Every finding on record at Avantara Lake Norden

Based on observation, interview, record review, and policy review, the provider failed to develop and implement interventions to address dementia (a group of symptoms affecting memory, thinking, and social abilities) care needs for one of one sampled resident (7), who wandered the hallways, attempted and successfully opened the facility's exit doors, and entered other residents' rooms that contained potentially hazardous blood sugar monitoring supplies.Findings include: 1. Observation on 7/7/26 at 9:22 a.m. from 9:22 a.m. through 11:25 a.m. revealed that resident 7 walked up and down the hallway outside of her room, telling the staff, I just have to keep busy. Director of nursing (DON) B attempted to redirect resident 7 to a recliner near the nurse's station, telling her to rest and put your feet up for a while. Resident 7 moved between the recliner in the living area, the main dining room, and the assisted dining room during the next two hours. 2. Interview on 7/7/26 at 9:28 a.m. with resident 30 revealed that she used her call light to summon the staff when resident 7 entered her room. 3. Interview on 7/7/26 at 9:30 a.m. with resident 37 revealed that he kept a mesh stop sign on his doorway to prevent resident 7 from entering his room. 4. Observation on 7/7/26 at 11:17 a.m. in the living area revealed that resident 7 got up from an electric recliner in the living area. She spoke to another resident sitting in a recliner, touched the other resident's shoulder, and tried to get the resident to get up and walk with her. A staff member who was nearby in the dining area told resident 7 no and directed her to sit down in a recliner, gave her a blanket, and told her to relax. At 11:25 a.m., resident 7 attempted to get out of the recliner. When she could not manually put the recliner's footrest down, she climbed out of the chair. She then moved among other residents in the main dining room, retrieved a clothing protector and a napkin from one table, and carried it with her into the assisted dining room. Staff members greeted her as they escorted other residents into the assisted dining room for the noon meal. 5. Interview on 7/7/26 at 11:31 a.m. with administrator A revealed that all doors were alarmed, and any residents who were an elopement risk resided in the Alzheimer's Care Unit (ACU). She stated, [Resident 7] is not an elopement risk. 6. Observation on 7/7/26 at 11:36 a.m. revealed there was a stop sign on the exit door in the assisted dining room. Resident 7 wandered into the assisted dining room and stated she wanted to go home to her mom and dad because school was almost done. 7. Observation on 7/7/26 at 11:49 a.m. revealed resident 7 wandering in the main dining room. She collected a set of silverware and a glass of water from one table, went into the assisted dining room and sat down at a table. She attempted to get up from the chair, and the staff redirected her to sit back down. 8. Observation on 7/7/26 at 11:51 a.m. revealed that resident 7 exited out the assisted dining room door and stood holding it open as she looked around at the parking lot. At 11:52 a.m., assistant director of nursing (ADON) F reached the door that resident 7 was holding open. She redirected resident 7 back inside and to her seat in the assisted dining room. 9. Interview on 7/7/26 at 11:52 a.m. with ADON F indicated that resident 7 sometimes pushed on the door handles, depending on her mood. 10. Observation on 7/7/26 at 12:04 p.m. in the assisted dining room revealed resident 7 was agitated, stuck her tongue out at the nurse, told the nurse to go home, refused to take her medication from the nurse, and threatened to throw her medication in the nurse's face. 11. Interview on 7/7/26 at 12:10 p.m. with licensed practical nurse (LPN) K revealed that resident 7 could become agitated when there was a lot of activity going on. LPN K said resident 7 tried to push open the edit doors at times but had never gotten outside. She thought the staff had once found resident 7 in the entryway between the two front exit doors. 12. Observation on 7/7/26 at 12:11 p.m. revealed that dietary aide J stopped resident 7 from attempting to follow her into the locked kitchen and laundry hallway. Resident 7 called the aide a a battleaxe and walked down the hallway toward her room. Social services director (SSD) P intercepted resident 7 and CNA R took resident 7 back to the assisted dining room. 13. Observation on 7/7/26 at 12:21 p.m. revealed that a staff member directed resident 7 to sit next to her in the assisted dining room. Resident 7 was holding a stack of clothing protectors and asked, Why is everyone picking on me today? At 12:26 p.m., resident 7 stood up and the staff told her to sit down. Resident 7 stated, No, why don't you? Meals were served to other residents at her table and resident 7 tried taking another resident's glass of water. A CNA said, This is not your water, and asked resident 7 to sit down. At 12:27 p.m., resident 7 was served her lunch. She stood up, picked up her plate and tried to walk away with it. The CNA attempted to redirect her and resident 7 told her to back up. Resident 7 started to walk away with the plate of food. 14. Observation on 7/7/26 from 12:28 p.m. through 12:45 p.m. revealed that resident 7 exited the assisted dining room with her plate and a glass of water. She told ADON F she wanted to eat in her room. ADON F redirected resident 7 to a recliner in the living area. Resident 7 refused to sit in the recliner and returned to her seat at the assisted dining table. At 12:31 p.m., resident 7 left the assisted dining room with ADON F and went to her room. ADON F brought resident 7 back to the assisted dining room at 12:45 p.m. 15. Observation on 7/7/26 at 2:15 p.m. revealed resident 7 rocking two baby dolls in a recliner near the nurse's station while listening to music. 16. Observation 7/7/26 at 2:31 p.m. in the living area revealed that DON B put resident 7's feet up in the recliner. Resident 7 told her, No. DON B told her to try to go to sleep and walked away from her. Resident 7 became anxious and called out for someone to come over to her. A surveyor walked over to her and talked to her. 17. Review of resident 7's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. She had diagnoses of severe cognitive impairment related to dementia, poor short-term memory, akathisia (an inability to control movements such as pacing or rocking), and a history of repeated falls related to her wandering behaviors. Her 6/1/26 Brief Interview for Mental Status (BIMS) assessment score was zero, indicating she had severe cognitive impairment. Resident 7's 6/2/26 elopement assessment had a score of five, meaning she was a low risk for elopement. The assessment indicated she had not attempted or had an actual elopement in the last year; she wandered throughout the facility and does not respond to staff direction; she attempts to leave the facility unsupervised and does not respond to staff redirection; she required frequent monitoring; and that the staff should be made aware of resident 7's risk of wandering and/or eloping. SSD P commented on the assessment, She has attempted [to] exit, but not trying to leave necessarily. Resident 7's 7/7/26 care plan indicated that her care should enable her to function at [her] most practical level and support the process that will enable [resident 7] to be comfortable in the LTC [long term care] setting. Her behaviors included moving care items and her roommate's items throughout her room, striking out at the staff, collecting items throughout the facility, rummaging, and making accusatory statements and negative comments toward others. Behavior interventions in her care plan included frequent monitoring, one-to-one time with the staff, and providing a blue basket of belongings for her to rummage through, along with a therapy baby, a stuffed cow, and magazines. Resident 7's care plan indicated she was able to independently move about the facility. It read, Resident is potential for elopement, and directed the staff to gently redirect away from the door if attempting to exit seek. Review of resident 7's EMR and the provider's grievance log revealed that resident 7 had resident-to-resident altercations on 11/29/25 and was to be redirected from entering other residents' rooms. On 2/10/26, she slapped another resident's hand. On 4/11/26, resident 7 threw a box of Kleenex at her roommate. On 4/30/26, when she wandered into resident 15's room and moved some of her belongings, the grievance resolution was for the staff to attempt to close [resident 15's] privacy curtain when she leaves her room to redirect [resident 7] from entering and rummaging through her belongings. 18. Observation on 7/8/26 at 8:03 a.m. revealed that resident 7 wandered into the resident hallway by ACU entrance door, carrying a stuffed animal and a blanket. The staff redirected her to sit in a recliner in the day area. 19. Observation on 7/8/26 at 8:06 a.m. revealed resident 7 standing by the exit door in the activity area. She moved items off the activity cart to the counter and reached into the drawers. SSD P redirected her to the assisted dining room. 20. Observation on 7/8/26 at 8:12 a.m. in resident 7's room revealed she did not have a basket of activity items and had stuffed animals on her bed. 21. Observation on 7/8/26 at 10:30 a.m. at the nurse's station revealed resident 7 walk between the staff offices and the main entry door. She attempted to open locked doors to restrooms and the staff's medication room and then entered DON B's office. At 10:34 a.m. she entered resident 1's room and was redirected back to the hallway by a staff member. At 10:42 a.m., resident 7 wandered into the business office, and business office and human resources manager I redirected her out of the office. 