Every finding on record at Avantara Arrowhead

A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, record review, and policy review, the provider failed to ensure physician's orders were entered in one of one resident's (57) electronic medical record (EMR) and implemented to mitigate that resident's risk for hospitalization. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's 3/16/26 submitted SD DOH FRI final report regarding resident 57 revealed that physician HH's 3/6/26 orders were noted (acknowledged as being read, understood, and entered in resident 57's EMR) by assistant director of nursing (ADON) P on that same date. The orders were not cross-checked by a second nurse per the provider's revised 11/18/25 Following Physician Orders policy. The provider's investigation confirmed that ADON P only noted and entered physician HH's 3/6/26 medication orders for resident 57 and not physician HH's 3/6/26 orders for a head CT and laboratory tests.2. Review of resident 57's EMR revealed physician HH's 3/16/26 Nursing Home Attending Physician Visit progress note stated that on 3/6/26, I [physician HH] ordered laboratory tests [for resident 57]. I [physician HH] also ordered a head CT scan because she [resident 57] had fallen the week before and hit her head. She [resident 57] is on anticoagulation [a blood-thinning medication]. Unfortunately, these orders were not entered at the nursing facility.After physician HH's examination of resident 57 on 3/16/26, the physician ordered the resident's transfer to the local emergency department related to her general decline: loose stools, hallucinations (a false sensory perception that feels real), lethargy (severe physical and mental sluggishness), and malaise (a vague feeling of being unwell). She was hospitalized from [DATE] through 3/24/26 for new diagnoses that included acute kidney injury and metabolic acidosis (a condition where the body produces too much acid, or the kidneys are not removing enough of it). An additional diagnosis of paroxysmal atrial fibrillation (episodes of irregular, rapid heartbeats start suddenly) was noted. Resident HH had a cardiac history. 3. Interview on 6/17/26 at 4:15 p.m. with resident 57 regarding her March 2026 hospitalization revealed that she had not felt well for some time before that hospitalization. She was having loose stools, losing weight, and feeling weak. She stated that on 3/16/26, the nursing staff were aware that her symptoms had not improved. The resident's condition was discussed with resident 57's representative, who came to the facility to see the resident. The resident's representative asked that physician HH be contacted to see resident 57 that day, which physician HH did. The resident was transferred to the local emergency department then hospitalized . 4. Interview on 6/17/26 at 5:30 p.m. with ADON P revealed that the above incident investigation and EMR findings were correct. The provider had a check and balance system to ensure accurate physician order entry occurred, but it was not followed by ADON P or the night shift nursing staff on 3/6/26 for resident 57's orders. 5. Interview and record review on 6/22/26 at 3:50 p.m. with regional nurse consultant (RNC) C revealed that the provider's failure to fully implement physician HH's 3/6/26 orders for resident 57 prevented the provider from having an accurate clinical picture of the resident's condition, which could have mitigated the resident's need for emergency care on 3/16/26.6. The disciplinary action, education, interviews, and audits referenced in the provider's 3/16/26 submitted SD DOH FRI were completed and documented. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 6/22/26 after record review revealed the facility had followed their quality assurance process, and on 3/17/26 a quality assurance and performance improvement (QAPI) meeting was held related to this FRI. Former director of nursing (DON) BB completed a corrective action plan with ADON P regarding the incident. Nurse leadership and nursing staff were educated regarding the expectations concerning a resident's change in condition, 24-hour chart checks, follow-up on registered dietitian recommendations, requesting and scheduling resident appointments and entering labs in the EMR. Education regarding pertinent policies and flow sheets accompanied this training. Audits of physician HH's residents' charts were reviewed to ensure that all of the orders the provider had received from the physician in the prior three months were acted upon. All other physicians' orders were also reviewed to verify that their orders were completed and implemented. There were audits of physician progress notes during the provider's daily clinical meeting to ensure any new physician's orders were entered in the EMR and any order follow-up was completed. There were audits to ensure the night shift had signed off on 24-hour chart checks, verified that all new physician's orders were implemented and followed up on, and that there were two nurse signatures to verify new physician order entries.Based on the above information, non-compliance at F684 occurred on 3/6/26, and based on the provider's implemented corrective actions initiated on 3/16/26, for the deficient practice confirmed on 3/6/26, the non-compliance is considered past non-compliance.B. Based on SD DOH FRI, interview, and record review, the provider failed to ensure an outpatient wound care appointment occurred in a timely manner for one of one resident (47) who had a worsening lower extremity wound. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's 3/18/26 submitted SD DOH FRI final report regarding resident 47 revealed that on 3/17/26, physician's assistant (PA) DD was notified by nursing staff that resident 47's foot wound had worsened. Resident 47's 3/12/26 OPWC appointment was canceled due to the provider having transportation issues. The appointment was rescheduled to 3/27/26. PA DD asked the provider to reschedule the appointment to a date earlier than 3/27/26. When PA DD contacted the OPWC clinic, she was told that an earlier appointment for resident 47 was offered to the facility, but it was declined. Former DON BB advised PA DD that there were not enough transport drivers to accommodate all residents' appointments. That prevented resident 47 from being seen in the OPWC clinic any sooner than 3/27/26.Resident 47's OPWC appointment was rescheduled to 3/20/26. 2. Review of resident 47's EMR revealed her diagnoses included diabetes, Charcot arthropathy (a progressive, degenerative condition affecting bones and joints) of the right foot and ankle, prior right foot and bilateral toe amputations, chronic osteomyelitis (a bone or bone marrow infection), obesity, heart disease, and cirrhosis (progressive, irreversible liver disease).She had regularly scheduled OPWC appointments and attended the scheduled May 2026 and June 2026 appointments. 3. Interview on 6/16/26 at 1:15 p.m. with resident 47 revealed she had no current care concerns and no issues regarding her medical appointments. The resident kept herself informed and educated regarding her medical care needs. 4. Interview on 6/16/26 at 2:30 p.m. with registered nurse (RN) T regarding resident appointments revealed the provider's updated appointment process facilitated communication between physicians, facility nursing staff, and the facility's appointment scheduler. The updated process ensured residents' medical appointments were kept and were not unnecessarily canceled. 5. Interview on 6/16/26 at 3:05 p.m. with transportation coordinator EE regarding resident appointments revealed the provider's updated appointment process facilitated communication between physicians, facility nursing staff, and transportation coordinator EE to ensure residents' medical appointments were kept and are not unnecessarily canceled. He was able to collaborate with the drivers in three other sister facilities to accommodate resident appointments if needed. Any medical appointment scheduling barriers were reported to a member of the facility's management team for guidance and resolution.6. Interview and record review on 6/17/26 at 11:15 a.m. with RNC C revealed the disciplinary action, education, interviews, and audits referenced in the provider's 3/18/26 submitted SD DOH FRI were completed and documented. 7. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 6/17/26 after record review revealed the facility had followed their quality assurance process, and a Quality Assurance and Performance Improvement (QAPI) meeting was held to identify the root cause for the provider's system failure related to resident appointments. Former DON BB, medical records coordinator LL, and former transportation coordinator CC, nurse management staff, and nursing staff were educated regarding the expectations for managing resident appointments, resident appointment communication, and notifications regarding resident appointment changes.All residents with OPWC appointments were audited to ensure they were not unnecessarily postponed and were rescheduled in a timely manner when indicated. Resident appointments were reviewed during the provider's morning interdisciplinary team meetings to ensure Appointment Request Forms were completed for resident appointments by nursing staff, and provided to transportation coordinator EE to schedule transport for those resident appointments.The resident appointment calendar form was reviewed and compared to the Daily Transportation Log form to ensure that appointments were completed as scheduled. There was documentation to support a rational reason why any appointment was canceled or rescheduled, and that canceled appointments were appropriately rescheduled.Based on the above information, non-compliance at F684 occurred on 3/12/26, and based on the provider's implemented corrective actions initiated on 3/17/26, for the deficient practice confirmed on 3/17/26, the non-compliance is considered past non-compliance.C. Based on SD DOH FRI, interview, record review, and policy review, the provider failed to ensure one of one resident (55) received prompt incontinence (involuntary urine or bowel leakage) care from one of one CNA (II). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's 3/27/26 FRI revealed that on 3/27/26 at 3:50 p.m. former transportation coordinator CC reported to facility management staff via secure facility email that resident 55 had possibly not been provided incontinence care since earlier that morning. The afternoon of 3/27/26, CNA/registered medication aide (RMA) E was in the resident's room to manage his oxygen tank when she observed resident 55 sitting in his wheelchair. His left pant leg was wet from his groin to his knee. There was a smell of urine in the room. CNA II was responsible for resident 55's care that day and was suspended from working pending an incident investigation. The provider's investigation revealed that resident 55's incontinence brief was last changed on 3/27/26 at approximately noon by CNA II. CNA II stated she was not able to return after that time to check the resident's brief again because she was busy with other residents' care. Resident 55's brief was expected to be checked for incontinence and changed, if needed, every 2 hours according to the provider's Check and Change policy. That had not occurred.2. CNA/RMA E was scheduled to work on 6/22/26, but called out sick and was not able to be interviewed. She was not scheduled to work again until after the survey ended. CNA II has not worked at the facility since 4/2/26. Resident 55 has severe cognitive impairment and was not able to be interviewed.3. Random observations made of resident 55 throughout the survey on 6/16/26, 6/17/26, 6/18/26, and 6/22/26 in the dining room and in the resident's room revealed that the resident's clothing was dry and there was no smell of urine.4. Interview on 6/22/26 at 12:30 p.m. with RNC C revealed caregivers are encouraged and expected to ask for assistance from other caregivers if they are not able to meet residents' care needs. The provider was adequately staffed on 3/27/26 for that to occur.5. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 6/22/26 after record review revealed the facility had followed their quality assurance process, and former transportation coordinator CC and CNA/RMA E were educated regarding notifying a facility manager of a reportable event (unexpected or adverse events) during regular business hours instead of communicating that information via secured electronic mail. All caregivers were educated on the provider's Abuse/Neglect policy at the 4/14/26 All Staff meeting. Five residents were observed each week for four weeks to ensure their incontinence care needs were met in a timely manner. Ten applicable residents were asked if they were checked for incontinence every two hours and assisted with their toileting needs.6. Based on the above information, non-compliance at F684 occurred on 3/27/26, and based on the provider's implemented corrective actions initiated on 3/27/26, for the deficient practice confirmed on 3/27/26, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, and interview, the provider failed to ensure an effective, comprehensive quality assurance and performance improvement (QAPI) program was implemented to track and measure performance; systematically analyze underlying causes of a systemic quality deficiency; develop and implement corrective actions or performance improvement activities; and evaluate the effectiveness of the corrective actions, and to revise those actions as needed.Findings include:1. Review of a 3/20/26 SD DOH FRI revealed that the incident investigation substantiated neglect occurred when the facility failed to provide resident 56 incontinence care. 2. Review of a 3/27/26 SD DOH FRI revealed that the incident investigation substantiated that the facility failed to provide resident 55 incontinence care. 3. Review of a 4/19/26 SD DOH FRI revealed that the incident investigation substantiated that the facility failed to provide resident 37 incontinence care. 4. The provider's corrective action plan for the above FRIs included staff disciplinary action, staff education, and auditing of residents' incontinence care. The same audit tool was used for each of the above FRIs. Five random residents were selected each week. They were observed for incontinence, if their care plan was followed regarding incontinence care, and if the resident reported concerns with their incontinence care.Every audit was marked yes in response to the resident reporting incontinence concerns, but there was no information related to those resident concerns. The Summary of Findings section on each audit was blank. 5. Review of a 6/12/26 SD DOH FRI revealed that the incident investigation substantiated that resident 62's preference to use a bedpan was not accommodated by staff, and the resident was instructed to urinate in her incontinence brief. 6. Review of the above FRIs and interview on 6/18/26 at 12:15 p.m. with regional nurse consultant (RNC) C revealed she thought that the yes response to the audit question regarding whether the resident reported concerns with their incontinence care was answered incorrectly and should have been marked no. RNC C confirmed that the provider failed to, but should have used information from the above FRIs to identify or rule out potential causes for the incontinence care and to provide education to the staff. 7. Review of the provider's April 2026 and May 2026 Quality Assurance and Performance Improvement (QAPI) meeting minutes revealed that the provider initiated a plan to work on specific areas to improve their quality of care, regulatory compliance, and staff morale. The Systems Review section of the minutes included Incident Investigations (State Reported [FRIs] and Internal). Instructions were to Include data analysis, RCA [root cause analysis] [a structured problem-solving process used to identify the underlying reasons behind an issue], and need for PIP [performance improvement plan] [a structured, data-driven framework used to address identified quality concerns or adverse events]/Action Plan. Neither the April 2026 nor the May 2026 QAPI minutes included a data analysis, RCA, or PIP/Action plan information related to the above FRIs. 8. Review of the April 2026 and May 2026 QAPI meeting minutes and interview on 6/22/2026 at 5:30 p.m. with RNC C and assistant administrator B revealed that the minutes failed to identify who was responsible for completing the Incident Investigations portion of the Systems Review Section. There was no documented RCA that identified the underlying cause(s) for the ongoing incidents of untimely and improper incontinence care. QAPI meeting minutes failed to reflect whether the provider's interventions (audits, staff education, and staff disciplinary actions) in response to the above FRIs were monitored or measured to determine their impact on residents' incontinence care or if alternate interventions were warranted. There was no PIP/Action plan related to incontinence care. RNC C and assistant administrator B stated that a QAPI committee should have been formed several months ago to more effectively and efficiently address the incontinence care issue. 9. Review of the provider's undated QAPI Plan revealed the provider will use data at every QAPI Committee to ensure performance measures are meeting QAPI goals. Regarding the section labeled, Feedback, Data Systems, and Monitoring: The primary sources for data collection included incident/event reports (FRIs). Data and its sources will be continuously monitored for accuracy and applicability to performance improvement. It is the responsibility of the QAPI Steering Committee to determine the relevance of data for performance improvement and to examine data for any gaps or discrepancies. Regarding the section labeled, Systemic Analysis and Systematic Action: The Plan-Do-Study-Act (PDSA) process and Root Cause Analysis (RCA) will be used to identify improvement opportunities and to understand how to improve them. The QAPI Steering Committee monitors progress to ensure that interventions or actions are implemented and effective in making and sustaining improvements.

Based on observation, interview, record review, and policy review the provider failed to ensure:*Resident's medication self-administration assessment was completed, and a physician's order was obtained for two of two sampled resident (63 and 43) who was not assessed to determine her ability to safely self-administer her medications or had a physician's order to self-administer those medications.*Resident's medication were not stored in a bedside lockbox for two of two sampled residents (10 and 43) per facility policy and self-administration evaluations. Findings included: 1.Observation and interview on 6/16/26 at 10:30 a.m. with resident 63 in her room revealed she had a small plastic cup containing five pills sitting on her nightstand. Resident 63 stated she was unsure what the medications were for and reported they had been sitting on her nightstand all morning, as she had an upset stomach and had not yet taken her medications. 2. Review of Resident 63's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities). Her Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated her cognition was intact. There was no medication self-administration assessment completed to determine whether she could safely self-administer her medications. There was no physician's order that indicated resident 63 was able to self-administer the medications. 3. Interview on 6/18/26 at 10:09 a.m. with licensed practical nurse (LPN) V, revealed she was in training with registered nurse (RN) T on 6/16/26. She stated she left resident 63's medications on the resident's nightstand on 6/16/26 and reported RN T had told her that, due to resident 63's behaviors in the morning, it was acceptable to leave her medications on her nightstand. LPN V stated she did return to resident 63's room to ensure the medications had been taken but was unsure of the time she returned. She was unaware whether resident 63 had completed a self-administration assessment that would permit medications to be left on her nightstand. 4. Interview on 6/18/26 at 10:23 a.m. with RN T revealed she was training LPN V on 6/16/26. She stated that LPN V was passing medications, and she had told LPN V that resident 63 can be moody in the morning and to be mindful of her approach with the resident. RN T stated she did not tell LPN V to leave the medication on resident 63's nightstand and was unaware the medications had been left there. RN T stated that LPN V did not inform her that resident 63 had not taken her medications, and RN T was not present when LPN V went into resident 63's room to administer them. 5. Interview on 6/18/26 at 10:33 a.m. with regional nurse consultant (RNC) C regarding resident 63's medications revealed she stated that during LPN V's training RN T should have been with LPN V while LPN V was administering medications to the residents. She stated if a resident wants to self-administer medications, staff are expected to follow the provider's policy. 6. Review of the provider's November 2025 Self-Administration of Medications policy revealed The interdisciplinary team will complete an evaluation of the resident's cognitive, physical and visual ability to carry out this responsibility. The facility may require that drug be administered by the nurse until the care planning team has the opportunity to obtain information necessary to make a determination on resident's ability to complete the task. Nursing is to get an order from the clinician for self-administration of medications. 7. Observation and interview on 6/16/26 at 8:47 a.m. in resident 43's room revealed that she had a tube of bacitracin (an antibiotic ointment), a bottle of nystatin powder (an antifungal powder), minoxidil hair spray (for hair growth), ciclopirox nail polish (an antifungal nail polish), and two saltshakers on her nightstand. Resident 43 stated that one of the saltshakers was filled with Gold Bond powder (used to absorb excess moisture) and the other saltshaker was filled with nystatin powder. She used the powders at least twice per day and they were easier to use in the saltshakers. She stated that the nursing staff would apply the nail polish for her every night. Review of resident 43's EMR revealed that she had a 4/10/26 BIMS assessment score of 15, meaning that her cognition was intact. She had a 10/14/25 self-administration of medication evaluation that revealed that she was allowed to self-administer the ciclopirox nail polish. The Gold Bond powder, nystatin powder, minoxidil hair spray, and bacitracin ointment were not listed on her self-administration evaluation. The end of her evaluation stated that resident 43 stores them in her lockbox. Resident 43's 10/15/25 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) included a focus of I have an order for self-medication administration with interventions of confirm and document the medications administered, I will inform the nurse when I need the medication re-ordered, medications will be stored in a lockbox in her room, and medications will be removed from [resident 43]'s room if the order is discontinued by [the] physician. Resident 43's June 2026 electronic medication administration record (eMAR) revealed no documented administrations of the nystatin powder. The eMAR listed the Gold Bond as administered daily. There were no physicians' orders for the bacitracin ointment or the minoxidil hair spray. 8. Observation on 6/22/26 at 12:16 p.m. in resident 10's room revealed a fluticasone inhaler (a corticosteroid used for daily maintenance of lung problems like asthma) on his bedside table. Resident 10 was not in his room, and his roommate was sleeping on his bed. Review of resident 10's EMR revealed that he had a 6/9/26 BIMS assessment score of 15, meaning that his cognition was intact. He had a 1/14/26 self-administration of medication evaluation that revealed that he was allowed to self-administer the fluticasone inhaler once daily. Resident 10's 10/15/26 care plan included a focus of I requested and was assessed as able to safely self-medicate and keep at the bedside in a lockbox. 9. Interview on 6/22/26 at 12:32 p.m. with registered nurse (RN) AA revealed that residents were not allowed to have medications at the bedside and he was not sure if any residents had lockboxes in their rooms to store medications. 10. Interview on 6/22/26 at 3:25 p.m. with regional nurse consultant C revealed that some residents were allowed to keep medications in their rooms if they were stored in a clear box with a combination lock. No medications were allowed to be kept at the bedside. She expected any non-nursing staff to alert nursing staff if they saw medications in a resident's room that were not locked up. 11. Review of the provider's November 2025 Self-Administration of Medications policy revealed that if the resident is deemed capable to self-administer medications, then the drugs will be stored in a locked box in the resident's room. The nursing staff was expected to ask the resident if PRN (as needed) medications were taken as ordered by the physician and recorded on the eMAR at the end of each shift.

A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review, the provider failed to ensure one of one resident (56) was provided timely incontinence (involuntary urine or bowel leakage) care by one of one certified nurse aide (CNA) (KK). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. Review of the provider's 3/20/26 submitted SD DOH FRI final report revealed that on 3/20/26 at 2:45 p.m. at resident 56's medical appointment, it was identified that the resident's incontinence brief was saturated. The appointment was not completed.CNA KK was responsible for resident 56's care that day. The resident required staff to check and change his incontinence brief. According to the SD DOH FRI, resident 56's incontinence brief was last checked at 8:00 a.m. by CNA KK, and the brief was dry.Former medical records coordinator LL transported resident 56 to the above medical appointment. She asked CNA KK to check and change resident 56's incontinence brief before she transported him to his scheduled appointment that afternoon.CNA KK attempted to check resident 56's incontinence brief before the appointment, but he was eating lunch at the time, and the resident declined to be assisted. Instead, he wanted to wait to have his brief changed until after he had eaten. CNA KK did not return after he had eaten to change his brief before he was transported to his appointment that afternoon. Resident 56 was provided prompt incontinence care after he returned to the facility on 3/20/26. Camera footage on 3/20/26 was reviewed by the provider during their investigation, and the above incident was substantiated. 2. Review of resident 56's electronic medical record (EMR) revealed that the nursing staff completed a skin evaluation after the 3/20/26 incident each day after that for 72 hours. No skin concerns were identified related to the 3/20/26 incident. 3. Observation and interview on 6/16/26 at 1:30 p.m. with resident 56 revealed that his appearance was neat and clean. He was unable to recall the 3/20/26 incident. He reported no concerns with the care that was provided to him by the staff.4. Interview and record review on 6/18/26 at 3:15 p.m. with regional nurse consultant (RNC) C revealed that the disciplinary action, interviews, and audits referenced in the provider's 3/20/26 submitted SD DOH FRI were completed and documented. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 6/18/26 after record review revealed the facility had followed their quality assurance process, and all residents CNA KK was assigned to on 3/20/26 were checked for incontinence issues, and incontinence care was provided as needed. CNA KK was terminated from employment on 3/21/26. Beginning on 3/20/26, all caregivers were educated regarding the provider's Abuse/Neglect policy and resident incontinence care and toileting expectations. Ten random residents were interviewed by the provider on 3/23/26 regarding other potential abuse or neglect concerns. Five random residents were observed each week for approximately six weeks to ensure their incontinence care needs were appropriately met. 5. Based on the above information, non-compliance at F600 occurred on 3/20/26, and based on the provider's implemented corrective actions on 3/20/26, for the deficient practice confirmed on 6/18/26, the non-compliance is considered past non-compliance.B. Based on SD DOH FRI, observation, interview, and record review, the provider failed to ensure one of one resident (37) was provided timely incontinence care by one of one CNA (F). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. Review of the provider's 4/19/26 submitted SD DOH FRI final report revealed that before lunch on 4/19/26, CNA/registered medication aide (RMA) E transported resident 37 in her wheelchair to her room. CNA/RMA E observed at that time that resident 37 required assistance with incontinence care. The resident required the assistance of two staff caregivers to complete that care.CNA/RMA E was not able to assist resident 37 with that care because she was responsible for administering medications to the residents on the opposite hall (west hall). CNA/RMA E activated resident 37's call light. CNA/RMA E left the resident's room before the call light was answered. She presumed that CNA F, who was responsible for resident 37's care that day, would answer the call light and assist resident 37.At 6:30 p.m. on 4/19/26, CNA/RMA E and registered nurse (RN) D observed resident 37 in her room. The resident's pants were saturated in urine. CNA/RMA E and RN D provided incontinence care. Resident 37 has severe cognitive impairment, and she was not able to provide any information to the staff regarding her incontinence care.RN D was not able to find CNA F after she and CNA/RMA E provided resident 37's incontinence care to discuss the incident. CNA F failed to respond to attempts by the provider to participate in the incident investigation.CNA F was suspended from working on 4/19/26 pending the outcome of the incident investigation and then terminated from employment. Resident neglect was substantiated by the provider based on their incident investigation. 2. Interview on 6/18/26 at 10:20 a.m. with CNA/RMA E regarding the 4/19/26 incident revealed that she confirmed the information in the above FRI. 3. Interview on 6/18/26 at 10:30 a.m. with CNA G revealed that on 4/19/26, she and CNA F were assigned to provide care to the east hall residents. The staff assignment sheet indicated that CNA F was assigned to resident 37's care that day. Both CNA F and CNA G were expected to communicate with each other throughout their work shift, so if a resident required the assistance of two staff for their ADL care, the second CNA could help. CNA G did not recall CNA F asking for her assistance to provide resident 37's incontinence care during their day shift together on 4/19/26. 4. Interview and record review on 6/18/26 at 3:15 p.m. with RNC C revealed that the disciplinary action, interviews, and audits referenced in the provider's 4/19/26 submitted SD DOH FRI were completed and documented. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 6/18/26 after record review revealed the facility had followed their quality assurance process and suspended, then terminated CNA F based on their investigation findings. Resident 37's skin was assessed by nursing staff on 4/19/26. No new skin findings related to the resident's lack of incontinence care on 4/19/26 were identified. Incontinence care audits were initiated the week of 4/16/26 and continued through the week of 5/9/26 to identify any potential systemic issues related to residents' incontinence care.5. Based on the above information, non-compliance at F600 occurred on 4/19/26, and based on the provider's implemented corrective actions on 4/19/26, for the deficient practice confirmed on 4/19/26, the non-compliance is considered past non-compliance.

A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interview, the provider failed to adhere to professional nursing standards of practice to ensure one of one resident's (99) pain medication was administered according to the physician's order by one of one licensed practical nurse (LPN) (H).This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include: 1. Review of the provider's 5/4/26 SD DOH FRI revealed that during the provider's investigation of a separate, unsubstantiated neglect allegation that involved LPN H, a medication error was identified that occurred on 4/30/26. It was determined that LPN H administered an incorrect dose of pain medication to resident 99. The provider submitted a FRI regarding this incident to the SD DOH because LPN H alleged that insufficient staffing contributed to her making that medication error. 2. Review of resident 99's electronic medical record (EMR) revealed her admission date was 4/30/26 and her discharge date was 5/15/26. The resident's April 2026 medication administration record (MAR) included a physician's order for the resident to receive two hydrocodone-acetaminophen tablets (brand name/Norco, an opioid pain medication) every six hours as needed for pain. LPN H documented on 4/30/26 that she administered resident 99 two Norco tablets as ordered. Each day at the change-of-shifts, the oncoming and off-going nursing staff accounted for the quantity of resident 99's Norco because it was a controlled substance (a medication with a high potential for abuse and severe dependence). LPN H documented on resident 99's 4/30/26 Norco accounting sheet that she administered three Norco tablets to resident 99 and not the two Norco tablets that were prescribed by the resident's physician. During the provider's incident investigation, LPN H confirmed she administered three Norco tablets to resident 99. There was no documentation to support that resident 99 incurred any adverse consequences after she was administered the incorrect pain medication dose on 4/30/26. 3. Review of the provider's posted staffing information for 6/16/26 and 6/17/26 revealed that the staffing ratio aligned with the provider's Facility Assessment (an annual evaluation of the facility's resident population that identifies the needed resources to provide the care and services required by those residents) and facility census of 59 residents. 4. Interview on 6/16/26 at 4:40 p.m. with registered nurse (RN) T revealed that she verbalized no concern with sufficient nurse staffing. The provider maintained a monthly nurse on-call schedule that was posted at the nurses' station. For each day of the month, there was a manager's name and contact number listed. RN T stated that the schedule was referred to as needed for manager support in addressing issues such as staff call-outs. 5. Interview and record review on 6/17/26 at 1:45 p.m. with regional nurse consultant (RNC) C revealed that the disciplinary action, interviews, and audits referenced in the provider's 5/4/26 submitted SD DOH FRI were completed and documented. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 6/17/26 after record review revealed the facility had followed their quality assurance process and completed an audit to ensure the 5/8/26 staffing ratio was in alignment with the Facility Assessment. Completed random resident interviews to ensure that their care needs were being met by the staff. Completed audits to ensure medications are administered per the physician's order, according to the manufacturer's directions, and according to the six rights of medication administration. Completed an additional audit to ensure proper medication accounting, storage, and disposal practices are followed. LPN H's employment with the provider was terminated on 5/4/26 based on the facility's progressive disciplinary action procedure. Based on the above information, non-compliance at F658 occurred on 4/30/26, and based on the provider's implemented corrective actions on 5/4/26, for the deficient practice confirmed on 5/4/26, the non-compliance is considered past non-compliance. B. Based on SD DOH FRI review, record review, interview, and provider's protocol review, the provider failed to ensure that one of one RN (T) completed the required post-incident follow-up documentation in the EMR following a choking incident of one of one sampled resident (66). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's 6/5/26 submitted SD DOH FRI regarding resident 66 revealed that on 6/2/26 resident 66 had aspirated (accidentally inhaling food, liquid, or saliva into the airway or lungs) during the lunch meal. She was served her prescribed mechanical soft diet (individual with chewing or swallowing difficulties) at the assisted dining table with staff supervision. Staff reported that resident 66 began coughing after taking a bite of food. She continued to cough experienced excessive mucus production and noted difficulties spitting out phlegm. Resident 66's provider was notified and the order was given to transport her out to the hospital. Resident 66's power of attorney (POA) was notified of the incident and the order to transport to the hospital, and they declined the hospital transfer. Resident 66 was placed on oxygen, received oral suctioning, and was able to clear the phlegm. She returned to her baseline on 6/2/26. Certified nursing assistant (CNA) U had checked on resident 66 on 6/5/26 at 6:00 p.m. and had found her unresponsive and reported it to RN T. Resident 66 was a do not resuscitate (DNR). The facility's investigation into the incident revealed that RN T was the RN assigned to resident 66 on the day of the incident and then on 6/4/26 and 6/5/26. She had checked resident 66 on 6/5/26 noting the resident appeared fatigued but was able to take her medications from RN T. RN T reported she did not enter any progress notes or assessment documentation into resident 66's EMR for the dates of 6/4/26 or 6/5/26. A review of camera footage identified that the staff obtained vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) of resident 66 multiple times on 6/4/26 and 6/5/26, but those assessments were not documented in her EMR. The facility determined that the staff had followed resident 66's care plan and diet order during the incident. Administrator A educated regional nurse consultant (RNC) C as she was the interim director of nursing (DON) at the time, on ensuring nursing staff were completing 72- hour post incident documentation. The facility educated the nursing leadership on ensuring that the follow-up documentation was occurring per facility protocol for 72-hour monitoring post event. Education was completed for the nurses on Post -Foreign-Body Airway Obstruction checklist, including the 72-hour monitoring. 2. Review of resident 66's EMR confirmed there was no 72-hour post incident documentation per facility's protocol to include the residents vitals on 6/4/26 and 6/5/26. 3. RN T was not available for an interview at time of the survey. 4. Interview on 6/22/26 at 11:29 a.m. with RNC C confirmed she had received education related to ensuring the nursing staff had completed the 72-hour post-incident documentation in the residents EMR. 5. Staff confirmed they received education regarding follow-up documentation per the provider's protocol for 72-hour monitoring post event, and education for nurses on Post Foreign-Body Airway Obstruction checklist, which included 72-hour monitoring. Record review confirmed that staff were educated about the follow-up documentation per the provider's protocol for 72-hour monitoring post-event, and education for Post Foreign-Body Airway Obstruction checklist. 6. Administrator A was not available for an interview at time of the survey. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed onsite on 6/22/26 after record review revealed the facility had followed their quality assurance (QAPI) process regarding 72-hour post incident documentation, education was provided to nursing staff regarding the follow-up documentation per facility protocol, and education on Post Foreign-Body Airway Obstruction checklist. Interviews revealed staff understood the education that was provided regarding those topics, and audits were implemented regarding the 72-hour post-incident documentation and will continue for two months. Based on the above information, non-compliance at F658 occurred on 6/2/26, and based on the provider's implemented corrective actions on 6/17/26, for the deficient practice confirmed on 6/17/26, the non-compliance is considered past non-compliance.

Based on observations, interviews, and policy review, the provider failed to ensure one of five certified nurse aide (CNA) (GG) wiped down a mechanical lift after resident use with disinfectant, two of five CNAs (L and GG) performed hand hygiene after resident cares or before putting on personal protective equipment (PPE), three of five CNAs (U, L, and S) had access to and could state how to use PPE per facility policy, and two of five CNAs (FF and L) maintained clean resident personal hygiene items in two of two sampled whirlpool rooms. Findings include:1. Observation on 6/16/26 at 9:45 a.m. in resident 17's room revealed CNA GG completed a full body lift (a mechanical lift and sling used to lift a person's full body) transfer to weigh resident 17. After the lift was completed, CNA GG moved the mechanical lift to the hallway outside of resident 17's door. She did not perform hand hygiene (cleaning hands with alcohol-based hand sanitizer or washing with soap and water), then went into another resident's room. 2. Observation on 6/17/26 at 4:06 p.m. in the [NAME] hallway soiled laundry room revealed a hopper (a specialized sink flushing device used to rinse soiled items and linens of body fluids). There was a set of reusable rubber gloves sitting on the counter next to that hopper. No other personal protective equipment (PPE) was available in that room or signage for how to properly use that hopper. 3. Interview on 6/17/26 with certified nurse assistant (CNA) U revealed that the facility had two hoppers, one in each resident hallway. She stated that she had never used goggles or face protection while rinsing resident's soiled linens in the hopper before. 4. Interview on 6/17/26 at 1:34 p.m. with CNA FF in the whirlpool room revealed that the facility used stock products for bathing personal hygiene items like shampoo, conditioner, and body wash. Some residents had their own, and their name was written on the bottle with a marker. She stated that some of the travel staff would donate their old, opened containers of body products, and the residents were welcome to use those if they wanted to. CNA FF also stated that if a resident discharged or passed away and they left behind some personal hygiene items, the staff would bring them into the whirlpool room for other residents to use instead of throwing them away. 5. Observation and interview on 6/18/26 at 9:34 a.m. with CNA L in the East hallway soiled utility room revealed that the hoppers were used to rinse off the resident's linens if there was excessive stool or urine on those linens. They were expected to rinse the linens, spray them with a sanitizer spray, put them in a plastic bag, tie that bag at the top, and put it in the soiled laundry container. CNA L could not find the spray that they were expected to use in the room. She stated that most of the traveling staff just used a pair of gloves when the hopper was used, and she thought that everyone was supposed to wear a gown too. She was not sure whether any kind of face protection was expected to be used. Observation of CNA L after the interview revealed that she left the soiled utility room, applied PPE consisting of a gown and gloves, and went into another resident's room without performing hand hygiene. 6. Further interview on 6/22/26 at 12:18 p.m. with CNA L revealed that sometimes staff would offer to run to the store to pick up specific personal hygiene items to be used in the whirlpool rooms, and some of the products were donated. If those bottles of product belonged to a specific resident, then staff would label the bottles with a marker. The facility used Procure Complete Bath as the stock shampoo and body wash. She used a smaller bottle with a pump top for all of the residents who did not have specific hygiene products. When the bottle was empty, she rinsed it out because it gets gross, then refilled it with the Procure Complete Bath. 7. Interview on 6/22/26 at 2:53 p.m. with CNA S revealed that the facility did offer a face mask for staff to use while rinsing soiled linens in the hopper, but she did not believe it was mandatory for staff to use face or eye protection. She thought that wearing a gown was mandatory. She stated that lifts were expected to be wiped down with sanitizer after each use. 8. Interview on 6/22/26 at 3:04 p.m. with regional nurse consultant (RNC) C revealed that staff were expected to perform hand hygiene before and after performing care for residents and using any PPE. She expected common use equipment, such as a mechanical lift, would be sanitized after every resident use. She expected staff to wear PPE, including a face shield, while performing duties that may splash, including rinsing linens in the hopper sink. She expected that the staff would use a new bottle of the stock Procure Complete Bath when the old one was out, that it would be cleaned between residents, and that no opened and unlabeled bottles would be used on residents during their baths. 9. Review of the provider's January 2026 Linen and Laundry Handling policy revealed that staff were expected to don (put on) goggles or a face shield, a mask, a gown, and gloves when there is a possibility of splashing or soiling their clothing. In the protecting employees during [the] sorting process section of the policy. PPE including fluid-resistant gowns or aprons, gloves, and masks/face protection, and hand hygiene facilities shall be made available to personnel who sort laundry/work with soiled laundry. PPE should be worn when handling laundry. 10. Review of the provider's January 2026 Transmission Based Precautions policy revealed that common equipment items should be adequately cleaned and/or disinfected immediately after use and hand hygiene should be completed prior to the don and after the doff (take off) of PPE.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review, the provider failed to ensure that one of one resident's (62) preference for incontinence care was observed by one of one certified nurse aide (CNA) (Y).This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident.Findings include:1. Review of the provider's 6/12/26 submitted SD DOH FRI final report regarding resident 62 revealed that on 6/12/26 at 10:15 p.m., resident 62 advised CNA Z that she needed to use a bedpan to urinate in. Resident 62 stated that earlier that same evening, CNA Y refused to accommodate the resident's request to use a bedpan and was told by CNA Y to urinate in her incontinence brief instead.CNA Z provided resident 62 a bedpan to use per the resident's request. When CNA Z returned to resident 62's room a short time later to check on her, CNA Y was in the resident's room. Resident 62 identified CNA Y as the CNA who, earlier that same evening, denied the resident's request to use a bedpan. CNA Z completed resident 62's continence care. Outside of resident 62's room, CNA Z asked CNA Y about the above incident. CNA Y confirmed that she had not provided resident 62 a bedpan as the resident requested and stated, she [resident 62] should wet her brief instead.CNA Y was suspended on 6/12/26 pending an investigation of the incident. She was terminated from employment on 6/13/26. 2. Review of resident 62's electronic medical record (EMR) revealed that a Skin Evaluation was completed after the above incident occurred. The resident had no new skin concerns. Resident 62's care plan reflected her need for staff to provide a bedpan for her to use when she requested it to preserve her dignity.3. Interview on 6/17/26 at 2:30 p.m. with resident 62 revealed she voiced no concerns regarding her continence care. 4. Interview and record review on 6/22/26 at 3:15 p.m. with regional nurse consultant C revealed the disciplinary action, education, and interviews referenced in the provider's 6/12/26 submitted SD DOH FRI were completed and documented. 5. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 6/22/26 after record review revealed the facility had followed their quality assurance process and educated all caregivers regarding the expectation that all residents will receive necessary staff assistance to ensure their toileting needs are met. Residents are not expected to wet or soil their briefs if the resident has a preference for or uses a specific toileting method, such as a bedpan, urinal, or toilet chair. 6. Based on the above information, non-compliance at F550 occurred on 6/12/26, and based on the provider's implemented corrective actions on 6/12/26, for the deficient practice confirmed on 6/12/26, the non-compliance is considered past non-compliance.

Based on observation, interview, and record review, the provider failed to ensure that services were provided to improve or maintain the range of motion for one of three sampled residents (37), who developed a contracture (a permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff) of her left hand while residing in the facility, did not receive therapy services in the past 12 months, a physician's order was in place for staff to follow regarding resident 37's brace management and use, and the care plan included goals and interventions to address resident 37's left-hand contracture and brace use. Findings include:1. Observation on 6/17/26 at 2:57 p.m. of resident 37 in her room revealed she was awake in bed, nonverbal, but followed with her eyes and smiled. She partially extended her left arm from her side and reached out her hand. This surveyor gently shook her hand and explained why she was there. She was noted to have a left-hand contracture; no brace or washcloth roll was applied to her left hand. 2. Review of resident 37's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 4/2/26 Brief Interview for Mental Status (BIMS) assessment was not completed because she rarely understood others or made herself understood, and a staff interview was conducted, which indicated her cognition was severely impaired. Her diagnoses included moderate intellectual disabilitiy, unspecified pain, and left-hand contracture that developed while at the facility.Review of resident 37's current physician orders revealed that there were no active orders for her left-hand brace, including the management or use of the brace, to include wear schedule, cleaning, tolerance, and monitoring, and showed no physical, occupational, or restorative therapy treatment orders related to her range of motion and contracture of her left hand and brace use. Review of resident 37's therapy records showed that resident 37's most recent therapy rehabilitation referral screening was conducted on 12/24/25, and her most recent restorative program evaluation was conducted on 1/25/23. The 12/24/25 referral documented that resident 37 was not appropriate for therapy intervention, as resident 37 had shown no change since her last therapy. Review of resident 37's June 2026 treatment administration record (TAR) revealed that daily documentation had been completed by nursing staff to clean and apply resident 37's left hand brace each morning and remove the brace at bedtime. Review of resident 37's 4/2/26 Minimum Data Set (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) dated 4/2/26 showed that resident 37 was coded 0 for assistance with a brace or splint, indicating that resident 37 did not receive any restorative nursing brace assistance for at least 15 minutes a day during that 7-day look-back period. This did not match the revised care plan dated 3/19/26, which indicated resident 37 has a palm protector brace that she wore on her left hand due to her hand contracture. Review of resident 37's revised 3/19/26 care plan showed that she wore a palm protector brace on her left hand due to her hand contracture; however, the care plan did not include goals and interventions to maintain her current range of motion or prevent further decline. The care plan did not include resident 37's brace use and management, including wear schedule, cleaning, brace tolerance, or monitoring, and did not include therapy involvement, range of motion interventions, skin monitoring, or positioning specific to resident 37's left-hand contracture and brace. The care plan did not reflect the need for a physician's order for brace use or a plan to monitor effectiveness.3. Interview on 6/16/26 at 2:54 p.m. with physical therapist assistant (PTA) M revealed that there was no restorative program for residents at the facility, and she was unsure when the last active restorative program was in place. 4. Observation on 6/17/26 at 9:09 a.m. in resident 37's room revealed that staff had just completed her morning care. She was dressed and sitting in her wheelchair, and she did not have a brace on her left hand.5. Interview on 6/18/26 at 10:45 a.m. with PTA N revealed that a restorative program for the facility was in progress, and training was being completed for a newly hired employee who will serve as the restorative aide. The facility and therapy departments hoped to start the restorative program the following week, after finalization. PTA N was unable to recall how long the facility had been without a restorative program for the residents and stated, It has been quite a long time. She acknowledged that resident 37 was not receiving physical or occupational therapy and did not know when she had last received those services. 6. Interview on 6/18/26 at 10:49 a.m. with interim director of nursing (IDON) O revealed that she had been at the facility since 6/8/26 and was assisting and coordinating with the therapy department to get the new restorative program up and running by the end of next week. She stated that she was made aware that the facility had no current restorative program when she started, but that a plan was in place. She acknowledged that resident 37 and other residents in the facility could benefit from the restorative program. She was unsure how long the facility had been without a restorative program for the residents. 7. Interview on 6/18/26 at 10:58 a.m. with assistant director of nursing (ADON) P. She revealed she had been employed at the facility since 1/6/26 and stated there had been no restorative program during her time there. She did not know when the facility last offered a restorative program for the residents. 8. Interview on 6/22/26 at 3:09 p.m. with occupational therapist (OT) R revealed that she worked as needed (PRN) in the facility's therapy department and was unsure about resident 37's current therapy service. She stated that she was unaware of resident 37's left-hand contracture, brace use, or management. 9. Observation on 6/22/26 at 3:10 p.m. of resident 37 in her room revealed that she was lying in bed looking at a book, and she did not have a brace on her left hand. 10. Interview on 6/22/26 at 3:28 p.m. with contracted certified nursing assistant (CNA) S revealed that she had been employed by the facility since 4/24/26 as PRN through a staffing agency. She stated, It was not an everyday thing to apply the brace, but we are asked to apply it. She acknowledged that some nurses ask CNAs to apply resident 37's brace in the mornings and that resident 37 is encouraged to wear it and keep it on. Contracted CNA S said that resident 37 allowed staff to apply her brace in the mornings, but at times during the day she would remove it. Staff was to remove the brace at bedtime. 11. Interview on 6/22/26 at 3:40 p.m. with physical therapist (PT) Q revealed that resident 37 was not currently on any therapy services with Physical, occupational, or restorative therapy services related to her left-hand contracture and brace use. She said that resident 37 last received speech therapy on 11/28/25, and that she could not find any current evaluation, plan, or order for physical, occupational, or restorative therapy services for resident 37 in the past 12 months. She acknowledged that resident 37 and other residents in the facility could benefit from a restorative program and was unsure why resident 37 had not been receiving therapy services for her left-hand contracture and brace use to maintain or improve mobility for so long. She stated that the referral and screening process for nurses was unclear and could be improved through better communication between the therapy department and facility leadership, along with clear procedural guidelines. 12. Interview on 6/22/26 at 4:06 p.m. with regional nurse consultant (RNC) C revealed that the facility was currently working on getting a restorative program implemented within the next week to ten days. She stated that a new employee had been hired and was being trained for the restorative aide position, and that the final plans were nearly complete between the therapy departments and leadership. RNC C was unsure when the facility last had a restorative program. She stated that the referral and screening process for therapy services, completed by the facility nurses, was an area needing improvement. She said that the facility identified areas of concern in March 2026 and began discussing them during its morning clinical meetings. She acknowledged that therapy referrals and screenings by the facility nurses had not been identified back in March 2026 as an identified area of concern and had not been addressed during the morning clinical meetings to date. RNC C acknowledged that resident 37 did not have a current physician's order in place for staff to follow regarding her left-hand brace, its management, and use. Resident 37 did not have therapy services provided in the past 12 months to provide range of motion with the contracture that developed while she resided in the facility, and her care plan did not include goals and interventions to address her left-hand contracture and brace use. RNC C expected the facility to have all those areas in place for resident 37 to help maintain her range of motion and prevent an unnecessary decline13. Interviews on 6/22/26 at 6:20 p.m. with CNAs K and L in the east hall revealed that neither CNA was aware that resident 37 had a brace for her left-hand contracture, nor were they aware that some staff were applying the brace in the mornings and removing it at bedtime. CNA K stated that she had been employed as PRN since 8/1/25 and had never seen a brace for resident 37, nor had she applied or removed a brace for her since she began working at the facility. CNA L said she has never seen resident 37 with a brace on her left hand and has never applied or removed one for her. 14. Unable to interview resident 37 due to her cognitive ability and being nonverbal. 15. Administrator A was unavailable for an interview during the survey. 16. The facility was unable to provide an updated therapy services policy, a brace-and-splint use policy, or a range-of-motion policy for review, as requested on 6/22/26 at 4:06 p.m.

