdominal pain and chronic generalized pain." *10/27/14 at 9:31 a.m. by RN A "Went into resident's room this a.m. to give morning medicine and check blood sugar. Her body was making jerking movements. She seemed coherent (oriented) but would make odd comments. Had a temperature of 101.6 (normal 98.6). Her pulse ranged from 88-165 beats a minute (normal 60-80 beats a minute). Her oxygen saturations (amount of oxygen in blood) ranged from 65% to 88% (normal greater than 90%) on 2 liters of oxygen. Called hospital and advised to use standing orders to send to the emergency room . Attempted to call daughter and number was bad. Called son and notified of same." 10/27/14 at 5:46 p.m. by RN A "Spoke with an RN at hospital. Resident is intubated (tube down throat and windpipe to maintain an airway) with severe septic shock (result of a severe infection in the blood that can lead to organ damage and death resulting from a drop in blood pressure). Getting intravenous antibiotics through a central line (catheter placed into the large neck vein, chest, or groin to administer medications, fluids, and obtain blood tests)." Review of resident 1's 10/22/14 through 10/26/14 vital signs (blood pressure, pulse, respirations, and weight) revealed: *Weight on 10/25/14 was 294.2 pounds (lb) standing and on 10/26/14 in wheelchair was 298.3 lb (a 4.1 lb weight gain in one day). *Blood pressure (normal reading is at or below 120/80 milliliters/deciliter (mg/dl): -10/22/14: 145/84 mg/dl. -10/23/14: 130/85 mg/dl. -10/26/14: Two readings 104/68 mg/dl and 82/53 mg/dl (significant drop since admission). -There were no blood pressure readings documented for 10/24/14 and 10/25/14. *10/26/14: Temperature 100.5 degrees Fahrenheit. *10/26/14: Oxygen saturation was 90% on room air (resident had 10/22/14 physician's orders [REDACTED]. Review of resident 1's 10/22/14 through 10/26/14 drain tube drainage form documentation revealed: *10/22/14 (no time identified): 350 ml and 200 ml. *10/23/14 (no time identified): 400 ml. *10/23/14 at 7:30 a.m. and 1:00 p.m.: 120 ml and 300 ml. *10/23/14: There was no documentation regarding any further drainage from 1:00 p.m. to 11:59 p.m. *10/24/14: There was no documentation of any drainage for the entire twenty-four hour period. *10/25/14 at 10:00 p.m.: 300 ml, 200 ml, and 450 ml. There was no other drainage documented from 12:01 a.m. until 10:00 p.m. *10/26/14 (no times identified): 150 ml, 200 ml, and 350 ml. Review of resident 1's 10/22/14 through 10/28/14 daily wound monitoring record revealed: *There was no documentation for 10/24/14. *There was documentation the assessment had been done on 10/28/14 (she had been sent to the hospital on [DATE]). Review of resident 1's 10/22/14 through 10/27/14 Medication Administration Record [REDACTED] *[MEDICATION NAME] inhaler was not administered on 10/22/14 at bedtime (had not arrived from pharmacy). *[MEDICATION NAME] capsules were not administered on 10/22/14 at 8:00 p.m. or on 10/23/14 at 8:00 a.m., 12:00 noon, 4:00 p.m., or 8:00 p.m. (had not arrived from pharmacy). *Senna was not administered at bedtime on 10/22/14 (had not arrived from pharmacy). *[MEDICATION NAME] was not administered on 10/22/14 at 6:00 p.m. (had not arrived from pharmacy). *Magnesium oxide was not administered on 10/22/14 at 6:00 p.m. nor on 10/23/14 and 10/24/14 at 8:00 a.m. and 6:00 p.m. (had not arrived from pharmacy). *[MEDICATION NAME] was not administered on 10/22/14 at 6:00 p.m. (had not arrived from pharmacy). *[MEDICATION NAME] powder was not administered on 10/22/14 at bedtime, on 10/23/14, 10/24/14, nor on 10/25/14 BID, and on 10/26/14 at 8:00 a.m. (had not arrived from pharmacy). *Montelukast was not administered at bedtime on 10/22/14 (had not arrived from pharmacy). *[MEDICATION NAME] was not administered on 10/22/14 at bedtime nor on 10/23/14 at 6:00 a.m. and 2:00 p.m. (had not arrived from pharmacy). *Atrovent nasal spray was not administered on 10/22/14 at bedtime (had not arrived from pharmacy). *[MEDICATION NAME] was not administered on 10/22/14 at 6:00 p.m. (had not arrived from pharmacy). *[MEDICATION NAME] was not administered on 10/23/14 at 6:00 a.m. (had not arrived from pharmacy). *[MEDICATION NAME] was not administered on 10/22/14 at bedtime (had not arrived from pharmacy). *[MEDICATION NAME]was not administered on 10/22/14 at 5:00 p.m. and at bedtime (had not arrived from pharmacy). There was no documentation of any blood sugar readings. *[MEDICATION NAME] nebulizer was not administered on 10/22/14 at 8:00 p.m. (had not arrived from pharmacy). *There was no documentation the [MEDICATION NAME] had been administered related to her allergy. There was no other antibiotic documented. *Roflumilast was not administered on 10/23/14 at 8:00 a.m. (had not arrived from pharmacy). *[MEDICATION NAME] was not administered on 10/22/14 at 8:00 p.m. (had not arrived from pharmacy). *[MEDICATION NAME] was not administered on 10/22/14 at 8:00 p.m. (had not arrived from pharmacy). *Intradry dressing was never documented as being administered (pharmacy record revealed it was delivered on 10/28/14 after she had been hospitalized ). *There was no documentation her drain had been flushed on 10/23/14 on the 6:00 p.m. to 6:00 a.m. shift. *[MEDICATION NAME] had been administered nine times for nausea: -Five of the doses had documentation of little or some relief of nausea. -Two of the doses had no documentation as to the effectiveness of the [MEDICATION NAME]. *[MEDICATION NAME] had been administered six times for abdominal pain: -Two of the doses had documentation of some relief. -One dose had no documentation as to the effectiveness of the [MEDICATION NAME]. Review of resident 1's 10/24/14 care conference summary sheet by LPN C revealed: *"Has had pain and got her medications." *"Does have complaints of nausea and does take medications for it." Review of resident 1's 11/2/14 medication return to pharmacy/destroyed record signed by RN E and RN H revealed the following discrepancies of what was sent from the pharmacy on 10/23/14, what was documented as administered on her MAR, and what was returned to the pharmacy or destroyed: *[MEDICATION NAME] inhaler: sixty doses had been dispensed. Seven doses had been documented as administered. Fifty-five doses had been documented as destroyed. *[MEDICATION NAME] inhaler: thirty doses had been dispensed. Four doses had been documented as administered. Twenty-seven doses had been documented as destroyed. *[MEDICATION NAME] nebulizer: seventy five doses had been dispensed. Sixteen doses had been documented as administered. Fifty-seven seven doses had been documented as destroyed. *[MEDICATION NAME]: thirty doses had been dispensed. Nine doses had been documented as administered. Nineteen doses had been documented as returned to the pharmacy. *[MEDICATION NAME]: ten doses had been dispensed. Four doses had been documented as administered. Five doses had been documented as returned to the pharmacy. Review of resident 1's 10/29/14 DON investigation report fromt the following interviews revealed: *"10/28/15 at 3:15 p.m. with RN A: She took care of resident on 10/24/14 from 6:00 a.m. to 6:00 p.m. She found the resident alert and oriented to person, place, and time, and was also answering questions appropriately. Her legs were [MEDICAL CONDITION], but had no signs of [MEDICAL CONDITION] (redness and warmth). No concerns. She was also in charge of resident's care on 10/27/14 starting at 6:00 a.m. I waited to assess her until after she ate breakfast because she does not like to take her medications until after she has eaten. Resident was found to be shaky and not quite right. She was answering questions appropriately but something was off. I took her vitals and her temperature was 101.6 degrees. I then called the emergency room to send her." *"10/28/14 at 4:00 p.m. with certified nursing assistant (CNA) I: She gave the resident her shower on the evening of 10/24/14. The resident's abdominal folds had a small amount of whitish, yellowish yeast noted on her Intradry that was placed between her folds (Intradry was placed in the hospital prior to admission). The only red area was to her buttocks, but was present on admission to this facility. The folds were cleaned by the CNA. She stated the pharmacy had not sent any Intradry to replace the old one. This is when the resident suggested that we use the towels in-between her folds to keep the area dry. She placed the towels between the folds and reported this to the night nurse." *"10/28/14 at 3:00 p.m. with RN H: She took care of the resident on 10/24/14 and 10/25/14 from 6:00 a.m. to 6:00 p.m. Legs had [MEDICAL CONDITION] but did not look to have signs of [MEDICAL CONDITION]. Temperature was 98.0 on 10/25/14 and elevated a little to 99.2 degrees on 10/26/14. She was receiving Tylenol in her pain medications and per my assessment I did not see any signs of infection." *"10/28/14 at 3:30 p.m. with RN E: She took care of the resident from 6:00 p.m. to 6:00 a.m. on 10/25/14 and 10/26/14. Legs were checked with no indication of [MEDICAL CONDITION]. Abdomen was tender to touch, but was so on admission. She washed resident's abdominal folds and groin area both mornings around 5:00 a.m. She washed them with soap and water and patted them dry. Pharmacy was still having an issue getting the Intradry to us. I applied [MEDICATION NAME] powder to the folds and groin and put clean towels in the folds and groin area to keep it dry. Resident did state she did not feel well on 10/26/14 in the evening. [MEDICATION NAME] and [MEDICATION NAME] were given. At around 11:50 p.m. the resident stated she felt a lot better. She did start to get more of a fever in the night 100.5 degrees. Upon assessing her early in the morning of 10/27/14 she noticed the resident shake a few times. She questioned the resident about shaking and she said that was normal for her and happens every now and then." *"10/28/14 at 6:00 p.m. with RN F: She took care of the resident on 10/24/14 and 10/25/14 from 6:00 p.m. to 6:00 a.m. She found that the resident was alert and oriented to person, place, and time. Biliary drain was flushed without problem. She had no concerns or issues with this resident." *"10/29/14 at 10:45 a.m. with CNA P: She took care of the resident on 10/26/14 from 6:00 a.m. to 2:00 p.m. She did in fact wash the resident's abdominal folds and groin area with soap and warm water. She patted areas dry and put wash cloths inbetween folds and groin area to keep them dry. Intradry was still not available from the pharmacy." *"Findings": -"Abdominal fold and groin area care was provided daily at minimal. She had no open areas to her abdomen or groin. Towels were used in lieu of Intradry until pharmacy could send it to the facility. [MEDICATION NAME] was applied to abdominal folds and groin area on 10/26/14 only due to unavailability from the pharmacy." -"Biliary drain was intact and flushed per nursing on all but one shift without problem. Drain site was slightly red with scant amount of drainage. Dressing was changed daily. Resident's legs showed no indication of [MEDICAL CONDITION]." -"Resident did have a temperature of 99.2 degrees on 10/26/14 during the day which continued to elevate to 100.5 degrees Sunday night (10/26/14) and then 101.6 degrees on Monday morning (10/27/14) at which time she was sent to the emergency room ." *"Conclusion": -"Allegation of neglect is not substantiated." -"Upon reviewing documentation and interviewing staff, resident received appropriate nursing care while in this facility." Interview on 11/4/14 at 3:30 p.m. with RN A regarding resident 1 revealed: *The provider had done no inservice training or education regarding her biliary tube prior to her admission. She had been employed there three years and during that time had never cared for a resident with a biliary tube. *She thought all the nurses were familiar with the procedure, but knew the resident was telling her family it had not been taken care of properly from 10/22/14 through 10/26/14. *She felt comfortable flushing the tube. *The resident was alert and oriented and involved in her care by asking a lot of questions. *She required more time and attention due to her many care issues, pain, and nursing procedures. Interview on 11/5/14 at 9:35 a.m. with the DON and ADON regarding resident 1 revealed: *If medications were ordered from the pharmacy before 2:00 p.m. they would have been delivered on the 6:00 p.m. to 7:00 p.m. pharmacy delivery. If medications were ordered from the pharmacy after 2:00 p.m. they would have been delivered on the 11:00 p.m. to midnight pharmacy delivery. *Her medications were ordered