22. Observation on 7/8/26 at 11:02 a.m. in resident 40's room revealed that her blood glucose testing supplies were stored in an unlocked pencil box in her closet, next to a container storing used blood glucose testing strips, bloody cotton swabs, and used lancets (a small, sharp, sterile needle designed for a single-use skin prick, primarily used to draw a small drop of capillary blood for testing blood sugar levels in diabetes management). The container's lid was open to provide access to the used supplies. 23. Review of resident 40's electronic medical record (EMR) revealed that she had a Brief Interview for Mental Status (BIMS) assessment score of 6, indicating she was severely cognitive impaired. She had a diagnosis of type 2 diabetes mellitus (a chronic condition where the body cannot resists insulin or cannot produce enough of it, leading to high blood sugar) and moderate dementia (a group of symptoms affecting memory, thinking, and social abilities). Her care plan indicated she had fluctuating cognitive impairment and poor safety awareness, and that the staff were to use cueing and task breakdown while allowing her to do as much on her own as possible. She was able to propel herself around her room independently using her wheelchair and used a handheld bell to alert the staff when resident 7 entered her room. 24. Interview on 7/8/26 at 11:05 a.m. with registered nurse (RN) D revealed that while blood glucose testing supplies for residents in the Alzheimer's Care Unit (ACU) were kept in the unit's locked med cart, testing supplies for all non-ACU residents were stored in unlocked pencil boxes in the residents' closets. She said the supplies were not a potential hazard for resident 40, resident 7, or others who were cognitively impaired or wandered into other residents' rooms, because they don't usually open closet doors. 25. Observation on 7/9/26 at 8:34 a.m. in resident 1's room revealed that her blood glucose testing supplies were kept in an unlocked pencil box in her closet. A small container next to the pencil box was open to provide access to used lancets and bloody testing strips and cotton swabs. 26. Review of resident 1's EMR revealed that she had a BIMS assessment score of zero, indicating she was severely cognitively impaired. She had a diagnosis of type 2 diabetes mellitus, unspecified symptoms and signs involving cognitive functions and awareness, and aphasia (a neurological disorder that impairs a person's ability to speak, write, and understand language). Her care plan indicated she was unable to verbalize needs but used hand gestures to communicate. The staff were to use simple, direct communication and repeat themselves if resident 1 was unable to understand. She used a walker and a wheelchair to independently propel herself around the facility, and she used a bell to alert staff when resident 7 entered her room. 27. Observation on 7/9/26 at 8:36 a.m. in resident 26's room revealed that his blood glucose testing supplies were kept in an unlocked pencil box in his closet. A small container next to the pencil box was open to provide access to used lancets and bloody testing strips and cotton swabs. 28. Review of resident 26's EMR revealed that he had a BIMS assessment score of 8, indicating he was moderately cognitively impaired. He had a diagnosis of type 2 diabetes mellitus, unspecified moderate dementia with behavioral disturbance, and severe bipolar disorder. His care plan indicated he had fluctuating impaired mental status and a tendency to wander independently throughout the facility using his front-wheeled walker (a mobility aid with two fixed front wheels and two rear glide caps, offering steady, weight-bearing support). His care plan included an intervention to keep potentially harmful items out of reach, including his cigarettes and lighter, which the staff kept in a locked box at the nurse's station. 29. Review of resident 46's EMR revealed that she wandered the halls and had poor safety awareness. She had a BIMS assessment score of zero, indicating she was severely cognitively impaired. She had a diagnosis of severe dementia with behavioral disturbance and Alzheimer's Disease (a progressive, irreversible brain disorder that accounts for 60 to 80 percent of dementia cases). Her care plan indicated she also had aphasia, used cueing and gestures to communicate, and exhibited behaviors that included urinating in inappropriate places. Resident 46's care plan revealed that she previously resided in the ACU but transferred to the non-ACU part of the facility on 6/3/26. To deter her roommate from rummaging through her belongings, resident 7 had child safety locks installed on her nightstand drawers. 30. Interview on 7/9/26 at 10:14 a.m. with CNAs G and H revealed that when resident 7 wandered into other residents' rooms, the staff were to redirect her to rest in a reclining chair or her bed, or to give her an activity to do at one of the dining room tables. CNA H stated resident 7 has tried to open any and every door. CNA G said, We [the staff] just try to keep a good eye on her and try to intervene if we see her bothering another resident or going into someone's room. 31. Interview and observation of the ACU resident rooms on 7/9/26 at 10:48 a.m. with RN L confirmed that all blood glucose testing supplies for the ACU's diabetic residents were kept in the unit's locked med cart. RN L stated that because the ACU residents are cognitively impaired, no medications or supplies are kept in their rooms, other than incontinence supplies. She said resident 7 was not a good fit for the ACU because she would be bothered by some of the unit's residents who constantly followed others around. 32. Interview on 7/9/26 at 11:30 a.m. with resident 20 revealed that she kept her door closed to prevent resident 7 from entering her room and stealing her belongings. 33. Interview on 7/9/26 at 12:27 p.m. with business office and human resources manager I revealed that all facility staff received training to care for residents with dementia, including how to handle aggressive behaviors and respond to resident elopements. 34. Interview on 7/9/26 at 3:13 p.m. with DON B revealed she agreed resident 7's cognitive impairment meant she was vulnerable and relied on the staff to meet her daily needs. She expected the staff to reference a resident's care plan to know how to care for them, including how to redirect cognitively impaired residents. She approved of the staff's repeated attempts to have resident 7 sit in a recliner near the nurse's station, stating it would benefit resident 7 to elevate her feet and rest. To minimize resident 7's interference with the rights of other residents, DON B said the staff were trained to respond to handheld bells the residents use to indicate resident 7 is in their room, and residents were told not to yell at resident 7 to prevent resident-to-resident altercations from occurring. We talk to the residents who really have a problem with her, that's how we handle it. DON B said resident 7 used to reside in the ACU but moved to the general care area after the staff determined she was not at risk for eloping. She felt the door alarm systems were successful at deterring resident 7 from exiting the building, despite her lunchtime elopement attempt on 7/7/26. She [resident 7] has opened doors but we've followed her out, she stated. We are set up to succeed. Our system worked. DON B confirmed that all diabetic testing supplies for non-ACU residents were kept in an unlocked pencil box in the residents' closets. She stated that the lancets were safety needles (featuring a spring-loaded, auto-retracting needle to prevent reuse) and agreed that the used lancets and blood glucose testing strips were not secure when stored in the residents' closets. 35. Interview on 7/9/26 at 4:11 p.m. with ACU director Q revealed that appropriate redirection for resident 7 would include having her rock baby dolls, listen to music, or fidget with items such as magazines or books. Basically, you create an environment where she accidentally has to rest, such as rocking her 'babies' while listening to music. But only for a few minutes, tops, because she's busy, busy and going all the time. 36. Review of the provider's current ACU Admission/Discharge Criteria indicated that residents were assessed on a case-by-case basis to determine whether they were appropriate for the ACU. The residents' medical needs should not outweigh the provider's programming needs, and behaviors could include wandering. 37. Review of the provider's 5/14/25 Elopement policy revealed that the facility should take steps to keep the residents safe and assess residents to identify those who were at risk for elopement. 38. Review of the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard revealed that the improper disposal of used lancets and needles is a safety hazard that increases the risk of exposure to bloodborne pathogens from needlestick injuries, including HIV/AIDS (a virus that attacks the body's immune system), hepatitis B (a highly contagious viral liver infection), and hepatitis C (a bloodborne viral infection that causes liver inflammation). Under OSHA's Bloodborne Pathogens Standard, a safe sharps container must be puncture-resistant, leakproof on its sides and bottom, and have a closable lid to prevent spillage or hand entry. 39. Review of the provider's 1/2018 Disposal of Medications and Medication-Related Supplies policy revealed that to avoid risk of needle-sticks, immediately after use, syringes and needles are to be placed into puncture-resistant, one-way sharps containers specifically designed for that purpose. The policy stated, Whether kept in the medication room or affixed to the medication cart, the disposal containers are fitted with a lid that prohibits reaching into the container.