Based on observation, interview, record review, policy review, and manufacturer's user guide review, the provider failed to ensure infection control practices were followed for the cleaning of a continuous positive airway pressure (CPAP) machine for one of one sampled resident (34).Findings included:1.Observation and interview on 6/16/26 at 10:46 a.m. of resident 34 in his room revealed there was a CPAP machine on top of his nightstand. The water chamber remained connected to the CPAP machine and contained water. After removing the water chamber, a dried white film was visible on the interior and exterior sides and the back area where the water chamber connects to the CPAP machine. The CPAP housing where the water chamber inserts into it had brown spots and dried white film on the bottom and a portion of the sides. The filter located at the back of the CPAP machine was dark brown.Resident 34 stated the staff were not cleaning the CPAP machine or water chamber daily or weekly. He also stated the staff had not changed the filter in the back of the CPAP. 2. Review of resident 34's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His diagnosis was obstructive sleep apnea (where the throat muscles relax during sleep, blocking the airway and causing pauses in breathing). His Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated his cognition was moderately impaired. He had a 4/13/26 physician's order for, CPAP: Clean CPAP tubing and water reservoir with warm and mild soap weekly and allow to dry everyday shift for CPAP cleaning and a 4/14/26 physician's order for, Clean CPAP weekly every evening shift every 7 day(s) for Apnea.The treatment administration record (TAR) showed staff had been documenting they had been cleaning the CPAP machine and water chamber daily and every seven days. 3. Interview on 6/16/26 at 3:45 p.m. with certified nursing assistant (CNA) W revealed she did not clean resident 34's CPAP machine. She stated she was the CNA that was responsible for getting resident 34 up in the mornings and believed night-shift staff were responsible for cleaning the CPAP machine. She agreed the CPAP machine and the water chamber did not appear clean. She was unaware there was a filter located at the back of the CPAP machine that needed to be cleaned. 4. Interviewed on 6/16/26 at 3:55 regional nurse consultant (RNC) C, revealed she agreed the CPAP machine and water chamber were not cleaned. She was unaware of the filter located at the back of the CPAP machine. Her expectation was for the staff to follow the provider's policy for CPAP machine cleaning and maintenance. 5. Review of the provider's revised January 2026 CPAP and BiPAP Cleaning policy revealed After each use, the mask/reservoir will be wiped with warm soapy water per manufacturer's instructions, rinsed and placed upside down to dry on a paper towel/clean dry hand towel. The machine should be wiped/cleaned with a disinfectant on at least a weekly basis and as needed. 6. Review of the manufacturer's user guide revealed Daily: Empty the humidifier tub [water chamber] and wipe it thoroughly with a clean disposable cloth. Allow it to dry out of direct sunlight. Weekly: Humidifier tub-in warm water using a mild dishwashing liquid.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interviews, and record review, the provider failed to ensure two of two registered nurses (RN) (D and E) had reported allegations of suspected abuse for two of two sampled residents (1 and 2). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's SD DOH FRI submitted on 12/1/25 at 6:52 p.m. revealed that resident 1 had informed RN E that he had felt the care that was provided by agency-certified nursing assistant (CNA) K was rough. Resident 1 commented to his son, over the phone, about the care that was provided. Administrator A and social services director L had interviewed the resident, and he reported to them that he had pain with the care provided by agency CNA K. RN E had talked to agency CNA K and instructed her to be more careful with resident 1 during his care. Agency CNA K was blocked from picking up any shifts during the investigation. RN E was educated on the reporting of allegations of suspected abuse and neglect. For resident 1's pain control, his provider increased his Tylenol 500 mg to three times a day and increased his hydrocodone-acetaminophen 5-325 mg to twice a day and prn (as needed). 2. Review of resident 1's electronic medical record (EMR) revealed he was admitted on [DATE]. His diagnoses included Parkinson's disease (disorder of the central nervous system), hypertension (high blood pressure), spinal stenosis (narrowing of the spaces within the spine), radiculopathy (pinching of the nerves), low back pain, and a history of falling. His Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated he was moderately cognitively impaired. His care plan revealed he was dependent on bathing, dressing, personal hygiene, oral hygiene, bed mobility and transfers, initiated on 6/14/25.A skin evaluation was completed on 12/1/25 at 6:15 p.m., indicating left dorsal [back] hand dry skin, raised, left forearm dry skin, raised 1 cm [centimeter] x 0.8 cm, left lat [lateral] calf scabbing 2.3 cm x 0.3 cm, left lat shin scab [scabbing] 1cm x0.9, right mid [middle] lat shin yellow bruise 2.1 cm x 1.8 cm, right side nose scab 0.6 cm x 0.2 cm, right upper medial calf yellow bruise 1.3 cm x 1.3 cm. Additional Skin/Treatment Note: Bruising consistent with sit/stand lift when legs rub against shin guard on lift. Scabbing to BLE [bilateral lower extremity] (r/t [related to] scratching. Resident [1] states my skin is dry and itchy3. Interview on 12/9/25 at 4:27 p.m. with resident 1 revealed that he thought agency CNA K was angry and handled him roughly while turning him to his right side. Resident 1 stated that during the turn, he struck the inside of his right ankle against the wall. He said agency CNA K did not talk to him during the care.4. Review of agency CNA K's personnel file revealed her professional certifications or license were current, and her pre-employment background checks identified no areas of concern. She completed abuse and neglect training and resident rights on 3/25/25. She completed training for the turning and repositioning of residents on 11/25/25. 5. Interview on 12/10/25 at 2:06 p.m. with RN E regarding resident 1 revealed that she had gone into his room to give him his morning medication, and he responded to her with that woman. RN E was able to figure out that it was agency CNA K that he was referring to, and he informed her that she was rough during his care. RN E informed resident 1 that she would speak with agency CNA K, and he thanked her and returned to sleep. RN E said she approached agency CNA K regarding allegations of being rough during care with resident 1. Agency CNA K denied the allegations of being rough during care but agreed to go more slowly and be more careful with him during care. RN E confirmed that she did not report the allegations of suspected abuse, but acknowledged she should have reported to management about the suspected abuse towards resident 1. 6. Interview on 12/10/25 at 2:32 p.m. with administrator A revealed she had received a call from resident 1's son stating that resident 1 had commented to him that he was not happy about the care he received from a CNA. Administrator A and social worker director (SSD) L interviewed resident 1, and he stated the CNA seemed angry and was working too fast. Administrator A interviewed agency CNA K, and she denied the allegations of being rough during care. Agency CNA K was blocked from picking up any shift at the facility during the investigation, but has now been unblocked and will have education and training to be completed before her first shift back at the facility.The provider implemented actions to ensure the deficient practice would not recur was confirmed after record review revealed the facility had followed their quality assurance process, 1:1 education was provided to RN E for not reporting suspected abuse and review of the abuse and neglect policy. They had provided education to all the staff on reporting suspected abuse and reviewed the abuse and neglect policy. Resident interviews were conducted, and asked if they felt safe in the facility. Based on the above information, non-compliance at F609 was determined to occur on 12/1/25, and the provider implemented 12/8/25 corrective actions for the deficient practice confirmed on 12/9/25; the non-compliance is considered past non-compliance. 7. Review of the provider's SD DOH FRI submitted on 12/8/25 at 11:55 a.m. revealed that on 12/8/25, during a review of progress notes by management, a progress note was entered by RN D on 12/6/25 that agency CNA M had reported to RN D that resident 2 told agency CNA M she was rough during care. Resident 2 was interviewed, and agency CNA M and RN D were suspended pending investigation, with prompt education on reporting of suspected abuse. Resident 2 had a skin assessment completed on 12/8/25, and all staff education was started on the reporting of allegations of suspected abuse of a resident. 8. Review of resident 2's EMR revealed she was admitted on [DATE]. Her diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), anxiety, weakness, dementia (a group of symptoms affecting memory, thinking, and social abilities), spinal stenosis (narrowing of the spaces within the spine), and low back pain. Her Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated he was moderately cognitively impaired. A skin evaluation was completed on 12/8/25 at 3:05 p.m., indicating, Additional Skin/Treatment Note: Resident skin noted to be intact upon assessment. Previously documented bruising to [the] left upper extremity from [the] dining room table in various stages of healing. Resident has documented edema to [the] bilateral lower extremities, utilizes TED hose daily. 9. Interview on 12/9/25 at 4:00 p.m. with resident 2 revealed she thought agency CNA M had come into her room approximately at 7 a.m. to assist her with incontinent care. Resident 2 stated that during the care, agency CNA M grabbed her around her chest and flipped her to her right side. She stated she has significant arthritis in her shoulders and experienced pain during the transfer. Resident 2 informed agency CNA M that the transfer hurt, and she was being rough. Resident 2 stated that agency CNA M slowed down her pace and completed the care before repositioning her back onto the bed and onto her back. Resident 2 reported that agency CNA M did not offer pain medication or ask whether she was having any pain. 10. Review of agency CNA M personnel file revealed her professional certifications or license were current, and her pre-employment background checks identified no areas of concern. She completed abuse and neglect training and resident rights on 11/17/25. She completed training on the turning and repositioning of residents on 12/4/25. 11. Interview on 12/10/25 at 9:07 a.m. with RN D revealed that agency CNA M informed her that resident 2 had reported that agency CNA M was rough with her during the care. RN D checked on resident 2 approximately 15 minutes later and she was sleeping. She documented the information in a progress note, but had not realized that the statement was an allegation of abuse and required reporting. RN D acknowledged that she should have informed management of the resident's report. 12. Interview on 12/10/25 at 9:15 a.m. with administrator A and director of nursing (DON) C revealed that they were reviewing daily progress notes when they found the documentation from RN D alleging that agency CNA M was rough during care with resident 2. They suspended both agency CNA M and RN D on 12/8/25 and reinstated RN D after education was provided to her on reporting of an allegation of suspected abuse of a resident. The provider implemented actions to ensure the deficient practice does not recur and was confirmed after record review revealed the facility had followed their quality assurance process, 1:1 education was provided to RN D for not reporting allegations of suspected abuse. Review of the abuse and neglect policy, and education to all staff on reporting suspected abuse and review of the abuse and neglect policy. Resident interviews were conducted, and asked if they felt safe in the facility. Based on the above information, non-compliance at F609 was determined to occur on 12/6/25, and the provider implemented 12/8/25 corrective actions for the deficient practice confirmed on 12/9/25; the non-compliance is considered past non-compliance.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review, the provider failed to ensure:*One of one agency certified nursing assistant (CNA) (O) followed the care plan regarding cares in pairs for one of one sampled resident (3).*One of one CNA (G) followed the care plan regarding the correct transfer device for one of one sampled resident (4), which resulted in a fall. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:Review of the provider's SD DOH FRI submitted on 11/14/25 at 7:30 a.m. revealed that resident 3 indicated she was touched inappropriately by agency CNA O earlier that morning on 11/14/25. Assistant director of nursing (ADON) P assessed resident 3 following the allegation. Review of resident 3's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) showed she was cares in pairs due to embellishing/fabricating stories. Resident 3 also has a pear emblem on her name plate to alert staff she was a cares in pairs resident. Resident 3's care sheet (a report of the resident's care needs and interventions) was reviewed, and it indicated she was cares in pairs (needs two staff members present). Immediately following the allegation agency CNA O was blocked from picking up future shifts at the facility. Staff were educated on cares in pairs procedures, and random audits were initiated to ensure compliance. The facility did not send resident 3 to the emergency department for a sexual assault evaluation; instead, a UA (urinalysis) was ordered and returned normal. A monitoring order was implemented to address resident 3's psychosocial needs. She was currently seen by a Mental Health Provider every two weeks. 2. Review of resident 3's electronic medical record (EMR) revealed she was admitted on [DATE]. Her diagnoses included ataxic cerebral palsy (affecting balance and coordination, causing unsteady, jerky movements, wide-legged walking, and difficulty with fine motor skills due to damage to the cerebellum), delusional disorder, major depressive disorder, and epilepsy (a brain disorder causing recurrent seizures). Her Brief Interview for Mental Status (BIMS) assessment score was 15, indicating she was cognitively intact. A skin evaluation progress note on 11/14/25 indicated, No concerns noted to any area. Physical exam completed with another CNA. Resident gave permission. Completed by Nurse supervisor/LPN N. Skin evaluations completed on 11/15/25, 11/22/25, 11/29/25, and 12/5/29 indicated no skin concerns. Review of resident 3's 12/2/25 care plan indicated she was cares in pairs. for oral care, toileting hygiene, transfer, bathing, personal hygiene, and bed mobility, which was initiated on 6/17/2025. 3. The care sheet dated 11/13/25 indicated resident 3 was cares in pairs. 4. Interview on 12/9/25 at 2:15 p.m. with resident 3 revealed that she stated agency CNA O had touched her on her bottom. Resident 3 stated that she was aware that agency CNA O would not be returning to the facility, and that she had felt safe in the facility since that night of the incident. 5. Review of agency CNA O's personnel file revealed his professional certifications or license were current, and his pre-employment background checks identified no areas of concern. He completed trainings on abuse and neglect on 4/2/25 and resident rights on 4/3/25. He completed proper repositioning training and Cares in Pairs training on 11/12/25. 6. Interview on 12/9/25 at 2:25 p.m. with DON C revealed she had seen resident 3 approximately two hours later, after the allegation was made, to obtain the urine specimen. She reported that she had not observed any bruising on resident 3, and the resident did not report any pain. 7. Interview on 12/9/25 at 3:35 p.m. with administrator A revealed she reviewed the camera footage from the night of 11/14/25. She observed agency CNA O working in the hallway and entering and exiting multiple resident rooms while providing care. Administrator A indicated that nothing unusual was noted on the footage and that agency CNA O did not spend any additional or unusual amount of time in resident 3's room. Administrator A confirmed that resident 3 was cares with pairs and agency CNA O should have had another staff member present when providing cares for resident 3. The provider implemented actions to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, audits were started to monitor her cares with pairs and updated her care plan to reflect the audits. A monitoring order has been put in place for resident 3 for psychosocial issues. Staff and residents were interviewed and asked if they had any issues and if they felt safe. Education was provided to all staff on cares with pairs. and education will be continued with all staff on how to follow a resident's care plan and care sheets.Based on the above information, non-compliance at F684 was determined to occur on 11/14/25, and the provider implemented 12/1/25 corrective actions for the deficient practice confirmed on 12/9/25; the non-compliance is considered past non-compliance. 8. Review of the provider's SD DOH FRI submitted on 11/24/25 revealed that resident 4 sustained a fall during a transfer by CNA G while using a gait belt. Review of resident 4's care plan and care sheet revealed he was a total body mechanical lift with the assistance of two staff members for all transfers. CNA G had asked the occupational therapist (OT) I for clarification on resident 4's transfer a couple of days before the fall, and CNA G believed OT I was informing her that therapy was working with resident 4 on using a total body mechanical lift. CNA G was suspended on 11/24/25 pending investigation and reinstated on 11/24/25 with 1:1 education and corrective action provided. 9. Review of resident 4's electronic medical record (EMR) revealed that he was admitted on [DATE]. His diagnoses are traumatic subarachnoid hemorrhage without loss of consciousness (bleeding in the space around the brain), insomnia, dysphagia (difficulty swallowing food or liquids), depression, hypertension (high blood pressure), and repeated falls. His BIMS assessment score was 0, which indicated he was severely cognitively impaired. A nursing evaluation was completed after the fall on 11/21/25. Vitals were within normal limits, and no additional documentation was noted. A lift evaluation was completed on 11/24/25, and resident 1 continued to require the use of a total body mechanical lift for transfers. Review of resident 3's 11/13/25 care plan, and it indicated he was a total body mechanical lift, which was initiated on 11/17/25. 10. Review of resident 4's care sheet revealed he was a total body mechanical lift. 11. Interview on 12/9/25 at 11:03 a.m. with OT I revealed she was asked by CNA G what resident 4's transfer status was. OT I clarified with physical therapy that he was a total body mechanical lift. OT I then informed CNA G of this, and CNA G responded with ok. OT I stated a random staff member overheard the conversation and confirmed that resident 4's transfer status was a total body mechanical lift. 12. Interview on 12/9/25 at 11:08 a.m. with director of rehabilitation (DOR)/physical therapist assistant (PTA) J revealed that resident 4 had been working in therapy on 2-person transfers to be able to go home. She stated that the nursing staff should have been using a total body mechanical lift. DOR/PTA J stated she had communicated that through their morning meetings and through emails to management to share that on the care sheets. 13. Review of CNA G's personnel file revealed her professional certifications or license were current, and her pre-employment background checks identified no areas of concern. She completed the abuse and neglect and resident rights on 4/28/25 and the mechanical lift training on 10/25/25. 13. CNA G was unavailable for an interview during the survey. 15. Interview on 12/9/25 at 2:24 p.m. with administrator A and DON B revealed they had initially believed the issue was a communication problem. As a result, they decided that therapy staff would make updates to the communication board behind the nurses' station to reflect any changes in transfer status and would complete a form to be submitted to the interdisciplinary team (IDT). Upon further review, they determined that CNA G had not followed resident 4's care sheet. Administrator A and DON B stated that staff education was required to reinforce staff to follow the resident's care plans and care sheets. DON B stated that all staff are required to have a care sheet with them during the shift. The provider implemented actions to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, 1:1 education on following care plans and care sheets, audits for correct transfer, education was provided to all staff on transferring according to the residents' care plans and care sheets, and the updated communication boards from therapy. Based on the above information, non-compliance at F684 was determined to occur on 11/21/25, and the provider implemented 12/5/25 corrective actions for the deficient practice confirmed on 12/9/25; the non-compliance is considered past non-compliance.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), complaint intake form, interview, record review, and policy review, the provider failed to ensure adequate pain management for one of one sampled resident (5) who consistently voiced concerns regarding unmanaged pain and the lack of staff response to her request for pain medication. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the provider's SD DOH FRI submitted on 11/21/25 revealed that resident 5 reported staff members had not assisted her throughout their shift. Resident 5 stated licensed practical nurse (LPN) F refused to assist her with her needs. Resident 5 stated she had long call light wait times. CNA H reported that resident 5's main request was for pain medication, and was upset the staff had not answered her call light immediately. LPN F informed the CNAs to use pairs with care with resident 5 due to her behaviors. Resident 5 continued to be aggressive and have escalated behaviors, and LPN F informed staff to steer clear of resident. LPN F was suspended pending investigation due to inaccurate and subjective charting and not following up on resident concerns. Resident left AMA (against medical advice) on 11/21/25. Other residents were interviewed and asked if they felt safe in the facility, and education was started with LPN F on inaccurate and subjective charting and instructing staff to stop giving care to a resident. 2. Review of the SD DOH complaint intake form revealed that resident 5 stated she did not remain at the facility for 24 hours. She went to the facility for care related to a C2 neck fracture. Resident 5 reported she had not received any pain medications because the medication dispensing machine was not functioning. Resident 5 stated LPN F was outside for more than an hour assisting with someone's car. 3. Review of resident 5's electronic medical record (EMR) revealed she was admitted on [DATE]. Her diagnoses included fracture of C2 vertebra, alcohol abuse, depression, anxiety disorder, insomnia (a common sleep disorder marked by persistent difficulty falling asleep, staying asleep, or getting quality rest, leading to daytime fatigue, irritability, poor concentration, and mood issues), and chronic pain syndrome. A progress note dated 11/20/25 at 3:27 p.m. indicated, At approx. [approximately] 1430 resident arrived to [the] facility via facility transportation in wheelchair from [local hospital]. A&O [alert and orientate] x3, able to make needs known. [Resident 5 was] X2 assist from wheelchair to bed. In stable condition. Has c/o [complaints of] pain and discomfort. Awaiting Rx [prescription] to be sent to pharmacy to get prn [as needed] pain medication from e-kit [emergency kit]. Does yell out ow ow ow when attempting to reposition. When asking what wrong or what pain is she is having, just continue to yell louder.A progress note dated 11/21/25 at 5:45 a.m. indicated, Resident has been rude as well as verbally abusive to all staff tonight, at one point she was yelling from her room after quiet time, we were able to hear her at [the] nurses station. Numerous attempts have been made to accommodate resident [5] even while being verbally battered and threatened by her. Staff has continued to assist or respond to resident in pairs at a minimum, resident [5] just called down to nurses station and this nurse [LPN F] answered, the conversation began with resident [5] raising her voice and threatening me of loosing [losing] my job I asked resident [5] what it is she needed from me and she responded with unclear answers and continued to assume me of doing something wrong yet never did tell me what it was that I have done to upset her. Resident [5] did state she has been waiting for 6 hours. The CNA [H] just reported to this nurse [LPN F] that resident [5] has now taken her neck brace off. I did advice the aide to leave resident [5] to herself at this point, we have been unable to accommodate her, this nurse believes it to be in the best interest of staff currently working to steer clear of resident [5] for safety of all, resident [5] continues to threaten staff.A progress note dated 11/21/25 at 8:46 a.m. indicated, spoke with pharmacy re:[regarding] oxycodone and lyrica, states just received script and will get it sent to facility on this date. This writer [nurse supervisor/LPN N] asks for medications to be stat delivery. Pharmacist states understanding. Pharmacist entered code in e-kit for staff to pull x1 oxycodone 5mg [milligrams] to administer to resident. This writer pulled oxycodone 5mg from e-kit and gave it to the floor nurse for administration.A progress note dated 11/21/25 at 9:00 a.m. indicated, oxycodone HCI oral Tablet 5Mg Give 1 tablet by mouth every 4 hours as needed for pain for 3 days.A progress note dated 11/21/25 at 1:32 p.m. indicated discharge summary, SSD [social services director [L] met with resident this morning after being told by the floor nurse that resident [5] was requesting to leave AMA. SSD [L] spoke to resident [5] and she would not go into detail or explain why she wanted to leave but was still wanting help packing and preparing to leave AMA. Resident [5] was educated by SSD [L] that this would be against medical advice, medication or services would not be set up for her. SSD [L] asked if resident [5] had services or medication at home, resident [5] stated no she did not and would figure it out. Resident [5] expressed her ride coming at 12:30 [p.m.] Residents ride arrived at 12:30. Resident [5] signed out AMA paperwork and was educated by the DON [C]. Resident [5] left AMA at 12:45 p.m. with her ride and all belongings. 4. Review of resident 5's medication administration record (MAR) revealed she had not received her acetaminophen oral tablet 325 MG on 11/20/25. She had received meloxicam oral tablet 15 MG (nonsteroid anti-inflammatory drug used to relieve symptoms of arthritis) on 11/21/25 with a pain score rating of 10, oxyCODONE HCI Oral Tablet 5 MG (used to treat nerve pain) at 9:00 a.m. on 11/21/25 with a pain score rating of 10, and her Pregabalin Oral Capsule 300 MG on 11/21/25. 5. Interview on 12/10/25 at 1:30 p.m. with LPN F revealed that her work shift was from 6:00 p.m. to 6:00 a.m. She reported that upon arrival, CNA H informed her that resident 5 had become upset when staff attempted to assist her to bed. According to CNA H, Resident 5 did not want help but was unsteady and required assistance. After the staff left the room, resident 5 got back up into her wheelchair. LPN F stated she sat with resident 5 for 30-45 minutes, and believed the resident was experiencing anxiety related to her injury. LPN F reported CNA H would notify her that resident 5 wanted to talk to her, which she believed was usually because the resident wanted pain medication. LPN F stated the resident's ordered narcotic pain medication had not arrived, so Tylenol was administered instead. LPN F reported that resident 5 was restless and worked up throughout the night and was not sure if resident 5 had slept at all. She stated she assisted a resident's family with jump-starting their car later that evening, but that had only taken 15 minutes, and occurred after she had already assisted with resident 5. 6. CNA H was unavailable for an interview during the survey. 7. Interview on 12/10/25 at 2:43 p.m. with administrator A and director of nursing (DON) C revealed that the hospital sent resident 5's prescription to the wrong pharmacy. Their overnight on-call provider had mistakenly sent an incorrect prescription to the pharmacy, prompting the pharmacy to contact the provider for clarification. The provider then sent the correct prescription. DON C stated that on 11/21/25 at approximately 7:30 a.m., she and nurse supervisor/LPN N entered the facility and were immediately approached by several individuals regarding concerns about resident 5's medications and her desire to leave AMA. DON C reported that she and nurse supervisor/LPN N separated to determine what was occurring with resident 5's medications and her plan to leave AMA. DON C stated they were able to get resident 5 her medications, but she had decided to leave AMA on 11/21/25. They suspended LPN F for inaccurate and subjective charting, and her instructing the staff to stop providing care to resident 5 pending the investigation, and reinstated LPN F on 11/25/25. DON C stated she reviewed the cameras on the night of 11/20/25, and it was observed that CNA H and LPN F had entered resident 5's room approximately 12 times between the times of 6:00 p.m. and midnight. Review of the provider's Medication Orders Controlled Substance Medication Orders policy revealed:Policy Before a controlled substance medication can be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe them.Procedures Written valid prescriptions for a controlled substance medication may be faxed to the pharmacy from the facility for dispensing and the original hard copy is then sent to the pharmacy following state and federal regulations. Incomplete prescriptions and verbal orders for controlled substances may not be edited or changed by facility nursing staff. Controlled substance medication prescriptions from physician assistants and nurse practitioners, who are authorized to prescribe controlled drugs, are valid if they comply with the requirements and comply with applicable formularies or prescribing protocols that have been provided to the facility by the responsible physician. The provider implemented actions to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, 1:1 education was provided to LPN F for inaccurate and subjective charting, and instructing staff to stop providing care to a resident. Nurses have been verbally confirming with the pharmacy that the correct prescriptions have been sent to the pharmacy for new admissions. Nursing staff assess all new residents for pain upon admission. Audits for pain levels above 7 out of 10, including those for newly admitted residents. New admission audits are completed to monitor and address pain evaluations, skin integrity, and orders to the facility received by the facility. The pharmacist completes an audit the night before each new admission. A 48-hour post-admission audit is conducted that has questions regarding medications matched with admission orders and all medications reconciled and ordered with the appropriate diagnosis. Education was provided to nursing staff on how to notify the physician when they were not able to access the emergency kit (e-kit). Resident interviews were conducted, and asked if they felt safe and free from harm in the facility. Based on the above information, non-compliance at F697 was determined to occur on 11/21/25, and the provider implemented 12/8/25 corrective actions for the deficient practice confirmed on 12/9/25; the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) reviews, interviews, record review, and policy review, the provider failed to ensure the safety of three of eight sampled residents (1, 2, and 3) who had incidents of falls related to equipment use between 9/11/25 and 11/5/25. The manufacturer's instructions and policies for safe use of the resident care equipment had not been followed by the staff. Findings include: 1. Review of a 10/24/25 SD DOH FRI revealed that resident 1 had fallen out of a bath chair in the bathing room. The root cause identified for that fall was certified nurse aide (CNA) C failing to secure the bath chair's safety belt around the resident's waist while the resident was seated in that chair. After bathing the resident, CNA C moved the unsecured resident who was sitting in the bath chair out of the whirlpool bathtub. The resident leaned forward in the bath chair, causing her to fall forward out of the chair and onto the bathing room floor. Resident 1 was transported by emergency medical personnel to the emergency room (ER) for evaluation of her injuries that resulted from that fall. CNA C was suspended from employment during the FRI investigation and then terminated from employment after the investigation was completed for failing to use the bath chair's safety belt to secure resident 1 in the bath chair. 2. Review of CNA C's 10/31/25 witness statement regarding resident 1's 10/24/25 fall revealed: [Resident 1] was not seat belted in [the bath chair]. I was not aware we are suppose to seat belt her in. 3. Review of the provider's 10/21/25 clinical all staff meeting agenda revealed bath aides and certified nurse aides were educated on the following topics related to recent resident falls: *Equipment/device use: per manufacturer's instructions. *Buckle all buckles, strap all straps, hook all hooks. *Always ask questions if something is unclear, always use two people if indicated. Short cuts can hurt the resident as well as the staff member. CNA C had signed the education sign-in sheet confirming that she had received the above education on 10/21/25. That education was three days prior to resident 1's fall on 10/24/25. 4. Interview on 11/4/25 at 2:15 p.m. with registered nurse (RN) D and director of nursing (DON) B regarding resident 1's 10/24/25 fall revealed RN D stated that after CNA C was heard calling for help on 10/24/25 from the bathing room, RN D entered the bathing room and observed resident 1 face down on the floor with her head turned to one side. The amount of blood she observed and the resident's position on the floor made RN D suspect that resident 1 may have sustained a head injury after falling. Resident 1 was making no sound and was not responding. RN E was already in the bathing room when RN D arrived. RN D said that RN E had instructed her to retrieve the vital signs cart. Before RN D exited the bathing room to get the cart, RN D told RN E to stabilize resident 1's head and neck before she was turned onto her back. Resident 1 was on her back when RN D returned to the bathing room with the vitals cart. RN D observed a bleeding laceration on resident 1's forehead. RN D said she had told RN E to complete a neurological evaluation (assessment of nerve function, reflexes, coordination, motor skills, sensation, reflexes, and mental status) of resident 1 in addition to taking her vital signs. RN E then instructed RN D to bring a Hoyer lift (a mechanical lift and sling used to lift a person's full body) to the bathing room. With the uncertainty of the extent of resident 1's injuries, RN D thought the resident should have remained on the floor until emergency medical services (EMS) arrived, but since RN E was managing the accident, she followed RN E's instructions. 5. Telephone interview on 11/4/25 at 2:50 p.m. with RN E on speaker phone and DON B listening regarding resident 1's 10/24/25 fall revealed that upon arrival to the bathing room after the resident's fall, RN E observed resident 1 face down on the floor with her head turned to the side. RN E noticed blood on the floor near the resident's face. She had not known at that time where the blood was coming from. She had not suspected that resident 1 may have injured her head. When RN D entered the bathing room, RN E stated that she asked RN D if a neck brace or a backboard should be used to roll resident 1 onto her back. RN D reportedly told her to use a Hoyer lift to move the resident. After RN E and CNA C rolled resident 1, RN E observed the laceration on the resident's forehead, a bruise to the resident's shoulder, and the resident's nose was bleeding. RN E stated that she suspected resident 1 may have had a head injury at that time. She said RN D shined a light into resident 1's eyes (an evaluation used during a neurological assessment) to determine how or if the resident's eyes had reacted to the light. RN E said RN D conducted this evaluation in both the bathing room and later in the resident's room. RN E said that resident 1 was responding to simple questions and commands at that time. Resident 1 was lifted off the bathing room floor with a Hoyer lift to her wheelchair, then transported to her room until EMS arrived. 6. Review of resident 1's electronic medical record (EMR) revealed a 10/24/25 emergency department After Visit Summary that indicated CT scans (non-invasive medical imaging procedure) of resident 1's head, chest, and back were negative for any acute abnormalities or fractures. A CT scan of her cervical spine (upper portion of the spinal column, consisting of the first seven bones located in her neck) showed C1 and C2 [the first two cervical vertebrae (bones), located at the base of the skull] cervical fractures. Resident 1 returned to the facility on [DATE] after her hospital evaluation. Her discharge instructions indicated she was to wear a neck collar for 12 weeks and follow up in the neurological trauma clinic in about three months with a repeat cervical spine CT scan. 7. Interviews on 11/4/25 at 3:00 p.m. and on 11/5/25 at 4:15 p.m. with DON B regarding resident 1's 10/24/25 fall revealed she agreed: There were significant discrepancies between RN D and RN E's versions of that fall that should have been, but were not, reconciled and followed up on. The above interviews and fall-related documentation failed to support whether resident 1 was appropriately repositioned onto her back by RN E and CNA C. She expected resident 1 to have been made as comfortable as possible by the nursing staff until EMS arrived and the resident should not have been moved out of the bathing room to mitigate the possibility of further injury. Resident 1's cervical fractures had likely occurred when she struck the bathing room floor during the fall, but those injuries could have been made worse by RN E and CNA C repositioning and then transferring the resident with the Hoyer lift into a wheelchair. A copy of resident 1's 10/24/25 neurological evaluation was requested from DON B on 11/4/25 at 3:00 p.m. On 11/5/25 at 4:15 p.m., DON B confirmed there was no documented neurological evaluation completed by nursing staff after resident 1's fall, but there should have been. Review of the provider's undated Fall Check List revealed: Do not move resident if major or life-threatening injury is suspected. Complete [a] neurological assessment (if fall was unwitnessed or [the resident] hit head). All assessment findings must be on paper neuros [neurological forms] and in PCC [Point, Click, Care]. (A type of electronic medical record). Complete [the paper neuros] end of shift. Review of the provider's January 2020 Neurological Evaluation policy revealed neurological evaluations were indicated c. following a fall or other accident/injury involving head trauma; Review of the provider's 2/20/24 Falls Management policy revealed: 7. Perform neurological checks (neuro-checks) per policy for any unwitnessed fall or any fall with evidence of injury to head. 8. Review of a 10/24/25 SD DOH FRI revealed that resident 2 had fallen while he was being transferred in the provider's sit to stand lift (a mechanical lift to help people who have some strength but need assistance to get from a seated position to a standing position) by CNA G. The root cause of the fall was determined to be a failure by the staff to use the leg straps on the sit to stand lift during the resident's transfer. The report indicated that the resident let go of the hand bars while in the lift and slid to the floor. The resident reported hip and leg pain after the fall and was transferred to the hospital for evaluation. 9. Review of resident 2's EMR revealed that he had an x-ray (a noninvasive medical image to check for broken bones) at the hospital that did not show any fractures after the 10/24/25 fall from the sit to stand lift. His 12/30/24 care plan had a focus of I am at risk for falls with the intervention ensure proper use of [the] sit to stand lift. This intervention was resolved and updated on 10/24/25 to I use a total body mechanical lift transfer. 10. Review of the undated CNA G's sit to stand training education revealed that he was watched while performing a lift with the sit to stand mechanical lift. The answer no was checked on the section if sit to stand has straps, affix straps across legs. The action taken section of the training form stated that education was performed with CNA G to clip the leg strap in place with resident transfers in the sit to stand lift. 11. Review of the provider's 2/20/2024 Mechanical Lifts policy revealed staff was to lock the wheels on any device that will receive the patient. They were expected to keep all clips, latches, and hangar bars securely fastened during operation. 12. Interview on 11/5/25 at 11:58 a.m. with DON B revealed she would expect all staff to perform transfers and lifts with the safety straps on and according to the manufacturer's instructions. She had followed CNA G on his first shift working in the facility on 10/22/25 and confirmed that he performed lifts using the sit to stand lift correctly. 13. Review of a 9/12/2025 SD DOH FRI revealed that resident 3 had fallen out of the bath chair in his room on 9/10/25. CNA F had transported resident 3 from the bathing room to his room in the bath chair. She put the call bell on for assistance then left the resident's room to get a mechanical lift from the hallway. Resident 3 was on the floor in front of the bath chair when CNA F returned to his room. The facility investigation determined resident 3 likely leaned forward in the chair causing the fall. He did not have the bath chair seatbelt in place, or the wheels locked. 14. Interview on 11/5/2025 at 2:14 p.m. with CNA F regarding resident 3's fall from the bath chair on 9/10/25 revealed that she was aware that the seatbelt should have been secured in place and the breaks on the lift should have been locked while the resident was sitting in the chair for safety. She had taken the seatbelt off when dressing resident 3 and had not replaced it before she left the room. 15. Interview with assistant DON H revealed that a morning meeting was done Monday through Friday with members of the provider's leadership team. They discussed any new falls including the investigation, root cause, and new interventions that needed to be added to the resident's care plan. She agreed that the care plan for resident 3 was not updated after his 9/10/25 fall as she would have expected. 16. Review of resident 3's EMR revealed that he got a skin tear to the left side of his head when he fell from the bath chair on 9/10/25. Review of the provider's 2/20/2024 Mechanical Lifts policy revealed staff was to lock the wheels on any device that will receive the patient. They were expected to keep all clips, latches, and hangar bars securely fastened during operation. Review of the revised G 10-16-2020 [NAME] Bathing, Safe Operation and Maintenance Manual revealed 9. All residents must always be securely safety belted at the waist when using any of the [NAME] Lift Systems (page 7). Review of the provider's 12/1/19 CNA job description revealed that they were to follow established safety precautions when performing tasks and using equipment and supplies.

Based on record review, interview, and policy review, the provider failed to ensure quality care by not promptly implementing physician-ordered treatments for one of one sampled resident (69) with a physician-ordered negative pressure wound (NPWT) and antibiotic medication treatment. Findings include: 1. Review of resident 69's electronic medical record (EMR) revealed:*Her admission date was 3/25/25.*Her 3/31/25, 7/1/25, and 7/29/25 Brief Interview of Mental Status assessment scores were a 15, which indicated her cognition was intact.*She was hospitalized from [DATE] through 7/23/25 and again from 8/7/25 through 8/22/25.*Hospice (a program for terminally ill individuals that focuses on comfort and symptom management) care was initiated on 8/23/25.*She passed away at the facility on 8/24/25. *Her 3/25/25 admission diagnoses included hemiplegia and hemiparesis (partial paralysis affecting one side of the body) following cerebral infarction (brain tissue death caused by a severe and prolonged lack of blood flow) affecting her left non-dominant side, muscle wasting (the loss of muscle tissue), and atrophy (loss of muscle mass), acute respiratory failure with hypoxia (a serious medical condition where the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to low levels of oxygen in the blood), transient ischemic attack (stroke), cerebral infarction without residual deficits (no lasting impacts), other malaise (a general feeling of discomfort, uneasiness, or lack of well-being), lymphedema (swelling, typically in the arms or legs caused by lymphatic system blockage), neuropathy (a condition that damages nerve function), obstructive sleep apnea (repeated episodes of partial or complete airway collapse during sleep, causing breathing to stop or decrease significantly), peripheral vascular disease (a slow and progressive circulation disorder of narrowing or blocked arteries and veins), chronic kidney disease, (a condition in which the kidneys gradually lose their ability to filter waste products and excess fluid from the blood), type 2 diabetes mellitus (a condition involving disruptions in how the body regulates blood sugar) with hyperglycemia (low blood sugar level), hypothyroidism (the thyroid gland does not produce enough thyroid hormone, which is essential for regulating many bodily functions), morbid (severe) obesity (excessive weight that significantly impacts health and well-being) due to excess calories.*Diagnoses added after her admission included:-On 4/8/25 a venous ulcer of her right lower leg and varicose veins.-On 5/23/25 venous insufficiency (a condition where the veins in the legs do not function properly, leading to poor blood flow back to the heart).-On 7/1/25 a non-pressure chronic ulcer (skin injury) of her left calf with unspecified severity.-On 7/23/25 restless leg syndrome (a common sleep disorder characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations such as tingling, crawling, or pulling), and necrosis of muscle (muscle tissue death).*Her 3/25/25 Braden Scale (a tool used to assess the risk of developing pressure ulcers) score was eleven, which indicated she was at high risk for the development of pressure ulcers (skin wounds caused by prolonged pressure). Resident 69's 3/25/25 nursing admission assessment indicated:*Her ability to walk [was] severely limited or non-existant [non-existent]. [She] Cannot bear [her] own weight and/or must be assisted into [a] chair or wheelchair.*[Her mobility was] Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.*[She required] moderate to maximum [staff] assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. Resident 69's nurse progress notes indicated:*On 3/25/25, she was admitted to the facility. Her left leg was very weak. She had non-pitting edema [observable swelling of body tissues caused by an accumulation of excess fluid] in her bilateral (both) lower legs. There was an open area to the calf of her right leg.*On 3/31/25, a note that included she required total assistance from a staff member for her oral hygiene, toileting, dressing, bed mobility, transfers, and personal hygiene. She was always incontinent (involuntary urine or bowel leakage) of her bladder and bowels. She had a skin treatment on her posterior [back] right leg . Resident 69's 5/7/25 monthly nursing summary indicated the area to document if she had edema was marked Yes and BLE (bilateral lower extremity). There were no other monthly nursing summaries documented in her EMR. A 5/20/25 nurse progress note included, During weekly wound assessment, states has a scratch to left leg. Upon assessment, open area, measuring 3.8cm [centimeter] x [by] 2.3cm. Depth unknow d/t [due to] slough [dead tissue]. Foul odor noted. Scant serosanguineous [wound drainage that is a mixture of clear, watery fluid and blood] drainage noted. Has left sided weakness. Uses sit stand lift [a mechanical lift used to assist from a seated to a standing position] with leg strap. Open area located where sit stand lift leg strap lays against skin. [The resident] States I was told it was a scratch, but my wheelchair is too small for me and my leg rubs against it. They ordered me a new wheelchair, but it's not here yet. Area noted to be in [the] same location on leg where [the] sit stand lift leg strap lays against [the resident's]skin during transfers. Cleansed with NS [normal saline], pat dry, covered with border foam dressing. Review of physical therapy and occupational therapy documentation from 4/16/25 through 7/15/25 did not indicate that resident 69's wheelchair was too small or that a different-sized wheelchair was obtained for the resident. Resident 69's nurse Wound Summary notes regarding her left lateral calf indicated:*On 5/20/25, the wound was unstageable, had light-serous drainage, infection was present, and the measured size was 3.80 cm by 2.30 cm, and the depth was unknown.*On 5/27/25, the clinical stage of resident 69's wound was documented as Full Thickness with light-serosanguineous exudate, infection was present, and the size was 5.40 cm by 3.00 cm, and the depth was unknown.*On 6/17/25, the wound was full thickness with moderate Serosanguineous, infection was present, and the size was 6.40 cm by 4.50 cm by 0.90 cm.*On 7/8/25, the wound was full thickness with moderate Serosanguineous exudate, infection indicated as not present, and the size was 6.90 cm by 3.8 cm with a depth of 1.20 cm.*On 7/15/25, the wound was full thickness, with moderate Serosanguineous exudate, with no infection present, and the size was 6.90 cm by 3.80 cm with a depth of 1.20 cm. On 5/27/25 a nurse progress note included, Left lateral calf [wound] measures 5.4cm x 3cm, depth unknown. On 6/3/25 a nurse progress note included, Left lateral calf [wound] noted with moderate serosanguineous drainage, no odor noted, Measures 6cm by 3 cm, depth unknown.On 6/10/25 a nurse progress note included, Left lat [lateral] calf [wound] measures 5.5cm x 3.5 cm, depth unknown. Foul odor noted. Light serosanguineous drainage noted. DON/RN, MD [medical doctor], RP [representative] aware. Resident 69's hospital wound care team consultation report indicated:-On 7/16/25, after resident 69's admission to emergency room (ER), Patient does have a chronic leg wound, Over the past couple days worsening wound with malodorous [an unpleasant or offensive odor]. Patient received IV [intravenous] vancomycin [antibiotic] and Zosyn [antibiotic] in the ER along with 1 L [liter] LR [Lactated Ringer's solution, a balanced electrolyte replacement] bolus. Exam concerning for left leg 10 [cm] x 6 cm ulcerating wound lateral [side] calf with purulent [containing or producing pus] malodorous drainage. General surgery was consulted and patient was taken to the OR [operating room] for washout [of the wound] directly from the ER.-- NPWT [a treatment that uses suction to remove fluid and debris from wounds to promote healing] placed, and the treatment plan included the NPWT to be at 125 mmHg (millimeters of mercury, a unit of pressure] continuous suction, and to change the NPWT dressing three times each week.--Wound measurement after the surgical procedure was 15 cm by 6 cm with a depth of 3.5 cm. The treatment included a NPWT to her left anterior [near the front], lower leg. Review of resident 69's 7/23/25 physician hospital discharge orders for resident 69's admission to the provider's facility revealed:*New diagnoses on 7/15/25 of obesity, and open leg wound, left, initial encounter, on 7/17/25 Myofasciitis [painful muscle and connective tissue inflammation), and on 7/22/25 of Necrotizing soft tissue infection (serious infection that destroys tissue under the skin).*An order for cefazolin (antibiotic) 2000 mg/20 mL (mg per milliliter) intravenous (IV) push (delivering the drug through an IV line in a small, concentrated amount over a short period) syringe for Necrotizing soft tissue infection, which had an order change handwritten on the form that indicated 2000mg in 100 mL NS IVPB [intravenous piggyback] (delivers medications at set intervals without interrupting the main IV fluid line) per verbal order of resident 69's physician. The discharge form was noted by a nurse on 7/23/25.-The area for information regarding where to get the cefazolin antibiotic IV push syringe was listed as not yet available.*Wound care instructions treatment plan for her left leg included:- Cleanse with Microcyn [wound cleanser] or NS-Picture frame peri wound with skin prep and drape-Contact layer to exposed tendon/muscle-Black foam to wound bed-125 mmHg low continuous suction [NPWT].- Change NPWT dressing three times each week.- Follow up with the wound care outpatient clinic on discharge.--Resident 69's NPWT was placed on her left lower leg on 7/29/25*Resident 69's first dose of the antibiotic, cefazolin, was administered on 7/24/25.- Patient is preparing to discharge to [provider]. Wound vac dressing to right leg removed and wet-to-dry packing placed for transportation. [Provider] will need to place their own wound vac upon admission to their facility.-She had a surgical wound on her left lower leg, which was described as Full thickness, had Serosanguineous drainage, no odor, well defined edges, and her muscle and tendon remain[ed] exposed.-She had a wound to her right calf, that had a scant amount of Serosanguineous drainage, and well-defined edges. A 7/23/25 nurse progress note included, resident returned to facility early pm [evening] . dressing intact on left lower posterior leg. *A 7/23/25 nurse progress note at 10:35 p.m. included, The resident has an order for cefazolin 2000 MG in 20 mL IV push. Order not sent to pharmacy. called [pharmacy] for clarification and request for medication stat [without delay] delivery. Pharmacy unable to provide ordered dose. Called [resident's primary physician] V.O [verbal order] given to change from IV push to IVPB per pharmacy's recommendation. Initial dose pulled from e-kit [emergency kit]. Medication expected to be delivered stat in AM.-That initial dose from the e-kit was given at midnight. A 7/25/25 nurse progress note included, Waiting for wound vac to get to the facility, wet to dry dressings done until wound vac placed. A 7/25/25 nurse progress note included the dressing to her left lower leg was in place. On 7/25/25, a physician order for cefazolin Sodium Intravenous Solution Reconstituted - use 2000 mg intravenously every 8 hours for necrotizing soft tissue infection for 19 days 2 g in 100 mL NS over 30 minutes. On 7/27/25, resident 69's administration documentation for her physician order of metronidazole (antibiotic) 500 mg twice a day for necrotizing soft tissue infection was listed as NN (see nurses' notes). A 7/27/25 nurse progress note included: reached out to provider regarding herbeing [her being] out of b complex-c-folic acid and metronidazole 500 mg . tried calling pharmacy at 20:50 [8:50 p.m.] stayed on hold and finally left [a] message for a call back. A 7/28/25 registered dietitian note included:* Braden score 16 at r4isk; L[left]-lateral calf vascular venous stasis wound and R[right]-lower leg back vascular venous stasis wound; noted edema is 4+ [very deep indentation when pressed] LLE [left lower extremity] especially calf, 3-4+ [deep to very deep indentation when pressed] RLE [right lower extremity].- Weight History-7/23/25 273.4# [pounds] (Current wt [weight])-7/10/25 266.2# (2.63% wt gain)-7/2/25 262.6# (3.95% wt gain)-6/4/25 238.8# (12.66% wt gain - significant)-4/16/25 239.6# (12.36% wt gain - significant)-3/25/25 250# (8.56% wt gain - admit wt)- resident readmit to facility s/p [status post] hospitalization from 7/15/25-7/23/25 for Left leg necrotizing [dying tissue] wound status post extensive operative debridement 7/15/25. A 7/28/25 nurse progress note included that the resident requested to switch to a different primary medical provider, and the resident was switched to a new provider. A 7/29/25 nurse progress note included Weekly wound assessment completed by this nurse. Wound vac in place at this time. A 7/29/25 nurse wound summary included the wound was full thickness, with moderate Serosanguineous exudate, with no infection present, and the size was 6.90 cm by 3.80 cm with a depth of 1.20 cm. An 8/5/25 nurse wound summary note included, the wound was full thickness, with moderate Serosanguineous exudate, with no infection present, and the size was 15.50 cm by 7.00 cm with a depth of 3.30 cm. *There were no documented measurements, after 8/5/25, of resident 69's left lower leg in her nurse wound summary notes. Resident 69's August 2025 medication administration record (MAR) included that a physician ordered treatment to her left leg to change the NPWT dressing three times each week was marked as NN on 8/2/25 and was not documented as completed on 8/5/25. An 8/5/25 nurse progress note included Weekly wound assessment completed by this nurse. Wounds remain stable. Wound vac in place and functioning. Resident 69 was sent to the emergency room on 8/7/25 for a change in condition and returned to the facility on 8/22/25. Resident 69's 8/22/25 hospital discharge summary included:*Diagnoses of: septic shock, recent necrotizing fasciitis, cardiac arrest due to acute hypoxic respiratory failure due to aspiration with successful resuscitation, aspiration pneumonia. An 8/23/25 hospice order included that resident 69 was admitted to hospice care services with a terminal diagnosis of Septic Shock. An 8/24/25 hospice nurse progress note included Resident passed away at 0755 [7:55 a.m.] this morning. 2. Interview on 9/11/25 at 9:25 a.m. and 9:59 a.m. with director of rehab (rehabilitation) I regarding resident 69 revealed:*Regarding resident 69's left leg wound, they had attempted to determine if it was caused by her wheelchair or her use of a sit-to-stand (STS) mechanical lift strap (a strap that goes across the lower calf area to assist in maintaining proper positioning of the person on the STS lift).*They assessed the STS lift strap to determine if it was digging into her calf or if it was from where the foot pedal was attached to her wheelchair.*She did not personally remember any interventions but said she would print all therapy notes for resident 69. *She reviewed resident 69's therapy notes, and reported that therapy had determined that the wheelchair was not the issue that caused the wound on her left leg.*They had determined it was either restless leg syndrome, as her legs rotated outward when she was in bed, or the wound was caused by the STS lift, they were unable to determine the cause.*Therapy did not participate in the residents' wound care.-The facility provided residents' wound care. Interview on 9/11/25 at 2:31 p.m. with infection preventionist (IP)/wound care nurse (WCN) C regarding resident 69 and wound care revealed:*She had been employed at the facility since 6/30/25, and was an IP/WCN for the facility.*She completed wound care rounds on Tuesdays.-She documented wound care in a wound summary or in the resident's progress notes.-Her process was to measure the wound and document that information in the wound rounds (summary).-She had not documented the resident's wound care in the resident's TAR, but she was able to.*She expected that if a resident refused a dressing change or repositioning, it would be documented as a refusal in the resident's TAR or progress notes.*She verified resident 69's left lower leg wound was vascular, and she thought it had started as a scratch.*Resident 69's primary physician had completed rounds (checking on residents' status and assistance needs) and wound care on Tuesday of each week.-He had completed resident 69's wound care on those days prior to her hospitalization on 7/15/25.*Resident 69's significant weight gain would have been a huge concern, her legs would have needed to be elevated, and the edema would have needed to be decreased.*Resident 69's NPWT was to be placed on her lower left leg, after she returned from the hospital on 7/23/25. The NPWT was ordered on 7/24/25 and was received and placed on 7/29/25.*She confirmed resident 69 was without her physician-ordered NPWT from 7/23/25 until 7/29/25, a total of six days.-She confirmed an acceptable amount of time would be 24 hours for a physician-ordered NPWT to be placed on a wound.*She thought the physician was notified that the NPWT was not placed for those days.-She stated resident 69's primary physician was present when the NPWT was put into place on 7/29/25.*Resident 69 had necrosis of muscle (death of muscle tissue).*She was not aware that resident 69's wheelchair was too small for her.-She started working at the facility on 6/30/25 and felt resident 69's wheelchair had been the appropriate size for her at that time.*Regarding CNA documentation for skin alteration, she indicated that when a resident had a skin alteration, the staff member would document Yes instead of No.*Resident 69's surgical wound on her lower left leg was cut open and drained of 4 cm of fluid and infection.*She stated the physician ordered IV medication was started right away.*Resident 69 had not refused care from IP/WCN C.*No staff member had notified IP/WCN C of resident 69 refusing her care. Interview on 9/11/25 at 5:08 p.m. with regional nurse consultant (RNC) L revealed:*She was not familiar with resident 69's physician's order for a NPWT, as she had no direct patient care with her.*Resident 69's IV Push order was changed as the provider had no documented competencies for all of the contracted travel/agency staff LPNs for IV Push administration. The provider would only provide medications [to residents] that everyone can provide.*The provider had no policy regarding the use of a NPWT wound vac for residents who had a physician order for placement of one.-The provider completed an NPWT competency with all nurses.*The provider hired an outside entity to conduct competency training for all nurses for IV push medications. Interview and review of resident 69's nurse progress notes on 9/11/25 at 5:25 p.m. and at 5:30 p.m. with IP/WCN C and RNC L revealed:*There were wet to dry orders [for resident 69's left lower leg wound] until the wound vac [NPWT] arrived on 7/29/25.*IP/WCN confirmed she had documented in resident 69's EMR on 7/25/25 that her left lower leg NPWT was in place and that resident 69 did not have a NPWT on her lower left leg until 7/29/25.-She was unsure why she had documented the NPWT was in place, as it had not been delivered to the provider until 7/29/25. Interview on 9/11/25 at 5:53 p.m. with IP/WCN C revealed:*Resident 69's nurse wound summary measurements from 7/29/25 were documented by herself and those measurements were wrong.*She stated the measurements documented on 8/5/25 were the actual measurements that should have been recorded on 7/29/25.-She knew it was wrong due to the surgical intervention to the wound prior to 7/29/25. 3. Review of the provider's 8/21 IV Push Medication Administration policy revealed:*Purpose-To safely administer small volume IV bolus medications.*Procedure- Consult with IV pharmacist as needed.- Verify medication order. The provider indicated there was no NPWT policy. Review of the provider's 3/13 Training and Knowledge Checklist for V.A.C. Therapy Systems revealed:*Assess wound dimensions, pathology, presence of undermining or tunnels, need for debridement or need for non-adherent layer to protect blood vessels/organs/nerves and measure wound.*Ensure therapy is maintained 22 out of 24 hours. Access therapy history if available.

