Every finding on record at Avantara Clark City

Based on record review, interview, observation, document review, South Dakota Department of Health (SD DOH) facility reported incidents (FRI), and policy review, the provider failed to ensure: *An environment was free of flammable materials where two of two sampled resdients (2 and 26) were observed smoking. *Assistive devices were used for one of one 1 sampled resident (2) who used cigarette holders to prevent a burn. *Appropriate supervision for one of three sampled resident (26) while smoking. *Facility exit and interior doors functioned appropriately, and staff were re-educated as stated in the corrective actions in the 11/16/25 and 11/26/25 FRI regarding one of one closed sampled resident (37) who eloped outside and entered a room where chemicals were stored. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *His 10/15/25 Brief Interview for Mental Status (BIMS) score was 13, which indicated his cognition was intact. *He did not have a physician's orders to smoke. *He had diagnoses of nicotine dependence and mild vascular dementia (a group of symptoms affecting memory, thinking, and social abilities). *His 10/15/25 smoking evaluation risk assessment indicated: -He was careless with smoking materials. -He was unable to safely light a cigarette. -He was not considered a safe smoker and required smoking management and supervision consistent with facility policy and may not have access to smoking material outside of supervised smoking. -He was to wear a smoking apron, be seated under the folding table, and a staff member was to light his cigarette. -He often attempted to smoke cigarettes down to the filter. *His 10/15/25 care plan indicated: -All smoking materials were kept at the nurses' station. -He was to be supervised, wear a smoking apron, and to use a cigarette holder when he smoked to prevent him from getting burned because he smoked the cigarette down past the filter. -He needed to be pushed up to the table when he smoked due to his history of burns to his feet from dropping ash. -At any time if it was determined that he could not smoke safely with the available levels of support and supervision as indicated on his care plan, the resident's individual smoking methods may need to be adjusted. *Resident 2's physician was notified on 1/4/26 that he had cigarette burns to his right thumb that measured 0.7 x 0.6 and right pointer finger that measured 0.7 x 0.4 that were brown and tan in color without signs of infection. 2. Interview on 1/6/26 at 3:56 p.m. with certified nursing assistant (CNA) J regarding resident 2 revealed: *Resident 2 smoked twice a day, once in the morning and once in the late afternoon. *His cigarettes were kept locked up at the nurses' station. *He had to wear a smoking apron, and the staff had to go outside with him when he smoked. 3. Observation and interview on 1/6/26 at 4:08 p.m. and 1/7/26 at 11:22 a.m. with CNA L in the designated smoking area revealed: *She took resident 2 outside to smoke. *The smoking area was just outside the staff entrance door and was in a partially covered area that had a wood privacy panel as a barrier to the area. *She put resident 2's coat and smoking apron on him and handed a cigarette. Resident 2 put it in his mouth, and CAN L lit the cigarette for him with a lighter. *Resident 2 sat at a folding table in the designated smoking area that had two ashtrays on top of it. A snow blower with a closed gas can on the ground beside it was along the interior side of the wood privacy panel, in the designated smoking area. -CNA L verified that the gas can was about half full and was approximately 8 to 10 feet away from resident 2 who was smoking at the folding table. *She encouraged resident 2 to put the cigarette out. When he did not, she removed the cigarette from his hand and put it out for him because he smoked it close down to the filter. *She did not usually take residents out to smoke, and she was not sure how long the gas can had been sitting there. *Staff were to dump the ashtrays out in the red metal trash can that sat next to the building. *She verified there was no signage posted to alert people that that was the designated smoking area or that flammable materials were not supposed to be in that area. 4. Interview on 1/7/26 at 11:29 a.m. with CNA M revealed: *She recalled seeing the gas can in the designated smoking area two days prior. *She had received education about fire safety and smoking. *She had not seen any signage in the designated smoking area that identified that it was the designated smoking area or that flammable items were to be kept out of that area. 5. Interview on 1/7/26 at 11:39 a.m. with resident 2 revealed he thought the snow blower had been sitting in the designated smoking area for the past few weeks and he did not see the gas can sitting on the ground by it. 6. Observation and interview in the designated smoking area on 1/7/26 at 12:04 p.m. with housekeeper N revealed: *She and resident 26 were in the designated smoking area, smoking cigarettes. *She thought resident 26 could be outside by himself some days, and other days he needed supervision. *Resident 2 was the only one who needed supervision while smoking. *She thought the snow blower had been outside in the designated smoking area for about a week and saw the gas can sitting by it the day before (1/6/26). *Residents who smoked unsupervised were to ring the doorbell to alert staff when they were ready to come back inside. *Housekeeper N was going back inside, leaving resident 26 unsupervised. 7. Observation and interview in the designated smoking area on 1/7/26 at 12:06 p.m. with regional maintenance O revealed: *He came to the facility once or twice a month to do the books, training, and updates. *He used acetone (a flammable cleaning solution) to remove glue from a metal strip while standing about 10 feet away from resident 26, who was smoking. *He was unsure if there was a policy regarding having flammable items near the designated smoking area and thought flammable items should be at least 50 feet away from someone smoking. *He was unsure if a sign needed to be posted that identified the smoking area as the designated smoking area and that flammable items should be kept away from that area. *He verified the acetone can was labeled as extremely flammable and stated he thought he should have been at least 50 feet away from someone who was smoking. 8. Interview on 1/7/26 at 12:16 p.m. with maintenance director P revealed: *He worked at the facility for about two years and had not reviewed the smoking policy. *He was unsure if signage needed to be posted in the designated smoking area. *He thought the snow blower and gas can had been sitting in the designated smoking area for about three to four days and that he got busy doing something else and forgot that they were in that area. *He stated it was common sense to keep flammable items away from the designated smoking area and the snow blower and gas can should not have been in the designated smoking area. 9. Review of resident 26's electronic medical record revealed his 12/18/25 care plan had a focus of: The resident is a smoker and expresses the desire to smoke at this facility. Currently needs supervision due to his deconditioning from hospitalization. 10. Observation on 1/7/26 at 12:20 p.m. of resident 26 revealed that he was outside smoking without supervision. At 12:25 p.m., RN D went outside and then brought resident 26 inside. 11. Interview on 1/7/26 at 12:29 p.m. with RN D revealed: *She thought resident 26 had been assessed and was safe to smoke outside without supervision. *She felt he was safe to smoke without supervision. 12. Interview on 1/7/26 at 1:05 p.m. with CNA F revealed: *He assisted resident 26 outside to smoke and left him unattended. *He thought that resident 26 had been assessed and was able to smoke without supervision. *When asked where he could find information about resident 26's assessment, he replied that he got the information from his director of nursing (DON). 13. Interview on 1/7/26 at 1:30 p.m. with DON B revealed: *She felt resident 26 was safe to smoke without supervision. *She stated that resident 26's care plan said that he was not safe to smoke unsupervised, but he would be re-assessed. *When asked how a staff member would know if a resident was able to smoke unsupervised, she said that information is on the smoke box (a metal box that holds residents' cigarettes and lighters). 14. Observation on 1/7/26 at 1:40 p.m. of the smoke box revealed on the inside of the smoke box, a note that read [resident 4] is the only independent/unsupervised smoker at this time. Both [resident 2] and [resident 26] are to be supervised. 15. Review of the provider's CNA sheet revealed it indicated that resident 2 and 26 smoked but did not list any safety measures or if they needed supervision. 16. Interview on 1/7/26 at 3:27 p.m. with administrator A revealed: *Smoking assessments were to be completed by the social worker or minimum data set (MDS) nurse. Those assessments indicate if the resident needed supervision while smoking. *The CNA sheet (a document that identifies a resident's care needs and interventions) and the smoke box would indicate if a resident was to have supervision while smoking. *If a resident needed items such as a smoking apron or cigarette extenders to smoke safely that would be indicated in the smoking safety assessment. *Residents were to sit at the folding table in the designated smoking area with their legs under it and be able to reach the ashtray. *They have never had signage posted in that area that indicated it as the designated smoking area and to keep flammable items away from that area. *They showed all residents the designated smoking area and told them what the smoking times were during the admission process for all residents. *She was aware they ran out of the cigarette holders last week, and stated that more were ordered on 1/2/26. She expected resident 2 not to have smoked until more cigarette holders arrived. *She was not aware that resident 2 sustained burns on his fingers. *Resident 26 was discharged last month, was readmitted , and last month he was able to smoke without supervision. *When resident 26 was readmitted his smoking assessment indicated he needed supervision for safety. *She expected the staff to supervise resident 26 while smoking. *All residents who smoked had their smoking materials in the smoking box that was located at the nurse's station. *She verified the facility assessment (a mandatory, annual evaluation determining the resources a facility needs to competently care for its residents) did not contain information about the designated smoking area. *She expected that flammable items should not be near the designated smoking area. when not in use. *She verified that having flammable items in or near the designated smoking area was a fire hazard. 17. Review of the providers 2/10/24 Smoking policy revealed: *The facility shall establish and maintain safe resident smoking practices while protecting the rights of the individual resident. * .all residents who smoke will be assessed for their ability to safely smoke with or without assistance or supervision and such will be included on the care plan. The Smoking Assessment will be completed at admission, readmission, quarterly, annually, and with a change in condition. Facility will provide staff, family or volunteer supervision when assessment determines supervision is required. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. *Designated smoking areas include: .b. Smoking aprons, or devices to assist residents in smoking per assessment findings. The location of the designated smoking area and provisions to ensure residents with the need for supplemental oxygen do not access the area while smoking is taking place. *Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's individual care plan. *The staff shall consult with the Attending Physician and/or the Director of Nursing to determine any restrictions on a resident's smoking privileges. 18. Review of the providers facility reported incident (FRI) regarding an incident involving resident 37 on 11/16/25 revealed: *Resident 37 had been able to exit the building and reviewed security camera footage. At 6pm on 11/16/25, resident 37, was self-propelling wheelchair throughout the facility and exited building unsupervised via a storage area door. Resident left wheelchair, was able to walk to door and push open emergency exit door which shut behind him and he was not able to get back inside. Resident then walked to employee entrance door and knocked on the door where a CNA saw him and assisted him inside. *Resident was outside for a total of 4 minutes. *Maintenance inspected emergency exit door on Monday 11/17 [11/17/25] and saw that a wire had come loose from [the] alarm plug in, causing it not to alarm when opened. Maintenance repaired the wiring in the alarm and the door and alarm are operational again. All exit doors are inspected weekly by maintenance and recorded in TELS [electronic platform to manage building maintenance]. Door check audits will be done daily to ensure the alarm and door remains functioning properly. *Point of care charting updated to ensure staff are checking and charting what [this] resident is doing every 30 minutes and CNA assignment sheets have been updated to notify all staff who [which residents] is an elopement risk. *Residents care plan updated to reflect elopement incident and risks. All staff will be re-educated on elopement policy prior to their next shift [worked] and an elopement audit will be conducted for continuance of care amongst all shifts. 19. Review of the 11/26/25 FRI revealed: *[Resident 37] (BIMS of a 4) was able to enter [the] housekeeping closet unsupervised and shut the door behind him. He was found by staff at 5:57 p.m. *Per review of the camera footage, the housekeeping closet door was not fully closed after CNA went to find trash bags and pulled the [door] shut but [the] closing mechanism did not close it [the door] fully. *He [resident 37] had just been seen in the hallway at 4:40 p.m. after CNA redirected him from another residents room *[Resident 37] has been placed on 1:1 [direct supervision of one resident by one staff member] staff supervision when awake and Foresite system activated when in room until further notice. Foresite fall detection system alerts [the] facility when there is a bed exit or a fall in real time so that staff can intervene promptly. [Resident 37's] care plan has been updated with this intervention. All staff are being educated to ensure all doors are latched when exiting a secured area, to leave key code doors locked when using, and that [resident 37] is to remain on 1:1 staff supervision until further notice. All doors, staff knowledge of elopement policy/procedure, and resident elopement risk assessment will be audited weekly, then monthly The housekeeping door closure was replaced on 11/28 [11/28/25] and is functioning. A daily audit of doors is completed and logged into TELS. Weekend MOD [manager on duty] has been trained on door checks and will report to admin [administrator]/maintenance director for recording. 20. Review of resident 37's EMR revealed: *He was admitted to the facility on [DATE]. *His 11/4/25 BIMS assessment score was 4, which indicated he had severe cognitive impairment. *He had diagnoses of Alzheimer's Disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions). *On admission, his Elopement Risk Evaluation indicated he had a low risk for elopement (leaving the facility without staff knowledge). *A 7/31/26 progress note indicated the resident was admitted to the facility after a hospitalization related to a hip fracture. It also indicated he had been previously at an assisted living memory care unit and prior to that he was at home and was found walking 2.5 miles from his home. *An 8/23/25 progress note indicated the resident wanted to go to his car and find his wife, was agitated, and unable to be redirected. *An 8/29/25 progress note indicated resident 37 would move himself in his wheelchair in and out of other resident's rooms, was agitated, and not able to be redirected. *A 9/7/25 progress note indicated he was agitated and got out of the secured door on the [NAME] hall. *A 9/8/25 progress note indicated he pushed the locked egress door until it opened and a staff member closed it before he got out. *On 9/8/25, his Elopement Risk Evaluation indicated he had a high risk for elopement, and a note indicated that he wandered the facility in his wheelchair and pushed on exit doors. *On 10/5/25 a progress note indicated he got out of the alarmed door twice, wandered into other residents' rooms, and wanted to go find his truck or tractor which caused him to be a flight risk and that he had gotten out of the facility several times since he was admitted . *A 10/6/25 progress note by administrator A indicated that she reviewed camera footage and resident 37 opened the front egress door but did not leave the building and staff were in line of sight of him. It also stated that he has never left the building without supervision but had pushed on emergency exit doors while wandering. (Exit doors are designed to alarm when pushed on and release after continuous pushing for 15 seconds and constant alarm is sounded.) *A 10/10/25 progress note indicated the resident had been exit seeking, and he wanted to find his truck. *An 11/16/25 at 6:09 p.m. progress note indicated that resident 37 was agitated and made it out inside of the back door (outer door alarmed/secured). *An 11/16/25 at 11:59 p.m. progress note indicated that he wandered the halls, opened the doors, and kept going behind the nurse's station. *An 11/17/25 progress note indicated the resident's daughter was notified that resident exited the facility last night through the storage area door. Resident went out the storage area door went over to the employee entrance, knocked and came through the door. *An 11/17/25 Elopement Risk Evaluation indicated the resident had a high risk for elopement. *A progress note on 11/26/25 indicated the resident was found the housekeeping room down the East Hall sitting in his wheelchair between two housekeeping carts. After the resident was removed from the housekeeping room, the staff checked that the door was locked, and it was locked. The administrator was notified. Camera footage was reviewed and found that CNAs had opened the housekeeping door at 1640 [4:40 p.m.] and left it open, resident propelled [self] into the room at 1648 [4:48 p.m.]. Full staff search started at approx [approximately] 1749 [5:49 p.m.] , and the resident was found at 1758 [5:58 p.m.]. 15 min [minute] checks were initiated and made him [resident 37] a 1:1 staff to resident ratio. *A 12/1/25 progress note indicated that the 1:1 ratio is effective in preventing wandering and reduces fall risks. *His care plan initiated on 7/31/25 stated, I am an elopement risk as evidenced by: previously leaving my home and being found 2.5 miles away. I have been residing at [facility] Memory Care Unit since May 2025 when this occurred. 9/7/25-wandering in facility in wheelchair and did push on exit door making alarm sound. Was in sight of staff who responded immediately. 11/16/25-attempted elopement. -The goal for that area was, My safety will be maintained through next review period. -Interventions for that area were: -Initiated on 7/31/25, to Provide structured activities: toileting, walking inside and outside, recreational activities, music, exercise; reorientation strategies. -Initiated on 11/17/25, to Offer snacks and diversional activities, looking at magazines, conversation, rummaging activity/items. -Initiated on 11/24/25, to Offer independent materials as desired, reading magazines and current events, pet visits, music, TV, social and conversation. Normalizing/Purposeful activity candidate: sorting, organizing, tools, tinkering. -Initiated on 11/24/25, for One-to-one [staff supervision] during all waking hours and redirection interventions include but are not limited to: tinkering/small purpose tasks (screwdriver board, sanding boards, measuring boards, clipboard for taking notes), sorting nuts and bolts, country western music, fidgets, rummage box, coloring, reading newspapers/magazines, picture books, looking at photo albums, reminiscing, socializing/talking, offering snacks. -Initiated on 11/24/25, Referral made to [facility] memory care unit-placed on waiting list. *After his elopement on 11/16/25 staff were to be checking on and charting what resident 37 was doing every 30 minutes. *After being locked in the housekeeping room on 11/26/25, he was to be on 15-minute checks and to be on 1:1 staff supervision during waking hours, and the Foresite system was to be activated when he was in his room. *He was discharged from the facility on 12/3/25 to a memory care unit. 21. Interview on 1/7/26 at 11:29 a.m. with CNA M revealed she received education about elopements a few months ago, was able to explain the elopement process, and had witnessed maintenance check the doors for security. 22. Observation on 1/8/26 at 11:04 a.m. revealed there was a button at the front desk, near the front door, that needed to be pushed to let someone exit the front door. 23. Observation on 1/8/26 at 11:10 a.m. revealed no one was sitting at the front desk to monitor the green button. 24. Review of door audits from 10/12/25 through 1/8/26 revealed: *They were completed daily, however door #7 was not listed as being checked from 10/13/25 through 11/15/25, just doors #1 through #6 were. *All doors were listed as passed the inspection from 11/17/25 through 11/21/25. *There was a note on the 11/17/25 through 11/21/25 door check log book that stated: -On 11/17/25, #7 door fixed wander guard so it could not be unplugged, also door is marked not an exit. -On 11/21/25, #7 door is no longer blocked. and Will have a Dynalock 30 seconds delay as well. -On the 11/17/25 door safety monitoring audit form, a note indicated that the north west (NW) exit door and alarm were not functioning and were to be repaired. -On the 11/18/25, 11/19/25, door safety monitoring audit form, it indicated the NW door were not functioning properly and repairs were pending. -On the 11/20/25 door safety monitoring audit form a note indicated that the north west (NW) exit door did and did not function properly. -On the 11/21/25 door safety monitoring audit form indicated that all doors were functioning properly and were repaired -On the 11/22/25 door safety monitoring audit form it indicated the east and west doors did not function properly because the doors needed to be pulled shut to latch. -The door monitoring log book on 11/22/25 indicated all doors were functioning properly. -On the 11/23/25 door safety monitoring audit form, it indicated that the east and west doors did not function properly. -There was no door safety monitoring audit form for 11/25/26. The door monitoring log book indicated all doors passed on 11/23/25 through 11/29/25. -On the 11/26/25 door safety monitoring audit form it indicated that all doors locked and worked properly and noted that the front door had to turn key mult. [multiple] times before it relocked and the west door was difficult to turn key and reset alarm-had to try a different key. -On the 11/29/25 door safety monitoring audit form it stated, maintenance checked all doors-all functioning properly. -On the 12/6/25 door safety monitoring audit form it indicated that all doors worked properly and a comment stated, west door-batch sticky. -On the 12/7/25 door safety monitoring audit form it indicated that all doors worked properly and a comment stated, west hall-key doesn't fit in all the way. Latch got stuck shutting the door. WD40 maybe? -On 12/7/25 the door monitoring log book indicated all doors passed. 25. Observation and Interview on 1/8/26 at 11:08 a.m., 11:17 a.m., 11:22 a.m., and 3:35 p.m. with administrator A revealed: *All exit doors were to be locked and alarmed. They no longer used the WanderGuard system. *Door audits were completed daily. *She completed weekly staff knowledge audits regarding elopements. *Maintenance completed the door audits Monday through Friday, and the manager on duty completed them on the weekends. *Two-door alarms were tested in the hallway where resident 37 had resided and were functioning. *The green button at the front desk needed to be pushed to open the door or staff could use their badge to open it. *If the green button was pushed, it would unlock the front door for three seconds. *After business hours, the button that opened the front door was not always monitored. *She verified that a resident could potentially leave the facility without the staff's knowledge. *Department heads educated their staff regarding elopements. *She verified that 29 staff did not receive education regarding elopements before working their next shift, as indicated in the 11/16/25 Facility Reported Incident report. *It was her responsibility to make sure all education had been completed for all staff before their next shift worked. *All staff should have been educated on the elopement policy, and signed a form once completed. Education regarding door safety was done verbally, and staff signed a form that they received that education. *An elopement risk assessment was not completed after resident 37's second elopement on 11/26/25, and per their policy, it should have been. 26. Review of the providers' 5/14/25 elopement policy revealed: *Each resident will be evaluated upon admission to ascertain elopement risk. Care plan interventions will be initiated based on results the evaluation will be completed should a resident have an elopement.