Based on record review, interview, and policy review, the provider failed to minimize the risk of residents acquiring and transmitting pneumococcal disease by ensuring that one of six sampled residents (38) was offered the pneumococcal vaccination. Findings include:1. Review of resident 38's electronic medical record (EMR) revealed that he admitted to the facility on [DATE] with a diagnosis of pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus). There was no documentation that he was offered and received or declined the pneumococcal vaccine. 2. Interview on 7/9/26 at 2:26 p.m. with assistant director of nursing (ADON) F revealed that she used a spreadsheet to track the residents' vaccination statuses. The facility provided different types of pneumococcal vaccines based on the residents' health status and age, and that some pneumococcal vaccines were two doses administered a year apart. Resident 38 did not receive the pneumococcal vaccine because Medicare charges the price of the vaccine to the facility, so we are waiting until he's off Medicare to make sure his insurance company pays for the vaccine. 3. Interview on 7/9/26 at 3:13 p.m. with director of nursing (DON) B revealed that she reviewed the resident vaccination statuses during a daily team meeting. She said, I wish payer source didn't play into that, and that the team would be auditing resident records to determine whether additional residents needed the pneumococcal vaccine. 4. Review of the provider's 1/14/26 Pneumococcal Vaccination - Resident policy revealed that residents were offered the pneumococcal vaccine upon admission to the facility, unless the vaccine had already been received or was medically contraindicated (inadvisable because it carries a high risk of harming the resident). Documentation of vaccine administration or refusal was stored in the resident's EMR.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure a physician orders for a therapeutic pureed (blended food) diet was followed for one of one sampled resident (1) who had a diagnosis of dysphagia (difficulty swallowing) and received a snack from one of one certified nursing assistant (CNA) (D) that was not the right texture and then required life-saving measures through use of the Heimlich maneuver after the food became lodged in his throat. On 2/18/26 at 12:59 p.m., an Immediate Jeopardy was identified for a facility reported incident (FRI) related to the quality of care and treatment that occurred on 2/11/26 at 12:59 a.m. for a resident who was served the wrong diet and required life-saving measures in an attempt to dislodge the food he choked on. The investigation revealed verbal and written education was initiated on 2/11/26 for the staff, and the resident's dietary information was changed to the correct diet on the snack cart for staff to follow. Those implemented processes allowed for the immediacy to be removed. Substantial compliance was confirmed on 2/19/26 at 2:58 p.m. after review of the provider's Quality Assurance and Performance (QAPI)/Quality Assessment and Assurance (QAA) minutes, documented staff education, audit information, observation of the kitchen, changes made to the snack cart and clipboards with the snack carts. Continued observations of the dining service, observations of resident meal tickets, and interviews with staff. The provider was found to have past non-compliance at F803 related to the provider's failure to ensure a physician-ordered resident diet was followed which required staff to perform the Heimlich maneuver [life-saving measure used to clear a blocked airway] on resident 1. On 2/19/26 at 3:50 p.m. the Immediate Jeopardy template was electronically emailed to administrator A for reference and review. After the immediacy was removed on 2/19/26 at 2:58 p.m. the scope and severity was lowered from a J to a G. Findings include:1. Review of the 2/11/26 SD DOH FRI regarding resident 1 revealed:*On 2/11/26 at 12:56 a.m. resident 1 was walking in the main lobby and stated he was hungry.*Certified nursing assistant (CNA) D had him sit down at a table by the nurse's station and handed him an Uncrustable sandwich (a prepackaged peanut butter and jelly sandwich without the crust).*Resident 1 had taken three bites and at 12:59 a.m. resident 1 set the Uncrustable sandwich on the table and stood up.*CNA D went to resident 1 and asked him if he was choking, resident 1 did not respond.*CNA D had given resident 1 back blows and called licensed practical nurse (LPN) E for assistance.*LPN E immediately came and began administering the Heimlich maneuver to resident 1.*Resident 1 was assisted to sit in a chair at 1:01 a.m. and LPN E continued to administer the Heimlich maneuver until he took a couple gasps of air.*At 1:04 a.m. resident 1 was transferred to the floor and laid on his side, he made a noise and began spitting phlegm.*CNA D was able to visualize food in his mouth.*She reached into his mouth and was able to grasp remnants of the Uncrustable sandwich and pulled them out of his mouth.*Resident 1 was assisted by LPN E to sit up and take sips of thickened liquid.*At 1:12 a.m. resident 1 was assisted to a dining room chair.*His vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse and respiration rate) were taken. His temperature was 96.9, pulse 64, respirations 20, blood pressure 158/76 and his oxygen saturation (percentage of oxygen in the blood) was 95 percent.*Resident 1's voice was a little raspy, he was assisted to the bathroom and then returned to the dining area to a recliner chair for further monitoring.*Resident 1's family, physician, and hospice program were notified of the incident.*CNA D and LPN E were suspended pending investigation for not providing resident 1 with the correct diet texture food. 2. Review of resident 1's electronic medical record (EMR) revealed:*His 11/24/25 Brief Interview for Mental Status (BIMS) assessment score was 0 indicating severe cognitive impairment. He was dependent upon the staff to ensure his physician orders were followed for his safety and well-being.*He was admitted to the facility on [DATE].*He was admitted to hospice services on 11/18/25.*His diagnoses included: Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body function), restlessness and agitation, delusional disorder, and depression.*A 11/22/25 quarterly nutritional assessment indicated he was on regular puree textures with thin liquids diet, had dysphagia, and had coughing or choking during meals or when swallowing medications.*A 11/24/25 physician's code status order for DNR (do not resuscitate)/DNI (do not intubate).*On 11/28/25 a physician-order was entered and his diet for regular, puree (level 1) texture remained the same, but his liquids were changed to nectar-thickened liquids. 3. Interviews on 2/18/26 at 10:35 a.m. and again on 2/19/26 at 10:49 a.m. with dietary manager (DM) H regarding the 2/11/26 FRI revealed:*She was notified on 2/11/26 at 8:30 a.m. of the choking incident with resident 1.*She added designated bins for puree and mechanical soft texture diet to the snack cart.*She added a posted list in the kitchen on the wall by the snack cart.*She updated the clipboard (contains diet information for residents) for the snack cart that now contains the correct diet texture.*She also added the allowable and not allowed foods education to the clipboard for the mechanical soft and puree diet textures.*Uncrustable sandwiches were not sent out on the snack cart.*Staff must go into the kitchen and get Uncrustable sandwiches from the refrigerator when requested.*She had completed education since the above incident occurred on 2/11/26, and all dietary staff had completed the education also on 2/11/26.*She completed audits regarding if the meal ticket was left with the meal, did the ticket and the meal match for diet ordered, was the meal the right texture, were the liquids the correct consistency, and was the correct adaptive equipment in place, at least weekly.*She audited to ensure there were back up bins in the refrigerator for snacks, labeled properly. She had ensured dietary staff had completed education on 2/11/26 regarding the new bins being used, and ensuring textures of the diets ordered for residents through her performed audit. 4. Interview on 2/18/26 at 11:30 a.m. and 2/19/26 at 10:30 a.m. with LPN E revealed:*She had worked the overnight shift on 2/10/26 at 6:00 p.m. until 2/11/26 at 7:00 a.m.*Resident 1 is awake most nights.*CNA D had given resident 1 an Uncrustable sandwich at the table.*LPN E had known that resident 1's ordered diet was regular puree texture with nectar-thickened liquids.*CNA D had reported to her that resident 1 was choking, and LPN E started the Heimlich maneuver on him while standing, then sat him in a chair while continuing the Heimlich maneuver.*Before finally placed resident 1 on the floor and switched to chest thrusts.*Resident 1 had made a noise,*LPN E and CNA D could see a piece of sandwich and CNA D performed a finger sweep, and removed the sandwich piece from his mouth.*LPN E continued to remove more small remnants after the first piece was removed.*CNA D had gone into the kitchen and got the Uncrustable sandwich for resident 1.*She had been aware that CNA D was giving resident 1 the Uncrustable sandwich because CNA D had asked if it was okay, and she had not answered CNA D.*Resident 1 had eaten the Uncrustable sandwiches before without problems.*She had been a nurse for thirty years, she was thankful she performed the Heimlich maneuver, and it was successful.