Based on observation, interview, record review, and policy review the provider failed to identify and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) preventative interventions for residents identified at risk for developing pressure ulcers for:*One of one sampled resident (31) who developed a pressure ulcer to her right heel, left upper buttocks, and left foot.*One of one sampled resident (11) who developed a pressure ulcer to his left lower and left upper buttocks.Findings include:1. Observation and interview on 9/9/25 at 9:22 a.m. with resident 31 in her room revealed:*There was a sign on resident 31's door that indicated she was on enhanced barrier precautions (personal protective equipment, such as gloves and a gown was to be worn with all close contact resident care) (EBP).*She had an air mattress on her bed.*She was lying in bed on her left side.*She had two Prevalon boots (a cushioned boot that floats the heel off the surface of the mattress, to help reduce pressure) on the counter in her room.*Her feet were not elevated off the mattress with the use of pillows or other devices.*She had foam dressings on both of her feet.*When she was admitted to the facility, she had an abrasion on her buttocks that worsened until a wound vac (a medical device used to promote wound healing by applying negative pressure) was used for wound treatment.*She no longer had a wound vac because it became dislodged frequently.*She was able to reposition herself somewhat in bed with the use of her side rails (bar/bars attached to the bed) but often required assistance from staff for complete repositioning.*She stated she often waits a long time for staff to answer her call light when she needed assistance with repositioning.Observation and interview on 9/10/25 at 8:40 a.m. with resident 31 in her room revealed:*She was lying in bed on her left side.*The Prevalon boots were in the same location on her counter as they were on 9/9/25.*Her feet were not elevated off the mattress with the use of pillows or other devices.*She thought her Prevalon boots were missing a part and that was why staff did not put them on her.*There was a gel cushion in her wheelchair.*Resident 31 stated she did not get out of bed as often as she would like to and felt that was due to the staff being busy.*She had difficulty moving her legs when she was in bed because they often got tangled up.Review of resident 31's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had a 7/24/25 Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated her cognition was intact.*She was involved in a motor vehicle crash which resulted in paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs).*She was admitted with pressure ulcers on her left foot and right sacrum (the base of the spine that forms the back wall of the pelvis).*She had pressure ulcers on her right heel, and left buttock area that developed after she was admitted to the facility on [DATE].*Resident 31's 11/5/24 Braden Scale (a tool used to assess the risk of developing pressure ulcers) assessment score was 7, which indicated she was at high risk for developing a pressure ulcer.*The pressure ulcer to her right heel was identified on 12/25/24 as a deep tissue pressure injury (a localized area of tissue damage that occurs when prolonged pressure or shear forces damage the skin and underlying soft tissues) that measured 1.4 centimeters (cm)in length by 1.5 cm in width.*The pressure ulcer to her left buttock area was identified on 1/21/25 as a stage III (3; open wound with full-thickness skin loss. Fatty tissue may be visible) pressure ulcer that measured 4.4 cm in length by 4.5 cm in width by 0.1cm in depth.-On 7/22/25 the pressure ulcer was documented as a stage IV (4; open wound with full-thickness skin and tissue loss. Bone, tendon, or muscle may be visible) pressure ulcer that measured 2.7 cm in width by 3.4 cm in length by 0.6cm in depth.*Review of resident 31's 11/5/25 baseline care plan revealed, a focus area of, I am at risk for impairment to skin integrity r/t [related to] impaired mobility and paraplegia -open wound to.-Resident-specific interventions for that focus area were, Air mattress to bed and w/c [wheelchair] cushion in place and HIGH RISK- skin check every shift. Report abnormalities to the nurse.*Review of resident 31's 9/10/25 care plan revealed a focus area of, I am at risk for impairment to skin integrity r/t impaired mobility and paraplegia -open wound to left medial dorsal [inner top of the] foot -left upper buttocks stage 3 -unstageable to the sacrum -SDTI [suspected deep tissue injury] right plantar aspect [bottom of foot] -SDTI right posterior heel.-Interventions identified related to that focus area in addition to the baseline care plan interventions were:--On 1/7/25 left foot and ankle, two layer wrap in place.--On 1/21/25 I will often refuse to offload [reposition to relieve pressure] and my wound care.--On 3/4/25 Turn and reposition q [every] 2hrs [two hours] per my request -I often refused repositioning when offered -I often request a pillow placed under one side or the other, which doesn't fully offload me.--There were no identified approaches or interventions identified if resident 31 refused repositioning, offloading, or wound care.--On 5/6/25 Double protein for wound healing.Review of resident 31's February 2025 treatment administration record (TAR) revealed:*Wound care to resident 31's right heel was not documented as completed on 2/24/25.*There were no documented resident refusals of the Prevalon boot to right foot to offload every, shift or Offload completely while in bed. Offload sacrum and bilateral feet.-Those were not documented as completed on the evening shift on 2/22/25.*There were no resident refusals documented for, Reposition every two hours to off load.-That was not documented as completed on 2/11/25 at 12:00 p.m. and 2:00 p.m., on 2/20/25 at 2:00 a.m. and 4:00 a.m., on 2/22/25 at 8:00 p.m. and 10:00 p.m., on 2/23/25 at midnight, 2:00 a.m., and 4:00 a.m., and on 2/24/25 at 4:00 p.m.Review of resident 31's April 2025 TAR revealed:*There was no documentation that wound care was completed on resident 31's right heel on the 4/7/25 and 4/29/25 day shift and the evening shifts of 4/8/25, 4/12/25, 4/13/25, 4/16/25, and 4/17/25.Review of resident 31's July 2025 TAR revealed:*There were no documented resident refusals of Reposition every 2 hours to offload.-That was not documented as having been completed on 7/19/25 at 8:00 p.m. and 10:00 p.m., and on 7/20/25 at 4:00 a.m. and 4:00 p.m. 2. Observation and interview on 9/10/25 at 9:24 a.m. with resident 11 in his room revealed:*There was a sign on resident 11's door that indicated he was on EBP.*Resident 11 was sitting in his wheelchair.*He had a cushion in his wheelchair.*He had a stroke, and he was unable to move his left leg without pulling on his pant leg with his right arm.*Resident 11 stated he spent the majority of the day in his wheelchair and only laid down after lunch, so he could take the pressure off his wounds on his buttocks.*He used the side rails to reposition himself in bed.*He had two wounds near the middle of his buttocks that staff had been telling him were improving.*He did not have an air mattress on his bed.*Resident 11 stated he previously had an air mattress, but it would leak air and he would be lying on the springs of the bed.Review of resident 11's EMR revealed:*He was admitted on [DATE].*His diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a nontraumatic intracerebral hemorrhage (a brain bleed) affecting his left non-dominant side and a pressure ulcer of the sacral region.*He had a 7/11/25 BIMS assessment score of 15, which indicted his cognition was intact.*His 3/4/25 admission assessment stated he had no skin alterations, such as a pressure ulcer.*Resident 11's 3/4/25 Braden scale assessment score was 6, which indicated he was at high risk for developing a pressure ulcer.*He had a 4/30/25 physician's order to, avoid prolonged sitting, shift weight every 20-30 [20 to 30] minutes when sitting, and a 5/19/25 physician's order to, Avoid prolonged sitting. Reposition every 15-20 [15 to 20] minutes and Strict offloading by bedrest with HOB [head of bed] lower than 30 degrees with use of pillows. Up for meals only with one hour per meal.*Review of resident 11's 9/10/25 care plan revealed he had a focus area of, I have the potential for impairment to skin integrity r/t impaired mobility that was initiated on 3/5/25 and revised on 8/1/25. -Stage 3 pressure ulcer to left buttock- resolved, -stage 4 [pressure ulcer] to left upper buttock.-3/5/25 interventions for that focus area were, Apply wound treatment as ordered by the physician, Assess for pain and administer pain medication as ordered, observe feedback and notify MD [medical doctor] as necessary, Encourage good nutrition and hydration in order to promote healthier skin, Keep skin clean and dry. Use lotion on dry skin, LOW RISK- Skin weekly. Report abnormalities to the nurse, Monitor/document locations, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc to MD, Off load heels, and Turn and reposition frequently.-Interventions for that focus area that had been added or changed since 3/5/25 were, Immersus [Brand of a pressure redistribution mattress] mattress trial on 6/17/25, and wound healing supplement as ordered on 7/14/25.*Review of resident 11's wound care summary for the pressure ulcer on his left upper buttocks revealed:-That pressure ulcer was identified on 3/15/25.-On 3/18/25 it was documented as Superficial and measured 2 cm in length by 2.5 cm in width by 0.1 cm in depth.-It was documented as unstageable (wound bed not visible due to covering such as debris, dead tissue, scabbing, or a non-removeable dressing) from 4/8/25 through 6/24/25.-On 7/1/25 the pressure ulcer was documented as a stage IV and measured 2 cm by 2 cm with an unknown depth.-On 9/9/25 the left upper buttocks pressure ulcer measured 0.4 cm by 0.3 cm by 0.2 cm.*Review of resident 11's wound care summary reguarding the pressure ulcer on his left lower buttocks revealed:-That pressure ulcer was identified on 3/15/25.-On 3/18/25 it was documented as a stage 3 pressure ulcer that measured 4.2 cm by 2.3 cm with an Unknown depth.-On 7/15/25 the pressure ulcer on resident 11's left lower buttocks was documented as healed.Review of resident 11's March 2025 TAR revealed:*The wound care to resident 11's left upper buttocks was not documented as having been completed on 3/22/25.Review of resident 11's April 2025 TAR revealed:* avoid prolonged sitting, shift weight every 20-30 minutes when sitting was not documented as completed for the evening shifts on 4/12/25, 4/13/25, and 4/17/25.* reposition every two hours when in bed every shift was not documented as completed for the evening shift on 4/8/25, 4/12/25, 4/13/25, and 4/17/25.* Offload left buttocks to aid in wound healing was not documented as completed for the day shift on 4/22/25, and the evening shift on 4/8/25, 4/12/25, 4/13/25, and 4/17/25.Review of resident 11's May TAR revealed:* avoid prolonged sitting, shift weight every 20-30 minutes when sitting was not documented as having been completed for the day shift on 5/17/25 and the evening shift on 5/28/25.* reposition every two hours when in bed every shift was not documented as having been completed for the day shift on 5/17/25 and the evening shift on 5/28/25.* Offload left buttocks to aid in wound healing was not documented as completed for the day shift on 5/17/25, and the evening shift on 5/28/25.Review of resident 11's June 2025 TAR revealed:*The wound care for resident 11's left lower buttocks or left upper buttocks wounds were not documented as completed on 6/26/25.* avoid prolonged sitting, shift weight every 20-30 minutes when sitting was not documented as completed for the day shift on the evening shift on 6/26/25.* Avoid prolonged sitting. Reposition every 15-20 minutes was not documented as completed on the evening shift on 6/26/25.* reposition every two hours when in bed every shift was not documented as completed for the evening shift on 6/26/25.* Strict offloading by bedrest with HOB lower than 30 degrees with use of pillows. Up for meals only with one hour per meal was not documented as completed on the evening of 6/26/25.Review of resident 11's July 2025 TAR revealed:*Wound care for resident 11's pressure ulcer on his left lower buttocks was not documented as completed on 7/7/25.*Wound care for resident 11's pressure ulcer on his left upper buttocks was not documented as completed on 7/7/25 and 7/24/25.* Avoid prolonged sitting. Reposition every 15-20 minutes was not documented as completed on the day shift on 7/7/25 and the evening shift on 7/30/25 and 7/31/25.* Strict offloading by bedrest with HOB lower than 30 degrees with use of pillows. Up for meals only with one hour per meal was not documented as completed on the day shift on 7/7/25 and the evening shift on 7/30/25 and 7/31/25.* reposition every two hours when in bed every shift was not documented as completed for the day shift on 7/7/25 and the evening shift on 7/30/25 and 7/31/25.Review of resident 11's August 2025 TAR revealed:* Avoid prolonged sitting. Reposition every 15-20 minutes was not documented as completed for the evening shift on 8/5/25, 8/9/25, 8/15/25, and 8/25/25.* reposition every two hours when in bed every shift was not documented as completed for the evening shift on 8/5/25, 8/9/25, 8/15/25, and 8/25/25.* Strict offloading by bedrest with HOB lower than 30 degrees with use of pillows. Up for meals only with one hour per meal was not documented as completed on the evening shift on 8/5/25, 8/9/25, 8/15/25, and 8/25/25.3. Interview on 9/11/25 at 9:49 a.m. with certified nursing assistant (CNA) Q revealed:*The staff were to offer repositioning to resident 31 every two hours, but she often refused.*Resident 31 would let staff know when she wanted to be repositioned.*Resident 31 often refused to wear her Prevalon boots but would allow staff to float her heels off her mattress with pillows.*She usually only got up into her wheelchair for appointments, about one to two times per week.*Staff would chart in the resident's EMR if the resident refused repositioning or the use of items such as resident 31's Prevalon boots as a refusal of care under behaviors, but that did not be specify the care area that was refused.*Resident 11 would let staff know if he was uncomfortable in his chair and needed to be repositioned.*Resident 11 would get out of his wheelchair three to four times per day.4. Interview on 9/11/25 at 9:58 a.m. with licensed practical nurse (LPN) K revealed:*Resident 31 was difficult to reposition and did not want to be offloaded.*If she refused to be offloaded staff would attempt to educate her on why she needed to be repositioned, but she was not always receptive to that education.*Resident 31 would allow staff to float her heels on pillows but usually refused her Prevalon boots.*Resident 11 was receptive to repositioning and often would seek out staff to assist him with repositioning.*He was able to reposition his buttocks in his chair but had a more difficult time adjusting his left leg.5. Interview on 9/11/25 at 2:31 p.m. with infection preventionist (IP)/wound care nurse C revealed:*She worked at the facility since 6/30/25, when she became the IP/wound nurse.*The wound nurse prior to her had documented resident 31's wounds as different location descriptors but she had two wounds on her buttocks and one wound on each of her feet.*Resident 31 has refused wound cares from IP/wound nurse C.*IP/wound nurse C completed wound care rounds on Tuesdays. She did not document her wound cares in the TAR, but she could do so.*Resident 31 often refused to wear the Prevalon boots, but IP/wound nurse C had not witnessed the resident refuse to have her heels floated off the mattress with a pillow.*She expected that if resident 31 refused the Prevalon boots, her heels would be floated off the mattress with a pillow.*She expected if a resident refused a dressing change or repositioning that would be charted as a refusal.*She stated if a resident was not repositioned the staff were not preventing pressure ulcers from developing or worsening.*She reviewed resident 11's and resident 31's TAR documentation and verified there were several missed intervention opportunities that could have resulted in the development or worsening of a pressure ulcer.*She verified both resident 11's pressure ulcers were considered facility-acquired pressure ulcers because his admission and 3/11/25 skin assessments documentation stated he had no skin alterations and noted the 3/11/25 assessment stated resident 11 refused to undress for evaluation of his skin.*Resident 11 has only been compliant with lying in his bed one time a day, after lunch.*She agreed when resident 11 laid on the mattress springs due to a deflated air mattress that created pressure to his skin and underlying tissues.*She agreed that the missing documentation did not support that the interventions were implemented to prevent pressure ulcers.6. Interview on 9/11/25 at 4:46 p.m. with director of nursing (DON) B revealed:*She expected the documentation of wound care and resident repositioning to be signed off in the TAR when completed.*If a resident refused wound care or repositioning, she would expect the refusal to be documented as a refusal.*If a wound care or repositioning documentation was left blank, she would consider it did not occur.*Due to the missed documentation on resident 11's and resident 31's TARs she considered those as missed intervention opportunities to prevent and treat a pressure ulcer.7. Review of the provider's 9/11/24 Skin and Pressure Injury Prevention Program revealed:* To ensure a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable.* To provide care an services to prevent pressure injury development and to promote the healing of pressure injuries/wounds that are present.* A baseline assessment of the resident's skin status will be completed upon admission/readmission by completing the Nursing Admission/readmission UDA.* Risk Assessments (Braden or PUSH) will be completed with admission/readmission weekly for four weeks, and then monthly thereafter.* A wound assessment will be completed:-A) When a pressure injury is identified: This assessment will include,--a) Site, stage, size, appearance of wound bed, (use %) undermining, depth, drainage (amount, color, type, consistency and odor) and status of peri-wound tissue'--b) Treatment of the pressure injury, (cleansing, debridement, dressings);--c) A review of the resident's current POC [plan of care] and medical status- any other possible risk factors, impaired healing due to diagnoses;--d).Reassess he wound at least weekly (If the wound has not improved within 2-3 weeks, contact MD [medical doctor]/Provider for a change in treatment).* Nursing personnel will develop a plan of care (POC) with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident's adherence to the pressure injury prevention/treatment plan. POC to include: Impaired mobility, including turning and repositioning at least every two hours or more if indicated by assessment. Pressure relief, Nutritional status and interventions, Incontinence, Skin condition checks, Treatment, Pain, Infection, Education of resident and family, Possible causes for pressure injury and what interventions have been put into place to prevent. Skin checks to be completed at least weekly by a Licensed nurse.* Pressure injuries are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue.* If pressure injuries are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected.* The most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes.

Based on observation, interview, record review, and policy review, the provider failed to ensure: Interventions were implemented or updated to mitigate falling incidents for one of one sampled resident (14) identified at risk for falling who fell and sustained facial bruising and to have completed and documented a thorough investigation of that fall.Findings include:1. Observation on 9/9/25 at 8:46 a.m. of resident 14 in her room revealed she was lying on her side in bed. There was purple colored bruising beneath and above her right eye, extending to her forehead hairline. The resident stated she had fallen but was not sure how that had occurred. Her bed was low to the floor. Her call light was held inside the top closed drawer of a three-drawer plastic storage container near the head of her bed. A fall mat was folded against the wall on her roommate's side of the room. A walker and a wheelchair were also by that wall. Observation and interview on 9/9/25 at 11:35 a.m. with occupational therapist (OT) X in resident 14's room revealed she was encouraging the resident to reach towards the walker in front of her and pull herself to a standing position. OT X stated resident 14 took a couple falls when she was recently sick. Observation on 9/9/25 at 3:30 p.m. revealed resident 14 was asleep in bed. Her call light remained positioned in the above manner inside the plastic storage container. The above fall mat, walker, and wheelchair remained near or against the wall. Review of resident 14's electronic medical record (EMR) revealed her diagnoses included Alzheimer's, anxiety, depression, and high blood pressure. Resident 14's 9/2/25 revised fall care plan included the following fall prevention interventions: Ensure that [resident 14's] FWW (front wheeled walker) is within her reach when she is in bed. Initiated on 5/24/23.Fall mat at bedside while in bed to prevent injury. Initiated on 9/2/25.Keep call light within reach when in bedroom and bathroom. Initiated on 4/18/22.Sign in room to remind resident to ask for assist with transfers. Initiated on 6/14/23.Signs in room to remind resident to lock wheelchair. Initiated on 8/4/22. Observation on 9/10/25 at 7:50 a.m. revealed resident 14 was asleep in bed. Her call light was inside the drawer of the plastic storage container. A wheelchair and one end of an over-the-bed table were positioned in front of the exit side of her bed. The fall mat was folded against the wall on her roommate's side of the room. Interview on 9/10/25 at 8:55 a.m. with certified nurse aide (CNA) T regarding the positioning of the above equipment in front of resident 14's bed revealed that it was done to create a clutter-free path for resident 14's roommate. Observation and interview on 9/10/25 at 3:50 p.m. with resident 14 revealed that she sat in her wheelchair in her room. Her call light remained inside the drawer of the plastic storage container. When she was shown the call light, she was able to explain that its purpose was to bring help to her. There was no fall prevention signage posted on resident 6's side of the room. Review of the 9/1/25 Fall Scene Investigation (FSI) Report revealed that at 4:00 a.m. that morning, resident 14 was found on the floor of her room after an unwitnessed fall. Per the report, the resident had stated she was going through cards in her three-drawer plastic storage container and fell out of her wheelchair. She had refused the staff's assistance to get into her bed. She had been agitated and confused before that fall had occurred. She was last assisted to use the bathroom at 2:00 a.m. The section in the above report used to identify the root cause of the fall was blank. The section on that same report used to identify interventions to prevent future falls was blank. The checkbox to indicate if the resident's care plan had been updated was unchecked. The space for the nurse who had completed the form to sign and date it was blank.The last section of the above report was titled Falls Team Meeting Notes and it included the following meeting summary: Resident [14] anxious and exhibiting behaviors. Staff checked on resident at 0355 [3:55 a.m.] and resident was medicated for anxiety. Placed floor mat to prevent injury.There was no indication if the fall prevention interventions that were identified in resident 14's care plan were implemented at the time of her fall. There was no indication whether those same fall prevention interventions were reviewed to determine if they remained appropriate after she fell on 9/1/25.Observation and interview on 9/11/25 at 11:05 a.m. with director of nursing (DON) B in resident 14's room revealed the cause of the resident's facial bruising was a result of her 9/1/25 fall. The resident had tested positive for COVID-19 at the end of August 2025 and was expected to isolate in her room until her isolation precautions were lifted on 9/4/25. Resident 14's anxiety and restlessness had increased during that isolation period. She had not understood why she was expected to stay in her room. Resident 14 had no fewer than three falls during that isolation period.Regarding resident 14's fall care plan interventions, DON B confirmed that having a walker in reach when the resident was in bed was no longer indicated due to a decline in the resident's physical abilities. A fall mat was still expected to have been placed on the floor at the exit side of her bed when the resident was in her bed. That intervention should have been added to the resident's care plan. Resident 14's call light was to be accessible to her when she is in her room. Fall prevention signage was expected to have been posted in a location visible to the resident. DON B stated the FSI regarding resident 14 was incomplete. Resident 14's fall prevention interventions had not been but should have been updated to reflect short-term strategies to mitigate her risk for falls, such as increased staff observation of and interaction with the resident, knowing that the isolation precautions had increased her agitation and restlessness.Review of the provider's revised 2/20/24 Falls Management policy revealed:Fall Injury Prevention-Post Fall:1. Assess the resident and ascertain the reason for the fall (resident interview, environmental causes/hazards, footwear, functional impairment, acute change in condition, resident poor safety awareness, responding to toileting needs, etc). 2. Determine and implement [a] new intervention for fall prevention and record on [the] care plan.7. Provide appropriate training for caregivers, noting any changes implemented.

Based on observation, interview, record review, and policy review, the provider failed to ensure pain management interventions were implemented and effective for one of one sampled resident (6).Findings include:1. Observation and interview on 9/9/25 at 9:53 a.m. in resident 6's room revealed he was lying on his back in bed wearing a hospital gown. He had a U-shaped pillow around the back of his neck. The resident had a grim expression on his face, and he strained to answer simple questions. He complained of being cold. Observation on 9/9/25 at 12:00 noon outside of resident 6's room revealed he was overheard telling an unidentified caregiver, I wish that nurse would come. I need that oxy [oxycodone, pain medication that is a controlled medication meaning at risk for abuse and addiction].Observation on 9/9/25 at 12:03 p.m. revealed licensed practical nurse (LPN) E entered resident 6's room. She explained to him that he had a physician's order for Tylenol, but there was no order for him to have oxycodone. LPN E stated she would have to call the resident's physician to discuss his request for oxycodone. She adjusted the resident's U-shaped neck pillow.Without first asking the resident what his pain level was or where his pain was, she administered two Tylenol tablets to resident 6. Observation and interview on 9/9/25 at 12:05 p.m. with resident 6 revealed he was lying on his back in bed, rubbing his forehead back and forth repeatedly and moaning, uh, uh. He stated on a scale of one to ten, with ten being the worst possible pain, that his pain was a ten. He identified his left ankle as the source of his pain. He described his pain as hot and stabbing and nearly constant. His eyes watered as he described his pain. Review of resident 6's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His diagnoses included multiple sclerosis (MS), metastatic malignant neoplasm (cancer), depression, peripheral vascular disease (circulation disease), a history of left lower leg pain, and a history of cellulitis (bacterial infection of the skin) of his left lower limb. His 6/18/25 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated he had moderate cognitive impairment. Review of resident 6's September 2025 medication administration record (MAR) revealed a 6/12/25 physician's order for acetaminophen (generic Tylenol), 325 milligrams (mg), two tablets every eight hours for pain rated one to seven on a pain scale from zero to ten. There was a 6/12/25 physician's order for oxycodone HCI (hydrochloride), one tablet every eight hours as needed for pain rated eight to ten on a pain scale from zero to ten. Review of resident 6's September 2025 MAR and interview on 9/9/25 at 2:00 p.m. with LPN E revealed it's [the oxycodone order] right below the Tylenol. She had not known that resident 6 had an order for oxycodone; otherwise, she would have administered the oxycodone instead of the Tylenol as the resident had requested.When asked why resident 6 had pain, she stated, I'm not honestly sure the cause of his pain. It may be related to an accident. She thought he had pain in his leg or his neck. She was not sure how often or if resident 6 had gotten out of bed. She had not reassessed resident 6's pain level after she administered the two Tylenol tablets two hours earlier.LPN E administered resident 6's oxycodone after she was made aware of his physician's order for oxycodone.Review of resident 6's September 2025 MAR revealed LPN E had reassessed the resident's pain after she administered the above oxycodone. That administration was documented as having been an effective response to his pain.Interview on 9/10/25 at 2:40 p.m. with director of nursing (DON) B revealed LPN E had not administered resident 6's pain medication per his physician's order. That had potentially caused resident 6 unnecessary pain. DON B had expected LPN E to have thoroughly reviewed resident 6's MAR for all physician-ordered pain medication options and to have administered the most appropriate pain medication to him based on his level of pain. LPN E should have assessed and documented resident 6's pain level before administering any pain medication. That assessment should have identified whether his pain was new, acute, chronic, or related to an injury and what medication to administer for effective pain relief. Observation and interview on 9/10/25 at 1:30 p.m. with resident 6 revealed he was lying in his bed on his back in a hospital gown. He was watching television. He stated his MS had worsened, and caused a decline in his physical abilities. He thought his MS was also partially to blame for his near-constant pain. Observation on 9/11/25 at 8:30 a.m. of resident 6 revealed he was lying in his bed on his back in a hospital gown. His television was on, and his eyes were closed.Interview on 9/11/25 at 2:15 p.m. with resident 6 revealed he had no significant pain and stated, in a minute or so the pain will start back up at a ten.Review of resident 6's EMR revealed:On 7/26/25, he was transferred to the local emergency room due to left lower leg pain. No pain medication changes were made, and the resident was referred to his primary care physician for follow-up.His 9/9/25 Monthly Nursing Summary describing his pain revealed, Hurts a whole lot. Review of resident 6's June 2025 MAR revealed that during that month, he was administered as-needed oxycodone on 17. The frequency of those administrations was either one or two times per day. His July 2025 MAR revealed that during that month, he was administered as-needed oxycodone 17 days. The frequency of those administrations was between one and three times per day.His August 2025 MAR revealed that during that month, he was administered as-needed oxycodone 10 days. The frequency of those administrations was either one or two times per day.Review of resident 6's 6/14/25 revised pain care plan revealed the following interventions: Evaluate efficacy [effectiveness] of pain management. Notify MD [medical doctor] if inadequate pain relief. Observe for non-verbal signs of pain. Provide analgesic as ordered. Utilize non-pharmacological intervention.Review of resident 6's June 2025 through August 2025 MARs and interview on 9/10/25 at 2:40 p.m. with DON B regarding the management of resident 6's pain revealed that she stated resident 6's pain descriptions were accurate. His pain was most likely related to his MS. The stabbing that resident 6 described was consistent with the neurological nature of MS.DON B confirmed resident 6's Tylenol and oxycodone frequency and dosing had remained unchanged since he was admitted . He had no scheduled pain medications that could have provided him with more consistent pain relief. When asked why, she stated, That's what I was wondering. I don't have an answer for that. She indicated that resident 6's physician should have been contacted to explore this and other, more effective pain management options, but that had not occurred.Review of the provider's 4/28/25 Pain Management policy revealed:5. Strategies that may be employed when establishing medication regimen include:a. Starting with lower doses and titrating upward as necessary.b. Administering medications around the clock rather than PRN [as needed]. c. Combining long-acting medications with PRNs for breakthrough pain;d. Combining several analgesics or analgesics with other drug classes; .

Based on observation, interview, record review, and policy review, the provider failed to ensure the respiratory treatment equipment for five of five sampled residents (40, 56, 57, 58, and 67) who used oxygen and one of one sampled resident (58) who used a continuous positive airway pressure (CPAP) machine (a machine used to keep a person's airway open while they sleep) was cleaned and stored according to the manufacturer's instructions and the provider's policies.Findings include: 1. Observation and interview on 9/9/25 at 9:06 a.m. with resident 67 in his room revealed: *He was on oxygen, and the flow rate on the oxygen concentrator (a device that filters room air into purified oxygen) was set to four liters per minute (4L/min). *The oxygen concentrator had a label on it that had another person’s name on it. * There was a thick, fuzzy layer of gray dust caked on the filter of the concentrator. *The nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) attached to the concentrator was not dated. *A wheelchair in his room had a portable oxygen tank on the back of it, with another nasal cannula tubing attached to the tank. -That nasal cannula was hanging over the back of the wheelchair, touching the wheels of the wheelchair, and was also undated. Observation on 9/9/25 at 4:23 p.m. in resident 67’s room revealed: *The flow rate on the concentrator remained at 4L/min. *The nasal cannula attached to the portable tank was lying on the floor. Observation on 9/10/25 at 9:46 a.m. in resident 67’s room revealed: *The flow rate on the concentrator was set to 2L/min. *Both nasal cannulas were labeled with the date “9/7.” *The label with another person’s name on it had been removed from the concentrator. *The filter remained dusty. *The nasal cannula on the portable tank was in a pocket on the wheelchair. Review of resident 67’s electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had 9/3/25 orders for: -“Oxygen continuous [at all times] [at] 2L/min via nasal cannula.” -“Concentrator Filter Cleaning” weekly, every Saturday. -Change oxygen tubing every Saturday, and as needed. 2. Observation and interview on 9/9/25 at 9:30 a.m. with resident 56 in her room revealed: *She used oxygen at night. *There was an oxygen concentrator near her bed. It had a nasal cannula attached to it that was hanging over a bedrail, tucked between the mattress and the bedrail. -That nasal cannula was dated “8/23.” 3. Observation and interview on 9/9/25 at 9:40 a.m. with resident 40 in his room revealed: *He was on oxygen, and there was a portable oxygen tank on the back of his wheelchair that was set to 3L/min. *That nasal cannula was dated “8/23/25.” Review of resident 40’s EMR revealed: *He had 12/21/24 orders for: -“Oxygen continuous 3L/min via nasal cannula.” -Change oxygen tubing every Saturday, and as needed. 4. Observation on 9/9/25 at 9:23 a.m. of resident 57’s room revealed: *There was a nasal cannula draped over a bed. *The nasal cannula was attached to an oxygen concentrator that was running. *There was no place for the nasal cannula to be stored to prevent potential contamination of the nasal cannula. *There was dust coating the outside of the oxygen concentrator. *The oxygen concentrator had a brown waxy oil on the vents of the filter cover. *The tab to release the cover over the filter was missing. *The filter in the oxygen concentrator was covered with gray dust particles. Observation and interview on 9/10/25 at 9:42 a.m. with resident 57 in her room revealed: *Resident 57 was sitting on the side of her bed. Her nasal cannula was draped on the bed beside her, and the oxygen concentrator was running. *She stated she wore the oxygen when she slept. *She stated she did not know if someone had replaced her nasal cannula or cleaned her oxygen concentrator. Review of resident 57’s electronic medical record (EMR) revealed she: *Was admitted on [DATE]. *Had a Brief Interview of Mental Status (BIMS) assessment score of 15, which indicated her cognition was intact. *Had diagnoses of respiratory failure (not enough oxygen passes from the lungs to the body), and thromboembolic pulmonary hypertension (a rare condition where blood clots in the lungs persist and cause high blood pressure in the artery that carries blood from the heart to the lungs, which results in damage to the heart and lungs). *She had a 1/3/25 physician’s order for, “Oxygen continuous 2L/min [liters per minute] via nasal cannula”. Review of resident 57’s August 2025 treatment administration record (TAR) revealed: *She was scheduled on Saturday night shifts to have her nasal cannula replaced and her concentrator filter cleaned. -There was no documentation that was completed on 8/9/25 or 8/30/25 as scheduled. 5. Observation on 9/9/25 at 9:26 a.m. of resident 58’s room revealed: *He was sitting in his wheelchair with his nasal cannula on. *His nasal cannula was attached to an oxygen concentrator, which was running. *The oxygen concentrator was covered in white flakes and dust particles. *The vent cover over the oxygen concentrator’s filter was covered in dust. *There was an assembled mask and tubing attached to a continuous positive airway pressure (CPAP) machine (a machine used to keep a person’s airway open while they sleep) on resident 58’s bedside table. Observation and interview on 9/10/25 at 9:39 a.m. with resident 58 in his room revealed: *He was sitting in his wheelchair with his nasal cannula on. *His nasal cannula was attached to the oxygen concentrator. *There was another nasal cannula draped over the handles on the back of his wheelchair was attached to a portable oxygen cylinder. *There was no place for the nasal cannula to be stored to prevent potential contamination of the nasal cannula. *The filter of the oxygen concentrator had a coating of gray dust on it, and the compartment surrounding the filter was dusty. *Resident 58 stated he wore oxygen all the time. *The CPAP mask and tubing remained assembled on his bedside table. *Resident 58 stated he wore the CPAP at night. *Resident 58 shrugged his shoulders when he was asked if someone cleaned his CPAP mask and tubing, or his oxygen concentrator. Review of resident 58’s EMR revealed he: *Was admitted on [DATE]. *Had a BIMS assessment score of 3, which indicated he had severe cognitive impairment. *Had diagnosis of chronic respiratory failure with hypoxia (low oxygen in the blood) and obstructive sleep apnea (a sleep disorder where the airway repeatedly collapses during sleep, leading to pauses in breathing). *Had a 12/16/24 physician’s order for “Oxygen 3LPM [liters per minute] via nasal cannula” and “CPAP Setting 11 with 2L [liters] o2 [oxygen] bleed in every evening shift for CPAP usage **Assist with placement at bedtime**”. Review of resident 58’s August 2025 treatment administration record (TAR) revealed: *He was scheduled on Saturday night shifts to have his nasal cannula replaced. -There was no documentation that was completed on 8/9/25 or 8/30/25 as scheduled. *Cleaning of the oxygen concentrator filter was not scheduled on the TAR to be completed. *Cleaning of the CPAP machine, mask, and reservoir was not scheduled on the TAR to be completed. *Replacement of the mask and tubing was not scheduled on the TAR to be completed. 6. Interview on 9/10/25 at 1:37 p.m. with certified medication aide (CMA) O revealed: *CPAP machines, masks, and tubing were to be scheduled to be cleaned weekly for residents who wore CPAPs. *The CPAP mask and tubing were to be disassembled, washed with soap and water, and then hung to dry. *Cleaning of the CPAP machines, masks, and tubing was to be documented on the resident’s TAR. *Nasal cannulas were to be replaced weekly on the night shift. *Nasal cannulas were to be stored rolled up in a bag when it was not in use. *The filters in the oxygen concentrators were to be checked weekly and replaced as needed. *CMA O observed resident 58’s oxygen concentrator and filter, and stated he would not have considered the oxygen concentrator or the filter clean and verified there was dust and white flakes on the concentrator and dust on the filter and in the filter compartment. 7. Interview on 9/11/25 at 9:58 a.m. with licensed practical nurse (LPN) K revealed: *There were to be orders for the residents’ nasal cannula to be replaced weekly by the nurse and documented in the resident’s’ TAR. *The nasal cannulas were to be stored coiled up and placed on the oxygen concentrator, off the floor, when not in use. *Nursing staff did not clean the filters in the oxygen concentrators, she thought the maintenance staff was responsible for cleaning the filters. *CPAP masks were to be cleaned or replaced weekly by the nurse and documented in the resident’s TAR. 8. Interview on 9/11/25 at 4:28 p.m. with the infection preventionist (IP)/wound care nurse C revealed: *Nasal cannulas were to be replaced weekly, and the replacement was to be documented on the resident’s TAR. *Nasal cannulas were to be stored in a bag off the floor when they were not being used. The bags were to be replaced weekly when the nasal cannula was replaced. *IP/wound nurse C expected the oxygen concentrators to be wiped down if they were visibly soiled. *She thought the oxygen concentrator filters were cleaned and replaced by the provider’s contracted oxygen company. *She was not aware that some residents had the cleaning of the oxygen concentrator filters scheduled on their TAR and others did not. *She verified if there was no schedule for cleaning of the oxygen concentrator filter on the TAR there was no place to document the cleaning was completed and therefore, the cleaning could not be verified as having been completed. *She expected the residents’ CPAP masks to be separated from the tubing and washed daily. *The CPAP tubing was to be washed with soap and water weekly and hung to dry. *The cleaning of the CPAP mask and tubing was to be documented on the residents’ TAR. *She verified if there was no schedule for cleaning of the CPAP machine and mask on the TAR there was no place to document the cleaning and therefore the cleaning would not be able to be verified as having been completed. 9. Interview on 9/11/25 at 4:46 p.m. with director of nursing (DON) B revealed: *Nasal cannulas were to be replaced weekly by the nurse and documented on the residents’ TARs. *The cleaning of the oxygen concentrators and the filters for the oxygen concentrators were completed weekly by the previous medical records staff member. *She expected the nasal cannulas to be stored in a bag, off the floor when they were not in use. *Cleaning of the CPAP machines, mask, and tubing should be completed according to the manufacturer’s instructions. *She stated she reviewed the different CPAP machines that were used in the facility and the manufacturers’ instructions indicated the tubing should be soaked weekly and changed monthly. *She verified that there was no documentation for the cleaning of the oxygen concentrator and CPAP supplies, or the replacement of the nasal cannulas weekly, she could not verify it had been completed. 10. Review of the provider’s 3/31/25 CPAP and BiPAP Cleaning policy revealed: *Procedures -“After each use, the mask/reservoir will be wiped with warm soapy water per manufacturer’s instructions, rinsed, and placed upside down to dry on a paper towel.” -“The tubing will be replaced at the time interval recommended by the individual machine’s manufacturer.” -“The machine should be wiped/cleaned with a disinfectant on at least a weekly basis and as needed.” Review of the provider’s 11/19/24 Oxygen Administration policy revealed: *”Oxygen masks and tubing will be changed weekly and as needed. Change of tubing and mask should be documented in the medical record. When not in use, the mask should be stored in a plastic bag.” *“The nasal cannula and tubing will be changed weekly and as needed. Change of tubing and cannula should be documented in the medical record. When not in use, the nasal cannula should be stored in a plastic bag.” *“Oxygen concentrators will have exterior wiped down when soiled and at least weekly. If equipped with a filter, [the] filter will be cleaned at least weekly by rinsing with water and allowing to dry…Weekly cleaning of the concentrator and filter should be documented in the medical record.”