Based on observation, interview, and policy review, the provider failed to ensure the staff followed infection control practices regarding: *Foley catheters (flexible tubing placed in the bladder to drain urine), tubing and urinary drainage bag placement for two of two sampled residents with foley catheter. *Hand hygiene by one of one registered nurse (RN) D observed administering medications to multiple residents during a noon meal service without sanitizing her hands in between each resident's medication administrations.*One of one certified nursing assistant (CNA) (F) observed without wearing a gown and gloves when transferring a resident (26) on enhanced barrier precautions (EBP), and did not clean the lift after transferring the resident. Findings include:1. Observation on 1/6/26 at 11:25 a.m. of RN D in the dining area administering medications to residents as they were seated for the noon meal revealed she did not sanitize her hands after each administration before preparing medications for the next resident. 2. Observation and interview on 1/6/26 at 3:49 p.m. of resident 2 being pushed in his wheelchair to his room revealed: *He was sitting in a wheelchair while CNA J pushed him from the dining room to his room. His urinary catheter tubing dragged on the floor, and he stepped on it numerous times. *CNA J stated she was not aware that the catheter tubing was not supposed to be on the floor and reported it was typical to see it on the floor. 3. Observation and interview on 1/6/26 at 2:56 p.m. of CNAs G and K transferring resident 3 in his room revealed: *He was sitting in a wheelchair with a urinary drainage bag about half full of urine that hung on the wheelchair. *A sign on his door indicated he was on enhanced barrier precautions, meaning gloves and gowns needed to be worn when providing direct care to the resident (EBP). *CNAs G and K put on gowns and gloves, and then used a total body lift (a mechanical lift and sling used to lift a person's full body) to transfer him to his bed. *They hung his urinary drainage bag on the sling, above the level of his bladder. *After lying him in bed his urinary drainage bag was attached to the side of the bed, below the level of his bladder. *CNA G emptied the urine from his urinary drainage bag into a designated container and dumped the urine into the toilet. *They then lowered his bed to the lowest position, and his urinary drainage bag was lying on the floor. *CNA G, using the same gloves, wiped off the mechanical lift with cleaning wipes. *CNA G removed her gloves, left the room with a garbage bag, entered the dirty utility room, exited that room and then sanitized her hands. *CNA G stated she did not receive education that the urinary drainage bag was to remain below the resident's level of the bladder to prevent backflow of urine into the resident's bladder. *CNA G stated that the urinary drainage bag was not supposed to be on the floor without a barrier. She then went to obtain a bin, returned to the room with a bin, and put the urinary drainage bag into it. 4. Observation and interview on 1/7/25 at 12:43 p.m. with CNA F revealed: *He was exiting resident 26's room, who was on EBP with a sit-to-stand lift (a manual lift used to assist from a seated to a standing position). *He stated he had used a stand lift to transfer resident 26 from his wheelchair to the recliner chair. *He placed the stand lift into room [ROOM NUMBER], a room with no resident residing in it. *When asked if he wore a gown or gloves while transferring the resident, he responded that he did not because he was not required to wear a gown and gloves when transferring resident 26. *When asked if he cleaned the stand lift after use with resident 26, he replied yes. When no cleaning wipes were seen in resident 26's trash receptacle, he replied that he cleaned the lift in room [ROOM NUMBER]. -There were no cleaning wipes in the trash can of room [ROOM NUMBER]. 5. Interview on 1/7/26 at 12:50 p.m. with housekeeper N revealed that she witnessed CNA F did not clean the stand lift after use. 6. Interview on 1/8/25 at 12:47 with RN/infection preventionist (IC) C revealed: *She expected staff to sanitize their hands between medication administration to different residents. *She expected staff to follow the facility's EBP policy and to gown and glove when transferring a resident on EBP. 7. Review of resident 3's EMR revealed: *His 11/4/25 BIMS assessment score was 9, which indicated his cognition was moderately impaired. *He had a physician's order: -On 3/14/25 for a Foley catheter for urine retention. -On 4/25/25 to irrigate his Foley catheter with 60 ml (milliliter) of sterile water as need for occlusion (blockage). -On 11/19/25 to change his Foley catheter monthly and as needed for occlusion. -On 12/22/25 to change his urinary drainage bag every two weeks and to date the bag. *His 12/2/25 care plan indicated he: -Was to be on enhanced barrier precautions (EBP) because he had a catheter. -Had a history of urine retention and urinary tract Methicillin-resistant Staphylococcus aureus (MRSA) (a drug-resistant infection) infection, so staff were to use infection control precautions when dealing with his urine. 8. Review of resident 2's EMR revealed: *His 10/15/25 BIMS score was 13, which indicated his cognition was intact. *His 10/15/25 care plan indicated: -He had a long-term Foley catheter for chronic urinary retention with a goal to remain free from catheter-related trauma. -He required EBP because he had a Foley catheter. *He had a physician's order: -On 4/1/25 to flush his Foley catheter with 60 cc (cubic centimeter) of sterile water to prevent blockages. -On 8/27/25 to change his Foley catheter monthly. -On 11/10/25 to change his urinary drainage bag every two weeks and to date the bag. *His EMR progress notes revealed: -On 6/30/25, his physician was notified that he had a large amount of mucous and sediment in his urine with a malodorous smell that was clogging his catheter, and an order for a urinary analysis (UA) was received. -On 7/27/25, resident's physician was notified he had purulent discharge from his urethra for a few days and foul-smelling urine, and an order for UA was received. -He had a UA collected on 7/30/25, and per the lab report his urine culture grew out Proteus mirabilis, Enterococcus faecalis, and stated that multiple microflora were present (which could represent contamination of the urine sample), and to recollect the specimen if urine culture was clinically indicated. His physician ordered for him to receive Rocephin by intramuscular injection (IM) daily for seven days on 8/4/25. -On 8/21/25, the physician notified the facility of urine culture results that grew out Pseudomonas Aeruginosa infection and ordered Augmentin (an antibiotic) 875 mg by mouth twice daily for three days. 9. Interview on 1/8/26 at 3:16 p.m. with director of nursing (DON) B revealed: *They did not have a bladder irrigation policy. *She acknowledged that resident 2 had frequent urinary tract infections. *She expected the staff to keep urinary drainage bags below the level of the resident's bladder and off the floor. *She expected the resident's Foley catheter tubing to be off of the floor. *She expected the staff to remove their dirty gloves before cleaning mechanical lifts. *She expected staff to wash their hands after removing their gloves, when leaving a resident's room, and not to touch the keypad on the dirty utility room door with uncleaned hands. 10. Review of the provider's 5/15/25 Enhanced Barrier Precautions policy revealed: *Enhanced Barrier Precaution (EBP): refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. *Multi Drug Resistant Organism (MDRO) are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. Although the names of certain MDROs describe resistance to only one agent (e.g., MRSA, VRE), these pathogens are frequently resistant to most available antimicrobial agents. *ENHANCED BARRIER PRECAUTIONS should be used for all resident or for those residents colonized/infected with a novel or targeted MDRO, when they no longer meet requirements for Contact Precautions: *a. Gowns and Gloves should be used during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing: Dressing, Bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting, device care or use of a device, as listed above, wound care. 11. Review of the providers 2/21/25 Catheter Care policy revealed: *The purpose of this policy is to prevent urinary catheter-associated urinary tract infections. *.the urinary drainage bag should still be positioned lower than the bladder to promote proper drainage. *Be sure catheter tubing and drainage bag are kept off the floor. 12. Review of the provider's 5/15/25 Hand Hygiene policy revealed: *This facility considers hand hygiene the primary means to prevent the spread of infections. Hand Hygiene is part of Standard Precautions. *All personnel shall follow the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub a. Before and after direct contact with residents b. When entering and leaving a Resident care area/room c. Before donning [putting on] and after removing gloves . e. Before preparing or handling medications. *Hand hygiene is always the last step after removing and disposing of personal protective equipment.