on [DATE] at 6:00 p.m. from the pharmacy. RN E had told them she had contacted the pharmacy and was told by the pharmacist she would not get out of bed to deliver the medications. The DON or ADON had not been informed of that when it had occurred and not until 10/28/14 when they had interviewed her. *The physician had not been contacted the pharmacy had not delivered any of her medications on 10/22/14. *The resident's daughter's phone number was incorrect on the face sheet. RN A had been unable to contact her on 10/27/14 when she had sent her to the emergency room . Social services had inputted the wrong telephone number on the face sheet. *RN A stated she had informed the resident's son of her transfer to the emergency roiagnom on [DATE]. She was aware the son and daughter-in-law had denied that had occurred. The documentation was in the medical record the son had been informed by RN A on 10/27/14 of the emergency room transfer. *They did not have a policy and procedure for the care of biliary drains prior to 10/22/14 and still had not put one together. *They confirmed they had done no education to the licensed staff regarding the care of her biliary tube. It was their expectation a nurse would come to them if they did not understand how to do a procedure. *They were aware the resident had told her family the nurses had not touched her biliary tube the whole time she was in the facility. The resident had not told them the nurses had not been flushing the tube, but they had not interviewed her since she was in the hospital. *They confirmed the documentation on the tube output shift was not complete as addressed above. *The physician had not been notified when pharmacy was unable to supply the Intradry and should have been. The pharmacy had told them it was back-ordered. *They had not notified the physician they did not have respiratory services and were unable to complete the evaluation ordered on [DATE]. *The resident's primary physician was on vacation during 10/22/14 through 10/27/14, and the medical director (on-call physician for her doctor) saw her on 10/23/14. He discontinued her [MEDICATION NAME] due to her allergy. Another antibiotic was not ordered. No one informed the doctor in the out-of-town hospital that ordered the [MEDICATION NAME] if another antibiotic should be given in place of the [MEDICATION NAME] or that her local doctor had discontinued the [MEDICATION NAME]. *They were unsure why it was documented on 10/26/14 her oxygen saturation was 90% on room air. The physician's orders [REDACTED]. *They confirmed no daily weight had been documented as it had not been done on 10/24/14. They were not aware of the 4.1 lb increase in weight from 10/25/14 to 10/26/14. According to the 10/22/14 admission orders [REDACTED]. *They confirmed the blood pressure on 10/26/14 was significantly lower than her previous blood pressure readings. *Her temperature was elevated on 10/26/14 to 100.5 degrees F., and the physician should have been notified then according to the 10/22/14 physician's orders [REDACTED]. There was no documentation another temperature had been taken until the morning of 10/27/14 when it was elevated to 101.6 degrees F., and she was sent to the emergency room . *They confirmed no skin monitoring had not been documented on 10/24/14. *They had not reviewed the 10/22/14 through 10/26/24 MARs and were not aware of the discrepancy between what was dispensed by the pharmacy, what was documented as administered, and what had been destroyed or returned to the pharmacy. They had no explanation regarding the discrepancies. *They had no reason to doubt any of the interviews the nurses had provided them for the investigation. They did confirm there were gaps in the documentation they had not identified or seen as a problem during their investigation. *They did not think the medical director had been informed of the gaps in documentation or of the medication discrepancies. *No disciplinary action had been taken regarding any of the nurses. Interview on 11/5/14 at 2:55 p.m. with LPN G regarding resident 1 revealed she had: *Worked on 10/23/14 from 6:00 p.m. to 6:00 a.m. with her. She had "swapped shifts" with an RN. *Received no inservice training on the biliary tube and was not sure it was within her scope of practice to flush the tube. She had not worked with that type of tube before. *No problems when she had flushed the tube. *Checked in her admission medications from the pharmacy that night. *Assisted the resident to the bathroom after she had administered her oral pain medications. Phone interview on 11/5/14 at 3:10 p.m. with resident 1's primary physician revealed: *He and the medical director were in the same clinic. *The medical director had been covering for him during 10/22/14 through 10/27/14 as he was on vacation. *He was not aware of any of the medication discrepancies or lapses in documentation. *He was sure the medical director would have informed him if he had been made aware by the facility. Interview on 11/5/14 at 3:30 p.m. with RN D regarding resident 1 revealed she: *Had worked with her on 10/23/14. *Had faxed the pharmacy on 10/22/14 at 1:00 p.m. with the resident's list of admission medications. *Said the resident had told her the [MEDICATION NAME] shots were not as effective for pain control as the pills. *Had used blood pressure medications from another resident, so resident 1 could receive them on 10/23/14. *Had felt comfortable with the biliary tube. RN E had gone over it with her prior to her shift as she was not sure what the tube looked like. *Had received no formal inservice training on biliary tubes from the facility prior to caring for the resident. Interview on 11/5/14 at 3:50 p.m. with RN H regarding resident 1 revealed she: *Had worked with her on 10/25/14 and 10/26/14 from 6:00 a.m. to 6:00 p.m. *Had no problem flushing the biliary tube. There was not much drainage, so she did not have to drain it. *Said the CNAs informed her they had been draining the tube. She told them they should not have been draining the tube. Interview on 11/5/14 at 4:25 p.m. with RN E regarding resident 1 revealed: *She had not had any inservice training or education regarding biliary tubes prior to the resident being admitted . *She felt comfortable working with tubes from previous hospital experience. *The