Every finding on record at Avantara Huron

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, record review, interview, and policy review, the provider failed to ensure resident safety and supervision for one of one cognitively impaired sampled resident (1) identified at risk for elopement (leaving the facility without staff knowledge), was to be monitored and redirected when near exits and was seen outside the facility, walking down the street by a community member, who notified the facility. The resident was located over two blocks away from the facility, walking on the sidewalk, by licensed practical nurse (LPN) D. Failure to adequately supervise and redirect the resident may have contributed to the resident's elopement placing the resident at risk for an accident and/or injury while she was out of the building and unsupervised. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include:1. Review of the provider's 6/11/26 SD DOH FRI revealed on 6/11/26 the staff was alerted by a visitor that resident 1 was seen walking down the street. The staff exited the building to look for resident 1. At approximately 3:21 p.m. resident 1 was found by a staff member walking on the sidewalk.Resident 1's husband passed away in May 2025, and since his death, resident 1 talked about going to visit her mother and father. On 6/11/26, before she eloped, resident 1 told receptionist G that her mother and father were going to pick her up soon.The provider's review of the video camera footage during their investigation revealed that at 3:15 p.m. resident 1 was seated on a bench near the front door. Receptionist G pushed a remote button to allow a visitor to enter the building. Once that visitor entered the building receptionist G looked away from the door. Resident 1 caught the door before it closed and exited the building without the staff being aware she exited the facility. 2. Observation of the facility's entrance on 6/23/26 at 12:30 p.m. revealed that the outer door was not locked, and opened to a small entrance room, that had a locked inner door. There were instructions beside the door to ring a doorbell for entrance into the facility. A receptionist was seated at a desk within view of the locked door. The receptionist unlocked the door. The door automatically began to close slowly and paused approximately three inches from being fully closed. After the brief pause, the door fully closed and latched. That door opened into an open commons area, and along the wall near the door was a wooden bench. 3. Review of resident 1's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. She had a Brief Interview of Mental Status (BIMS) assessment score of 7, which indicated her cognition was significantly impaired. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbance, anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and delusional disorder (a mental illness where a person holds strong, false beliefs despite evidence to the contrary).Her 6/23/26 care plan indicated she was at risk for elopement due to increased confusion since the death of her husband. The interventions for her elopement risk included, Exit and stairwell alarms, If resident looks for family and/or significant other, reassure [her] that others know where to find them, Redirect [her] away from exits as needed and Photo in high risk for elopement to alert staff. The Photo in high risk for elopement to alert staff was revised on 6/11/26 from Maintain Elopement Binder, which was initiated on 6/1/26.The certified nursing assistants' (CNA) behavior documentation from 5/25/26 through 6/23/26 revealed that resident 1 was wandering on 5/28/26, 5/30/26, 5/31/26, 6/3/26, 6/5/26, 6/7/26, and 6/10/26.Resident 1's 5/28/26 Elopement Risk Evaluation indicated that The resident verbalized a strong desire to leave the facility and has the ability to do so and she was to be monitored by the staff for elopement.Resident 1's 6/2/26 Minimum Data Set (MDS) significant change assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) indicated she wandered four to six days during the seven day look-back period (the time period over which the resident's condition or status is captured by the MDS assessment), and yes was marked for the section this places the resident at significant risk of getting into potentially dangerous place.A 6/10/26 progress note written by social service designee (SSD) C indicated, When I was in [the] room speaking with [the] resident [resident 1] and [the resident's] daughter, [the] resident was very upset with [her] daughter and myself saying 'why are you doing this to me?' What do you think your [you're] doing with [resident 1's husband's] stuff. I tried to get [the] resident to go on a walk with me so [her] daughter could clean out [the] room. Resident was very upset about moving someone else in her husbands space.A 6/11/26 at 3:15 p.m. progress note written by licensed practical nurse (LPN) D indicated, Resident [resident 1] left through the front door after a visitor entered the facility. Staff [were] notified of [a] potential elopement. At 3:21 p.m. staff seen [saw] resident [resident 1] on the side walk in front of them. Staff [LPN D] ran to residents [resident 1's] side where she [resident 1] stated she was walking to her parents house. Resident [resident 1] was wearing socks, shoes, capri pants, a shirt with a sweater over the top, and was using her walker. The temperature was 69 [degrees Fahrenheit] and it is sunny outside. Resident was redirected to DON [director of nursing] car where she was driven back to the facility with no issues. Vitals were taken and are 138/66 [blood pressure], temp [temperature] 98.1 [degrees Fahrenheit], pulse 82, resp [respirations] 18, and O2 [blood oxygen saturation] 96 [percent]. A skin assessment was done and there are no skin issues found from elopement. 4. Interview on 6/23/26 at 3:10 p.m. with LPN D revealed she worked at the facility on 6/11/26, when resident 1 eloped from the facility. She stated resident 1 had dementia and since her husband passed away on 5/1/26 she had increased confusion and wandering. On the day she eloped (6/11/26), she received a new roommate which upset her. That same day she wandered around the facility with a bag stating she was going to her parents' house. LPN D saw resident 1 in the common area near the entrance to the building visiting with another resident before she eloped.When the staff were notified that resident 1 eloped, LPN D ran outside to look for her. LPN D found resident 1 approximately two and one-half blocks away from the facility. Resident 1 had crossed two streets but was walking on the sidewalk when LPN D found her. LPN D stated that resident 1 was laughing and stated she was going to her mother's and father's home. LPN D was able to get resident 1 into DON B's car, and they brought her back into the building.LPN D stated that after resident 1's husband passed away resident 1 began wandering and exit seeking. She did not attempt to elope from the facility before 6/11/26. Her picture was placed in the elopement binder (a reference binder for staff that contained the names and pictures of residents who were identified by the provider as being at risk for elopement from the facility) after her husband passed away because of her increased wandering and exit seeking.When resident 1 would wander and exit seek LPN D would remind resident 1 that her parents had passed away in the 1970s and her husband had passed away in May 2026 and then redirect her away from the building's exits. LPN D stated that she could usually redirect resident 1, but other staff members, at times, could not redirect her. 5. Interview and review of the elopement risk sheet at the reception desk on 6/23/26 at 3:46 p.m. regarding elopements with receptionist G revealed she was working as the receptionist on 6/11/26, when resident 1 eloped from the facility. On 6/11/26 receptionist G unlocked the door for a visitor to enter. Resident 1 was seated on the bench near the facility entrance. Resident 1 snuck between two visitors and exited the building. Receptionist G did not see resident 1 leave the building. Receptionist G thought resident 1 was seated on the bench near the door for about 15 minutes before she eloped.On 6/11/26 resident 1 told receptionist G that she wanted to leave multiple times and that she was very fast and she would get out. Resident 1 often came to the reception desk and told the receptionists that she wanted to go home. Resident 1 did not attempt to leave the building before that incident, but receptionist G said she was not surprised that resident 1 eloped because the resident often sat on the bench by the entrance and stated she wanted to go home. Receptionist G stated she told SSD C about resident 1's restlessness and that she stated she wanted to go home on 6/11/26 because SSD C often talked with resident 1 when she was upset. Receptionist G stated that the receptionists had a laminated elopement risk sheet that indicated the residents' names and their photographs if they were an elopement risk. The form was dated 5/21/26 and had resident 1's name and picture on it. 6. Interview on 6/24/26 at 10:20 a.m. with SSD C revealed she worked on 6/11/26 when resident 1 eloped from the building. She was told by a visitor that resident 1 was about two blocks from the facility. SSD C called a code walk (the provider's code to announce an elopement) and began looking for resident 1. SSD C was aware that resident 1's wandering increased after her husband's death, and that she was upset she had a new roommate. SSD C was not aware that resident 1 stated she was going to leave on 6/11/26. Resident 1 told SSD C that when she was upset, she would go for walks, but she never attempted to elope from the building before 6/11/26. 7. Review of the video camera footage from resident 1's 6/11/26 elopement revealed resident 1 was seated on the bench near the entrance. She was bent over doing something with her shoe. Receptionist G opened the door with the remote button on the receptionist's desk for a visitor at the door. The visitor entered the building. Receptionist G then looked down at the papers and her computer on the receptionist's desk. Resident 1 stood up, caught the door before it closed, and exited the building at 3:15 p.m. without receptionist G seeing her leave. 8. Interview on 6/24/26 at 11:23 a.m. with DON B revealed she was working on 6/11/26, when resident 1 eloped from the building. After the code walk was called DON B got in her car to look for resident 1. She found resident 1 and LPN D about two and one-half blocks away from the facility. She had crossed two streets but was walking on the sidewalk when they found her. Resident 1 was laughing and stated she got out of there really fast and that she was going to her parent's home. Resident 1 was redirected into DON B's car and brought back into the facility.Resident 1 became more confused shortly before her husband's death in May 2026. She began wandering and exit seeking after his death. After she began wandering and exit seeking, she was identified as having a high risk for elopement, her care plan was updated, and the receptionist elopement risk sheets were updated. After her elopement her picture was placed in the elopement binder (a binder that identified the residents who were at high risk for elopement to alert the staff they needed to redirect those residents away from exits) that resident 1 had been identified as being at risk for elopement and the staff needed to redirect her away from exits when she was exit seeking.On 6/11/26 DON B initiated education for all staff to be sure they were not looking away from the entrance door until it closed and latched to prevent a resident from exiting the building without staff being aware. She was auditing five staff members weekly to be sure the staff watched the building front entrance door until the door closed and latched. The elopement incident was scheduled to be reviewed at the provider's next Quality Assurance and Performance Improvement (QAPI) meeting.DON B was aware that resident 1 liked to sit on the bench near the building's front entrance and expected staff to redirect her away from that bench if she was exit seeking. 9. Review of the provider's 5/14/26 Elopement policy revealed, The facility must take steps to keep the resident safe and assess residents who identify those who are risk for elopement. Upon return of the resident to the facility, the Director of Nursing or charge nurse should: .Make appropriate notations in the resident's medical record and update the care plan. 10. Based on the above information, non-compliance at F689 occurred on 6/11/26, and based on the provider's corrective action plans that were initiated on 6/11/26 and implemented for the deficient practice confirmed on 6/23/26, the non-compliance is considered past non-compliance.