Based on record review, interview, and policy review, the provider failed to report to the South Dakota Department of Health (SD DOH) that one of one sampled residents (2) received cigarette burns to his fingers. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *His 10/15/25 Brief Interview for Mental Status (BIMS) score was 13, which indicated his cognition was intact. *He did not have a physician's orders to smoke. *He had diagnoses of nicotine dependence and mild vascular dementia (a group of symptoms affecting memory, thinking, and social abilities). *His 10/15/25 smoking evaluation risk assessment indicated: -He was careless with smoking materials. -He was unable to safely light a cigarette. -He was not considered a safe smoker and required smoking management and supervision consistent with facility policy and may not have access to smoking material outside of supervised smoking. -He was to wear a smoking apron, be seated under the folding table, and a staff member was to light his cigarette. -He often attempted to smoke cigarettes down to the filter. *His 10/15/25 care plan indicated: -He was to be supervised, wear a smoking apron, and was to use a cigarette holder when he smoked to prevent him from getting burned because he smoked the cigarette down past the filter.-He needed to be pushed up to the table when he smoked due to his history of burns to his feet from dropping ash. -At any time if it was determined that he could not smoke safely with the available levels of support and supervision as indicated on his care plan, the resident's individual smoking methods may need to be adjusted. *Resident 2's physician was notified on 1/4/26 that he had cigarette burns to his right thumb that measured 0.7 x 0.6 and right pointer finger that measured 0.7 x 0.4 that were brown and tan in color without signs of infection. 2. Observation and interview on 1/6/26 at 4:08 p.m. of resident 2 outside smoking with CNA L revealed: *She put his coat and smoking apron on him, handed him the cigarette, he put it in his mouth, and she lit the cigarette for him with the lighter. *When the cigarette was close to the filter, she encouraged him to put the cigarette out, and when he did not, she removed the cigarette from his hand and put it out for him, and said he typically tried to smoke it close to the filter. 3. Interview on 1/7/26 at 3:27 p.m. with administrator A revealed: *She expected resident 2 to use cigarette holders when smoking if that was indicated on his smoking evaluation risk assessment. *They had been out of cigarette holders for about a week, and resident 2 should not have been allowed to smoke without the use of the cigarette holders. 4. Interview on 1/8/26 at 3:35 p.m. with administrator A revealed she was not aware that resident 2 had cigarette burns to his fingers and would have reported that to the SD DOH within 24 hours of the incident had she known. 5. Interview on 1/8/26 at 4:04 p.m. with registered nurse (RN) E revealed: *If an injury was found on a resident, she would try to determine the cause of the injury, correct it, notify management, the resident's physician, and the resident's family. 6. Interview on 1/8/26 at 4:06 p.m. with director of nursing (DON) B revealed she expected the nursing staff to report resident injuries to administration immediately. 7. Review of the provider's 5/14/25 Abuse and Neglect policy revealed: *Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care 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. *If abuse/neglect is suspected the facility will: 1.Take immediate steps to assure the protection of the resident(s). 2.Notify the appropriate/designated organization/authority that an investigation is being initiated immediately following intervention for the resident's safety 5.Report the investigation findings to all necessary state/and or local agencies and any other identified persons as required by law.*VII. Reporting/Response.-All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to provide adequate supervision and assistance to ensure the safety of one of one sampled resident (1) who fell while being transferred by certified nursing assistant (CNA) C who did not transfer the resident as directed in the resident's care plan and did not report the incident as a fall to the nurse for timely and appropriate assessment of the resident. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident.Findings include:1. Review of provider's 7/1/25 SD DOH FRI for resident 1 revealed:* On 6/30/25 at 7:30 p.m. licensed practical nurse (LPN) E notified director of nursing (DON) D that certified nursing assistant (CNA) B stated resident 1 fell on 6/29/25.*CNA B reported to LPN E that CNA C had been looking for assistance to transfer resident 1 on 6/29/25 around 5:30 p.m. up from the floor.*There was no fall assessment completed.*No neurological assessments were started.*No family notification of the incident was documented in resident 1's chart.*DON D notified administrator A on 6/30/25 to review fall sensor footage.*Administrator A reviewed the footage on 6/30/25 at 8:10 p.m. while on the phone with DON D and saw that CNA C had completed a stand pivot transfer of resident 1 from her bed to her wheelchair. CNA C appeared to have:-lost her balance and tipped resident 1 in her wheelchair, along with herself, over backwards.-CNA C was seen in the footage going and getting CNA B to assist with getting resident 1 upright in her wheelchair.-CNA C was seen going to get registered nurse (RN) F from the dining room. *CNA C reported to RN F that she tipped resident 1's wheelchair back, but it was not a fall, and she did not hit her head.-RN F went to resident 1's room, observed resident 1 in her wheelchair with no injuries, and instructed CNA C to bring resident 1 to the dining room to eat supper.*After reviewing that information, DON D instructed LPN E on 6/30/25 to initiate fall follow-up, and to complete a head-to-toe assessment and neurological checks.*Administrator A suspended CNA C pending an investigation.*Upon completing assessment on resident:-Neurological assessment (evaluation of nerve function, reflexes, coordination, motor skills, sensation, reflexes, and mental status) was within normal limits (WNL).-Range of motion (measurement of movement around a joint or body part) was WNL.-Resident 1 complained of pain in her left upper extremity from a previous fracture.-Vital signs (measurement of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were WNL.*On 7/1/25 witness statements were obtained from CNA B and RN F who had worked with CNA C on 6/29/25 and confirmed what administrator A saw on security camera footage.*CNA C was interviewed regarding the incident with resident 1 and revealed:-She was not aware the incident was considered a fall since resident 1 remained in her wheelchair.-She confirmed that resident 1was to be transferred with the assistance of two staff members, and she did not wait for another staff member's assistance.*CNA C's employment was then terminated immediately on 7/1/25.*Resident 1's family, primary care provider, and orthopedic doctor were notified of the fall.*All staff were educated on the fall management policy.*CNAs demonstrated competencies with full mechanical lift (a mechanical lift and sling used to lift a person's full body) and sit-to-stand lift (a mechanical lift used to assist from a seated to standing position).*A whole-house audit was of transfer assistance needs was completed of all resident care plans, Kardex, CNA assignment sheets, and current therapy orders.*Transfer status and staff would be audited weekly for one month, then monthly for three months, and then quarterly for a year for continuance of care. 2. Review of resident 1's electronic medical record (EMR) revealed:*She admitted to facility on 5/26/22.*Physical therapy's 4/28/25 recommendations were for her to be transferred with maximum staff assistance (staff member provides the majority of the support) with the use of a mechanical lift and two staff members' assistance, and to use a sit-to-stand or total mechanical lift if she was too lethargic (tired).*Occupational therapy's 4/29/25 recommendations were for a mechanical sit-to-stand lift with two staff members assistance when able, or a total mechanical lift with two staff members' assistance if she was unsafe in the sit-to-stand.*Her care plan indicated transfers with total mechanical lift initiated 6/7/22.*Review of fall risk assessments completed on 2/28/25 and 6/1/25 identified resident 1 as having a high risk for falling. 3. Interview on 7/16/25 at 2:47 p.m. with CNA B revealed:*On 6/29/25 at approximately 5:30 p.m. CNA C was in the west hallway, motioning for her to come to resident 1's room.*Upon entering resident 1's room, CNA B observed resident 1 in her wheelchair tipped over and lying on the floor.*CNA C had told her she had lowered resident 1 to the floor, and that she did not fall.*CNA B told CNA C to notify the nurse because she thought what happened was a fall.*CNA C was already trying to sit the wheelchair up, so CNA B assisted resident 1 into an upright position.*CNA B left the room to notify RN F, but CNA C passed her in the hallway, and went to RN F.*She assumed CNA C told RN F of the fall as RN F went to resident 1's room.*On 6/30/25, she asked LPN E if she was aware of resident 1's fall from the previous day.*She wrote a statement about the events involving resident 1 on 6/29/25.*She was aware resident 1 needed the assistance of two staff members and the use of a mechanical lift for transferring.*She had received education on the fall policy after the incident, and a disciplinary teaching moment for failing to report a fall to the nurse.*She completed competencies on the safe use of the total mechanical lift and sit-to-stand lift following the incident. Interview on 7/17/25 at 9:25 a.m. with administrator A revealed:*She considered the 6/29/25 incident with resident 1 as a fall.*The fall policy should have been followed.*Resident 1's incident occurred because the staff did not follow her care plan and need to be transferred with a total mechanical lift and two staff.Education was provided to caregiver staff on the mechanical lift policy and the fall policy following the incident.*Competencies for the mechanical lift were completed with the nursing staff following the incident.Audits were being completed weekly, and adjustments like sling size and needed lift evaluations completed, and care plans being updated with the needed information was being made to ensure similar incidents do not happen again.*A quality assurance and performance improvement (QAPI) meeting was held on 7/1/25 regarding safe resident transfers, updating resident care plans, competencies being completed and transfer status updated to reflect safest option for the resident's transfers, and timely reporting of incidents to the nurse. 4. Review of the provider's revised February 2024 Fall management policy revealed:*It is the policy of the facility to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence.- A fall is the unintentional change in position coming to rest on the ground, floor or onto the next lower surface.- An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person-this is still considered a fall. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 7/17/25 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding mechanical lift policy and fall policy, mechanical lift competencies were completed for caregiver staff, and audits were being completed and will be ongoing. Interviews with nursing staff revealed they understood the education provided regarding those topics. Observation of mechanical lift transfers in residents' rooms were conducted and confirmed staff understood how to use lifts and transfer residents safely. A QAPI meeting was held on 7/1/25 to implement a plan and will continue to be a part of their QAPI process for review and further advise staff as needed. Based on the above information, non-compliance at F689 occurred on 6/29/25, and based on the provider's 6/30/25 implemented corrective actions for the deficient practice confirmed on 7/17/25, the non-compliance is considered past non-compliance.

Based on interview, observation, and record review, the provider failed to ensure a bed frame was maintained and free of hazardous sharp areas for one of one sampled resident (1) who acquired a skin tear to her right lower outer ankle. Findings include: 1. Interview on 9/09/24 at 3:51 p.m. with resident 1 revealed: *She was lying in her bed and stated she had a cut on her right leg that was caused from the metal on her bed when they were putting her to bed after using the bathroom. *She stated she had no other skin concerns. 2. Record review of resident 1's skin alteration evaluations revealed: *On 8/18/24 resident 1 received a skin tear to her right outer ankle while CNA I transferred her into bed. -The skin tear measured 6.0 L X 3.0 W x 0.5 centimeters (cm) deep. -Resident 1 declined go to the emergency room (ER) for an evaluation. *The residents wound was cleaned, Steri strips and a gauze pad were applied, and then her leg was wrapped in a gauze bandage. -The family was notified and agreed that she would not go to the ER for evaluation of the right leg wound. *On 9/11/24 the wound measured 6 cm X 2.2 cm X 0.1 cm. 3. Observation and interview on 9/10/24 at 9:26 a.m. with resident 1 revealed: *She stated nothing had been done to her bed to prevent her from being cut again. *The bed frame was exposed under her mattress and had seven metal square bars. -Three of those bars, from the middle of the bed to the head of the bed, had plastic protective caps on the ends of them. -Four those bars, from the middle of the bed to the toot of the bed, did not have protective caps. 4. Observation and interview on 9/10/24 at 9:52 a.m. with certified nursing assistant (CNA) G revealed: *She stated, I am almost positive she cut her leg on those bars. *She pointed to the bars on the bed frame. 5. Observation on 9/10/24 at 2:58 p.m. with resident 1 while she was asleep in her bed revealed sheepskin cover was under the mattress and over the edge of the bed covering the bed frame. 6. Interview on 9/10/24 at 3:24 p.m. with registered nurse (RN) C and administrator A revealed: *They both confirmed a sheepskin cover had been placed over resident 1's bed frame. *Administrator A stated she had informed maintenance staff H of the resident's bed frame that past weekend when she was the manager on duty, but he had not been notified previously. *She agreed nothing had been done about the bed frame until today (9/10/24). 7. Interview on 9/10/24 at 3:45 p.m. with RN E revealed: *Resident 1 acquired a skin tear to her right leg during a transfer on 8/18/24 and was bleeding pretty good. *Resident 1 and her family did not want her to go the ER for evaluation because the bleeding had stopped. *She would monitor the resident's leg for redness and cellulitis because she worked the next day. -The wound was not red. *She had evaluated the resident's bed and wheelchair but did not see anything dangerous that would have caused the skin tear, so she did not report it to others. *She agreed that resident 1 had acquired a skin tear to her right leg that measured 8.0 X 3.0 x 0.5 cm when staff had transferred her from the wheelchair to her bed. 8. Observation on 9/11/24 at 9:18 a.m. of resident 1's bed revealed. *Her bed was made with the blankets tucked under the mattress. *There was no sheepskin on the bed to cover the bed frame. *There were end caps on all the square bars. 9. Interview and observation on 9/11/24 at 10:06 a.m. with administrator A revealed: *She said TELS (a building management software system) communication was how staff communicated with maintenance staff if something needed his attention. *She stated nothing had been put in TELS for maintenance staff about resident 1's bed. *She clarified she had taken a picture of the bed with her phone and had sent it to maintenance staff when she was the manager on duty and showed the message to the surveyor. 10. Observation and interview on 9/11/24 at 1:00 p.m. with resident 1 revealed: *She was in the hall in her wheelchair and was heading to her room. She stated, My bed was fixed, I wish it had been done before I cut my leg on it. *She asked the surveyor to return to her room with her. *The sheepskin was back on the bed, and it was held in place with Velcro. *She said she should have gone to the ER for an evaluation but, it was in the middle of the night, and I didn't want to go. 11. Observation on 9/11/24 at 2:26 p.m. of resident 1's wound care with licensed practical nurse (LPN) F and CNA D revealed: *CNA D removed the dressing to resident 1's lower outer right leg. *LPN F said Resident 1 had a skin tear on her right lower leg. *LPN F cleansed the wound with saline wound cleaner, applied medihoney (a topical medication) with a cotton -tipped applicator, and applied a Mepilex bandage. -The wound bed was wet with pink outer edges. *LPN F did not measure the wound's size and said that measurements were done weekly on Mondays. 12. Interview on 9/11/24 at 2:46 p.m. with director of nursing (DON) B revealed: *She expected staff would have reported an equipment problem to maintenance staff and or her after a resident acquired a skin tear or injury. *She stated the bed should have been investigated because of the skin tear. *She agreed that equipment problems would have been reported to maintenance staff through TELS communication. *She confirmed the CNA I that had assisted resident 1 with her the transfer when she received the skin tear 8/18/24 was a traveler and no longer worked there.