hospital had sent the transfer sheet with the resident's medications prior to her being admitted on [DATE] at 5:30 p.m. *RN D had told her she had faxed the transfer sheet with all her medications about 1:00 p.m. *The resident did report her pain at a 7 on a 0 to10 scale upon admission. She thought she had not done the full initial assessment until 9:30 p.m. to 10:00 p.m. on 10/22/14. *When her medications had not arrived from the pharmacy on the first run between 5:00 p.m. and 6:00 p.m. she refaxed the transfer sheet with her medications to the pharmacy. *She called the on-call pharmacist between 9:30 p.m. and 10:00 p.m. on 10/22/14. *She called the on-call physician who was the medical director about 10:30 p.m. on 10/22/14. Since her pain medications had not arrived from the pharmacy he ordered [MEDICATION NAME] to be used from their emergency kit. *She called the on-call pharmacist back about midnight, and she said "I am not going to go to the pharmacy and you will have to wait until morning." *She did not notify the DON or ADON on the night of 10/22/14 of the pharmacy problems obtaining the resident's medications. Most of the medications did not arrive until later in the day on 10/23/14 and caused the resident to miss multiple medications. *She knew RN D had borrowed medications from other residents for as many as she could on 10/23/14 until the resident's medications arrived from the pharmacy. *The resident did express she did not like getting the shot and would have liked to have her oral pain medications. "The shot hurt as she really did not have much muscle to inject the [MEDICATION NAME]." *The DON had not reviewed with her during her investigation interview her weight gain or her elevated fever on 10/26/14. There had been no discussion she should have informed the physician of those symptoms on 10/26/14. *She should have notified the physician on 10/26/14 of her weight gain, her temperature, her decreased blood pressure, and her complaints of "not feeling well." *She had spoken to the resident early in the morning on 10/27/14 while she was doing her abdominal and groin care. Interview on 11/5/14 at 5:10 p.m. with RN F regarding resident 1 revealed she: *Worked with her on 10/23/14. *Had received no specific training for biliary tubes, but she had no problems with flushing the tube. *Had been informed to circle medications on the MAR indicated [REDACTED]. *Had spent three days with the staff development person when she had started on 6/23/14. *Had followed another nurse for about two and one-half days when she had first started, but she really had limited hands-on training. Interview on 11/5/14 at 5:25 p.m. with CNA I regarding resident 1 revealed she: *Had worked with her on 10/22/14, 10/23/14, and 10/24/14. *Had given her a shower on 10/25/14. She had put a plastic bag over the dressing and taped it. *Had emptied the biliary tube bag "whenever it needed it. We usually do things like that." She reported to the nurse on duty the amount of any drainage she had emptied. Phone interview on 11/6/14 at 10:10 a.m. with consultant pharmacist M regarding resident 1 revealed: *The transfer sheet from the hospital with her medications had been faxed from the facility on 10/22/14 at 1:33 p.m. It was a human error the orders were not processed like they should have been. The triage technician had accidently hit a wrong button. When she had hit the curser the orders should have gone to admit but had gone somewhere else. *They had spoken to the triage technician regarding that error. *The first call from the facility regarding the resident came on 10/23/14 at 12:26 a.m. from RN E. RN E called them back at 12:51 a.m. and gave the pharmacist the on-call physician's phone number. *The pharmacist had

Based on record review, interview, and policy review, the provider failed to investigate thoroughly one of one sampled newly admitted resident's (1) adequacy of nursing care. Findings include: 1. Interview on 11/5/14 at 9:35 a.m. with the director of nursing and the assistant director of nursing regarding resident 1 revealed they had: *Interviewed all the nursing staff that had provided care to the resident from 10/22/14 when she had been admitted to 10/27/14 when she had been transferred to the emergency room . *No reason to believe the staff were not being accurate in their interviews regarding her care. *Not identified any lapses in their documentation regarding her daily weights, wound monitoring, or irrigating and emptying the biliary tube. *Not contacted the pharmacy after registered nurse (RN) E had difficulty obtaining her medications. The lapse in receiving her medications from pharmacy caused the resident to miss multiple doses of all her medications. *Not instructed the nursing staff to call the physician from out-of-town who had ordered the antibiotic that the antibiotic needed to be discontinued due to her allergy. She confirmed the resident was not on an antibiotic because of that from 10/22/14 through 10/27/14. *Not identified the discrepancies on the pharmacy return/destroy records for what amount of medications had been dispensed from the pharmacy, what had been documented as administered, and what had been destroyed/returned. *Not instructed the nursing staff to inform the physician of the inability of the pharmacy to provide the Intradry dressing ordered. *Put no other interventions in place regarding teaching of any new procedures for residents after this incident. They were still going to just ask the nurses to inform them if they had any questions about a particular procedure. *Not identified that RN E should have informed the physician on 10/26/14 regarding her weight gain, low blood pressure, and temperature. *Not identified any issues with neglect regarding the resident's care from 10/22/14 through 10/27/14. Refer to F224, finding 1. Review of the provider's 12/11/11 Abuse, Neglect, and Misappropriation of Property Prevention policy revealed: *The facility supports a "Zero Tolerance" for patient abuse, neglect, and/or misappropriation of property. *"Neglect is a failure, through inattentiveness, carelessness, seclusion, or omission, with a reasonable justification, to provide timely, consistent, and safe services, treatment, and care to a resident." *"All incidents will be investigated thoroughly by administration."