Based on the South Dakota Department of Health (SD DOH) complaint report, interview, document review, record review, and policy review, the provider failed to protect the resident's right to be free from sexual abuse by one of one certified nursing assistant (CNA) (D) for one of two sampled resident (57) who reported she was touched in a private area without her consent. And by one of one unidentified staff member for one of two sampled resident (78) who reported she was touched in a private area without her consent. Immediate Jeopardy (IJ) at F600, severity J., began on 3/11/26 at 11:40 a.m. when resident 57 revealed in an interview that she had a concern about being touched by a staff member on 1/23/26 during the night rounds. Resident 57 reported that certified nursing assistant (CNA) D had pulled back the blankets and checked her incontinence (involuntary urine or bowel leakage) brief by touching her. She was unsure whether it was on the inside or outside of her brief, which startled her. Resident 57 reported this concern to registered nurse (RN) H on 1/23/26. The facility failed to recognize the resident's concern as a potential abuse situation and failed to implement immediate measures to protect all residents within the facility following resident 57's allegation of abuse. The facility failed to report and thoroughly investigate the allegation of abuse to other entities, provide education to all staff, interview any further residents and staff regarding the allegation, and provide safety to resident 57 and all the residents to prevent similar situations from occurring. Review of a SD DOH complaint report revealed that resident 78 had reported an allegation of inappropriate touching to her perineal area by an unidentified female staff member that occurred between 11/6/25 and 12/8/25 during the night shift. Resident 78 no longer resided at the facility. While she resided there the resident reported her allegation to certified occupational therapy assistant (COTA) E. Interview on 3/11/26 at 1:20 p.m. with COTA E confirmed the resident had reported the allegation to her and COTA E transported resident 78 to report it to social service designee (SSD) F. Interview on 3/11/26 at 1:45 p.m. with SSD F revealed she denied knowledge of the resident's allegation of being touched inappropriately by a staff member. Further interviews on 3/11/26 at 3:10 p.m. with administrator A and director of nursing (DON) B confirmed there was no documentation to support any other allegations had been reported or investigated as a potential abuse situation. Administrator A was notified of the IJ on 3/11/26 at 6:52 p.m. and a removal plan as requested. The removal plan was received on 3/12/26 at 12:58 a.m. by email. The edited removal plan was received on 3/12/26 at 7:31 a.m., and it was accepted on 3/12/26 at 8:35 a.m. The IJ was removed on 3/12/26 at 9:35 a.m. as confirmed by onsite verification by the survey team. After the IJ removal, the severity of the non-compliance remained at a G. The current census was 71. Findings include:1. Review of the complaint report submitted to the SD DOH on 2/6/26 revealed that either a student or an aide had stuck their hands down her [resident 78's] pants to check if she was dry, without her permission. She stated her mind is good, and she had told the person that she didn't need to go to the toilet, and that she was dry. The aide or student proceeded to 'check' her without asking. She felt very embarrassed by this. She stated she spoke with facility management the next day, and they verified the person should not have done that. There was no further follow-up with the resident. She could not recall the name of the person who had done it, and the incident bothered her. 2. Interview on 3/10/26 at 12:21 p.m. with DON B revealed that an internal investigation was completed after resident 57 complained to RN H that a staff member checked her incontinence brief to see if it was wet, which startled her since she was independent with using the bathroom. RN H reported that to DON B. DON B explained that CNA D did not mean it in a sexually inappropriate way so she did not report the incident to the SD DOH. The incident happened on 1/23/26 during the night shift rounds. She stated CNA D currently worked at the facility and she disciplined and educated CNA D after the incident. She stated that resident 57's pocket care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) was updated, and the staff who cared for her reviewed that. She thought the CNAs that read that were educated on the changes to her care plan. She did not have a signature sheet to verify that staff education regarding resident 57's abuse allegation was completed. She acknowledged that touching a resident's incontinence brief was not an acceptable way to see if they were incontinent. She said the investigation report she completed indicated that resident 57's brief was not checked by touching her. If CNA D had touched the brief to see if it was wet, DON B would have reported it to the SD DOH, and CNA D would have been suspended until the investigation was completed, and possibly had his employment at the facility terminated. No audits were completed after the incident occurred to ensure it would not occur again. DON B told resident 57's daughter about the incident and asked her daughter to notify them if resident 57 brought it up. The investigation documentation stated SSD F had followed up with resident 57 a few days after the incident. 3. Review of the provider's internal investigation form revealed that resident 57's abuse allegation was reported on 1/23/26 to RN H by resident 57 and stated the night aide came in her room and pulled back her blanket and checked her brief which had startled her. [RN H] reported that [resident 57] did not feel that this was completed inappropriately towards her, but more of a lack of education. RN H reported this to DON B, and DON B had SSD F conduct a social service visit to discuss the incident with [resident 57]. Review of SSD F interview documents that were attached to the internal investigation form revealed it stated, I spoke with [resident 57] about what happened and checked on how she was feeling about the situation. [Resident 57] reported that staff entered her room during the overnight rounds while she was sleeping and she was not expecting someone to come in at that time. The CNA pulled down her blanket to check her brief which startled her. [Resident 57] and I talked about how the CNA was completing routine rounds and may not have known her usual nighttime routine. [Resident 57] stated she understood and said she does not believe the CNA meant anything inappropriate towards her. She also stated she is not upset with the CNA and felt he likely did not know her routine. I stayed with [resident 57] for a while and we continued to talk about the situation. During the visit she appeared calm and comfortable with discussing what happened. She did not express ongoing concerns. I asked if she would like me to notify family and she declined. Social Services will continue to monitor and remain available if she has any concerns. [Resident 57] reports that she feels safe at the facility. On 1/26/26 SSD F interviewed resident 57 regarding the incident, and it stated [Resident 57] reported that she has had no further issues. She remains to feel safe at the facility. On 1/27/26 SSD F interviewed resident 57 regarding the incident, and it indicated that resident 57 had no further issues, felt safe, and she would notify SSD if she had further issues. The outcome of the investigation summary section described the incident that had occurred. It stated that administrator A and DON B called resident 57's daughter to notify her of the incident, and her daughter said she would call them if resident 57 said anything about it. It stated that DON B interviewed CNA D on 1/23/26, and he reported that he said the resident's name before pulling the resident's blankets back. He thought she knew what he was doing, and he apologized that he startled her. DON B gave him a written warning. DON B told resident 57 that her care plan was changed, and the investigation summary indicated that resident 57 was happy with that. It stated, In review of South Dakota's reporting guidelines this did not rise to the level of abuse/neglect due to [resident 57's] denial of inappropriate action towards her and [CNA D's] lack of touching her and therefore was not reported to the Department of Health. 4. Interview on 3/11/26 at 11:15 a.m. with SSD F revealed that CNA D touched the resident's incontinence brief to see if she was wet. SSD was unsure if resident 57's incontinence brief or private area was touched when CNA D checked her for incontinence. She verified that it was not an appropriate way to see if a resident was incontinent. 5. Interview on 3/11/26 at 11:40 a.m. with resident 57 revealed that the CNA touched her on the inside of her incontinence brief. She became tearful, and by the end of the interview she was not sure if she was touched on the inside or the outside of her incontinence brief, and she just wanted to forget about it. 6. Interview on 3/11/26 at 9:08 a.m. with RN H revealed that during a night shift, a CNA was confused about which residents needed to be checked for incontinence, and that the residents down the D wing were startled by this. The CNA still worked here, and she was not aware whether he continued to do that, and no residents had complained about that. 7. Interview on 3/11/26 at 12:50 p.m. with independent living specialist QQ regarding resident 78's complaint about a female staff member who put her hands down resident 78's pants to feel if she was wet, revealed resident 78 was no longer at the facility. Resident 78 was just there for rehab and at the time of the incident, she was independent with toileting. The incident made resident 78 feel uncomfortable and she reported to independent living specialist QQ that she had nightmares about it and recalled resident 78 saying got an eerie gross feeling about it. Independent living specialist QQ continued to stay in contact with her. She was not sure who resident 78 reported the incident to at the facility, but said resident 78 made a formal complaint, and she did not hear back from anyone about it. Independent living specialist QQ was unsure when the incident occurred. 8. Phone interview on 3/11/26 at 12:58 p.m. with resident 78 revealed she was unsure when the incident occurred, but she was able to recall that it happened during a night shift. The female staff member asked her if she needed to use the bathroom, and when resident 78 said no, the female staff member put her hand down resident 78's pants and said, Nope, you're dry. Resident 78 reported that she had resided in the D wing, she wore her own underwear, and that a female staff member put her hand on the inside of her underwear when she checked her. She said she did not do anything about it that night, but the next day, she told COTA E about it. Resident 78 reported that COTA E brought her to SSD F's office for her to report the incident to SSD F. She said she reported the incident to the two women in that office, and said they had looked surprised. When she was telling them what happened, she thought it appeared that SSD F was looking at the staffing schedule to see who was working that night. Resident 78 was told that they had students from a vocational school there at the facility. Resident 78 stated that she had made a formal complaint with SSD F and the other lady that was in the office, and when she read her discharge paperwork from the facility, she did not see anything about the incident, so she made a complaint report with the SD DOH so it would not happen to other residents. She said no one from the facility followed up with her after she made the formal complaint. 9. Interview on 3/11/26 at 1:20 p.m. with COTA E revealed that resident 78 told her about the incident that occurred during the night shift, where a staff member put their hands in resident 78's pants to see if she was incontinent. COTA E reported that resident 78 was upset and that she was sleeping when that staff member came into her room. She said she took resident 78 directly to the social services office, and SSD F was there, but she was unsure if anyone else was in there. COTA E stated that was not the first time residents had reported this concern to her. She was not sure how many residents had, but thought five or less, in the last six months. Residents reported to her that the staff ripped off their blankets and would feel around to see if they were incontinent. It happened to the residents who were both continent and incontinent. She listed two other residents who were still in the facility, who she recalled having that happen to. 10. Interview on 3/11/26 at 1:45 p.m. with SSD F revealed that she did not recall COTA E bringing resident 78 to her office or that resident 78 made a formal complaint to her. She reported that the therapy department brought the residents to her office frequently about this or that. She stated that their process for filing resident grievances was to listen to them, document the grievance, investigate them, and report them to the SD DOH if needed. SSD F said that she did not recall any other residents, besides resident 57, reporting that staff put their hands in their pants to check if they were incontinent and stated, it's a pretty serious thing. She said that and incident like that would be reported to administrator A and DON B for them to investigate it. Regarding resident 57, she stated she wrote her follow-up notes in a notebook, which she no longer had, and did not document about it in the electronic medical record (EMR). She said she did not talk to other staff or residents to see if a similar incident occurred with them. She said she visited with resident 57, but no other counseling was offered to her. When she talked to resident 57 about the incident, she told SSD F that she was embarrassed about it. 11. Interview on 3/11/26 at 2:27 p.m. with SSD G revealed that she did not recall any complaints regarding staff putting their hands down residents' pants to check to see if they were incontinent, and she did not recall COTA E bringing resident 78 to her office. If she were to receive a resident grievance, she was to document it on a form and turn it in to administrator A. 12. Interview on 3/11/26 at 3:10 p.m. with DON B revealed she only received a complaint from resident 57 regarding staff putting their hands in her pants to check to see she was incontinent. If a resident had a complaint concerning abuse allegations, she would investigate it. If the investigation determined that the staff were inappropriate, then she would report it to the SD DOH. She stated that their grievance process depended on the situation. They had grievance forms to fill out, but if she completed an internal investigation, she did not need to fill out the grievance form. Regarding the incident that involved resident 57, she interviewed RN H and the other night nurses about CNA D, but she did not document those interviews. She did not interview other residents to see if there was a similar incident that had happened to them. Mental health services were not offered to resident 57. 13. Interview on 3/11/26 at 5:00 p.m. with administrator A and DON B revealed that they were not aware that resident 57 had was touched to check to see if she was incontinent. DON B had SSD F visit with resident 57 regarding the incident, and she thought resident 57 told SSD F that CNA D did not touch her. She explained how she updated the pocket care plan and that she talked with CNA D, provided him with education, and wrote him up. She stated that no other residents were interviewed. Administrator A stated that allegations of sexual abuse were to be reported to the SD DOH within two hours, reported to law enforcement, and Dakota at Home. She expected staff not to put their hands in the residents' incontinence briefs or touch the brief to check if the resident was incontinent. The incontinence brief had lines on it that turned color when it was wet, and the staff were to let the residents know what they were going to do and get their permission before they did anything. If a resident did not want to be checked, the staff were to report it to the charge nurse. 14. On 3/11/26 at 6:52 p.m., administrator A was notified of the IJ. On 3/12/26 at 12:58 a.m., the removal plan was received by email. On 3/12/26 at 7:31 a.m., the edited removal plan was received, and on 3/12/26 at 8:35 a.m., it was accepted. REMOVAL PLAN: 1. Resident 57's allegation of sexual abuse was reported to the South Dakota Department of Health (DOH), [NAME] County Sheriff's Department, Dakota at Home, her power of attorney (POA), and provider on 3/11/26. Resident 57 refused skin assessment on 3/11/26. Her previous skin assessment was completed by registered nurse (RN) on 3/5/26 with no skin alterations or other injuries noted. Resident 57 will be offered counseling services. Certified Nursing Assistant (CNA) D was immediately suspended upon notification of allegation on 3/11/26. Resident 78's allegation of sexual abuse was reported to the DOH, [NAME] County Sheriff's Department, Dakota at Home, and the facility Medical Director on 3/11/26. Resident 78 was discharged from the facility on 12/8/25. No immediate corrective action could be taken to ensure no injury occurred. Certified Occupational Therapy Assistant (COTA) and Social Service Designee (SSD) were immediately suspended on 3/11/26 for failure to report an allegation of sexual abuse. 2. On 3/11/26, Nurse Managers completed interviews with all cognitive residents that have a Brief Interview for Mental Status (BIMS) score of 12 or greater, this included 32 residents, to determine if they had concerns regarding inappropriate touch by a staff member or whether they had witnessed another resident being touched inappropriately by a staff member. Nurse Managers completed interviews with all staff working evening and night shift on 3/11/26 to determine if a resident has ever reported that they had been touched inappropriately, whether they have ever witnessed a staff member touching a resident inappropriately, and if they know who to report abuse concerns to. Director of Nursing (DON) or designee will complete interviews with all remaining staff prior to their next shift worked to determine if a resident has ever reported that they have been touched inappropriately, whether they have witnessed a staff member touch a resident inappropriately, and if they know who to report abuse concerns to. 3. Senior Regional Nurse Consultant educated the Administrator and DON on the Abuse and Neglect policy, including immediate reporting and investigating, to ensure interventions are implemented to safeguard all residents from abuse that continues to put all residents at risk on 3/11/26. Regional Nurse Consultant educated all Nurse Managers on the Abuse and Neglect policy, including immediate reporting requirements, to ensure all residents remain free from abuse and/or neglect on 3/11/26. Nurse Managers educated all staff working the evening/night shift on 3/11/26 on the Abuse and Neglect policy, including immediate reporting and investigating, to ensure all residents remain free from abuse and/or neglect. Admin [administrator], DON, or designee will educate all other facility and contract staff on the Abuse and Neglect policy, including immediate reporting and investigating, to ensure all residents remain free from abuse and/or neglect prior to their next shift worked. DON or designee will ensure new staff, including contract staff, receive education on the Abuse and Neglect policy, including immediate reporting requirements, prior to their first shift worked. DON or designee will interview 5 random residents each week to ensure they remain free from abuse and/or neglect and feel safe in the facility. Additionally, the DON or designee will observe 5 CNAs each week on random shifts to ensure residents are approached and touched appropriately when assisting them with incontinent care. These interviews and audits will continue for four weeks and then monthly for three months. Results of audits will be reviewed by the Administrator, DON or designee with IDT and Medical Director at monthly Quality Assurance Performance Improvement (QAPI) for analysis and recommendation for continuation/discontinuation/revision of audits based on findings. 15. Interviews were completed by the survey team on 3/12/26 between 9:12 a.m. and 9:29 a.m. with residents 3, 35, and 65 and staff members LPN I, CNA T, medical records director OO, activity aide PP, housekeeper RR, and activity aide SS to ensure the provider followed through with their removal plan. 16. The survey team verified onsite, through interviews, and document review that the provider followed their IJ removal plan and the immediacy was removed. The scope and severity level of the noncompliance remained at a G. 17. On 3/12/26 at 9:54 a.m., administrator A was notified that the IJ was removed. 18. Review of resident 57's EMR revealed she was admitted to the facility on [DATE]. Her 2/6/26 Brief Assessment for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had diagnoses of Generalized Anxiety Disorder (GAD) (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), other manic episodes (a period of abnormally high energy, extreme happiness, or severe irritability), Agoraphobia (a fear of being in situations where escape might be difficult or help unavailable if a panic attack occurs), Major Depressive Disorder (MDD) (a persistent feeling of hopelessness, emptiness, or low mood). Review of resident 57's 2/22/26 care plan revealed that social services would visit with her to assess her psychosocial needs and would follow up as needed. She had a hearing deficit, and she was independent with toileting. Review of resident 57's medication record revealed she took Lexapro 20 milligrams (mg) (an antidepressant) daily and Seroquel 50 mg every night for MDD, and Depakote 250 mg twice daily for MDD and other manic episodes. 19. Review of resident 78's EMR revealed she was admitted to the facility on [DATE] and discharged to home on [DATE]. Her 12/8/25 BIMS assessment score was 15, which indicated her cognition was intact. She had diagnoses of anxiety disorder and depression. Resident 78's 11/17/25 care plan did not indicate what assistance she required for personal hygiene care, ambulating (walking), or using the bathroom. Resident 78 had physician orders to take Mirtazapine 15 mg (a depression medication) daily. 20. Review of the provider's 5/14/25 Abuse and Neglect policy revealed that the facility would provide care services in an environment that was free from any type of abuse. And to follow federal guidelines to prevent abuse and investigate allegations of abuse. The abuse coordinator was the administrator, and she was responsible for developing and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect. Sexual abuse included implied or actual contact between a caregiver and resident of sexual nature. If an allegation of sexual abuse towards a resident is reported., the facility will send resident to the emergency room to be evaluated if ordered by the resident's physician. A report will be made to the local police department the same day the allegation is made. If abuse was suspected the facility would immediately protect the residents, notify appropriate authorities that an investigation would be conducted, conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses, notify law enforcement if needed (example- Sexual abuse), and report the investigation findings to all necessary state and/or local agencies and other identified persons as required by law. The steps indicated to prevent abuse were screening, training, prevention, identification, investigation, protection, and reporting/responding. The provider was to inform residents, residents' families, and staff how to report grievances or concerns and to whom they could report it to. The provider was to respond to the residents, families, or staff concerns that reported grievances or concerns. The administrator or designee was to investigate all abuse allegations of abuse immediately. The provider was to interview all people who might know information about the allegation to determine if abuse had occurred. The investigation was to be documented thoroughly. The provider was to protect residents from physical and psychosocial harm during the investigation, assess the resident for injury, notify the physician, and suspend the accused employee during the investigation. The provider was to report to the administrator immediately any allegations or suspicions of abuse. The allegation of abuse needed to be reported to the SD DOH within two hours of the allegation. A final investigation report was to be submitted to the state agency within five working days.

Based on the South Dakota Department of Health (SD DOH) complaint report review, interview, document review, record review, and policy review, the provider failed to ensure two of two sampled residents' with expressed feelings of emotional distress (57 and 78) allegations of sexual abuse reported to social services designee (F) regarding having been touched in their private areas without the residents' consent by one of one certified nursing assistant (CNA) (D) and an unidentified staff member were thoroughly investigated to prevent further emotional distress, further staff-to-resident sexual abuse or to mitigate the risk of sexual abuse. Findings include:1. Review of the provider's complaint report submitted to the SD DOH on 2/6/26 revealed that either a student or an aide had stuck their hands down her [resident 78's] pants to check if she was dry, without her permission. She stated her mind is good, and she had told the person that she didn't need to go to the toilet, and that she was dry. The aide or student proceeded to 'check' her without asking. She felt very embarrassed by this. She stated she spoke with facility management the next day, and they verified the person should not have done that. There was no further follow-up with the resident. She could not recall the name of the person who had done it, and the incident bothered her. 2. Interview on 3/10/26 at 12:21 p.m. with director of nursing (DON) B revealed that an internal investigation was completed after resident 57 complained to RN H that a staff member checked her incontinence brief to see if it was wet, which startled her since she was independent with using the bathroom. RN H reported that to DON B. DON B explained that CNA D did not mean it in a sexually inappropriate way so she did not report the incident to the SD DOH. The incident happened on 1/23/26 during the night shift rounds. She stated CNA D currently worked at the facility and she disciplined and educated CNA D after the incident. She acknowledged that touching a resident's incontinence brief was not an acceptable way to see if they were incontinent. She said the investigation report she completed indicated that resident 57's brief was not checked by touching her. If CNA D had touched the brief to see if it was wet, DON B would have reported it to the SD DOH, and CNA D would have been suspended until the investigation was completed, and possibly had his employment at the facility terminated. No audits were completed after the incident occurred to ensure it would not occur again. DON B told resident 57's daughter about the incident and asked her daughter to notify them if resident 57 brought it up. The investigation documentation stated SSD F had followed up with resident 57 a few days after the incident. 3. Review of the provider's internal investigation form revealed that resident 57's abuse allegation was reported on 1/23/26 to RN H by resident 57 and stated the night aide came in her room and pulled back her blanket and checked her brief which had startled her. [RN H] reported that [resident 57] did not feel that this was completed inappropriately towards her, but more of a lack of education. RN H reported this to DON B, and DON B had SSD F conduct a social service visit to discuss the incident with [resident 57]. Review of SSD F interview documents that were attached to the internal investigation form revealed it stated, I spoke with [resident 57] about what happened and checked on how she was feeling about the situation. [Resident 57] reported that staff entered her room during the overnight rounds while she was sleeping and she was not expecting someone to come in at that time. The CNA pulled down her blanket to check her brief which startled her. [Resident 57] and I talked about how the CNA was completing routine rounds and may not have known her usual nighttime routine. [Resident 57] stated she understood and said she does not believe the CNA meant anything inappropriate towards her. She also stated she is not upset with the CNA and felt he likely did not know her routine. I stayed with [resident 57] for a while and we continued to talk about the situation. During the visit she appeared calm and comfortable with discussing what happened. She did not express ongoing concerns. I asked if she would like me to notify family and she declined. Social Services will continue to monitor and remain available if she has any concerns. [Resident 57] reports that she feels safe at the facility. The internal investigation form indicated that the physician, police, ombudsman, and the state agency were not notified of the incident. On 1/26/26 SSD F interviewed resident 57 regarding the incident, and it stated [Resident 57] reported that she has had no further issues. She remains to feel safe at the facility. On 1/27/26 SSD F interviewed resident 57 regarding the incident, and it indicated that resident 57 had no further issues, felt safe, and she would notify SSD if she had further issues. The outcome of the investigation summary section described the incident that had occurred. It stated that administrator A and DON B called resident 57's daughter to notify her of the incident, and her daughter said she would call them if resident 57 said anything about it. It stated that DON B interviewed CNA D on 1/23/26, and he reported that he said the resident's name before pulling the resident's blankets back. He thought she knew what he was doing, and he apologized that he startled her. DON B gave him a written warning. DON B told resident 57 that her care plan was changed, and the investigation summary indicated that resident 57 was happy with that. It stated, In review of South Dakota's reporting guidelines this did not rise to the level of abuse/neglect due to [resident 57's] denial of inappropriate action towards her and [CNA D's] lack of touching her and therefore was not reported to the Department of Health. 4. Interview on 3/11/26 at 11:15 a.m. with SSD F revealed that CNA D touched the resident's incontinence brief to see if she was wet. SSD was unsure if resident 57's incontinence brief or private area was touched when CNA D checked her for incontinence. She verified that it was not an appropriate way to see if a resident was incontinent. 5. Interview on 3/11/26 at 11:40 a.m. with resident 57 revealed that the CNA touched her on the inside of her incontinence brief. She became tearful, and by the end of the interview she was not sure if she was touched on the inside or the outside of her incontinence brief, and she just wanted to forget about it. 6. Interview on 3/11/26 at 9:08 a.m. with RN H revealed that one night, a CNA was confused about which residents needed to be checked for incontinence, and that the residents down the D wing were alerted by this. He still worked here, and she was not aware whether he continued to do that. She had not had a resident come to her to complain about that. 7. Interview on 3/11/26 at 12:50 p.m. with independent living specialist QQ regarding resident 78's complaint about a female staff member who put her hands down resident 78's pants to feel if she was wet, revealed resident 78 was no longer at the facility. Resident 78 was just there for rehab and at the time of the incident, she was independent with toileting. The incident made resident 78 feel uncomfortable and she reported to independent living specialist QQ that she had nightmares about it and recalled resident 78 saying got an eerie gross feeling about it. Independent living specialist QQ continued to stay in contact with her. She was not sure who resident 78 reported the incident to at the facility, but said resident 78 made a formal complaint, and she did not hear back from anyone about it. Independent living specialist QQ was unsure when the incident occurred. 8. Phone interview on 3/11/26 at 12:58 p.m. with resident 78 revealed she was unsure when the incident occurred, but she was able to recall that it happened during a night shift. The female staff member asked her if she needed to use the bathroom, and when resident 78 said no, the female staff member put her hand down resident 78's pants and said, Nope, you're dry. Resident 78 reported that she had resided in the D wing, she wore her own underwear, and that a female staff member put her hand on the inside of her underwear when she checked her. She said she did not do anything about it that night, but the next day, she told COTA E about it. Resident 78 reported that COTA E brought her to SSD F's office for her to report the incident to SSD F. She said she reported the incident to the two women in that office, and said they had looked surprised. When she was telling them what happened, she thought it appeared that SSD F was looking at the staffing schedule to see who was working that night. Resident 78 was told that they had students from a vocational school there at the facility. Resident 78 stated that she had made a formal complaint with SSD F and the other lady that was in the office, and when she read her discharge paperwork from the facility, she did not see anything about the incident, so she made a complaint report with the SD DOH so it would not happen to other residents. She said no one from the facility followed up with her after she made the formal complaint. 9. Interview on 3/11/26 at 1:20 p.m. with COTA E revealed that resident 78 told her about the incident that occurred during the night shift, where a staff member put their hands in resident 78's pants to see if she was incontinent. COTA E reported that resident 78 was upset and that she was sleeping when that staff member came into her room. She said she took resident 78 directly to the social services office, and SSD F was there, but she was unsure if anyone else was in there. COTA E stated that was not the first time residents had reported this concern to her. She was not sure how many residents had, but thought five or less, in the last six months. Residents reported to her that the staff ripped off their blankets and would feel around to see if they were incontinent. It happened to the residents who were both continent and incontinent. She listed two other residents who were still in the facility, who she recalled having that happen to. 10. Interview on 3/11/26 at 1:45 p.m. with SSD F revealed that she did not recall COTA E bringing resident 78 to her office or that resident 78 made a formal complaint to her. She reported that the therapy department brought the residents to her office frequently about this or that. She stated that their process for filing resident grievances was to listen to them, document the grievance, investigate them, and report them to the SD DOH if needed. SSD F said that she did not recall any other residents, besides resident 57, reporting that staff put their hands in their pants to check if they were incontinent and stated, it's a pretty serious thing. She said that and incident like that would be reported to administrator A and DON B for them to investigate it. Regarding resident 57, she stated she wrote her follow-up notes in a notebook, which she no longer had, and did not document about it in the electronic medical record (EMR). She said she did not talk to other staff or residents to see if a similar incident occurred with them. She said she visited with resident 57, but no other counseling was offered to her. When she talked to resident 57 about the incident, she told SSD F that she was embarrassed about it. 11. Interview on 3/11/26 at 2:27 p.m. with SSD G revealed that she did not recall any complaints regarding staff putting their hands down residents' pants to check to see if they were incontinent, and she did not recall COTA E bringing resident 78 to her office. If she were to receive a resident grievance, she was to document it on a form and turn it in to administrator A. 12. Interview on 3/11/26 at 3:10 p.m. with DON B revealed she only received a complaint from resident 57 regarding staff putting their hands in her pants to check to see she was incontinent. If a resident had a complaint concerning abuse allegations, she would investigate it. If the investigation determined that the staff were inappropriate, then she would report it to the SD DOH. Regarding the incident that involved resident 57, she interviewed RN H and the other night nurses about CNA D, but she did not document those interviews. She did not interview other residents to see if there was a similar incident that had happened to them. Mental health services were not offered to resident 57. 13. Interview on 3/11/26 at 5:00 p.m. with administrator A and DON B revealed that they were not aware that resident 57 had was touched to check to see if she was incontinent. DON B had SSD F visit with resident 57 regarding the incident, and she thought resident 57 told SSD F that CNA D did not touch her. She explained how she updated the pocket care plan and that she talked with CNA D, provided him with education, and wrote him up. She stated that no other residents were interviewed. She expected staff not to put their hands in the residents' incontinence briefs or touch the brief to check if the resident was incontinent. The incontinence brief had lines on it that turned color when it was wet, and the staff were to let the residents know what they were going to do and get their permission before they did anything. If a resident did not want to be checked, the staff were to report it to the charge nurse. 14. Review of resident 57's EMR revealed she was admitted to the facility on [DATE]. Her 2/6/26 Brief Assessment for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had diagnoses of Generalized Anxiety Disorder (GAD) (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), other manic episodes (a period of abnormally high energy, extreme happiness, or severe irritability), Agoraphobia (a fear of being in situations where escape might be difficult or help unavailable if a panic attack occurs), Major Depressive Disorder (MDD) (a persistent feeling of hopelessness, emptiness, or low mood). Review of resident 57's 2/22/26 care plan revealed that social services would visit with her to assess her psychosocial needs and would follow up as needed. She had a hearing deficit, and she was independent with toileting. Review of resident 57's medication record revealed she took Lexapro 20 milligrams (mg) (an antidepressant) daily and Seroquel 50 mg every night for MDD, and Depakote 250 mg twice daily for MDD and other manic episodes. Resident 78's 11/17/25 care plan did not indicate what assistance she required for personal hygiene care, ambulating (walking), or using the bathroom. Resident 78 had physician orders to take Mirtazapine 15 mg (a depression medication) daily. 15. Review of resident 78's medical record revealed she was admitted to the facility on [DATE] and discharged home on [DATE]. Her 12/8/25 BIMS assessment score was 15, which indicated her cognition was intact. And she had diagnoses of Anxiety Disorder and Depression. Review of resident 78's 11/17/25 care plan revealed it did not indicate what assistance she required for hygiene care, ambulating, or using the bathroom.Review of resident 78's physician orders revealed she took Mirtazapine 15 mg (depression medication) daily. 16. Review of the provider's 5/14/25 Abuse and Neglect policy revealed that the facility would provide care services in an environment that was free from any type of abuse. And to follow federal guidelines to prevent abuse and investigate allegations of abuse. The abuse coordinator was the administrator, and she was responsible for developing and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect. Sexual abuse included implied or actual contact between a caregiver and resident of sexual nature. If an allegation of sexual abuse towards a resident is reported., the facility will send resident to the emergency room to be evaluated if ordered by the resident's physician. A report will be made to the local police department the same day the allegation is made. If abuse was suspected the facility would immediately protect the residents, notify appropriate authorities that an investigation would be conducted, conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses, notify law enforcement if needed (example- Sexual abuse), and report the investigation findings to all necessary state and/or local agencies and other identified persons as required by law. The steps indicated to prevent abuse were screening, training, prevention, identification, investigation, protection, and reporting/responding. The provider was to inform residents, residents' families, and staff how to report grievances or concerns and to whom they could report it to. The provider was to respond to the residents, families, or staff concerns that reported grievances or concerns. The administrator or designee was to investigate all abuse allegations of abuse immediately. The provider was to interview all people who might know information about the allegation to determine if abuse had occurred. The investigation was to be documented thoroughly. The provider was to protect residents from physical and psychosocial harm during the investigation, assess the resident for injury, notify the physician, and suspend the accused employee during the investigation.