Based on observation, interview and record review the provider failed to ensure quarterly side rail assessments were completed for three of seven residents (4, 5, and 19). 1.Observation on 6/14/23 at 9:00 a.m. of resident 5's room revealed she had a one-half side rail on the left side of her bed. Interview on 6/14/23 at 9:30 a.m. with maintenance director E revealed: *He stated the assessments had been completed in the four months since he began working at this facility. *He provided documentation of a side rail audit with one bed rail audit conducted on 5/30/23 for room [ROOM NUMBER] which was not resident 5's room. *He admitted that he had not done as many assessments as he thought. Interview on 6/14/23 at 3:34 p.m. with director of nursing A and Minimum Data Set coordinator F regarding resident 5's side rails revealed: *There were no assessments completed for residents who use side rails. *Resident 5 had no assessment for side rails. *Their expectation would have been that the assessments had been completed. Review on 6/14/23 at 3:45 p.m. of resident 5's electronic medical record revealed: *She had no assessment completed for the use of a side rail. *There were no physician's order for the use of the side rail. *She had a signed side rail consent form on her admission on 2/14/20. 45683 2. Observation and interview on 6/12/23 at 4:01 p.m. with resident 4 revealed: *She was in her room seated in her wheelchair. *A u-shaped side rail was elevated on the upper half of her bed. *She used her side rail to reposition in bed and to assist herself to sit up on the edge of the bed. Review of resident 4's medical record revealed: *She was admitted on [DATE]. *She had diagnoses of symptomatic epilepsy and epileptic syndrome with complex partial seizures. *Her most recent Brief Interview of Mental Status (BIMS) of 13 revealed no cognitive impairment. *Quarterly side rail/other device evaluation forms were completed on 8/18/22 and on 1/25/23. 3. Observation and interview on 6/13/23 at 10:02 a.m. with resident 19 revealed: *She was in her room sitting in her recliner with the footrest elevated. *A u-shaped side rail was elevated on the upper half of her bed. *She used the side rail to reposition in bed and to transfer to her recliner or wheelchair. Review of resident 19's medical record revealed: *She was admitted on [DATE]. *She had diagnoses of epileptic seizures related to external causes, a mild neurocognitive disorder due to known physiological conditions without behavior disturbance, type two diabetes mellitus with unspecified complications and Parkinson's disease. *Quarterly side rail/other device evaluations were completed on 9/29/21 and on 11/13/22. A side rail policy was requested from the director of nursing but was not recieved by the end of the survey.

Based on record review, interview and policy review the provider failed to ensure the 48 hour nutritional care plans for two of four sampled residents (11 and 22) were updated in their comprehensive care plan. Findings include: 1. Review of resident 11's medical record revealed he: *Was admitted on [DATE]. *Had diagnoses that included: Anemia secondary to blood loss, type 2 diabetes mellitus with hyperglycemia and pneumonitis due to inhalation of other solids and liquids. *Was on a consistent carbohydrate (CCHO) diet. Review of resident 11's care plan problems initiated on 5/12/23 revealed: *Altered cardiovascular functioning related to post-op blood loss anemia. -The goal was to be free from signs and symptoms of complications of cardiac problems through the next review window. -The intervention was to give the diet as ordered. *Resident 11 was at risk for fluctuating blood sugars due to diabetes mellitus with hyperglycemia. -The goal was blood sugars would remain within parameters set forth by the physician through the next review window. -The intervention was to provide the diet per physician's order. 2. Interview on 6/13/23 at 1:47 p.m. with resident 22 revealed she: *Was in her room sitting in her recliner. *Knew she was on a ground meat diet because of her Barrett's esophagus diagnosis. *Had been dealing with acid reflux. *Had lost over 100 pounds in the last two years. -Due to a loss of appetite. -Dealing with her acid reflux. Review of resident 22's medical record revealed she: *Was admitted on [DATE]. *Had diagnoses that included: dysphagia, unspecified, gastroesophageal reflux disease without esophagitis and Barrett's esophagus without dysplasia. *Was on the provider's nutrition at-risk list for weight loss. -Weighed 133.6 pounds on 4/15/23. -Weighed 127.8 pounds on 6/8/23. Review of resident 22's care plan problems initiated on 4/13/23 revealed: *{Name} is at risk for altered cardiovascular functioning related to hyperlipidemia, anemia, obesity hypertension, peripheral vascular disease (PVD). -The goal was to have been free from cardiac overload through the next review period. -The intervention was to give the diet as ordered. *{Name of the resident} has an actual impairment to skin integrity to bilateral lower extremities (BLE) classified as unhealing leg ulcers. These were present upon admission. -The goal was not to develop signs and symptoms of infection on the wound site through the next review. -The intervention was to encourage good nutrition and hydration in order to promote healthier skin. Interview on 6/14/23 at 1:39 p.m. with dietary manager H revealed: *She completed the dietary portion of the initial care plan upon the resident's admission within 48 hours. *The comprehensive care plan should have been completed by the 21st day after admission. -She thought the comprehensive care plans had been updated for residents 11 and 22. -She agreed the comprehensive care plans were not updated in a timely manner. Interview on 6/14/23 at 3:35 p.m. with director of nursing (DON) A regarding resident 11 and 22's care plans revealed: *The interdisciplinary team (IDT): -Implemented the 48-hour resident care plans for all new admissions. -Completed the comprehensive care plan within 21 days after admission. *She agreed that the dietary portion of the comprehensive care plan was not updated for residents 11 and 22. *It was her expectation the resident care plans would have been completed in a timely manner. Review of the provider's September 2019 Care Planning policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. In doing so, the following considerations are made: 1. Each resident is an individual. The personal history, habits, likes and dislikes, life patterns and routines, and personality facets must be addressed in addition to medical/diagnosis-based care consideration . 3. Care planning is constantly in process; it begins the moment the resident is admitted to the facility and doesn't end until discharge or death . 6. The DON will be responsible for holding the team accountable to intitiating and completing the admission care plan within 48 hours and the long-term care plan by day 21 and updated as necessary thereafter.

A. Based on observation, interview, record review, policy review, and review of the provider's facility assessment, the provider failed to ensure five of twelve sampled residents (3, 7, 10, 11, and 12) received a bath weekly. Findings include: 1. Observation and interview on 10/4/22 at 10:50 a.m. with resident 12 sitting in his wheel chair revealed: *He was admitted on [DATE]. *He was receiving therapy for strengthening. *He had not had a bath since he was admitted . *His face was unshaven. *His call light was on because he needed to use the bathroom before his care conference at 11:00 a.m. *It takes a while for staff to answer his call light. Record review of resident's 12 bathing record revealed he had only received a bath on the day he had been admitted . *Two missed opportunities for a bath. 2. Observation and interview on 10/4/22 at 11:05 a.m. with resident 7 sitting in his wheel chair revealed: *He was admitted on [DATE]. *He was receiving therapy for strengthening. *He had not had a bath since he was admitted . *His face was unshaven. *His razor had broken and no one had helped him with shaving. *It takes staff a long time to answer his call light. -After 10:00 p.m. at night is when it took the longest for call lights to be answered. Record review of resident's 7 bathing record from 9/22/22 to 10/5/22 revealed no documentation of resident receiving or refusing a bath. *Two missed opportunities for a bath. 3. Observation and interview on 10/4/22 at 11:30 a.m. with resident 10 sitting in his wheel chair revealed: *His face was unshaven. *He got a shower every Friday. *It takes a long time for staff to answer his call light in the evening and at night. Record review of resident 10's bathing record from 9/5/22 to 10/5/22 revealed he had received a bath on 9/9/22 and 9/16/22. *Two missed opportunities for a bath. 4. Observation and interview on 10/4/22 at 11:55 a.m. with resident 11 while sitting on the edge of her bed revealed: *She had moved in to the facility on [DATE]. *She received a bath once since she had lived here. *Staff took a long time to answer her call light around mealtimes and at bedtime. Record review of resident 11's bathing record from 9/5/22 to 10/5/22 revealed she had last received a bath on 9/20/22. *Three missed opportunities for a bath. 5. Interview on 10/4/22 at 2:42 p.m. with resident 3 and her daughter revealed: *Resident 3 had complained to her daughter about her lack of baths. *Resident 3's daughter stated a few weeks ago she had inquired about the last time her mother had received a bath. *She was told it had been nine days prior. *The nurse had told her they did not have a schedule of when a resident received a bath, but thought it was a good idea. *She stated she was very upset there was no schedule to ensure the residents received baths. 6. Interview on 10/5/22 at 2:25 p.m. with administrator A and director of nursing (DON) B regarding bathing and waiting for call lights to be answered revealed: *They had not had a bath aid working as much as needed to give baths. *Residents should have received a bath weekly. *DON B stated that she had noticed the lack of bathing, and started performing an audit to track the issue. *Many of their staff members had returned to college in August leaving open shifts. Review of provider's Bathing policy date September 2019 revealed: *The purpose of the bathing procedure is promote cleanliness, provide comfort to the resident and observe the resident's skin condition. Review of the provider's undated Facility Assessment Tool revealed: *Based on the provider's resident population and their needs for care and support, the assessment revealed the staffing to ensure sufficient staff to meet the needs of the resident included: -One full-time DON. -RN or licensed practical nurse (LPN) one for each shift. -RN or LPN treatment nurse one for each shift. -Medication aide as needed. -Three to four certified nursing assistants (CNA) for day shift. -Two to three CNAs for evening shift. -One to two CNAs for night shift. -One registered nurse assessment coordinator Monday through Friday. *Charge and Treatment nurses oversee the entire resident population. C.N.A.s are assigned an area with approximately 10-13 residents. One C.N.A. on the day shift works with the residents that have a restorative program. One C.N.A. per day is assigned to complete bath/showers for the residents. Interview on 10/5/22 at 2:20 p.m. with administrator A and DON B revealed: *Both administrator A and DON B felt the staffing they had was adequate to provide care to the residents. *They agreed the facility assessment had not been followed as written. *There was usually one charge nurse and either a treatment nurse or medication aide for a 12 hour day shift from 7:00 a.m. to 7:30 p.m. and one licensed nurse from 7:00 p.m. to 7:30 a.m. *Three certified nursing assistants (CNA) were scheduled during the day shift. Those CNAs assisted the residents and that included the bath aide. The shifts varied to extend into the evening. *Two CNAs were scheduled for the evening shift and one CNA for the night shift. B. Based on observation, interview, record review, policy review, and review of provider's facility assessment, the provider failed to ensure two of five sampled residents (1 and 2 ) had received consistent skin assessments. Findings include: 1. Review of resident 1's medical record revealed: *She had been hospitalized on [DATE] and returned to the facility on [DATE] after a fall with injury. *A deep tissue injury (DTI) to her left heel was discovered on 6/14/22. -The DTI measured 2 centimeters (cm) by 3 cm. *A 6/20/22 skin assessment completed by a licensed nurse revealed she had a: -Alteration in skin integrity. -There were no measurements. -The treatment note stated left heel wound-boots on at night-off loaded to reduce pressure. *Skin assessments revealed she had no alteration to her skin when completed on 7/4/22, 7/13/22, 7/27/22, and 7/31/22. *Skin assessments completed on 7/18/22, 8/16/22, 8/30/22, and 9/12/22 revealed skin issues due to red, rashy areas to her lower abdomen and/or buttocks. There was no mention of her left heel DTI. *There were skin assessment forms on 6/29/22, 8/4/22, and 8/26/22 revealed measurements and a description for her left heel DTI had been completed. 2. Review of resident 2's medical record revealed: *He developed open areas to his right toes on 6/29/22. *Skin assessments had been completed in regards to his toes on his right foot on 8/26/22, 8/29/22, 9/8/22, and 9/20/22. Those were the only skin assessments that included measurements and a comprehensive description of his wounds. *Skin assessments from 6/5/22 through 9/26/22 had not been completed on 6/5/22, 6/17/22, 7/23/22, 8/20/22, and 9/26/22. Interview on 10/5/22 at 2:20 p.m. with administrator A and DON B revealed: *DON B confirmed documentation on alteration in skin documentation had been inconsistent. *There was not a primary nurse who evaluated the residents skin. *Each resident was to have a weekly skin assessment. *Any residents with impaired skin should have had those areas measured and assessed on a weekly basis.

Based on observation, interview, record review, and policy review, the provider failed to ensure proper hand hygiene had been performed by three of five observed staff (C,D, and E) while providing care for three of five sampled residents' (14, 20, and 28) as evidenced by: *One of one sampled resident (28) during observed personal care performed by certified nursing assistant (CNA) E. *One of one sampled resident (20) during observed wound care performed by registered nurse (RN) C and licensed practical nurse (LPN) D. *One of one sampled resident (28) observed medication administration via feeding tube performed by LPN D. Findings include: 1. Observation on 2/15/22 at 3:44 p.m. of CNA E who assisted resident 28 with personal care revealed: *She was lying in bed with her brief pulled down. *CNA E: -Pulled up her pants and brief while wearing gloves. -Assisted her to a seated position on her bed. -Applied a gait belt. -Transferred her to her wheelchair. -Removed her gloves and put on a new pair. -Transferred her from her wheelchair to the toilet. -Provided peri care and pulled up her clean brief and pants with her contaminated gloves. -Repositioned her in her wheelchair with the same contaminated gloved hands. -Removed her contaminated gloves and without performing hand hygiene put on a new pair. -Assisted her with oral care. -Removed her gloves and washed her hands. Interview on 2/15/22 following the observation with CNA E revealed: *She had not been aware that hand hygiene needed to be completed after changing gloves. Review of the provider's October 2019 Hand Hygiene policy revealed: *All personnel shall be trained and regularly educated on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. *All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Before putting on and removing gloves hand hygiene shall be performed. 2. Observation on 2/16/22 at 10:44 a.m. with RN C and LPN D who completed wound care for resident 20 revealed: *RN C removed the dressing from his right knee and turned off the wound vac. *LPN D grabbed gauze with her gloved hand and turned the faucet handle on. -Using her gloved hands, she soaked that same gauze with water from the faucet, then dabbed the wound. -Moistened more gauze with tap water and cleaned his pinhole sites. *RN C applied Santyl ointment to the wound bed using a sterile Q-tip applicator. -Removed her gloves without performing hand hygiene and applied a new pair. *LPN D opened a Xeroform gauze package and applied gauze to the pinhole sites. -Removed her gloves and performed hand hygiene. Interview on 2/16/22 at 11:42 a.m. with RN C regarding the above observation revealed: *She had followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *The 1/11/22 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 2/16/22 at 11:43 a.m. with DON B regarding the above observation revealed: *She would expect staff to use wound cleanser if not cleansing with soap and water. *Staff should use sterile water or sterile saline when cleaning wounds with soap. Review of the provider's undated Dressing Change Competency-Aseptic Technique procedure revealed: *Cleanse wound with prescribed solution. 3. Observation on 2/17/22 at 7:55 a.m. with LPN D administering medication via a feeding tube for resident 14 revealed: *LPN D: -Prepared the medications and placed them on a tray. -Applied a pair of gloves. -Removed the old dressing from around the feeding tube site. -Instilled air into the tube and listened for air to check tube placement. -Removed her gloves to fill the graduate container with water for flushes. -Put on a new pair of gloves without performing hand hygiene. -Flushed the feeding tube with 60 milliliters of water before and after medication administration. -Removed her gloves. -Left the graduate container with water remaining in it on the nightstand next to resident's bed. Interview on 2/17/22 with LPN D following the above medication administration revealed she: *Had followed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . * Stated, She normally would have removed the remaining water from the graduate when done but did not do that this time. *Cleaned the inside of the medication tray with an alcohol prep pad, but not the outside of the tray before placing it back in the med cart. *Stated, She did not think about that. *Agreed she had not performed hand hygiene between glove changes. Interview on 2/17/22 at 8:30 a.m. with DON B regarding the above medication administration observation revealed: *She would expect staff to remove any remaining water from the graduate. *She would expect staff to perform proper hand hygiene according to their policy.