Based on observation, interview, record review, policy review, and manufacturer's recommendations review, the provider failed to ensure a medication error rate of less than 5 percent related to:*A topical pain medication was not applied according to the manufacturer's recommendations for one of one sampled resident (11) by one of one observed licensed practical nurse (LPN) (K).*An extended release medication was crushed and administered to one of one sampled resident who required their medications to be crushed (12) by one of one observed LPN (K).Those observed medication errors resulted in a medication error rate of 6.9%.Findings include:1. Observation and interview on 9/11/25 at 8:00 a.m. of LPN K during medication administration revealed:*She dispensed an unknown amount of diclofenac sodium external gel 1% (for arthritis pain and inflammation) into a medicine cup and administered the gel to resident 11's left upper back/shoulder.-The order on resident 11's medication administration record (MAR) indicated he was to receive two grams of the gel.*When asked how she knew she was administering the correct dose, she stated, I guess I don't.*She was unaware that there was a measuring device included in the box that was to be used to determine the dose of the gel to be administered. Three-fourths of that tube of diclofenac sodium 1% gel had been used.-That measuring device was still secured to the diclofenac sodium 1% gel box.-She removed the measuring device from the box and stated, Oh. So, you just lay it on there?*She crushed resident 12's oral medications, mixed them with applesauce, and administered them to her.-There was no indication on the MAR that those medications should be crushed. *Omeprazole [used to treat and prevent conditions caused by excessive stomach acid] 20mg [milligram] Delayed Release Oral Tablet was included in those medications that were crushed.*She did not think the omeprazole was a delayed-release tablet.*She reviewed the label on the bottle and stated, Oh, it is delayed release. I shouldn't have crushed that. 2. Interview on 9/11/25 at 1:36 p.m. with DON B about the above medication administration observations and errors revealed she agreed that a delayed-release medication should not have been crushed.*She stated, I think we'll do some follow-up and education. 3. Review of the manufacturers' 2023 recommendations for the diclofenac sodium 1% gel revealed:*Read the label and use the enclosed dosing card.*Dosage-Using the dosing card, apply the following amounts:--Upper body areas (hand, wrist, elbow): 2.25 inches 4. Review of the provider's 9/18 Medication Administration Guidelines revealed:* Policy-Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.* Procedures-Medication Preparation:--If safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from prescriber.---The need for crushing medications is indicated on the residents' orders and the MAR so that all personnel administering medications are aware of this need and the consultant pharmacist can advise on safety and alternatives, if appropriate, during Medication Regimen Reviews.---Long-acting, extended release, or enteric-coated dosage forms should generally not be crushed; an alternative should be sought.- Medication Administration:-- Medications are administered in accordance with written orders of the prescriber.-- Verify medication is correct three (3) times before administering the medication.a. When pulling medication package from med [medication] cartb. When dose is preparedc. Before dose is administered

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure:*Handwashing was completed be three of five observed kitchen staff (cook N, dietary aide Z, and dietary aide AA) according to the provider's policy. *Food observed in one of one dining room refrigerator belonging to three sampled residents (4, 5, and 44) was stored according to the provider's policy. *One of one kitchen where resident's food was prepared stored, and served was maintained in a clean condition. Findings include:1. Observation on 9/9/25 at 10:10 a.m. in the kitchen revealed:*A power cord was hung from the ceiling and draped down to the floor by the middle of the food prep countertops.-The power cord was covered in dust.-The cord was above clean bowls and plates on a shelf.-The hot food steamer used for serving residents' food was under the cord and the shelf storing clean dishware.*Serving utensils were stored in clear plastic containers under the food preparation counter. They were not covered.-The filter to the ventilation system was under the sanitizing sink was covered with dust and black in color.*Air vents next to the sanitization sink and in the dishwashing room were covered in dust.*A thick tan substance was built up in the filter next to the dishwasher.*Cook N, dietary aide Z, and dietary aide AA washed their hands in the designated handwashing sink and failed to use a paper towel to turn off the sink faucet. They repeated that same process for six of the nine handwashing observations during the food preparation for the lunch meal service.-The sign above the handwashing sink had instructions to:--a.Wet your hands with warm running water. Lather with soap and scrub between your fingers, on the backs of your hands, and under nails. Wash for at least 20 seconds, or as long as it takes to sing Happy Birthday to yourself twice. Dry hands. Use single-use paper towels. Use a paper towel when you turn off the tap.2. Interview with dietary manager Y on 9/10/25 at 9:27 a.m. revealed:*The provider's handwashing policy and procedures was to use a paper towel to turn the faucet off after handwashing.*She would expect all kitchen staff to follow the correct procedure as directed in the policy.*She agreed that turning off the sink with bare hands would potentially contaminate those hands.3. Interview with infection preventionist/wound care nurse C on 9/11/25 at 4:28 p.m. revealed:*Her expectation for performing hand hygiene is to wash with soap and water when hands are visibly soiled or use alcohol-based hand rub following all times in the facility's policy.*She would expect a single use paper towel to be used to turn off the faucet after every hand washing in the sink.4. Review of the provider's 5/15/25 Hand Hygiene policy revealed:*Employees must wash hands using soap and water before and after eating or handling food.*Washing hands:-Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for at least twenty seconds under a moderate stream of running water, at a comfortably temperature.-Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to the inside of the sink.-Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel.5. Observation on 9/10/25 at 8:39 a.m. of the refrigerator in the dining room revealed:*Both the refrigerator and freezer compartments were locked. The keys were kept on top of the fridge.*Inside the refrigerator was:-A Styrofoam container with a dry baked potato. It was labeled with resident 5's name but no date was written on the container.-A plastic container labeled with resident 44's name and no date. There was meat, vegetables, and a type of dumpling in the container. There was a foul odor when the container was opened.-A plastic grocery bag filled with a green vegetable. It was sitting in liquid, and mold could be seen throughout the bag. The bag was labeled with resident 4's name. No date was written on it.6. Interview with activities director (AD) V on 9/11/25 at 9:20 a.m. revealed:*She and activity aide W were responsible for managing the refrigerator in the dining room.*She was to check the refrigerator temperature daily and record it in a log.*It is deep cleaned weekly or sooner if needed. The deep clean included:-Making sure every food item has a label with the resident's name and the date it was put in the refrigerator.*The cleaning log showed the last clean of that refrigerator was 9/2/25.*She agreed that the food without a date on it should have been thrown away with the last cleaning on 9/2/25. *Food was to be thrown away after three to five days.7. Review of the provider's 11/19/24 Food Brought in by Outside Sources policy revealed:*All food brought by visitors and family members from the outside of the facility will be labeled with the date it was brought to the facility'.*If refrigeration is required, the food items will be placed inside the refrigerator.*After three to five days, these food items will be discarded'.*All undated food items will be discarded to ensure safety of the residents''.

Based on interview, record review, observation, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, and policy review, the provider failed to ensure an assessment, physician notification, initiation of a skin treatment, and monitoring for one of one sampled resident's (2) newly discovered skin injury. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *Her admitted was 12/12/23 and her 2/21/25 Brief Interview for Mental Status (BIMS) assessment score was 0 which indicated she was severely cognitively impaired. *Her diagnoses included: hemiplegia, stroke, stage IV chronic kidney disease, diabetes, vascular dementia, and anxiety. She had a suprapubic catheter (tube inserted into the bladder to drain urine) related to acute cystitis (inflammation of the bladder). *She had a change in her medical condition on 2/17/25 and received intravenous (IV) fluids and an IV antibiotic for treatment of a urinary tract infection. *Her 2/7/25 Braden scale (pressure sore risk indicator) score was 18 which indicated she was at high risk for pressure ulcer development. *A 2/27/25 physician's progress note indicated: -Patient [resident] with progressive decline over the past several weeks, now with rapidly progressive ulcer to sacrum [bone at the base of the spine]. Reviewed picture on HUCU, [a type of electronic medical record] dark purple border, rapidly progressive over [the] past week and large necrotic appearing center. In context of poor oral intake, declination in health generally, this certainly appears to be a Kennedy ulcer [a type of skin breakdown that occurs in people who are nearing the end of their life. The cause is unknown but believed to be related to the physiological changes that occur during the dying process]. She is on comfort cares currently, DNH [do not hospitalize]. Review of resident 2's 3/4/25 physician's orders summary revealed: *She had received a twice daily liquid protein supplement ordered on 4/4/24. *A topical wound paste was applied to her buttocks once daily for excoriation and sequelae (a long term residual effect after an initial skin trauma has resolved) was ordered on 5/9/24. *She was laid down between meals to offload her buttocks, initiated on 5/9/24. *She had a pressure-relieving mattress for her bed, initiated on 8/22/24. *Weekly skin assessments, initiated on 8/24/24. *Wound care instructions: Cleanse sacrum with NS [normal saline], pat dry, apply hydrogel to wound bed, cover with border foam. Change every other day and PRN [as needed] every day shift every 2 day(s) for wound care, ordered on 2/25/25. Review of resident 2's February 2025 weekly skin assessments revealed: *On 2/15/25: Redness to buttocks with treatment in place. *On 2/22/25: Area on both buttock[s] is still there. *On 2/24/25: A left buttock wound measurement was 5 cm (centimeters) by 5 cm. -That same wound had measured 8.70 cm X 8.30 cm on 2/25/25, and on 3/4/25 the wound had measured 8.20 cm X 8.00 cm. Observations on 3/4/25 at 2:30 p.m. and again at 4:00 p.m. of resident 2 in her room revealed: *She was sleeping on her back in bed lying on top of a pressure-reducing mattress. *She was wearing protective heel boots. *There was a pressure-reducing cushion on her wheelchair seat. *She remained asleep in her bed, but she had been repositioned. Interview on 3/4/25 at 2:40 p.m. with doctor of nursing practice (DNP)/registered nurse (RN) B regarding the provider's FRI submitted to the SD DOH on 2/26/25 at 1:30 p.m. revealed: *While performing resident 2's personal cares on 2/20/25, certified nurse aide (CNA) J observed resident 2 had a new skin injury on her buttock. -She described the size of that injury as quarter-size. *CNA J had notified unit manager/licensed practical nurse (LPN)/wound care nurse H and RN E of the above observation. -RN E was responsible for resident 2's nursing care on 2/20/25. *After the above notification from CNA J, RN E failed to: -Complete and document an assessment of resident 2's new skin injury. -Notify resident 2's physician, obtain, and implement the physician's order for treatment of that skin injury. -Report to the oncoming shift that resident 2 had a new skin injury. *Resident 2's weekly skin assessment was completed on 2/22/25 by RN F. RN F failed to: -Document a measurement or a description of the new skin injury in his assessment. -Notify the resident's physician, obtain, and implement the physician's order for treatment of that skin injury. *During the evening/overnight shift on 2/22/25 through the morning of 2/23/25 it was reported to RN G that resident 2's buttock dressing was coming off. -She had not known resident 2 had a skin injury to her buttock. *She had completed a skin assessment and measured the skin injury as having been 5 cm (centimeters) by 5 cm. -RN G failed to initiate wound care standing orders (written protocol allowing certain healthcare staff to perform certain tasks without a specific order from a medical provider) for treatment of that skin injury until the resident's physician was able to be reached during regular business hours. *RN G had reported resident 2's skin injury to assistant director of nursing (ADON)/C the morning of 2/24/25. -ADON C and other management team members investigated and identified the root causes for the above process failures then developed and implemented corrective actions to mitigate the likelihood of them reoccurring. Interview on 3/4/25 at 3:00 p.m. with RN E revealed: *She stated she was busy and failed to complete a skin evaluation for resident 2 after it was reported to her by CNA J resident 2 had a new skin injury on her buttock. -She had not asked for assistance from another licensed nurse working that day to have ensured the skin assessment was completed. *RN E had worked on 2/21/25 and had not completed resident 2's skin assessment on that date. Telephone interview on 3/4/25 at 3:30 p.m. with physical therapist (PT)/certified wound therapist (CWT) K revealed: *He was employed by a company specializing in wound care that consulted with the nursing home on their residents' wound care. -He had reviewed the facility's residents who had skin wounds with unit manager/LPN/wound care nurse H on 3/4/25. *After reviewing documentation regarding resident 2's skin injury and observing that injury, he had concurred with the above 2/27/25 physician's progress note that resident 2's skin injury was appropriately classified as a Kennedy terminal ulcer based on its size, appearance, and the rapid development of that ulcer. -He felt the skin injury was unavoidable. The facility had identified resident 2 was at high risk for pressure ulcer development and had implemented appropriate preventative measures to mitigate her risk for pressure ulcer development. Resident 2's current treatment plan was appropriate. Interview on 3/4/25 at 4:15 p.m. with unit manager/LPN/wound care nurse H revealed: *On 2/20/25, CNA J had reported resident 2's new skin injury to her. -She had directed CNA J to notify resident 2's nurse, RN E. *Unit manager/LPN/wound care nurse H confirmed RN E, RN F, and RN G failed to follow the facility's process for the management of resident 2's new skin injury. CNA J, RN F and RN G were not available to interview. Review of the provider's revised 9/11/24 Skin and Pressure Injury Prevention Program revealed: *Section 1: -5. A wound assessment will be completed: A) When a pressure injury is identified: This assessment will include, a) Site, stage, size, appearance of wound bed, undermining, depth, drainage, and status of peri-wound tissue; b) Treatment of the pressure injury, c) A review of the resident's current POC (plan of care) and medical status-any other possible risk factors, impaired healing due to diagnoses; d) Type of skin injury, and provide skin treatment orders. Reassess the wound at least weekly. The changes the provider implemented to ensure the above deficient practices did not reoccur was reviewed and confirmed on 3/5/25. Those changes were based on a Root Cause Analysis of the FRI and resulted in the development of multiple improvement plans. The plans and actions included resident interviews regarding staff compliance with their repositioning schedules, staff interviews regarding their knowledge and understanding of the process and expectations after identification of new resident skin injuries, staff education and re-training related to the care and treatment of residents' skin, audits of all residents' skin, and staff-specific disciplinary action. Staff interviews confirmed those actions. Based on the above information, non-compliance at F686 occurred on 2/22/25. Based on the provider's implemented corrective actions for the deficient practice confirmed on 3/5/25, the non-compliance is considered past non-compliance.

Based on record review, interview, and policy review, the provider failed to ensure the physician and family had been notified for a change in condition for one of one sampled resident (1) following a laceration to her left leg. Findings include: 1. Review of resident 1's medical record revealed: *She had been admitted on [DATE]. *Her (Brief Interview for Mental Status (BIMS) was 11 which indicated her cognition was moderately impaired. *Her diagnoses included paroxysmal atrial fibrillation, abrasion left lower leg, secondary malignant neoplasm of bone marrow, acute kidney failure, malignant neoplasm of unspecified site of left female breast and congestive heart failure. * She received a skin tear to her left lower leg on 6/21/24. *The on-call care provider was notified of her left leg laceration and agreed it could be addressed in the facility. *Resident 1's son was informed of her left leg laceration and provider's recommendation. *A physician's notes on 6/21/24 stating Staff called Friday 6/21 10 p.m. Staff stated she had abrasion/skin tear to leg from catching it on wheel chair. Verbal order for steri-strips and bandage. Will monitor close. Staff agreed with plan. *A progress note on 06/22/24: Call from RN L on Sat 6/21 at 1 p.m. Nurse stated wound was bleeding and with blood thinners was weeping. She recommended she can do pressure dressing. Verbal order for pressure dressing to stop bleeding and monitor close. Discussion with nurse-she was on blood thinners. Pt has severe hx [history] of PAD [peripheral artery disease] and CAD [coronary artery disease]- medical discussion making considered and elected to not stop blood thinner due to PAD. Discussed with nurse to continue to monitor close and continue pressure dressing. If worse can consider sending to ED. Will f/u this week for eval. *A progress note on 06/22/24 at 14:24: Resident has skin tear to LLE [left lower extremity] that is bleeding. Skin has been approximated, putting pressure dressings on and change dressing when resident bleeds through the dressing. Dressing has been changed x2 [two times] so far. [NAME] notified and stated to keep putting pressure dressing on. *A wound note on 06/23/24 at 12:00 a.m.: This RN changed residents dressing on L calf. Bandage was saturated in blood. No steri-strips available at this time. *A wound note on 06/23/24 at 4:11 a.m.: This RN changed dressing on L calf. Bandage was saturated with blood. No steri-strips available at this time. *A wound note on 06/23/24 at 1:51 p.m.: Skin tear to LLE still bleeding but has lessened. This nurse has changed the dressing x2. There are blood clots present. Monitor. *A wound note on 06/24/24 at 4:29 a.m.: Resident dressing on L calf was saturated in blood, observed blood clots within the saturated bandage. Removed, cleaned the area gently and applied new sterile dressing. *A wound note on 06/24/24 at 8:33 a.m. Was notified at arrival to facility of wound to her left pretibial surface. Pictures obtained with size documented. Pressure bandage reapplied. Will do dressing change later this morning. Follow up on wound care orders. Patient expressed that she was not in pain. She is on Eliquis. *No wound care notated for residents left lower leg skin tear in treatment administration record (TAR). *She passed away on 6/24/24 at 10:45 a.m. 2. Interview on 0709/24 at 10:20 a.m. with certified nursing assistant (CNA) H revealed: *She was not working during the time resident 1 received the skin tear to her left leg. *She stated when residents have accidents CNAs know to let the nursing staff know and they will advise on what the next step is. *Staff had training monthly on how to deal with different issues that may arise. 3. Interview on 06/10/24 at 7:32 a.m. with CNA J regarding resident 1 revealed: *She was in resident 1's room assisting her roommate. *on 6/21/24 she saw resident 1 slipping out of her wheelchair, stopped her from falling, and assisted her to her bed. *She stated that resident 1 had cut her left lower leg on her wheelchair at which point she notified the nurse. *She checked on resident 1 twice throughout the night between 8:00 p.m. and 5:00 a.m. on 6/22/24 and had to change dressing twice due to it being soaked. *She had to change resident 1's bedding before leaving due to the bedding being soaked in blood. 4. Interview on 06/10/24 at 10:00 a.m. with Licensed Practical Nurse (LPN) F revealed: *She did not work the weekend of resident 1's injury but had heard about it. *She stated that when a resident would have an injury the CNAs would inform the nurses who would then evaluate the injury and inform the provider, management and family if needed. *The nurse would measure skin tears and inform the wound nurse. *She would have pushed for resident 1 to be sent to the emergency room if she had seen the injury. 5. Interview on 06/10/24 at 10:53 a.m. with RN L revealed: *She was working the weekend that resident 1 cut her left lower leg on her wheelchair. *The resident's family, management, and physician's assistant (PA) K were notified of the injury. *PA K never mentioned taking resident 1 to the emergency department. *PA K advised there was not much to be done about the injury and to keep putting a pressure dressing on it. *She applied non-adherent ABD (abdominal) pads and Coban (self-adherent wrap) to the wound. *She changed resident 1's dressing four times from Friday 06/21/24 to Saturday 06/22/24 and twice from Saturday 06/22/24 to Sunday 06/23/24. *The bleeding had lessened on 06/23/24. *If the bleeding had not lessened, she would have called PA K back. *She would not have done anything differently and that there was not much you could have done for that skin tear. 6. Interview on 06/10/24 at 4:06 p.m. with RN M revealed: *She was working the weekend resident 1 cut her left lower leg on her wheelchair. *She was informed of resident 1's skin tear then called on-call provider PA K. *She was told by PA K that resident 1 did not need to go to the emergency department and was told to call her son. *On 06/22/24 the skin tear was still bleeding, and she did not have any steri-strips. *She called management who advised that the wound nurse would be in on Sunday 06/23/24 to look at the wound. She was not sure if the wound nurse came in that Sunday. *She called the provider again, but no one directed to send the resident out to the emergency department. *She did not think sutures, staples or going to the emergency department would have helped the resident. *She was upset that she did not have the right supplies to assist the resident. 7. Interview on 06/10/24 at 3:12 p.m. with CNA I revealed: *He worked the weekend resident 1 cut her left lower leg. *He was informed that she had a small abrasion on her left leg at the shift change meeting. *He stated when he checked on resident 1 the dressing was soaked through and there was a pool of blood in the resident's bed. *He notified RN L every hour that the dressing needed to be changed. *He asked RN L multiple times if resident 1 would be sent to the emergency department and did not get an answer from her. *When he came back to work on Sunday 06/23/24 resident 1's wound looked the same to him as it had on 06/22/24. * He watched the resident go from vibrant on 06/22/24 to pale and quiet on 06/23/24. 8. Interview on 06/10/24 at 1:51 p.m. with assistant director of nursing (ADON) D revealed: *She was the nurse on-call on the weekend resident 1 cut her left lower leg. *She stated she had made notes for this incident to keep her thoughts straight. *She provided a color picture of the wound and stated that the blood in the picture was moderate and called the wound an abrasion. *She stated that she did not believe anything was done incorrectly and she trusted her nurses. *She was never contacted about not having enough steri-strips for the wound. *She stated in hindsight the family could have been notified again and been asked to have made the decision to send to the emergency department or the provider could have been contacted to come and look at the wound. *She stated that the incident was not reported to the Department of Health (DOH) due to it not being an unknown injury and she did not think that it needed to be reported, even though it did not stop bleeding for three days. 9. Interview on 06/10/24 at 4:07 p.m. with Administrator A revealed: *She did not think anything had been done incorrectly. *She stated due to having advanced cancer she did not think sending the resident to the emergency department would have been beneficial. *She stated that in hindsight she would not have done anything differently. *She stated that she expected her staff to treat the resident, notify the provider and the family and to monitor the situation. 10. Review of provider's February 2024 Abuse and Neglect policy revealed: *Neglect -Neglect is the failure to provide necessary and adequate (medical, personal, or psychological) care. Neglect is the failure to are for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware or should have been aware of the service the resident requires but fails to provide that service. 11. Review of provider's June 2024 Wound Care Protocol by Wound Type revealed: *Cleanse with normal saline. -Reapproximate skin over wound when possible. -Xeroform or Vaseline gauze to skin tear. -Silicone border dressing, when possible ,otherwise ABD and roll gauze to secure dressing. -Change dressing every 3 days and as needed until resolved to keep dressing clean, dry, and intact. Do not remove to shower, cover to bathe. Do not soak. Change dressing if it becomes saturated with drainage, shower water or becomes compromised.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to assess, and implement preventative pressure injury interventions for one of one sampled resident (2) who was identified as at risk for pressure injuries and developed a pressure injury. Failure to assess and implement pressure injury prevention interventions potentially contributed to resident 2's development of a pressure injury. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. A review of facility reported event (FRI) for resident 2 revealed: *He admitted to facility on 6/5/24. *He was at risk for skin breakdown at admission. *He should have been turned and repositioned every two hours. *Only intervention in place at admit was heel lift boots for skin integrity. 2. A review of resident 2's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had diagnoses of: -Cerebral infarction (stroke). -Hypertensive emergency. -Acute respiratory failure. -Epilepsy (seizure disorder). -Spinal stenosis. *His 6/5/24 Braden scale (assessment for predicting pressure injury risk) score indicated he was at high risk for developing pressure ulcers. *His care plan dated 6/6/24 revealed: -He was to turn and reposition every two hours and as needed (PRN). -He needed total staff assistance with activities of daily living (ADLS) including bed mobility, dressing, hygiene, and locomotion. -Staff were to use a full-body mechanical lift with the assistance of two staff. -Staff were to apply a moisture barrier product to his peri-area after incontinent episodes. *On 6/7/24 a request was made for a bariatric air mattress and wheelchair cushion for skin integrity as he cannot move independently. *On 6/9/24 his family and provider were notified he had a blister on his coccyx (tailbone). *On 6/9/24, the provider ordered a foam border dressing and barrier cream to be applied to his coccyx. *On 6/11/24 orders were received for: -Bariatric air mattress. -Pressure redistribution wheelchair cushion. -Wound care referral for new wound on coccyx -Reposition every two hours (was a verbal order). *On 6/13/24 his Braden scale score indicated his risk had increased to being at very high risk for developing pressure ulcers. *His weekly skin assessments dated 6/10/24, 6/17/24, and 6/24/24 were signed off as being completed, but were not completed. 3. Review of provider's wound report dated 5/1/24 to 7/9/24 revealed resident 2 had a Stage one Pressure/Ulceration wound to the right outer rim of his ear identified on 6/14/24. 4. Interview on 7/9/24 at 1:05 p.m. with Administrator A regarding weekly skin assessments revealed: *Resident 2's skin assessments 6/10/24 and 6/17/24 had not been completed, but were signed off as completed. *His skin assessment dated [DATE] was signed off, but the resident was admitted to the hospital on 6/18/24 and then discharged . *An audit was completed on 6/21/24 for wound/skin documentation and follow-up. 5. Interview on 7/9/24 at 1:12 p.m. with certified nursing assistant (CNA) G revealed: *Skin alterations were documented under the skin task in the EMR system. *She would report those to the nurse. *Red skin would be observed and placed on the wound watch list. 6. Interview on 7/9/24 at 1:16 p.m. with licensed practical nurse (LPN) F revealed: *She would check skin notes first to see if something was documented. *A risk management report would be completed for all skin areas/concerns. *She would then contact the resident's family and provider. *Wound nurses would do rounds on Tuesdays. *Floor nurses were responsible for doing the weekly skin assessments on residents. *She would notify the on-call RN for management, of any immediate concerns/problems. 7. Interview on 7/9/24 at 1:28 p.m. with CNA H revealed: *Skin issues were reported to the charge nurse. *She documented them in the skin task in the EMR system. *Nurses assessed the area and took over from there. 8. Interview on 7/9/24 at 2:13 p.m. with assistant director of nursing (ADON) B revealed: *When resident 2 came to the facility she had just started her position. *There was a lesion/blister found on his coccyx over the weekend. *A silicone barrier was placed per standing orders. *On 6/11/24 on wound rounds she and ADON C had removed the old dressing. -Another blister under the adhesive had occurred. -When the dressing was removed the blister popped. -They cleaned the area and replaced the dressing. *She was unaware why every two-hour repositioning was not initiated per his care plan. *On-call was also notified of skin issues. *Weekly wound rounds are done every Tuesday. *Management meeting's were on Wednesdays, and they discussed patients who were at risk for skin breakdown. 9. Interview on 7/10/24 at 12:36 p.m. with Minimum Data Set (MDS) coordinator E revealed: *She completed the care plans for all residents. *She opened the sections for completion by other disciplines. *The floor nurses completed the user-defined assessments on admission. *She put every two-hour repositioning for resident 2 in his care plan dated 6/6/24. *Based on diagnosis and history and physical data on admission. *ADON C would have put in the treatment administration record order for every two-hour repositioning. -She was unsure of the date of that order. 10. Follow-up interview on 7/10/24 at 12:43 p.m. with ADON C revealed: *She had entered the every two-hour repositioning order in resident 2's chart on 6/11/24 most likely due to observations during wound rounds. *She would have expected the nurse's to verify the repositioning was being completed by the CNA's. *MDS coordinator E would have put the task in the system for CNAs to complete the repositioning. 11. Follow-up interview on 7/10/24 at 12:58 p.m. with MDS coordinator E revealed: *She thought it was, a miscommunication on who was doing what. *For resident 2 It was not in the CNAs tasks (to reposition). *The order for nurses to sign off on the repositioning was initiated on 6/11/24. *She was no longer able to access any tasks for resident 2 because, he had discharged from the facility. 12. Interview on 7/10/24 at 4:02 p.m. with Administrator A revealed: *The standard of care would be something that should be followed, the task are just extra items for the CNA's and that would be that they checked on and reposition every two hours. 13. Review of providers Skin and Pressure Injury Prevention Program policy last reviewed on 3/23/23 revealed: *To ensure a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable. *To provide care and services to prevent pressure injury development and to promote the healing of pressure injuries/wounds that are present. *A plan of care will be put in place for residents that are identified with actual skin breakdown or at-risk for skin breakdown. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 6/24/24 after: record review and staff interviews revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding wound/skin documentation and follow-up, and staff were aware of the provider's procedure for assessing, monitoring, implementing interventions, and documentation of interventions provided to prevent the development of pressure injuries. Based on the above information, non-compliance at F686 occurred on 6/9/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 7/9/24, the non-compliance is considered past non-compliance.

Based on observation, record review, interview, and policy review, the provider failed to ensure: *A bowel management program was monitored for one of one sampled resident (9) who had multiple diarrhea consistency stools and unintentional weight loss. *Appropriate and necessary notification of resident 9's physician assistant (PA) H and registered dietician (RD) I about the consistency and amount of her stools. Findings include: 1. Observation on 5/13/24 from 5:30 p.m. to 6:00 p.m. of resident 9 while in the dining room during the evening meal revealed: *She was sitting in a wheelchair and had a small, frail, bony appearance. *She was eating a meal from a fast-food restaurant. Interview on 5/14/24 at 9:30 a.m. with resident 9 revealed: *She felt she was losing weight because she poops all the time and everything goes right through me. -She stated she was having a watery bowel movement (BM) with every toileting and often had incontinent (uncontrolled) BMs. -She stated, I have had water poop for a long time. I think it is those pills they give me. Review of resident 9's electronic medical record (EMR) revealed: *She was admitted on [DATE] with the primary diagnosis of ataxic (impaired coordination) cerebral palsy. *Her weight on admission was 115.8 pounds. *On 2/6/24 the resident weighed 99.7 pounds. -On 5/7/24 her weight was 93.6 pounds. -That was a 6.12% weight loss within a three month time period. *She was not on a physician prescribed weight loss program. *She was eating between 50 and 100 percent of her meals and also accepted a snack most evenings. *Her medication administration record (MAR) revealed she was drinking 100% of Liquacel dietary supplement, one ounce, twice a day, and a 2.0 calorie supplement drink, four ounces, three times a day. *Her 4/12/24 Brief Interview of Mental Status (BIMS) score was 14, indicating she was cognitively intact. Review of resident 9's Point Click Care (PCC) BM record from 4/14/24 to 5/14/24 revealed: *Resident 9 had 48 BMs in a 30-day period. -33 of those stools were documented as diarrhea loose. -8 stools were putty like and 7 were formed stools. Further review of resident 9's April and May 2024 MARs revealed the following: *A 7/19/23 physician's order for a MiraLax (a laxative)17 gram oral packet to have been mixed with fluid daily in the morning. *A 11/25/21 physician's order for docusate sodium (stool softener)100 milligram tablet to be given daily in the morning. *The MiraLax was refused by the resident seven times on 4/5, 4/7, 4/8, 4/10, 5/11, 5/13, and 5/14. -There was no documentation found that indicated staff had held her laxative or stool softener due to diarrhea (loose) stools. Further review of resident 9's EMR revealed: *There was no documentation found that indicated the physician had been notified of her frequent loose stools. *Her 4/12/24 quarterly Minimum Data Set (MDS) assessment's section H revealed she was occasionally incontinent of BM. *Her 4/12/24 Braden skin assessment revealed a score of 18, indicating she was at high risk for skin breakdown. Interview on 5/14/24 at 3:38 p.m. with certified nursing assistant (CNA) G regarding resident 9 revealed: *She was aware the resident was having frequent loose stools. -She stated the CNA's charted the consistency of the BMs in PCC for the nurses to use as a reference. Interview on 5/14/24 at 3:42 p.m. with registered nurse (RN) F revealed she: *Stated since PCC was updated, she was unable to view CNA charting on BM consistency. *Was aware resident 9 had loose stools and stated that was normal for her. -Was unable to explain why the resident was taking both a laxative and a stool softener every day if she was having loose stools. *Was unsure if the physician had been notified of the resident's loose stools. Interview on 5/14/24 at 4:05 p.m. with MDS coordinator E revealed: *She was aware resident 9 was having loose stools. -Stated resident 9's loose stools were sporadic and she expected the nurses to have held the laxative medication when her stools were loose. *Stated the nurses were able to view a resident's BM consistency in PCC. -It was located under a separate tab in the bowel documentation area. *She was unaware if the physician had been notified of the resident's loose stools. 2. Interview on 5/15/24 at 8:30 a.m. with resident 9's physician assistant (PA) H regarding weight loss and loose stools revealed: *She was not aware the resident was having multiple loose, diarrhea consistency stools. -It was her expectation for staff to have notified her about that issue. -She stated that during her monthly visits with the resident, she had never complained of having loose stools. *She confirmed multiple diarrhea stools could be a factor in the resident's weight loss. Interview on 5/15/24 at 9:40 a.m. with administrator A, director of nursing (DON) B, and nurse supervisor D regarding resident 9's weight loss and loose stools revealed: *They stated it was the resident's normal to have loose stools on occasion, but were unaware of how frequently it was occurring. *They were aware of the resident's weight loss despite nutritional interventions. -They had attributed the weight loss to her progression of cerebral palsy disease and mental decline. *Their expectation was for the aides to communicate to the nurses when the resident was having loose, diarrhea stools. Interview on 5/15/24 at 10:54 a.m. with consulting dietitian I regarding resident 9 revealed: *She had worked as the provider's dietitian on a consultant basis for at least 2 years. *She reviewed the resident's charts remotely and performed an on-site visit with the residents and the interdisciplinary team once a month. *She was aware the resident had been losing weight and was monitoring her as a nutritionally high-risk resident. *She was able to view a resident's BM frequency in PCC, but had not known how to view the BM's consistency. *Staff had not informed her of the resident's loose stools. -She depended on staff to notify her of changes in a resident's condition. Review of the provider's 8/23/23 Notification of Change of Condition policy revealed: *1. The facility must immediately inform the resident; consult with the resident's medical provider; and notify, consistent with his or her authority, the resident representative(s) when: -c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or . Review of the provider's 12/1/19 CNA and RN job description and the March 2021 Toileting and Incontinence policy revealed: *There was no mention of reporting frequent loose stools to the nurse or the physician. *There was no mention of holding laxatives or stool softeners during episodes of loose stools.