Based on the interview, record review, call light log documentation review, and policy review, the provider failed to ensure staff responded promptly to two of four sampled residents (30 and 82) who indicated they had concerns with the call lights not being answered in a timely manner. Resident 82 reported being in pain while waiting for her call light to be answered, and Resident 30 reported urinary incontinence when having to wait for her call light to be answered. Findings Include:1. Interview on 3/8/26 at 2:03 p.m. and 3/9/26 at 10:42 a.m. with resident 30 revealed she had concerns that the facility was short of staff, staff were quitting, and the facility needed to use contracted travel staff. She had concerns that her call light sometimes was not answered quickly enough, causing her to incontinent of urine. 2. Review of resident 30's electronic medical record (EMR) revealed her 3/3/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. She had physician orders on 4/4/25 for oxybutynin chloride 10 milligrams (mg) daily (a medication used to treat frequent urination, urgency, and incontinence). She had diagnoses of reduced mobility, urinary incontinence (involuntary urine leakage), and urinary tract infection. Resident 30's 1/26/26 care plan revealed she required the assistance of one staff member to use the bathroom. 3. Review of resident 30's call light response time report (a report that indicated how long a call light was on before it was turned off) revealed that on 2/25/26 at 1:38 p.m. her call light was on for 16 minutes (min) and 53 seconds (sec), and at 5:00 p.m. for 15 min and 51 sec. On 3/1/26 at 9:29 p.m. her call light was on for 16 min and 41 sec. On 3/4/26 at 9:28 p.m. her call light was on for 26 min and 28 sec. On 3/6/26 at 7:04 p.m. her call light was on for 28 min and 4 sec. On 3/8/26 at 7:06 a.m. her call light was on for 26 min and 5 sec. 4. Interview on 3/8/26 at 2:15 p.m. and 3/11/26 at 11:30 a.m. with resident 82 revealed that she waited up to an hour for her call light to be answered when requesting assistance to the bathroom or for pain medications. She feels upset and as if the staff have forgotten about her when she had to wait a long time for her call light to be answered. She stated she was in pain since she had to wait for pain medications. 5. Review of resident 82's EMR revealed her 3/5/26 BIMS assessment score was 14, indicating she was cognitively intact. Resident 82 had diagnoses of unspecified depression, and multiple fractured ribs on her right side. 6. Review of resident 82's medication administration record (MAR) revealed that resident 82 was given an as needed (PRN) oxycodone HCl 5mg tablet for pain on 3/4/26 at 7:39 p.m., 3/7/26 at 6:02 a.m., 3/7/26 at 2:15 p.m., and on 3/7/26 at 10:10 p.m. 7. Review of the call light report from 2/23/26 through 3/8/26 revealed resident 82 had nine call response times greater than 15 minutes.Resident 82's call light response times revealed on 3/4/26 at 3:54 p.m. her call light was on for 27 minutes, on 3/4/26 at 7:01 p.m. her call light was on for 25 minutes, on 3/5/26 at 11:21 p.m. her call light was on for 20 minutes, on 3/6/26 at 3:25 p.m. her call light was on for 20 minutes, on 3/7/26 at 4:42 a.m. her call light was on for 36 minutes, on 3/7/26 at 5:27 a.m. her call light was on for 33 minutes, on 3/7/26 at 1:29 p.m. her call light was on for 39 minutes, on 3/7/26 at 3:19 p.m. her call light was on for 16 minutes, and on 3/7/26 at 9:24 p.m. her call light was on for 27 minutes. 8. Interview on 3/9/26 at 8:57 a.m. with CNA T revealed CNAs knew a call light was on because it could be heard from the hallway, and a light was visible above the resident's doorway. It would alert on a pager that the staff were to carry. He did not have a pager and stated he should have. 9. Interview on 3/9/26 at 10:48 a.m. with LPN N revealed pagers were locked up in the medication room, and the nurses had to check them out to the CNAs. The CNAs had to give them a personal item to temporarily exchange for the pager. Some staff did not want to do that, so some CNAs did not carry a pager. 10. Interview on 3/10/26 at 9:37 a.m. with CNA DD revealed she was a contracted travel CNA. This was her second shift here at the facility, and she did not know the facility had pagers. 11. Interview on 3/11/26 at 8:45 a.m. with CNA Y revealed the facility would like the call lights answered in under 5 minutes. 12. Interview on 3/11/26 at 9:05 a.m. with CNA M revealed that the call lights should be answered within a timely manner of no more than 15 minutes. 13. Interview on 3/11/26 at 9:30 a.m. with registered nurse (RN) H revealed that the call lights should be answered as quickly as possible but no more than 15 minutes. 14. Interview on 3/11/26 at 11:35 a.m. with director of nursing (DON) B revealed that the call lights should be answered in under 15 minutes. 15. Review of the provider's reviewed 11/18/2025 Call Light policy revealed the facility shall answer call lights in a timely manner.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (7) who eloped (left the facility without staff knowledge) from the front door of the facility on 9/2/25, and one of one sampled resident (77) who fell while being transferred by certified nursing assistant (CNA) V, who did not transfer the resident as directed in the resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions). This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incidents.Findings Include:1. Review of the provider's 9/3/2025 SD DOH FRI revealed on 9/2/25 at 2:48 p.m. resident 7 exited the building following a staff member leaving the property. Resident 7 was seen outside in the parking lot by the front door at 2:50 p.m. and escorted back into the facility. A skin assessment, blood pressure, pulse, temperature, and respirations were taken by registered nurse (RN) K on 9/2/25 upon resident 7 entering the facility. The staff education on the elopement policy and where the elopement photographs (photographs taken and displayed of residents who are a high risk for leaving the facility) were located was initiated. Elopement audits were started on 9/9/25 and reviewed in Quality Assurance and Performance Improvement (QAPI) meeting. Staff were aware of which residents were at risk of elopement. Resident 7's care plan and elopement risk assessments were reviewed. Her primary care provider (PCP) and family were notified of the incident. 2. Review of resident 7's electronic medical record (EMR) revealed that her Brief Interview for Mental Status (BIMS) score on 8/6/25 was three and on 1/26/26/26 was zero, which both indicated her cognition was severely impaired. Resident 7's 7/3/25 and 9/2/25 elopement risk assessments' scores were 5, which indicated she had a high risk for elopement. 3. Resident 7's care plan in use prior to the elopement revealed non-pharmaceutical (no medications) interventions for when resident was wandering. Interventions initiated on 8/28/24 were to cue, reorient and supervise resident 7. Interventions added to her care plan on 3/5/25 were the use of animatronic dog, conversation, walking with resident, inviting her to activities, encouraging rest and providing less stimulation when exhibiting anxious behaviors, delusions or wandering. Interventions added to her care plan on 9/2/25 identified resident 7 as an elopement risk due to diagnosis of dementia and delusional disorders with additional interventions that include exit and stairwell alarms, follow a familiar routine, keep photographs of resident on the unit and at the front desk, redirect the resident with familiar pictures and items, and maintain a calm environment. Interventions added on 1/19/26 resident 7's visitors would notify staff when they leave her room so staff will know resident 7's whereabouts within the facility. 4. Resident 7's progress notes revealed at the time of the elopement on 9/2/25, she was ambulating with a walker throughout the facility. 5. Observation on 3/8/26 at 6:35 p.m. of resident 7 revealed she was maneuvering around the dining room in a wheelchair. 6. Observation on 3/10/26 at 8:57 a.m. with receptionist BB revealed that anytime a new resident showed signs of possible elopement risk, staff posted a picture at the front desk and in the time clock room where staff clock in and out for the day. 7. Observation on 3/10/26 at 9:00 a.m. revealed that residents who are at risk for elopement had photos laminated on a sheet of paper in the time clock room and at the front desk. 8. Interviews on 3/11/26 at 8:45 a.m. to 9:30 a.m. with certified nursing assistants (CNA) (Y, M, V) and RN H revealed they identified elopement-risk residents by using the pictures in the time clock room, and the pocket care plans (a document that identifies residents' care needs and interventions) that say if they were an elopement risk. 9. Interview on 3/11/26 at 3:00 p.m. with director of nursing (DON) B revealed she did not consider resident 7's elopement a lack of staff supervision. She stated, the residents are mobile and deemed an elopement risk, but if they were to get outside that it is an elopement based on our policy. She expected staff to know the photos of the residents and which residents were high elopement risks. She expected staff to respond to door alarms immediately and if there was an elopement she expected the staff to call her immediately. DON B stated that during resident 7's elopement, the staff member let in five family members into the front door, which crowded the direct sight of receptionist at the front desk from seeing resident 7 use her walker to leave the facility. 10. Review of the provider's staff education provided on 9/2/25 revealed that all staff received education on the elopement policy, including the expectation that staff know which residents were in the area of the exit door when they were leaving the facility for any reason, and that they ensure the door closes behind them once they exited the building. 11. Review of the provider's quality assurance and performance improvement (QAPI) notes from October 2025 revealed the elopement for resident 7 was being monitored. 12. Review of the provider's audits after resident 7's elopement revealed weekly audits of four staff members or visitors that were exiting the building were visually checked to ensure no resident followed them from the building. Audits were completed over the course of four weeks from 9/9/25-9/30/25. All 28 audits were documented to show the doors were being monitored by staff and visitors when they were exiting. 13. Review of the provider's February 2024 Elopement policy revealed The facility must take steps to keep the resident safe and assess residents to identify those who are risk for elopement. 14. The provider implemented actions to ensure the deficient practice did not reoccur. On 3/12/26, observation, interviews, and record review confirmed the facility had followed its quality assurance process. The facility provided education to all nursing staff regarding the elopement policy, and the elopement photographs were placed at the front reception desk and the time clock room. Staff interviews showed they understood the education provided. The facility completed audits demonstrating staff knowledge of expectations when exiting the facility and awareness of residents at risk for elopement and their surroundings. The QAPI committee was monitoring the progress of the audits as noted in their meeting documentation. 15. Based on the information above, non-compliance at F689 occurred on 9/2/25. Because the provider implemented corrective actions from 9/2/25 through 9/30/25, and those actions were confirmed on 3/12/26, the non-compliance is considered past non-compliance. 16. Review of the provider's 11/25/25 SD DOH FRI for resident 77 revealed that on 11/11/25 at 8:00 a.m., licensed practical nurse (LPN) I was called to resident 77's room by CNA V. Resident 77 was lying on her right side on the floor at the foot of her bed. CNA V reported he had been assisting resident 77 from the bathchair to her wheelchair when she was unable to stand any longer and he eased her to the floor. LPN I immediately assessed resident 77 and found a one-centimeter skin tear to her right eyebrow that was closed with a steri-strip [an adhesive strip used to close small, shallow wounds], and a light blue bruise that measured ten centimeters by three centimeters on her right upper arm. Resident 77's range of motion was at baseline, and her neurological assessments (an assessment of nerve function, reflexes, coordination, motor skills, sensation, and mental status) and vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were within normal limits. Resident 77 complained of pain at 3 on a scale from 0 (no pain) to 10 (worst imaginable pain). Pain medication was provided, and an icepack was applied to resident 77's arm. Resident 77's care plan indicated she was to be transferred by one-person assist with a gait belt (a waist strap gripped as support for safe mobility and transfers). CNA V did not use a gait belt when he transferred resident 77 and was suspended immediately. The provider's interdisciplinary team (IDT) met following resident 77's fall and reviewed her care plan, which remained appropriate. Education regarding gait belts and the provider's Transfer Gait Belt Use policy was initiated with all staff members on 11/25/25. Audits will be conducted on [CNA V] weekly x [for] 4 weeks and 3 random residents weekly x 4 weeks. Residents 77's primary care physician and power of attorney were notified. 17. Review of resident 77's EMR revealed she was admitted to the facility on [DATE]. Her 8/13/25 care plan indicated she transferred with one person's assistance using a walker and a gait belt. Her 8/13/25 Fall Risk Evaluation indicated she was at a high risk for falling. 18. Interview on 3/10/26 at 1:10 p.m. with CNA V revealed that he recalled the events of resident 77's 11/25/25 fall and confirmed the information reported in the FRI was accurate. He knew that he needed to use a gait belt when he transferred resident 77 from the bath chair to the wheelchair, and was unsure why he had not used one that day. He received education on resident care plans, the use of gait belts, and safe transfers with residents. 19. Interview on 3/10/26 at 1:10 p.m. with DON B revealed resident 77's fall occurred because CNA V did not follow the resident's care plan, which included that she needed to be transferred with a gait belt. Education was provided to all caregiver staff on following the resident care plans, the use of gait belts, and safe transfers with residents. Audits were started and completed weekly on CNA V and other staff members when transferring residents to ensure that resident care plans were followed, and gait belts were used when required. A QAPI meeting was held on 12/3/25 and included resident falls, including resident 77's 11/11/25 fall, safe resident transfers, and ensuring transfer status and equipment were included in the resident care plans. 20. Interview on 3/11/26 at 4:19 p.m. with administrator A regarding resident 77's 11/25/25 fall revealed that she confirmed they immediately suspended CNA V, reported the incident to the SD DOH, resident 77's physician, and the resident's power of attorney, and conducted an investigation. They identified that CNA V had not used a gait belt, as indicated in her care plan, when he transferred resident 77 that day, and she fell. They provided immediate education to CNA V and initiated education with all caregiver staff members on 11/25/25. They completed weekly audits of CNA V and other staff members completing transfers. They included those audits in their QAPI program and are continuing to monitor falls throughout the facility. 21. Review of the provider's Transfer and [NAME] Belt Use, Care Plan, and Falls Management policy staff education initiated on 11/25/25 revealed that all staff were educated. 22. Review of the provider's QAPI notes from 12/3/25 revealed that resident falls, including resident 77's 11/25/25 fall, were reviewed, and a gait belt performance improvement project (PIP) had been initiated. 23. Review of the provider's audits after resident 77's 11/25/25 fall revealed the provider completed three audits a week for four weeks, and no further issues were observed. Care plans were followed, including the use of the gait belt, and further education was provided to staff members when needed. 24. The provider's implemented actions to ensure the deficient practice does not recur were confirmed on 3/12/26 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding care plans, the use of gait belts, and the provider's fall management policy, and audits were completed. Interviews with nursing staff revealed they understood the education provided regarding the resident safety with transfers, the use of gait belts, and following the resident care plan. Observations of transfers in residents' rooms were conducted, and confirmed that staff understood how to use gait belts, followed the resident care plan, and transferred residents safely. A QAPI meeting was held on 12/5/25 to implement a plan, and will continue to be a part of their QAPI process for review and further advise staff as needed. 25. Based on the above information, non-compliance at F689 occurred on 11/25/25, and based on the provider's 12/5/25 implemented corrective actions for the deficient practice confirmed on 3/12/26, the non-compliance is considered past non-compliance.