*She had received a lot of education since the 2/11/26 incident on what a mechanical diet and puree diet consists of. She also received education on changes to the kitchen snack cart. That education included that it now had labeled bins with items safe for puree texture and mechanical soft texture diets, and allowable and not allowed list attached to the clipboard that is on the snack cart. All the residents were listed with their diets. diet texture and fluid consistency.*She monitored resident 1 in the sitting area by the nurse's station the remainder of her shift. No other interventions were initiated.*She had completed Basic Life Support training on 2/17/25.*She had notified administrator A and director of nursing (DON) B on 2/11/26 at around 7:00 a.m. via text message.*She had notified family representative and physician on 2/11/26 at 6:49 a.m. 5. Interview on 2/18/26 at 1:30 p.m. with CNA D revealed:*She worked the overnight shift on 2/11/26.*She had asked LPN E what to get resident 1 for a snack and she suggested the Uncrustable sandwich.*After giving resident 1 the Uncrustable sandwich, she observed him stand-up from the table. *She had asked him if he was choking.*Resident 1 did not answer, and she gave back blows. *LPN E came over and started the Heimlich maneuver on resident 1.*She thought resident 1 might have passed out so they placed him on the floor, then LPN E completed abdominal thrusts.*She saw a chunk of the sandwich in resident 1's mouth and removed it.*She had given resident 1 Uncrustable sandwiches before the above incident and he had no problems with eating it.*She was aware resident 1's diet was regular puree texture with nectar thickened liquid.*She was able to find resident diet orders on the Kardex (a report of the resident's care needs and interventions).*She received education on 2/11/26 at 3:30 p.m. from assistant director of nursing (ADON) F, and there are signs in the kitchen about what is acceptable for residents who have mechanical soft texture and puree texture diets.*She had completed Obstructive Airway-Choking training on 12/4/25.*She had received a disciplinary warning and signed an acknowledgement of the required education following the above incident. 6. Interview on 2/19/26 at 9:58 a.m. with speech language pathologist (SLP) H revealed:*She had seen resident 1 from 9/12/25 through 10/2/25.*He was on a mechanical soft texture diet at that time.*Resident 1 was unresponsive to cues and so his diet was downgraded to regular puree diet with nectar thickened liquids.*She had not received a request from the facility for further evaluation after the 2/11/26 choking incident.*The facility might not have requested further evaluation due to resident 1 already being regular puree diet with nectar thickened liquids.*She agreed that resident 1 should not be eating Uncrustable sandwiches as that is mechanical soft texture consistency. 7. Interview on 2/19/26 at 11:03 a.m. with assistant director of nursing (ADON) I revealed:*She was notified of resident 1's choking incident on 2/11/26 at 9:30 a.m. when she arrived at the facility.*She ensured that the family and physician had been notified.*She started initial verbal education for staff working, after receiving additional information by email communication with administrator A on 2/11/26 at 10:12 a.m. and the education was completed before 12:00 p.m. when lunch was served to residents.*Education for all staff was started after 12:30 p.m. following further communication from the corporate meeting.*All staff were given the required education on 2/11/26 at a 2:00 p.m. staff meeting.*Staff who were unable to attend were sent the education materials and documents via text message and had to acknowledge receipt of the education. *Two as needed (PRN) staff were sent a letter containing the information by certified mail. 8. Interview on 2/19/26 at 2:48 p.m. with DON B revealed:*She and administrator A were the primary contacts for emergencies.*She would then notify other staff needing to be notified of incidents.*She and administrator A were notified via text message on 2/11/26 at 7:15 a.m. by LPN E of resident 1's choking incident.*LPN E should have called as soon as resident 1's choking incident happened.*LPN E had received disciplinary action after the incident.*She had not asked for a speech evaluation following resident 1's choking incident because he had one that was completed one month before. His diet order was regular puree diet with nectar-thickened liquids, and he was on hospice and comfort care already.*Neither she nor administrator A was in the building on 2/11/26.*Education to all staff started 2/11/26 around 10:12 a.m. with an email to ADON I regarding dietary changes and what to include in initial education for mechanical soft and puree diets for staff.*Information was added to the snack cart clipboard about allowable and not allowable food items for mechanical soft and puree texture diets.*Staff know resident diet orders by looking at the Kardex, meal tickets, care plans and the resident diet order.*She and administrator A were in contact with the corporate office on 2/11/26 at 12:30 p.m. and notified ADON I of the final education for staff and the added dietary changes on the snack cart clipboard.*The first interventions were put in place on 2/11/26 at 12:00 p.m. before the noon meal to protect all residents before their lunch was served by ADON I.*She and administrator A both completed QAPI for the facility.*Through QAPI audits will be reviewed:-How many were completed.-The retraining needs of staff.-What corrections are needed. *Audits were to continue until full compliance is obtained and were to continue for at least three months.*The audits will be re-evaluate and adjusted if non-compliance within the audits is found.*Further steps included re-education of staff, with audits completed every time they work. 9. Review of the provider's Pureed diet policy revealed:*General Information:This modification is designed for people who have severe chewing and /or swallowing problems. Properly pureed foods eliminate the chewing phase. Pureed diet menus follow the foods on the regular menu as closely as possible and differ primarily in consistency. Puree all foods to smooth, lump-free, Extremely Thick consistency (not firm or sticky). Use an appropriate recipe. This diet is also appropriate for Dysphagia Pureed (Level1).*Transitional foods are NOT allowed unless assessed and ordered by the SLP and/or a physician. *A detailed plan of action was completed by the facility on 2/11/26 related to resident 1's choking incident. The plan was based on Root Cause Analysis of the FRI and resulted in the development of multiple performance improvement plans. -These plans include systemic changes and actions with all staff's education and re-training. Audits on staff awareness of resident diet textures as ordered by physicians. Updated snack cart clipboard with diet texture information for staff, allowable and not allowed foods for mechanical soft texture and puree texture diets. Labeling of new bins with stocked approved snacks for snack carts for mechanical soft and puree texture diets. Back-ups bins in refrigerator in kitchen which will be audited by DM H. The changes and actions were confirmed on 2/19/26 through observation, interview and review of the Provider's Plan of Correction documentation. Based on the above information, non-compliance at F803 occurred on 2/11/26. Based on the provider's implemented plan of correction for the deficient practice confirmed on 2/19/26, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported (FRI), observation, interview, record review, and policy review, the provider failed to ensure: Ten of forty-six sampled residents (3,4,5,6,7,8,10,11, and 13) had received their hour of sleep (HS) medications and Two of forty -six sampled residents (9 and 12) had recived the morning medicatons per physicians orders by one of of one licensed vocational nurse (LVN) J. *One of one LVN J had folowed physcian orders and applied a pain patch at the correct dosage for one one resident (2). Findings include:1. Review of the providers 9/9/25 SD DOH FRI involving residents (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) revealed:*On 9/9/25 at 7:30 a.m., a resident reported she had received her medications that morning. *An audit was conducted by registered nurse (RN) F and indicated residents on the main floor and Alzheimer Care unit (ACU) had their medications signed out on their electronic medication administration record (EMAR), indicating that the residents had received those medications.*The audit for the ACU revealed that 6 out of 7 residents' medication cards still contained their medications in the bubble cards on 9/8/25 for the (HS) med pass. *The audit for the main floor revealed that 2 residents had not received their medications even though they were signed out on their EMAR on 9/9/25 for the morning med pass. *The residents had been assessed by RN F and the director of nursing (DON) B for any adverse outcomes after they had not received their HS and morning medications. No negative outcome was identified. *Resident 2, who had received the incorrect dose of Fentanyl, had been monitored and had no negative outcomes. *LVN J, who had worked had been blocked from returning to the facility to work. *The physicians and the resident responsible parties had been notified. 