Based on observation, interview, record review, and policy review, the provider failed to ensure six of eight sampled residents (23, 29, 31, 48, 56, and 118) who were at high risk for skin breakdown and dependent upon staff to assist them with activities of daily living (ADL) had the appropriate interventions in place to prevent pressure ulcers from developing or worsening. Findings include: 1. Review of resident 31's medical record revealed: *She had been been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had: -Good memory recall and was capable of making her needs known. -Been dependent upon the staff to assist her with all ADL. --That had included bed mobility and transfers. -A history of pressure ulcers to her coccyx area. *Her Braden Scale for Predicting Pressure ulcers score as of 11/9/18 was a fourteen indicating she was at moderate risk for skin breakdown. Observation on 1/7/19 at 3:44 p.m. of resident 31 revealed she: *Had been sitting in a bariatric wheelchair (w/c) in the doorway to her room. *Had pressure relieving devices for her w/c. *Had pressure relieving boots on both of her feet that were resting on the w/c pedals. *Was able to move her arms without difficulty, but no spontaneous movement of her legs was observed. Observation on 1/7/19 at 4:00 p.m. with certified nursing assistants (CNA) L and M with resident 31 revealed: *They had prepared to assist the resident to lay down in her bed. *The resident had: -Required the use of a mechanical lift to transfer from her w/c to the bed. -Required the use of a bariatric bed due to her obesity. -Been incontinent of urine. -Required the CNAs to assist her with positioning, incontinence care, and dressing. *When she had been turned onto her right side there was a 4 x (by) 4 protective dressing covering her coccyx area. *The CNAs: -Positioned her on her back and took the pressure relieving boots off her feet. -Placed her heels directly on the mattress without using any devices to ensure relief from pressure. -Raised the head of her bed to a forty-five degree angle. --That position had placed pressure directly on her coccyx area. Interview on 1/7/19 at 4:54 p.m. with the assistant director of nursing (ADON) regarding resident 31 revealed the resident had a wound on her coccyx. That wound had been acquired while in the facility and receiving care from them. Random observations on 1/8/19 from 7:45 a.m. through 3:15 p.m. of resident 31 revealed: *She had been laying in bed on her back with feet/heels directly on the mattress. *The head of her bed was a forty-five degree angle putting direct pressure on her coccyx area. *She had been laying in bed and in the same position for almost four hours. *No observation of staff attempting to reposition her to ensure pressure relief had occurred on the heels and coccyx areas. *At 11:30 a.m. staff assisted her out of her bed and into her w/c. -She had an appointment out of the facility. *At 2:35 p.m. she returned from her appointment. -An unidentified staff member took her directly to the dining room for an activity. *At 3:15 p.m. that same staff member assisted her to her room and laid her down to rest. -She was positioned in her bed as observed above. *From 11:30 a.m. through 3:15 p.m. she had been sitting her w/c for almost four hours without pressure relief to her coccyx area. Observation and interview on 1/9/19 at 7:30 a.m. with resident 31 revealed she: *Had been laying in bed and in the same position as observed above on 1/8/19. *Preferred to stay in her bed during the morning hours. *Was not: -Sure if the staff had offered to turn her onto another side. -Able to reposition herself without their assistance. -Sure what offloading was. *Did not wear the pressure relieving boots in bed. Interview on 1/9/19 at 8:45 a.m. with certified nursing assistant (CNA O) regarding resident 31 revealed: *She confirmed the resident: -Had preferred to stay in bed during the morning hours. -Required the staff to assist her with repositioning and incontinence care. *She stated: -We will check on her to see if she is wet. -She can tell us when she is wet. -We will position her onto her sides if she allows it. -I just placed her on her back. -She will stay in that position until I get her up around 10:30ish. -Once she is up she will stay up through the rest of my shift which is 2:00 o'clock. -I'm not sure what the evening shift does with her but we check to make sure she is not wet. Review of resident 31's 11/9/18 quarterly Minimum Data Set (MDS) assessment revealed she had: *A risk for skin breakdown/ulcers. *Pressure relieving devices for her bed and w/c. *No repositioning program in place. Review of resident 31's weekly skin check assessment forms revealed: *On 12/14/18 the staff identified a small opened area to her coccyx. -An unidentified type of cream had been applied to that area of concern. -There was redness noted to her buttocks. *On 12/21/18 no change from the 12/14/18 documentation. *On 12/18/18 she had no new skin issues. *On 1/4/19 the staff identified a stage 2 pressure ulcer to her coccyx area with a referral to the wound evaluation form. -She continued to have redness noted to her buttocks. *No documentation in the comment section to support: -The physician, family, dietician, and wound nurse had been notified. -The appearance, size, and type of wound that had been identified on three of the four assessments. -Who had identified and assessed those areas of concern. Review of resident 31's weekly wound evaluation assessment forms revealed: *On 12/24/18: -A stage 2 pressure ulcer had been identified on her coccyx as of 12/21/18. -The physician had been notified of that pressure ulcer by a faxed message. -No documentation to support the family or resident's representative had been notified. -No treatment had been ordered nor recommended. -A w/c cushion and vitamin supplements had been used as preventative interventions. -The resident had been educated to offload every two hours when she was in her bed and every fifteen to thirty minutes when sitting in the w/c. She had verbalized understanding. -There was no documentation to support she required: --A turning/repositioning program. --The use of positioning devices. *On 12/31/18 a treatment for [REDACTED]. -The rest of the documentation remained unchanged from 12/24/18. *On 1/7/19: -The pressure ulcer had progressed and worsened from a stage 2 to a stage 3. -The rest of the documentation remained unchanged from 12/24/18 and 12/31/18. *All the assessments had been completed by the facility wound nurse. *Those assessments had not: -Noted the wound was initially identified on 12/14/18. -Been initiated until ten days after an unidentified staff member had first observed the pressure ulcer on 12/14/18. -Supported her inability to reposition and offload herself to ensure pressure ulcers would not have occurred. -Supported her risk of pressure ulcers and the need for a repositioning program and repositioning devices. Continued medical record review for resident 31 revealed: *On 12/14/18 a stage 2 pressure ulcer had been observed on her coccyx. -Twenty-five days later that wound had worsened and progressed to a stage 3. *On 12/24/18 the physician had been notified of the pressure ulcer by a faxed order. -That was ten days after the wound had been initially identified. *On 12/28/18 the physician had faxed them a treatment for [REDACTED]. -That was fourteen days after the wound had been identified and four days after the notification had been sent. *On 12/31/18 the staff had noted the faxed order they had received from the physician on 12/28/18. -That treatment was not initiated until the next day on 1/1/19. *On 1/7/19 the physician had been updated on the status of the wound with a request for a different treatment. -That wound had worsened from a stage 2 to a stage 3. *No documentation to support: -The dietary department had been informed and involved with the healing process of that wound prior to 1/9/19. -When the resident's representative had been notified of that wound. Review of the resident 31's comprehensive care plan revealed: *Had different initiation and revision dates for all the focus areas developed for her. *A focus area identifying a risk for skin breakdown related to (r/t) incontinence and impaired mobility. -Goals and interventions had been put in place to promote prevention and healing of wounds. -The staff were to have repositioned and changed her incontinent brief every two hours. *A focus area identifying a stage 3 pressure ulcer r/t her to immobility. -The staff were to have avoided positioning her on her coccyx. -She had required reminding and assistance with repositioning every two hours or more as needed or upon request. Interview on 1/9/19 at 1:45 p.m. with the registered dietician (RD) regarding resident 31 revealed she: *Was not aware of the stage 3 pressure ulcer to her coccyx. *Had been on vacation and could have missed an email sent to her regarding that concern. *Would have typically received an email from the wound nurse regarding the identification of a wound. *Confirmed the wound nurse was in the facility weekly. *Could not confirm if the other staff nurses would have notified her of a wound in the absence of the wound nurse. *Would check her emails and get back to the surveyor. Further interview on 1/9/19 at 2:15 p.m. with the RD regarding resident 31 revealed: *She: -Had received an email from the wound nurse on 12/24/18 notifying her of a wound. -Had not received any other notification prior to that date. *The administration would have discussed the wounds in the facility every day Monday through Friday. *She was currently on a fortified cereal, and she felt that was sufficient at the time of the notification. *She agreed: -Her assessment and documentation of the resident and her wound was not completed in a timely manner. -Proper nutrition and diet was important to help with the healing of a wound. *She had completed an assessment later that day on 1/9/19 for her and added additional supplements to her diet to promote the healing of that wound. -Those recommendations were not put in place until twenty-seven days after the pressure ulcer was initially observed. 2. Review of resident 23's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *He had: -Good memory recall and was capable of making his needs known. -A history of poor decision making abilities to ensure negative outcome would not have occurred. *Confirmed he had been: -Capable of transferring himself in and out of the bed with a transfer board. -Able to reposition himself with the use of side rails. *He: -Would have requested their assistance when needed. -Was admitted with an unstageable wound to the coccyx region. *His Braden Scale for Predicting Pressure ulcers score as of 11/5/18 was a fifteen indicating he was at moderate risk for skin breakdown. Observation on 1/7/19 at 4:22 p.m. of resident 23's room revealed: *He was not in his room. *The bed had an alternating pressure low air loss mattress on it. *There were multiple wound care and dressing supplies placed on his dresser. Interview on 1/7/19 at 4:52 p.m. with the ADON regarding resident 23 revealed he: *Was a paraplegic and had been admitted with a pressure ulcer on his coccyx area. *Did have a pressure ulcer on his left buttock that was acquired during his stay here. *Required daily dressing changes to those wounds. Observation and interview on 1/7/19 at 5:20 p.m. of resident 23 revealed he: *Was at a dining room table sitting in a w/c by himself. *Had been waiting for his granddaughter to join him for supper. *Was able to propel the w/c away from the table and independently throughout the facility. *Was able to move his arms without difficulty, but no spontaneous movement of his legs was observed. *Had pressure relieving devices for his w/c. *Confirmed the pressure ulcers to his bottom and gave the surveyor permission to watch the dressing changes for them in the morning. Observation on 1/8/19 at 9:35 a.m. with registered nurse (RN) C with resident 23 revealed: *She had prepared to complete dressing changes to the wounds above. *The resident had: -Been laying in bed on his back. -Been able to position himself onto his right side for easier access to his wounds. -Three 4x4 gauze dressings attached to his bottom area. --Those dressings were intact with no discoloration on the exterior surface. *RN C: -Had removed the old dressings to expose an opened stage 3 pressure ulcer to his coccyx and several other smaller wounds on his buttocks. --There had been approximately seven other wounds located on both sides of his buttocks. --Those wounds were all located on pressure point areas. --Those wounds were random in size from approximately 0.5 centimeter (cm) x (by) 0.5 cm to 1.5 cm x 2.5 cm. --The wound beds had varied in depth, were moist, and were either pink or yellow in color. -Stated I don't believe he had all of these yesterday when the wound nurse did his assessment, esp (especially) the small one at the crease of his right buttock. -Cleaned the wounds with the same pair of gloves she had used to set-up the supplies and remove the old dressings with. -Removed her gloves, washed her hands, and left the room to allow the physical therapy department to complete a heat treatment to those wounds. Interview and observation on 1/8/19 at 10:50 a.m. with RN C regarding resident 23 revealed: *She had confirmed he was: -At high risk for skin breakdown. -Capable of moving and repositioning himself in the bed and w/c without difficulty. *He would have: -Spent the majority of his morning in the bed. -Limited his amount of time he spent sitting in his w/c to promote the healing of the wounds. *The staff were to have encouraged him to reposition himself every two to three hours. Interviews on 1/8/19 at 1:30 p.m. and on 1/15/19 at 10:43 a.m. with resident 23 revealed: *Both times he was laying in bed resting on his back. *He: -Was capable of repositioning himself in the bed. -Only required assistance from the staff with transfers and care of his [MEDICAL CONDITION]. -Remained in his bed the entire morning to promote the healing of the wounds on his bottom. -Would have gotten out of bed at approximately 2:30 p.m. and would not have returned to his room and to bed until after 8:30 p.m. -Confirmed he had little to no feeling and sensation from the waist down. -Would have remained in the same position for two to three hours or when his hips started to feel uncomfortable. -Confirmed he was at high risk for skin breakdown and thought two to three hours was an appropriate length of time between repositioning. -Stated I've been taking care of myself for a very long time, so there is no need for them to do it for me. *The staff would not have reminded him to reposition himself. Interview on 1/15/19 at 10:46 a.m. with certified nursing assistant (CNA O) regarding resident 23 revealed she: *Confirmed the above interview with the resident. *Stated: -He typically stays in bed from 6:00 a.m. to 2:00 p.m. on the day shift. -I'm not sure what he does during the evenings. -We don't have to remind him to reposition or move because he does it himself. -He prefers his independence. -We only help him if he asks like with the transfer board or taking care of his [MEDICAL CONDITION]. Review of resident 23's admission MDS assessment revealed he had: *Required extensive assistance with bed mobility. *Required limited assistance with dressing and hygiene. *A risk for skin breakdown/ulcers and had a history of [REDACTED]. *Pressure relieving devices for his bed and w/c. *No repositioning program in place. Review of resident 23's 11/5/18 comprehensive care plan revealed: *A focus area identifying him at risk for skin breakdown d/t (due to) immobility, and [MEDICAL CONDITION] with a history of recurrent pressure ulcers. -Goals and interventions had been put in place to promote prevention and healing of wounds. -The staff were to have offered assistance with repositioning every two hours. *A focus area identifying a stage 3 pressure ulcer to his coccyx r/t (related to) immobility. -The staff were to have avoided positioning him on the wound. -The staff were to have encouraged or reminded the resident to limit his time on his back. *No documentation to support all of the other areas of concern observed on both of his buttocks with wound care. Interview on 1/15/19 at 11:30 a.m. with physical therapist (PT) and certified wound specialist (CWS) U regarding resident 23 revealed: *He was the wound care consultant for the facility and for those residents receiving Medicare part B benefits for their wounds. *He was working with the wound nurse on the care and treatment for [REDACTED]. *He confirmed: -The resident had been admitted with one wound, and that had been located on his coccyx. -He was alert, oriented, and preferred his independence with repositioning and personal care. -He was at high risk for skin breakdown d/t his multiple co-morbidities that had included [MEDICAL CONDITION] and the decreased sensation from the waist down. -He had several areas of concern that he had acquired after his admission. *He: -Was aware of the wounds he had acquired on his left buttock. -Was not aware of the wounds he had recently acquired on his right buttock. -Was not aware the staff had not been assisting him with repositioning or reminding him to move. -Not aware he had remained in one position until his hips became uncomfortable. --That had been approximately two to three hours. -Would have expected the resident to have been repositioned at a minimum of every hour. -Did not consider his new wounds to have been from pressure. *He stated: -Those wounds are from friction and the removal of the tape or adhesive from the dressings. -Those wounds started from the top (outside surface of the skin) and did not start from the bottom (underneath the surface of the skin) from the bottom up. --He repeated that statement multiple times. *He agreed the new wounds had been located in high pressure point areas. -Again he repeated the above statements. *He had not monitored or watched the staff complete dressing changes on the resident. *He agreed an unsanitary dressing change could have: -Interfered with the healing process of the wound. -Created the potential for infection to have occurred. *He agreed the resident had the right to not acquire any type of new wounds after he had been admitted . Interview on 1/15/19 at 11:50 p.m. with the medical director regarding resident 23 revealed she: *Had not been aware of all the above concerns identified through observation, interviews, and record review for the resident. *Agreed the resident: -Had been at high risk for skin breakdown. -Preferred to be as independent as possible and was capable of making his needs known. -Was unable to properly care for himself prior to his admission. -Required assistance with ADLs and wound care to promote the healing of that wound on his coccyx. *Agreed the staff should have been involved with the repositioning and care of the resident to ensure no further skin breakdown had occurred. Interview on 1/15/19 at 3:40 p.m. with the director of nursing (DON), ADON, MDS assessment coordinator, and clinical consultant regarding resident 23 revealed they: *Had not been aware of above the concerns identified through observation, interviews, and record review for the resident. *Confirmed he had been: -At high risk for skin breakdown d/t the severity of his diagnoses. --That had included his decreased sensation and mobility. -admitted with one wound to his coccyx area. *Confirmed: -He had acquired several more opened wounds since his admission. -Those new wounds should have been identified as pressure ulcers d/t their location and his risk factor for developing them. *Had not been aware the staff had not been involved with ensuring he was moving and repositioning himself frequently. *Would have expected him to have been repositioned every hour or more. *Had no documentation to support he had been educated on the risk factors of acquiring more wounds from the routine he currently used for self care and positioning. 3. Review of resident 29's medical record revealed: *He had been readmitted on [DATE] from an acute care setting. *His [DIAGNOSES REDACTED]. *He had been dependent upon the staff to assist him with all (activities of daily living) ADL including bed mobility and transfers. *He had not been readmitted on [DATE] with wounds to his right buttock. *On 1/9/19 at 4:30 p.m. LPN E had documented on the appearance of the resident's BM and had sent a fax to the MD regarding that concern. -That documentation and fax had not mentioned the two areas of concern observed on the resident's right buttock. *On 1/10/19 no documentation to support the MD, wound nurse, administration, dietary department, and family representative had been notified about the two areas of concern identified on the resident's right buttock the day before. *No documentation to support the physician and wound nurse had been notified of the red areas on his buttocks until 1/11/19. -That notification had occurred after the surveyor had interviewed the staff on their process for wound notifications and treatment. Random observations on 1/8/19 from 7:50 a.m. through 11:30 a.m. and from 1:30 p.m. through 4:30 p.m. of resident 29 revealed: *He had appeared: -Very thin, weak, and frail with a flat affect. -To be able to move his upper body and arms without difficulty. *He had on the same clothes he was wearing the day before. -Not to be able to extend his legs out fully when laying in the bed. *He had been laying: -In his bed resting and was positioned on his back. -With his knees bent and a Rook boot on his left foot with a pressure relieving boot on his right foot. *He was awake occasionally and had talked very little when spoken to. *He had responded with short yes/no or one/two word answers and closed his eyes frequently. *He had a suprapubic catheter attached to a collection bag hanging from the bed frame. -The urine in the collection bag was gold colored. *His room had a pungent urine odor. *He required the use of oxygen to be delivered continuously at 3 liters per minute (LPM). Random observations on 1/9/19 from 8:43 a.m. through 11:30 a.m. of resident 29 revealed the same observation as above on 1/8/19. Observation and interview on 1/9/19 at 11:30 a.m. of CNAs V and T with resident 29 revealed: *They had prepared to assist him with personal care and transfer him from the bed into his w/c. *He had been laying on his back and in the same way as observed above. *He had been incontinent of a moderate amount of sticky and red/brown colored bowel movement (BM). *The CNAs assisted the resident with cleaning the BM off his bottom. *There were two areas of concern observed on his right buttock. -Those areas were red in color and approximately 1.5 cm x 1.0 cm in size. -One of the reddened areas had blanched when the CNA touched it, but the other one did not. *CNA V left the room to get the charge nurse to further observe the color of his stool and the areas of concern identified during his care. Further observation and interview on 1/9/19 at 11:40 a.m. of LPN E with resident 29 revealed: *She: -Assessed the areas of concern, and initially stated there was nothing there. -Upon re-assessment with the surveyor she was able to identify the two areas of concern on his right buttock. *She stated: -We have a wound nurse that comes in every Monday. -I'll have (staff name) look at it and will send a fax to the MD (medical doctor). -Typically we just use barrier cream for areas like that. Random observations on 1/9/19 from 1:30 p.m. through 4:30 p.m. of resident 29 revealed the same observation as above on 1/8/19 and the morning of 1/9/19. Observation and interview on 1/15/19 at 8:15 a.m. of CNA G with resident 29 revealed: *He had prepared to assist the resident with personal care and laying down in his bed. *He had positioned the resident on his back. *He had not offered nor attempted to position the resident on his side. *The resident was to have been moved every two hours. *CNA G: -Checked the Kardex to show the surveyor where they checked for guidance on repositioning and care of a resident. --That Kardex indicated he should have been repositioned every hour. -Was not aware of the change and checked further into the care plan area. --That care plan area did not agree with the Kardex and directed the staff to reposition him every two hours. -Checked with the MDS assessment coordinator for clarification, and she confirmed he was to be repositioned every hour. *The MDS assessment coordinator had not been aware the two areas had not matched, and they should have. -She had to look at the system to ensure the changes would occur in both places. *She confirmed the staff utilized the Kardex and care plan to direct them with resident care. Review of resident 29's 1/8/19 comprehensive care plan revealed: *He: -Was at high risk for skin breakdown d/t immobility concerns. -Was to have worn the black foam boots when he was in bed. -Required extensive assistance of one staff person with bed mobility. -Had preferred to stay in bed most of the day. *No documentation to support he required a repositioning program to ensure skin breakdown had not occurred. 4. Interview on 1/9/19 at 4:40 p.m. with RN N revealed she: *Had been the wound care nurse for the facility. *Was hired for that position in (MONTH) (YEAR). *Had not completed any courses to have been considered a wound care specialist. -Her training had been from webinars and various online courses. *Would have been in the facility on Mondays to do wound care, assessments, and ensure they were receiving the appropriate care and treatment for [REDACTED]. *Was aware: -The staff would not have completed a full assessment on any of the wounds and waited for her to complete them. -The staff would not have put interventions in place or notified the appropriate parties to ensure treatment and healing of those wounds was initiated and started in a timely manner. -There was a delay in physician notification and the request for treatment from them. -The staff had not followed-up on her faxed requests and notifications to the physicians. -The physicians had not been responding to the faxed concerns and request for treatments in a timely manner. -There was no process in place to notify her of new or worsening wounds. --She would have to review all the resident's weekly skin sheets every Monday prior to completing her assessments to identify any new or worsening wounds she should have assessed. *Would have updated the care plans with any wound issues, concerns, and changes required. *Was not aware resident 31: -Had acquired the wound to her coccyx on or before 12/14/18. -Was unable to reposition or offload herself without staff support when laying in bed or sitting up in the w/c. -Was not having her heels/feet offloaded when laying in bed. -Was laying in bed or sitting up in her w/c for extensive lengths of time without being repositioned. *She confirmed resident 23 had been at high risk for skin breakdown and preferred his independence with care. *Was not aware: -Of all the new areas of concern identified on resident 23's bottom when his treatment was completed on 1/8/19. -The staff would not have ensured resident 23 had been repositioning himself in a timely manner to ensure no further skin breakdown had occurred. *She confirmed: -The PT/CWS from American Medical Technologies (AMT) was her resource and consultant for wound care management. -Provider did not have any other resources in place for her or the staff to follow to ensure proper care and treatment for [REDACTED]. *Agreed: -A treatment completed in an unsanitary manner would have created the potential for poor healing and infection to have occurred. -The current process for wound management and care had been reactive versus proactive to ensure skin breakdown and healing would not have occurred. *She would have expected: -The staff to have followed-up on her faxed notifications to the physician in her absence. --That had not been occurring. -The staff to have documented, assessed, notified the appropriate parties, and put interventions in place to ensure the timeliness of wound healing would have occurred. Interview on 1/15/19 at 9:25 a.m. with RN C revealed: *The staff would have faxed over notifications, treatment, and order change requests to the physician. *Each wing had their own clipboard and those faxes were placed on them until they received a response from the physician. *The staff should have refaxed the request to the physician or called them if there was no response within twenty-four to forty-eight hours. *Depending on the type of request the physicians might not return the fax for several days. -Such as a fall without injury. *A wound or skin concern should have had more timely response and been refaxed if no response within that timeframe. *She stated Wounds are more urgent and should be handled sooner. *The wound nurse would have put her faxed requests on that clipboard, and the nurses on each unit should have checked on them in her absence. *She confirmed the medical record review of resident 29 and stated: -They didn't followup on him and those areas until 1/11/19. -On 1/11/19 the wound nurse assessed him and those areas blanched. -But no one did anything until you started questioning about it. Interview on 1/15/19 at 11:10 a.m. with the medical director revealed she: *Had only been notified regarding the appearance and concern of resident 29's BM. *Was informed of resident 29's reddened areas after the surveyor questioned the facility staff and their process on care and treatment of [REDACTED]. *Had been aware: -Of the delay with physician notification regarding wounds and treatment. -The physician's had not been responding to the notifications of wounds and request for treatments in a timely manner. -The staff had been waiting for the wound nurse to assess the wounds on Mondays. -The staff would have waited for the wound nurse to notify the physicians, dietary department, and family representatives regarding wounds. -The staff were not proactive in putting interventions in place to ensure wounds would not have occurred or to promote the healing of wounds. --They would have waited for the wound nurse to put those interventions in place weekly on Mondays. -The documentation and assessment of the wounds had been weak an

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being for all sixty-two residents. Findings include: 1. Interviews, observations, record reviews, and policy reviews throughout the course of the survey from 1/7/19 through 1/10/19 and from 1/15/19 through 1/16/19 revealed the administrator and the director of nursing had not ensured the safe management and overall well-being of the residents. Surveyor: Interview on 1/15/19 at 10:17 a.m. with the medical director revealed she:*Visited the facility frequently and was highly involved with the residents under her care. *Was available in-between her scheduled visits by phone or fax and made additional visits if needed. *Attended care conferences and therapy conferences in-person or by phone conference often. *Started as the medical director in (MONTH) (YEAR) but had been a medical director at other long-term care facilities for several years. *Indicated she was aware of the facility's high rate of facility-acquired pressure ulcers and had talked to them about it recently. *Attended the quality assurance performance improvement (QAPI) meetings at least quarterly but tried to come monthly. -If she missed the scheduled meeting she reviewed the minutes with the director of nursing at her next visit. *Was made aware of infection control concerns identified by the surveyors and confirmed there could have been a lack of communication, staff knowledge, and overall breakdown in that system. *Agreed proper nursing assessments should have been done for residents' changes in condition. -Those should have been documented and the physician notified. Review of the provider's 10/1/16 CEO (chief executive officer) job description revealed: *Purpose To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's business objectives. *Job duties had included monitoring of: -Each department's activities. -Nursing care. -Ensuring resident needs had been met. -Maintained a working knowledge of and ensured compliance with all governmental regulations. -All rules regarding resident's rights. -Positive relationships with the residents. Review of the provider's 10/1/16 Director of Nursing (DON) job description: *Plans, coordinates and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Maintains quality care that is consistent with company and regulatory standards. Assumes responsibilities of daily operations in the absence of CEO. *Oversees the nursing staff for the provision of quality and appropriate resident/patient care that meets or exceeds company and regulatory standards. *schedules and performs rounds to monitor and evaluate the quality and appropriateness of nursing care. *Maintains administrative authority, responsibility and accountability for the proper charting and documentation of care, medications and treatments. *Evaluates current and potential residents and patients to determine and maintain living center's ability to provide appropriate level of care. *Maintains regular and ongoing communication with the facility's Medical Director to identify educational needs for staff and provide quality care and services to meet the needs of residents. *Conducts daily Clinical Start-up meeting with the interdisciplinary team to review resident and patient status. *Attends the weekly at risk meeting and reviews modifications to residents' an patients' plan of care. *Oversees and monitors the Resident Assessment process for accuracy, attends care planning conferences periodically to determine compliance with care planning guidelines. *Collects, reviews and analyzes clinical outcome data and determines trends. Brings identified concerns to the QA&A committee for development of appropriate plans of action. *Supervises nursing staff and others for whom they are administratively or professionally responsible. Refer to F657, F658, F660, F684, F686, F690, F745, F759, F837, F842, F867, F880, and F881.

Based on observation, interview, record review, job description review, and policy review, the governing body failed to ensure the facility was operated in a manner that ensured the safe management and overall well-being for all sixty-two residents. Findings include: 1. The following deficiencies were repeated deficiencies from the previous recertification survey on 10/5/17: F658 and F880. The following deficiencies were newly cited for the current survey: F657, F660, F684, F686, F690, F745, F835, F842, F867, and F881.

Based on interview, record review, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been implemented to identify and address concerns related to residents' care within the facility. Findings include: 1. Interview on 1/16/19 at 8:51 a.m. with the administrator and regional director of operations regarding the QAPI program revealed: *The committee met monthly. *The medical director was new to the facility since (MONTH) (YEAR). -She had only missed the (MONTH) (YEAR) meeting. *They discussed and reviewed the Casper reports, reports generated in Point Click Care, and any departmental concerns brought to their attention. *They had recently identified a concern with the care plans and Kardexes. *They had not identified all the areas of concern identified during this recertification survey. *They had no performance improvement plans (PIP) in place right now. Review of the provider's (MONTH) (YEAR) Quality Assurance and Performance Improvement policy revealed: *It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. *The committee should have implemented appropriate plans of actions to correct identified quality deficiencies. Refer to F657, F658, F660, F684, F686, F690, F745, F842, F880, and F881.

Based on observation, record review, interview, guideline review, and policy review, the provider failed to provide the necessary care and services for three of three sampled residents (29, 41, and 42) who had changes in their condition and who required hospitalization for serious infections related to: *Lack of appropriate nursing assessment related to their conditions. *Incomplete documentation regarding their current condition and symptoms. *Inappropriate infection prevention measures. Findings include: 1. Random observations and interviews with resident 42 throughout the survey on 1/7/19 from 3:00 p.m. through 7:00 p.m.; on 1/8/19 from 7:15 a.m. through 7:00 p.m.; on 1/9/19 from 7:15 a.m. through 6:15 p.m.; on 1/10/19 from 7:15 a.m. though 10:45 a.m.; on 1/15/19 from 7:15 a.m. though 6:15 p.m.; and on 1/16/19 from 7:15 a.m. through 1:30 p.m. revealed she:*Had been admitted on [DATE]. *Was alert and oriented. *Had a suprapubic catheter. *Required staff assistance for care of her catheter including: -Site care. -Emptying the drainage bag -Changing from the large drainage bag to the leg bag and vice versa. *Felt her catheter site care was not happening as it should have been, and that could have been causing some of her urinary tract infections (UTIs). -She only got catheter care about every other day. --Refer to F690, finding 1. --Refer to F880, finding 8. *Preferred to have the catheter changed by the urology clinic staff. *had a history of [REDACTED]. -She was currently being treated for [REDACTED]. -The antibiotic for that infection had not been started timely. -Refer to F658, finding 1. Review of resident 42's medical record revealed she had been hospitalized for [REDACTED]. *From 2/18/18 through 2/22/18 for a [DIAGNOSES REDACTED]. *From 10/13/18 through 10/16/18 for an infected suprapubic catheter site. *From 12/6/18 through 12/8/18 for a UTI. Review of resident 42's eLTC notes from 2/17/18 revealed: *At 7:47 a.m. she was seen using a telehealth phone encounter. -The comments included: .Advised of weight trending up, need new weight not done since 8th. C/O (complaint of) SOB (shortness of breath) documented. No assessment to view, Possible heart failure exacerbation, need above completed to fully assess. Please complete this AM. -The orders included: STAT (immediate) weight. STAT head to toe assessment, listen to lung sounds and check for [MEDICAL CONDITION]. Weight patient (resident) every Monday, Wednesday, and Friday. Call if weight gain of 2 pounds in 3 days or 5 pound in 1 week . *At 12:35 p.m. she was seen again using telehealth. -The comments included: .resident with diminished lung sounds and shortness of breath. Oxygen increased to 3 LPM (liters per minute) with saturations in the 90s. Non [MEDICAL CONDITION] to legs and ankles. Outbreak of influenza at facility with confirmation . -The orders included nebulizer treatments four times a day while awake and every six hours at night as needed and to encourage fluids. Review of resident 42's interdisciplinary (IDT) progress notes related to the (MONTH) (YEAR) hospitalization revealed:*On 2/17/18 at 2:47 p.m. Received a call from eLTC this am in regards to residents c/o SOB. they wanted a full assessment, weight, vitals completed and a return call. -There was no documentation to support that assessment had been completed. -The documentation had not included the details in the eLTC note about her weight trending up. *On 2/17/18 at 3:48 p.m. Resident has had no behaviors. Resident is feeling under the weather, eltc (eLTC) notified, new orders received. Been sleeping in her wheelchair or her bed most of the day. *There was no mention of the above eLTC ordered nebulizer treatments being given or if they had helped or not.*On 2/17/18 at 11:30 p.m. an SBAR (Situation Background Assessment Recommendation) - change of condition note indicated she was not arousable, was laboring to breath, and using oxygen. eLTC was called and gave an order to send her to the emergency room (ER). -There was no further notes about her being admitted or why she had been hospitalized until the following 2/20/18 note that stated: -- .resident remains at RCRh (hospital). *On 2/22/18 there was a note about her returning, and she had been in the hospital with pneumonia. *The documentation for earlier in the day on 2/17/18 had not: -Been clear as to what was happening with her condition other than they had notified eLTC service. -Supported a thorough nursing assessment of her condition or symptoms relating to her [DIAGNOSES REDACTED]. Review of resident 42's IDT progress notes related to her (MONTH) (YEAR) hospitalization revealed: *On 10/12/18 at 10:58 a.m. Resident has c/o pain to bladder area. Urine is dark and cloudy. Resident has stated that her output has decreased. Nurse has advised resident to increase fluid intake. Nurse has suggested to have catheter flushed or changed. Resident has refused, stating that she has an appointment on 10/18 to have catheter changed. Left message for urologist . *On 10/12/18 at 3:47 p.m. .Urology nurse advised resident have suprapub (suprapubic) catheter changed .Urology said that resident could wait for her appointment or have nursing staff change the catheter .resident declined, stated that she would wait until her appointment with urology on 10/18 . *On 10/12/18 at 5:04 p.m. PCP (primary care provider) in facility and assessed resident. PCP stated advised that the catheter should be changed to help prevent an infection. Resident refused to allow catheter to be changed . Resident stated that she wanted to be seen at the ER or wait until her appointment. PCP gave order for resident to be seen in ED (emergency department), to have catheter changed, urine sample collected .Resident to be picked up at 0615 (6:15 a.m.) on 10/13/18 and be taken to ED. *On 10/13/18 at 7:00 a.m. Resident left facility to be evaluated by ER with UA (urine analysis) and suprapubic catheter change.*On 10/13/18 at 12:37 p.m. Phoned ER to check on resident and informed that resident will be admitted to (hospital) for infected suprapubic site. *Prior to her hospital admission on 10/13/18 there was no nursing assessment documentation of what the suprapubic catheter site looked like or if there were symptoms of an infection such as: -Redness. -Drainage. -Odor. -Change in the appearance of the site. --The documentation was focused on her refusal to have the facility change the catheter. *On 10/16/18 at 4:45 p.m. Resident returned to facility .Suprapub in place; urine draining yellow, with some discoloration notes . -There was no documentation to support a nursing assessment of the suprapubic catheter site upon her re-admission. Review of resident 42's IDT progress notes related to her (MONTH) (YEAR) hospitalization revealed: *She started treatment for [REDACTED]. *According to the documentation she was no longer on an antibiotic on 11/17/18. *On 12/4/18 physician orders [REDACTED]. -There was no supporting documentation of symptoms or a nursing assessment to indicate why the UA was ordered. *Notes on 12/4/18 and 12/5/18 had no nursing assessments or documentation of symptoms related to the UA order other than waiting for a culture of the urine. *On 12/6/18 a SBAR- Change of Condition note stated Resident urine cx (culture) results available. Complaints of increased back pain 9/10 .Chronic uti's, Dr. (name) notified of cx results. Ordered to have patient direct admitted to (hospital) for IV (intravenous) antibiotics d/t morganella morganii ua cx . -The only noted symptom was her back pain. -There was no documentation to support a nursing assessment related to the UTI such as: --Urine color. --Change in urine output. --Vital signs. --Any other concerns. *On 12/8/18 she returned from the hospital with orders for continued antibiotic therapy. Interview on 1/09/19 at 4:35 p.m. with registered nurse (RN) C and the assistant director of nursing (ADON) regarding resident 42 revealed:*She had a history of [REDACTED]. *They confirmed the documentation in her record had not supported complete and appropriate nursing assessments related to her above changes in condition. Interview and record review on 1/15/19 at 10:56 a.m. with RN C regarding resident 42 revealed: *She confirmed there had been a lack of nursing assessment documentation related to the resident's hospitalization s in February, October, and (MONTH) (YEAR). *The documentation should have supported the nurse's assessment and if the resident was having any symptoms or concerns. *For the (MONTH) (YEAR) hospitalization related to her infected suprapubic catheter site there was no documentation to support nursing staff had visualized the site other than her refusing to allow them to change the catheter. -She had a weekly skin check on 10/10/18 (three days prior to the hospitalization ) that indicated her suprapubic catheter site was slightly reddened with a treatment in place, but there were no further notes about it. *McGeer's criteria evaluations for infections should have been done by the nurse for any infections. -Those had not been completed for any of the above infections/hospitalization s. *Nursing Home to Hospital Transfer Forms (Interact Tools) should have been completed any time a resident went to the hospital. Review of those forms related to the resident's hospitalization s revealed:-The 2/18/18 form had not been completed until 9/26/18 (approximately seven months later). --That indicated she was transferred for abdominal pain that conflicted with the IDT notes. -The 10/13/18 form was completed on 10/15/18 after she had already been admitted for the infected suprapubic catheter site. It had not mentioned any symptoms prior to the transfer. -The 12/6/18 form was completed on 12/7/18 after she was had already been admitted and had not mentioned symptoms. Interview on 1/15/19 at 3:41 p.m. with the DON, ADON, Minimum Data Set (MDS) coordinator, and the regional clinical manager regarding resident 42 revealed:*They confirmed nursing assessments should have been done for the resident's change in condition and symptoms or any concerns identified especially prior to hospitalization s. *Nursing assessments should have been documented when they had been completed. *They were aware of concerns with nursing documentation. *They reviewed nursing documentation periodically, but there were no specific audits done. *If a nurse had not documented appropriately the DON would have spoken to them specifically about that concern. -It would have been verbal only and not written education. 2. Review of resident 41's medical record revealed:*She was admitted on [DATE]. *On 10/25/18 she was sent to the hospital and admitted with [DIAGNOSES REDACTED]. *While in the hospital she was also diagnosed with [REDACTED]. *On 10/30/18 she returned to the facility. Random observations of resident 41 throughout the survey on 1/7/19 from 3:00 p.m. through 7:00 p.m.; on 1/8/19 from 7:15 a.m. through 7:00 p.m.; on 1/9/19 from 7:15 a.m. through 6:15 p.m.; on 1/10/19 from 7:15 a.m. though 10:45 a.m.; on 1/15/19 from 7:15 a.m. though 6:15 p.m.; and on 1/16/19 from 7:15 a.m. through 1:30 p.m. revealed she:*Was non-verbal. *Was totally dependent on staff for all of her activities of daily living (ADL). *Spent most of her time in bed in her room. *Was fed through a continuous tube feeding. *Was incontinent of bowel and bladder. Review of resident 41's IDT notes from her admission on 10/3/18 through 1/8/19 revealed:*Her 10/3/18 admission note included she:-Came from the hospital with a [DIAGNOSES REDACTED]. -Was nonverbal with her eyes open. -Was on a continuous tube feeding. -Would have been working with therapies. *Several notes stated she was incontinent of bowel and bladder and required total staff assistance for all care. *On 10/25/18 at 4:10 a.m.: Resident is having some episodes of vomiting. Contacted On Call no answer left VM (voice mail). Contacted DON for further instructions. Called On call again with no answer awaiting call back.-There had been no mention of: --Vomiting or concerns prior to that. --Any other concerns or indication of a nurse's assessment. *On 10/25/18 at 6:05 a.m.: Received call back from Physician regarding Resident vomiting episodes that occurred during the night. Received verbal order to give PRN (as needed) [MEDICATION NAME]. -Review of the (MONTH) (YEAR) medication and treatment administration records indicated the [MEDICATION NAME] was not administered. *On 10/25/18 at 11:30 a.m. an SBAR - Change of Condition note stated: -Situation: Resident has been having emesis episode last night and several this AM. Very thick mucusy, yellow in color. -Background: Resident is a constant tube feed, Diabetic, Quad (quadriplegic) with a Peg (gastrostomy tube) site. -Assessment: vitals within normal limits. Thick emesis with light yellow color. Notified father, who wanted her sent out. Received order to send resident out via ambulance from Dr. (name) .*On 10/25/18 at 7:33 p.m.: Resident was admitted to the hospital [MEDICAL CONDITION], UTI, dehydration, and cough . *On 10/27/18 at 4:08 p.m.: .Called hospital .nurse there was (name). Stated that resident was weaned down to 1L (one liter) of O2 (oxygen), antibiotic was changed to [MEDICATION NAME], had 1 loose stool, congested and is being suctioned, and resident tested positive for Norovirus . *Prior to her hospitalization the only mention of a change in her condition was her vomiting episodes. *There had been no supporting documentation of a thorough nursing assessment such as: -Lung sounds or oxygen levels. -What her vital signs were. -If she was having any change in her urination or bowels. -If she had a cough while in the facility. Interview on 1/15/19 at 10:17 a.m. with the medical director who was also resident 41's physician revealed she:*Confirmed the resident was totally dependent on staff for ADLs. *Was aware of the resident's hospitalization in (MONTH) (YEAR) [MEDICAL CONDITION], UTI, dehydration, and cough along with her testing positive for Norovirus. *Indicated the facility had other episodes of Norovirus during that same time frame. *Stated Norovirus was highly contagious and the resident could have been exposed to it from staff working with her since she spent most of her time in her room and was dependent on them for care. *Proper nursing assessments should have been done and documented when residents had concerns or changes in their condition. Interview on 1/15/19 at 4:13 p.m. with the DON, ADON, MDS coordinator, and regional clinical director regarding resident 41 revealed: *They confirmed the resident was totally dependent on staff, non-verbal, and unable to communicate her needs. *Staff were responsible for observing for changes in her condition. *Nursing assessments should have been done related to any changes in condition or symptoms. -Those assessments should have been documented. *They felt she had gotten Norovirus while at the hospital. -They did not think other residents or staff had Norovirus or she was exposed to it in the facility prior to her hospitalization . Review of the provider's (MONTH) (YEAR) Employee Infection Record revealed: *Four employees had reported illnesses related to nausea, vomiting, and diarrhea from 10/22/18 through 10/24/18. *The resident's hospitalization occurred on 10/25/18. Review of the provider's (MONTH) (YEAR) Infection Log for residents revealed: *On 10/25/18 another resident had been listed for a UTI only, but she had Norovirus listed as an organism. *Resident 41 was listed only for a blood infection with nothing about her UTI or Norovirus. *Neither resident was listed as having facility-acquired infections. 3. Review of resident 29's medical record revealed: *He had recently been hospitalized from [DATE] through 1/5/19 for a catheter insertion site infection, pneumonia, and urinary tract infection [MEDICAL CONDITION]. -There had been purulent drainage surrounding the catheter insertion site. -During his hospitalization he had required the catheter insertion site to be cleaned four times a day. -On 1/7/19 the site cleaning had been decreased to twice a day per the resident's request. *He was currently being treated for [REDACTED]. Random observations and interviews with resident 29 on 1/8/19 from 7:50 a.m. through 11:30 a.m. and from 1:30 p.m. through 4:30 p.m.; on 1/9/19 from 8:43 a.m. through 11:30 a.m. and 1:30 p.m. through 4:30 p.m.; and on 1/10/19 from 8:10 a.m. through 11:35 a.m. of resident 29 revealed: *He appeared: -Very thin, weak, and frail, with a flat affect. -To be able to move his upper body and arms without difficulty. *He had worn the same clothes he was wearing the day before. *He had been laying in his bed resting and was positioned on his back. *He was awake occasionally and had talked very little when spoken to. *He had responded with short yes/no or one/two word answers and closed his eyes frequently. *He had a suprapubic catheter attached to a collection bag hanging from the bed frame. -The urine in the collection bag was golden colored. *He required staff assistance to take care of the catheter including site care and emptying the drainage bag. *He stated Ya, they clean the site, maybe every other day at the most. *His room had a pungent urine odor. Review of resident 29's IDT progress notes related to his hospitalized from [DATE] through 1/5/19 revealed: *On 12/18/18 at 5:09 p.m. Resident reported pain during pain assessment interview but declined offer of prn (as needed) pain medication. -No documentation to support where the pain was located and level of pain. *On 12/22/18 at 3:12 p.m. Resident has had no c/o (complaint of) rib pain this shift. He was noted with wheezing to L (left) upper lobe; received breathing tx (treatment) and was noted to have wheezing through-out, post tx. Resident denies c/o SOB (shortness of breath), difficulty with breathing or pain from ribs. P[NAME] (plan of care) continues. -That assessment had been completed four days after his initial complaints of pain. -No documentation to support the physician had been notified of his change in condition. *On 12/24/18 at 5:44 p.m. Resident continues to c/o pain to chest. States that it hurts when he moves or coughs. L upper lobe had minimal wheezing noted; all other lobes were clear but diminished. Resident has not 'held onto' his chest this shift. Nurse explained importance of his breathing txs and getting up out of bed. Resident stated that he understood. *On 12/24/18 at 11:53 p.m. Remains alert to self with some confusion. Staff encourage him to come to dining room for meals, poor appetite noted. Staff assist with all ADLs and transfers. Wears foam boots in bed. Oxygen continual and saturation above 90% (percent). Denies pain at this time. Takes medications whole without difficulty. Staff do attempt to encourage some independence as he often requests staff assistance with sips of water etc (etcetera). -That documentation had occurred two days after the initial assessment of abnormal lung sounds. -No documentation to support at 11:53 p.m. the unidentified staff member had assessed his lung sounds. *On 12/27/18 at 3:40 p.m. Resident was having a decline in condition this shift. (physician name) was notified via fax and then phone calls had taken place. Order received to send resident in to the ER for evaluation. Ambulance arrived at facility and the resident was transferred to gurney and taken out of building. -That documentation and assessment did not occur until three days later. *Prior to his hospitalization on [DATE] there was no documentation and nursing assessment to support: -What the suprapubic catheter insertion site looked like and if there were signs of infection such as: --Redness, drainage, odor, and appearance. *The documentation was focused on his lung status and pain. *There was no documentation to support the physician had been notified of a change in his condition until nine days after his initial complaints of pain. Review of resident 29's comprehensive care plan revealed: *A focus area: Alteration in elimination of bowel and bladder history of UTIs, suprapubic catheter, incontinent of bowel. Initiated on 2/26/17, revision date 4/11/17. -No other revision dates documented under that focus area. *An intervention under the above area: Suprapubic catheter care every shift and PRN; keep bag below bladder level; s/s infection - odor, cloudiness, pain, blood, fever, drainage from site. Initiated on 8/2/17 with no revision dates. The surveyor requested to observe the staff clean resident 29's suprapubic catheter site multiple times throughout the day on 1/8/19, 1/9/19, and 1/10/18. The staff had not contacted the surveyor to observe them clean that site on those dates. Upon leaving from the facility on 1/10/19 the surveyor requested from administration to observe the staff clean resident 29's suprapubic catheter upon return on 1/15/19. On 1/15/19 at 7:30 a.m. the surveyor had reminded the administrative staff of the need to watch the staff clean his suprapubic site. The surveyor had asked licensed practical nurse (LPN) F on 1/15/19 at 9:50 a.m. to observe her clean the resident's catheter site. LPN F stated This is my first day by myself and I won't be doing it. (Staff member C name) will be doing it today. The surveyor asked RN C to watch her complete care on his suprapubic catheter site, and she had referred the surveyor back to LPN F. Suprapubic catheter care was never observed. Interview on 1/15/19 at 4:10 p.m. with the DON, ADON, MDS assessment coordinator, and regional clinical manager regarding resident 29 revealed: *The staff were responsible for observing, assessing, and notifying the physician with any change in health conditions. *They had been aware of the assessment and documentation concerns with the staff. *There was no documentation to support the staff had been reviewed, audited, and educated for incomplete assessments, documentation, and physician notification with any change in condition status. -Any education provided to the staff had been verbal and not written. *They had not been aware there was the possibility the suprapubic catheter sites were not being cleaned as ordered. *The DON was not aware the surveyor had been requesting for multiple days to observe the staff clean resident 29's site, and that had not occurred. *They had no documentation process or policy in place for the staff to follow. 4. Review of the provider's (MONTH) (YEAR) Notification of Changes policy revealed: *It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). *Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. *The intent of the policy is to provide appropriate and timely information about changes relevant to a resident's condition to the parties who will make decisions about care, treatment, and preferences to address the changes. Review of the provider's revised 10/20/16 Clinical Health Status-Change of Condition Guideline revealed: *This process will assist in driving a thorough evaluation of resident/patient conditions on admission, quarterly and with significant change in condition . *The process for identification of change of condition includes gathering objective data and documenting assessment findings, resident/patient response, and physician and family notification. *The SBAR process assists in coordinating change of condition information for concise communication with the Physician/NP/PA/CNS. *The situation included a concise statement of the problem. *The background included pertinent and brief information related to the situation. *The assessment included: -Subjective and Objective Assessment of Condition. -What is the nurse's assessment of the situation. *The recommendation included what action or recommendation is needed to correct the problem? Review of the provider's RN job description revealed: *Responsible for the independent supervision of the delivery of care to a group of residents in a nursing unit. *Assess resident needs, develop individual care plans, administer nursing care, evaluate nursing care. *Assure that effective quality nursing care is delivered which is outcome focused through utilization of the nursing process. *Identify needs and provide input for discharge planning and follow-up throughout length of stay. *Develop individualized plan of care in collaboration with the resident/responsible party and interdisciplinary care team. *Implement plan of care consistently, effectively and cost efficiently with focus on resident centered outcomes by utilizing all appropriate, available resources for resident/family/responsible party counseling and discharge planning. *Work in collaboration with physician and/or other health care professionals by sharing information relevant to changing plan of care. *Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices. *Must adhere to the company's code of conduct and business ethics policy including documentation and reporting responsibilities.