Based on the South Dakota Department of Health (SD DOH) complaint report review, interview, document review, record review, and policy review, the provider failed to implement policies and procedures to report to the SD DOH and law enforcement, allegations of sexual abuse for two of two sampled residents (57 and 78) who reported sexual abuse allegations to social service designee (SSD) (F) that they were touched in their private area by one of one certified nursing assistant (CNA) (D) and an unidentified staff member. The provider's failure to report those allegations to law enforcement for review and investigation may have put those residents at continued risk for further abuse and all residents at risk for potential abuse. Findings include: 1. Review of the complaint report submitted to the SD DOH on 2/6/26 revealed that either a student or an aide had stuck their hands down her [resident 78's] pants to check if she was dry, without her permission. She stated her mind is good, and she had told the person that she didn't need to go to the toilet, and that she was dry. The aide or student proceeded to 'check' her without asking. She felt very embarrassed by this. She stated she spoke with facility management the next day, and they verified the person should not have done that. There was no further follow-up with the resident. She could not recall the name of the person who had done it, and the incident bothered her. 2. Interview on 3/10/26 at 12:21 p.m. with director of nursing (DON) B revealed that an internal investigation was completed after resident 57 complained to RN H that a staff member checked her incontinence brief to see if it was wet, which startled her since she was independent with using the bathroom. RN H reported that to DON B. DON B explained that CNA D did not mean it in a sexually inappropriate way so she did not report the incident to the SD DOH. The incident happened on 1/23/26 during the night shift rounds. She stated CNA D currently worked at the facility and she disciplined and educated CNA D after the incident. She acknowledged that touching a resident's incontinence brief was not an acceptable way to see if they were incontinent. She said the investigation report she completed indicated that resident 57's brief was not checked by touching her. If CNA D had touched the brief to see if it was wet, DON B would have reported it to the SD DOH, and CNA D would have been suspended until the investigation was completed, and possibly had his employment at the facility terminated. 3. Review of the provider's internal investigation form revealed that resident 57's abuse allegation was reported on 1/23/26 to RN H by resident 57 and stated the night aide came in her room and pulled back her blanket and checked her brief which had startled her. [RN H] reported that [resident 57] did not feel that this was completed inappropriately towards her, but more of a lack of education. RN H reported this to DON B, and DON B had SSD F conduct a social service visit to discuss the incident with [resident 57]. Review of SSD F interview documents that were attached to the internal investigation form revealed it stated, I spoke with [resident 57] about what happened and checked on how she was feeling about the situation. [Resident 57] reported that staff entered her room during the overnight rounds while she was sleeping and she was not expecting someone to come in at that time. The CNA pulled down her blanket to check her brief which startled her. [Resident 57] and I talked about how the CNA was completing routine rounds and may not have known her usual nighttime routine. [Resident 57] stated she understood and said she does not believe the CNA meant anything inappropriate towards her. She also stated she is not upset with the CNA and felt he likely did not know her routine. I stayed with [resident 57] for a while and we continued to talk about the situation. During the visit she appeared calm and comfortable with discussing what happened. She did not express ongoing concerns. I asked if she would like me to notify family and she declined. Social Services will continue to monitor and remain available if she has any concerns. [Resident 57] reports that she feels safe at the facility. The internal investigation form indicated that the physician, police, ombudsman, and the state agency were not notified of the incident. On 1/26/26 SSD F interviewed resident 57 regarding the incident, and it stated [Resident 57] reported that she has had no further issues. She remains to feel safe at the facility. On 1/27/26 SSD F interviewed resident 57 regarding the incident, and it indicated that resident 57 had no further issues, felt safe, and she would notify SSD if she had further issues. The outcome of the investigation summary section described the incident that had occurred. It stated that administrator A and DON B called resident 57's daughter to notify her of the incident, and her daughter said she would call them if resident 57 said anything about it. It stated that DON B interviewed CNA D on 1/23/26, and he reported that he said the resident's name before pulling the resident's blankets back. He thought she knew what he was doing, and he apologized that he startled her. DON B gave him a written warning. DON B told resident 57 that her care plan was changed, and the investigation summary indicated that resident 57 was happy with that. It stated, In review of South Dakota's reporting guidelines this did not rise to the level of abuse/neglect due to [resident 57's] denial of inappropriate action towards her and [CNA D's] lack of touching her and therefore was not reported to the Department of Health. 4. Interview on 3/11/26 at 11:15 a.m. with SSD F revealed that CNA D touched the resident's incontinence brief to see if she was wet. SSD was unsure if resident 57's incontinence brief or private area was touched when CNA D checked her for incontinence. She verified that it was not an appropriate way to see if a resident was incontinent. 5. Interview on 3/11/26 at 11:40 a.m. with resident 57 revealed that the CNA touched her on the inside of her incontinence brief. She became tearful, and by the end of the interview she was not sure if she was touched on the inside or the outside of her incontinence brief, and she just wanted to forget about it. 6. Interview on 3/11/26 at 9:08 a.m. with RN H revealed that during a night shift, a CNA was confused about which residents needed to be checked for incontinence, and that the residents down the D wing were startled by this. The CNA still worked here, and she was not aware whether he continued to do that, and no residents had complained about that. 7. Interview on 3/11/26 at 12:50 p.m. with independent living specialist QQ regarding resident 78's complaint about a female staff member who put her hands down resident 78's pants to feel if she was wet, revealed resident 78 was no longer at the facility. Resident 78 was just there for rehab and at the time of the incident, she was independent with toileting. The incident made resident 78 feel uncomfortable and she reported to independent living specialist QQ that she had nightmares about it and recalled resident 78 saying got an eerie gross feeling about it. Independent living specialist QQ continued to stay in contact with her. She was not sure who resident 78 reported the incident to at the facility, but said resident 78 made a formal complaint, and she did not hear back from anyone about it. Independent living specialist QQ was unsure when the incident occurred. 8. Phone interview on 3/11/26 at 12:58 p.m. with resident 78 revealed she was unsure when the incident occurred, but she was able to recall that it happened during a night shift. The female staff member asked her if she needed to use the bathroom, and when resident 78 said no, the female staff member put her hand down resident 78's pants and said, Nope, you're dry. Resident 78 reported that she had resided in the D wing, she wore her own underwear, and that a female staff member put her hand on the inside of her underwear when she checked her. She said she did not do anything about it that night, but the next day, she told COTA E about it. Resident 78 reported that COTA E brought her to SSD F's office for her to report the incident to SSD F. She said she reported the incident to the two women in that office, and said they had looked surprised. When she was telling them what happened, she thought it appeared that SSD F was looking at the staffing schedule to see who was working that night. Resident 78 was told that they had students from a vocational school there at the facility. Resident 78 stated that she had made a formal complaint with SSD F and the other lady that was in the office, and when she read her discharge paperwork from the facility, she did not see anything about the incident, so she made a complaint report with the SD DOH so it would not happen to other residents. She said no one from the facility followed up with her after she made the formal complaint. 9. Interview on 3/11/26 at 1:20 p.m. with COTA E revealed that resident 78 told her about the incident that occurred during the night shift, where a staff member put their hands in resident 78's pants to see if she was incontinent. COTA E reported that resident 78 was upset and that she was sleeping when that staff member came into her room. She said she took resident 78 directly to the social services office, and SSD F was there, but she was unsure if anyone else was in there. COTA E stated that was not the first time residents had reported this concern to her. She was not sure how many residents had, but thought five or less, in the last six months. Residents reported to her that the staff ripped off their blankets and would feel around to see if they were incontinent. It happened to the residents who were both continent and incontinent. She listed two other residents who were still in the facility, who she recalled having that happen to. 10. Interview on 3/11/26 at 1:45 p.m. with SSD F revealed that she did not recall COTA E bringing resident 78 to her office or that resident 78 made a formal complaint to her. She reported that the therapy department brought the residents to her office frequently about this or that. She stated that their process for filing resident grievances was to listen to them, document the grievance, investigate them, and report them to the SD DOH if needed. SSD F said that she did not recall any other residents, besides resident 57, reporting that staff put their hands in their pants to check if they were incontinent and stated, it's a pretty serious thing. She said that and incident like that would be reported to administrator A and DON B for them to investigate it. 11. Interview on 3/11/26 at 3:10 p.m. with DON B revealed she only received a complaint from resident 57 regarding staff putting their hands in her pants to check to see she was incontinent. If a resident had a complaint concerning abuse allegations, she would investigate it. If the investigation determined that the staff were inappropriate, then she would report it to the SD DOH. 12. Interview on 3/11/26 at 5:00 p.m. with administrator A and DON B revealed that they were not aware that resident 57 had was touched to check to see if she was incontinent. DON B had SSD F visit with resident 57 regarding the incident, and she thought resident 57 told SSD F that CNA D did not touch her. She explained how she updated the pocket care plan and that she talked with CNA D, provided him with education, and wrote him up. She stated that no other residents were interviewed. Administrator A stated that allegations of sexual abuse were to be reported to the SD DOH within two hours, reported to law enforcement, and Dakota at Home. She expected staff not to put their hands in the residents' incontinence briefs or touch the brief to check if the resident was incontinent. The incontinence brief had lines on it that turned color when it was wet, and the staff were to let the residents know what they were going to do and get their permission before they did anything. If a resident did not want to be checked, the staff were to report it to the charge nurse. 13. Review of resident 57's EMR revealed she was admitted to the facility on [DATE]. Her 2/6/26 Brief Assessment for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had diagnoses of Generalized Anxiety Disorder (GAD) (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), other manic episodes (a period of abnormally high energy, extreme happiness, or severe irritability), Agoraphobia (a fear of being in situations where escape might be difficult or help unavailable if a panic attack occurs), Major Depressive Disorder (MDD) (a persistent feeling of hopelessness, emptiness, or low mood). Review of resident 57's 2/22/26 care plan revealed that social services would visit with her to assess her psychosocial needs and would follow up as needed. She had a hearing deficit, and she was independent with toileting. Review of resident 57's medication record revealed she took Lexapro 20 milligrams (mg) (an antidepressant) daily and Seroquel 50 mg every night for MDD, and Depakote 250 mg twice daily for MDD and other manic episodes. Resident 78's 11/17/25 care plan did not indicate what assistance she required for personal hygiene care, ambulating (walking), or using the bathroom. Resident 78 had physician orders to take Mirtazapine 15 mg (a depression medication) daily. 14. Review of resident 78's medical record revealed she was admitted to the facility on [DATE] and discharged home on [DATE]. Her 12/8/25 BIMS assessment score was 15, which indicated her cognition was intact. And she had diagnoses of Anxiety Disorder and Depression. Review of resident 78's 11/17/25 care plan revealed it did not indicate what assistance she required for hygiene care, ambulating, or using the bathroom.Review of resident 78's physician orders revealed she took Mirtazapine 15 mg (depression medication) daily. 15. Review of the provider's 5/14/25 Abuse and Neglect policy revealed that the facility would provide care services in an environment that was free from any type of abuse. And to follow federal guidelines to prevent abuse and investigate allegations of abuse. The abuse coordinator was the administrator, and she was responsible for developing and implementing the abuse prevention training curriculum and conducting the investigation in situations of alleged abuse/neglect. Sexual abuse included implied or actual contact between a caregiver and resident of sexual nature. If an allegation of sexual abuse towards a resident is reported., the facility will send resident to the emergency room to be evaluated if ordered by the resident's physician. A report will be made to the local police department the same day the allegation is made. If abuse was suspected the facility would immediately protect the residents, notify appropriate authorities that an investigation would be conducted, conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses, notify law enforcement if needed (example- Sexual abuse), and report the investigation findings to all necessary state and/or local agencies and other identified persons as required by law. The steps indicated to prevent abuse were screening, training, prevention, identification, investigation, protection, and reporting/responding. The provider was to inform residents, residents' families, and staff how to report grievances or concerns and to whom they could report it to. The provider was to respond to the residents, families, or staff concerns that reported grievances or concerns. The administrator or designee was to investigate all abuse allegations of abuse immediately. The provider was to interview all people who might know information about the allegation to determine if abuse had occurred. The investigation was to be documented thoroughly. The provider was to protect residents from physical and psychosocial harm during the investigation, assess the resident for injury, notify the physician, and suspend the accused employee during the investigation. The provider was to report to the administrator immediately any allegations or suspicions of abuse. The allegation of abuse needed to be reported to the SD DOH within two hours of the allegation. A final investigation report was to be submitted to the state agency within five working days.

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure:*Food was maintained at a safe temperature to prevent food-borne illness for one of two observed meal services in one of two dining rooms (Independence).*Ten of eleven observed staff (B, C, D, F, O, HH, II, JJ, KK, and LL) who washed their hands in the Independence kitchenette with food uncovered, without hair restraints to prevent hair from contacting the food, during an observed supper meal service.*Four of five observed staff (C, G, NN, OO) who washed their hands in the [NAME] kitchenette with food uncovered, without hair restraints to prevent hair from contacting the food during an observed lunch meal service. Findings include:1. Observation of the supper food service on 3/8/26 in the Independence kitchenette revealed that at 5:53 p.m., cook GG arrived at that kitchenette with a cart that had a container of pre-made egg salad sandwiches, which sat on a container of ice. [NAME] GG took the temperature of the egg salad sandwiches, and they were 45 degrees Fahrenheit (F). Beginning at 5:55 p.m., staff members periodically went behind the kitchenette to wash their hands in the sink when uncovered food was in the steam table and on the cart, and they were not wearing hair nets or hair restraints. Those staff included certified nursing assistant (CNAs) D, HH, JJ, KK, and LL, certified medication assistant (CMA) II, registered nurse (RN) supervisor O, RN/Minimum Data Set (MDS) coordinator C, director of nursing (DON) B, and social service designee (SSD) F. Some of those staff members had touched the cart that had egg salad sandwiches on it with their backs while washing their hands in the sink. At 6:05 p.m. cook GG began plating the egg salad sandwiches to serve to the residents. When asked, she stated the egg salad sandwiches were to be at 41 degrees F or less, so she should not serve them. She retook the temperature of the egg salad sandwich, and it was 50 degrees F, and stated that all the ones she checked were above 41 degrees F. She called dietary manager (DM) Q, and she said she would call her back. At 6:14 p.m., someone called her on the phone in the kitchenette and told her not to serve the egg salad sandwiches and to take them back to the kitchen. At 6:23 p.m., she received new egg salad sandwiches, and the temperature of them was 55 degrees F, so they were not served to the residents. At 6:58 p.m., new egg salad sandwiches were brought to the kitchenette, and their temperature was under 41 degrees F, so they were served. At 7:20 p.m., cook GG checked the temperature of the milk on a resident room meal tray that was on the tray since the start of food service. It was 60 degrees F. She said it was to be under 41 degrees F, so she did not serve that and replaced it. At 7:21 p.m., DON B reheated soup in the microwave behind the kitchenette and did not wear a hair net. 2. Interview on 3/8/26 at 7:25 p.m. with cook GG revealed she verified she was going to serve the egg salad sandwiches that were 45 degrees F and the milk that was on the room tray and was 60 degrees F. 3. Observation on 3/9/26 during the lunch food service in the [NAME] kitchenette revealed that at 11:59 a.m., the food was in the steam table and was uncovered. SSD G washed her hands in the kitchenette, and she was not wearing a hair net or hair restraint. At 12:01 p.m., staffing coordinator NN washed her hands in the kitchenette, and she was not wearing a hairnet. At 12:02 p.m., medical records director OO washed her hands again in the kitchenette and was not wearing a hairnet or hair restraint. At 12:03 p.m. RN/MDS coordinator C washed her hands in the kitchenette. She wore her hair in a ponytail that did not contain all of her hair, and she did not wear a hairnet or hair restraint. At 12:04 p.m., SSD G washed her hands again in the kitchenette, and was not wearing a hair net or hair restraint. 4. Interview on 3/11/26 at 8:32 a.m. with DM Q revealed she expected the cook to call her if the temperature of the food was not at the required serving temperature. [NAME] GG should not have started to serve the egg salad sandwich or the milk if it was not at a safe temperature. Staff routinely washed their hands behind the kitchenette, and only dietary staff wore hairnets/hair restraints. 5. Interview on 3/12/26 at 10:25 a.m. with DON B revealed she expected staff to wear hairnets if they were around food that would be served to the residents. 6. Review of the provider's 2020 Serving Temperature for Hot and Cold Foods policy revealed that cold food and dairy products were to be served at 41 degrees or colder to ensure a safe dining experience. 7. Review of the provider's 2020 Hair Restraints policy revealed that staff shall wear hair restraints in all food production, dishwashing, or serving areas. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food.