2. Interview and observation on 2/18/26 at 7:56 a.m. with RN F revealed:*She worked full-time on the day for 21 years. *She explained that the medication cards have 30 bubbles for 30 days' worth of medications. She checked the medication card against the resident's name and punched the medication out of the bubble into a cup. She clicked save on the computer after the resident had taken their medication, and it turned green, which indicated completion. She stated that if the medications were not saved as administered, the medications would turn red. She stated that the red would have been noted at the end of her shift as something she had missed. She stated after she gave the medication, she placed the cards for that resident at the back of the row. Each medication pass is indicated on the medicaton card with a colored sticker on each of them. The stickers had a.m., p.m. or HS on them. She stated that if she had come to work in the morning and noticed that a resident's medication for HS was remaining at the front, that would have indicated those HS medications were never given. 3. Observation and interview on 2/18/26 at 8:20 a.m. with LPN G revealed:*She had worked at the facility since August 2025. *She completed the narcotic count for the main unit with this surveyor. *The completed shift-to-shift count of narcotics with the oncoming and the nurse going off shift to ensure they were accounted for. *The narcotics were accounted for by their count. When a new medication was brought into the facility for a resident, the medications are counted and noted, and subtracted each time it is administered to the resident.*She stated that the regular medication cards are in the medication cart, per each resident's name, and separated by a.m., p.m., and HS shift. She could have seen if a medication was not administered if the medication had not been punched out for that date. The medication would have been left in the bubble pack for that date. The medication would have been left in the bubble pack for that date. She had reported a concern regarding medications left in a bubble pack in the past to the DON, but she had not seen that happen again. She stated she was not sure if that person still worked at the facility, as she didn't know who had done it. 4. Interview on 2/19/26 at 2:20 p.m. with DON B and administrator A, revealed:*DON B stated she was not currently auditing bubble cards for medication errors. *She stated she had not had problems with medications that had been signed off in the EMAR and left the medication in the bubble cards before the incident of 9/8/25 and 9/9/25.*She stated that that LVN J had been blocked immediately from all of their facilities, and the contract agency had been notified. *LVN J had started on 9/5/25 and had only worked one day and that was the was the date of the incident 9/8/25. *She stated she gets calls or text messages from her staff all the time. She stated that, depending on the situation she would have decided if that situation warranted her to come in right away. She had come in later that morning after receiving report regarding the patch. She stated she then discovered the HS medication cards were not moved to the back of the medication cards which indicated the medications had not been given for the HS on 9/8/25 and the morning on 9/9/25. She would run reports so that she could tell if medications had been missed because they would be in red. LVN J had signed them out on the EMAR that they had been given but the medications were still in the medication cards. *DON B and Administrator A agreed that the dose of Fentanyl that was given to the incorrect resident (2) was a lot. The DON stated that due to that dose, the resident had been monitored a lot after that with no negative outcome. 5. Review of the resident's (EMR) who had medication errors on 9/8/25 and 9/9/25 by by LVN J revealed: *Resident 2 was admitted to the facility on [DATE].-She had a Brief interview for mental status (BIMS) score of 3, which indicated severely impaired cognition.-She had a physician's medication order for a Fentanyl (pain medication absorbed through the skin) Patch 12 MCG/HR (micrograms/hour) every 72 hours and had received the wrong dose of 25 MCG on 9/8/25. -She had no documented negative outcomes.*Resident 3 was admitted to the facility on [DATE]. -She had a BIMS score of 6 that indicated severe cognitive impairment. -She had a physician's order for Dilantin (antiseizure), Terazosin (blood pressure), Calcium (supplement), Olanzapine (antipsychotic), Oxcarbazepine (antiseizure), Depakote (seizures), Hydralazine (blood pressure), Seroquel (antipsychotic), and Lactulose (lower ammonia levels) that she had not receive d on 9/8/25, but had been signed out on the EMAR as given.-She had no documented negative outcomes.*Resident 4 was admitted to the facility on [DATE]. -She had a BIMS score of 15 that indicated her cognition was intact.-She had medication orders for Protonix (reflux), Crestor (lower cholesterol), Venlafazine (antidepressant), Buspar (anxiety), Eliquis (blood thinner), Sulfasalazine (ulcerative colitis), Calcium (supplement), and Loperamide (chronic diarrhea). She had not received those medications, but they were signed out on her EMAR as given. -She had no documented negative outcomes.*Resident 5 was admitted to the facility on [DATE].-He had a BIMS score of 2 that indicated his cognition was severely impaired. -He had physicians' medication orders for Donepezil (manage cognitive symptoms), Tamsulosin (decrease frequent urination), Trazodone (depression), and Metformin (lower blood sugars) that he had not received, but were signed out on his EMAR as given. -He had no documented negative outcomes.*Resident 6 was admitted to the facility on [DATE].-He had a BIMS score of 10 that indicated he had moderately impaired cognition.-He had physicians' medication orders for artificial tears (dry eyes), Melatonin (regulates body's sleep - wake cycle), and Trazodone (depression) that he had not received, but they were signed out on his EMAR as given. -He had no documented negative outcomes.*Resident 7 was admitted to the facility on [DATE].-He had a BIMS score of 11 that indicated he had moderately impaired cognition. -He had a physician's medication order for Tamsulosin (decrease frequent urination) and Trazodone (depression) that he had not received, but they had been signed out on his EMAR. -He had no documented negative outcomes. *Resident 8 was admitted to the facility on [DATE].-She had a BIMS score of 00 that indicated she had severe cognitive impairment.-She had a physician's medication order for Gabapentin (nerve pain medication) that she did not receive, but it was signed out on the EMAR as given.-She had no documented negative outcomes.*Resident 9 was admitted to the facility on [DATE]. -He had a BIMS score of 12 that indicated his cognition was moderately impaired.-He had a physician's medication order for Synthroid (treat low thyroid hormone), Flonase (nasal spray for nasal congestion), Prilosec (treats heartburn), and Tylenol (pain reliever) that he did not receive but they were signed out on his EMAR as given.-He had no documented negative outcomes.*Resident 10 was admitted to the facility on [DATE]. -He had a BIMS score of 7 that indicated he had severe cognitive impairment. -He had a physician's medication order Synthroid (treat low thyroid hormone), Tamsulosin (treat frequent urination), Trazodone (depression), Clonazepam (treat panic disorders), and Fluticasone (treat itchy, runny/stuffy nose) that were signed outon the EMAR as given.-He had no documented negative outcomes.*Resident 11 was admitted to the facility on [DATE].-He had a BIMS score of 00 that indicated he had severe cognitive impairment. -He had physicians' medication orders for Depakote (treat seizures), Hydroxyzine (antihistamine), Melatonin (regulates sleep/wake cycle), and Trazodone (treat depression) that he had not received, but they were signed out on his MAR as given. -He had no documented negative outcomes.*Resident 12 was admitted to the facility on [DATE].-She had a BIMS score of 15 that indicated her cognition was intact. -She had physicians' medication orders for Gabapentin (nerve pain reliever), Protonix (treat reflux), and Synthroid (treat low thyroid hormone) that she had not received, but they were signed off on her EMAR as given. She had no documented negative outcomes.*Resident 13 was admitted to the facility on [DATE].-She had a BIMS score of 2 that indicated her cognition was severely impaired.-She had a physician's medication order for Prilosec (treat heartburn) that she had not received, but it was signed off on her EMAR as given. -She had no documented negative outcomes. 6. Review of the provider's undated Medication Administration Policy revealed:*B. Administration* 2) Medications are administered in accordance with written orders of the prescriber.* 15) Medications supplied for one resident are never administered to another resident.* D. Documentation (including electronic).*1) The individual who administers the medication dose records the administration on the resident's MAR/eMAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.*6) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other that the scheduled time (e.g., the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is [initialed and circled]. If electronic MAR is used, documentation of the unadministered dose is done as instructed by the procedures for use of the eMAR system. An explanatory note is entered on the reverse side of the record. If [XX consecutive doses] of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response.

Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were updated to accurately reflect the residents' abilities to use call lights effectively for five of five observed sampled residents (5, 18, 20, 21, and 23) with impaired cognition who resided in the memory care unit (MCU). Findings include: 1. Observation and interview on 3/18/25 at 9:35 a.m. and again on 3/19/25 at 1:38 p.m. with resident 5 revealed: *Resident 5 sat on the edge of her bed and her call light was attached to the curtain in the center of the room between the two beds on the opposite side of the room from her bed on her roommate's side of the room on both days. -Both call lights were on the same side of the room away from resident 5. -She was unsure if there was a call light. She looked around and stated, It wouldn't do me any good if I can't get to it. -She said she would go to the dining room when she needed something. Review of resident 5's electronic medical record (EMR) revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was 4, which indicated she was severely cognitively impaired. *Her diagnosis included dementia (a decline in memory, thinking, and reasoning abilities that significantly impacts daily life) and amnesia (a loss of memory, either temporary or permanent, that can involve forgetting past events, personal information, or the inability to form new memories) *Her care plan included interventions that were initiated: -On 8/2/24 to Keep call light within reach when in bedroom or bathroom. -On 8/15/24 to [Keep] Call light within reach and provide reminders to use call light to ask for assistance. 2. Observation on 3/18/25 at 8:51 a.m. and again on 3/19/25 at 1:32 p.m. revealed resident 18's call light was clipped on the curtain in the center of the room approximately five feet from the floor inaccessible to the resident from the bed or chair on both days. Review of resident 18's EMR revealed: *Her BIMS score was 4, which indicated she was severely cognitively impaired. *She had a diagnosis of dementia. *Her care plan included interventions that were initiated: -On 5/15/24 to Keep call light within reach. -On 9/3/24 to Keep call light and personal items available and in reach. 3. Observation and interview on 3/18/25 at 8:53 a.m. with resident 20 revealed: *Resident 20 was lying in bed and his call light was clipped to the top left corner of his mattress near his head. -He was unsure how to get a nurse to come to his room. -When asked, he did not know where the call light was located. Review of resident 20's EMR revealed: *His BIMS score was 9, which indicated he was moderately cognitively impaired. *His diagnoses included dementia and seizures. *His care plan interventions included, Keep call light within reach, initiated on 9/30/24. *A 2/22/25 progress note, indicated Resident found by CNA [certified nursing assistant] after she heard something. He was sitting on [his] buttocks on [the] floor. Stated he was reaching for water .Call light clipped to wall .Did not ring for assistance. *A physician's order May have silent alarm to alert staff without alarming him, was dated 2/24/25 and discontinued on 3/18/25. 4. Observation on 3/18/25 at 8:47 a.m. and again on 3/19/25 at 1:30 p.m. with resident 21 revealed: *Resident 21's call light was clipped to the curtain in the center of the room between the two beds, which was inaccessible to the resident from his bed on both days. Review of resident 21's EMR revealed: *His BIMS score was 3, which indicated he was severely cognitively impaired. *He had a diagnosis of dementia. *His care plan interventions included, Keep call lights within reach when in bedroom or bathroom, initiated on 4/26/21. 5. Observation and interview on 3/18/25 at 8:57 a.m. and again on 3/19/25 at 1:33 p.m. with resident 23 revealed: *Resident 23's call lights were clipped to themselves on the wall in the center of the room on both days and were inaccessible to the resident. -She stated she did not know if there was a button to push if she needed help and she would just go out in the hallway and call for help. Review of resident 23's EMR revealed: *Her BIMS score was 4, which indicated she was severely cognitively impaired. *She had a diagnosis of dementia. *Her care plan interventions included, Keep call light within reach when in room or bathroom, encourage to use and to wait for assistance. Doesn't always understand/remember to use. Keep call lights within reach when in bedroom or bathroom initiated on 9/3/21. 6. Interview on 3/19/25 at 10:50 a.m. CNA F revealed: *Some residents in the MCU knew how to use their call lights but many did not. *One resident had a silent alarm that alerted staff when she got out of bed. *Resident 20's silent alarm was discontinued yesterday (3/18/25). 7. Interview on 3/19/25 at 2:51 p.m. with Alzheimer's care director D regarding resident call lights on the memory care unit revealed: *Residents in the MCU never used their call lights. *They tried to keep the call lights close by in case the staff needed to use them. -Staff also used radios to call for help when needed. *She declined to look at the call lights in specific resident rooms and stated, I know where they are. -She stated some call lights were clipped on the curtain and others were clipped to themselves at the wall. *Some call lights were intentionally left out of reach of the residents for safety reasons. *She was not responsible for the care plan areas that had indicated to leave resident call lights within reach of the residents. -She indicated the Minimum Data Set (MDS) coordinator would have completed that specific part of the residents' care plans. *She expected the care plan would indicate that the call lights were within reach for staff. *She expected the care plans to represent the residents' abilities. *Resident 5 might have moved the call light herself when she made her bed. *Resident 18 was unable to use a call light to request assistance. Staff were to anticipate her needs. *She was unsure if resident 20 knew what the call light was. *Resident 23 may have clipped her call light to the wall because she removed pictures from the walls and moved items around in her room. 8. Interview on 3/19/25 at 3:17 p.m. with MDS coordinator E revealed: *She completed the resident care plan areas related to activities of daily living, mobility, and toileting. *Information was updated in the resident's care plan with every assessment. *She made sure to add that call lights were within reach in the bathroom or within their room to every care plan. -She had been told it needed to be on every care plan regardless of the resident's ability. *She felt the residents' care plans should be a reflection of the resident's needs and be person-centered. *She had not worked in a facility with a memory care unit before working at this facility. *She was unaware that the call lights in the memory care unit would sometimes be intentionally placed out of reach of the resident for safety reasons. *If call lights were determined to be a safety risk to the resident that should have been indicated on the care plan. 9. Interview on 3/19/25 at 3:40 p.m. with administrator A, director of nursing B, and regional nurse consultant G revealed: *They expected the care plans would accurately reflect the residents' individualized needs. *Some residents in the MCU might not be able to use their call lights. *It was possible that the call light could present a safety hazard to a resident in the memory care unit. Review of the provider's revised 9/30/24 Care Plans policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. In doing so the following considerations are made: Each resident is an individual . *Care Plans should be updated between care conferences to reflect the current care needs of the individual resident as changes occur.