Based on observation, record review, interview, and policy review, the provider failed to: *Ensure pain was controlled for one of one sampled resident (3). *Educate nursing staff regarding mobility assistance needed for one of one sampled resident (7) causing mental anguish and anxiety. Findings include: 1. Observation on 11/4/14 from 2:50 p.m. through 3:07 p.m. of resident 3 revealed: *He was laying on his right side in bed in a hospital gown. *His legs were shaking. *He was moaning and mumbling loud enough to be heard in the hallway. *Three unidentified staff had walked by his room and had not checked in on him. *At 3:00 p.m. certified nursing assistant (CNA) I had stood by his door and asked CNA Q who had been walking by if he was okay. -CNA Q stated "Yeah, why?" *Neither CNA had stopped into his room and asked him what he needed. *At 3:07 p.m. the director of housekeeping had stopped into his room and asked him what he needed. *Interview at that time with the director of housekeeping revealed he had requested pain pills. Observation on 11/4/14 at 4:15 p.m. of resident 3 revealed he was resting in bed. His legs were no longer shaking. Observation and interview on 11/4/14 at 4:50 p.m. with resident 3 revealed: *His legs were shaking again. *He was hard to understand but had asked this surveyor for pain pills. *When asked what hurt he replied "my legs." *He put on his call light and asked an unidentified CNA for pain pills. *The unidentified CNA stated she would go tell the nurse and left the room. Interview on 11/4/14 at 4:55 p.m. with registered nurse (RN) R regarding resident 3 revealed: *She was not his nurse, but she had given him as needed (PRN) pain pills ([MEDICATION NAME]-[MEDICATION NAME]) at 3:15 p.m. due to his nurse being on break at that time. *He would have to wait for other pain pills as he had just received some at 3:15 p.m. Observation on 11/4/14 at 5:10 p.m. revealed CNA I had reported to RN H resident 3 was in pain and requesting pain pills. RN H replied "he will have to wait for another pill." She had not gone to check on him at that time. Review of resident 3's 10/21/14 care plan revealed: *He had a [DIAGNOSES REDACTED]. *He had no identified focus area for pain. *There had been one focus area that addressed the restless leg syndrome along with other health concerns. *Interventions for that focus area had included the following: -"Administer medications as ordered by physician. -Monitor and document signs and symptoms of acute disease. -Notify physician as needed. -Obtain and report labs (laboratory test results) as directed by physician." *There had been no non-medication interventions addressed for pain. *Wearing a hospital gown had not been care planned. Review of resident 3's 10/18/14 Minimum Data Set (MDS) assessment revealed: *He had not been on a scheduled pain regimen. *He had received PRN pain medications. *He had not received any non-medication interventions. *At the time of the assessment interview he had stated he was not in pain. *No further questions were asked of him. Review of resident 3's 7/24/14 MDS assessment revealed: *He had not been on a scheduled pain regimen. *He had received PRN pain medications. *He had not received any non-medication interventions. *During the assessment interview he had answered he experienced pain. *The pain he had experienced had been "almost constantly." *It had made it hard for him to sleep through the night. *The pain had limited his day-to-day activities. *He had a pain intensity of eight out of ten (zero would be no pain and ten would be the worst pain). *Review of the care area assessment revealed pain had been identified as an area of concern, but it had not been care planned. Review of resident 3's 11/1/14 through 11/5/14 Medication Administration Record [REDACTED] *He had been on a scheduled medication ([MEDICATION NAME] solution) for "pain in joint, upper arm" since 6/6/14. *He had received the [MEDICATION NAME]-[MEDICATION NAME] PRN pain medication seven times within those five days for leg pain. *On 11/2/14 and 11/3/14 the result of receiving the pain medication had not been documented. *11/4/14 [MEDICATION NAME]-[MEDICATION NAME] had been given at 1515 (3:15 p.m.). *At 1515 (5:15 p.m.) on that same day it had been documented "still asking for pain meds (medication)." *No pain scale or pain assessment had been documented prior to or after administering pain medication those seven times. Review of resident 3's October 2014 MAR indicated [REDACTED] *He had received [MEDICATION NAME]-[MEDICATION NAME] thirty-seven times based on the PRN sheets. *Thirty-six of the thirty-seven times the medication had been given for leg pain. *"Resting, some relief, helped, and effective" had been used to explain if the medication had been effective. *No pain scale or pain assessment had been documented prior to or after administering the pain medication those thirty-six times. Interview on 11/6/14 at 9:00 a.m. with CNA T regarding resident 3 revealed: *If he was in pain he would holler out. *She had not had any instructions on specific non-medication interventions to use with him. *She would attempt to reposition him and then inform the nurse he was in pain. Interview on 11/6/14 at 9:02 a.m. with CNA U regarding resident 3 revealed no one had told her what non-medication interventions to use with him regarding his pain. If he was in pain she would notify the nurse. Interview on 11/6/14 at 9:05 a.m. with MDS coordinator V revealed: *In the last assessment she completed on 10/16/14 he had denied pain. *She reviewed the prior five days of the MARs for PRN pain medication. *She had known he used the PRN pain medication [MEDICATION NAME]-[MEDICATION NAME] four out of the five days. *She had not identified that on the assessment and went by what he said. *She had not care planned pain. Interview on 11/6/14 at 11:15 a.m. with the director of nursing and RN J regarding resident 3 revealed: *Their hope was all residents would deny being in pain, because it was controlled. *Pain assessments should have been completed for each resident even if they denied being in pain. *The MDS coordinator should have identified in the comment section of the MDS pain assessment that he had been taking PRN [MEDICATION NAME]-[MEDICATION NAME]. *Pain should have been addressed on his care plan. *Non-medication interventions should have been identified and attempted. *They stated he preferred to be wearing a hospital gown, and that it should have been care planned. Review of the provider's June 2009 Pain Management policy revealed: *"The management of pain must be a priority for nurses and other personnel who provide care to resident's in pain." *"Persons who are experiencing pain have the right to have their pain relieved to the greatest extent possible." *"A comprehensive nursing assessment includes the subjective description of pain, objective data, and the identified need for psychosocial/spiritual support." *"Nurses will use a standardized scale to periodically assess and document a resident's pain." *"Nurses, along with the interdisciplinary team, develop and implement a plan of care that prevents and alleviates pain as much as possible." *"Nurses intervene to address pain issues before pain becomes severe." *"Nurses initiate non-pharmacological nursing interventions as indicated." *"Pain management requires thorough pain assessment." *"Pain assessment is an on-going process." *"All residents should be assessed for pain with each new complaint of pain." *"Standardized pain tools will be used and shall be appropriate to the condition of the resident." *"A plan of care shall be implemented." *"Both non-pharmacological and pharmacological interventions shall be implemented." Review of the provider's September 2011 Care Plan policy revealed all care plans should include all current acute and chronic conditions for which residents may be receiving medications, treatment, or care for including pain. 2. Interview on 11/4/14 at 4:00 p.m. with resident 7 revealed he: *Had been admitted to the facility on [DATE] from the hospital after left hip surgery. *Was receiving skilled occupational therapy (OT) and physical therapy (PT). *Was planning on returning home when he was discharged . *Felt some of the staff liked him and some of them did not. He based that on some of the staff who liked him pushed him to meals and activities in his wheelchair. The staff that did not like him made him push his own wheelchair. *Said no one had explained to him he should have been pushing his own wheelchair to keep his upper body strength. Review of resident 7's 10/10/14 care plan revealed no documentation regarding if he should be propelling his own wheelchair or if staff were to assist him. Interview on 11/4/14 at 4:45 p.m. with licensed practical nurse (LPN) Minimum Data Set coordinator C regarding resident 7 revealed: *PT would tell them what the resident could or could not do. *His care plan stated "Extensive assistance of one with wheelchair." *She confirmed extensive assistance with wheelchair did not give specific directions to the staff if the resident should be propelling his wheelchair or if they should have been. Extensive assistance usually meant the staff were more highly involved than the resident. *If a resident told them they did not want to do something "We do not push them." Review of resident 7's 10/6/14 care plan summary sheet by LPN C revealed "Wants to know a time for therapy and wants to know ahead of time." Interview on 11/6/14 at 3:30 p.m. with certified occupational therapy assistant S regarding resident 7 revealed: *Nursing had not spoken to OT regarding the wheelchair issue. *They had informed nursing he should have been propelling his own wheelchair as much as he could to maintain his upper body strength. She was unsure who documented that on the care plan. *She would visit with him and explain he should be propelling his wheelchair by himself as much as he was able to.