Based on interview, record review, and policy review, the provider failed to notify the physician of two of three sampled residents (57 and 61) who had unplanned significant weight loss (a loss of 5% (percent) of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days). Findings include:1. Interview on 3/8/26 at 2:35 p.m. with resident 61 in her room revealed that she was unhappy with the food. She stated she lost weight since she admitted to the facility about one month ago because the food gave her diarrhea and was inedible and disgusting. She had not met with the dietitian or the doctor about her concerns with the food or her weight loss. She ate all her meals in the dining room. She was frustrated that her daughters would not let her return home and felt that she was in a cage. She stated that she had attempted multiple times to leave the facility but that staff members had prevented her from doing so. 2. Observation on 3/8/26 at 5:37 p.m. with resident 61 in the dining room revealed that she walked independently to the dining room, asked what was for dinner, and stated, It sounds good. Resident 61 stated, This looks good, when she was served her meal, moved the food around on her plate, removed the beans from her soup, took a couple of small bites of the broth, and drank a few sips of water. When a staff member encouraged her to eat, resident 61 stated she had eaten all she wanted and declined the staff's offer of other food items. 3. Interview on 3/8/26 at 6:19 p.m. with resident 61 revealed that she stated the food was awful. She then stated that her stomach was awful and the food was fine. She stated that she did not want to eat any food and that she was afraid she would have diarrhea. 4. Observation and interview on 3/10/26 at 8:21 a.m. with resident 61 in the dining room revealed she was served hot tea, milk, juice, hot cereal, an egg sandwich, and a banana. She stated the breakfast was good. She moved food items around on her plate but was not observed to eat any of the food. 5. Review of resident 61's electronic medical record (EMR) revealed she was on a regular diet with mechanical soft textures and a Nutrition Intervention Plan (NIP). Her care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated to monitor her for difficulty chewing or swallowing, signs and symptoms of dehydration, and weight loss. Staff members were to obtain her weight every week and to monitor and record her intake at every meal. Resident 61's admission weight on 2/9/26 was 173.4 pounds (lbs). On 2/16/26, her weight was 154.4 lbs. That was a 19 lb. weight loss in seven days. On 2/23/26, her weight was 153.3 lbs. That was a 0.9 lb. weight loss in seven days. On 3/2/26, her weight was 146.4 lbs. That was a 7.1 lb. weight loss in seven days. On 3/9/26, her weight was 142.6 lbs. That was a 3.8 lb. weight loss in seven days. Resident 61 had lost 30.8 lbs. since her admission, a 17.8% (percent) weight loss. There was no documentation that resident 61 had been reweighed or refused to be weighed when there was a documented weight loss. There was no documentation that physician FF was notified of resident 61's weight loss. Resident 61 had been at the facility for 27 days. She was documented as refusing to eat 13 meals, had eaten 0-25% at 16 meals, and there was no documentation of how much resident 61 had eaten or if she refused for 19 meals. 6. Interview on 3/10/26 at 8:37 AM with certified nursing assistant (CNA) P in the dining room revealed she was responsible for recording the amount of food and liquid each resident in the dining room ate and drank that day. The CNAs took turns completing that task depending on who was working and who was in the dining room. Those amounts were to be recorded in the residents' EMR. She thought that resident 61 ate pretty well, did not complain about the food, and had never asked for or accepted substitute food items from her. For breakfast, when she looked at resident 61's plate after she left the dining room, CNA P stated it appeared that resident 61 had not eaten very much. CNA P stated that resident 61 had moved the food around on her plate, but she was unsure if resident 61 had eaten anything. She would mark zero to 25 percent (0-25%) in resident 61's EMR because resident 61 had not refused to come to the dining room. CNA P stated that she was unaware of whether resident 61 had experienced weight loss since her admission to the facility. She did not weigh residents because the bath aide weighed the residents. She did not notify the nurse regarding the amount resident 61 ate because she thought the EMR alerted the nurse when a resident ate less than 50% of their meal. 7. Interview and review of the bath and weight sheets on 3/10/26 at 8:44 a.m. with CNA T revealed he was the bath aid. The bath and weight sheets indicated which residents were to receive a bath and have their weight taken that day, and which residents needed to be reweighed. Those weight sheets indicated the residents' last weight, and he would record the resident's current weight on those sheets and in the resident's EMR. He would provide the completed sheet to the nurse at the end of his shift. If he noticed a weight loss of more than three pounds (lbs.), he would reweigh the resident and tell the nurse. Resident 61 was scheduled for a bath and a weight check on 3/10/26. She refused the bath, but he weighed her. He was aware that resident 61 had lost weight, and he had notified the nurse. He offered her many different food items, but she refused to eat. 8. Interview on 3/10/26 at 8:57 a.m. with licensed practical nurse (LPN) W revealed she had recorded resident 61's weight in the EMR when she admitted about a month ago, but the CNA that day had weighed her. She recalled that resident 61 was in a wheelchair when her weight was taken, and the CNA subtracted the weight of the wheelchair before she entered the weight in the EMR. She was aware that resident 61 was refusing to eat until she was allowed to discharge to her home, and had a significant weight loss since her admission to the facility. She thought that resident 61's physician was aware of the resident's weight loss. She did not notify resident 61's physician of the weight loss because she was not assigned to be resident 61's nurse on 2/16/26 or 2/23/26 when she was weighed. She expected that the nurse on duty that shift would have notified the physician. 9. Observation and interview on 3/10/26 at 9:30 a.m. with LPN N revealed she was aware that resident 61 had a weight loss since her admission to the facility because she was on a hunger strike. She thought that staff members were able to get resident 61 to eat a few things. She did not notify physician FF of resident 61's weight loss because she thought that resident 61 told physician FF she was refusing to eat when he was at the facility to see her. When a resident had a three-pound weight loss, the resident would be reweighed, and the physician would be notified. 10. On 3/10/26 at 9:35 a.m., administrator A was requested to provide documentation of resident 61's weights and reweighs, and documentation that the physician was notified of resident 61's weight loss. Resident 61's weekly weights were provided. There was no documentation of resident 61 having been reweighed or that the resident's physician was notified regarding resident 61's weights. 11. Observation and interview on 3/9/26 at 9:00 a.m. with resident 57 revealed she had a few teeth left in the front that were broken, making it hard for her to chew certain foods. She did not want to go to the dentist, and she did not want a specialized diet. 12. Review of resident 57's medical record revealed her weight on 3/4/26 was 133.7 lbs, and on 3/8/26, was 125.4 lbs. In one month, her weight was down 5%. Review of resident 57's diet intakes for the past 30 days indicated she ate 26-50% of her meals 28 times, and 51-75% of her meals 22 times. She had physician orders on 2/23/23 for 4 ounces (oz) of a nutritional supplement daily at breakfast, on 1/25/25 for ice cream daily at supper, and on 12/23/24 for a regular diet with regular texture. Resident 57's 2/27/26 care plan revealed she had a history of weight loss and nutrient deficiencies. She had poor dentition but was still able to eat a regular diet, and the staff were to monitor her for weight loss. Resident 57's 2/6/26 Brief Assessment for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. A 1/6/26 dietitian note by registered dietitian (RD) CC did not address resident 57's difficulty chewing certain foods related to her teeth. There was no progress note to indicate that resident 57's physician was notified of her weight loss. 13. Interview on 3/10/26 at 9:50 a.m. with LPN N revealed resident 57 had difficulty eating certain foods, did not want to see a dentist, and did not want her diet changed. If a resident's current weight was three to five pounds different from the previous weight, she would have the staff reweigh the resident. If that weight had a three to five pound difference, then the registered dietitian (RD) and physician were to be notified. She was not sure who was supposed to notify the RD, but the nurse was to notify the physician. 14. Interview on 3/11/26 at 9:27 a.m. with RD CC revealed she was at the facility on Tuesday and Thursday each week, but was on vacation during the week of 2/18/26. Each week, she attended a meeting with registered nurse (RN) supervisor O and X to discuss the residents' weights. All residents who experienced weight loss were discussed. If the CNAs noticed a change in the residents' weight, they were to tell the nurse supervisors. The nurse supervisors were to request a reweigh within 24 hours, and she stated, I am not sure if that happens every time. She ran a weight report weekly, and if she noticed a resident's weight changed, she would request a reweight. If a resident had a notable change in weight, the nurse supervisors were to notify the physician right away, and could add them to the physician rounds (when the physician comes to the nursing home to see the resident) list if they needed to be seen. Changes in the residents' weight should not wait to be followed up on at their weekly meeting. Regarding the 8.3 lb. weight loss for resident 57, RD CC stated that RN supervisor O should have followed up with her weight loss. She was aware that resident 61 had a significant weight loss in the month since her admission because she was eating very little. She asked for resident 61 to be reweighed during the weeks of 2/9/26 and 3/2/26, but was unaware if those weights were obtained. Resident 61 was placed on a nutrition intervention program (NIP) where extra nutrients were added to hot cereal, vegetables, and potatoes, and residents were provided with whole milk and ice cream. Resident 61 had also been offered a supplement, chocolate milk, and ice cream. She had not been aware that resident 61 had told staff she was on a hunger strike. She confirmed that resident 61's 30 lb. weight loss was very significant, but resident 61's BMI was 24.5 and considered within the normal range. She expected that physician FF and resident 61's family would be notified by the facility staff members of her weight loss, but was unsure if those notifications occurred. She expected meals to be recorded three times a day, even if a resident refused to eat. 15. Interview on 3/11/26 at 9:40 a.m. and again at 10:09 a.m. with RN nurse supervisor O revealed that the CNA was to notify the charge nurse if a resident's weight was different by three to five lbs. The charge nurse would then have the CNA complete a reweigh. If the reweigh indicated the resident had an eight lb weight loss, then the charge nurse was to notify the resident's physician. The bath aides turned in their bath sheets, which contained the residents' weights documented on them, at the end of the day for the nurse to review. The nurse then was to give them to the case managers to review. Regarding resident 61's weight loss, RN nurse supervisor O revealed that resident 61 had not been eating very much since she was admitted to the facility. She reviewed resident 61's weights each week when she met with RD CC since she was admitted to the facility. Resident 61 was not happy about being at the facility, attempted to leave the facility, refused to eat, and refused to go to the dining room at times. Resident 61 was on a hunger strike. She thought physician FF was aware of all resident 61's behaviors since she was admitted . She had not notified physician FF of resident 61's weight loss, but thought that he was aware because physician FF visited resident 61 at the facility. She expected resident 61 to have been reweighed on 2/17/26 and on 3/3/26. She was unsure if those reweighs had been obtained or if resident 61 had refused to be weighed. 16. Interview and review of bath sheets and resident 61's EMR on 3/11/26 at 10:44 a.m. with director of nursing (DON) B revealed she expected resident 61 to be reweighed if she had a weight loss of more than three pounds since her previous weight. There was no documentation that resident 61 had been reweighed after she was weighed on 2/16/26 or 3/2/26. DON B became aware of resident 61's weight loss on 3/4/26. She expected that resident 61's physician would have been notified after her 2/16/26 weight loss and again after the 3/2/26 weight loss. There was no documentation that physician FF had been notified. 17. Phone interview on 3/11/26 at 11:08 a.m. with physician FF revealed that he noticed a downward trend in resident 61's weight when he visited her at the facility. He was not notified of that weight loss by the nurses at the facility. He was addressing resident 61's behavior and mood issues. He was aware that resident 61 did not want to be at the facility, attempted to leave the facility several times, and that she was not eating well. He expected to be notified if a resident had a 10% weight loss. He was notified on 3/10/26 that resident 61 was on a hunger strike. He felt there were many issues that contributed to resident 61's weight loss. On 3/6/26, resident 61 had told him she was having difficulty swallowing, and he ordered a swallow study, which was scheduled for 3/16/26. He had a scheduled meeting on 3/13/26 with resident 61, her family, and facility staff to discuss her discharge plan and possible psychiatric consultation. 18. Review of the provider's 5/14/25 Weighing the Resident policy revealed If weight does not appear correct, re-weigh [the] resident to ensure [the] weight is accurate. Consider re-weighing the resident if there is a 5[five]-pound difference from the resident's last weight. Report significant weight loss/ weight gain to the charge nurse who will then report to the RD and [the] physician. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria. 1 [One] month- 5% weight loss is significant; greater than 5% is severe. 3 [Three] months – 7.5% weight loss is significant; greater than 7.5% is severe. 6 [Six] months – 10% weight loss is significant; greater than 10% is severe. Notify the charge nurse if the resident refuses to be weighed. Document [the refusals in the medical record and reapproach [the] resident as needed. Notify [the] physician if [the] resident refuses three consecutive attempts to weigh. 19. Review of the provider's revised 11/18/25 Notification of Change of Condition policy revealed, The facility must promptly inform the resident; consult with the resident's medical provider.when. A significant change in the resident's physical, mental, or psychosocial status. Continued resident refusals of ordered treatments or procedures 9at least three consecutive refusals).

Based on record review, interview and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, the provider failed to ensure three of five sampled residents' (7, 10, and 57) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop and individualized care plan to manage the resident's care needs) assessments were accurately coded for the areas of medications and Pre-admission Screening and Resident Review (PASRR). Findings include:1. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. *She had an 8/22/24 physician's order for Escitalopram (an antidepressant medication) 20 milligrams (mg) once daily for depression. *Her 1/28/26 significant change MDS assessment, section N (medications) indicated she was taking antipsychotic, antianxiety, opioid, and anticonvulsant medications, but it did not identify her as taking an antidepressant medication. 2. Interview and record review on 3/11/26 at 10:36 a.m. with registered nurse (RN)/MDS coordinator C revealed: *She acknowledged that resident 7 had a physician's order dated 8/22/24 for Escitalopram 20 mg tablet once daily. *She reviewed resident 7's 1/28/26 significant change MDS assessment, section N for and agreed it was not marked correctly since she was taking an antidepressant medication. *She stated RN Z completed section N of residents' significant change MDS assessment. *When completing the MDS assessments they pull the residents' medication administration records (MAR) and treatment administration records (TAR). *She used the CMS Long-Term Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 to complete the residents' MDS assessments. 3. Review of resident 57's EMR revealed she had an approved PASRR Level II (an in-depth evaluation required by federal law for anyone applying to a Medicaid-certified nursing home who is suspected of having a serious mental illness [SMI] or an intellectual/developmental disability [I/DD]) on 4/22/25. Her 10/27/25 comprehensive MDS assessment, indicated she did not have a PASRR level II. Resident 57's care plan indicated that her PASRR level II was added on 2/22/26. Resident 57 had diagnoses of generalized anxiety disorder (GAD) (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), other manic episodes (a period of abnormally high energy, intense euphoria, or extreme irritability, where a person feels on top of the world or reckless), Agoraphobia (fear of certain places or situations), and major depressive disorder (MDD) (persistent feeling of sadness, emptiness, or loss of interest in activities). Resident 57's physician's orders included social services as needed and psychiatric consult started on 10/11/22, Lexapro 20 mg (a medication for depression) daily started on 5/26/23, monitor for behaviors started on 4/25/25, Depakote 250 mg twice daily started on 3/12/25, and Seroquel 50 mg daily started on 6/17/25. 4. Review of resident 10's EMR revealed he was admitted to the facility on [DATE]. His diagnoses included bipolar disorder (a mental condition causing extreme shifts in mood, energy, and activity levels), anxiety disorder, and adjustment disorder with depressed mood. He had a level I (1) PASRR completed on 12/27/23 and again on 10/16/24 due to a potential change in his mental status. The 12/27/23 and 10/16/24 Level I PASRRs stated, Your Level I screen was submitted for a potential status change. It shows that you have evidence of serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation. -The facility should mark yes for question A1500 on the MDS 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?' Item A1500 in section A of his 9/22/25 comprehensive MDS assessment was coded No to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? -Item A1500 in section A was coded No on resident 10's 9/26/24 and 5/12/23 comprehensive MDS assessments, and yes on his 9/15/23 comprehensive MDS assessments. 5. Interview on 3/9/26 at 2:34 p.m. with RN/MDS coordinator C revealed she confirmed resident 10 had a severe mental illness, the 12/27/23 Notice of PASRR Level I Screening Outcome indicated the facility should mark yes for question A1500 on the MDS, and that section A1500 of resident 10's 5/12/23, 9/26/24, and 9/22/25 MDS was marked no. She stated she had miscoded that section of the MDS assessment for resident 10. 6. Interview on 3/11/26 at 11:36 a.m. with director of nursing (DON) B revealed social services designee (SSD) F completed the PASRR screenings, and RN/MDS coordinator C coded that information on the MDS assessment. She was unaware that resident 10's MDS assessment was not coded correctly. 7. Interview on 3/11/25 at 12:48 p.m. with SSD F revealed she completed PASSR screenings, and RN/MDS coordinator C completed the MDS assessment. 8. Interview on 3/11/25 at 4:23 p.m. with administrator A revealed she expected SSD F to complete the PASSR screening and to communicate with RN/MDS coordinator C for accurate coding on the MDS assessments. 9. The provider's 5/15/26 Preadmission Screening and Resident Review PASRR policy revealed the Preadmission Screening and Resident Review (PASRR) is a federal requirement to ensure the Nursing Facility (NF) residents with Serious Mental Illness (SMI) or Intellectual and Developmental Disability (ID/DD) are identified and evaluated, placed in the most appropriate and least restrictive setting available, transitioned to an appropriate community setting when they no longer meet criteria for NF placement, and to provide with the MI/ID/DD services they need, including specialized services. 10. Review of the CMS Long-Term Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed: Section N, Page N6 and N7, Steps for Assessment: -1. Review the resident's medical record for documentation that any of these medications were received by the residents and for the indication of their use during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Review documentation from other health care settings where the resident may have received any of these medications while a resident of the nursing home (e.g., valium given in the emergency room). When answering the PASRR question on the MDS assessment, question A1500 should be coded as a yes if the resident had a PASRR Level II, which would then require question A1510 to be answered to indicate the reason for PASRR Level II, Serious mental illness, Intellectual Disability, or Other related conditions.

Based on record review, interview, and policy review, the provider failed to complete a Level II (2) Preadmission Screening and Resident Review (PASRR) for one of one sampled resident (32) with a new psychosis diagnosis. Findings Include: 1. Review of resident 32's electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and had a diagnosis of unspecified psychosis that was documented on 1/23/26.2. Resident 32's 1/19/26 PASRR level 1 screening form did not a indicate a confirmed or suspected mental illness diagnosis.3. Interview on 3/11/26 at 12:45 p.m. with social services designee (SSD) F revealed that she did not complete a PASRR level 2 on resident 32. The nursing staff was to let her know if there was an update in the residents' diagnoses within the facility. SSD F was not aware if the nursing staff informed her of resident 32's psychosis diagnosis.4. Review of the provider's May 2025 Preadmission Screening and Resident Review (PASRR) policy revealed individuals who have or are suspected to have MD [mental diagnosis], ID [intellectual disability] or a related condition (as indicated by a positive level 1 screen) may not be admitted to a Medicaid-certified nursing facility unless approved based on level II PASARR evaluation and determination.

Based on interview, record review, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was complete within 48 hours of the resident's admission to the facility for two of five newly admitted sampled residents (42 and 56). Findings include:1. Review of resident 42's baseline care plan revealed she was admitted to the facility on [DATE]. She required the assistance of one staff member and a gait belt [a waist strap gripped as support for safe mobility and transfers) for ambulation (walking) and was to use a wheelchair for long distances, which was indicated on her baseline care plan on 3/8/26. 2. Review of resident 56's baseline care plan revealed she was admitted to the facility on [DATE]. She required the assistance of one staff member, which was added to her baseline care plan on 3/4/25. Her diet order was for a liberal renal diet (a diet that is kidney-friendly to reduce the workload on damaged kidneys), which was added to her baseline care plan on 8/22/25. 3. Interview on 3/11/26 at 8:51 a.m. with registered nurse (RN) nurse supervisor O revealed that she and the charge nurse on duty completed the baseline care plans when a resident was admitted to the facility. She verified that resident 42's baseline care plan did not include how the resident transferred within 48 hours of admission, and that it should have. She verified that resident 56's baseline care plan did not include how the resident transferred or what her diet was within 48 hours of admission, and that it should have. 4. Interview on 3/12/26 at 10:25 a.m. with director of nursing (DON) B revealed that resident baseline care plans were expected to have information on how the resident transferred within 48 hours of their admission to the facility. She did not think that the resident's diet needed to be on the baseline care plan and thought it was acceptable for it to state, diet as ordered. If the staff needed to know the resident's diet, then they needed to look at the physician's order. 5. Review of the provider's 5/14/25 Care Plans policy revealed that 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. A Baseline Care Plan is started by nursing staff on the first day of admission to provide guidance to direct care givers as soon as possible after admission and [is] completed no later than 48 hours after admission. Nursing, Dietary, Activities and Social Services staff complete formal assessments, interviews and observation and begin formulating the full care plan as soon after admission as possible. (These departments do have areas that need to be completed by the 48-hour deadline). The areas that must be addressed in the baseline care plan include the minimum healthcare information necessary to properly care for a resident including, but not limited to: a) Initial goals based on admission orders. b) physician orders. c) dietary orders. d) therapy services. The DON will be responsible for holding the team accountable to initiating and completing the admission care plan within 48 hours.