Based on observation, interview, and policy review the provider failed to ensure necessary infection control practices in one of two shower rooms that included: *Maintenance of a plastic three drawer towel and washcloth storage bin. *An appropriate and sanitary process for the removal of and transport of bowel movement(s) occurring during showering. *Appropriate care and maintenance of a multi-resident use foot soak basin. *Appropriately individualized resident identified personal hygiene products. Findings include: 1. Observation and interview on 11/15/23 at 2:35 p.m. with certified nursing assistant (CNA) E regarding cleaning the shower room revealed: *The shower room was in the south hallway and was used by all residents except for those residents who resided in the memory care unit. *The shower room was a 6 x 6 feet room with no toilet, sink, or hand sanitizer dispenser. *From the doorway at the back right wall was a shower head, with a commode-style shower chair and a floor drain under it. *Approximately 1.5 feet to the left of the shower chair was a three-drawer plastic storage bin with towels and washcloths stored in it. -The storage bin was observed as black at one time but now was covered in a white hard water build-up from the shower water. -The storage bin had approximately one-fourth to one-half inch of white hard water build-up inside the handles and along the left bottom edge from the shower water. *On the floor in front of the storage bin was an empty white ice cream bucket. *On the left wall above the storage bin was a wood cabinet and when opened it contained a box of gloves and more than a dozen assorted bottles and tubes of personal hygiene products consisting of baby powders, barrier cream, lotions, body washes, deodorants, shampoos, and conditioners. -None of the above containers were labeled with the resident's names. *Stored on top of the wood cabinet approximately one-half inch below the ceiling was a pink plastic basin and sitting inside of that basin was a gray bucket. *Hanging off the top edge of the cabinet were three disinfectant spray bottles. *On the wall between the shower and the plastic storage bin was a laminated instruction sheet for cleaning the shower that included a three-minute disinfectant contact time. -The instruction sheet had no instructions for cleaning the storage bin, pink basin or buckets. *She was able to refer to the shower cleaning instructions on the wall and demonstrate appropriate shower cleaning. *When asked about cleaning the storage bin next to the shower she reported she had not cleaned it when she cleaned the shower and confirmed the shower cleaning instructions on the wall did not include cleaning it. *She stated the ice cream bucket on the floor was used by CNAs to put under the commode chair if a resident had a bowel movement during their shower and she used it to put her wet washcloths in to take to the soiled laundry. *She stated the bucket used for residents having a bowel movement during their showers was taken to either the bathroom outside the shower room or the soiled utility room around the corner and down the hall to discard the feces. *When asked how the bucket was transported, she denied having bags or a lid for the bucket. *She stated she cleaned the bucket with the same disinfectant spray they used for the shower. *She denied receiving any training on how to remove the feces in the bucket from the shower room or how to clean that bucket. *When asked about the pink basin on top of the cabinet she stated they used it to soak residents' feet before trimming their toenails. *She reported that the pink basin was cleaned with the same spray bottle of disinfectant used to clean the shower and denied receiving any training on how the basin was to have been cleaned between each resident. *When asked about the personal hygiene products inside the cabinet she reported they belonged to multiple residents and were used during their showers and despite that there was no resident's names on those products she stated she sort of knew what belonged to the residents. Observation and interview on 11/15/23 at 3:00 p.m. with the director of nursing (DON) B in the shower room revealed: *All CNAs were responsible for giving their assigned residents showers during their scheduled shifts. *The instructions for shower cleaning were on the wall and they were to also clean the outside of the storage bin when they cleaned the shower between residents. *The white build-up on the storage bin was from the hard water and they replaced the storage bin several times. -She agreed the build-up in the drawer handles was a concern for the shower water leaking into the drawers and contaminating the clean towels and wash clothes. *She stated the plastic bin on top of the cabinet was for soaking resident's feet before clipping their toenails and the gray bucket sitting inside of it was to have been placed under the commode chair if a resident was having a bowel movement while taking a shower so the feces would not go down the water drain and clog it. *She stated the pink basin was cleaned with the same disinfectant spray they used to clean the shower and denied that there were instructions posted in the room or a policy instructing on how to clean the basin used for multiple residents. *She stated a biohazard bag could have been placed in the gray bucket before a resident had a bowel movement and then tied to transport it to the soiled utility room for disposal. *She agreed there were no biohazard bags or lids for the bucket stored in the shower room. *She agreed hand hygiene would have been difficult to maintain in the shower room as there was no handwashing sink and no hand sanitizer in that room. *She agreed the personal products located in the cabinet should have residents' names on them and posed a concern for cross-contamination. *She was not aware of how staff were using the white ice cream bucket located on the floor next to the storage bin with clean towels and washcloths. Interview on 11/16/23 at 12:40 p.m. with assistant director of nursing (ADON) C regarding infection control and the shower room revealed: *She was the infection preventionist. *She had a Centers for Disease Control (CDC) infection preventionist training certificate with a completion date of 1/31/2022. *CNAs received training on showering residents during their CNA course. *She had not trained or monitored staff for infection prevention in the shower room. *She had not made rounds or performed any spot checks in the shower room. *Housekeepers have a routine cleaning schedule for deep cleaning, and it included the shower room. *If the housekeepers had seen something that was not cleaned in the shower room, they would have let the appropriate person know. *The storage bin next to the shower was to have been cleaned when the shower was cleaned. *She agreed the shower cleaning instructions posted in the shower did not include spraying disinfectant and wiping down the storage bin. *She agreed the drawers of the storage bin were not leakproof and agreed that shower water leaking into the drawers and onto the clean towels and washcloths was an infection control concern. *She stated the buckets in the shower room were used if residents had a bowel movement while they were in the shower. *There was no process in place for transporting that bucket from the shower room to the utility room. *She stated staff could use a bag and then take it to the soiled utility room down the hall with the hopper and throw the bag away. *She had not placed bags in the shower room or developed a process for staff to follow. *She agreed leaving the shower room with a bucket of feces that was not covered with a bag or lid did not follow the infection control process. *The pink basin on top of the cupboard was for soaking residents' feet before clipping toenails. *Basins could be a one-time use or could have been used for more than one resident if the staff would disinfect it with the same spray, they used to clean the shower. *She does not train staff on cleaning basins after use or between multiple residents use. *She expected that the dozen or more personal hygiene products stored in the cabinet were to have been labeled with the resident's name. *She agreed that since they were not labeled, there was the potential that the personal hygiene products had been used on multiple residents and that was an infection control concern. A review of the provider's 1/24/23 Infection Prevention Program policy revealed: *The goals of the infection prevention and control program are to: -A. Decrease the risk of infection to residents and personnel. -B. Prevent, to the extent possible, the onset and spread of infection. -C. Monitor for occurrence of infection and control outbreaks and cross-contamination. -D. Monitor for the occurrence of infection and implement appropriate control measures. -E. Identify and correct problems related to infection prevention practices. -F. Maintain compliance with state and federal regulations and standards of practice relating to infection prevention and control. *The facility-wide comprehensive infection prevention and control program addresses detection, prevention, and control of infections among residents and personnel. It is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for all.