Based on observation, interview, record review, and policy review, the provider failed to: *Ensure the staff provided and offered appropriate urinary catheter care for three of four sampled residents (29, 42, and 48) to prevent infections. *Ensure one of three sampled residents (42) had been appropriately monitored and treated for [REDACTED]. Findings include: 1. Review of resident 42's medical record revealed:*She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had a suprapubic catheter in place. *Her 11/19/18 quarterly Brief Interview for Mental Status Score was fifteen indicating she was cognitively intact. *She had been treated for [REDACTED]. *She required assistance of one staff person with personal hygiene, toileting, and dressing. *She had been hospitalized three times in the last year for infections along with having other emergency room visits. *Her hospitalization s were:-From 2/18/18 through 2/22/18 for pneumonia. -From 10/13/18 through 10/16/18 for an infected suprapubic catheter site. -From 12/6/18 through 12/8/18 for a UTI. *There were concerns identified with nursing assessments for her changes in condition related to her hospitalization s. -Refer to F684, finding 1. Review of resident 42's last revised 1/6/19 care plan revealed: *It had not been updated related to her recurrent urinary tract infections and catheter concerns such as: -Site infections. -Treatment changes. -Her refusals of daily bathing according to the physician's orders [REDACTED]. *The interventions were general and not resident individualized and included:-Keep skin clean and dry. -Treatments as ordered/prn (as necessary). *There was no mention of catheter care: -How often it should have been done. -Which staff were responsible for it. -If she refused it what was to happen next. Interview on 1/07/19 at 4:42 p.m. with licensed practical nurse (LPN) E who was the charge nurse of resident 42's wing revealed:*She had a suprapubic catheter. *She had frequent UTIs and only allowed the urology clinic to change her catheter. *The nurses had a treatment they should have done to the catheter site. *The certified nursing assistants (CNA) emptied the catheter bag when needed. *Surveyor requested to observed the resident's personal care including care of her catheter when it worked for the resident and staff. -The Minimum Data Set (MDS) coordinator nurse was also informed of the surveyor's request at that time. Observation and interview on 1/07/19 at 5:20 p.m. with resident 42 revealed she was in the dining room in a wheelchair. She was okay with the surveyor observing her personal care the following day. Observation on 1/08/19 at 7:56 a.m. of resident 42 revealed she was sleeping in her bed. At 8:04 a.m. the surveyor spoke with CNA H and requested to watch resident 42's personal and catheter care when she woke up. On 1/08/19 at 8:18 a.m. registered nurse (RN) R and LPN F were resident 42's charge nurses and were notified the resident's personal and catheter care needed to be observed. They stated they would let the staff know. Observation and interview on 1/08/19 at 10:41 a.m. with resident 42 and CNA H in the resident's room revealed:*She was already up and dressed for the day. -The surveyor had not been informed by staff when they had assisted her with that process. *The resident stated she had just gotten up but needed the staff to empty her catheter bag. *She indicated she used a leg bag during the day and a large drainage bag during the night. -It had already been changed that morning. *Observation of catheter emptying by CNA H included:-She put the collection container directly on the floor. -She emptied the urine into the container and accidentally dripped some onto the floor. -Then she dumped the urine into the toilet. --She did not clean up the urine that had dripped on the floor. *She thought the resident got an ointment or cream to the area around her catheter. -Sometimes the CNAs did that treatment and sometimes the nurses did it. -She was unsure what the ointment was. *When the resident was asked if staff cleaned around the suprapubic site the CNA answered for her and stated it was done daily. -The resident gave a look of disagreement and quietly stated she was lucky if it was done every other day. *CNA H stated the site should have been cleaned with soap and water. -Alcohol wipes were used when changing from one catheter bag to the other and when they emptied the bags. *She left the room and the resident continued speaking about her catheter concerns. *She stated she: -Preferred to have the urology clinic change her catheter versus facility staff. -Had gotten infections frequently. -Had been hospitalized for [REDACTED]. -Currently had a UTI and the antibiotic should have been started a few days ago, but it had not been. --She had been told the antibiotic was not available from the pharmacy. --That had also happened in the past with antibiotics. Refer to F658, finding 1. Interview on 1/08/19 at 10:58 a.m with CNA T regarding catheter care revealed: *It was done by the CNAs and should have been done every day. *Her usual process included first cleaning the insertion area with a wet disposable wipe and then an alcohol wipe. *She would have done the same process for indwelling catheters or suprapubic catheters. On 1/08/19 at 6:45 p.m. documentation for resident 42's catheter care for the last thirty days was requested from the director of nursing (DON). No documentation had been received prior to the end of survey on 1/16/19. Observation on 1/09/19 at 8:21 a.m. of resident 42 revealed:*She was in bed sleeping. *Her large catheter drainage bag was laying uncovered directly on the floor. Observation and interview on 1/09/19 at 9:16 a.m. with resident 42 revealed she had finally started her antibiotic the evening before. Interview and record review on 1/09/19 at 4:35 p.m. with RN C and the assistant director of nursing (ADON) regarding resident 42 revealed:*They confirmed the antibiotic for her current UTI had not been given timely. *She had a history of [REDACTED]. *They confirmed there was no documentation to support catheter care was getting done. *The CNAs should have documented on catheter care in the electronic medical record. Interview on 1/09/19 at 5:34 p.m. with the DON regarding resident 42 confirmed: *The antibiotic should have been started promptly. *There was no documentation to support catheter care was getting done. *Routine catheter care should have been done daily at the minimum. Interview on 1/10/19 at 9:56 a.m. with the DON and the regional clinical manager regarding resident 42 revealed: *There should have been documentation to support the resident had received catheter care. *Any resident with a catheter should have received routine catheter care at least daily. *General catheter care was an important aspect of infection prevention and potentially preventing UTIs. *She had been treated for [REDACTED]. -The documentation had not supported appropriate assessments related to her infections or symptoms of infection. During the first week of survey on 1/08/19 from 7:15 a.m. through 7:00 p.m.; on 1/9/19 from 7:15 a.m. through 6:15 p.m.; and on 1/10/19 from 7:15 a.m. through 10:45 a.m. no staff had provided the opportunity for the surveyor to observe resident 42's suprapubic catheter site or catheter site care. Observation on 1/15/19 at 7:50 a.m. of resident 42 revealed she was sleeping in bed. Her large catheter drainage bag was again laying uncovered directly on the floor. Observation and interview on 1/15/19 at 8:00 a.m. with resident 42 and CNA H in her room revealed: *The CNA stated the resident's catheter drainage bag should not have been laying uncovered directly on the floor.-It should have been hanging on the side of the bed. *She stated she was going to change the resident's large catheter drainage bag to the small leg bag for her to be able to get up and dressed. *She attempted to wipe the outside of the catheter bag with alcohol wipes but had not covered the whole surface. -She stated she was trying to clean the outside that had touched the floor. *She went to the resident's bathroom and brought out a plastic basin holding the leg bag. -She set that basin directly on top of the garbage can. *She detached the large drainage bag and set it into the plastic basin that the leg bag was originally in. -The end of the drainage bag tubing was hanging out of the basin against the resident's bedding. --That eventually fell to the floor and leaked a large amount of urine onto the flooring. *Once she was done attaching the leg bag she attempted to clean up the urine on the floor. -First she wiped it up with dry paper towels and then used a disposable perineal care wet wipe. -The floor had not been disinfected at all. *After she was done cleaning up the urine on the floor she removed her gloves and without performing hand hygiene she continued helping the resident with dressing. *She stated she would get a new large drainage bag since that one had touched the floor. *She indicated there should have been dates on the bags to indicate when they had last been changed. -There were no dates on either the large catheter bag or the leg bag. *Prior to the CNA leaving the surveyor asked her about the resident's catheter site care and if the suprapubic catheter site could be observed. *The resident stood up with the CNA's assistance to show the site. -It was difficult to view the suprapubic catheter site due to the resident's abdominal fold and position of standing in front of the wheelchair. *It appeared the drain sponge was not located around the catheter site, was folded/bunched up, and had a yellowish color to it. *The CNA thought the drain sponge got changed every day by the nurse. *The resident gave a look of disagreement and when the surveyor asked her how often it was changed she stated everyday I guess. -She further stated the sponge had not been changed that morning. *The CNA asked the resident if the catheter care had been done the night before, and the resident indicated it had been. *She assisted the resident with dressing and to sit back down in her wheelchair. -She had not performed catheter site care during the observation. --When asked how often catheter care should have been done she stated every shift. Interview and record review on 1/15/19 at 8:15 a.m. with LPN F regarding resident 42 revealed:*She was the charge nurse for the resident. *That was her first day on her own as the charge nurse. -She had started two weeks ago and had been in training. *She was unsure if the CNAs or the nurse should have performed the resident's catheter site care. *She looked up the resident's treatments in her record and stated the catheter care should have been done every shift by the nurse. -That order had started on 1/8/19 after the surveyor's questions about catheter care the week before. *The drain sponge around her catheter site should have been changed every morning and evening. *The surveyor asked to observed when the nurse performed catheter care and changed the drain sponge this shift. -LPN F stated she had not done the resident's catheter care before and had not been trained on how to do that. --She had not seen any nurses do it during her orientation. --Since she had not seen it she would ask another nurse for assistance with that. Interview on 1/15/19 at 8:20 a.m. with resident 42 regarding her catheter care revealed she:*Had been encouraged by the physician to shower daily, but she sometimes told the staff no to those showers. *Had not declined or refused the catheter care though. *Needed staff to help with catheter care since she could not see the site or reach it well herself. Interview and record review on 1/15/19 at 10:56 a.m. with RN C regarding resident 42 revealed: *She stated the resident sometimes refused her daily showers and refused to let the staff change her suprapubic catheter. -Daily bathing was ordered by the urologist on 12/14/18. *According to the resident's CNA documentation for bathing for the past thirty days there were: -Thirteen days she received a bath or shower. -Nine days the resident had refused. -Four days were marked as not applicable. --She stated those were probably refused and not charted correctly. -Four days with no documentation on 12/10/18, 12/13/18, 12/14/18, and 1/4/19. *There should have been documentation to support the daily bathing was offered and completed or refused, and catheter care was being done or refused. *The resident's UTIs sometimes came on all of a sudden without warning or specific symptoms. -That should have been documented if that was what had happened though. *She confirmed the documentation had not supported complete nursing assessments related to her changes in condition, UTIs, and other infections. Continued interview and record review with RN C related to resident 42's recent physician's orders [REDACTED].*On 12/12/18 a fax was sent to her primary physician to clarify her two different treatment orders for her suprapubic catheter site. -One was for [MEDICATION NAME]-[MEDICATION NAME] cream, and one was for [MEDICATION NAME] ointment. *On 12/13/18 she had seen a gynecologist for pelvic pain who wrote .Drainage and foul odor noted at suprapubic catheter site. Recommend evaluation (with) urology as planned . *On 12/14/18 she had seen the urologist who wrote orders for [MEDICATION NAME] twice daily and a drain dressing to her suprapubic catheter site along with showers daily. *On 12/16/18 the primary physician's certified nurse practitioner responded to the 12/12/18 fax and discontinued the [MEDICATION NAME] and ordered to continue the [MEDICATION NAME]-[MEDICATION NAME] cream. *RN C stated the 12/12/18 fax should have been sent to the urologist since the resident's concerns with her suprapubic catheter site were usually addressed by them. -When they had not heard back from the 12/12/18 fax until 12/16/18 they should have clarified the order again since the urologist had just changed the orders on 12/14/18. *She confirmed there was miscommunication with the different providers, and the nurse should have noticed that and clarified the orders to ensure accuracy. On 1/15/19 at 12:01 p.m. LPN F and RN C were asked again about watching resident 42's catheter care since it still had not been observed during the survey. They stated it had not been done yet for the day, but staff would let the surveyor know when that happened. On 1/15/19 at 1:35 p.m. RN C stated she had to do resident 42's catheter care and change the drain sponge while the surveyors had left the building briefly. Surveyor was unable to observe resident 42's catheter site care during the first or second weeks of survey. Multiple requests had been made to several different staff members (see above interviews) throughout the survey. 2. Review of resident 48's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. -She was on intravenous antibiotics for those concerns from admission through 12/25/18. *She was admitted with an indwelling urinary catheter for skin protection. *She had been readmitted to the hospital on [DATE] with concerns of bowel distension, weight loss, and a UTI. -She returned on 12/10/18. Observation on 1/08/19 at 7:56 a.m. of resident 48 in her room revealed: *She was laying on her left side in bed. *A large urinary catheter bag was hanging on the side of her bed. Observation and interview on 1/08/19 at 9:27 a.m. with resident 48 in her room revealed:*She was sitting up in bed with the head of the bed in an upright position. *She had no idea about why she had a catheter. -She had it since she had been admitted to the facility. Observation and interview on 1/08/19 at 10:12 a.m. with RN C and CNA T during resident 48's personal care revealed:*RN C performed the resident's wound care treatment to her sacral wounds. -She stated the catheter was in place to help with wound healing. *Following wound care CNA T was asked about catheter care. *She demonstrated her process by doing the following: -First she used a wet wipe to the resident's perineal area. -Then she used two alcohol wipes to the catheter tubing insertion area. -She then removed her gloves and without hand hygiene opened the resident's dresser drawer to put the wipes package in. *Then she washed her hands and put on new gloves to empty the urine from the large catheter drainage bag. -She put the plastic container directly on the floor and while emptying the bag a few drops of urine dripped on the floor. -She clamped the bag shut again after wiping the end with alcohol wipes. -The urine on the floor was not cleaned up nor the floor disinfected. *She stated that was her usual process for catheter care. Observation on 1/09/19 at 8:23 a.m. of resident 48 revealed: *She was laying in her bed sleeping. *Her catheter bag was hanging on the edge of the bed uncovered and touching the floor. Interview on 1/09/19 at 1:41 p.m. with the primary physician's certified nurse practitioner (CNP) regarding resident 48 revealed:*Her catheter was in place to promote wound healing. *She was at higher risk for UTIs due to the catheter placement. *Appropriate catheter care was important for infection prevention. Review of resident 48's last revised 1/8/19 care plan revealed Position catheter bag and tubing below the level of the bladder and in a privacy bag . 3. Random observations and interviews with resident 29 on 1/8/19 from 7:50 a.m. through 11:30 a.m. and from 1:30 p.m. through 4:30 p.m.; on 1/9/19 from 8:43 a.m. through 11:30 a.m. and 1:30 p.m. through 4:30 p.m.; and on 1/10/19 from 8:10 a.m. through 11:35 a.m. of resident 29 revealed: *He had appeared: -Very thin, weak, and frail with a flat affect. -To be able to move his upper body and arms without difficulty. *He had been laying in his bed resting and was positioned on his back. *He had a suprapubic catheter attached to a collection bag hanging from the bed frame. -The urine in the collection bag was golden colored. *He required staff assistance to take care of the catheter including site care and emptying the drainage bag. *He stated Ya, they clean the site, maybe every other day at the most. Review of resident 29's medical record revealed: *He had recently been hospitalized from [DATE] through 1/5/19 for catheter insertion site infection, pneumonia, and a UTI. -There had been purulent drainage surrounding the catheter insertion site. *During his hospitalization he had required the catheter insertion site to be cleaned four times a day. -On 1/7/19 the site cleaning had been decreased to twice a day per the residents request. *He was currently being treated for [REDACTED]. Review of resident 29's comprehensive care plan revealed: *A focus area: Alteration in elimination of bowel and bladder history of UTIs, suprapubic catheter, incontinent of bowel. Initiated on 2/26/17 with a revision date of 4/11/17. -No other revision dates were documented under that focus area. *Intervention under the above area: Suprapubic catheter care every shift and PRN; keep bag below bladder level; s/s infection - odor, cloudiness, pain, blood, fever, drainage from site. -That intervention had been initiated on 8/2/17 with no revision dates. The surveyor requested to observe the staff clean resident 29's suprapubic catheter site multiple times throughout the day on 1/8/19, 1/9/19, and 1/10/18. The staff had not contacted the surveyor during anytime to observe them clean that site on those dates. Upon leaving from the facility on 1/10/19 the surveyor requested from administration to observe the staff clean resident 29's suprapubic catheter upon return on 1/15/19. On 1/15/19 at 7:30 a.m. the surveyor had reminded the administrative staff of the need to watch the staff clean his suprapubic site. The surveyor had asked licensed practical nurse (LPN) F on 1/15/19 at 9:50 a.m. to observe her clean the resident's catheter site. LPN F stated This is my first day by myself and I won't be doing it. (Staff member C name) will be doing it today. The surveyor asked RN C to watch her complete care on his suprapubic catheter site, and she had referred the surveyor back to LPN F. Suprapubic catheter care was never observed. Interview on 1/15/19 at 4:10 p.m. with the DON, ADON, MDS assessment coordinator, and regional clinical manager regarding resident 29 revealed: *They had not been aware there was the possibility the suprapubic catheter sites were not being cleaned as ordered. *The DON was not aware the surveyor had been requesting for multiple days to observe the staff clean the resident's site and that had not occurred. *They agreed the resident was not capable of handling and managing his suprapubic catheter independently. -He had required staff support for all activities of daily living. Review of the provider's 5/1/11 Personal Needs policy revealed: *The facility strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents/patients. *Personal care and support includes but is not limited to the following: Catheter care. *Observe compliance with individualized interventions during daily rounds and monitor resident/patient outcomes. *Review and revise the Plan of Care as needed. Refer to F684, finding 3. Surveyor: 4. Interview on 1/09/19 at 12:15 p.m. with LPN E and CNA V regarding catheter care revealed: *Catheter bags should not have been uncovered and touching the floor for appropriate infection control. *Catheter care of the insertion site did not include using an alcohol wipe to that area. -Alcohol wipes were used to clean the end of the bag when emptying or to the end of the tubing when changing to/from the large drainage bag or leg bag. Interview on 1/10/19 at 7:30 a.m. with the DON regarding UTIs and routine catheter care revealed: *There was no specific policy on prevention of UTIs. -That would have been part of the overall infection control policies. *The facility followed follow McGeer's criteria for appropriate use of antibiotics related to infections. -Those should have been completed for all infections. *She confirmed the McGeer's criteria forms had not been filled out for all the residents' infections. *She expected the facility's policies for infection control and catheters to have been followed. *Catheter care should have been documented in the residents' medical records when it was completed or if it was refused. Interview on 1/15/19 at 3:41 p.m. with the DON, ADON, MDS coordinator, the regional clinical director revealed: *If urine was spilled or dripped on the floor that area should have been cleaned and disinfected properly. *Appropriate hand hygiene should have been completed for infection prevention. *Staff should have provided and offered appropriate catheter care for infection prevention. -If the resident refused that should have been documented. *Resident's with changes in their condition or symptoms of a possible infection should have: -Had appropriate nursing assessments and documentation of those. -Been appropriately monitored and received their physician ordered treatments. -Received antibiotics timely if they had been ordered. Review of the provider's 8/9/16 Indwelling Catheter Care policy revealed:*The purpose was: To prevent infection. To reduce irritation. Perform twice daily with am and pm care, and as needed after incontinence or bowel movements. *The procedure included: -4. Both the meatus and the catheter will need to be cleansed during catheter care. Wash from the meatus and up the catheter tube about six inches or further to remove any obvious debris. Hold the tube in place with your other hand for stability and it won't get pulled during washing. Change the cloth or wipe as needed due to excessive soiling. Wash perineum well with soap and water, perineal cleanser, or cleansing wipes taking care to wash from front to back. -5. Rinse well with warm water and pat dry gently with clean towel. -7. Empty, clean and store bedpan or measuring device properly. -When done remove gloves and wash hands. *Documentation included: -The date and time the care occurred. -If any unusual condition or change in condition was noted. -Color, amount, consistency, and odor of urine. -Notification of the physician of any condition change. -Who performed the procedure or assessment. Review of the provider's (MONTH) (YEAR) Infection Prevention and Control Program policy revealed:*It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.*2. The RNs and LPNs supervise direct care staff in daily activities to assure appropriate precautions and techniques are observed . *a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects, after PPE removal, before/after eating, before/after toileting, and before going off duty. *b. Staff shall wash their hands before and after performing resident care procedures.

Based on observation, interview, record review, and policy review, the provider failed to ensure care and services were provided to maintain the possible physical health of two of five sampled residents (5 and 9) with skin issues. Findings include: 1. Observation and interview on 1/10/17 at 9:00 a.m. with resident 9 during the initial tour revealed: *He was sitting in his recliner. *He had flaky white specks that appeared to be skin from his face down the front and shoulders of his sweatshirt. *His face appeared to have patches of flaky and dry skin. *He had a Bandaid across the bridge of his nose under his glasses. *He was friendly and confused. *He could not explain why he had a Bandaid on his nose. Review of resident 9's complete medical record revealed: *He had been admitted on [DATE]. *He had an 11/24/16 Brief Interview for Mental Status (BIMS) score of six indicating he was mentally impaired. *He had no [DIAGNOSES REDACTED]. *A 12/19/16 call to the physician because his skin had reddened patches, and he complained of itching. *A 12/20/16 nurse's note res (resident) c/o (complains of) burning on face from lotion sister brought in. *A 12/20/17 physician's order for [MEDICATION NAME] for two days, every six hours as needed for the rash on his face. *No follow-up to the effectiveness of the treatment. *No ordered treatment for [REDACTED]. *No documentation regarding the Bandaid across his nose. *No documentation of an order for [REDACTED].>*No physician notification of any injury to his nose. *No physician's orders regarding his nose or dry skin. *No investigation or explanation of injury to his nose. *No documented treatment on his treatment administration record (TAR) for his dry skin or his nose. *Skin assessments on 11/30/16, 12/14/16, 12/21/16, and 12/28/16 stated his skin was intact. Further observation and interview on 1/11/17 at 10:50 a.m. of resident 9 revealed: *The Bandaid over his nose had been removed. *He appeared to have a small, dime-size, scabbed-over wound under the right nosepiece of his glasses. *He had flaky white specks that appeared to be skin from his face and head down the front and shoulders of his sweatshirt. *He said the wound on his nose was starting to look better. *He said his dry skin had been like that a long time, and he tried to get used to it. Interview on 1/11/17 at 1:55 p.m. with the director of nursing (DON) revealed: *She had not been aware of any injury to resident 9's nose. *Staff had not come to her about any issue with his nose. *They had tried using a lotion on the dry skin on his face. -That had just irritated it. -That was when they had called the doctor to get the [MEDICATION NAME] order. *The physician had not been notified of his dry skin any other time. *The physician had not been notified of the injury to his nose. Interview on 1/11/17 at 2:40 p.m. with certified nurse aide (CNA) A regarding resident 9 revealed: *The scab on his nose was from a wound he had gotten from wearing his glasses. -It was from the nosepiece pressing down. *He needed a protector for his glasses that he was getting soon. *He had the wound about a month, and it had gotten better and then worse. *His sister had put the Bandaid on to try to protect his skin. Interview on 1/11/17 at 2:55 p.m. with licensed practical nurses E and F regarding resident 9 revealed: *His sister worked at the facility in activities. *She had put the Bandaid on him to keep his glasses from rubbing. *They were not sure what the wound on his nose had been from. *They were not sure how long he had the wound. *They were not sure if anything had been done to treat his dry flaking skin on his face. Interview on 1/11/17 at 3:00 p.m. with resident 9's sister revealed: *The wound on his nose had been there a while. *She had told someone about it at one time, but was not sure if they had said or done anything about it. *She was unsure if the wound had been from his current glasses or his old ones that were heavier. *She did not think the Bandaid had been working to protect his nose, because it had not stayed on very well. *The physician had not been notified as far as she knew. Interview on 1/11/17 at 4:30 p.m. with the DON and the regional clinic manager confirmed: *They had been unaware of the circumstances of his nose wound. *An investigation had not been done. *Nothing had been done by the provider for his nose or his dry skin. 2. Interview on 1/10/17 at 11:40 a.m. with resident 5 revealed: *His dressing changes to his right foot wounds were not being done twice a day as ordered. *The first dressing change in the morning was usually done. *The second dressing change was often so late he was sleeping. *He tried to stay up so they could do the dressing change. *It should not have been done that late. *He was really worried about losing his foot. -He had already lost his left one. Review of resident 5's complete medical record revealed: *He had been admitted [DATE]. *He had a BIMS of fifteen meaning he was mentally intact. *He had diagnoses of: complications of amputation stump, [MEDICAL CONDITION], other diseases of pulp and periapical tissue, complete traumatic amputation of two or more right lesser toes, diabetes mellitus due to underlying condition with unspecified complications. *An 11/23/16 physician's order to cleanse right dorsal foot wound with normal saline .change BID (twice a day) and PRN (as needed) every day and evening shift. *The December 2016 TAR for that order had been left blank 11 of 62 times. *The January 2017 TAR for that order had been left blank 4 of 19 times. *There had been no way to know if that treatment had been done. *There had been no nurses' notes to explain the gaps in the TARs. *An 11/23/16 physician's order to cleanse right lateral foot wound .BID and PRN every day and evening shift. *The December 2016 TAR for that order had been left blank 11 of 62 times. -12/22/16 through 12/29/16 that treatment had been left blank, been refused or held, or the resident had been out of the facility fifteen of sixteen times when the dressing should have been changed. --Nursing notes had documented the treatment had been held, because the resident told them wound care was supposed to do his dressing changes. --No order from wound care had ever been received. --No one followed-up with wound care for over two days to clarify. --It had not been documented if his dressing had been changed while he was out of the facility from 12/24/16 through 12/25/16. *The January 2017 TAR for that order had been left blank 3 out of 19 times. -There had been no way to know if that treatment had been done. *There had been no nurses' notes to explain the blanks in the TARs. Observation on 1/11/17 at 9:05 a.m. of resident 5's room revealed Nurse E went in to check his vitals and closed the door. Interview with her following the above observation revealed: *She had checked resident 5's vital signs and they were not good. *He was not feeling well. *She had trouble taking his pulse. *She had changed his dressing that morning, and it had looked and smelled very foul. *She had told him they were sending him to the hospital. Review of resident 5's physician's orders revealed his nurse practitioner ordered him sent to the hospital. He might have [MEDICAL CONDITION] with nausea, vomiting, diarrhea, and low blood pressure. Interview on 1/11/17 at 1:55 p.m. with the DON revealed: *Blank spaces in the TAR were probably missed treatments as well as missed documentation. *There should not have been any blanks on the TAR. *Nurses' notes should have documented any refusals and reasons a treatment had not been given. Review of the provider's 2014 Skin Integrity Guideline policy revealed: *Purpose: -To provide a comprehensive approach for monitoring skin conditions. -To decrease pressure ulcer and/or wound formation by identifying those patients/residents who are at risk, and implementing appropriate interventions. -To promote healing of wounds of any etiology whether admitted or acquired. *Objectives: -Provide a guideline for optimal care to promote healing to patients/residents with all identified alterations in skin integrity . *Documentation of skin evaluations or observations should have been completed within the first twenty-four hours of significant change of condition using the skin review or wound review flow sheets. *Interventions should have been documented in the resident's care plan. *Residents should have been observed by CNAs daily for red or opened areas. *A licensed nurse was responsible for performing skin evaluations and observations weekly. *Dry and flaking skin had not been included in the policy.

Based on observation, interview, record review, and policy review, the provider failed to ensure oxygen (O2) was provided and administered continuously for one of three sampled residents (1) using O2. Findings include: 1. Observation on 1/10/17 at 10:30 a.m. revealed resident 1 was seated in her wheelchair in her room. She had a nasal cannula in place attached to a portable O2 tank. Interview with her at that time revealed she was unsure if there was O2 coming through the tubing. Observation of the tank at that time revealed it was empty. That was confirmed by licensed practical nurse (LPN) C at 10:33 a.m. The resident's oxygen saturation (O2 sat) rate at that time was 80%. A normal O2 sat rate is 90% or above. LPN C removed the O2 tubing and attached it to the O2 concentrator. Resident 1's O2 sat rate increased to 91% in less than one minute. She stated she was unsure how long the resident might have gone with an empty O2 tank. She stated the certified nursing assistants (CNA) were to have checked the portable O2 tanks before and after meals to ensure they were full. 2. Observation on 1/10/17 at 11:48 a.m. revealed resident 1 was seated in her wheelchair in the dining room. Her nasal cannula was in place and attached to a portable O2 tank. Observation at that time revealed the O2 tank was empty. Multiple staff walked around and near resident 1 while serving meals in the dining room. They provided her with thickened water and placed a clothing protector on her. No staff stopped to check the status of the portable O2 tank. At 12:32 p.m. resident 1 had been provided with her lunch. LPN C was asked at that time to check the resident's portable O2 tank. She confirmed it was empty. The resident's O2 sat rate was 76%. Interview at that time with LPN C revealed she had not told anyone the O2 tank was empty earlier. She had not filled that portable tank. She stated the CNA who had brought the resident to lunch should have checked it at that time. She immediately took the O2 tank to fill it. The resident's O2 sat rate climbed to 92% within one minute after having the O2 tank filled. LPN C stated she might have gone without O2 for quite some time if her O2 tank had not been checked until she had returned to her room following her meal. Review of resident 1's December 2016 and January 1 through 10, 2017, treatment administration records revealed documentation had been incomplete for ensuring every two hours during the day and evening her liquid portable O2 tank was full: -December, 22 of 248 times. -January, 16 of 84 times. Interview on 1/10/17 at 2:30 p.m. with the director of nursing confirmed CNAs were to have checked the portable O2 tank a minimum of every two hours. When residents were in their rooms they were to have been hooked up to the O2 concentrator. She stated CNAs should have always checked the contents of the O2 tank when taking a resident to and from meals. She confirmed resident 1's low O2 saturation rates could have had negative consequences for her. Review of the provider's revised 6/20/16 Oxygen Administration policy revealed: *The purpose of the administration of O2 was to ensure O2 was being carried by the blood to the tissues for residents with an insufficient O2 supply. *A reserve O2 tank should have been available to provide continuity of care. *At regular intervals: -Check liter flow contents of the O2 cylinder. -Assess resident's respirations to determine further need for O2 therapy.

Based on interview and policy review, the provider failed to ensure all residents including resident 10 with cognitive impairment were free from verbal and mental abuse by one registered nurse (RN) (E) and one licensed practical nurse (LPN) (F). NOTICE: On 8/17/16 at 3:15 p.m. notice of immediate jeopardy was given verbally to the administrator and director of nurses (DON). They were asked for an immediate plan of correction (POC) to ensure all residents were free from abuse. PLAN: During the survey on 8/17/16 at 5:22 p.m. the surveyors confirmed removal of the immediate jeopardy situation. The following is the plan for the removal of the immediate jeopardy. *All residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents have the right to exercise his/her rights. *Initial investigation will be completed immediately by the facility. An Executive Director or Consultant from outside the facility will complete the final investigation. Two nurses involved in the allegations of abuse are suspended effective August 17, 2016. *All oncoming staff will be re-educated on the Abuse and Neglect Policy and Procedure and the appropriate steps to prevent the occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of resident property and to ensure that all alleged violations of Federal and State law which involve mistreatment, neglect, abuse, injuries of unknown origins, and misappropriation of resident property (alleged violations), Mandatory Reporting, and Caring for Residents with Dementia. *All staff will be re-educated on the Long Term Care Facilities Resident's Bill of Rights provided by the SD Department of Social Services Adult Services and Aging: Ombudsman Program. Leadership: ED, DNS, HRG will receive the education as listed above as well: Elder Justice Acts, Reporting Suspected Crimes Under the Federal Elder Justice Act, and Reporting and Investigations of Alleged Violations of Federal State Laws Involving mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident's property. *All residents have the potential to be affected. The Abuse and Neglect Policy and Procedure will be followed as well as disciplinary actions as warranted. *Staff currently working and oncoming staff will be immediately re-educated on the Abuse and Neglect Policy and Procedure and the appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin, and misappropriation of resident property and to ensure that all alleged violationsof Federal and State laws which involve mistreatment, neglect, abuse, injuries of unknown origin, and misappropriation of resident property (alleged violations) and on the Long Term Care Facilities Resident's Bills of Rights provided by the SD Department of Social Services Adult Services and Aging: Ombudsman Program. *ED and/or DNS or designee will complete resident x 5 and staff x 5 interviews weekly x 8 weeks to ensure residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion and residents feel they have the right to exercise his/her resident rights. Findings include: *The results of these interviews will be brought to the QAPI committee for further review and recommendations. Findings include: 1. Interview on 8/17/16 at 10:16 a.m. with an anonymous certified nursing assistant (CNA) revealed: *Approximately a couple of weeks ago she had reported resident abuse to the director of nursing (DON). *At approximately 6:00 a.m. regarding that incident revealed the anonymous CNA had observed RN E and LPN F at the end of west hall. *RN E was screaming hello over and over again at resident 10. *Resident 10 had a [DIAGNOSES REDACTED]. *RN E was mocking what resident 10 was saying. *LPN F was laughing. *She stated she along with other staff members had reported abuse to the DON and human resources more than once. *The DON and the human resources staff member had laughed at them when they reported abuse. *An anonymous resident had witnessed RN E mocking resident 10. *An anonymous resident had reported the abuse to the DON. *This morning RN E told staff State is in the building and you all need to be very scared for your jobs. Interview on 8/17/16 at 2:35 p.m. with the DON, emergency permit holder (EPH), and the EPH's preceptor revealed: *They defined physical abuse as an inappropriate laying-on of hands to any part of the resident's body. *They defined verbal abuse as yelling, speaking to a resident in a childish manner, belittling, or ridiculing a resident. *They defined emotional abuse as speaking down to a resident. *They would consider an employee hollering down the hall and mocking a resident with dementia as verbal and emotional abuse. *The EPH if made aware of the situation would have immediately removed staff from the situation and started an investigation. The staff person in question would have been placed on suspension pending the results of the investigation. *Their goal was to ensure resident safety. *They confirmed the DON and EPH were aware of the situation where an RN and LPN had mocked and laughed at a resident with dementia. *The EPH and DON confirmed they had been told of the situation by staff and residents. *The DON had been told by the nurses in question they were just being silly. *They confirmed neither nurse had been removed from the situation or suspended. *They confirmed an investigation had not been started. *They confirmed mocking and laughing at a resident did not create a safe environment for all residents.

Based on record review, interview, and policy review, the provider failed to ensure: *An allegation of abuse for one of one sampled resident 10 with dementia by a registered nurse (RN) (E) and licensed practical nurse (LPN) (F) had been investigated and reported to the South Dakota Department of Health (SD DOH). *An injury of unknown origin for one of one sampled resident (14) who was unable to speak for herself had been documented, investigated, and reported to the SD DOH. Findings include: 1. Review of the providers 11/17/15 Preventing, Investigating, and Reporting Alleged Sexual Assault and Abuse Violation policy revealed: *It is the responsibility of all employees to immediately report any alleged violation of abuse, neglect injuries of unknown origin, source and misappropriation of resident property. *It is the policy of this center to take appropriate steps to prevent the occurrence of: -Abuse -Neglect Misappropriation of resident property. *It is also the policy of this center to take appropriate steps to ensure that all alleged violations of federal and state laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property (alleged violation) are reporting immediately to the executive director of the center. *Such violations are also reported to state agencies in accordance with existing state law. The center investigates each such alleged violation thoroughly and reports the result of all investigations to the executive director or his or her designee, as well as to state agencies as required by state and federal law. * If the suspected perpetrator is an employee or family, friend or visitor the ED (executive director) places the employee on immediate investigatory suspension while completing the investigation. It is explained to the employee that if the investigation results do not require suspension or termination, the employee may be allowed to return to work and any scheduled days missed during the investigation time may be paid. If it is a family member, visitor or friend, they will not be allowed to visit the resident until the investigation is completed. The results of the investigation will determine the future contact with the resident. *Where the circumstances of the alleged violation warrants, the DNS or designee initiates a physical and mental assessment of the resident and documents the findings. Only factual information is documented, not assumptions. The DNS also notifies the attending physician regarding the alleged violation and findings and documents the contact. *An employee who suspects an alleged violation immediately notifies the ED, or designee. The ED notifies the appropriate state agency in accordance with state law and the regional vice president. *The results of all investigations are reported to the ED or designee and the appropriate state agency, as required by state law and the regional vice president. *The center reports to the state nurse aide registry and licensure authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. *The DNS, or designee, initiates a care plan to reflect the resident's condition and measures to be taken to prevent recurrence, where appropriate. *Appropriate steps are taken to prevent recurrence of the incident. This may include in-services or other measures as appropriate. The steps taken are documented. *Documentation in the medical record is made where necessary for continuity of care for the resident. *Separate incident reports or other written reports, when required by state law, are maintained and produced in accordance with state law. Refer to tag F223, findings 1 and 2. 2. Review of resident 14's medical record revealed: *She had been readmitted to the facility on [DATE] from an acute care hospital. *[DIAGNOSES REDACTED]. *She had no muscle control and required assistance from the staff for positioning and transfers. *She had required the use of a transfer aide to get in and out of the bed. *She would have sat in her wheelchair (w/c) once or twice a week per her choice. *On 7/25/16 a skin tear had been identified on her sacral area after she had returned from a trip to the emergency room . *On 8/22/16 another skin tear had been identified below the first skin tear. Review of resident 14's nurses' progress notes revealed on: *7/25/16, Resident back to facility by ambulance via stretcher. Resident has a new skin tear noted in lumbar area. Made MD aware and order received to cleanse with normal saline, apply [MEDICATION NAME] and dressing. Change dressing every 3 days or as needed. *8/22/16 She has a sore on her sacrum that started out as a skin tear. Just below this at the 5 o'clock area she has a small skin tear is 1.0 cm (centimeter) x 0.3 cm. -No documentation the MD or family had been notified of the new skin tear. Interview on 8/23/16 at 4:05 p.m. with licensed practical nurse D regarding resident 14 revealed: *The resident received the first skin tear when the ambulance crew transferred her from their gurney to her bed. *She had identified the second skin tear yesterday, 8/22/16. *She had not been aware how the second skin tear had occurred. The above progress notes revealed no documentation to support: *An incident report for an injury of unknown origin had been completed on both of the skin tears. *The skin tears had been investigated and reported to the SD DOH to support physical abuse had not occurred. LPN D had not been available for further interview after the continued review of resident 14's progress notes. Interview on 8/24/16 at 10:30 a.m. with the field services clinical director revealed: *She had not been aware resident 14 had acquired two skin tears during her stay in the facility. *She not been able to locate an incident report for injuries of unknown origin for those skin tears. *She would have expected the staff to have: -Completed an incident report for an injury of unknown origin on both of the skin tears. -Completed an investigation to support physical abuse had not occurred on the first skin tear that occurred on 7/25/16. -Started an investigation on the second skin tear that had been identified on 8/22/16. *She confirmed any type of injury of unknown origin should have ben investigated and reported to the SD DOH. 4. Interview on 8/17/16 at 8:15 a.m. with two residents who wished to remain confidential revealed: *About two to three weeks ago they had heard a staff member yelling in the hallway. They stated it was around 6:00 a.m. when the yelling had occurred. *They were aware that staff person yelling was a nurse. *The resident had been repetitively requesting help. *The nurse began mocking the resident by yelling down the hall what the resident had been saying. *Another nurse in the middle of the hallway had been laughing at the nurse's mocking words. *One of the confidential residents yelled out You need to be quiet. We are trying to sleep. *They were scared by what they had heard. *One confidential resident stated I am starting to lose my memory. I'm scared that they will treat me the same way. *They had reported their concerns to the DON. 5. Interview on 8/17/16 at 1:10 p.m. with a CNA who requested to remain confidential revealed: *About two and a half weeks ago she had heard an RN yelling down the hall mocking a resident with dementia who had been requesting assistance. *That had occurred at the time of a shift change and was around 6:00 a.m. *The RN was repeating over and over Nurse, nurse, help me, help me. After that the nurse started yelling Hello. Hello. *An LPN who was down the hall was laughing at what the above nurse was doing. *She had reported it to the DON. *She felt nothing had been done to reprimand the nurse. *She stated that same RN had threatened many aides they might be fired. *She also stated that same RN had refused to help residents in need. She had stated that was not her job as she was in management. 6. Interview on 8/17/16 at 2:35 p.m. with the DON, emergency permit holder (EPH), and the EPH's preceptor revealed: *They defined physical abuse as an inappropriate laying-on of hands to any part of the resident's body. *They defined verbal abuse as yelling, speaking to a resident in a childish manner, belittling, or ridiculing a resident. *They defined emotional abuse as speaking down to a resident. *They would consider an employee hollering down the hall and mocking a resident with dementia as verbal and emotional abuse. *The EPH if made aware of the situation would have immediately removed staff from the situation and started an investigation. The staff person in question would have been placed on suspension pending the results of the investigation. *Their goal was to ensure resident safety. *They confirmed the DON and EPH were aware of the situation where an RN and LPN had mocked and laughed at a resident with dementia. *The EPH and DON confirmed they had been told of the situation by staff and residents. *The DON had been told by the nurses in question they were just being silly. *They confirmed neither nurse had been removed from the situation or suspended. *They confirmed an investigation had not been started. *They confirmed mocking and laughing at a resident did not create a safe environment for all residents. Review of the provider's 7/12/16 Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriate of Resident's Property policy revealed: *It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin are reported immediately to the Executive Director (ED) of the center and the Director of Rehabilitation. *Such violations will also be reported to state agencies in accordance with existing state law. *The ED will direct a thorough investigation of each such alleged violation unless there is a conflict of interest or the Ed is implicated in the alleged violation. *The Ed is responsible to report the results of all investigations to the state agencies as required by state and federal law.

Based on interview, and policy review, the provider failed to follow their abuse policies for: *A witnessed event of verbal abuse for one of one sampled resident (10) with dementia by one of one registered nurse (RN) (E) and one of one licensed practical nurse (LPN) (F). *One of one sampled resident (14) who had been unable to speak for herself and had an injury of unknown origin. Findings include: 1. Interview on 8/17/16 at 10:16 a.m. with a certified nursing assistant (CNA) who wished to remain anonymous revealed: *Approximately a couple of weeks ago she had reported resident abuse to the director of nursing (DON). *At approximately 6:00 a.m. regarding that incident the anonymous CNA had observed RN E and LPN F at the end of the west hall. *RN E was screaming hello over and over again at resident 10. *Resident 10 had a [DIAGNOSES REDACTED]. *RN E was mocking what resident 10 was saying. *LPN F was laughing. *The anonymous CNA stated she along with other staff members had reported abuse to the DON and human resources person more than once. *The DON and human resources staff member had laughed at them when they reported abuse. *An anonymous resident had witnessed RN E mocking resident 10 and had reported the abuse to the DON. *An anonymous resident had reported the abuse to the DON. *That morning RN E told staff State is in the building and you all need to be very scared for your jobs. 2. Review of the provider's Protection from Abuse policy revealed All residents in the LivingCenter will be free from verbal, sexual, physical, or mental abuse, neglect, corporal punishment, and involuntary seclusion, according to the outlined in the LivingCenter abuse prevention plan. Refer to F223 and F225. 3. Review of resident 14's medical record revealed: *She had been readmitted on [DATE] from an acute care hospital. *[DIAGNOSES REDACTED]. *On 7/25/16, a skin tear had been identified on her sacral area after she had returned from a trip to the emergency room . *On 8/22/16, another skin tear had been identified below the first skin tear. Review of resident 14's nurses' progress notes revealed: *On 7/25/16, Resident back to facility by ambulance via stretcher. Resident has a new skin tear noted in lumbar area. Made MD aware and order received to cleanse with normal saline, apply [MEDICATION NAME] and dressing. Change dressing every 3 days or as needed. *On 8/22/16, She has a sore on her sacrum that started out as a skin tear. Just below this at the 5 o'clock area she has a small skin tear is 1.0 cm (centimeter) x 0.3 cm. There was no documentation the MD or family had been notified of the new skin tear. Interview on 8/23/16 at 4:05 p.m. with licensed practical nurse D revealed: *The resident had received the first skin tear when the ambulance crew transferred her from their gurney to her bed. *She had identified the second skin tear yesterday, 8/22/16. *She had not been aware of how the second skin tear had occurred. The above progress notes revealed no documentation to support: *An incident report for an injury of unknown origin had been completed on both of the skin tears. *The skin tears had been investigated and reported to the SD DOH to support physical abuse had not occurred. Interview on 8/24/16 at 10:30 a.m. with the field services clinical director revealed: *She would have expected the staff to have: -Completed an incident report for an injury of unknown origin on both of the skin tears. -Completed an investigation to support physical abuse had not occurred on the first skin tear that occurred on 7/25/16. -Started an investigation on the second skin tear that had been identified on 8/22/16. *She confirmed any type of injury of unknown origin should have ben investigated and reported to the SD DOH. Review of the provider's 7/12/16 Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriate of Resident's Property policy revealed: *It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin are reported immediately to the Executive Director (ED) of the center and the Director of Rehabilitation. *Such violations will also be reported to state agencies in accordance with existing state law. *The ED will direct a thorough investigation of each such alleged violation unless there is a conflict of interest or the Ed is implicated in the alleged violation. *The Ed is responsible to report the results of all investigations to the state agencies as required by state and federal law. 4. Interview on 8/17/16 at 8:15 a.m. with two residents who wished to remain confidential revealed: *About two to three weeks ago they had heard a staff member yelling in the hallway. They stated it was around 6:00 a.m. when the yelling had occurred. *They were aware that staff person yelling was a nurse. *The resident had been repetitively requesting help. *The nurse began mocking the resident by yelling down the hall what the resident had been saying. *Another nurse in the middle of the hallway had been laughing at the nurse's mocking words. *One of the confidential residents yelled out You need to be quiet. We are trying to sleep. *They were scared by what they had heard. *One confidential resident stated I am starting to lose my memory. I'm scared that they will treat me the same way. *They reported their concerns to the DON. 5. Interview on 8/17/16 at 1:10 p.m. with a CNA who requested to remain confidential revealed: *About two and a half weeks prior she had heard an RN yelling down the hall mocking a resident with dementia who had been requesting assistance. *That had occurred at the time of a shift change and was around 6:00 a.m. *The RN was repeating over and over Nurse, nurse, help me, help me. After that the nurse started yelling Hello. Hello. *An LPN who was down the hall was laughing at what the above nurse was doing. *She reported it to the DON. *She felt nothing had been done to reprimand the nurse. *She stated that same RN had threatened many aides that they may be fired. *She also stated that same RN refused to help residents in need. She had stated that was not her job as she was in management. 6. Interview on 8/17/16 at 2:35 p.m. with the DON, emergency permit holder (EPH), and the EPH's preceptor revealed: *They defined physical abuse as a inappropriate laying-on of hands to any part of the resident's body. *They defined verbal abuse as yelling, speaking to a resident in a childish manner, belittling, or ridiculing a resident. *They defined emotional abuse as speaking down to a resident. *They would consider an employee hollering down the hall and mocking a resident with dementia as verbal and emotional abuse. *The EPH if made aware of the situation would have immediately removed staff from the situation and started an investigation. The staff person in question would have been placed on suspension pending the results of the investigation. *Their goal was to ensure resident safety. *They confirmed the DON and EPH were aware of the situation where an RN and LPN had mocked and laughed at a resident with dementia. *The EPH and DON confirmed they had been told of the situation by staff and residents. *The DON had been told by the nurses in question they were just being silly. *They confirmed neither nurse had been removed from the situation or suspended. *They confirmed an investigation had not been started. *They confirmed their policy and procedures for abuse/neglect of residents had not been followed. -They had not interviewed staff and residents regarding the situation. -They had not reported the abuse to the South Dakota Department of Health nor to the South Dakota Board of Nursing. -They had been told by the CNAs that morning a nurse had told them their jobs were on the line. -No follow-up or investigation had been started regarding that treatment of [REDACTED]. Review of the provider's 7/12/16 Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source, and Misappropriate of Resident's Property policy revealed: *It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin are reported immediately to the Executive Director (ED) of the center and the Director of Rehabilitation. *Such violations will also be reported to state agencies in accordance with existing state law. *The ED will direct a thorough investigation of each such alleged violation unless there is a conflict of interest or the Ed is implicated in the alleged violation. *The Ed is responsible to report the results of all investigations to the state agencies as required by state and federal law.

Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that attained or maintained the highest practicable physical, mental, and psychosocial well-being of all sixty-five residents. Findings include: 1. Interview on 8/17/16 at 3:00 p.m. with the emergency permit holder (EPH) and the director of nursing (DON) revealed they confirmed they were responsible for the overall management of the building. Review of the 10/14/15 EPH job description revealed: *The provider had given to the survey team the Executive Director job description for the EPH job description. *The general purpose of that job was To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's business objectives. Serve as a mentor to guide and support all other assigned facilities. Review of the 10/16/14 DON job description revealed the general purpose was to Plan, coordinates, and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Maintains quality of care that is consistent with company and regulatory standards. Assumes responsibilities of daily operation in the absence of the Executive Director. Interviews, observations, record reviews, and policy reviews throughout the course of the extended survey from 8/16/16 through 8/18/16 and 8/22/16 through 8/24/16 revealed the administration had not ensured all residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being. Refer to F166, F223, F225, F226, F241, F248, F280, F281, F311, F312, F314, F323, F325, F328, F353, F441, and F520.

Based on observation, record review, interview, and policy review, throughout the course of the survey from 8/16/16 through 8/18/16 and from 8/22/16 through 8/24/16 revealed the governing body had not ensured the safe management and necessary care and services for 65 of 65 residents. Findings include: 1. Review of the last licensure survey completed on 3/3/16 revealed the following deficiencies had been cited: F176, F241, F253, F280, F281, F325, F431, F441, F466, and F520. Review of the complaint survey completed on 7/14/16 revealed the following deficiencies had been cited: F281 and F309. The following had been cited and/or recited (*) for the current survey: F166, F223, F225, F226, *F241, F248, *F280, *F281, F311, F312, F314, F323, *F325, F328, F353, *F441, F490, F493, F501, and *F520.

Based on interview and job description review, the provider failed to include the medical director in the implementation and/or coordination of residents care in the facility. Findings include: 1. Interview on 8/23/16 at 1:10 p.m. with the medical director revealed he had not been notified until approximately fifteen minutes ago the facility had been in an Immediate Jeopardy situation regarding resident abuse. Review of the 10/14/15 emergency permit holder (EPH) job description revealed: *The provider had given to the survey team the Executive Director job description for the EPH job description. *The general purpose of that job was To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's business objectives. According to the Society for Post-Acute and Long-Term Care Medicine (AMDA-American Medical Directors Association) website accessed on 8/24/16 (http://www.paltc.org/amda-white-papers-and-resolution-position-statements/nursing-home-medical-director-leader-manager) revealed there were functions that were relevant for all nursing home medical directors: *Administrative-participates in administrative decision making and recommends and approves relevant policies and procedures. *Professional services-organizes and coordinates physician services and the services provided by other professionals as they relate to patient care. *Quality Assurance and Performance Improvement-participates in the process to ensure the quality of medical care and medically related care, including whether it is effective, efficient, safe, timely, patient-centered, and equitable. *Rights of Individuals-participates in establishing policies and procedures for assuring that the rights of individuals are respected.