Based on observation, interview, record review, and policy review, the provider failed to ensure the residents' care plans (personalized plan that addresses a resident's care needs, goals, and interventions) were reviewed and revised to reflect the current care needs for three of twenty sampled residents (10, 32, and 84).Findings include: 1. Interview and observation on 3/8/26 at 3:24 p.m. of resident 84 in his room revealed he had a right abdominal drainage bag under his shirt with red drainage in the bag. He denied staff using gloves or gowns when they emptied the drainage bag. There was no signage or supplies for enhanced barrier precautions (EBP) (glove and gown use when providing contact care) in his room. 2. Observation on 3/9/26 at 8:22 a.m. of resident 84's room and outside of his room, revealed there was no signage for the use of EBP. 3. Observation on 3/9/26 at 3:01 p.m. of resident 84's room revealed, there were EBP supplies for the staff to use and a sign hanging on his door indicating he was on EBP. 4. Review of resident 84's electronic medical record (EMR) revealed: *His was admitted to the facility on [DATE]. *His 3/3/26 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated his cognition was intact. *His primary diagnosis was a peritoneal abscess (localized collection of pus/infection within the abdominal cavity). *He had a 2/27/26 physician's order to cleanse the right abdomen tube site daily with saline and cover it with gauze and tape. *His 2/26/26 nursing admission UDA (user-defined assessment) indicated: -Section V was marked as having a right upper quadrant (RUQ) 16 French (a medium-to-large tube) abdominal drain. -Section X was marked no for needing any type of isolation to prevent the spread of infection. *His care plan indicated he had a potential for infection related to: I.V. Line, other; specify) initiated on 2/26/26 with a goal of not developing signs and symptoms of infection initiated on 3/6/26. The interventions were to access for signs and symptoms of infection and to give medications and treatments as ordered, which were initiated on 2/26/26. *His care plan indicated he had a potential for skin impairment, with a goal of not developing signs and symptoms of infection on the wound site and to apply wound treatment as ordered by the physician, which was initiated on 2/26/26. 5. Interview and record review on 3/10/26 at 10:44 a.m. with certified nursing assistant (CNA) S revealed: *She had worked at the facility for ten years. *Resident 84 had the abdominal drainage bag when he was admitted to the facility. *She agreed that resident 84 had no EBP in his room until 3/9/26 when it was placed. *She stated there was EBP available in the resident room next door. *She used the Kardex (a report of the resident's care needs and interventions) to know how to care for the residents. *She acknowledged that resident 84's information on the current 3/6/26 Kardex did not indicate he was required to be on EBP, but it did indicate that he had a drain to the right side of his abdomen. 6. Interview on 3/10/26 at 10:50 a.m. with licensed practical nurse (LPN) AA revealed: *CNA's refer to the Kardex for the residents' information. *Resident 84's current Kardex dated 3/6/26 indicated he requires EBP to be used by the staff when they were providing him with direct care. 7. Interview on 3/10/26 at 11:39 a.m. with LPN L revealed: *It was her responsibility to place all EBP supplies in the resident rooms. *She knew resident 84 was admitted to the facility on [DATE]. *She was not aware resident 84 needed the EBP until 3/9/26 around 9:00 a.m., which was when she placed the EBP sign and supplies on his door. *She would read through a resident's physician's orders to see if the resident needed EBP placed upon admission or readmission. *She would tell registered nurse (RN) nurse supervisors O and X to update the care plan for a resident who needed EBP. 8. Interview on 3/10/26 at 11:53 a.m. with RN nurse supervisors O and X revealed: *They updated the resident care plans. *They assumed that resident 84 needed EBP with his abdominal drain. *They would notify LPN L if a resident needed EBP to be placed. *They agreed resident 84's care plan did not include EBP or his abdominal drain. *They updated the Kardex and added the EBP for the residents who needed it. *They had added EBP to the Kardex on 2/27/26 for resident 84. *They should have added EBP and his abdominal drain to resident 84's care plan when he was admitted on [DATE]. 9. Interview on 3/11/26 at 9:22 a.m. with RN H revealed: *She worked the overnight shift at the facility from 7:00 p.m. to 7:00 a.m. *She contacted RN nurse supervisor O and X if there were changes to be made to a resident's care plan. *She did not make changes to resident care plans. *She did have EBP supplies for newly admitted resident if she noticed they were not placed. *She was not aware resident 84 had an abdominal drain. *She only worked in resident 84's hallway if she was called in. *She was aware that EBP sign and supplies were not placed on resident 84's door until 3/9/26. 10. Interview on 3/11/26 at 10:45 a.m. with RN/Minimum Data Set (MDS) Coordinator C revealed: *Resident 84 admitted on [DATE] with an indwelling drainage device. *She or RN supervisors O and X would add EBP to resident care plans. *The EBP was missed when resident 84 was admitted to the facility on his 2/26/26 admission UDA. *She would expect EBP to be started upon admission for a resident that had a catheter, indwelling devices, or wound care orders. *She agreed EBP had not been started until 3/9/26. 11. Interview on 3/11/26 at 11:30 a.m. with director of nursing (DON) B revealed: *She was the infection preventionist (IP). *The RN supervisors O and X add EBP to the resident care plans and the Kardex that is used by the CNAs. *LPN L is responsible for placing signage and supplies for EBP in resident rooms when an admission occurs. *She expects the EBP would be added for a resident that required it on admission or with a change in orders or care. *She would expect it to be added to resident care plans within a short period of time. *She expected resident 84's EBP to be added to his care plan before 3/9/26. 12. Review of resident 10's EMR revealed he was admitted to the facility on [DATE]. His diagnoses included bipolar disorder (a mental condition causing extreme shifts in mood, energy, and activity levels), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and adjustment disorder with depressed mood. He had a level I (1) Pre-admission Screening and Resident Review (PASRR) completed on 12/27/23 and again on 10/16/24 due to a potential change in his mental status. The 12/27/23 and 10/16/24 Level I PASRRs stated, Your Level I screen was submitted for a potential status change. It shows that you have evidence of serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation. There was no documentation that his 1/29/26 revised care plan included his PASSR recommendations. 13. Interview on 3/11/26 at 11:36 a.m. with DON B revealed that social services designee (SSD) F completed the PASRR screenings, and RN/MDS coordinator C completed the MDS (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs). She was unaware that resident 10's PASSR information was not included in his care plan. She was unsure who was responsible for updating resident 10's care plan because resident care plans could be updated by RN/MDS coordinator C, SSF F, or the unit nurse managers. 14. Interview on 3/11/26 at 12:48 p.m. with SSD F revealed she completed PASSR screenings, and RN/MDS coordinator C completed the MDS. She stated she should have included resident 10's PASSR information in his care plan, and that she was just learning. 15. Interview on 3/11/26 at 4:23 p.m. with administrator A revealed she expected SSD F to complete the PASSR screening and to communicate with RN/MDS coordinator C for accurate coding on the MDS. She expected RN/MDS coordinator C and SSD F to work together to ensure resident care plans were updated and accurate. 16. Review of resident 32's MDS assessment revealed that resident 32 was receiving hospice services. 17. Review of resident 32's EMR revealed his 1/28/26 BIMS assessment score was zero, which indicated his cognition was severely impaired. His EMR included a hospice care plan and hospice notes starting 1/21/26, the date of the resident's hospice admission. 18. Review of resident 32's care plan revealed that the hospice care plan was not incorporated into the resident's facility care plan that was used by the facility staff. 19. Interviews on 3/11/26 between 8:45 a.m. and 9:30 a.m., with CNA Y, M, V, and RN H revealed that the staff used the pocket care plans (a document that identifies residents' care needs and interventions) to know what care they needed to provide the residents. 20.Review of the pocket care plans revealed that they did not include information regarding resident 32's hospice care plan goals or interventions. 21. Interview on 3/11/26 at 12:30 p.m. with RN nurse supervisor X revealed that the facility care plan should have been updated to include the hospice care plan when it was initiated. 22. Review of the provider's revised 5/14/25 Care Plan 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.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices by: *Not having personal protective equipment (PPE) (gloves and gowns) available for staff use for two of two sampled residents (82 and 84) on enhanced barrier precautions (using gowns and gloves during high-contact care to reduce the spread of multidrug-resistant organisms (MDROs) in a nursing home).*One of one observed certified nursing assistant (CNA) (EE) while providing urinary catheter (flexible tubing placed in the bladder to drain urine) care for one of one sampled resident (20).*One of one observed licensed practical nurse (LPN) (G) who did not perform hand hygiene (handwashing) while completing one of one sampled resident's (20) wound care treatment. Findings Include:1. Observation on 3/8/26 at 2:13 p.m. of licensed practical nurse (LPN) L revealed she was putting up yellow enhanced barrier precautions (EBP) personal protective equipment (PPE) organizers on resident 82's doorway. 2. Review of resident 82's electronic medical record (EMR) revealed she was admitted on [DATE] with an indwelling Foley catheter. She had a 3/3/26 physician's order to monitor and record her foley catheter output three times daily (TID). Her Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment, completed on 3/3/26, indicated in Section X that she was not on isolation or additional precautions. 3. Observation on 3/8/26 at 3:24 p.m. of resident 84 in his room revealed he had a right abdominal drainage bag under his shirt with red drainage in the bag. There were no PPE supplies in his room or signage posted that would alert staff or visitors that he was on EBP. 4. Review of resident 84's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His 3/3/26 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated he was cognitively intact. His primary admitting diagnosis was peritoneal abscess (localized collection of pus/infection within the abdominal cavity). He had a 2/27/26 physician's order to cleanse the right abdomen tube site daily with saline and cover with gauze and tape. His 2/26/26 nursing admission UDA was marked as having a right upper quadrant (RUQ) 16 French drain in section V. 5. Observation on 3/9/26 at 8:22 a.m. of resident 84's room and outside his room revealed the drainage bag was present on his right abdominal area. There was no PPE available for the staff to use. No EBP signage was posted. 6. Observation on 3/9/26 at 3:01 p.m. of resident 84's room revealed signage was posted and PPE supplies were hanging on his door for staff to use. 7. Interview on 3/10/26 at 10:44 a.m. with certified nursing assistant (CNA) S revealed she had worked for provider for ten years. Resident 84 had the drainage bag when he was admitted to the facility on [DATE]. She agreed resident 84 had no PPE in his room before 3/9/26. She stated there was PPE available in the room next door. She used the Kardex (a report of the resident's care needs and interventions) to know how to care for residents. She noted the Kardex dated 3/6/26 did not state resident 84 required EBP to be used when she looked, but stated he had a drain to his right side of abdomen. 8. Interview on 3/10/26 at 10:50 a.m. with licensed practical nurse (LPN) AA revealed CNA's referred to the resident information from the Kardex to know how to care for the residents. Resident 84's information on the Kardex was last updated on 3/6/26, and he required EBP. 9. Interview on 3/10/26 at 11:39 a.m. with LPN L revealed she was responsible for placing all PPE supplies in resident rooms who were on EBP. She knew resident 84 was admitted to the facility on [DATE]. She was not aware resident 84 needed to be on EBP until 3/9/26 around 9:00 a.m. She had placed the PPE on his door after that. She would usually go through the residents' orders to determine if that resident needed to be on EBP and would place the PPE supplies to be available to use. 10. Interview on 3/10/26 at 11:53 a.m. with registered nurse (RN) supervisor O and X revealed they assumed that resident 84 would need EBP because the resident had an abdominal drain. They would notify LPN L of the need for EBP signage and PPE supplies to be placed in the resident's room to be available for use. They were responsible for updating the resident's Kardex's and would add a resident's need to be on EBP in the Kardex. They added that resident 84 needed to be on EBP to the resident's Kardex on 2/27/26. 11. Interview on 3/11/26 at 9:22 a.m. with RN H revealed she worked the overnight shift from 7:00 p.m. to 7:00 a.m. She had access to PPE items to place to be available for use for a newly admitted resident if she noticed the resident needed to be on EBP and did not have a supply of PPE available for use. She was not aware that resident 84 had an abdominal drainage device. She was aware that PPE was not placed on resident 84's door until 3/9/26. 12. Interview and record review on 3/11/26 at 10:45 a.m. with RN/Minimum Data Set (MDS) coordinator C revealed she confirmed resident 84 admitted on [DATE] with an abdominal drainage device. Resident 84's 2/26/26 admission user-defined assessment (UDA) (tailored data collection for nursing in long term care) did not indicate the resident needed to be on EBP. She would expect EBP to be started upon admission for a resident who had a catheter, indwelling device, and wound care orders. She agreed EBP had not been started for resident 84 until 3/9/26. 13. Interview on 3/11/26 at 11:30 a.m. with director of nursing (DON) B revealed she was the facility's infection preventionist (IP). RN supervisors O and X were to add if a resident was on EBP to the resident's Kardex. LPN L was responsible for placing EBP signage and PPE supplies in residents' rooms when a resident was on EBP. She expected that EBP would be added to a resident's Kardex if that resident required EBP and that PPE supplies would be placed in the resident's room to be available for staff to use. 14. Review of the provider's revised 5/15/25 Enhanced Barrier Precautions policy revealed Enhanced Barrier Precautions (EBP) should be used for all residents with wounds or indwelling devices. And/or for residents with a novel or targeted MDRO [Multi Drug Resistant Organism} when they are infected or colonized with one of these organisms, and Contact Precautions do not apply. Also for those residents that have risk factors for MDRO acquisition (e.g., immunocompromised etc.). 15. Observation on 3/10/26 at 3:50 p.m. of certified nursing assistant (CNA) EE providing catheter care for resident 20 revealed she washed her hands, put on a gown, and a pair of gloves. She placed washcloths in the residents' sink and got them wet with warm water. She used a washcloth from that sink to clean the left and right sides of the resident's abdominal folds. With those same gloved hands, she put soap on the rest of the washcloths in the sink, used one of those washcloths to clean the resident's left perineal area (genital area), and used the other side of that washcloth to clean the right side of the resident's perineal area. She used a towel to dry the resident's groin folds and the perineal area. With those same gloved hands and the last washcloth from the sink, she wiped the catheter tubing, starting from approximately four inches away from the urethral meatus (external opening to the urethra [that carries urine from the bladder out of the body)] down the catheter tubing, away from the resident. After cleaning the first few inches of that tubing, she used those same gloved hands and grasped the area of the tubing she had just cleaned and wiped the rest of the tubing downward away from the resident, with the same washcloth. With those same gloved hands, she wet another washcloth and cleaned under the resident's right breast, which was red with open areas. CNA EE said she made a mistake, and she should have changed her gloves before cleaning under the resident's breast. CNA EE then took off her gown and gloves and washed her hands in the resident's sink and then left the room. 16. Observation on 3/10/26 at 4:22 p.m. of LPN W applying powder on resident 20's open and reddened skin areas revealed she washed her hands, put on a gown, and gloves. She obtained a towel, wet it, and applied soap on it. She cleaned and dried the resident's left and right abdominal folds. She removed her gloves. Without performing hand hygiene, she put on a new pair of gloves. She applied antifungal powder under the resident's right breast and then to her left and right abdominal folds. She removed her gown, gloves, and washed her hands in the resident's sink. 17. Interview on 3/10/26 at 4:34 p.m. with LPN W and CNA EE revealed LPN W stated she should have washed her hands after removing her unclean gloves and before putting on a new pair of gloves. CNA EE agreed that after cleaning the tubing near the insertion site, she should not have touched that tubing with her contaminated gloves. CNA EE verified she was to wash her hands and apply new gloves before performing catheter care. CNA EE stated they had a refresher class about how to perform catheter care yearly, which was scheduled to be held on 3/11/26. 18. Interview on 3/12/26 at 10:25 a.m. with DON B revealed she expected the CNAs to perform hand hygiene before completing catheter care. She expected the CNAs to use washcloths and towels from the towel bar and not place them in the resident's sink. She expected the staff to remove unclean gloves and perform hand hygiene before putting on a clean pair of gloves to apply powder. 19. Review of resident 20's medical record revealed she was admitted to the facility on [DATE]. She had physician's orders for Miconazole powder (antifungal powder) on 3/5/26, and for a Foley catheter on 3/23/26. She had physician orders from 3/6/26 through 3/9/26 for Ertapenem Sodium (antibiotic) 1 gram intravenously (IV) daily for a urinary tract infection. Her 3/9/26 care plan indicated that, she was on IV antibiotics for a UTI, required EBP due to having a Foley catheter, and was to have catheter care performed every shift and as needed. 20. 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. All personnel shall be initially trained as part of their orientation and regularly educated on the importance of hand hygiene in preventing the transmission of healthcare-associated infections (HAIs). All personnel shall follow the hand hygiene procedures to help prevent the spread of infections. Staff were to perform hand hygiene before putting gloves on, after taking them off, and when moving from a dirty body site to a clean body site. 21. Review of the provider's 1/14/26 Urinary Catheter/Catheter Care/Catheter Associated Urinary Tract Infections (CAUTI) Prevention Policy revealed When a urinary catheter is in place we also need to adhere to the following procedure to assist in the prevention of catheter-associated urinary tract infections. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), observation, interview, record review, and policy review, the provider failed to protect residents from neglect by: A. CNA Z who did not provide nighttime cares for one of one sampled resident (425) who was observed the following morning in her clothing from the previous day and incontinent of bowel. Findings include: B. Certified nursing assistant (CNA) (G) who did not provide the appropriate transfer assistance as directed in the care plan for one of one sampled resident (46) who fell . Findings include: A. 1. Review of provider's SD DOH FRI for resident 425 revealed: *At approximately 8:00 a.m. on 8/4/24 resident 425 was in bed, dressed in the same clothes she had on the day before. She was incontinent of stool. -A head to toe skin assessment was completed and reports that all skin is intact, but that her buttocks and peri area are reddened. -Resident 425 was admitted back to us from the hospital this week and her buttocks at that time was [were] very red and sore. *CNA Z and LPN AA were on duty during the night of 8/3/24. -CNA Z received disciplinary action and education to follow resident pocket care plans at all times and ensure that all residents get proper bedtime and nighttime cares they require. -LPN AA received disciplinary action regarding the incident as the charge nurse expectation is to ensure staff follow care plan and ensure residents get proper bedtime and nighttime cares they require. 2. Review of resident 425's electronic medical record (EMR) revealed: *Her admitted was 10/27/23. *She was hospitalized from 7/16/24 until 7/30/24 when she returned to the facility. *Her 6/27/24 Brief Interview for Mental Status assessment (BIMS) score was a 14 ehich indicated her cognition was intact. *Her 8/5/24 BIMS score was a 99 which indicated she was unable to complete the evaluation. *Her diagnoses included: depression, macular degeneration (eye disease that cause vision loss), neuropathy (nerve damage), anxiety disorder, post-traumatic stress disorder, lymphedema (swelling of body tissue), reduced mobility, chronic kidney disease, difficulty in walking, need for assistance with personal care, irritable bowel syndrome with diarrhea, and altered mental status. *She had passed away on 8/29/24. 3. Interview on 11/14/24 at 4:36 p.m. with administrator A regarding the above FRI for resident 425 on 8/4/24 revealed: *She confirmed their investigation into the incident validated resident 425 was in her bed the morning of 8/4/24 dressed in the same clothes she had on the day before and was incontinent of stool. *Her expectation was for resident 425's care plan to have been followed. -Resident 425's care plan had been updated and reviewed upon her return from the hospital. *After the above incident, all staff were educated on providing appropriate care to residents, and audits of that were being completed. *FRIs and grievances were reviewed at every QAPI meeting. 4. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/14/24 after record review revealed the facility had followed their quality assurance process, education was completed, competency of providing care was completed, audits were completed regarding following resident care plans, and observations and interviews revealed staff understood the education provided regarding those topics. 5. Based on the above information, non-compliance at F600 was determined occurred on 8/4/24, and based on the provider's implemented corrective actions on 8/4/24 for the deficient practice confirmed on 8/14/24, the non-compliance is considered past non-compliance. 6. Review of the provider's 2/20/24 Abuse and Neglect policy revealed: *It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. *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 required but fails to provide that service. 50916 B. 1. Review of the provider's submitted SD DOH FRI regarding resident 46 revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was 5 which indicated she had moderate cognitive impairment. *On 10/24/24 at 8:10 p.m. the resident fell during a stand and pivot transfer with CNA G. *The resident had a gait belt on and did not acquire any injuries from the fall. *The resident's power of attorney (POA) and physician were notified of the incident. *The resident's care plan was reviewed and indicated: -She was to perform stand and pivot transfers with the use of a gait belt during the day shift with one staff's assistance. -She was to perform stand-up lift (a mechanical lift used to assist from a seated to a standing position) transfers during the evening and night shift with one staff's assistance. *Interventions included: -Education was provided to all staff regarding the importance of following care plans for all residents. -The resident's pocket care plan wording was updated to lessen confusion to staff. -CNA G as well as four random staff members were to be audited weekly for four weeks to ensure they were following residents care plans. -Interviews with seven random residents were conducted to ensure staff were following their care plans for transfers. 2. Observation and interview on 11/13/24 at 10:41 a.m. with resident 46 in her room revealed: *She was seated in her wheelchair watching TV and her call light was within her reach. *She did not recall any falls that she had recently. *Her room appeared free of environmental hazards. 3. Observation and interview on 11/13/24 at 2:10 p.m. with licensed practical nurse (LPN) Q revealed: *There were updated resident care plans located at the nurse's station on each hallway called pocket care plans. *The pocket care plans were updated daily if something changes for a resident. *If a staff member is unsure of how a resident transferred, they could look at the pocket care plans for their assigned hallway. *The pocket care plan located in resident 46's hallway indicated she was to be transferred by standing and pivoting with the use of a gait belt and one person's assistance during the day shift and to be transferred with the use of a stand-up lift and one person's assistance during the evening and night shift. 4. Interview on 11/13/24 at 2:15 p.m. with certified medication aide/CNA X regarding how resident 46 transferred revealed: *She was to be transferred by standing and pivoting with the use of her walker and a gait belt. *She would get weaker in the evening which would be when they would use the stand-up lift. 5. Observation on 11/13/24 at 4:10 p.m. with CNA G and resident 46 in her room revealed: *CNA G transferred resident 46 from the toilet to her wheelchair with the use of her walker and a gait belt. Interview with CNA G immediately following the above observation revealed: *CNA G had been working at the facility since April of 2024. *When she was assigned to a hallway, she would get the pocket care plan so she could reference the residents' care needs if she needed to. *She had been with resident 46 when she fell . -She was assisting the resident to bed with a stand and pivot transfer, a gait belt and her walker when resident 46 said she would not be able to make it. *She lowered the resident to the floor and notified the nurse. *She stated she had misread resident 46's care plan which had indicated she was to be transferred with a stand-up lift during the evening and night shifts. 6. Interview on 11/14/24 at 11:31 a.m. with director of nursing (DON) B revealed education was provided to all staff after resident 46's incident above and audits were being conducted. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/14/24 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding following resident care plans, and observations and interviews revealed staff understood the education provided regarding those topics. Based on the above information, non-compliance at F600 occurred again on 10/24/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 10/26/24, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to maintain clean and sanitary conditions in one of one observed kitchen where residents' food was stored and prepared. Findings include: 51472 1. Observation on 11/12/24 at 3:30 p.m. of the kitchen revealed: *The walk-in freezer revealed: -There was a form (form 403) on the door of the walk-in refrigerator/freezer titled [NAME] Frig Freezer where daily temperatures for November were documented. --It indicated Code for adequate temperature: Freezer: Not greater than 0 degrees F [Fahrenheit] or food maintained solid. --Daily documented freezer temperatures of the walk-in freezer were recorded chronologically in November were as follows: 12, 15,12, 28, 12, 23, 29, 30, 2, 0, 5, 0 degrees F. --There was no documented actions taken for temperatures that were outside the adequate temperature range. -There was ice build up around the door to the walk-in freezer. -The metal lining of the walk-in freezer door was separated and had exposed cracked foam. -There was frost on the cooling unit in the walk-in freezer and ice build-up on the pipes on the back of the unit. *The 3 Door Fridge Unit had: -Two temperature gauges were being documented daily on the provider's form 403. -The temperature gauges were identified as GUAGE A and GUAGE2. -Between November 1st through the 12th GUAGE A was documented as reading 36-41 degrees Fahrenheit. -During the same time frame GUAGE2 was documented as 38-45 degrees F. -There were four days with greater than the 2-degree variance from 40 degrees. --There was no documentation of actions taken for temperatures that were outside the adequate temperature range. -A container of diced ham in the three-door refrigerator dated 10/24. -There was uncooked corn beef hash stored above the potatoes and wine. *Another stand-up freeezer had: -Two baked pies with pieces removed that were dated 9/22 and 8/18. --The pies were covered loosely with plastic wrap. *The plastic liners in the flour and sugar containers were ripped. 2. Observation on 11/14/24 at 9:22 a.m. of the kitchen revealed: *The office freezer had: -Chicken nuggets that were not dated. -One thermometer that had a solid red line that extended to 34 degrees Fahrenheit with a broken red line extending from 34 degrees to 52 degrees Fahrenheit. *The walk-in refrigerator had dust on the front of the cooling unit and on the walls and ceiling. *The walk-in freezer had: -There were no documented actions taken for the temperatures that were outside the adequate temperature range. -Dates on the bags of cut up chicken ranged from 1/8 to 11/3. -There were multiple bags of undated cut-up chicken. -One bag of undated chicken pieces appeared freezer burned, and the bottom of the bag contained a frozen bloody liquid. -There was 3/4 inch of frost build-up on the side of the walk-in cooler cooling unit that extended to 1/3 of the front portion of the unit. -The back of the walk-in cooler cooling unit had one to three inches of ice build-up on the back of the unit that extended onto the tubing behind the unit. *In the three-door refrigerator there was a container of frozen meat that extended above the sides of the container and was stored above wine and a box of pastries. 3. Interview on 11/14/24 at 9:22 a.m. with dietary manager T revealed: *She indicated that all freezer and refrigerator temperatures were documented daily and there needed to be two thermometers in the refrigerator and one in the freezer. *She indicated that if the two thermometers in the refrigerators did not match, she would check the temperature with another thermometer and discard the thermometer that did not read accurately. -She stated that this action was not documented anywhere. *When asked how she determined when food was discarded according to the dates on the packages, she stated she did not know the answer. *She stated she had discarded all the food that was thawed out in the walk-in freezer when the temperatures were out of range. *She stated she was told the walk-in freezer door was being replaced. *She indicated that on Friday (11/8/24) the cooling unit in the walk-in freezer was not working. -Maintenance director I removed the ice from the cooling unit and the cooling unit then began working. -Maintenance director I installed longer screws on the wall side exterior latch of the walk-in freezer so the door would latch. *She stated that the ice currently present on the cooling unit of the walk-in freezer was better than it was previously. *She agreed that the metal liner on the door of the walk-in freezer was separated with exposed cracked foam and light was visible around the door. *When shown the undated bag of chicken pieces that appeared freezer burned with frozen bloody liquid on the bottom of the bag, she indicated that this bag appeared to have thawed and refrozen. -She did not throw out any of the turkey or chicken on that Friday because she felt they had not thawed. -She said she would dispose of that bag of chicken. -The bags of chicken should be dated. *She stated that maintenance oversaw the cleaning of the cooling unit in the walk-in refrigerator. *She indicated that when she defrosted meat in the cooler, and raw meat needed to be stored on the bottom shelf in a container. *If meat was precooked, she did not put it on the bottom of the refrigerator. *If meat needed to be defrosted more rapidly than able to in the refrigerator she would run it under cool water. 4. Review of the provider's temperature logs revealed: *On 10/9/24 dietary manager T documented on the [NAME] Frig and Freezer titled temperature log margin Got rid of the stuff out of [the] freezer. -Below the above documentation was written Freezer door wouldn't shut but got fixed on the 8th. *Daily documented freezer temperatures for [NAME] Frig and Freezer reported in degrees Fahrenheit between October 1st and 11th, 2024 were 22, 20, 18, 20, 20, 20, 18, 20, 20, 22, 23. -There was a note in the margin that stated, walk in door not shutting properly Got rid of all the food *Logs of freezer defrosting was requested but not provided 5. Interview on 11/14/24 at 9:40 a.m. with dietary aide P revealed that she was unfamiliar with the process of checking temperatures in the coolers because the cooks performed this task. 6. Interview on 11/14/24 at 9:45 a.m. with dietary aide V revealed: *If the two thermometers in the refrigerator did not match, she would double-check the gauge that was reading out of range. *If she determined that gauge was reading inaccurately, she would notify her supervisor to replace the inaccurate gauge. 7. Interview on 11/14/24 at 4:39 p.m. with administrator A regarding the kitchen revealed: *She was aware the walk-in refrigerator door had ice build-up around the door. *They had thrown out food numerous times after identifying the food had partially thawed out. -She was not aware the chicken and turkey had not been thrown away after having been partially thawed out. 8. Review of the provider's 8/31/18 Freezer policy revealed: *Freezer defrosting was to be completed monthly. *Freezers should remain frost free. 9. Review of the provider's 10/15/18 Freezer Storage Chart revealed: *Unopened frozen chicken nuggets were to be disposed of after 1-3 month *Unopened whole or cut up chicken was to be disposed of after 10 months. *Baked pies were to be stored unopened and be disposed of after 8 months. *Opened baked pies recommended storage was not applicable. 10. Review of the provider's 3/9/20 Food Storage policy revealed: *Products were to be examined for signs of defrosting. *The refreezing of defrosted food is not recommended because of increase in growth of-food bacteria and the deterioration in food quality. *Thaw meat preferably by placing in deep pan and setting on the lowest shelf in refrigerator. *Thawing food under cold running water is no longer recommended due to strict guidelines set forth by the 2013 Food Code. *Alcoholic beverages must be stored in a separate locked area. 11. Review of the provider's 8/8/19 Record of Refrigeration Temperatures policy revealed: *A daily temperature record is to be kept of refrigerated items. *The freezer must be clean and food must be frozen solid with no indications of thawing and must be frost free. *The refrigerator must be 41 degrees Fahrenheit or less (1-2-degree variance) *Note on temp forms the plan of action when temps are not acceptable. 12. Review of the provider's 12/28/20 Refrigerated Storage Chart policy revealed that opened ham should be discarded after one week.