Based on observation, interview, record review, and policy review, the provider failed to follow the Centers for Disease Control and prevention (CDC) infection control guidelines regarding the coronavirus (COVID-19) pandemic for quarantine precautions for: *Two of two sampled residents (1 and 2) who had been recently admitted to the facility. *Two of two sampled residents (3 and 4) who had previously had hospitalization s and had been readmitted . Findings include: 1. Observation and interview on 1/12/21 at 2:40 p.m. with certified nursing assistant A revealed: *Rooms eight and nine had residents that were in quarantine. *They were in quarantine as they had been recently admitted . *It meant they couldn't come out of their rooms. *Agreed the doors to both rooms were open. *They kept the doors open to reduce the risk of falls. *No signs were present on what type of precautions were to have been used when entering those rooms. *A cart was located by the door to resident 2's room. *There were no supplies on the top of that cart. *There were some isolation gowns and red garbage bags located in the drawers. 2. Review of resident 1's medical record revealed: *She had been admitted on [DATE] from an acute care hospital. *She had a pelvic fracture and required physical and occupational therapies. *Her 1/6/21 nursing-admission/readmission assessment indicated: -The question of Is the resident on isolation? was marked as no. -Type of Isolation indicated Isolation due to New Admission/Readmission (per protocol) -Standard Precautions and Transmission-based Precautions include: Contact, Droplet, Droplet Enhanced. -Areas checked under the precautions to have been used included: --Services (treatment/procedures) are brought to the resident room. --Hand hygiene before and after patient care. --Glove Technique. --Use of dedicated masks. *Review of resident 1's Nursing - Daily Evaluation (Skilled) revealed: *There were no daily skilled evaluations completed for 1/7/21 and 1/8/21. *Under the heading Isolation Precaution nothing was marked from 1/9/21 through 1/12/21. Review of resident 1's interdisciplinary progress notes revealed no mention of her quarantine status. 3. Review of resident 2's medical record revealed: *She had been admitted on [DATE] from an acute care hospital. *She had stroke which required physical, speech, and occupational therapies. *Her 1/7/21 nursing-admission/readmission assessment indicated: -The question of Is the resident on isolation? was marked as no. -Type of Isolation indicated Isolation due to New Admission/Readmission (per protocol) -Standard Precautions and Transmission-based Precautions include: Contact, Droplet, Droplet Enhanced. -Areas checked under the precautions to have been used included: --Services (treatment/procedures) are brought to the resident room. --Hand hygiene before and after patient care. --Glove Technique. --Use of dedicated masks. --Eye Protection (e.g., goggles, faceshield, etc.). *Review of resident 2's Nursing - Daily Evaluation (Skilled) revealed under the heading Isolation Precaution nothing was marked from 1/7/21 through 1/12/21. Review of resident 2's interdisciplinary progress notes revealed no mention of her quarantine status. 3. Review of resident 3's medical record revealed she: *Had been hosptalized on [DATE] and had been re-admitted on [DATE] after having surgery for [REDACTED]. *Required physical and occupational therapies. *Returned to the same room and roommate when she had been readmitted . *Her 12/10/20 nursing-admission/readmission assessment indicated: -The question of Is the resident on isolation? was marked as yes. -Type of Isolation indicated Isolation due to New Admission/Readmission (per protocol) -There were no areas selected for isolation precautions, standard precautions, and transmission based precautions. *Review of resident 3's Nursing - Daily Evaluation (Skilled) revealed under the heading Isolation Precaution: *No areas had been marked from 12/11/20 through 12/14/20, 12/16/20, 12/17/20, 12/21/20, and 12/22/20. *There was no evaluation completed for 12/18/20. *The evaluations on 12/15/20, 12/19/20, 12/20/20, and 12/23/20 only indicated contact precautions due to her colonized [MEDICATION NAME] resistant [MEDICATION NAME] status. The contact precautions addressed the precautions for her urine. *Her COVID-19 quarantine status had not been included. *There was no documentation of her sharing a room when resident 4 had returned from the hospital on [DATE]. Review of resident 3's interdisciplinary progress notes revealed no mention of her quarantine status. 4. Review of resident 4's medical record revealed she: *Had been hosptalized on [DATE] and returned on 11/5/20 for chest pain. *Required physical therapy. *Returned to the same room and roommate when she had been readmitted . *There was no documentation of her sharing a room when resident 3 had returned from the hospital on [DATE]. Review of the provider's 10/23/20 New Admissions and Re-Admissions During COVID-19 Pandemic policy revealed: *All new Admissions and Re-Admissions to our facility will be placed on a Receiving Unit/Area for 14 days from date of Admission/Readmission. *Resident will be cared for by staff that are utilizing full PPE (personal protective equipment). Interview on 1/12/21 at 3:45 p.m. with administrator B and director of nursing C revealed: *They agreed resident's 1 and 2's room should have had the type of isolation precaution signs posted. *All staff were aware if who were new residents and what precautions were to have been used. *Resident's 3 and 4 had not left their rooms during their respective COVID-19 quarantine periods.

Based on observation, interview, and policy review, the provider failed to have an appropriate medication management process in place for safe and secure medication administration for all residents that received medications for: *Dispensing and tracking medications on a consistent basis. *Securing medication carts. *Storage of expired medications. Findings include: 1. Observation of medication distribution revealed medications were not dispensed from bubble packs consistently. It depended upon many factors including but not limited to; which nurse was giving the medication, how many cards the pharmacy had sent for a resident of a medication, and/or when the medication was ordered. Tracking sheets for schedule one, schedule two, and narcotics were not utilized as intended when sent from the pharmacy. 2. Observation on 9/5/19 at 3:49 p.m. with registered nurse (RN) A revealed: *She left the medication cart in the hallway outside a resident's room. -The medication cart was left unlocked, the computer was on and had private resident information open for anyone to see when passing. -Several individuals passed by the cart including a visitor, a resident that had been identified as having a history of drug seeking behavior, and other residents walking in the hallway. Observation on 9/5/19 at 4:17 p.m. revealed: *Two medication carts sitting outside the nurse's station, which was outside the dining room and in the pathway of the entrance to the building. -Both carts were unlocked. -No nursing staff were present. *Visitors, staff, and other residents walked through the area of the carts. *The medication carts were locked at 4:30 p.m. when the nurse consultant was made aware by the surveyor. 3. Review of the medication carts revealed three packets of [MEDICATION NAME] sulfate that expired (MONTH) 2019. These were in a box with a new prescription label and dosage packets that had not expired. Phone interview on 9/6/19 at 9:34 a.m. with pharmacist H revealed: *The pharmacy sent a card for a medication based on how many times a day the medication was given. -For example, if the resident got the medication one time a day, they got one card. --If they got the medication three times a day the facility got three cards with medications for each dosing time. *They sent a controlled tracking sheet per card for schedule one, schedule two narcotics. -If there were three dosing times for a medication three cards with three sheets were received. Interview on 9/6/19 at 10:23 a.m. with the director of nursing (DON) revealed: *They had started obtaining medications from a new pharmacy (MONTH) 2019. *She usually checked the medication carts and locked room for expired medications and removed them. -She did that weekly. -She would remove medications at the beginning of the month in which they expired. -She stated the expired doses should have been removed when she pulled out the medications at the beginning of August. *The pharmacist would also go through the carts and remove the expired medications. *They were told they could not write on the cards per the pharmacist that helped set up the new medication carts. -This was in response to why when multiple cards with the same medication for the same resident had not reflected which dosage time the card was for. *The surveyor reviewed the medication carts with the DON and showed her the numerous ways the medications were being dispensed and tracked. -She said they had been told to punch out the medications by the dates and she was not sure why some were doing it different. -She had not completed any audits to ensure the issue had been resolved after she had instructed staff to punch medications out by the date. *She had not made any contacts to the pharmacy to inquire if they were able to write on the cards. *She agreed the numerous ways the medications were being tracked and dispensed made it difficult to determine if a medication was given, if medications were being diverted or stolen. Phone interview on 9/6/19 at 10:46 a.m. with pharmacist I revealed: *They could write on the bubble packs. *They could not change the label with the prescription information. *They could also use labels to keep dosage times separate. Review of the provider's (MONTH) (YEAR) Medication Administration General Guidelines revealed: *During the administration of medications, the medication cart is kept closed and locked when out fo sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked. *Resident's health information needs to remain private. The pages of the MAR (medication administration record) notebook containing resident health information must remain closed or covered when not in direct use. Review of the provider's (MONTH) (YEAR) Medication Storage Storage of Medication policy revealed outdated medications were to be immediately removed from stock and destroyed.

Based on observation, interview, record review, and policy review, the provider failed to accurately complete weekly assessment and documentation for one of one sampled resident (19) with pressure ulcers. Findings include: 1. Observation on 9/5/19 at 9:56 a.m. of resident 19 revealed: *She had stage four pressure ulcers to her right and left buttock. *She had stage two pressure ulcers to her right outer ankle, right heel, and left heel. *She had an air mattress on her bed. *Registered nurse (RN) A had changed the bandages and measured the pressure ulcers. -She had not measured the depth of any of the pressure ulcers. Review of resident 19's medical record revealed: *There were Skin Alteration Evaluation User Defined Assessments (UDA) completed on 8/2/19 and on 8/29/19. -No other UDAs were found since (MONTH) 1st. *There were measurements in nurses notes on: -7/4/19, this note had only measurements from the left and right buttocks and had not included assessment of wound appearance or drainage. -7/25/19, this note had only included assessment of wound appearance and drainage for the pressure ulcers on the left heel and right heel. -9/5/19, this note had not included assessment of wound appearance or drainage on any of the pressure ulcers. Review of resident 19's revised 8/9/19 care plan revealed: *A focus of impaired skin integrity related to immobility ., stage four pressure ulcer to bilateral buttocks, as well as stage two pressure ulcers to right ankle, right heel, and left heel. *A goal of skin issues will decrease in size in the next ninety days. *Interventions included: -She was able to be up in her wheelchair twice a day for three hours each time. -Nursing was to educate resident to change position at least every two hours and she was not compliant with this at times. -Pressure reducing air mattress on bed. -Pressure reducing cushion on wheelchair. Interview on 9/6/19 at 9:00 a.m. with RN A regarding resident 19 revealed: *Her pressure ulcers were measured every Thursday. *She had put the measurements of the pressure ulcers in her nurse note on 9/5/19. *She should have put them in the UD[NAME] *She should have measured the depth and sometimes she did. Interview on 9/6/19 at 9:15 a.m. and at 10:41 a.m. with the director of nursing revealed: *She expected the nurses to measure and document on pressure ulcers weekly. *They had changed to new ownership on 7/6/19 and the name of the UDA used to document on pressure ulcers had changed to Skin Alteration Evaluation. *She had not been able to get the nurses to complete the UDA weekly. *There was a process improvement plan (PIP) in place for the UDA and wound measurements. -She did not have evidence of the PIP. *She expected the nurse to measure the depth of wounds. *She was going to assign one specific nurse to do measurements each week. *Documentation on the pressure ulcers had not been done weekly. Review of provider's undated Skin Integrity Guideline revealed: *Director of nursing services or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. *Licensed nurse will be responsible for performing a skin evaluation/observation weekly, utilizing the Weekly skin Review UD[NAME] *Licensed nurse to document weekly on identified wounds using the Wound Evaluation Flow Sheet (WEFS) UDA (one UDA per wound identified). -The name of this had been changed to Skin Alteration Evaluation UD[NAME] *Each LivingCenter must create a manual tracking system to monitor completion of weekly WEFS since this UDA cannot be scheduled.