Based on observation, record review, interview, and policy review throughout the survey, the provider failed to ensure an effective quality assurance (QA) program had been maintained to identify concerns, and to develop and implement corrective action. Findings include: 1. Review of the previous complaint survey on 7/14/16 revealed the following deficiencies had been cited: F281, and F309. Review of the recertification survey on 3/3/16 revealed the following deficienies had been cited: F176, F241, F253, F280, F281, F325, F431, F441, F466, F520. During the current survey the following deficiencies had been cited and/or recited (*): F166, F223, F225, F226, *F241, F248, *F280, *F281, F311, F312, F314, F323, *F325, F328, F353, *F441, F490, F493, F501, *F520. The provider did not have a quality assurace or quality assurance process improvement (QAPI) coordinator job description. Interivew on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director confirmed the priior emergency permit holder (EPH) conducted the QA meetings. Unable to interview the EPH due to absent from the second part of the survey. Review of the QA minutes for June and July 2016 revealed: *No tracking and trending of resident falls. *In June they had identified concerns with: -Care planning and audits were initiated and continued to find the care plans were not accurate. Refer to F280. -Weights not being completed and stated they found complainace with weights. Refer to F325. -QAPI (quality assurance process improvement) had not included the past survey concerns for weights and infection control. Refer to F441. -Review of the falls that had occured within the facility for May, they were to include a root cause analysis, review of causal factors specific to policy, procedue, people and physical plant. No findings for the above were identified. Refer to F323. *In July they had identified concerns with: -Care planning, and audits were initiated and continued to find the care plans were not accurate. Refer to F280. -Weights not being completed and stated yet they found complainace with weights. Refer to F325. -QAPI had not included the past survey concerns for weights and infection control. Refer to F325 and F441.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Weekly skin reviews and wound documentation had occurred for 7 of 7 sampled residents (2, 4, 5, 8, 13, 14, and 18). *Physicians' orders were in place for wound treatment for 1 of 6 sampled residents (14). *The correct wound treatment had been completed by 1 of 1 licensed practical nurse (LPN) (D) on 1 of 4 sampled residents (13) who required a daily dressing change for a pressure ulcer. *Physician's order to hold a medication was in the medical record for 2 of 21 sampled residents (2 and 7). Findings include: 1a. Review of resident 13's medical record revealed: *He had been admitted on [DATE]. *[DIAGNOSES REDACTED]. *He had good memory recall. *His blood pressure medication had been discontinued on 8/9/16. *His blood pressure was to have been checked every day. *He had been admitted with multiple wounds. Those wounds had been: -A surgical wound to his left knee. -A stage II pressure ulcer to his coccyx. -A stage II pressure ulcer to his right buttock. -An unstageable pressure ulcer to his right heel. *He had been dependent upon the staff to assist him with activities of daily living (ADL). *Incomplete wound documentation. *A 7/29/16 physician's order for his skin to be assessed weekly. Review of resident 13's weekly skin review sheets from 7/22/16 through 8/10/16 revealed no documentation to support his skin had been assessed after 8/10/16. Those assessments had not been signed or dated by the licensed nurse. Review of resident 13's weekly wound evaluation flow sheets revealed: *On 7/28/16: -The wound on his coccyx had been assessed. -No other wounds had been assessed. *No documentation to support his wounds had been assessed for improvement, worsening, and healing after 7/28/16. *No date or signature from the licensed nurse who had completed the assessment on 7/28/16. Review for resident 13's nurses' progress notes from 7/22/16 through 8/23/16 revealed no documentation to support complete wound assessments had been done on all of his wounds after 7/22/16. b. Review of resident 14's medical record revealed: *She had been readmitted on [DATE] from an acute care hospital. *[DIAGNOSES REDACTED]. *She had: -No muscle control and required assistance from the staff for positioning and transfers. -Required the use of a transfer aide to assist her with transfers in and out of the bed. -The staff assisted her out of bed once or twice a week per her choice. -Wounds to her sacral area. *An 8/18/16 physician's order to assess her skin every week on Wednesday. Review of resident 14's 7/5/16 admission skin condition assessment revealed: *Skin concern Tiny open spot on right buttock. *No documentation to support the type of wound, size, and description of the wound to her right buttock. Review of resident 14's weekly skin review sheets from 7/5/16 through 7/25/16 revealed: *The description and documentation of the wound to her right buttock had been conflicting. *On: -7/5/16 and 7/13/16, a small open area to her right buttock. -7/18/16 and 7/24/16, moisture to right buttock. -7/25/16, she had a skin tear to her sacral area. *No documentation weekly skin assessments had been completed after 7/25/16. *No date or signature from the licensed nurse who had completed the weekly skin sheets. Review of resident 14's weekly wound evaluation flow sheets 7/5/16 through 8/23/16 revealed on 8/16/16: *Site Coccyx. *Type Skin tear. *Stage Unstageable. *Additional descriptions Received skin tear when being transferred to gurney by EMS personal (personnel). -Additional comments Wound is not open, has red edges, turning to white and has a dark center, suspecting deep tissue injury at this time. Patient is on a turn schedule but will refuse to reposition. *No documentation wound had been assessed prior to and after 8/16/16. That wound assessment had not been signed or dated by the licensed nurse. Review of resident 14's nurses' progress notes from 7/5/16 through 8/23/16 revealed no documentation a complete wound assessment had been done after her admission on 7/5/16. c. Review of resident 4's medical record revealed an 8/17/16 signed physician's order: -Wound care to the right foot daily on the evening shift and as needed (PRN). --That physician's order had been initiated 6/27/16. -Weekly skin assessments every Thursday. -Weekly skin reviews. The provider was unable to produce from the electronic medical record any weekly skin assessments for resident 4. Review of nurses progress notes from 6/23/16 through 8/22/16 revealed three progress notes about the wound dressing change on the right foot. There was no documentation to determine a complete wound assessment had been done. Review of the July and August 2016 Weekly Skin Reviews completed for resident 4 revealed: *7/7/16: He had a bruise on the abdomen from insulin injections and pre-existing open area on right toes with scab and dry red areas. *7/14/16: He had a bruise and open area. Under other it stated he had a PICC (special intravenous device) line in his left arm, amputated toes, multiple bruises on abdomen. *7/21/16: He had pre-existing dry skin and pre-existing open area on the right toes; healing wounds due to post amputation of toes. *8/4/16: He had bruises from insulin shots on both upper arms and on his abdomen. He had a pre-existing open area right toes (amputation of toes before admission). *8/5/16: His skin was intact. No further weekly skin reviews were found. d. Review of resident 18's medical record revealed an admission date of [DATE] with a 7/21/16 signed physician's orders stating: -Weekly skin reviews every Thursday. -Those signed physician's orders did not include the admission order for : --Wound care to her LLE (left lower extremity). --Wound care to her right buttock. Review of resident 18's 7/15/16 admission nursing assessment of the skin conditions revealed: -No indication of where the wounds were on the pictures of the body. -A skin concern was documented for the LLL (left lower leg). An open area was observed on 7/15/16. --It did not indicate the stage of the wound or how the surrounding tissue appeared. --It was 4 cm (centimeters) by 2.5 cm but did not indicate how deep the wound was. -- It stated open area R/T (related to) [MEDICAL CONDITION] (skin infection); small amt (amount) of yellow drainage noted. -No other skin concerns were noted. Review of the resident 18's July and August 2016 Weekly Skin Review documentation revealed: *7/15/16: Open area r/t [MEDICAL CONDITION] to left lower leg (lateral side) approx. 4cm L X 2.5 cm W. Small amount of yellow drainage noted. Cleansed with normal saline applied [MEDICATION NAME]. *7/21/16: Her skin was dry with pre-existing redness and a pre-existing open area. -The open area was left lower leg stating wound from fall that occurred before admission. *8/4/16: An open area that was pre-existing on the outer aspect of LLE due to [MEDICAL CONDITION]. And the sacrum-open area due to sheer and moisture, barrier cream applied. *8/8/16: An open area on right thigh front. A skin tear measuring 4 inches by 0.5 inches. Review of the resident 18's Wound Evaluation Flow Sheet revealed: *A pressure ulcer on the coccyx measured 0.1 X 0.1 X 0.1 cm, a stage two, red wound bed was identified on 7/15/16 upon admission. There was a pain management plan in place for the wound. There were preventative measures in place of a pressure redistribution mattress and a turn/reposition schedule. The care plan had been reviewed. *That wound document was not signed or dated by the licensed nurse. *There was no other wound documentation. Interview on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director confirmed she would have expected the weekly skin assessments to have included the wound length, width, depth, drainage, stage, surrounding tissue, and tunneling. The weekly skin reviews were to have been completed with baths to monitor for potential skin issues. Surveyor: 6. Review of resident 14's 8/8/16 nurse's progress note revealed New orders for daily dressing changes with hydrogel please see TAR (treatment administration record). Review of resident 14's physician's orders revealed no documentation an order had been noted by the licensed nurse who received the above treatment order change from the physician. 7. Review of resident 2's 8/23/16 nurse's progress note revealed: *Updated PCP (primary care provider) re: wound care today and residents wishes. *PCP gives order to hold collagen powder for 2 days and then to restart. Review of resident 2's August 2016 TAR revealed: *She was to have collagen powder applied to her open wounds on her buttocks daily. *On 8/24/16 and 8/25/16 the above treatment to her wounds was to have been held. Review of resident 2's physicians' orders revealed no documentation to support an order had been noted by the licensed nurse who received the above treatment order change from the PCP. Interview on 8/24/16 at 9:20 a.m. with the field services clinical director confirmed she would have expected a physician's order to have been noted for the above wound treatment changes. 8. Observation on 8/23/16 at 3:15 p.m. of LPN D with resident 13 revealed: *The nurse had: -Prepared to complete a dressing change to the resident's right heel. -Applied [MEDICATION NAME] to his right heel wound. Review of resident 13's medical record revealed: *He had been admitted on [DATE]. *He had been admitted with an unstageable pressure ulcer to his right heel. -The wound was to have been treated daily with [MEDICATION NAME]. *On 8/16/16 the physician had changed the treatment to his right heel. -The [MEDICATION NAME] had been discontinued and Santyl ointment was to have been applied to the wound. The licensed nurse had not been available for interview regarding the above observation. Interview on 8/24/16 at 9:25 a.m. with the field services clinical director confirmed the treatment orders for resident 13 had changed on 8/16/16. She would have expected the licensed nurse to have followed the current physician's order of Santyl ointment. e. Review of resident 5's physician's orders revealed a weekly skin assessment was to have been completed. That order had been initiated on 1/10/16 and discontinued on 7/28/16. She had been admitted [DATE] with a stage 4 pressure ulcer. Surgery had been performed on 4/14/16 to close that wound. She was at high risk for redevelopment of a pressure ulcer. Review of her weekly skin assessments from 3/3/16 through 8/23/16 revealed documented assessments had been completed on: *March: 3/30/16. *April: 4/13/16. *May: 5/16/16, 5/18/16. *June: 6/15/16, 6/22/16, 6/29/16. *July: 7/20/16. *August: 8/3/16, 8/10/16. Those skin assessments had not been completed weekly as ordered by the physician. Review of her weekly wound documentation from 3/3/16 through 8/23/16 revealed it had been completed: *3/10/16. *3/23/16. After that time no further wound documentation was found in her record. Interview on 8/24/16 at 9:10 a.m. with the field services clinical director and the Minimum Data Set (MDS) coordinator revealed their expectation was weekly skin reviews should have been documented per physician's orders until it had been discontinued on 7/28/16. Wound documentation should have been maintained and completed until the wound had healed completely. Both confirmed a surgical incision and repair would have been considered a wound and appropriate assessment and documentation should have occurred. 10. Review resident 7's April, May, June, July, and August 2016 medication administration records (MAR) revealed: *A physician's order for Xtandi Capsule 160 mg by mouth one time a day. -April MAR indicated [REDACTED]. -May MAR indicated [REDACTED]. -June MAR indicated [REDACTED]. -July MAR indicated [REDACTED]. Review of the medical record revealed no physician's order to hold the medication for resident 7. Interview on 8/23/16 at 3:15 p.m. with the administrator preceptor confirmed there was no physician's order to hold the medication. Interview on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director confirmed the expectation would have been to have a physician's order to hold the medication and to document the physician's order. She stated the provider was ordering a Lippincott Manual as the professional reference for nurses. 11. Review of resident 8's complete medical record revealed: *He was admitted on [DATE]. *He had a stage 2 pressure ulcer on his coccyx. *A 6/30/16 physician's order for a weekly skin review. *A wound care assessment sheet had not been initiated upon admit. *Weekly skin assessments had not been completed during that time. *He had two weekly skin assessments during his stay. *On 7/11/16 there was an incomplete weekly skin review with only: -Open area to coccyx. -No measurement of the area. Refer to 314, finding 4. 12. Review of resident 2's complete medical record revealed: *She was admitted on [DATE] with four pressure ulcers. *On 1/16/16 a skin tear had been identified. *On 6/19/16 she acquired a pressure ulcer on her left lower hip area. *Her wound evaluation flow sheets and weekly skin assessments were incomplete or had not been completed from admit through 8/18/16. *Her care plan had not been updated: -When she had changes in her skin condition. -To reflect her current skin integrity. -From that incomplete documentation there was know way to know the current status of her wounds. Refer to F314, finding 5.

Based on interview, schedule review, time card punch records, and policy review, the provider failed to ensure staffing was adequate to provide the necessary care and services for all 65 of the residents. Findings include: 1. Interview on 8/16/16 at 5:00 p.m. with resident 5 revealed there was never enough help. Interview with certified nursing assistant (CNA) G revealed there was a staffing shortage. Residents were not getting their baths because of that staff shortage. Refer to F312. 2. Review of the working nursing schedule revealed Sunday 8/14/16 three of the four scheduled CNAs had called off shift for the 6:00 a.m. until 2:00 p.m. time period. Review of the time card punches for that day revealed one CNA had worked from 6:00 a.m. until 10:00 p.m. There was a light duty CNA on duty from 6:00 a.m. until 9:30 a.m. The director of nursing was written in from 6: 00 a.m. until 3:30 p.m. along with the manager on duty from 7:00 a.m. until 3:30 p.m. 3. Interview on 8/17/16 at 3:30 p.m. with a confidential CNA revealed the administrative staff was in the building but did not assist with resident care. She stated they were on the phone the whole time. Surveyor: 4. Interview on 8/16/16 at 4:45 p.m. with resident 2 revealed: *Her call light times could be up to an hour. *She was told they were short staffed. Refer to F241, finding 1. 5. Interview with an anonymous CNA on 8/17/16 at 10:16 a.m. revealed: *They were short staffed. *There had been only one traveling CNA during the a.m. shift on 8/14/16. *When they were short staffed management will not help them. *Resident 10 always tried to self-transfer, There are not enough staff to watch him. Refer to F323, finding 1. 6. Interview on 8/17/16 at 1:10 p.m. with an anonymous staff member revealed: *They were short on CNAs. *Residents sat in their chairs in the hallways and dining room. -Staff did not come and get them out of the dining room. *Other staff and management could pitch in and help, but they did not. *Residents' hair and hygiene needs were not being met. 7. Interview on 8/17/16 at 1:20 p.m. with CNA H revealed there had been a short staffing issue here. Surveyor: 8. Review of the provider's undated Golden Living Scheduling Guide policy revealed Appropriate scheduling is the foundation to successfully managing your workforce. Review of the 10/14/15 emergency permit holder (EPH) job description revealed: *The provider had given the survey team the Executive Director job description for the EPH job description. *The general purpose of that job was To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's business objectives. Serve as a mentor to guide and support all other assigned facilities. Review of the 10/16/14 DON job description revealed the general purpose was to Plan, coordinates, and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Maintains quality of care that is consistent with company and regulatory standards. Assumes responsibilities of daily operation in the absence of the Executive Director. For the necessary care and services that had not been provided refer to: F223, F225, F226, F241, F248, F280, F281, F311, F312, F314, F323, F325, F328, and F441.

Based on observation, interview, record review, and policy review, the provider failed to assess, implement interventions, and follow their policy to prevent or ensure worsening of pressure ulcers had not occurred for six of six sampled residents (2, 4, 8, 13, 14, and 18). Findings include: 1. Random observations of resident 13 on 8/22/16 from 4:00 p.m. through 6:20 p.m., on 8/23/16 from 8:00 a.m. through 11:10 a.m., and 1:50 p.m. through 4:00 p.m. revealed: *He been laying in his bed. *He had a pressure relieving air mattress device on his bed. *Head of bed was in the up position. *He had been positioned on his back and down far in the bed. *His right foot/heel had been positioned up against the foot board of the bed. -That foot board was a hard surface. *The back of his right heel and ankle had been positioned directly on the air mattress. -No pressure relieving device (pillows, wedges) was placed underneath that area to ensure no increase in pressure on it had occurred. *He had remained in that position during all the above time frames. Review of resident 13's medical record revealed: *He had been admitted on [DATE]. *[DIAGNOSES REDACTED]. *He had good memory recall. *His blood pressure medication had been discontinued on 8/9/16. *He had been admitted with multiple wounds. Those wounds had been: -A surgical wound to his left knee. -A stage 2 pressure ulcer to his coccyx. -A stage 2 pressure ulcer to his right buttock. -An unstageable pressure ulcer to his right heel. *His 8/2/16 Braden Risk Assessment Scale score had been a 15. -That score made him at high risk for developing pressure ulcers. *He had been dependent upon staff to assist him with activities of daily living (ADL). *A 7/29/16 physician's orders [REDACTED]. *He had been: -Dependent upon staff to assist him with ADLs. -Weak and was working with the therapy department on strengthening. -Having a problem with his blood pressure dropping when he was out of bed for any length of time. -Assisted out of his bed with the therapy department once a day because of his blood pressure problems. *On 8/16/16 staff had faxed the physician requesting a change in treatment for [REDACTED]. -There was no documentation in his medical record that the request to the physician had been made. *Incomplete wound documentation and assessments from 7/22/16 admission through 8/23/16. Observation and interview on 8/23/16 at 3:15 p.m. with licensed practical nurse (LPN) D with resident 13 revealed: *She had prepared to change the dressing on his right heel. *His right heel wound: -Was dark brown/black in color. -Encompassed the entire base of heel and extended up the back area of his ankle. *She could not identify if the wound had worsened since his admission. *She had not performed a formal wound assessment during the entire dressing change. 2. Review of resident 14's medical record revealed: *She had been readmitted on [DATE] from an acute care hospital. *[DIAGNOSES REDACTED]. *She had: -No muscle control and required assistance from staff for positioning and transfers. -Required the use of a transfer aide to assist her with transfers in and out of the bed. -Required staff assistance to get her out of bed once or twice a week per her choice. -Been incontinent of both urine and bowel. -Wounds to her sacral area. *An 8/18/16 physician's orders [REDACTED]. Random observations of resident 14 on 8/22/16 from 4:15 p.m. through 6:00 p.m. and on 8/23/16 from 8:05 a.m. through 4:00 p.m. revealed: *She had been laying in bed that had a pressure relieving air mattress on it. *She appeared very thin and weak. *Her bones were easily noticed through her skin. *The head of her bed had been in the upright position. *She had been positioned on her back and down far in the bed. *Her left foot had been positioned up against the hard surface of the beds foot board. *The back of her heels and ankle had been positioned directly on the air mattress. -She could not move her legs without staff assistance. -No pressure relieving devices were placed underneath of her feet/legs to ensure no increase in pressure on them had occurred. *She had remained in that position during all the above time frames. Observation and interview on 8/23/16 at 4:05 p.m. with LPN D with resident 14 revealed: *She had prepared to change the dressing to the sacral area. *That wound was approximately 2 centimeters (cm) by 2 cm in diameter and red with areas of yellow in it. *It started as a small skin tear from the ambulance gurney. *She confirmed the wound had worsened significantly. *The resident had a small opening/slit below the sacral wound on her right buttock. -It was a new area identified on 8/22/16 as another skin tear. *She had not performed a formal wound assessment during the entire dressing change on either of the wounds. Review of the provider's 2011 manufacturer's MicroAir air mattress user manual revealed no documentation when it was in-use that: *Pressure relieving devices were not required. *Residents had not required repositioning in bed. 3. Interview on 8/24/16 at 9:15 a.m. with the Minimum Data Set (MDS) assessment coordinator and field services clinical director confirmed: *The above medical record reviews for residents 13 and 14. *When using the MicroAir mattress: -The residents should have continued to be repositioned. -Pressure relieving devices should have been utilized. Refer to F281, finding 2. 4. Review of resident 8's complete medical record revealed: *He was admitted on [DATE]. *He had a stage 2 pressure ulcer on his coccyx. *A 6/30/16 physician's orders [REDACTED]. *A wound care assessment sheet had not been initiated upon admit. *Weekly skin assessments had not been completed during that time. *He had two weekly skin assessments during his stay. *On 7/11/16 there was an incomplete weekly skin review with only: -Open area to coccyx. -No measurement of the area. Interview on 8/17/16 at 9:05 a.m. with the local ombudsman regarding his interview with resident 8 and the director of nursing (DON) during that monthly visit on 7/13/16 revealed: *The resident voiced his pressure ulcer had not been looked at. *The director of nursing (DON) confirmed she had not assessed his pressure ulcer. Review of resident 8's 6/30/16 care plan revealed: *Focus area: of a pressure ulcer, stage 2, coccyx. *Interventions included: -Conduct weekly skin assessments per LivingCenter policy. -Weekly wound assessments. Interview on 8/17/16 at 11:15 a.m. with the DON regarding resident 8 revealed: *A wound care assessment sheet had not been initiated upon his admission. *Weekly skin assessments had not been completed. *They had not followed their care plan regarding his pressure ulcer. *They had not followed their pressure ulcer policy. 5. Review of resident 2's complete medical record revealed: *She was admitted on [DATE] with four pressure ulcers. *On 1/16/16 a skin tear had been identified. *On 6/19/16 she acquired a pressure ulcer on her left lower hip area. *Her wound evaluation flow sheets and weekly skin assessments were incomplete or had not been completed from admit through 8/18/16. *Her care plan had not been updated: -When she had changes in her skin condition. -To reflect her current skin integrity. -From that incomplete documentation there was know way to know the current status of her wounds. Interview on 8/16/16 at 4:45 p.m. with resident 2 revealed: *Her call light response from staff at times could be up to an hour. -Usually that happened in the mornings. *She had a wound on her bottom. *Sometimes her bed would be soaked from her catheter leaking. -Staff told her they would change her bed when the nurse came in to do her dressing change. -Sometimes staff would only change the turn sheet instead of all of the bedding. -The last time it happened was that morning. *Some days she had to lay in bed until 10:30 a.m. -She had asked to get up earlier between 8:00 a.m. and 9:00 a.m. -She had been told she could not get up until the nurse had come in to do her dressing change. *She was told they were short staffed. *She was supposed to have a bath every Tuesday, Thursday, and Saturday. *It had been well over two weeks since she had a bath. Interview on 8/17/16 at 8:05 a.m. with certified nursing assistant G regarding resident 2 revealed: *She wanted to get up earlier. *They could not get her up for the day until the nurse changed her dressings. *She had observed a couple of nurses just changed the turn sheet when the bedding had been soaked with urine. Interview on 8/17/16 at 10:16 a.m. with a CNA who wished to remain confidential revealed LPN F would not change resident 2's sheets when they were wet. Interview on 8/17/16 at 10:55 a.m. with the director of nursing revealed: *LPN F and RN E were responsible for wound care. *The wound care documentation was incomplete and inaccurate. Surveyor: Refer to F241, finding 3. Refer to F281, finding 7. 5. Review of resident 4's medical record revealed: *He had been admitted on [DATE] with a bone infection. *He also had a surgical wound on the right foot. *Refer to F281, finding 3. 6. Review of resident 18's medical record revealed: *She had been admitted on [DATE] with pressure ulcer on her right buttock. *She had also been admitted with a wound on her left lower extremity. Review of resident 18's 7/18/16 care plans revealed conflicting information as to where the pressure ulcer was. *The pressure ulcer care plan indicated on the right buttock. *The pain managment care plan indicated on the sacrum (tailbone area). Neither care plan indicated the treatment that was to have been done to those areas. *Refer to F281, finding 4. 7. Review of the provider's undated Skin Integrity Guideline policy revealed: *The purpose was to: -Provide a comprehensive approach for monitoring skin conditions. -Decrease pressure ulcer and/or wound formation by identifying those patients/residents who are at risk, and implementing appropriate interventions. -Promote healing of wounds of any etiology, whether admitted or acquired. *The objectives of the policy were to: -Decrease the prevalence and incidence of patients/residents who develop pressure ulcers. -Provide a guideline for optimal care to promote healing to patients/residents with all identified alterations in skin integrity (i.e. surgical incisions, skin tears, bruising, etc.). *General Guidelines were: -Patients/Residents will be assessed or observed for risk of skin breakdown within 24 hours of admission or readmission, quarterly, before transfer or discharge to any setting (unless emergent nature of transfer does not allow), and as necessitated by change in condition. -Living Center develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings. -DNS or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. -The interdisciplinary plan of care will address problems, goals and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified.

2. Review of resident 6's medical record revealed: *She had been admitted on [DATE]. *She had fallen five times in July. *Refer to F280, finding 1. 3. Review of the provider's Monthly Event Log revealed: *For July 2016 there were forty-two resident falls. *For August 1 through 16 there were thirteen resident falls. Review of the provider's 8/10/16 Falls Management Guideline policy revealed: *At risk residents are identified through a 'fall alert' communication system to care givers. -During orientation new employees are educated to the fall managment system. *Following a resident's fall: -Appropriate interventions are implemented. -Care plan is updated. *QAPI (quality assurance process improvement) committee minutes reflect data analysis using the information driven by the Quality Control Event Reporting System to identify systemic trends and patterns related to resident falls and appropriate plans of action. *For monitoring/Compliance the following elements are in place for the center to demonstrate satisfactory compliance with the guide: -Residents are evaluated for fall risk. -Communication system to identify the residents at risk for falls. -Residents at risk for falls are care planned with individualized interventions. -The IDT (interdisciplinary team) evaluation is completed on the Change of Condition Report-Post Fall and validation of individualized interventions. Interview on 8/23/16 at 9:10 a.m. with the field services clinical director revealed: *The provider did not have a fall alert communication system. *The Quality Control Event Reporting System was not used to track and trend resident falls. Interview on 8/24/16 from 9:07 a.m. through 10:10 a.m. with the field services clinical director revealed there was no formal activity program. The only activities were provided by volunteers, such as church and bingo. Those activities were not documented in the resident medical record. The activity director had resigned approximately two months ago causing the residents to have nothing to do and increasing the risk of falls. Based on observation, record review, interview, and policy review, the provider failed to ensure the safety of 2 of 21 sampled residents (6 and 10) who had multiple falls with injury. Findings include: 1. Review of resident 10's complete medical record revealed: *He was admitted on [DATE]. *He was identified as a fall risk. *He had a [DIAGNOSES REDACTED]. *He had sixteen falls in the eighty days from admission on 5/24/16 through 8/11/16 for the following: -May: 5/25/16, and two on 5/27/16. -June: 6/1/16, 6/9/16 that resulted in a left hip fracture, 6/15/16, 6/17/16, 6/21/16, 6/23/16. -July: 7/8/16, 7/14/16, 7/19/16, 7/21/16, 7/29/16. -August: 8/3/16, 8/11/16. Interview with an anonymous CNA on 8/17/16 at 10:16 a.m. revealed: *They were short staffed. *There had been only one traveling CNA during a shift on 8/14/16. *When they were short staffed management would not help them. *Resident 10 always tried to self-transfer There are not enough staff to watch him. Observation on 8/18/16 at 9:00 a.m. and 9:05 a.m. of resident 10 after breakfast revealed: *At 9:00 a.m. he was sitting in his wheelchair in his room by himself. *At 9:05 a.m. he was in his bathroom alone trying to self-transfer himself to the toilet. Review of resident 10's 7/29/16 revised care plan revealed: *Focus area: at risk for falls. *Intervention stated: Needs to be at nurses station or activity programs; can not be left alone in his room unless going to bed. *Intervention stated: Resident will be laid down after meals to rest. *Intervention stated: Staff must anticipate needs, resident is not able to verbalize when he needs assistance due to his short term memory loss. *Intervention stated: Will toilet before and after meals, before laying down for a nap, at hs, once during the night, and as needed. Review of resident 10's Post Fall Analysis/Plan forms from 5/26/16 through 7/21/16 revealed: *He had no report for the following dates: -5/27/16 -6/1/16 -7/29/16 -8/3/16 -8/11/16 *The forms that had been initiated for other falls were incomplete. *There was no interdisciplinary review or recommendations on any of those forms. Interview on 8/18/16 at 9:40 a.m. with the administrator's preceptor revealed she was unsure what the fall communication system was. Interview on 8/23/16 at 9:00 a.m. with an anonymous CNA revealed: *Their were no activities. *The activities director quit approximately a month and a half to two months ago.

Based on record review, interview, and policy review, the provider failed to ensure complete respiratory nursing assessments were done for one of two sampled residents (2). Findings include: 1. Review of resident 2's medical record revealed she had been admitted to the hospital on [DATE] with pneumonia and [MEDICAL CONDITION]. The resident's respiratory assessment had not been completed. Refer to F309.

Based on record review, interview, and policy review, the provider failed to ensure complete respiratory nursing assessments for one of two sampled residents (2) had been done. Findings include: 1. Review of resident 2's medical record revealed she had been admitted on [DATE]. Her [DIAGNOSES REDACTED]. *[MEDICAL CONDITIONS] with acute exacerbation. *Pneumonia due to pseudomonas. *Dependence on supplemental oxygen. *Malignant neoplasm of lung. *Helicobacteria pylori *Humerus fracture. *[MEDICAL CONDITION] *Diabetes mellitus. *[MEDICAL CONDITION]. *Hypertension. *Anxiety. *Pain. *Constipation. Resident 2 had been seen by the: *Physician on 6/1/16 for her admission visit. *Certified nurse practitioner (CNP) on 6/3/16 for order clarification. *CNP on 6/16/16 for anxiety. *CNP on 6/28/16 for a thirty day follow-up for the physician. *CNP on 6/29/16 for medication management that had included an order for [REDACTED]. Resident 2 had the following medications ordered during June 2016: *[MEDICATION NAME] HandiHaler Capsule 18 micrograms, inhale one daily for [MEDICAL CONDITION]. *[MEDICATION NAME] Diskus Aerosol Powder Breath Activated 500-50 microgram dose, one puff orally two times a day for [MEDICAL CONDITION]. *[MEDICATION NAME] HCl Nebulization Solution 1.25 milligram (mg), three times daily for [MEDICAL CONDITION]. *[MEDICATION NAME] HCl Nebulization Solution 1.25 mg every two hours as needed for cough related to [MEDICAL CONDITION] with acute exacerbation, ordered on [DATE]. *Continuous oxygen at three liters per nasal cannula. Resident 2 had the following medications ordered during July 2016: *[MEDICATION NAME] HandiHaler Capsule 18 micrograms, inhale one daily for [MEDICAL CONDITION]. *[MEDICATION NAME] Diskus Aerosol Powder Breath Activated 500-50 microgram dose, one puff orally two times a day for [MEDICAL CONDITION]. *[MEDICATION NAME] HCl Nebulization Solution 1.25 milligram (mg), three times daily for [MEDICAL CONDITION]. *[MEDICATION NAME] HCl Nebulization Solution 1.25 mg, every two hours as needed for cough related to [MEDICAL CONDITION] with acute exacerbation. -She had received that as needed medication for exacerbated [MEDICAL CONDITION] on 7/1/16, 7/5/16, 7/6/16, and 7/7/16. -She had not needed the prn nebulizer in June 2016. *Continuous oxygen at three liters per nasal cannula. The resident's antibiotic [MEDICATION NAME] HCl tablet 500 mg used to treat pneumonia had been completed on 6/7/16. On 5/31/16 the director of nurses had completed resident 2's admission assessment. The resident's lung sounds had been diminished in the bases and had bilateral wheezes. That had been recorded on the Clinical Health Status assessment at 5:30 p.m. on that date. During resident 2's entire admission and stay there had been only one progress note that had recorded assessment of her lung sounds. That note had been completed on 5/31/16 by the director of nurses at 5:40 p.m. Resident 2 had been taken to the emergency room by her family on 7/7/16. She had been admitted to the hospital with [REDACTED]. Review of the resident's care plan initiated on 6/10/16 revealed a focus area for: *Altered respiratory status. There had been a goal to have adequate gas exchange as evidenced by no adventitious breath sounds, absence of respiratory distress, and absence of shortness of breath. -There had been no interventions specific for monitoring the resident's audible gas exchange. *Impaired cardiovascular status related to hypertension and abdominal aortic aneurysm. -The interventions stated to assess breath sounds as necessary and report abnormalities. -There had been no monitoring of the resident's breath sounds. 3. Interview on 7/13/16 at 4:30 p.m. with the director of nurses revealed she agreed assessments of resident 2's lung sounds had not been completed. She had been aware the shift nurses had not been assessing lung sounds when they should have been. Interview on 7/14/16 at 11:45 a.m. with the interim administrator and consulting administrator revealed they agreed an assessment that included lungs sounds had not been completed for resident 2. Review of the provider's version 4 last reviewed 2/3/16 Clinical Health Status-Change of Condition Guideline policy revealed an objective assessment was to have been completed including the physical assessment. Review of Patricia A. Potter et al., Fundamentals of Nursing, 8th Ed., Televise, St. Louis, Mo., 2013, page 834, revealed: Auscultation of lung sounds involves listening for movement of air throughout all lung fields: anterior, posterior, and lateral. Adventitious, or abnormal breath sounds occur with collapse of a lung segment, fluid in a lung segment, or narrowing or obstruction of an airway. Review of the http://sdlegislature.gov South Dakota Codified laws accessed on 7/18/16 at 3:30 p.m. revealed: *36-9-3. Practice of registered nurse. The practice of a registered nurse includes: - (1) Providing comprehensive nursing assessment of health status of patients; - (2) Collaborating with the health care team to develop and coordinate an integrated patient-centered health care plan; - (3) Developing the comprehensive patient-centered health care plan, including: (a) Establishing nursing diagnosis; (b) Setting goals to meet identified health care needs; and (c) Prescribing nursing interventions; - (4) Implementing nursing care through the execution of independent nursing strategies and the provision of regimens requested, ordered, or prescribed by authorized health care providers; - (5) Evaluating responses to interventions and the effectiveness of the plan of care; - (6) Designing and implementing teaching plans based on patient needs; - (7) Delegating and assigning nursing interventions to implement the plan of care; - (8) Providing for the maintenance of safe and effective nursing care rendered directly or indirectly; - (9) Advocating for the best interest of the patient; - (10) Communicating and collaborating with other health care providers in the management of health care and the implementation of the total health care regimen within and across settings; - (11) Managing, supervising, and evaluating the practice of nursing; - (12) Teaching the theory and practice of nursing; - (13) Participating in development of health care policies, procedures, and systems; and - (14) Other acts that require education and training consistent with professional standards as prescribed by the board, by rules promulgated pursuant to chapter 1-26, and commensurate with the registered nurse's education, demonstrated competence, and experience. *36-9-4. Practice of licensed practical nurse. A licensed practical nurse practices under the supervision of a registered nurse, advanced practice registered nurse, licensed physician, or other health care provider authorized by the state. A licensed practical nurse is guided by nursing standards established or recognized by the board and includes: - (1) Collecting data and conducting a focused nursing assessment of the health status of a patient; - (2) Participating with other health care providers in the development and modification of the patient-centered health care plan; - (3) Implementing nursing interventions within a patient-centered health care plan; - (4) Assisting in the evaluation of responses to interventions; - (5) Providing for the maintenance of safe and effective nursing care rendered directly or indirectly; - (6) Advocating for the best interest of the patient; - (7) Communicating and collaborating with patients and members of the health care team; - (8) Assisting with health counseling and teaching; - (9) Delegating and assigning nursing interventions to implement the plan of care; and - (10) Other acts that require education and training consistent with professional standards as prescribed by the board, by rules promulgated pursuant to chapter 1-26, and commensurate with the licensed practical nurse's education, demonstrated competence, and experience.

Based on interview, job description review, and policy review, the provider failed to create an atomosphere free from abuse, intimidation, and demeaning (seeming of little importance or value) for the following: *Four of four individuals that attended the group interview and requested confidentiality (unidentified per request). *Four of five residents interviewed and requested confidentiality. *One of two families interviewed and requested confidentiality. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 3/24/15 at 6:27 p.m. to the interim administrator and the interim director of nursing (DON). The administrator was asked for an immediate plan of correction to ensure all residents would be free from abuse. PLAN: On 3/24/15 at 8:00 p.m. the interim administrator and the administrator preceptor provided the surveyors with an immediate written plan of correction (POC) for that night. That POC dated 3/24/15 was accepted that same night at 8:03 p.m. by the surveyors and included: 1. "All residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents have the right to exercise his/her rights." 2. "All oncoming staff will be reeducated on Abuse and Neglect policy and procedure appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property ("alleged violations")." 3. "All staff will be reeducated in the Long Term Care Facilities Resident's Bill of Rights provided by the SD (South Dakota) Department of Social Services Adult Services and Aging: Ombudsman Program (resident advocate)." 4. "Staff currently working and oncoming staff will be immediately reeducated on the Abuse and Neglect policy and procedure appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property ("alleged violation") and on the Long Term Care Facilities Resident's Bill of Rights provided by the SD Department of Social Services Adult Services and Aging: Ombudsman Program." 5. "A Golden Living management staff member assigned throughout the evening and night shift will provide onsite coverage and monitoring of resident safety and well being throughout the night of March 24, 2015." 6. "ED (executive director) and/or DNS (director of nursing services) and staff interviews will be completed weekly X (times) eight weeks to ensure residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion and residents feel they have the right to exercise his/her resident rights." 7. Interview on 3/25/15 at 11:40 a.m. with the transitional leader, registered nurse/nursing home administrator consultant confirmed the alleged certified nursing assistant was on administrative leave pending the police investigation. During the survey on 3/25/15 at 12:16 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Interview on 3/24/15 at 11:15 a.m. with a confidential resident revealed: *She had overheard staff in the hallway speak badly of residents multiple times. *A friend of hers (another resident) in the facility was "too afraid to say anything" because last time she had voiced a concern staff had left her on the toilet for forty-five minutes (that resident needed staff toileting assistance). *She was concerned about the treatment of [REDACTED]. A review of the roommate's Brief Interview for Mental Status (BIMS) revealed her score was an eight indicating her thinking was moderaterly impaired. -One night she had heard her roommate tell a night staff member to stay away from her underwear. -She stated the male staff member replied "just lay there or I'll get in bed with you and you know what happens then." -She was not sure if the staff member had been trying to "kid" but she did not think it was appropriate. 2. Interview on 3/24/15 from 3:00 p.m. to 4:40 p.m. with four of four residents who attended the group interview wanted to remain unidentified revealed: *Four of four residents agreed certain staff members were very "rude and mean" to residents. *Two of four residents expressed they had been spoken to harshly when they had tried to voice a preference or concern. *Two of four residents expressed a certain staff member told multiple residents the problem with them (regarding their [DIAGNOSES REDACTED]." *Four of four residents agreed they had heard staff members call residents negative names. 3. Interview on 3/24/15 beginning at 3:00 p.m. with a confidential resident revealed: *She had been crying in the dining room, asked for one of her medications, and had been told she needed to "just grow up and deal with it." *When requesting assistance to go to the bathroom: -The aide was not listening to her. -The aide put her in front of the bathroom door and left. -The aide had returned with a nurse. -They yelled at her to "stop that" for trying to voice an opinion. *Staff instructed each other not to help her when she asked for assistance. *When she put her call light on for assistance for the bathroom staff had made comments such as "you just went, you go more than anyone I know, or are you done yet?" 4. Interview with a confidential resident revealed she had been left on the toilet for lengthy periods of time. She stated she had been told by staff "That's what you get when you complain." She stated she had not shared that concern with administration, because she was afraid things would get worse. 5. Interview on 3/24/15 at 4:15 p.m. with a resident revealed: *The resident care coordinator (RCC) had stated to the resident "you are a leech off the state and are sucking the government dry." *Certified nursing assistant (CNA) K had stood at his door and announced she could not come into his room as he had an infection. The resident did not have a [DIAGNOSES REDACTED]. *The residents would "change their own moods and personalities to match the staff on duty." If any of the residents voiced a concern they were "immediately treated differently." The staff would then "act and care for them with a coldness or that they weren't important." *He was afraid of repercussion and harassment and no longer went to the dining room for meals. *He only came out of his room to go outside to smoke and revealed he would "avoid staff if I can help it." Review of the above confidential resident's Brief Interview for Mental Status score revealed he was at fifteen and had a recent score of thirteen (intact thought processes). Surveyor 6. Interview on 3/31/15 at 8:15 p.m. with a confidential family member of a resident revealed: *He visited his family member every day. *He had spoken with social services (SS), nurses, and other staff several times regarding the care of his family member, and nothing had been done. *After he spoke with the staff his family member had been treated "differently." He then gave a summary of his term 'differently'. He stated he had noticed the following after consultation with staff: -"As an example ____ (resident name) would request pain medication at let's say 4:30. Staff would give him the meds. ____ (resident name) would then request the pain meds again at 8:30 and staff would say the first dose had been given at 5:30 and they couldn't give another dose until 9:30." The family member stated "it seemed to me they gave the pain meds and then wrote it down an hour later and used that time for when they gave it to him." -"____ (resident name) told me he didn't always get his breathing treatments that were ordered by the doctor." He stated when his family member asked for his breathing treatment he would be told by the resident care coordinator (RCC) "you're needy and always needing something." The RCC would "yell at him in the hall." *The family member stated he was afraid to say anything else to the staff at the nursing home as he was afraid of "further repercussions" to his family member when he was not there. Review of that confidential resident's BIMS score revealed he tested at fifteen (thought process intact). His family member revealed he was the resident's power of attorney and had tried and was still trying to get his family member relocated to another nursing home. Surveyor 7. Review of the provider's 8/30/11 Social Services Coordinator job description revealed: *The general purpose was to "Identify and provide for each resident's social, emotional, and psychological needs, and the continuing development of the resident's full potential during his/her stay at the facility and to assist in the planning for his/her discharge." *Some of the essential job duties were to "Develop a social history, social assessment and care plan which identifies pertinent problems and needs, realistic goals to be accomplished and the specific action to be taken in resolution of the problems and/or needs upon admission of each new resident...Organize family groups to promote communication, education and support between family members, facility staff and administration, and provide counseling as needed. Assist in the education of the community regarding aging, rights of residents, facility services and other related topics. *The code of conduct stated "Must adhere to the Company's Code of Conduct and Business Ethics policy including documentation and reporting responsibilities." Review of the provider's 9/25/14 CNA job description revealed: *The general purpose was to "Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a [MEDICATION NAME] physical and psychosocial (social) environment for the residents." *Some of the essential job duties were to: "Directly respond, within scope, to needs and concerns of residents and family members including call lights. Ensure residents' comfort while assisting them in achieving their highest practicable level of functioning." *The code of conduct stated "Must adhere to the Company's Code of Conduct and Business Ethics policy including documentation and reporting responsibilities." Review of the provider's 3/1/13 revised Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy revealed: "Each employee shall receive annual training on the requirements of the center/location's policies and procedures regarding alleged violations and the requirements of state and federal law. Staff, families and employees are required to report incidents of suspected abuse, neglect or misappropriation of resident property without fear of reprisal. Families, residents and volunteers shall be encouraged to report incidents of suspected abuse, neglect, or misappropriation of resident property without fear of reprisal."