Based on record review, interview, and policy review, the provider failed to ensure: *Two of seven sampled residents (1 and 4) received laboratory (lab) tests as ordered by the physician. *One of seven sampled residents (5) had physician orders [REDACTED]. *Three of seven sampled residents (1, 3, and 5) had physicians' orders accurately transcribed to their medication administration records (MAR). *One of seven sampled resident's (3) physician was notified of the unavailability of an ordered medication. Findings include: 1. a. Review of resident 1's medical record revealed: A report dated 9/9/13 from an appointment at __________ (specialty clinic) with the following: *Resident 1's lab tests had been stable. *Labs were to have been done twice weekly until her next appointment scheduled for 10/9/13. *Those lab test were to have been done on Mondays and Thursdays. *That order had been signed by a certified nurse practitioner (CNP) from the clinic. *Those orders had not been noted by the provider. A Clinic Referral Form from the provider revealed: *That form had been sent to the clinic for resident 1's appointment on 9/9/13. *There had been physician's orders [REDACTED]. -Those orders stated "twice a week labs Monday/Thursday." *The orders had been signed by a CNP. *Those orders had been noted by registered nurse (RN) B. A fax from the provider that had been sent to resident 1's primary physician on 10/3/13 stated: *The resident had not had any lab work done for one month. *Her last lab tests had been completed while ahe had been hosptalized on [DATE]. *The resident had voiced a concern to RN A and wondered if her physician wanted any lab tests completed. *A physician's orders [REDACTED]. ______(specialty physician) who takes care of the resident's _______(specific illness). -That faxed ordered had been received on 10/4/13. *That order had been noted by RN A on 10/4/13 at 6:00 p.m. *There had been no documentation identified in the resident's medical record that would have indicated RN A had contacted the resident's specialty physician for clarification of lab test orders. Review of the resident 1's nurses notes revealed:*On 10/5/13 she had been more lethargic than usual. *On 10/6/13 she had been very lethargic. *On 10/7/13 at 10:13 a.m. she had been very lethargic and unable to walk by herself. She had a small emesis of white phlegm. *On 10/7/13 at 11:59 a.m. her speciality physician had been contacted, and she had been sent to the emergency room for evaluation. *The resident had then been admitted to the hospital intensive care unit. -Her potassium level had been critically low at 2.4 (normal range 3.7 to 5.0 mmol/L) (mmol/l is millimoles/liter, a measurement for lab tests). Interview with RN B on 10/16/13 at 4:20 p.m. revealed she had not contacted resident 1's specialty physician as ordered by her primary physician. She stated she had not done that, because the resident had an appointment with her specialty physician later in the week. That appointment had been scheduled for five days after 10/4/13. That time frame included a weekend. Interview on 10/16/13 from 4:15 p.m. to 4:45 p.m. with the interim director of nurses revealed: *She would have expected RN A to have followed through with the noting of the physician orders [REDACTED]. *She would have expected RN B to have clarified the primary physician's orders [REDACTED]. *She agreed not completing the ordered lab tests may have contributed to resident 1's need for hospitalization . 1b. Review of resident 4's physician's orders [REDACTED]. *[MEDICATION NAME] level every 3 months (February, May, August, and November). therapeutic drug monitoring. *Fasting blood glucose every three months (February, May, August, and November for abnormal glucose (blood sugar). *Fasting lipid panel annually (November). *Liver function tests every three months (February, May, August, and November). *WBC (white blood count) with differential (w/diff) every four weeks (or 28 days), for therapeutic drug monitoring. Review of the laboratory test results in resident 4's medical record revealed: *The WBC w/diff every four weeks had been completed monthly from November 2012 through September 2013. October had been highlighted on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. *The July 2013 laboratory tests showed the glucose results, the lipid (fat) profile test results, the liver function, and the WBC with diff test results. *The findings related to fasting blood glucose or liver function test results revealed: -None had been done prior to July 2013. -Those lab tests were done in July 2013 instead of in August 2013 as outlined by the physician's orders [REDACTED]. -Those lab tests were not highlighted on the November calendar. *There were no findings of any lab tests completed for the [MEDICATION NAME] levels. Interview with the director of nursing (DON) and the provider's regional nurse consultant at 4:10 p.m. on 10/16/13 revealed: *The provider's nurse had sent a Laboratory Requistion sheet on 9/19/13 for the WBC test for resident 4. *She had written [MEDICATION NAME] in the ICD -signs and symptoms box. *The DON stated their nurse should have written it down on the bottom of the sheet in the Additional Tests box and circled it. *They had received the 9/19/13 test results and only the WBC test had been done. Interview with the DON at 4:50 p.m. on 10/16/13 revealed: *She had called the clinic and had talked with the physician's nurse who did not know anything about the physician's laboratory tests for resident 4 that included [MEDICATION NAME] levels, fasting blood glucose, fasting lipid panel, and liver function tests. *The physician's nurse asked the DON to fax a copy of the those physician's orders [REDACTED]. *She stated they had not done those tests. *The DON stated she did not think the provider was responsible for requesting those laboratory tests as the physician usually ordered them when he made rounds. Interview with the provider's regional nurse consultant at 5:15 p.m. on 10/16/13 revealed: *She confirmed it was the responsibility of the provider to get the laboratory tests appointments completed when the monthly physician orders [REDACTED]. 