Based on observations, interviews, record review, and policy review, the provider failed to ensure incontinence care was provided in a timely manner for one of one sampled resident (18) with incontinence concerns. Findings include: 1. Review of resident 18's medical record revealed: *She had the following Diagnoses: [REDACTED]. *Her 7/12/19 quarterly Minimum Data Set assessment revealed she was: -Frequently incontinent of bowel and bladder. -Dependent on others to assist her into and out of her wheelchair. -Her Brief Interview of Mental Status assessment was blank. When this surveyor attempted to communicate she would smile or not respond to questions. Observation on 9/4/19 from 1:30 p.m. through 4:00 p.m. of resident 18 while in the activity area revealed: *She was sitting in a recliner. *She had a doll and threw it on the floor. *She moved her upper body forward and leaned to right of the chair with her head drooping. *The certified dietary manager (CDM) passed through the area and picked up the doll and placed it on a piano in the area. *Another unidentified staff came into the room and positioned her upright and gave her the doll. *During this entire observation resident 18 was not checked for incontinence or taken to the bathroom. Observation on 9/5/19 from 11:41 a.m. through 12:01 p.m. of resident 18 revealed: *She was participating in a group activity in the activity area adjacent to the dining room. *When the activity ended, she was moved to the dining room and positioned at a table for her lunch meal. *No incontinence care was provided or offered prior to placing her at the table for her noon meal. Observation and interview on 9/5/19 at 1:09 p.m. of resident 18 with the activities director (AD) and certified nursing assistant (CNA) revealed: *She was sitting in the dining room at the table in the same position she was in at 11:41 a.m. *She was alone at the table holding a creamer packet. *Her pants were wet in front between her legs and around her hips. *At 1:15 p.m. the CDM stopped at the table to speak with the resident. -She noticed the resident was wet and said she would go get her help. *At 1:25 p.m. the AD took resident 18 to her room. -The call light was turned on by the AD so she could get help and assist the resident to the toilet. *At 1:43 p.m. CNA C came in and assisted getting the resident to the toilet. *The AD and CNA C used the standing lift to transition her onto the toilet. *Her brief was soaked with urine and she had a bowel movement in the brief. *Resident 18 was positioned on the toilet where she urinated and had a bowel movement. *She was provided personal care and placed in her wheelchair and taken back out to the activity area. *CNA C stated there was 2 CNAs for the facility and 1 bath aide so it was difficult to answer all the call lights and get all the daily tasks done. Interview on 9/5/19 at 2:57 p.m. with the director of nursing regarding resident 18's toileting schedule revealed: *Her expectation was that staff take resident 18 to the bathroom at the following times minimally: -When they got her up in the morning before breakfast. -After breakfast. -Before and after lunch. -Or if she appeared restless while sitting. Observation on 9/6/19 at 8:02 a.m. of resident 18 revealed: *She was sitting in the activity area facing the television with a doll, leaning forward holding her head. *At 8:15 a.m. she was moved over to the dining table to eat by CNA B. *CNA B said she did not usually help resident 18, so she was unsure what her toileting schedule was. *At 8:46 a.m. CNA [NAME] came in and moved her from the table to the recliner in the activity area. -CNA [NAME] positioned her into the recliner without offering continence care or asking her if she needed to use the bathroom. Random observation on 9/6/19 at 11:19 a.m. of resident 18 revealed she was sitting in the recliner and had not appeared to be moved after she was placed in the recliner at 8:46 a.m. Interview on 9/6/19 at 11:19 a.m. with the clinical care coordinator F revealed: *She was in charge of the quality measures that flagged incontinent concerns. *There was a performance improvement project (PIP) started on 4/3/19. -The PIP addressed new admits without incontinence concerns and shortly after admission being incontinent and using briefs. -It was determined this was due to the CNAs putting the individuals in a brief after one incontinent episode. *Part of the plan of improvement was to educate all CNAs when residents were to be taken to the bathroom. *They had not looked at any residents that had been previously admitted , just new admits after 4/3/19. *The PIP was closed on 7/15/19 because it was determined to have been resolved. -They had not audited any new admits after the resolution of the PIP. -Residents that were already admitted were not reviewed as part of this PIP. Review of resident 18's 7/5/19 care plan revealed interventions to: *Check for incontinence at least every two hours. *Monitor and evaluate incontinence episodes. *Evaluate frequency and timing of incontinence episodes. Review of the CNA's care plan sheet revealed resident 18 should have been taken to the bathroom after meals. According to the nurse advisor the provider did not have a policy on bowel and bladder.

Based on observation, record review, interview, and policy review, the provider failed to ensure one-on-one activities (individualized programming) were provided for one of two sampled residents (21) who had one-on-one activities. Findings include: 1. Observations on 9/4/19 from 9:03 a.m. to 4:03 p.m. of resident 21 revealed: *She had been lying in bed and sleeping at 9:03 a.m., 9:58 a.m., 2:07 p.m., 3:36 p.m., and 4:03 p.m. *She was not observed participating in any activities. Review of resident 21's 7/16/19 annual Minimum Data Set assessment revealed: *She had a Brief Interview for Mental Status score of six indicating severe cognitive impairment. *She needed one person assist for transfers to bed/chair/wheelchair. *Listening to music, being around animals such as pets, going outside to get fresh air when the weather was good, participating in religious services or practices, and doing her favorite activities had been very important to her. *Doing things with groups of people had been somewhat important to her. Review of resident 21's 5/1/19 care plan revealed: *Focus: Impaired communication due to: [MEDICAL CONDITIONS](stroke), episodes of disorganized speech, dementia. My speech is unclear. I usually understand others, and am usually understood. I have a dx (diagnosis) of dementia. -Goal: I will be able to communicate my basic needs. -Interventions: --Allow calm unhurried environment to encourage communication. --Answer questions as needed and repeat as necessary. --Encourage patient to verbalize needs. -- I can usually understand staff and I know what I want to say but have a difficult time speaking. -- I usually ask for the same few requests: close curtains, chuck (underpad) for bed (but says pad), a night gown, or make my bed. --Listen carefully, validate verbal and non-verbal expressions. --Maintain eye contact if possible. --Provide for quiet setting. --Use simple and direct communication to promote understanding. *Focus: I prefer independent activities or spending time with my family when they are present, rather than doing things in groups. Family rarely visits. I am shy and also a private person. I used to enjoy painting. I spend much of my time in my bed. -Goal: I will continue participating in independent activities or things with my friends and family. -Interventions: --Invite me to sit in during activity programs you think I might enjoy, allowing me to join in at my own comfort level. --Offer me activities and supplies for things I can do in my room. I have shown some interest in reading/looking at pictures again. I look at the pictures in my magazines. I have also been watching TV in the evening before supper. --Offer me and my family activities we can do together such as afternoon coffee and fell owship. Spiritual gatherings. --Please assist me in participating in my favorite activities at my highest level. I enjoy 1:1 (one-on-one) and will converse. Questions need to be simple with simple answers. Do not rush me. Offer 1:1 prn (as needed) as I prefer to sleep. --Please monitor for any problems with my room and/or roommate. Interview on 9/4/19 at 3:36 p.m. with certified nursing assistant (CNA) C regarding resident 21 revealed she: *Got assistance to get up and get dressed. *Liked to sleep a lot. *Had been offered group activities but chose not to go most of the time. *Had been interested in art but had not done any art projects recently and was unsure why. *Had not been involved with one-on-one activities as far as she knew. Interview on 9/4/19 at 4:16 p.m. with CNA D regarding resident 21 revealed she: *Tended to sleep quite often. *Had family come and see her last weekend and she was very active during the visit but the family was not able to visit often. *Had no difficulty with communicating her needs to staff members. Observations of resident 21 on the following days revealed: *On 9/5/19 she had been asleep in her bed at 9:26 a.m., 10:08 a.m., 11:15 a.m., 1:25 p.m., 2:52 p.m., and 4:17 p.m. *On 9/6/19 at 8:01 a.m. she ate breakfast in the dining room and returned to her room to sleep shortly after she had finished eating. *She had not participated in any activities on either day. Interview on 9/6/19 at 8:47 a.m. with the activities director (AD) regarding resident 21 revealed: *She was responsible for completing group and one-on-one activities for all of the residents. *The resident had gotten a magazine sent to her from her daughter that she delivered to her when it arrived. *She had offered word searches and adult coloring books to her but she had not shown interest in them. *Painting had been important to her in the past but she thought she had lost interest in painting due to poor vision from [MEDICAL CONDITION]. After she had cataract surgery she thought she might have already lost interest in painting. *She had completed one-on-one activities with her but had not done them as much as she should due to all of the other responsibilities she had. *She had probably completed one-on-one sessions with the resident every couple of weeks. *The social services designee (SSD) might also complete one-on-ones with the resident but she was unsure. Review of resident 21's one-on-one activity documentation for July, August, and (MONTH) 2019 revealed: *One completed art activity with her on 7/24/19. *The AD confirmed there were no others completed or documented. Interview on 9/6/19 at 10:09 a.m. with the SSD regarding resident 21 revealed: *She had tried to do a brief one-on-one with the resident twice a week. *She had not always documented the sessions. *The resident slept most of the time. -Had not participated in activities much. *Once the resident had been up, she interacted with other residents in a friendly manner and appeared to have a good time. *The resident had gone to counseling for concerns of depression for a year or more but it had been discontinued due to a lack of participation from the resident. *From (MONTH) through (MONTH) 2019 she had documented one one-on-one interaction with the resident on 8/1/19. Interview on 9/6/19 at 10:59 a.m. with the director of nursing regarding resident 21 revealed: *The resident had refused group activities offered to her at times. *She was not aware there was little to no documentation to show the resident had been receiving one-on-one sessions from the AD, SSD, or other staff. -She would expect staff to document group or one-on-one interactions in the chart and follow their policy for all activities. Review of the provider's 7/6/16 Individual Programming policy for resident recreation and recreation programming revealed: *Programming will be offered to all residents who are unable or choose not to attend group activities. -Individual programming ensures that all residents who are unable to or choose not to participate in group programs have consistent, goal-oriented and individualized recreation opportunities. --Residents who are unable or prefer not to participate in group activities will be identified through the assessment process. --Structured individual interventions will be developed based on each resident's history and assessed needs and preferences.

Based on observation, interview, record review, and policy review, the provider failed to ensure female resident's facial hair had been removed for three of four sampled residents (19, 25, and 27). Findings include: 1. Observations of resident 19 revealed she had facial hair on her upper lip and chin on: *6/26/18 at 4:30 p.m. *6/26/18 at 5:15 p.m. *6/27/18 at 8:15 a.m. *6/27/18 at 10:15 a.m. *6/27/18 at 3:05 p.m. Observation of resident 25 revealed she had facial hair on her chin on: *6/26/18 at 4:35 p.m. *6/26/18 at 5:18 p.m. *6/27/18 at 8:20 a.m. *6/27/18 at 10:25 a.m. *6/27/18 at 3:08 p.m. Observation of resident 27 revealed she had facial hair on her chin on: *6/26/18 at 4:40 p.m. *6/26/18 at 5:25 p.m. *6/27/18 at 8:22 a.m. *6/27/18 at 10:35 a.m. *6/27/18 at 3:15 p.m. Interview on 6/27/18 at 2:25 p.m. with licensed practical nurse (LPN) C revealed: *CNAs (certified nurses assistant) were responsible for facial hair removal. *Everyone was responsible to help out. Interview on 6/27/18 at 2:33 p.m. with CNA A regarding womens' facial hair removal revealed: *It was had usually shaved on the morning shift with morning care. *She had not been aware that resident 19, 25, and 27 had facial hair. *She would have shaved it if she would have noticed it. Interview on 6/27/18 at 2:40 p.m. with CNA B regarding womens' facial hair removal revealed she: *Was hired on 4/13/18. *Was trained as a CNA. *Had not been trained on female facial hair removal. *Had thought the morning shift was responsible for removing womens' facial hair. Interview on 6/27/18 at 2:50 p.m. with resident 27 revealed she: *Would have liked it removed. *Stated she Always did it at home. *Had used a Norelco razor. Interview on 6/27/18 at 2:58 p.m. with resident 19 revealed she would have liked her facial hair removed. Interview on 6/27/18 at 3:05 p.m. with resident 25 revealed she agreed her facial hair should be removed. Review of resident 19, 25, and 27's care plans revealed no mention of womens' facial hair removal. Review of the CNA assignment sheets and bath aide report sheets revealed no mention of womens' facial hair removal. Interview on 06/27/18 at 3:15 p.m. with the director of nursing (DON) revealed: *Women's facial hair should have been shaved as needed. *It was routinely done in the morning by the CNAs during resident grooming. Interview on 6/27/18 at 3:38 p.m. with the DON revealed womens' facial hair removal should have been on the following: *Certified nursing assistants assignment sheets. *Care plans. *Bath aide report sheets where they would have made check marks on what care were provided with residents' baths. Review of the provider's (MONTH) (YEAR) Promoting/Maintaining Resident Dignity policy revealed: *All staff members are involved in providing care to residents to promote and maintain residents dignity. *The resident's former lifestyle and personal choices willl be considered when providing care. *Groom and dress residents according to resident preference.

Based on observation, record review, interview, and policy review, the provider failed to ensure one-to-one activities were provided and documented for one of one sampled resident (13) who was on hospice. Findings include: 1. Review of resident 13's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Heart failure, unspecified. -[MEDICAL CONDITION], stage 3. -Pain in unspecified joint. -Dysphagia, unspecified. -[MEDICAL CONDITION] with late onset. -Major [MEDICAL CONDITION], single episode, unspecified. -Unspecified dementia with behavioral disturbance. -Dizziness and giddiness. -Retention of urine, unspecified. -[MEDICAL CONDITION]. -Anxiety disorder, unspecified. -Other chronic pain. -Extrapyramidal and movement disorder, unspecified. -[MEDICAL CONDITION], unspecified site. -Constipation, unspecified. -Presence of cardiac pacemaker. -[MEDICAL CONDITION], unspecified. -Other specified [MEDICAL CONDITION]. -[MEDICAL CONDITION], unspecified. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -Unspecified sensorineural hearing loss. -Essential (primary) hypertension. -Unspecified [MEDICAL CONDITION]. *She had been admitted to hospice services on 11/1/17. Review of resident 13's 4/30/18 Minimum Data Set assessment revealed: *Her Brief Interview for Mental Status score had not been completed. -The staff interview indicated she had long and short term memory problems. -Her cognitive skills for daily decision making were severely impaired. Observation on 6/26/18 from 3:00 p.m. through 3:30 p.m. of resident 13 revealed: *She had been lying in her bed. *She had not been able to move her arms or legs due to contractures. *Her son had been visiting but had not been talking. *The TV was located in the corner of the room behind his head with the volume on low. -The closed caption was on. *She was wide awake. *During the visit with the son she began talking. *It was difficult to understand what she had been saying. *The son had stated she was hard of hearing and had a cochlear implant long ago. *He used to take her outside, but she was usually in her bed when he visited now. *At 3:15 p.m. the son left and stated This is the most she has talked in a long time. *At 3:25 p.m. the newspaper was delivered to her and left on her lap. -She was unable to move to pick it up or move it. *She was staring out the window while talking. *She continued to talk until 3:30 p.m., and then closed her eyes. -It had been hard to make out all the words she was saying throughout the visit. Observation on 6/26/18 at 4:25 p.m. of resident 13 revealed she was still in bed. Her eyes were opened, and she was awake. There had been no one in the room. The TV had been on across the room, but the volume had been turned down and the closed caption was on. She had not been staring at the TV. Observations on 6/27/18 at 9:34 a.m., 10:44 a.m., and 1:22 p.m. of resident 13 revealed she was in bed with her eyes closed. The TV had been on with the volume turned down low. The closed captioning had been on. There had been no one in the room with her. Review of resident 13's current undated care plan revealed she was to receive one-to-one activities initiated on 1/9/17. Review of resident 13's activity documentation from 4/1/18 through 6/26/18 revealed: *In (MONTH) (YEAR): -She had attended one group activity. -The only other activity listed was self-directed activity. -There had been no documentation of one-to-one activities. *In (MONTH) (YEAR): -She had five documented one-to-one activities. --Two had been watching TV. --Three had been hand massages. -The only other activity listed was self-directed activity. *They had not provided any (MONTH) (YEAR) activity documentation. Review of resident 13's social service progress notes from 1/1/18 through 6/26/18 revealed: *1/17/18: Stopped by to visit with resident this afternoon, and she was sound asleep on her bed. *2/20/18: Stopped to visit resident this afternoon. She is resting on her bed, awake. Glasses on, and her T.V. was on, but screen was black. Changed channel, and turned volume up for her. Asked her if she would like her drapes opened a little, and she agreed. Draped opened for a little sunshine. *4/6/18: Stopped to visit/see resident this afternoon. She was lying on her bed, awake, T.V. was on. She was happy I stopped to see her. Hearing is very poor, hard to communicate with, but did seem to appreciate this writer visiting, and holding her hand. *4/24/18: Stopped by resident's room this morning to visit. Resident was sound asleep on her bed, resting comfortably. This writer did not wake her. *5/8/18: Stopped in to see resident this morning. Res (resident) awake, lying on her bed. Tried to converse, but she is unable. She did mumble some words, but not making sense. She would smile at this writer. I applied hand lotion to her legs, and turned on her T.V. She appreciated that, as she was looking at and commenting at what was on the T.V. *6/22/18: Checked on resident this afternoon. Res. was lying on her bed, but not asleep. Eyes opened up wider when this writer approached her, and when I held her hand, she said oh, your hand is cold. This writer covered her hand with her blanket, visited, and showed her the pictures on the front of her daily newspaper. Daughter arrived a short time later. *6/26/18: Visited with resident this afternoon. She was resting in her bed, wide awake. She got a big smile on her face when I said hello to her. We looked at the daily newspaper, and she recognized that their were little children in the pictures on the front page. She said a few words about 'the grandchildren.' We talked a little about Heaven. She didn't say any words, but this writer believes she was listening. *There had been no other documentation regarding interactions or activities completed with the resident. The activity director was unable to be interviewed, as she was on vacation during the survey. Interview on 6/27/18 at 1:24 p.m. with the social services designee regarding resident 13 revealed: *She had gotten better, and they had even thought about taking her off of hospice. *Hospice had re-evaluated her, and she had remained eligible for their services. *She used to use the white board in her room to communicate but hardly used it anymore. *She liked to look out the window. *She liked the local newspaper being read to her. *She used to like music. *She was not sure if she would have liked to have music on in her room or if she would have liked to be taken outside. *She agreed she would not have been able to see the closed caption on the TV when she was lying in bed. Interview on 6/27/18 at 1:55 p.m. with the administrator regarding resident 13 revealed: *She had contacted the activity director. *The activity director tried to do one-to-one visits on Tuesdays and Thursdays. *Those one-to-one activities might have included: -Hand massages. -Watching TV. -Visiting. -Looking at the bird feeders out the window. *The activity director told her she had not charted or documented the one-to-one activities for any of the residents. *She agreed self-directed activity had not been appropriate for the resident. Interview on 6/27/18 at 2:43 p.m. with the director of nursing revealed she agreed the activity director should have been documenting the one-to-one activities. She also agreed self-directed activity had not been appropriate for resident 13. Review of the provider's 7/6/16 Individual Programming policy revealed: *Programming will be offered to all residents who are unable or choose not to attend group activities. *Structured individual interventions will be developed based on each resident's history and assessed needs and preferences. *The individual program will be scheduled based on resident preference as to day, time of day and duration.