A. Based on interview, record review, job descriptions review, and policy review, the provider failed to create an atmosphere free from neglect (willful overlooking) for the following: *Four of four individuals that attended the group interview and requested confidentiality (unidentified per request). *Four of five residents interviewed and requested confidentiality. *One of two families interviewed and requested confidentiality. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 3/24/15 at 6:27 p.m. to the interim administrator and the interim director of nursing (DON). The administrator was asked for an immediate plan of correction to ensure all residents would be free from neglect. PLAN: On 3/24/15 at 8:00 p.m. the interim administrator and the administrator preceptor provided the surveyors with an immediate written plan of correction (POC) for that night. That POC dated 3/24/15 was accepted at 8:03 p.m. that same night by the surveyors and included: 1. "All residents will be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents have the right to exercise his/her rights." 2. "All oncoming staff will be reeducated on Abuse and Neglect policy and procedure appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property ("alleged violations")." 3. "All staff will be reeducated in the Long Term Care Facilities Resident's Bill of Rights provided by the SD (South Dakota) Department of Social Services Adult Services and Aging: Ombudsman Program (resident advocate)." 4. "Staff currently working and oncoming staff will be immediately reeducated on the Abuse and Neglect policy and procedure appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin (how it happened) and misappropriation of resident property and to ensure that all alleged (supposed) violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown origin and misappropriation of resident property ("alleged violation") and on the Long Term Care Facilities Resident's Bill of Rights provided by the SD Department of Social Services Adult Services and Aging: Ombudsman Program." 5. "A Golden Living management staff member assigned throughout the evening and night shift will provide onsite coverage and monitoring of resident safety and well being throughout the night of March 24, 2015." 6. "ED (executive director) and/or DNS (director of nursing services) and staff interviews will be completed weekly X (times) eight weeks to ensure residents are free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion and residents feel they have the right to exercise his/her resident rights." Interview on 3/25/15 at 11:40 a.m. with the transitional leader, registered nurse/nursing home administrator consultant confirmed the alleged certified nursing assistant was on administrative leave pending the police investigation. During the survey on 3/25/15 at 12:16 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Interview on 3/24/15 at 11:15 a.m. with a confidential resident revealed: *She was on PRN pain medications. *Staff had not always administered her pain medications on time when she had requested. *Staff were on their phones in the hallways and would ignore residents' requests. *She was concerned about the treatment of [REDACTED]. 2. Interview on 3/24/15 from 3:00 p.m. to 4:40 p.m. with four of four residents who attended the group interview wanted to remain unidentified revealed: *All four residents stated staff would come in, turn off a call light, leave, and not come back. *All four residents agreed it took "a very long time" to get assistance for the bathroom. If they couldn't wait, staff would get "mad." *Two of four residents stated if an aide was helping one resident, another aide would come in and they would have personal conversations with each other and ignore the resident. *All four residents voiced concern about staff standing around talking and playing games on their phones and ignoring residents. *Two of four residents stated they had not received PRN (as needed) medications in a timely manner. -They had been told it was not time for them when they were within the ordered time. *All four residents agreed they had not been given baths or showers as requested. -Three of the four residents had gone two weeks without one. -One resident had gone ten days without one. *One resident told of an instance where a staff member had found a resident's "reacher" (device used to reach and grab objects) in the hallway and had left it there instead of returning it stating "they'll figure it out eventually." 3. Interview on 3/24/15 at 3:00 p.m. with a confidential resident revealed: *She was not given her PRN medications when she asked for them and had been told it was too early. *Staff had told each other not to help her when she asked for assistance. Review of the above resident's medical record revealed: *She had a current order for an anxiety medication that could be given every six hours as needed (PRN). *A 2/10/15 progress note at 4:01 p.m. in regards to her asking for PRN anxiety medication stated she was anxious, multiple attempts were made to explain her medications were ordered at specific times, and staff could only administer it as ordered. They would have to contact the doctor to get time changes approved. -Her 2/10/15 Medication Administration Record [REDACTED] -The medication could have been given at 4:01 p.m. as requested. *A 3/15/15 progress note stated she had requested an anxiety pill at 9:00 a.m. Nurse I told her it was too early and re-offered it at 12:18 p.m. -Her 3/14/15 MAR indicated [REDACTED] -The medication could have been given at 9:00 a.m. as requested. Interview on 4/1/15 at 1:00 p.m. with the director of nursing revealed the time a PRN medication was given was indicated on the MAR. Residents should have been getting their PRN medications as requested when it was within the ordered times. 4. Review of the provider's 8/30/11 reviewed Social Services Coordinator job description revealed: *The general purpose was to "Identify and provide for each resident's social, emotional, and psychological needs, and the continuing development of the resident's full potential during his/her stay at the facility and to assist in the planning for his/her discharge." *Some of the essential job duties were to "Develop a social history, social assessment and care plan which identifies pertinent problems and needs, realistic goals to be accomplished and the specific action to be taken in resolution of the problems and/or needs upon admission of each new resident...Organize family groups to promote communication, education and support between family members, facility staff and administration, and provide counseling as needed. Assist in the education of the community regarding aging, rights of residents, facility services and other related topics. *The code of conduct stated "Must adhere to the Company's Code of Conduct and Business Ethics policy including documentation and reporting responsibilities." 5. Review of the provider's 9/25/14 certified nursing assistant (CNA) job description revealed: *The general purpose was to: "Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a [MEDICATION NAME] physical and psychosocial (social) environment for the residents." *Some of the essential job duties were to: "Directly respond, within scope, to needs and concerns of residents and family members including call lights. Ensure residents' comfort while assisting them in achieving their highest practicable level of functioning." *The code of conduct stated "Must adhere to the Company's Code of Conduct and Business Ethics policy including documentation and reporting responsibilities." 6. Review of the provider's 3/1/13 revised Reporting and Investigation of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property policy revealed: "Each employee shall receive annual training on the requirements of the center/location's policies and procedures regarding alleged violations and the requirements of state and federal law. Staff, families and employees are required to report incidents of suspected abuse, neglect or misappropriation of resident property without fear of reprisal. Families, residents and volunteers shall be encouraged to report incidents of suspected abuse, neglect, or misappropriation of resident property without fear of reprisal." 7. Review of the provider's January, February, and March 2015 grievance (complaint) tracking logs revealed grievances by residents and residents' families had been filed: *In January: -Baths not provided as scheduled two to three times a week. The resolution was to provide baths at least once a week until staffing improved. -Oral care was not provided. The resolution was to place oral care on the treatment administration record. -Long call light response time and call lights not within residents' reach. The resolution was to conduct audits and educate staff. A conversation had been held with staff regarding customer service. -Soiled briefs (disposable undergarments) left on residents too long and not checked and changed frequently. The resolution was to conduct audits and educate staff. -Hot food was cold and residents had been brought to the dining room too early. The resolution was to microwave the food and not take residents to the dining room too early. -Residents' fingernails had not been cleaned. The resolution was to make rounds on residents to ensure their nails had been cleaned. *In February: -Oxygen tanks had not always been filled. The resolution was staff education. -Staff have "inappropriate boundaries/conversations with residents." The resolution was to follow-up with residents. -Baths had not been provided as scheduled twice weekly. The resolution was to resume two baths per week when staffing improved. -Call lights were not placed properly. The resolution was staff education. -Medications were not provided in a timely manner. The resolution was staff education. -Staff had promised to provide a medication, and it was not given. The resolution was staff education and audits. A whiteboard (erasable board to write on) was provided to the resident, so he could write down the times of his medications. -Pain medications had not been provided for one week as scheduled. It was determined that was a pharmacy issue, and a plan would be put into place to prevent it from happening again. -Medications were left next to residents' meal tray when incapable of self-administration. The resolution was staff education. -Infrequent toileting. The resolution was staff education. -Residents had not been receiving phone messages. The resolution was to place a note pad at the desk specifically for resident messages. -Residents being made to "feel bad when struggling to accept cares." The resolution was staff education on customer service. -Floors had not been cleaned thoroughly especially under furniture. The resolution was education for housekeeping staff. -Briefs were not changed and overly saturated. The resolution was staff education. -Staff were not friendly and had not been greeting residents and visitors. The resolution was staff education. *In March: -Staff "threatened to send resident to the West Unit (Behavioral/Psychiatric Unit at hospital). The resolution was to interview other residents and no one stated they felt threatened. The resident in question had been discharged so it "was not a concern." -Slow call light response. Sometimes "up to 3 hours." -Not getting baths/showers as scheduled. -Floor staff using cell phones. -Staff having unprofessional discussions overheard by residents. -Snack pass had not been completed daily. -Medications and treatments not provided in a timely manner. --The above six grievances had no resolutions documented. B. Based on record review, the provider failed to ensure staff were aware and followed physician's orders [REDACTED]. Findings include: 1. Review of resident 25's medical record revealed: *A 3/2/15 [DIAGNOSES REDACTED]. *A 3/16/15 physician's orders [REDACTED]. *Review of the 1/23/15 care plan showed the following: -Interventions: --Administer oxygen per nasal canula at 4 liters per physician order. Monitor oxygen flow rate and response. --The care plan had not been updated to show the 3/16/15 physician's orders [REDACTED]. -Focus: --"3/31/15 Resident has hx (history) of self-adjusting O2 & (and) not following MD (medical doctor) prescribed O2 orders." That note had been hand written. *Review of the resident's progress notes from 3/25/15 through 3/26/15 revealed: -3/25/15: "O2 per NC (nasal canula) as ordered. Instructed resident to leave O2 concentrator and tank at settings as MD prescribed." -3/26/15: "Resident has been manually turning up O2 to 6L and would state he is having difficulty breathing. Resident was informed to keep levels at prescribed 4L." -3/26/15: "Resident was admitted to ICU (intensive care unit) with a [DIAGNOSES REDACTED]. *Review of the nurses notes from 3/16/15 through 3/25/15 revealed several notations that indicated the resident would turn the concentrator up to 6L. Each time that happened, the nurse or CNAs would turn down the concentrator and remind the resident to keep it at 4L per physician's orders [REDACTED]. C. Based on observation, record review, and interview, the provider failed to follow post-fall guidelines for 1 of 12 sampled residents (23) with falls. Findings include: 1. Observation and interview on 3/24/15 at 7:45 a.m. revealed the following in resident 23's room: *Resident 23 was in his wheelchair and stated he was waiting to go to breakfast. *The other resident was sleeping. *Hard plastic push button call lights were laid on both beds. *Grab bars were not noted in the residents' bathroom. *A night light was not on in the room, the drapes were closed, and the room was dusky and dim. Review of resident 23's 5/7/14 care plan revealed: *Focus area: "At risk for falls related: History of falls and needing assist with transfers-balance impairments." *Goal: "Revision on 12/15/2014," and "Target Date 03/13/2015." *Interventions: --"Footwear to prevent slipping." --"Grab Bar in the bathroom." *Immediate 3/19/15 plan of care for falls risk: -Problem: --At risk for falls related to: "fell in the past 30 days" was checked. -Interventions: --"9. Institute fall prevention program" was not checked. --"Other: soft touch call light" was written. Review of the following Minimum Data Set (MDS) assessments revealed the following: *Re-admission 12/10/14 MDS: -"Yes" was noted for a fall in the last month. -"Yes" was noted for fracture in the last six months. -"Yes" was noted for falls since admission or reentry. -"One" was noted for number of falls with no injury. *Significant change 3/11/5 MDS: -"Yes" was noted for falls since admission or reentry. -"Two" was noted for number of falls with no injury. Review of the following Care Area Assessments (CAA) revealed: *12/10/14 - falls had been checked. *3/11/15 - falls had been checked. Those indicated areas should have been addressed with appropriate interventions. Physician order [REDACTED]. *"OTH (Other) & UNS (Unspecified) ACCIDENTAL FALL ON SAME LEVEL (E886.9)." [DIAGNOSES REDACTED]. E886.9 described the circumstance causing an injury, not the nature of the injury). *"Weight Bearing As Tolerated (WBAT)." Hospital discharge orders dated 3/19/15 revealed a physician's orders [REDACTED]." Review of resident 23's post-fall reports and post-fall analysis/plans from January through March 2015 revealed: *1/5/15 at 9:50 p.m. Post-Fall Report: -"Resident was found next to the bed; had white socks on his feet; used his wheelchair for adaptive equipment (equipment used to aid to move around)." -No actions/suggestions were listed to help prevent future falls. -No post fall analysis/plans could be located for the post-fall report. *2/5/15 at 9:45 p.m. Post Fall Analysis/Plan: -"Resident rolled or slid out of bed; no sheets were on the bed; had socks on his feet; was getting up to his wheelchair." -Contributing factors were "surface of bed was slippery with no sheets." -Interventions taken to prevent reoccurrence were to "make beds right after they are stripped." -No post fall report was found. *2/17/15 at 12:10 a.m. Post Fall Report and Analysis/Plan: -"Resident fell next to bed; had bare feet; used his wheelchair for adaptive equipment; slipped; history of falls; remind him to use call light." -"Change in footwear, and w/c (wheelchair) positioning" were listed for actions/suggestions to prevent future falls. *3/12/15 at 8:30 p.m. Post Fall Analysis/Plan: -"Roll/slid out of bed; had socks on his feet; resident was getting up out of bed and slid off bed to floor; history of falls; not wearing shoes." -"Remind resident to wear shoes and ask for assistance" was noted under interventions taken to prevent reoccurrence. -"Change in footwear" and "w/c positioning" was listed for actions/suggestions to prevent future falls. *3/13/15 at 1:02 a.m. Post Fall Analysis/Plan: -"Rolled/slid out of bed; history of falls; socks on his feet." -"Clear environmental obstacles" was listed under interventions. -"Remind resident to not lay close to the edge of the mattress" and "remind resident to call for assist" were noted under actions/suggestions to prevent future falls. -"Sent to ER (emergency room ). R/t (related to) pain; Dx (diagnosis) sesptic (septic: infection) to knee." -Hospital record review revealed resident had a history of [REDACTED]. A fluoroscopy (x-ray of internal tissue of the body) was performed and 85 (over three ounces) cc (cubic centimeters) of purulent (pus) fluid was removed from the knee. *3/23/15 at 1:10 a.m. Post Fall Report and Analysis/Plan: -"Lost strength in an attempt to self-transfer to go to the bathroom; history of falls; impaired safety awareness; socks on his feet." -"Not able to see clearly to transfer, room was dark; slipped on floor--has socks, no shoes" was listed under possible causes. -"Soft touch call light to assist with calling for help due to limited ROM (range of motion: flexibility) of hands, change in footwear, remind resident to call for help" was listed under interventions. Interview on 4/1/15 at 9:45 a.m. with the interim director of nursing, interim administrator, and west regional transitional leader/registered nurse revealed: *They could give no rational reason why a resident's bed had not been made at 9:50 p.m. at night. *Gripper socks, positioning of the wheel chair with the brakes on, or an over-the-toilet transitioning device had not been care planned or put in place for fall preventions. *The call light was burned out, and maintenance had not been notified. *A scoop mattress (concave) had not been put in place as they had considered a scoop mattress a restraint. They had not contacted the doctor to request a scoop mattress due to the resident's history of falls. Review of the provider's 1/22/15 Falls Management Guideline revealed: *Process: -"Newly admitted /readmitted residents are assessed for all risk by means of the Clinical Health Status tool. -At risk residents are identified through a "fall alert" communication system to care givers. -Following the completion of the MDS, if a resident triggers at risk for falls, the resident has further assessment utilizing the CAA guidelines. The plan of care is updated, if indicated, to further minimize the risk for falls. -Appropriate interventions are implemented. -Care plan is updated." *Monitoring/Compliance: -"Residents at risk for falls are care planned with individualized interventions. -Licensed nurse completes Change of Condition-Post Fall Analysis following a resident fall."

Based on record review, observation, interview, and job description review, the provider failed to ensure the facility was operated and administered in a manner that attained or maintained the highest practicable physical, mental, and psychosocial well-being for all sixty-nine residents residing in the facility. Findings include: Surveyor : 1. Review of the provider's letters of notification to the South Dakota Department of Health of administrative changes revealed: *Effective 8/15/14 a new executive director (ED) had been named. *Effective 3/6/15 an interim ED was named. That ED was also the permanent administrator at another nursing home within the community. *Effective 3/23/15 a new interim ED was named until a permanent ED could be hired. *Effective 2/27/15 a new interim director of nursing services had been named. Interview on on 4/1/15 at 1:25 p.m. with the West regional transitional leader confirmed there had been a lack of continuity in leadership positions within the facility. She confirmed that would have the potential to lead to a breakdown in communication for staff. Surveyor : 2. Interview on 3/24/15 at 7:45 a.m. with the interim administrator revealed he had arrived at this current position at the facility on 3/18/15. He was new to the facility. Review of the provider's 3/26/14 job description for Executive Director Temporary (Administrator) revealed: *The general purpose was "To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents/patients while achieving the facility's business objectives." *Some of the Essential Job Duties were: -"Leads the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments." -"Oversees regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; moral of the staff; and ensures resident needs are being addressed." -"Maintain a working knowledge of and ensure compliance with all governmental regulations." -"Promote and understanding of compliance with all rules regarding resident's rights; promote positive relationships with residents, visitors and regulators, to include presenting a professional appearance and attitude." Review of the provider's 10/15/14 job description for Director of Nursing Services Temporary (DON) revealed: *The general purpose was to: "Plan, coordinate and manage the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care ans services provided to residents. Maintains quality care that is consistent with company regulatory standards. Assumes responsibilities of daily operations in the absence of the Executive Director." *Some of the essential job duties were: -"Oversees the nursing staff for the provision of quality and appropriate resident/patient care that meets or exceeds company and regulatory standards." -"Hires nursing staff, oversee the provision of orientation/training by a qualified Director of Education and retains qualified staff to carry out nursing programs and services. Reviews employee performance and conducts periodic performance appraisals timely." -"Develops and implements the written staffing plan and nursing schedule that reflects the needs of the resident and patient population." -"Manages clinical aspects of state or federal government survey processes." The following deficiencies had been cited for the current licensure survey: F157, F164, F165, F223, F224, F241, F246, F248, F252, F253, F280, F281, F314, F323, F431, F441, F490, F494, F514, and F520. Review of the last licensure survey completed on 2/12/14 revealed the following deficiencies had been cited and were being recited: F280, F281, and F441. Review of a previous licensure survey completed on 1/16/13 revealed the following deficiencies were being recited: F157, F281, and F431.

Based on observation and record review, the governing body failed to ensure the facility was administered in a manner that ensured the safe management and overall well-being for all sixty-nine residents in the facility. Findings include: 1. The following deficiencies had been cited for the current survey: F157, F164, F165, F223, F224, F241, F246, F248, F252, F253, F280, F281, F314, F323, F431, F441, F490, F494, F514, and F520. 2. Review of the last licensure survey completed on 2/12/14 revealed the following deficiencies had been recited: F280, F281, and F441. 3. Review of a previous licensure survey on 1/16/13 revealed the following deficiencies had been recited: F157, F281, and F431. 4. Interview on 4/1/15 at 5:10 p.m. with the field services clinical director confirmed: *The governing body had been involved during the transition period after the former administrator and director of nursing terminated their employment at the facility. *The governing body had been actively involved since 3/2/15. *There had been onsite clinical and operational visits weekly since that date. *Extra support had been provided to the facility by the governing body. *Areas of concern had been identified. *Those areas had been staffing, skin issues, falls, and documentation. *Other areas had been identified that she could not recall at that moment. *Inservices had been held for the frontline staff. *No documentation was offered for review of the above support given the facility.

Based on record review, interview, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been maintained to: *Review residents' care concerns and plans. *Identify trends in the quality indicator measures. *Identify trends and tracking of infection controls. *Identify needs and issues with electronic medical records. *Review admissions and discharges of residents. *Discuss new and old policies and procedures. *Discuss the monthly pharmacist reports. *Discuss incident and safety reports. *Discuss staff concerns and needs. Findings include: 1. Review of the provider's QAPI meeting minutes from December 2014 through the survey dates revealed the QAPI committee had identified areas based off reports run by members of the committee. There had been no notes explaining what QAPI activities had been done, their effectiveness, and if corrective action had been taken if they were not successful. Interview on 3/31/15 at 10:00 a.m. with the interim administrator revealed: *He was the responsible party for QAPI. *The QAPI committee met monthly and included himself, the interim director of nursing (DON), the medical director, and other department supervisors. *They followed the facility's policy for QAPI. *Issues were brought up the following month to see if they had improved from the previous meeting. *The monthly resident council meeting minutes were not reviewed for issues. Interview on 3/31/15 at 10:00 a.m. with the DON revealed she had started doing internal audits. Staff were informed about QAPI topics through morning staff meetings. Interview on 3/31/15 with certified nursing assistant (CNA) G revealed she had not been familiar with QAPI activities or the process. Interview on 4/1/15 with nurse F revealed she had not been familiar with anything for QAPI. She thought maybe staff could go to morning meetings to learn more about it. Review of the August 2014 QAPI Committee Guideline revealed five steps used to review operations, identify opportunities for improvement, prioritize them, determination of root cause (determining factor(s)), and implementation of performance improvement projects. There had been no evidence all the above steps had been done. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO., 2005, p. 365, revealed: " ...organizations must be responsible and accountable for evaluating and improving the quality of client care services being provided to all clients. This requires health professionals at all levels to critically evaluate their practices, to incorporate the latest scientific findings into client care, and to measure the success of meeting client outcomes on an ongoing basis." Refer to: F157, F164, F165, F223, F224, F241, F246, F248, F252, F253, F280, F281, F323, F431, F441, F490, F493, F494, and F514.

Based on record review, interview, and pressure ulcer decision making tool, the provider failed to ensure: *One of one sampled resident (2) had not acquired six pressure ulcers (break in skin from continued pressure) after admission to the facility. *One of one sampled resident (2) had not acquired an osteo[DIAGNOSES REDACTED] (infection in the bone) in a pressure ulcer. *One of one sampled resident's (5) pressure ulcer had been identified in a timely manner to prevent further skin damage. Findings include: 1. Review of resident 2's medical record revealed: *She had been admitted on [DATE] with a fracture of her left femur (large bone in thigh). She had no pressure ulcers on admission. *She had additional [DIAGNOSES REDACTED]. *She did not have any preventative measures put in place when she had been admitted . *During her stay she had acquired six pressure ulcers (medial coccyx (center of tailbone), right coccyx (right of the tailbone), left heel, left hip, right iliac crest (top of right hip bone), and left first toe). Those pressure ulcers included: -A stage two (shallow open area of skin) pressure ulcer to her medial coccyx on 4/15/14. It was closed as of 5/13/14 when she readmitted after a hospitalized from [DATE] through 5/12/14. -A stage two admitted pressure ulcer to her right coccyx on 5/13/14. It was healed as of 5/26/14. -She was hospitalized from [DATE] through 6/16/14 and the pressure ulcer to her right coccyx was not present. -The right coccyx pressure ulcer was reacquired on 6/23/14 and was a stage two. There was no record of that pressure ulcer after 6/23/14 when it was open and a stage two. -A stage two pressure ulcer to her left heel on 5/5/14 that healed on 7/14/14. -An unstageable (Full skin thickness tissue loss covered by slough (yellow, tan, gray, green, or brown tissue) and/or eschar (scabbed appearance)) pressure ulcer to her left hip was still present on 3/23/15. -A stage one (Intact skin with redness that does not resolve) pressure ulcer to her right iliac crest. That pressure ulcer became unstageable on 1/26/15 and on 3/16/15 it was healed. -A stage two pressure ulcer to her left first toe on 11/3/14 was still present, and was unstageable on 3/23/14. Review of resident 2's clinical health status assessments for the following dates revealed: *4/8/14 She had no pressure ulcers present. She had a Braden (scale for predicting pressure ulcer risk) score of sixteen and was at risk for developing a pressure ulcer. *5/2/14 One sacral pressure ulcer that stated "Sore covered with [MEDICATION NAME] (dressing), CDI (clean, dry, and intact)," no stage noted. She had a Braden scale score of thirteen and was a moderate risk for a pressure ulcer. *6/16/14 One stage two pressure ulcer to her left coccyx with a Braden scale score of seventeen and was at risk for a pressure ulcer. *9/19/14 revealed: -An unstaged pressure ulcer to the left outer foot. -An unstaged pressure ulcer to her left heel. -An unstaged pressure ulcer to her right heel. -An unstaged pressure ulcer to the upper left of her coccyx with documentation "Tunneled, reddened around site, packing placed." -An unstaged pressure ulcer to the lower left of her coccyx with documentation "Area that is red, no blanching (color remains red when skin is pressed), closed." -An unstaged pressure ulcer to the left hip with documentation "Sore, red, no blanching w (with) black area in middle." -She had a [DIAGNOSES REDACTED]. -Her Braden scale score was seven at a severe risk for pressure ulcers. *10/20/14 revealed: -A stage two pressure ulcer to her right hip. -A stage two pressure ulcer to her coccyx. -A unstageable pressure ulcer to her first left toe. -A unstageable pressure ulcer to her left hip. -Her Braden scale score was fourteen with am moderate risk for pressure ulcers. *2/9/15 Pressure ulcer to both her right and left hip with a Braden scale score thirteen for a moderate risk for pressure ulcers. Review of a 9/13/14 hospital history and physical revealed [DIAGNOSES REDACTED]. Review of the 9/19/14 hospital discharge summary revealed discharge [DIAGNOSES REDACTED]. Review of resident 2's wound evaluation flow sheets for her pressure ulcers revealed: *A waffle overlay (cover over regular mattress) was placed on her bed on 4/15/14. *Bilateral Prevalon boots (pressure reducing boots for feet and heels) had been placed on 5/5/14. *She was on a specific turning and repositioning program to be turned or repositioned every one to two hours starting on 4/15/14. *An Alpha active mattress (A pressure redistributing mattress overlay system for the prevention and management of pressure ulcers.) was initiated on 5/13/14 when she returned from a hospitalization . *Her turning and repositioning program was changed on 9/1/14 to thirty to sixty minutes on her left side and one to two hours on her right side. *A MA 65 mattress (Mattress with alternating air pressure) Review of resident 2's focus area for pressure ulcers initiated on 6/30/14 revealed interventions that included:*Bilateral Prevalon boots at all times. *She had a MA 65 lipped mattress for wound care purposes. *Turning and repositioning schedule per assessment. *Provide assistance with changes in position every two to three hours as resident will allow. Review of the provider's undated Pressure Ulcer Risk Identification/Prevention Diagram revealed:*Upon admission a skin assessment would have been completed. *If the resident was at risk for a pressure ulcer immediate interventions would have been implemented. *If the resident had a pressure ulcer present a pressure reduction mattress would have been initiated. *Develop an individualized care plan. 2. Review on 3/24/15 of resident 5's treatment administration records (TAR) revealed: *March 2015 TAR had: -A daily treatment for [REDACTED]. -No documentation for four of those twenty-four days that the treatment above had been completed. -No documentation to support why it had not been completed. *February 2015 TAR had: -A treatment to be done every Monday, Wednesday, and Friday for a pressure ulcer on her left medial foot from 2/1/15 through 2/23/15. -It had not been documented as completed on 2/4/15, Wednesday. -A change in the treatment to her left foot to be done every day starting on 2/24/15. -It had not been documented as completed on 2/26/15. *January 2015 TAR had: -A treatment to be done as needed for a pressure ulcer on her left medial foot that had started on 1/21/15 and ended on 1/23/15 to be cleansed with normal saline and cover with a [MEDICATION NAME] dressing (An absorbent dressing that provided a moist healing atmosphere to the wound). -Another treatment using a [MEDICATION NAME] dressing to be done every Monday, Wednesday, and Friday for a pressure ulcer on her left medial foot from 1/23/15 through 2/24/15. -No treatments had been documented in January as being completed to her foot until they had been scheduled on Monday, Wednesday, and Friday starting on 1/23/15. Review of her nursing progress notes from 1/1/15 through 3/24/15 regarding resident 5 revealed: *On 1/13/15 licensed practical nurse (LPN) B documented the resident had a "wound" on her sacrum (bottom). *The rest of the resident's skin remained intact (without open areas) but fragile in appearance. *On 1/26/15 the daughter was called by registered nurse (RN) A to update her on the resident's skin. *The daughter had agreed the "wounds" had caused the resident less pain, and the treatments were effective. *There had been no documentation to indicate the resident's foot was red or had any other signs of skin breakdown until an order request was sent by facsimile to the physician on 1/19/15. Review of the resident's weekly skin assessments documented on her January 2015 TAR revealed: *She had a weekly assessment completed on 1/13/15 before the ulcer was documented. *The next one had been completed on 1/20/15 after the pressure ulcer had been documented on her left foot. Review of resident 5's physician's facsimile orders revealed she had a newly acquired pressure ulcer on her medial left foot. The pressure ulcer was described as unstageable. It had been covered with eschar and measured 1.5 by 1.0 by 0 and it had not stated inches or centimeters. The facsimile sent to the physician had requested orders to change the [MEDICATION NAME] dressings on Monday, Wednesday, Friday, and as needed. The request had been sent to the physician on 1/19/15, and those orders were received on 1/21/15. Review of her care plan last revised on 2/9/15 revealed: *She had a pressure ulcer listed as a focus. *It had not addressed that she had two pressure ulcers or where they were located. *Her goals were she would not have any further skin breakdown, and the pressure ulcers would heal without complications. *For interventions it had included a Prevalon boot to the left foot and to float her left heel in bed as she had allowed. *Weekly skin assessments were to have been completed by the licensed nurse. *Those interventions had been initiated on 8/16/13. *She had goals under her dietary assessment her skin would remain intact initiated on 8/8/14. -It was last dated as reviewed on 4/21/15. -It was not changed to reflect the presence of two pressure ulcers, one on her coccyx (bottom) and one on her left foot. *On 1/28/15 the dietary services manager had stated the resident was on a magic cup (nutrition supplement) twice a day for extra protein and calories. *She had not addressed the resident's dietary needs related to her pressure ulcers. Review of her weekly wound evaluation flow sheets documentation from 1/19/15 through 3/23/15 for her left medial foot revealed: *Current preventative interventions had included: -An Alpha Active mattress. -A wheelchair cushion. -A specific turn/reposition program. *It had not addressed the use of the Prevalon boot. Interview on 3/25/15 at 3:29 p.m. with the provider's west region transitional leader/RN confirmed: *Resident 5's weekly wound documentation had not been entered on 3/23/15 by RN A. *RN A had forgotten to enter the measurements. *She had re-measured and documented it today. Interview on 3/25/15 at 3:55 p.m. with RN C confirmed treatments were to be done as ordered or documented why it had not been done, example refused by the resident. She confirmed there had been no documentation done on a daily basis to support the Prevalon boot was used as ordered. Interview on 3/25/15 at 5:08 p.m. with the provider's west region transitional leader/RN confirmed: *The use of the Prevalon boot was a nursing initiated order. *It was poorly written on the nursing assistant "cheat sheets" that directed resident care. *It had stated "foam boots" on the cheat sheet. 3. Review of the provider's revised November 2014 Skin Integrity Guideline revealed: *The purpose was to decrease pressure ulcer and/or wound formation. *Residents at risk were to be identified and interventions implemented to prevent breakdown. *Residents were to have been observed by the certified nursing assistant (CNA) daily for any reddened or open areas. *The CNA was to have reported any of those changes to the nurse. *Nutritional assessments were to have been completed to identify nutritional needs. *Documentation was to have been completed on a monthly basis by the dietary manager on any resident with a stage II or greater pressure ulcer until it had healed. *The care plan was to have implemented, evaluated, and revised care based on the resident needs.

Based on record review, interview, and pressure ulcer decision making tool, the provider failed to ensure: *One of one sampled resident (15) had not acquired six pressure ulcers (break in skin from continued pressure) after admission to the facility. *One of one sampled resident (15) had not acquired an osteo[DIAGNOSES REDACTED] (infection in the bone) in a pressure ulcer. *One of one sampled resident (5) pressure ulcer had been identified in a timely manner to prevent further skin damage. Findings include: 1. Review of resident 15's medical record revealed: *She had been admitted on [DATE] with a fracture of her left femur (large bone in thigh). She had no pressure ulcers on admission. *She had additional [DIAGNOSES REDACTED]. *She did not have any preventative skin care measures put in place when she had been admitted . *During her stay she had acquired six pressure ulcers (medial coccyx (center of tailbone), right coccyx (right of the tailbone), left heel, left hip, right iliac crest (top of right hip bone), and left first toe). Those pressure ulcers included: -A stage two (shallow open area of skin) pressure ulcer to her medial coccyx on 4/15/14. It was closed as of 5/13/14 when she readmitted after a hospitalized from [DATE] through 5/12/14. -A stage two admitted pressure ulcer to her right coccyx on 5/13/14. It was healed as of 5/26/14. -She was hospitalized from [DATE] through 6/16/14 and the pressure ulcer to her right coccyx was not present. -The right coccyx pressure ulcer was reacquired on 6/23/14 and was a stage two. There was no record of that pressure ulcer after 6/23/14 when it was open and a stage two. -A stage two pressure ulcer to her left heel on 5/5/14 that healed on 7/14/14. -An unstageable (Full skin thickness tissue loss covered by slough (yellow, tan, gray, green, or brown tissue) and/or eschar (scabbed appearance)) pressure ulcer to her left hip was still present on 3/23/15. -A stage one (Intact skin with redness that does not resolve) pressure ulcer to her right iliac crest. That pressure ulcer became unstageable on 1/26/15 and on 3/16/15 it was healed. -A stage two pressure ulcer to her left first toe on 11/3/14 was still present, and was unstageable on 3/23/14. Review of resident 15's clinical health status assessments for the following dates revealed: *4/8/14 She had no pressure ulcers present. She had a Braden (scale for predicting pressure ulcer risk) score of sixteen and was at risk for developing a pressure ulcer. *5/2/14 One sacral pressure ulcer that stated "Sore covered with [MEDICATION NAME] (dressing), CDI (clean, dry, and intact)," no stage noted. She had a Braden scale score of thirteen and was a moderate risk for a pressure ulcer. *6/16/14 One stage two pressure ulcer to her left coccyx with a Braden scale score of seventeen and was at risk for a pressure ulcer. *9/19/14 revealed: -An unstaged pressure ulcer to the left outer foot. -An unstaged pressure ulcer to her left heel. -An unstaged pressure ulcer to her right heel. -An unstaged pressure ulcer to the upper left of her coccyx with documentation "Tunneled, reddened around site, packing placed." -An unstaged pressure ulcer to the lower left of her coccyx with documentation "Area that is red, no blanching (color remains red when skin is pressed), closed." -An unstaged pressure ulcer to the left hip with documentation "Sore, red, no blanching w (with) black area in middle." -She had a [DIAGNOSES REDACTED]. -Her Braden scale score was seven at a severe risk for pressure ulcers. *10/20/14 revealed: -A stage two pressure ulcer to her right hip. -A stage two pressure ulcer to her coccyx. -A unstageable pressure ulcer to her first left toe. -A unstageable pressure ulcer to her left hip. -Her Braden scale score was fourteen with a moderate risk for pressure ulcers. *2/9/15 Pressure ulcer to both her right and left hip with a Braden scale score thirteen for a moderate risk for pressure ulcers. Review of a 9/13/14 hospital history and physical revealed [DIAGNOSES REDACTED]. Review of the 9/19/14 hospital discharge summary revealed discharge [DIAGNOSES REDACTED]. Review of resident 15's wound evaluation flow sheets for her pressure ulcers revealed: *A waffle overlay (cover over regular mattress) was placed on her bed on 4/15/14. *Bilateral Prevalon boots (pressure reducing boots for feet and heels) had been placed on 5/5/14. *She was on a specific turning and repositioning program to be turned or repositioned every one to two hours starting on 4/15/14. *An Alpha active mattress (A pressure redistributing mattress overlay system for the prevention and management of pressure ulcers.) was initiated on 5/13/14 when she returned from a hospitalization . *Her turning and repositioning program was changed on 9/1/14 to thirty to sixty minutes on her left side and one to two hours on her right side. *A MA 65 mattress (Mattress with alternating air pressure) Review of resident 15's focus area for pressure ulcers initiated on 6/30/14 revealed interventions that included:*Bilateral Prevalon boots at all times. *She had a MA 65 lipped mattress for wound care purposes. *Turning and repositioning schedule per assessment. *Provide assistance with changes in position every two to three hours as resident will allow. Review of the provider's undated Pressure Ulcer Risk Identification/Prevention Diagram revealed:*Upon admission a skin assessment would have been completed. *If the resident was at risk for a pressure ulcer immediate interventions would have been implemented. *If the resident had a pressure ulcer present a pressure reduction mattress would have been initiated. *Develop an individualized care plan. 2. Review on 3/24/15 of resident 5's treatment administration records (TAR) revealed: *March 2015 TAR had: -A daily treatment for [REDACTED]. -No documentation for four of those twenty-four days that the treatment above had been completed. -No documentation to support why it had not been completed. *February 2015 TAR had: -A treatment to be done every Monday, Wednesday, and Friday for a pressure ulcer on her left medial foot from 2/1/15 through 2/23/15. -It had not been documented as completed on 2/4/15, Wednesday. -A change in the treatment to her left foot to be done every day starting on 2/24/15. -It had not been documented as completed on 2/26/15. *January 2015 TAR had: -A treatment to be done as needed for a pressure ulcer on her left medial foot that had started on 1/21/15 and ended on 1/23/15 to be cleansed with normal saline and cover with a [MEDICATION NAME] dressing (An absorbent dressing that provided a moist healing atmosphere to the wound). -Another treatment using a [MEDICATION NAME] dressing to be done every Monday, Wednesday, and Friday for a pressure ulcer on her left medial foot from 1/23/15 through 2/24/15. -No treatments had been documented in January as being completed to her foot until they had been scheduled on Monday, Wednesday, and Friday starting on 1/23/15. Review of her nursing progress notes from 1/1/15 through 3/24/15 regarding resident 5 revealed: *On 1/13/15 licensed practical nurse (LPN) I documented the resident had a "wound" on her sacrum (bottom). *The rest of the resident's skin remained intact (without open areas) but fragile in appearance. *On 1/26/15 the daughter was called by registered nurse (RN) F to update her on the resident's skin. *The daughter had agreed the "wounds" had caused the resident less pain, and the treatments were effective. *There had been no documentation to indicate the resident's foot was red or had any other signs of skin breakdown until an order request was sent by facsimile to the physician on 1/19/15. Review of the resident's weekly skin assessments documented on her January 2015 TAR revealed: *She had a weekly assessment completed on 1/13/15 before the ulcer was documented. *The next one had been completed on 1/20/15 after the pressure ulcer had been documented on her left foot. Review of resident 5's physician's facsimile orders revealed she had a newly acquired pressure ulcer on her medial left foot. The pressure ulcer was described as unstageable. It had been covered with eschar and measured 1.5 by 1.0 by 0 and it had not stated inches or centimeters. The facsimile sent to the physician had requested orders to change the [MEDICATION NAME] dressings on Monday, Wednesday, Friday, and as needed. The request had been sent to the physician on 1/19/15, and those orders were received on 1/21/15. Review of her care plan last revised on 2/9/15 revealed: *She had a pressure ulcer listed as a focus. *It had not addressed that she had two pressure ulcers or where they were located. *Her goals were she would not have any further skin breakdown, and the pressure ulcers would heal without complications. *For interventions it had included a Prevalon boot to the left foot and to float her left heel in bed as she had allowed. *Weekly skin assessments were to have been completed by the licensed nurse. *Those interventions had been initiated on 8/16/13. *She had goals under her dietary assessment her skin would remain intact initiated on 8/8/14. -It was last dated as reviewed on 4/21/15. -It was not changed to reflect the presence of two pressure ulcers, one on her coccyx (bottom) and one on her left foot. *On 1/28/15 the dietary services manager had stated the resident was on a magic cup (nutrition supplement) twice a day for extra protein and calories. *She had not addressed the resident's dietary needs related to her pressure ulcers. Review of her weekly wound evaluation flow sheets documentation from 1/19/15 through 3/23/15 for her left medial foot revealed: *Current preventative interventions had included: -An Alpha Active mattress. -A wheelchair cushion. -A specific turn/reposition program. *It had not addressed the use of the Prevalon boot. Interview on 3/25/15 at 3:29 p.m. with the provider's west region transitional leader/RN confirmed: *Resident 5's weekly wound documentation had not been entered on 3/23/15 by RN F. *RN A had forgotten to enter the measurements. *She had re-measured and documented it today. Interview on 3/25/15 at 3:55 p.m. with RN L confirmed treatments were to be done as ordered or documented why it had not been done, example refused by the resident. She confirmed there had been no documentation done on a daily basis to support the Prevalon boot was used as ordered. Interview on 3/25/15 at 5:08 p.m. with the provider's west region transitional leader/RN confirmed: *The use of the Prevalon boot was a nursing initiated order. *It was poorly written on the nursing assistant "cheat sheets" that directed resident care. *It had stated "foam boots" on the cheat sheet. 3. Review of the provider's revised November 2014 Skin Integrity Guideline revealed: *The purpose was to decrease pressure ulcer and/or wound formation. *Residents at risk were to be identified and interventions implemented to prevent breakdown. *Residents were to have been observed by the certified nursing assistant (CNA) daily for any reddened or open areas. *The CNA was to have reported any of those changes to the nurse. *Nutritional assessments were to have been completed to identify nutritional needs. *Documentation was to have been completed on a monthly basis by the dietary manager on any resident with a stage II or greater pressure ulcer until it had healed. *The care plan was to have implemented, evaluated, and revised care based on the resident needs.

Based on interview, record review, and policy review, the provider failed to ensure residents felt free to voice grievances (complaints) without fear of punishment for three of five residents (unidentified per request) and one of two family members (unidentified per request) interviewed. Findings include: 1. Interview on 3/24/15 at 3:15 p.m. with a confidential resident revealed she was unwilling to answer the question if anyone in the facility had either abused or neglected her. She stated "I don't want to talk about that." Her roommate, whom the resident had said could be a part of the interview, stated "She doesn't want to tell you that if she complains about something they will leave her on the toilet for forty-five minutes." The resident then stated "Yes, that has happened." 2. Interview on 3/24/15 at 3:00 p.m. with a confidential resident revealed: *Staff had been rude to her. *Staff would tell each other "don't help (resident's name)" if she had a problem. *Staff would not give medications when asked for and would tell her it was not time, even though it was within the ordered timeframe. 3. Interview on 3/24/15 at 4:15 p.m. with a confidential resident revealed: *The resident care coordinator (RCC) had stated to the resident "You are a leech off the state and are sucking the government dry." *Certified nurse assistant (CNA) K had stood at his door and announced she could not come into his room as he had an infection. Review of the resident's record revealed no [DIAGNOSES REDACTED]. *The residents would change their own moods and personalities to match the staff on duty. If any of the residents voiced a concern they were "immediately treated differently." The staff "would then act and care for them with a coldness or that they weren't important." *He was afraid of repercussion and harassment, and no longer went to the dining room for meals. *He only came out of his room to go outside to smoke and revealed he would "avoid staff if I can help it." Review of the above confidential resident's Brief Interview for Mental Status (BIMS) score revealed he was at fifteen and had a recent score of thirteen (thought processes intact). 4. Interview on 3/31/15 at 8:15 p.m. with a confidential family member of a resident revealed: *He visited his family member every day. *He had spoken with social services (SS), nurses, and other staff several times regarding the care of his family member, and nothing had been done. *After he spoke with the staff his family member had been treated "differently." He then gave a summary of his term "differently." He stated he had noticed the following after consultation with staff: -"As an example ____ (resident name) would request pain medication at let's say 4:30. Staff would give him the meds. ____ (resident name) would then request the pain meds again at 8:30 and staff would say the first dose had been given at 5:30 and they couldn't give another dose until 9:30." The family member stated "it seemed to me they gave the pain meds and then wrote it down an hour later and used that time for when they gave it to him." -"____ (resident name) told me he didn't always get his breathing treatments that were ordered by the doctor." He stated when his family member asked for his breathing treatment he would be told by the resident care coordinator (RCC) "you're needy and always needing something." The RCC would "yell at him in the hall." *The family member stated he was afraid to say anything else to the staff at the nursing home as he was afraid of "further repercussions" to his family member when he was not there. Review of the above confidential resident's BIMS score revealed he tested at fifteen (thought processes intact). His family member revealed he was the resident's power of attorney and had tried and was still trying to get his family member relocated to another nursing home. Review of the provider's May 2001 Grievance Process policy revealed: *All individuals residing within the facility and their family members and/or responsible people would be provided with a means to communicate concerns, conflicts, complaints, grievance, or opportunities for improvement in care and services. *"Each individual is encouraged and assisted throughout their stay to exercise their rights as a citizen by freely voicing their grievances and recommended changes without fear of interference, coercion (threats), discrimination, or reprisal (revenge)." *The facility was responsible for protecting resident rights when an individual or their responsible person voiced grievances. *Encouraging an individual to express their feelings and concerns would maximize their quality of life, improve their care, and promote customer satisfaction. *All staff were responsible for ensuring customer satisfaction within the facility.

Based on record review, interview, and policy review, the provider failed to ensure the highest practical level of well-being was maintained for 1 of 26 sampled residents (6) reviewed. Findings include: 1. Review of resident 6's 5/17/11 quarterly Minimum Data Set (MDS) revealed he: *Had scored six points on his Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. *Understood conversation and was understandable in his replies. *Was steady with balance at all times during walking. *Was independent in walking. *Had [DIAGNOSES REDACTED]. *Was taking [MEDICATION NAME], an anticoagulant. *Had no complaints of pain. Review of resident 6's 7/13/11 interdisciplinary progress notes (IPN) revealed his left lower leg was very warm to the touch, and was red, swollen, and painful. His range of motion was normal at that time. He had refused offers of a pain medication. The physician was notified and his 7/14/11 response indicated the resident was to: *Start on Keflex (antibiotic) 500 milligrams (mg) three times a day. *Elevate his left lower leg when sitting. *Have warm compresses to his left lower leg twice daily for five days. Resident 6 was not seen by the physician at that time. Review of resident 6's 7/14/11 IPN revealed his left leg remained reddened and swollen. He had difficulty walking to meals. Review of resident 6's 7/15/11 IPN revealed his left leg remained reddened and warm to the touch. He had complained of pain but had declined Tylenol when offered. He was placed in a wheel chair to attend meals due to his discomfort. Review of his 7/18/11 IPN revealed redness and warmth continued to his left leg. He had been complaining of occasional pain. On 7/19/11 his IPN revealed he had reported pain when anything touched his leg. Review of his 7/20/11 IPN revealed he remained on the antibiotic and continued to complain of pain. He was using a wheelchair for mobility due to leg pain. He continued to complain of pain on 7/21/11 per his IPN. Review of resident 6's 7/22/11 IPN revealed he continued to take the antibiotic and was complaining of severe pain. The physician was notified at that time, and an order was received for [MEDICATION NAME], a narcotic pain reliever. Review of the 7/23/11 IPN revealed the resident had good relief of the pain when the [MEDICATION NAME] was taken. On 7/24/11 his leg remained warm to touch, reddened, and very tender. He had received [MEDICATION NAME] twice on that day for complaints of leg pain. The resident's left leg remained unchanged on 7/25/11 with the completion of the antibiotic. He continued to receive [MEDICATION NAME] for complaints of leg pain. Review of the 7/26/11 IPN revealed resident 6's left leg was reddened and tight. He complained of pain to that leg with no relief from the pain medication. The physician was notified and an appointment was scheduled for him to be seen on 7/27/11. Following that appointment a different antibiotic was ordered. He was started on the new antibiotic on 7/28/11. He continued to complain of pain, but the pain medication provided some relief. Review of resident 6's July 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of that same MAR indicated [REDACTED]. Interview with the director of nursing at 9:45 a.m. on 8/11/11 revealed she did not think the increase in the resident's pain, his inability to walk independently, or no improvement in the condition of the left lower leg warranted notification of the physician. She stated the physician would only have been notified if there had been a significant change in the resident's condition. She confirmed the resident had not been seen by a physician with the onset of symptoms. She confirmed the resident was not seen by the physician until fifteen days after the initial symptoms. She stated the provider did not have a policy regarding physician notification. She confirmed the resident's condition did improve after the change in antibiotic which was fifteen days after the onset of symptoms. She confirmed documentation revealed the resident complained of severe pain, but a stronger pain medication had not been requested until eight days after the onset of that pain. She also confirmed the resident's condition had improved with the use of the new antibiotic and the stronger pain medication.