2. Review of the providers 10/31/12 Standing Order Protocols revealed when a resident had been on [MEDICATION NAME] (medication to strengthen the heart beat) and a diuretic (water pill) the provider was to have drawn a [MEDICATION NAME] level every six months. Resident 5 had been admitted on [DATE]. The physician had ordered [MEDICATION NAME] and [MEDICATION NAME] (water pill) medications. He had been hospitalized in March 2013 with the following noted: *During that hospitalization it had been noted he had a [MEDICATION NAME] level that had been higher than the normal limits. *His [MEDICATION NAME] level had been monitored closely during that hospital stay. He had returned to the provider on 3/19/13. The following was noted: *There had not been clarification sought from the physician as to when the next [MEDICATION NAME] level should have been drawn. Review of resident 5's medical record revealed there had not been a [MEDICATION NAME] level completed during the month of September 2013 as directed by the standing orders that were in his medical record. Interview on 10/16/13 at 4:00 p.m. with the administrator confirmed there had not been clarification as to when the next [MEDICATION NAME] level was to have been drawn. She confirmed the [MEDICATION NAME] level had not been completed in September 2013 as directed by the standing orders. Surveyor: 3.a. Review of resident 1's medical record revealed: *Her August 2013 consolidated physician's orders [REDACTED]. *Her September 2013 consolidated physician's orders [REDACTED]. *Her October 2013 MAR indicated [REDACTED]. Interview on 10/16/13 with the DON revealed she agreed the dosage for resident 1's [MEDICATION NAME] had been incorrect on the resident's September 2013 consolidated physician's orders [REDACTED]. Surveyor: b. Review of the January through March 2013 consolidated physician's orders [REDACTED]. *The resident had been admitted on [DATE]. *The January through March 2013 consolidated physician's orders [REDACTED]. *The January 2013 MAR indicated [REDACTED]. *The February 2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The medication had not been given. *The March 2013 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The medication had not been given. Interview on 10/16/13 at 4:00 p.m. with the administrator confirmed the order should not have been on the February and March consolidated physician's orders [REDACTED]. c. Review of resident 5's medical record revealed: *He had been admitted on [DATE]. *The consolidated sixty day physician's orders [REDACTED]. *Review of the MARs and treatment administration records (TAR) for July through September 2013 revealed the order had not been included. *Review of the nurses notes had not indicated the order had not been discontinued. The record also had not indicated why the order had not been included on the MARs or TARs. Interview on 10/16/13 at 4:00 p.m. with the administrator confirmed the order had not been included on the MARs or TARs 4. Review of the October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. *The MAR indicated [REDACTED]. *The MAR indicated [REDACTED]. *The recording of the administration then had been initialed and circled (indicated not given) for the 11th through the 15th. *Under the circled initials on the 11th it stated "none in cart." *The 12th and 13th under the circled initials it stated "not here." Review of the medical record did not indicate the medication had not been there or had been not given on the dates indicated. The record did not reveal the physician had been notified or the medication had not been given or available. Interview on 10/16/13 at 4:00 p.m. with the administrator confirmed the medications had not been given on the 11th through the 15th. She confirmed the physician had not been notified of the situation. Surveyor: Review of the provider's undated registed nurse job description revealed the RN was to have had: *The ability to priortize tasks. *The ability to focus efforts toward quality resident care. *Excellent oral and written communication skills. *Sound mature judgement. *Completed daily assignments as assigned. *Verified the completion of all required documentation at the end of the assigned shift. *Prepared, administered, assessed effectiveness of, and documented medications, and treatments for each resident is accordance with physician's orders [REDACTED]. *Ordered lab as indicated. *Obtained specimens for lab tests as needed. *Received, transcribed, and carried out physician's orders [REDACTED]. *Demonstrated knowledge of and enforced state and federal regulations. Review of the provider's June 2009 Transciption of Orders policy and procedure did not reveal instructions for transcribling or receiving physician orders [REDACTED]. From: http://legis.state.sd.us/statutes/DisplayStatute.aspx Type=Statute&Statute=36-9-3. 36-9-3. Scope of registered nursing practice. As used in this chapter, the practice of nursing by a registered nurse means the: (1) Nursing [DIAGNOSES REDACTED]. The registered nurse may perform in addition to the foregoing, those acts which require additional education which shall be authorized by the board through its rules.

Based on record review, interview, and policy review, the provider failed to ensure laboratory tests had been completed as ordered by the physician for two of seven sampled residents (1 and 4). Findings include: 1. Review of resident 1's medical record revealed she had not received laboratory tests as ordered by her physician. Refer to F281, finding 1a. 2. Review of resident 4's physician's orders [REDACTED]. Refer to F281, finding 1b.