Based on observation, interview, record review, and policy review, the provider failed to ensure sanitary conditions were maintained: *While personal care was performed for two of two sampled residents (6 and 5). *For the proper placement of Foley catheter tubing for one of one sampled resident (6) who required the use of a catheter. *For the storage of residents' personal care items in shared bathrooms for five of five sampled residents (1, 3, 4, 11, and 12). *To prevent the potential for cross-contamination of clean resident use items stored in one of three soiled utility rooms (west wing). *To ensure the policy and procedure for cleaning oxygen concentrator filters had been followed for three of three randomly observed oxygen concentrator filters. *For the storage of residents' treatment supplies located in one of one treatment cart. *For the appropriate use and storage of incontinent soaker pads and blankets on three of three recliners located in one of one sitting area. Findings include: 1. Observation on 3/28/17 from 9:55 a.m. through 10:15 a.m. revealed certified nursing assistant (CNA) C assisting resident 6 with a whirlpool bath. The CNA missed three opportunities for hand washing during that time where she did not wash her hands between glove use. Interview on 3/28/17 at the time of the above observation with CNA C revealed: *She had confirmed the above was her usual process for assisting the residents with their baths. *She was not aware she had not washed or sanitized her hands when changing gloves. *She stated We are supposed to sanitize our hands when we change gloves. 2. Observation on 3/27/17 at 2:20 p.m. of resident 5's doorway revealed: *A sign on the wall by the entrance into her room. *That sign directed staff and visitors to check with the nurse prior to entering her room. *No personal protective equipment (PPE) located in the immediate area of her room. Review of resident 5's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had required staff support to assist her with activities of daily living (ADL). *The resident shared her room with another resident. -That roommate had used a bedside commode for toileting. Observation on 3/28/17 at 1:45 p.m. with CNA B assisting resident 5 with personal care revealed: *The resident had been attempting to get out of her bed and into her wheelchair (w/c). *The resident stated I have to go to the bathroom really bad. *There had been a bedside stand beside the resident's bed. *CNA B: -Opened the middle drawer of that stand, retrieved a protective disposable gown, and put it on. -Washed her hands and put on clean gloves. -Assisted the resident into her w/c and then into the bathroom. *The resident had been incontinent of bowel movement. *CNA B assisted the resident with personal care and cleaning off that bowel movement. -During that process the CNA missed four opportunities to wash her hands between glove use. Continued observation on 3/28/17 of resident 5 during the above process revealed: *After she had been assisted by CNA B into her w/c she propelled herself over to her bedside. *While she was at her bedside the resident: -Reached inside of the middle drawer of the bedside table and re-arranged the protective gowns. -Closed the middle drawer and left the room. Interview on 3/28/17 at the time of the above observation with CNA B revealed: *She: -Had been a traveling CNA and worked at the facility. -Had confirmed the above was her usual process for assisting resident 5 with personal care. -Was not aware she had not washed or sanitized her hands when changing gloves. -Had not been educated on the type of infectious disease the resident had. *She stated: -All I know is we are supposed to wear a gown and gloves when helping her with care, and she can come out of her room. -Her roommate and the resident next door don't use the bathroom. *She agreed: -The staff should have been educated on the type of infection the resident currently had. -The process above had created the potential for cross-contamination of bacteria to the other residents. -The PPE: --Should not have been stored in a place where the resident had access to the product. --Should have been readily available for the staff and visitors to use. Interview on 3/28/17 at 2:30 p.m. with the director of nursing (DON) regarding the above observations and resident 5 revealed: *She had: -Been the DON and infection control nurse since October 2016. -Not completed random audits on the bathing process or the personal care process for the resident. -Confirmed the resident had CRE, but it was not currently active, was allowed to come out of her room, and resided in a shared room. -Stated The other residents do not use her bathroom. -Not reviewed the process and availability of PPE for the staff and visitors for the resident -Not been aware the resident had been able to access the disposable gowns. *The administrator had provided the traveling staff with a packet of information for them to review prior to working. -She had not been aware of what information was provided in those packets. *She agreed: -The above processes had not been completed in a sanitary manner. -Those processes had created the potential for cross-contamination and spread of bacterial germs from one resident to another. -All staff should have been educated on the infectious disease resident 5 had. 3. Observation on 3/27/17 at 2:07 p.m. of resident 6 revealed: *She had been laying in her bed sleeping. *There had been a Foley catheter attached to the side of her bed. Review of resident 6's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had: -Been dependent upon the staff to assist her with all ADLs. -Required the use of a Foley catheter to assist her bladder with emptying. Random observations on 3/27/17 at 5:15 p.m. through 3/28/17 from at 3:30 p.m. of resident 6 revealed: *She had been sitting in her w/c at a dining room table or in her recliner. *During those random observations her Foley catheter tubing had been laying on the floor. Interview on 3/28/17 at 2:40 p.m. with the DON regarding resident 6 revealed: *She agreed: -The catheter tubing should not have been laying on the floor. -That tubing should have been tucked into the cloth bag holding the catheter bag. -That process had created the potential for the increased risk of urinary tract infections for the resident. 4. Observation on 3/27/17 from 2:07 p.m. through 2:30 p.m. of residents 1, 3, 11, and 12's bathrooms revealed: *They had all shared a bathroom with three other residents. *The bathrooms had four shelves attached to the wall by the sink. *Those shelves had contained multiple residents' personal care items. *Those items had been lotions, toothbrushes, toothpaste, deodorant, denture cups, combs, and brushes. *There was no identification indicating which items on those shelves belonged to each resident in the shared rooms. Surveyor: Observation on 3/28/17 at 10:15 a.m. of resident 4's bathroom revealed: *She had: -Shared a bathroom with three other residents. -Her personal care items neatly arranged on a shelf. *Shelves were not identified as to whose items were whose. Surveyor: Interview on 3/28/17 at 9:35 a.m. with the DON regarding the above observations confirmed the residents' personal care items or the shelves should have been marked to ensure proper identification of those products. 5. Observation on 3/27/17 at 2:45 p.m. in the soiled utility west wing room revealed: *A hopper with an attached spray hose for cleaning heavily soiled items. *A double-sink with several cupboards above and below it. -That sink was located approximately two feet from the hopper. *A pair of jeans had been laying directly on the floor between the hopper and the cupboard. -Those jeans were soiled with bowel movement. *Inside one of the sinks was a pair of sweat pants. -Those sweat pants were soiled with bowel movement and were soaking in a bucket of water. *The cupboards and the shelves next to the sink contained multiple clean resident use items including: -Emesis basins. -Plastic tubs for bed baths and resident use. -Clear plastic graduates. -Bed pans. Observation on 3/28/17 at 8:00 a.m. in that same soiled utility room revealed the above things remained unchanged. Observation and interview on 3/28/17 at 8:45 a.m. with the DON revealed she: *Confirmed the above findings. *Agreed the room was unsanitary and created the potential for the spread of germs from one resident to another. *Had been unaware of how long the soiled items had been in the room. *She could not guarantee: -Any of the resident use items above would have been clean due to being stored in the soiled utility room. -Those resident use items would have been cleaned prior to being used. *Stated We have a storage issue in the facility. *Relied upon the maintenance director to ensure the cleanliness and upkeep of that room. 6a. Random observations on 3/28/17 from 8:30 a.m. through 12:00 noon in the dining room revealed an oxygen concentrator that had two filters attached to it. Both of the filters were covered with a moderate amount of dust and gray colored lint. An unidentified resident had used that oxygen concentrator during meal time. Surveyor: b. Observations on 3/28/17 at 8:00 a.m. and at 2:30 p.m. and on 3/29/17 at 8:15 a.m. of resident 3's oxygen concentrator revealed two filters with a moderate amount of dust and lint on them. c. Observation on 3/29/17 at 3:15 p.m. of resident 8's oxygen concentrator revealed two filters with a moderate amount of dust and lint on them. Interview at that time with resident 8 revealed the nurse had replaced the oxygen tubing on Saturday or Sunday, but she had not cleaned the filters. d. Interview on 3/29/17 at 10:35 a.m. with registered nurse (RN) D and the Minimum Data Set (MDS) assessment coordinator revealed: *The oxygen concentrator filters were to have been cleaned weekly on Saturday or Sunday by the treatment nurse. *There was no documentation to support those filters had been cleaned weekly. *RN D: -Had not been aware of any policy or procedure to support the cleaning process of those filters. -Stated It's an in-house policy. *The MDS assessment coordinator stated We should probably just put them on the treatment assessment record to ensure completion. Interview on 3/29/17 at 2:45 p.m. with the DON confirmed the above interview with RN D and the MDS assessment coordinator. 7. Observation and interview on 3/29/17 at 2:17 p.m. of the nurses' treatment cart with the DON revealed: *Multiple opened commingled tubes and bottles of topical medications were stored in one of the drawers. -Those medications had included antifungals, medicated powder, and antibiotic cream. *The bottles and tubes were for several different residents. *There was no barrier separating the tubes from one item to another. *She agreed there was the potential for cross-contamination from one to another. *She stated All of the treatment supplies are supposed to be inside of plastic bags. 8. Random observations on 3/27/17 from 4:30 p.m. through 5:30 p.m. of the sitting area off of the dining room revealed: *There had been several chairs and recliners located in that area. *Three of the recliners had incontinent soaker pads and folded blankets on them. *Several unidentified residents sat on those chairs. Random observations on 3/28/17 from 8:15 a.m. through 12:00 noon of that sitting area revealed it remained unchanged from the above observation. Interview on 3/29/17 at 2:50 p.m. with the DON revealed: *She confirmed the staff had placed soaker pads and blankets for the residents to use in the above chairs. -Those soaker pads and blankets were used during the night for the residents who wandered or preferred to be in the sitting area. *The day shift staff were to have removed those items from the chairs/recliners every morning at the beginning of their shift. *She agreed those soaker pads and blankets created the potential for the spread of germs. 9. Review of the provider's October 2009 Handwashing and Hand Hygiene policy revealed: *This facility considers hand hygiene the primary means to prevent the spread of infections. *Employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: After removing gloves. Review of the provider's undated orientation packet provided to the traveling staff revealed no education to review on infection control policies and procedures. Review of the provider's 2/2/16 Care of Catheters and Leg Bags policy revealed no procedure directing or instructing the proper placement of the catheter tubing. Review of the provider's 12/15/14 Cleaning and Disinfection of Resident-Care Items and Equipment revealed Critical and semi-critical items will be sterilized/disinfected in a central storage of location and stored appropriately until use. Review of the provider's 5/1/10 Cleaning Respiratory Equipment policy revealed Oxygen tanks, connectors, and concentrators: Clean oxygen concentrator filters weekly. Review of the provider's October 2009 Infection Control policy revealed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, record review, and policy review, the provider failed to review and revise care plans for seven of nine sampled residents (1, 2, 4, 5, 6, 7, and 9) to reflect their current needs. Findings include: 1. Observation on 3/27/17 at 2:20 p.m. of resident 5 revealed: *She had been laying in her bed sleeping. -That bed was not placed in a low position. *There had been an assistive device of a quarter rail attached to the upper left and right sides of her bed. -Those assistive devices were attached to the bed to aide her with bed mobility and transfers. Review of resident 5's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had: -Required supervision of one staff person to transfer in and out of her bed. -A history of falls from attempting to get in and out of the bed without staff assistance. *An initial side rail assessment completed on 10/24/15. *On 1/9/17 the side rail assessment had been reviewed for safety and continued appropriate use by the resident. Interview on 3/28/17 at 2:20 p.m. with resident 5 confirmed she had used the assistive devices to help herself with bed mobility and transfers. Review of resident 5's updated 2/14/17 care plan revealed: *No documentation to support she required the use of a quarter side rail for transfers or bed mobility. *She had been at risk for falls, and her bed was to have been placed in a low position. 2. Observation on 3/27/17 at 2:07 p.m. of resident 6 revealed: *She had been laying in her bed sleeping. -That bed was not placed in a low position. *There had been: -A quarter side raile attached to the upper left and right sides of her bed. -A Foley catheter attached to the side of her bed. Review of resident 6's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had: -A history of falls with injury to her left pelvis prior to her admission on 1/19/17. -Been dependent upon the staff to assist her with all activities of daily living (ADL). -Required the use of a Foley catheter to assist her bladder with emptying. -Not been able to bear weight on her left leg and required the use of a total body lift for all transfers. *On 1/19/17 an initial side rail assessment had been completed for safety and appropriate use by the resident. Observation on 3/27/17 at 5:15 p.m. of resident 6 revealed: *She had been: -Sitting in her wheelchair (w/c) at a dining room table. -Eating her supper independently and without any staff assistance. *There had been a full body transfer sling located underneath her body. Observation on 3/28/17 at 9:43 a.m. with certified nursing assistants (CNA) B and C with resident 6 revealed: *The CNAs had prepared to assist the resident with transferring her out of the bed. *The resident used the quarter side rails to help the CNAs move her from side-to-side in the bed. *The CNAs transferred the resident out of her bed and into a whirlpool chair with the use of a total body lift. Review of resident 6's 1/23/17 care plan revealed: *No documentation to support she required the use of a quarter side rail for transfers or bed mobility. *She had: -Been at risk for falls, and the bed was to have been placed in a low position. -Impaired vision and required the staff to assist her with transfers and ambulation. -Been dependent upon the staff to assist her with eating. 3. Observation on 3/27/17 at 2:30 p.m. of resident 9 revealed: *He had been laying in his bed sleeping. -That bed had not been placed in a low position. *There had been a quarter side rail attached to the upper left and right sides of his bed. Review of resident 9's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had: -A history of falls prior to his admission. -Been independent with all ADLs. *On 2/2/17 a side rail assessment had been reviewed for safety and continued appropriate use by the resident. Review of resident 9's 1/26/17 care plan revealed: *No documentation to support he required the use of quarter side rails for transfers or bed mobility. *He had been at risk for falls, and the bed was to have been placed in a low position. Interview on 3/29/17 at 10:10 a.m. with resident 9 confirmed he had used the assistive devices to help himself with bed mobility and transfers. 4. Random observations from 3/27/17 through 3/29/17 of resident 1's bed revealed he had two quarter side rails (SR) attached. Review of resident 1's medical record revealed a 2/26/17 side rail assessment for 1/4 SR as enabler to position in bed; uses for support and positioning. Review of resident 1's 3/1/17 revised care plan revealed no interventions in place for side rail use. 5. Observation on 3/27/17 at 4:35 p.m. of resident 2 revealed he had been: *Sitting in a recliner in the dining room. *Watching bowling on television. Observation on 3/27/17 at 4:35 p.m. of resident 2's room revealed: *An assistive device attached to the upper left and right sides of his bed. *Those assistive devices were attached to the bed to aide him with bed mobility and transfers. *That bed was placed in a low position. Review of resident 2's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had: -A history of falls without injuries on the following dates: 9/10/16, 9/19/16, 9/24/16, 9/25/16, 10/13/16, and 11/18/16. -Been dependent upon the staff to assist him with activities of daily living (ADL). -Needed specialized rehabilitation for balance and stairs. *On 9/10/16 an initial side rail assessment had been completed for safety and appropriate use by the resident. Review of resident 2's care plan revealed there was no documentation to support he required the use of an assistive device for transfers or bed mobility. 6. Observation on 3/27/17 at 2:04 p.m. of resident 4 revealed she had been: *Sitting in her wheelchair in the dining room. *Listening to current events. Observation on 3/27/17 at 2:04 p.m. of resident 4's room revealed: *An assistive device attached to the upper left and right sides of her bed. *Those assistive devices were attached to the bed to aide her with bed mobility and transfers. *That bed was placed in a low position. Review of resident 4's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had: -A history of falls with injuries on 2/23/16, 8/22/16, and 2/11/17. -A history of falls without injuries on 1/15/16 and 2/11/17. -Been dependent upon the staff to assist her with all ADLs. *On 1/14/16 an initial side rail assessment had been completed for safety and appropriate use by the resident. 7. Observation on 3/27/17 at 2:14 p.m. of resident 7's room revealed: *An assistive device attached to the upper left and right sides of her bed. *Those assistive devices were attached to the bed to aide her with bed mobility and transfers. Review of resident 7's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *She had: -A history of a fall with major injury in October 2016 prior to admission. -Been dependent upon the staff to assist her with all ADLs. *On 10/26/16 an initial side rail assessment had been completed for safety and appropriate use by the resident. Review of resident 2, 4, and 7's current care plans revealed there was no documentation to support the residents the use of any assistive devices for transfers or bed mobility. 8. Interview on 3/29/17 at 4:15 p.m. with the director of nursing regarding side rail use for residents 1, 2, 4, 5, 6, 7, and 9 revealed she: *Agreed the use of side rails were not on the care plans. *Side rail use should have been on all of the above mentioned residents care plans. Surveyor: Interview on 3/29/17 at 4:10 p.m. with the director of nursing (DON) revealed: *She had: -Confirmed the above observations and medical record reviews. -Little to no involvement with the completion and updating of the care plans. *The Minimum Data Set (MDS) assessment coordinator had been responsible for the reviewing and revising of the care plans. *She agreed the care plans had not reflected the residents' current levels of care. Interview on 3/29/17 at 4:15 p.m. with the MDS assessment coordinator revealed: *She confirmed the above observations and medical record reviews. *She had been responsible for the completion, reviewing, and revising of the residents' care plans. *She agreed the above care plans did not reflect the residents' current levels of care. Review of the provider's 1/26/17 policy and procedure for care planning revealed: To ensure a care plan will be developed that is appropriate for each resident's needs and /or wishes based on the assessment and reassessment (Resident Assessment Instrument-RAI) process within the required timeframes. The plan of care shall be individualized to, and based upon, the assessment and [DIAGNOSES REDACTED]. Plans of care shall be updated as appropriate, with revisions reflecting the reassessment of a resident's needs. To provide a comprehensive health care environment, all staff members should consider interdisciplinary collaboration to establish goals and appropriate interventions, and ongoing evaluations and revisions to resident care.