A. Based on observation, interview, record review, policy review, and manufacturer's recommendations, the provider failed to ensure one of two observed ice machines were maintained in a clean and sanitary manner. Findings include: 1. Observation on 11/14/24 at 9:22 a.m. of an ice machine located in the therapy room revealed: *The water/ice spout had pink slime (a bacteria colony that can grow in ice machines) in it. *The water tray had metal bars over the top of it that were rusted. *There was a white, flaky, residue, that covered the underside of the machine where the spout extended from. Interview on 11/14/24 at 9:22 a.m. with certified medication aide (CMA) U regarding the ice machine located in the therapy room revealed that the ice machine was used three times daily for resident water passes. Interview on 11/14/24 at 1:42 p.m. with housekeeper K regarding the ice machine located in the therapy room revealed:*Each housekeeper is assigned a different area to keep clean. *He has cleaned the ice machine, by having wiped down the outside areas of it. *He said the housekeepers do not clean the internal parts of the ice machine. *He said supervisor would know more about the ice machine. Interview on 11/14/24 at 1:46 p.m. with housekeeper supervisor R regarding the ice machine located in the therapy room revealed: *Housekeepers wiped down the outsides of the ice machine. *She said housekeepers had tried to keep the ice machine clean. *She confirmed the bars on the tray were rusted, and did not know if they could be replaced. *She confirmed there was pink slime on spout of the machine. *She said the maintenance staff takes apart and does the internal cleaning of the ice machine. Interview on 11/14/24 at 1:49 p.m. with maintenance director I regarding the ice machine located in the therapy room revealed: *Confirmed there was pink slime on the spout of the ice machine. *Used a brush to clean it every six months. *A chlorine spay product was used. *The product observed was CDS liquid chlorinator pool water disinfection. -He said he would pour that into a spray bottle and would add a little water to it. -He said he does not measure the amounts of the product or the water he would add to the spray bottle. Review of the provider's Ice Machine Log Semi-Annual Inspection revealed: *The 4/13/24 documentation included cleaned/checked. *The 7/27/24 documentation included checked cleaned as needed cleaned air filters. *The 10/22/24 documentation included Cleaned all Ice machine/cleaned Ran through cleaning cycles/filters. Review of the provider's June 2019 Sanitization policy revealed: *Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. *Damaged or broken equipment that cannot be repaired shall be discarded. Review of the manufacturer's instructions for installation, operation, and maintenance of the Manitowoc ice machine that was located in the therapy room revealed: *Manitowoc Ice Machine Cleaner and Sanitizer are available in convenient 16 oz (473 ml) and 1 gal (3.78l) bottles. These are the only cleaner and sanitizer approved for use with Manitowoc products. *Preventative Maintenance Cleaning Procedure Perform this procedure as required for your water conditions. Recommended monthly. -Allows cleaning the ice machine without removing all of the ice from the bin -Removes mineral deposits from areas or surfaces that are in direct contact with water during the freeze cycle (reservoir, evaporator, auger, drain lines). *Cleaning/Sanitizing Procedure This procedure must be performed a minimum of once every six months. -All ice must be removed from the bin -The ice machine and bin must be disassembled cleaned and sanitized -The ice machine produces ice with the cleaner and sanitizer solutions -All ice produced during the cleaning and sanitizing procedures must be discarded. *Ice machine sanitizer is used to remove algae or slime. *Refer to the chart and add the correct amount of sanitizer and cool water for your model ice machine. *Remove the top cover from the ice chute and pour the sanitizer/water solution into the evaporator. Add the entire amount of premixed solution. Interview on 11/14/24 at 4:39 p.m. with administrator A regarding the ice machine located in the therapy room revealed: *She was not aware the appropriate chemicals for cleaning and sanitizing the machine were not being used. *Her expectation was for the manufacturer's recommendations for cleaning and sanitizing to be followed. 45383 B. Based on observation, record review, interview, and policy review the provider failed to ensure two of two sampled residents (274 and 424) had been placed on contact precautions due to having been diagnosed with a multi-drug resistant organism (MDRO) infection. Findings include: 1. Observation on 11/14/24 at 2:30 p.m. of resident 274's door revealed: *She had a sign that indicated to check in with the nurse before entering the color of the sign was pink indicating enhanced barrier precautions. *PPE (personal protective equipment worn to minimize exposure to a hazard, such as gowns, gloves, face shield and masks) was on the outside of the door. Review of resident 274's electronic medical record (EMR) revealed: *She had been admitted [DATE] with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) to her left ankle. *She had been receiving intravenous (IV) antibiotics through her peripherally inserted central catheter (PICC) and had been using a wound vacuum. *Resident 274's care plan indicated she had been on enhanced barrier precautions due to her wound and PICC line. Interview on 11/14/24 at 2:45 p.m. with clinical care coordinator registered (RN) C regarding resident 274's enhanced barrier precautions revealed: *She had known that resident 274 had a diagnosis of MRSA upon admission. *Agreed that resident 274 had not been on contact precautions for her MRSA infection in her wound. 2. Observation on 11/12/24 at 4:22 p.m. of resident 424 revealed: *There was PPE hanging in a supply caddy on her door. *She had a sign that indicated to check in with the nurse before entering the color of the sign was pink indicating enhanced barrier precautions Observation on 11/13/24 at 8:37 a.m. of resident 424 revealed: *She was being propelled in her wheelchair by an unknown staff member out of the dining room. *The same unknown staff member stopped in the hallway and assisted her to stand and ambulated with assistance of one staff and a front wheeled walker in the hallway. Interview on 11/13/24 at 10:03 a.m. with resident 424 revealed that she: *She was admitted to the facility about three weeks ago. *She had sores on her feet that she said resulted from her falling and laying on a garage floor for about two to three days before she was found. Review of resident 424's electronic medical record (EMR) revealed: *She was admitted on [DATE]. * On 10/6/24 she was diagnosed with a positive Methicillin-resistant Staphylococcus aureus (MRSA) (a bacteria that is resistant to multiple antibiotics) in her right ankle wound. *She was taking Linezolid for the MRSA infection. Interview on 11/13/24 at 11:58 a.m. with licensed practical nurse (LPN) Y revealed: *She identified that resident 424 was on EBP by the color of the sign on her door. *She stated that resident 424 was on EBP due to her wounds. Interview on 11/14/24 at 1:38 p.m. with clinical care coordinator, RN C and director of nursing (DON) B regarding resident 424 revealed: *She was on EBP due to her wounds. -She was recently diagnosed as being positive for MRSA in one of her wounds. --That was an indication to advance her precautions from EBP to contact precautions. *RN C agreed that resident 424 was not advanced from EBP to contact precautions. 3. Review of the provider's 2/20/24 MRSA policy revealed: * Risk of transmission increases in the following situations and therefore, contact precautions and/or droplet precautions should be considered: Any site with active MRSA infection. * Consideration could be to use Enhanced Barrier Precautions [EBP] when the resident no longer meets the definition for contact precautions. * Resident may not leave the room while in precautions except for medically necessary reasons. When the resident leaves the room, precautions should be maintained to minimize the risk of transmission of pathogen to others and containment of environmental surfaces or equipment. 50916 C. Based on observation, interview, and policy review, the provider failed to ensure infection control and prevention practices were maintained by one of one licensed practical nurse (LPN) Q during medication administration for one of one sampled resident (44). Findings include: 1.Observation on 11/13/24 at 9:35 a.m. of LPN Q during resident 44's medication administration revealed: *Resident 44 was on precautions for COVID-19. *With personal protective equipment (PPE) (gown, gloves, shield, and N95 mask) on: -She picked up a medication cup off of the medication cart that contained resident 44's prepared medications. -She knocked on resident 44's door and went into her room. -She sat the cup of medications and a nasal spray, down on a bedside table. -She assisted the resident into a more upright position in bed. -She administered the nasal spray into the left nostril, recapped the nasal spray, and set it back down on the bedside table. -Once she finished administering the rest of the medications, she removed the full trash bag in the bathroom and replaced it with a new one. -She removed her shield, gown, and gloves and washed her hands with soap and water. -She picked up the nasal spray and trash bag and then left the room. *Outside of the room by the PPE cart she: -Placed the trash bag into another trash can. -Placed the nasal spray on the PPE cart, discarded her mask into the trash can, and used hand sanitizer to disinfect her hands. -Picked up the nasal spray, opened the medication cart, and put the nasal spray back into the nasal spray manufacturer's original box. 2. Interview on 11/13/24 at 4:26 p.m. with LPN Q revealed: *She knew she did not wipe off the nasal applicator after administering the nasal spray to resident 44. *She did not think she was allowed to wipe down something that went into a nasal cavity. 3. Interview on 11/14/24 at 10:30 a.m. with registered nurse (RN) infection preventionist E revealed: *Nurses were to wipe off the nasal spray applicator in precaution rooms with an alcohol wipe. *Nurses were to clean the bottle outside of the room and then put it back in the medication cart. 4. Interview on 11/14/24 at 11:25 a.m. with staff development coordinator D revealed: *She educated staff on PPE, handwashing, different isolation precautions, infection control, and types of transmission every year. *She stated for nasal sprays, staff were supposed to wipe the tip off after every application with an alcohol wipe. *She did not believe there was any education regarding wiping off nasal spray bottles once out of precaution rooms. 5. Interview on 11/14/24 at 11:35 a.m. with director of nursing DON B revealed: *Staff had not received education recently regarding infection control practices. *They had not provided staff education for administering nasal spray in precaution rooms. *Her expectation was for staff to place a barrier down for nasal sprays and wipe the nasal applicator after each use. The provider's Nasal Spray Administration policy dated 11/21/18 and Infection Prevention Program policy revised 2/20/24 did not address infection control practices following nasal spray administration in precaution rooms. 51472