Based on record review, interview, and policy review, the provider failed to ensure adequate interventions were in place for the prevention of a pressure ulcer for one of three sampled residents (2) with pressure ulcers. Findings include: 1. Review of resident 2's medical record revealed: *An admission date of [DATE]. *On admission she had skin issues on her lower legs and feet from blisters. *A [DIAGNOSES REDACTED]. Review of resident 2's initial Minimum Data Set (MDS) with an assessment reference date of 8/1/12 revealed: *A score of five (severe impairment) on the Brief Interview for Mental Status (BIMS). *Inattention (difficulty focusing attention, easily distracted, or difficulty following what was said). *Disorganized thinking (or incoherent thinking). *A two person assist with a stand lift for any transferring to or from her wheelchair or her bed. *No independent ambulation. A wheelchair was used for mobility. *An extensive assist of two for dressing, hygiene, and bathing. *An extensive assist of one person for eating. *Mobility impairment on both sides of the lower extremities (hip, knee, ankle, and foot). *Frequent bladder incontinence. *Occasional bowel incontinence. *She was at risk for developing pressure ulcers. *A pressure reducing device was used for her bed and for her chair (wheelchair). Review of resident 2's pressure ulcer skin assessment tool (Braden) dated 7/30/12 revealed: *"Responds to verbal commands but cannot always communicate discomfort or need to be turned, or has some sensory impairment which limits ability to feel pain or discomfort in one or two extremities." *"Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected everytime client is moved or turned." *"Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair." *"Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently." *"Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures, or agitation leads to almost constant friction." *Score/Risk was eleven. High risk was a total score from 10 to 12. *The next item on the assessment entitled "Care plan for skin risk updated" had not been checked. Review of the Pressure Ulcer Comprehensive Clinical Risk Assessment 4-11 dated 7/30/12 revealed: *A Braden Pressure Ulcer Risk Score of eleven. The next item listed the Braden score as low. An eleven was high risk. *[DIAGNOSES REDACTED]. *Interventions marked for the high risk for pressure ulcer development were "Perineal care after incontinent episode, barrier cream/ointment to areas exposed to moisture, pressure relieving/reducing mattress on bed and cushion in the wheelchair, keep linens dry and wrinkle free, use lifting sheet or assistive device to decrease friction, weekly skin inspection by licensed staff." Review of resident 2's care plan initiated 7/30/12 revealed: *On 8/3/12 the intervention was noted for a pressure relieving/reducing mattress on the bed and a cushion in the wheelchair. *No other focus, goals, or interventions were noted on the care plan from the above pressure ulcer risk assessment. *Two handwritten focus entries dated "10/12" with goals and interventions were noted regarding a "Potential for skin integrity related to incontinence" and an "Actual skin integrity to coccyx area." *Those goals and interventions included "Skin will be clear and intact through next review, check and change every two hours and as needed, care after each incontinence, and turn and reposition every two hours and as needed. Area will be clear and intact through next review. Dressing changed as ordered from the physician." Review of resident 2's nursing notes revealed: *A registered nurse (RN) note on 9/17/12 at 1:58 p.m. reported by a certified nursing assistant (CNA) a reddened area on the resident's bottom that morning. *An RN note on 9/18/12 at 2:54 p.m. revealed "Resident has a 9 x 9 cm (centimeter) blister area on coccyx. area partially open and is grayish in color. xeroform applied and dr _____ notified. will be out to see her." *An RN note on 9/18/12 at 2:57 p.m. revealed the resident had complained of pain in her feet, legs, and coccyx. No as needed (PRN) pain medication was administered at that time as noted on the September 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *Nursing notes reviewed from 9/17/12 through 9/29/12 noted the resident was incontinent, needed repositioning from staff to relieve pressure to buttock area every two hours, and required a full mechanical lift for transfers with the assist of two staff. Interview on 10/10/12 at 7:50 a.m. with clinical coordinator C revealed resident 2 had a pressure ulcer on her coccyx starting on 9/17/12. A CNA had reported it to the nurse. The coordinator had assessed the ulcer on 9/18/12 as a stage 2, 9 x 9 cm fluid filled blister that was partially open. She agreed the resident was incontinent, diabetic, and had been treated since admission for other skin issues on her feet. She had been responsible for the weekly skin checks on all current skin issues in the north area. The CNAs had been responsible for checking residents' skin during baths and any other times they were assisting the residents. The CNAs should have reported any skin issues to the nurses. Interview on 10/10/12 at 10:55 a.m. with MDS coordinator D revealed no weekly skin checks were documented by licensed nurses if the resident had no skin issues. The CNAs were responsible for reporting to the licensed nurses any resident skin problems. Interview on 10/11/12 at 8:40 a.m. with the administrator and clinical coordinator B revealed: *They had been unsure if any special training was provided to the CNAs regarding assessing for pressure ulcers and other skin conditions. *They agreed any skin problems or pressure ulcer risk should have been noted on the care plan and interventions provided to prevent skin breakdown. *They agreed a 9 x 9 cm, stage 2 pressure ulcer was a large area and might have been noticed earlier. Random interview on 10/11/12 at 9:05 a.m. with a CNA revealed a pamphlet had been given to staff at a meeting regarding pressure ulcers. Resident 2 liked to sit in her recliner chair in her room quite a bit. The CNA had been told resident 2 should not be allowed to sit in the recliner due to a pressure ulcer and should not have been placed on her back in bed. It was observed after that conversation the recliner in the resident's room had no pressure relieving cushion in place. Interview on 10/11/12 at 10:00 a.m. with the director of nursing revealed she: *Agreed the care plan should have reflected the care needed for the resident regarding any skin issues, mobility, and incontinence with specific interventions. *Agreed the reported reddened area one day and the next day the reported 9 x 9 cm pressure ulcer was a big difference in size. *Agreed the resident should have been assessed previously during cares by the CNAs. *Agreed the CNAs were responsible for reporting any skin issues to the nurses. *Was unable to answer why licensed nurses were not doing a weekly skin check on all residents. *The education director had provided training for all new CNAs regarding skin issues. Review of the provider's policy for pressure ulcer prevention dated November 2002 revealed: *"Resident care plans reflect any specific skin care needs." *"Dependent residents will be repositioned to allow for capillary refill." *"Reposition resident to allow for capillary refill." *"Position resident with pillows or pads protecting bony prominence." *"Inspect skin for redness." *"If redness does not readily disappear the turning schedule should be shortened to 1 hour. Charge nurse to notify physician." *"Employ active and passive range of motion exercises to improve circulation." *"Protect bony prominences with cushions and pads."