Based on observation, interview, and policy review, the provider failed to ensure: *Manufacturer's recommendations for disinfecting therapy equipment had been followed for one of one therapy room. *Medical supplies in one of one medical supply room had not expired. Findings include: 1. Observation and interview on [DATE] at 10:45 a.m. with physical therapy assistant A revealed she: *Used the spray and wipe method to clean the therapy room equipment. *Sprayed the equipment and immediately wiped it with a cloth. *Had not been instructed on how to clean the therapy room equipment. *Stated housekeeping cleaned the equipment nightly and on weekends if used by residents. -Therapy staff would let housekeeping know on the weekends if equipment was used. Observation and interview on [DATE] at 10:50 a.m. with restorative certified nurse aide B revealed she: *Used Clorox wipes to wipe down therapy room equipment after resident use. *Could not find the Clorox wipes therapy used. *Agreed the therapy room equipment had not been wiped off today after being used. Interview and observation on [DATE] at 11:00 a.m. with the housekeeping supervisor revealed: *She had not instructed the therapy staff on how to clean the therapy room equipment between resident use and what disinfectant to be used. *She saw the disinfectant bottle in the therapy room and stated it had been labeled a disinfectant that was no longer used in the facility. *She had not instructed housekeepers on how to clean the therapy room equipment. -Housekeepers had not cleaned the therapy room equipment that the residents used. Interview on [DATE] at 11:05 a.m. with the administrator revealed: *She expected the therapy room equipment would be cleaned per manufacturer's instructions between residents. *She expected the therapy room would have been cleaned by housekeeping daily. Review of the contracted therapy service's [DATE] Surface Disinfection Modality Equipment policy revealed exposure time for disinfectant chemical was ten minutes or to follow manufacturer's recommendations. It did not specify chemicals that were to be used. 2. Observation on [DATE] at 3:45 p.m. of the clean medical supply room located on the west wing revealed the following expired medical supplies: *A box: -Three fourths full of 5 milliliter syringes, expired [DATE]. -Full of insulin syringes, expired [DATE]. -Half full of oxygen extension tubing with the years of expiration ranging from 2006 through 2010. -Full of 25 foot oxygen extension tubing with the years of expiration ranging from 2006 through 2014. -Half full of nebulizer masks with the years of expiration ranging from 2011 through 2015. *Six nasal feeding tubes, expired [DATE]. *Ten suction swabs, expired [DATE]. Interview on [DATE] at 4:20 p.m. with the director of nursing and the business office manager revealed: *The business office manager had been responsible for keeping the medical supply room stocked. *They had: -Not been aware the above medical supplies had expired. -Never checked for expiration dates on any of the medical supplies. -Assumed the supplies were useable if the packages remained intact and un-opened. Interview on [DATE] at 4:25 p.m. with registered nurse C revealed she would not have checked any of the medical supplies for expiration dates prior to using them. Review of the provider's [DATE] Central Supply policy revealed no procedure in place for ensuring medical supplies had not been used beyond their expiration dates.

Based on interview, record review, and policy review, the provider failed to ensure documentation of social services being provided for two of five sampled residents (1 and 3) with symptoms of depression. Findings include: 1. Interview on [DATE] at 5:00 p.m. with resident 1 and his daughter revealed: *His wife had died in [DATE] and it had been a very difficult loss for him *He had been admitted in [DATE] from his home with the hope of returning to his home at that time. *Since his admission he had two heart procedures including a valve replacement. *He had gone through some very down times in the past couple months and for awhile had not gotten out of bed. Review of resident 1's [DATE] and [DATE] Minimum Data Set (MDS) assessments revealed he had: *A decline in interests. *Felt down. *Decreased energy. *A change in sleep pattern. *Felt bad about himself. Review of resident 1's [DATE] care plan revealed: *Problem: "At times I feel sad and hopeless. Have no energy. Have no appetite. Can't sleep or having trouble falling asleep. I have had thoughts that I would be better off dead some days, but I would never hurt myself in any way." *Interventions: -"May see a counselor (name of agency) per physician orders. -Medications that help with depression and sleep. -Please tell my doctor if my symptoms are not improving to see if I need a change in my medication. -Take the time to discuss my feelings when I'm feeing sad." *There were no specific social service interventions to assist him with grief over loss of wife, adjusting to the facility, sense of hopelessness, and monitoring for prevention of self harm. Review of resident 1's social services (SS) progress notes revealed: *[DATE] "Visited with ___(family member) regarding doctors order for __(name of counseling agency) evaluation/consult. Resident having s/s (signs and symptoms) of increased depression. Expressing verbal statements of wishing to die." *[DATE] "Resident score of 14 indicates moderate depression. He did state that he had thoughts that he would be better off dead, but states that he would not harm himself in any way. Very tired this morning, Eyes closed most of the time during the interview." *[DATE] "Resident was seen today for the first time by ___(name of counseling agency)." *Additional notes included assessments that were completed related to mood and behavior or Medicare requirements, but there was no documentation of interventions. *There were no notes indicating SS was purposefully meeting with the resident to support the resident with the adjustment to the facility, follow-up on the counseling that had been provided, assisting with the grief counseling, and putting measures in place to ensure the safety of the resident from self harm. Interview on [DATE] at 10:00 a.m. with the SS director regarding resident 1 revealed she: *Had been in her position about seven months and was continuing to learn her responsibilities. *Had met almost daily with the resident and was aware that he had gone through a lot of loss recently and was showing signs of depression. *Tried to get him to look at the bright side of things but acknowledged he needed an opportunity to grieve the loss of his wife and his many health changes. *Agreed the SS documentation had not reflected the support that resident had received. 2. Review of resident 3's [DATE] quarterly and [DATE] significant change MDS assessments revealed the resident: *Exhibited decreased energy. *Moved slowly. *Felt down. *Was tired. *Had a decreased appetite. *Felt bad about herself. Review of resident 3's medical record revealed she received psychological services every two weeks. A random review of those reports revealed: *[DATE] "Pt (patient) remains with feelings of daily unhappiness, worthlessness, hopelessness, depressed and anxious mood/affect (lack of emotion) related to the loss of her independence." *[DATE]-"Pt (patient) observed with depressed mood and affect. Increased lethargy (decreased energy). Pt complained of fatigue (tired) and loss of interest." *[DATE] "Pt (patient) was observed with increased depressed mood. Resident reports increased depression and loss of interest with quality of life, decreased contact with family." Review of resident 3's [DATE] care plan revealed: *Problem: "She had a potential for depression due to expressions of depressed feeling down and increased fatigue. Uses antidepressant and will express sadness at times." *There were no discipline specific interventions to assist the resident in coping with her depression. Review of resident 3's [DATE] Mood and Behavior status revealed she: *"Exhibited mood problems. *Had told the nursing staff once that she thought she would be better off dead, but denied ever having thoughts of hurting herself. *Was less interested in personal grooming but still takes care of self for the most part. *Slept much of her day and was out for meals." Interview on [DATE] at 10:00 a.m. with the SSD regarding resident 3 revealed she: *Had been sick in January, and since then she had not resumed her previous level of activity. *Seemed depressed. *Was seen routinely by a counselor. *The counselor usually talked to the SSD after her visit, but never talked to the staff about how to support her visits in-between each one. *Did not document visits she made with residents routinely. *Confirmed her documentation would not have supported her visits with the resident. 3. Review of the provider's [DATE] social services interdisciplinary progress notes policy revealed: *"The SS staff will document interventions provided upon admission and throughout the resident's stay in the medical record. The frequency of interventions will be determined by each individual resident's needs. Interventions involving another discipline or requiring their immediate awareness will be documented upon identification provision of the intervention, including but not limited to: -Death of a family member/friend/roommate. -Significant increases in mood indictors, and/or behavioral symptoms. -Significant change in functional or health status impacting mental and/or psychosocial status. -Referrals for psychological services. *At a minimum SS notes will contain the following: -Description of resident's behavior, status or data. -Specific intervention provided. -Resident response or outcome of intervention."