Based on record review, interview, and policy review the provider failed to ensure: *Fourteen of twenty-nine residents (10, 23, 46, 49, 53, 55, 64, 65, 67, 70, 224, 274, 375 and 424) had received a summary of their baseline care plan. *One of one sampled resident (424) had a baseline care plan completed within forty-eight hours of admission. Findings include: 1. Record review of resident 64's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 2. Record review of resident 65's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 3. Record review of resident 53's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR a baseline care plan summary had been reviewed with the resident or resident's representative. 4. Record review of resident 67's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 5. Record review of resident 55's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 6. Record review of resident 23's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 7. Record review of resident 10's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 8. Record review of resident 46's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 9. Review of resident 49's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 10. Review of resident 70's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 11. Review of resident 274's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 12. Review of resident 224's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 13. Review of resident 375's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 14. Review of resident 424's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. *Her baseline care plan was not signed as completed until 10/29/24. 15. Interview on 11/13/24 at 4:30 p.m. with social services designee F regarding residents' baseline care plans revealed: *She would have completed the baseline care plan upon admission. *She would not have reviewed the baseline care plan with the resident or the resident's representative. *She had not provided a summary of the baseline care plan to the resident or the resident's representative. *She had been in her position since June 2024 and felt she had not received very much training for her position. 16. Interview on 11/14/24 at 1:38 p.m. with clinical care coordinator registered nurse (RN) C regarding residents' baseline care plans revealed: *She would have reviewed the baseline care plan with the resident or the resident's representative. *She had not been documenting in the resident's EMR that the baseline care plan had been reviewed with the resident or representative or that a summary of that care plan had been offered. 17. Review of the provider's September 2019 Care Plans policy revealed: *A Baseline Care plan is started by nursing staff on the first day of admission to provide guidance to direct care givers as soon as possible after admission and completed no later the 48 hours after admission. 51472

Based on interview, record review, and policy review, the provider failed to provide bed-hold notice to the resident and/or their representative regarding the transfer to a hospital for one of one sampled resident (5) for two of three occasions. Findings include: 1. Review of resident 5's electronic medical record (EMR) revealed: *He was transferred to the hospital on 12/27/23, 4/23/24, and on 7/6/24. *His representative was notified of resident 5's 12/27/23 transfer and the bed hold policy. *There was no documentation that the bed hold information was given to the resident or his representative for the 4/23/24 and 7/6/24 hospital transfers. 50916 Interview on 11/15/24 at 4:39 p.m. with social service designee F revealed she was unable to find documentation to support bed hold information had been provided to resident 5 or his representative for the hospital transfers on 4/23/24 and 7/6/24. Review of the provider's undated Bed Reserve Policy Notification revealed: *This Bed Reserve Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. *Under normal circumstances, if you leave the facility for a hospitalization , you will be readmitted to the first available bed in a semi-private room. Under certain conditions, we can reserve your existing bed for you at your request, so when you return to the facility, you will have the same bed and room as before. Review of the provider's April 2021 Bed-Hold and Return Agreement revealed the resident, or their representative would be given the opportunity to request a bed-hold and pay a basic per-diem (daily) rate when absent from the facility.

Based on observation, interview, record review and policy review the provider failed to ensure the timely review and revision of one of one (424) sampled resident's care plan. Findings include: 1. Observation on 11/12/24 at 4:22 p.m. of resident 424 revealed: *There was personal protective equipment (equipment worn to minimize exposure to a hazard, such as gowns, gloves, face shield and/or masks) (PPE) sign on her door. *There was PPE hanging in a supply caddy on her door. *She had a sign that indicated to check in with the nurse before entering the color of the sign was pink indicating enhanced barrier precautions *She was sitting in her recliner, feet elevated, with Prevlon pressure reduction boots on both of her feet. *A pressure reduction cushion was in her wheelchair. Interview on 11/13/24 at 10:03 a.m. with resident 424 revealed that she: *She was admitted to the facility about three weeks ago. *Her husband also lived in the facility. *She had sores on her feet that she said resulted from her falling and laying on a garage floor for about two to three days before she was found. Review of resident 424's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses include: rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood) and acute kidney failure. *Her nurse progress notes indicated: -She had barricaded herself in her husband's room on 10/26/24 and 10/28/24. -Her family had been called in to help calm her behaviors on 10/26/24 and 10/27/24. Interview on 11/13/24 at 11:46 a.m. with nurse supervisor, registered nurse (RN) S revealed: *She was unable to identify which transmission-based precaution was to be followed when attending to resident 424 by looking at the sign on the door. *She identified that she would look in resident 424's care plan to identify which precautions were to use. Interview on 11/13/24 at 11:58 a.m. with licensed practical nurse (LPN) Y revealed: *She identified that resident 424 was on EBP by the color of the sign on her door. *She stated that resident 424 was on EBP due to her wounds. Review of resident 424's 11/13/24 care plan revealed: *Upon admit she was placed on EBP related to multiple wounds. *She had a focus area of impaired skin integrity. -Prevalon boots were not listed as an intervention related to her wounds. *She was diagnosed with MRSA on 11/6/24. -Her care plan indicated the antibiotic therapy related to wound infection with MRSA. -Contact precautions were not added to her care plan with the addition of the MRSA diagnosis. -EBP remained on her care plan related to multiple wounds. *Her admitting diagnosis was Rhabdomyolysis. -There were no focus areas, goals, or interventions that addressed possible complications related to this diagnosis. *There was a focus area that identified barricades self in husbands room. -There were no interventions for that focus area. -Her care plan did not address the use of family as an intervention for her behaviors. Interview on 11/14/24 at 1:38 p.m. with clinical care coordinator, RN C and director of nursing (DON) B regarding resident 424 revealed: *She was on EBP due to her wounds. -She was recently diagnosed as being positive for Methicillin-resistant Staphylococcus aureus (MRSA) (a bacteria that is resistant to multiple antibiotics) in one of her wounds. --That was an indication to advance her precautions from EBP to contact precautions. -Her care plan was not changed from EBP to contact precautions. *She had a history of behaviors that involved barricading herself in her husband's room. -RN C agreed there was no intervention addressed on the care plan related to this. -Her family had been called multiple times as an intervention to her behaviors. -RN C agreed the use of family as an intervention for her behaviors was not addressed in her care plan. Review of the provider's September 2019 Care Plans policy revealed: * Individualized, resident- centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay. * The personal history, habits, likes and dislikes, life patterns and routines, and personality facets must be addressed in addition to medical/diagnosis-based care considerations. * Interventions act as the means to meet the individual's needs. * Care Plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur.

Based on interview, record review, and policy review, the provider failed to ensure adequate pain management for one of one sampled resident (375) who expressed she had pain. Findings include: 1. Interview on 11/13/24 at 10:08 a.m. with resident 375 revealed she: *She had asked for medication for pain relief that morning during medication administration time for her pain. *Reported she had pain to the whole left side of her body. *Was told by licensed practical nurse (LPN) L there was no pain medication available. 2. Review of resident 375's current care plan on 11/8/24 revealed: *She was at risk for pain, she had: -Recently had a right-hand surgery and an incision. -Back pain due to a fall. -Diagnoses of peripheral vascular disease, congestive heart failure, and type 2 diabetes. *A focus area indicated that she was at risk for pain. *The goal for this focus, states that level of pain is through next review. *The interventions included: * Evaluate efficacy of pain management. * Notify MD if inadequate pain relief. * Provide analgesic as ordered. *Utilize non-pharmacological intervention (cold/warm wash cloth, massage, distractive activities, reposition, etc.) or ordered analgesic medications. If interventions not effective, then notify MD. 3. Review of resident 375's Electronic Medical Record (EMR) revealed: *She was admitted to the facility on [DATE]. *Her Brief Interview of Mental Status assessment (BIMS) score was a 9, which indicated she was moderately cognitively impaired. *Her diagnoses included: dorsalgia (pain in the back), gout, postural kyphosis (spinal deformity), peripheral vascular disease, type 2 diabetes mellitus without complications, rhabdomyolysis (muscle tissue break down), pain in left shoulder, pain in left hip, pain in left knee. *A progress note (PN) on 11/13/24 at 2:39 a.m. indicated Resident 375 complained of pain and requested pain medication. -There was an active order for Tramadol on the medication administration record (MAR). -She was agreeable to changing positions by moving from her bed to her recliner. -There was no Tramadol in the medication cart. *She had a physician order for Tramadol (pain medication) 50mg give 1 tablet by mouth every 8 hours as needed (PRN) for severe pain. *There was no documentation that the Tramadol had been administered. *A PN on 11/13/24 at 1:29 p.m. by LPN L indicated The resident calling out in pain to the bottom while sitting upright in reclining chair. Resident has an PRN order for Tramadol without medication available to issue. LPN L, had called the clinic and awaiting signature from the doctor to have the prescription sent to pharmacy for the medication. *No current order for additional available pain medications indicated in her EMR. 4. Interview on 11/14/24 at 1:39 p.m. with director of nursing (DON) B and clinical care coordinator (CCC) C revealed: *The pharmacy had not received a written prescription from the physician for the Tramadol. *The pharmacy is not able to fill the order until the written prescription is received. *CCC, C confirmed the provider should have followed up with the physician regarding the Tramadol. *Standing orders for additional pain control were not always put in a resident's EMR when they were admitted . 5. Interview on 11/14/24 at 1:00 p.m. LPN L, regarding resident 375's pain revealed: *She had assessed resident 375's pain level and location of her pain on 11/13/24. -She confirmed resident 375 had complained of pain in her bottom. *She checked resident 375's MAR to see what pain medication the physician had ordered. *She confirmed resident 375 had an order for Tramadol and there was no Tramadol available on the medication cart for administration to resident 375. *She called the clinic and requested the written Tramadol prescription be sent to the pharmacy. *It had been 7 days since the physician had ordered the Tramadol. 6. Observation on 11/14/24 at 3:05 p.m. with LPN L, verified the Tramadol was now available on the medication cart for resident 375. Review of the provider's 3/23/23 Pain Management Policy revealed: *The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. *'Pain Management' is defined as the process that includes the following: a. Assessing the potential for pain. b. Effectively recognizing the presence of pain. c. Identifying the characteristics of pain. d. Addressing the underlying causes of pain. e. Developing and implementing approaches to pain management. f. Identifying and using specific strategies for different levels and sources of pain. g. Monitoring for effectiveness of interventions; and h. Modifying approaches as necessary. *Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: -Peripheral vascular disease *Pain management interventions shall be consistent with the resident's goals for treatment. Such goals will be specifically defined and documented. *Pain management interventions shall reflect the sources, type and severity of pain. *Strategies that may be employed when establishing the medication regimen include: -Combining long-acting medications with PRNs [as needed] for breakthrough pain. *Implement the medication regimen as ordered, carefully documenting the results of the interventions. *Report the following information to the physician or practitioner: -Significant changes in the level of the resident's pain.

Based on observation, interview, record review, and policy review, the provider failed to ensure proper use of assistive devices resulting in an injury for one of four residents (49). Findings include: 1. Observation and interview on 8/1/22 at 4:35 p.m. with resident 49 revealed she: *Was seated in a wheelchair in her room facing her bed, rubbing her forehead with her left hand, and breathing out at times through her lips. *Had a large, scabbed area on her upper lip. *When the surveyor asked about having pain and then if the injury on her lip was the result of a fall, the resident nodded her head yes both times to confirm her head hurt and the injured lip happened from a fall. Interview on 8/2/22 at 11:02 a.m. with resident 49's responsible party revealed: *His only comment in response to the surveyor's mention of the recent fall with the injury on her lip was that she had a history of falling. *He believed they were treating her for pain management. Observation and interview on 8/3/22 at 9:40 a.m. with resident 49 revealed: *She was in her room with the door closed, seated in her wheelchair facing her bed, rubbing her forehead with her left hand, and breathing out at times through her lips. *She used her feet to wheel back and forth slightly until she locked her wheelchair brakes. *When surveyor asked: -What were her plans for the day, she pointed to her bed. -How do you call staff for assistance to get into bed, she turned her wheelchair around, headed to the bathroom door and opened it, reached into the bathroom and turned on the call light. -The bedside call light was within reach on the lounge chair next to her bed. Interview on 8/3/22 at 9:50 a.m. with certified nursing assistant (CNA) K after she responded to resident 49's call light, revealed: *She seemed to use the bathroom call light more than her bedside one. *She liked to lie down in bed most of the time. *She did not speak very much. *Her injury was from a fall, but CNA K was not working on that day. Review of the provider's report completed by director of nursing (DON) B and submitted to the South Dakota Department of Health (SD DOH) revealed: *The fall event occurred on 7/31/22 at 3:40 a.m. *The initial report, submitted on 7/31/22 at 4:14 a.m. to the SD DOH noted: -Resident 49 was witnessed falling forward out of her wheelchair. -CNA L was pushing [resident name] in her wheelchair .causing [resident name] to fall on the floor. -Staff member reports she believed that [resident's name] feet went underneath the wheelchair. -The Charge nurse conducted a head-to-toe assessment and found a laceration to her upper lip and was missing one and a half of her teeth. -[Resident name] reported she was having pain .Nursing assessment revealed 9 of 10 on painad (sic) scale. *The final report, submitted on 8/2/22 at 8:52 a.m. to the SD DOH noted: -[Resident name] returned from the emergency room with no acute fractures or bleeds. Sutures were applied to [resident's name] upper lip with orders to follow up with dentist and PCP (primary care physician) in a few days. -CNA L was questioned .and it was founded that [CNA L] did not have wheelchair pedals on [resident's name] wheelchair when she was pushing her in the hallway. -DON B provided education to CNA L and planned to complete audits weekly x [times] 4 weeks to ensure [CNA L] has wheelchair pedals on wheelchairs prior to assisting with locomotion along with 5 random residents weekly x 4 weeks. Review of resident 49's care plan interventions with the dates they were initiated and revised revealed: *No reference to the use foot pedals when transporting the resident in her wheelchair. *Most interventions to keep her free from fall related injury had not been updated based on the most recent assessments. *To maintain my current self care and mobility status her wheelchair was equipped with anti roll back brakes - [resident name] is able to self propel. Date initiated 3/06/20, revised 4/05/22. Review of the 4/1/22 significant change Minimum Data Set (MDS) assessment revealed resident 49: *Demonstrated moderate difficulty with orientation to year and month and short-term recall. *Needed weight bearing assistance of two persons to transfer and move about [locomotion or transport] on the unit. *Reported having pain in the last five days without stating how frequently. *Received scheduled pain medications and as needed pain medications were received or offered and refused. *Had two falls without injury and one with an injury since the prior MDS. Review of the 6/16/22 quarterly MDS revealed resident 49: *Demonstrated severe difficulty with orientation to year and short-term recall. *Continued need for weight bearing assistance to transfer and move about on the unit *Reported having mild pain almost constantly that made it hard for her to sleep at night and limited her daily activities. *Received scheduled pain medications but as needed pain medications was marked as not received, offered, or declined. *Had two falls without injury and one since the prior MDS. Interview on 8/4/22 at 9:38 a.m. with registered nurse/MDS coordinator F revealed: *She had been on vacation when the fall occurred so she could not comment on the circumstances that caused the fall. *She needed to get caught up on making care plan revisions. *She confirmed the importance of foot pedals for residents at risk for not holding their feet up when being transported in a wheelchair but also commented on the risk that foot pedals could cause for residents that move themselves using their feet. Interview on 8/4/22 at 10:15 a.m. with DON B and corporate nurse consultant (CNC) C revealed: *Audits of CNA L had begun. *No comment was offered about the reason CNA L was pushing the resident in her wheelchair rather than letting the resident self-propel the wheelchair. *After the surveyor reported a random observation on 8/3/22 at 12:17 p.m. of receptionist H pushing resident 26 up to the dining room table with her shoes squeaking as they dragged across the floor, CNC C suggested to DON B that the audits should be expanded to include other residents at risk for an event similar to resident 49. Review of the provider policy, Falls Management, 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. * The procedures included: -Assess and review resident risk factors for falls and injuries upon admission, with a significant change in condition, quarterly, annually, or after a fall. -Implement goals and interventions .based on individual needs and identified risks. -Communicate interventions to the caregiving teams.