Based on observation, interview, and record review the provider failed to ensure a Foley catheter change was completed per a physician's order for one of one sampled resident (93). Findings included: 1. Observation and interview on 11/14/23 at 9:05 a.m. with resident 93 revealed: *He was in his room sitting in a recliner watching television. *There was a catheter drainage bag hanging below his waist attached to the recliner and covered with a blue bag. *The urine in the catheter bag was concentrated and dark yellow. *There was sediment in the urine and the catheter tubing. *He stated he was seen by a urologist. *The staff were good about emptying the urine from the drainage bag and completed catheter care every morning and evening. *He could not recall if the nursing staff had changed his Foley catheter since he arrived at the facility a couple of months ago. Review of resident 93's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had a Brief Interview for Mental Status (BIMS) score of 14 indicating he was cognitively intact. *His diagnoses included urine retention. *Physician orders included the following: -Change catheter monthly and PRN [as needed] every night shift starting on the 1st and ending on the 1st of every month. initiated on 10/5/23 to start on 11/1/23. -Foley catheter 16 French with 10 cc balloon. change if becomes dysfunctional or if sterility is compromised. Initiated on 9/9/23. -Change Foley catheter per facility protocol or MD order Initiated on 09/09/2023. -Monitor urine/catheter output every shift Initiated on 09/09/2023. -Follows urology, [name of urologist], change catheter monthly Initiated on 09/21/2023. *A review of his care plan revealed: -He had an alteration in bladder functioning related to urinary retention with a Foley catheter. -On 9/29/23 they attempted to discontinue the catheter, but he was unable to void (urinate), and the catheter was reinserted. *A review of his November 2023 treatment record revealed: -Change catheter monthly and PRN every night shift starting on the 1st and ending on the 1st of every month with a start date of 11/1/2023 had been listed to have been completed on 11/1/23 but it was not initialed or documented that it had or had not been completed. Interview on 11/16/23 at 10:53 a.m. with the director of nursing (DON) B regarding a missed Foley catheter change for resident 93 revealed: *They had removed his Foley catheter on 9/29/23 per the physician's order and had to replace it because he could not void. *Urology ordered catheter changes monthly for resident 93 on 10/5/23. *His Foley catheter change was scheduled on the 1st of November, and had not been documented as completed. *She was not sure why his Foley catheter change was not completed on the 1st of November as scheduled or within 48 hours after, she had been gone. *Perhaps he refused as they were in a COVID outbreak at that time. *Her day nurse from November 1st reported she had not changed the catheter, and the night nurse was home sleeping and could not be reached. *She had the day nurse change his Foley catheter on 11/16/23 and sent an order/notification to urology that it had been changed late. *Nurses were alerted to tasks due through the dashboard in the PointClickCare EMR system. *If the treatment was not completed it continued to show up for 48 hours as not done until the task was completed and then would fall off the dashboard alerts. *If the treatment was not done within 48 hours, they fell off the dashboard alerts. *She or the assistant director of nursing (ADON) checked missed tasks daily. *She expected that if a treatment was due and it was not completed when scheduled it would have been documented as to the reason why it was not completed, the physician was notified with new orders, and for the scheduled task to have been completed at another time. Interview on 11/16/23 at 11:25 a.m. with registered nurse (RN) D regarding the missed Foley catheter change for resident 93 revealed: *Treatments or tasks scheduled during shifts were located on the resident's treatment administration record and were highlighted on the dashboard in the EMR. *If the scheduled treatment or task was not signed off, it did not go away and hung out on the dashboard in the EMR. *If a nurse had not completed a scheduled treatment, it would have been documented as to why in the EMR, they would have notified the physician by a facsimile (fax), notified the DON or ADON, rescheduled or had the ADON reschedule the treatment in the EMR and reported it to the next shift. *If the above process was not completed then it would have stayed on the treatment record until it was completed. *There was a way to set up treatment orders in the system to have the system continue to notify on the dashboard until the treatment was signed off. *Typically, urology ordered Foley catheter changes every 30 days. Interview on 11/16/23 at 12:40 p.m. with the assistant director of nursing (ADON) C regarding a missed Foley catheter change revealed: *Foley Catheters scheduled to be changed were all set up on the resident's treatment administration record in the EMR per the physician's order. *Most physician's ordered routine Foley catheter changes and the urologists wanted the Foley catheters changed monthly. *Foley catheters scheduled to have been changed alerted the nurses by popping up on the treatment record dashboard in the EMR. *If the Foley catheter change was not completed for some reason on the scheduled date the nurses should have passed it on through the shift change report with the next shift. *She would have expected the missed Foley catheter change to have been reported to the physician and rescheduled in the treatment administration record. *They typically had not had any issues with missed treatments. *His Foley catheter change was missed due to the COVID outbreak all the staff were busy. *She had planned to look at the system and find a way for treatments to not fall off the EMR dashboard alert until completed.

Based on observation, interview, record review, and policy review, the provider failed to put appropriate interventions in place for one of two sampled resident (289) to prevent a pressure ulcer from developing. Findings include: 1. Observation and interview on 1/18/23 at 11:49 a.m. revealed resident 289: *Was sitting in a recliner in his room with his legs elevated and a heel boot on his left foot. *Stated he had a wound on his heel. *Reported displeasure that it had developed since he moved into the nursing home. 2. Observation on 1/18/23 at 3:49 p.m. of registered nurse (RN) F changing the dressing on resident 289's heel revealed: *She described it to the resident as a nickel size compared to a quarter and then stated to this surveyor that it could not be staged (rated based on how deep the wound was) because of the eschar (dead tissue covering the wound). Review of the nursing admission documentation on 11/16/22 in the electronic medical record (EMR) for resident 289 revealed: *A nursing-admission/readmission UDA (user defined assessment) at 11:44 a.m. by RN E noted a skin alteration to his left trochanter (hip) and a score of six (meaning high risk) on the Braden Scale [a standardized tool to assess pressure ulcer risk] based in part on: -No sensory impairment that would limit his ability to feel or voice pain or discomfort. -Spends majority of each shift in bed or chair. -Requires minimum assistance to move causing a potential problem with friction to the skin when repositioning in bed or in the chair. *An admission summary progress note (PN) at 6:46 p.m. by RN E noted he was admitted after a recent fall with a left hip fracture that required surgical repair. *A late entry PN at 8:58 p.m. by director of nursing (DON) B reported an admission bed bath was completed. There was no notation regarding skin condition in that note. Further review of the EMR revealed: *A skin alteration evaluation on 11/18/22 at 8:10 p.m. by RN F noted resident 289's left heel had redness. No measurements of the redness were noted on that evaluation. *A change of condition PN on 11/21/22 at 11:56 a.m. by DON B reported: -A certified nursing assistant (CNA) informed her that resident 289's left heel was breaking down. -DON B observed resident 289 sitting in his recliner, with both legs elevated. Heels do not touch recliner. -Resident 289 reported he had pin point [sic] pain to his feet all the time. -The heel had intact skin with a localized area of persistent non blanch able [sic] deep red area measuring 10cm (centimeters) x (by) 5cm with increased warmth surrounding a maroon/purple centered wound bed and area of fluid filled blister that is clear that measures 8.1cm x 3.6cm. Will suspend heel with off loading [sic] boot. *A skin evaluation on 11/21/22 at 1:53 p.m. by licensed practical nurse (LPN) D noted: -The Braden Scale score was 17, which was still considered high risk. -Resident has alteration in skin integrity. -The pressure ulcer section was blank. -The Additional Skin/Treatment Note stated, See skin alteration evaluation assessment. No other skin conditions noted at this time. *An admission summary PN on 11/21/22 at 6:14 p.m. by DON B noted resident 289 resists all movement made to left leg. Although he refused to allow off loading [sic] heel boots before due to discomfort, he states he will give it another try. *A skin alteration evaluation on 11/22/22 at 8:10 p.m. by RN F noted the left heel pressure ulcer with an onset date of 11/21/22 using the same description as noted in the 11/21/22 PN by DON B. Review of resident 289's care plan revealed: *A focus for fluctuating blood sugars with increased risk for skin breakdown was initiated on 11/19/22 but there were no interventions to address the left heel redness discovered on 11/18/22. *A focus for the left heel pressure ulcer was initiated on 11/28/22 with interventions initiated on: -11/28/22 to alert nurse of skin breakdown or potential for skin breakdown noted while completing ADL's (activities of daily living) -12/14/22 for heel boots as he will allow, encourage not to wear left shoe. Interview on 1/19/23 at 12:51 p.m. with Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessment coordinator C to clarify the timing of the skin evaluation and skin alteration evaluation related to resident 289's pressure ulcer revealed she would attempt to provide a timeline of the development of it and documented interventions to prevent it. Follow-up interview on 1/19/23 at 3:52 p.m. with RAI/MDS coordinator C revealed we cannot find any documented interventions between the skin alteration evaluations on 11/18/22 noting the left heel redness and on 11/22/22 noting the unstageable left heel pressure ulcer. Review of the Skin Program policy with a revision date of April 2021 revealed: *A baseline assessment of the resident's skin status would have been completed upon admission by completing the Nursing Admission assessment, which includes a physical exam of the resident's skin. *Nursing personnel will utilize the results of the physical exam and the Pressure Injury Assessment tools to determine an individualized pressure injury prevention program for each at-risk resident. *A comprehensive wound assessment will be completed when a pressure injury is identified. *When a pressure injury is identified, a Skin Evaluation UDA should be completed. *Following identification of a skin issue, the Skin Alteration Evaluation UDA will be completed weekly until resolved. *Nursing personnel will develop a plan of care with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident adherence to the pressure injury prevention/treatment plan. Routine skin checks will be completed weekly and recorded on the Skin Evaluation UDA. Nursing personnel who will be providing care for the resident will receive pressure injury training, to include checking potential pressure areas and recognize pressure injuries in 'at-risk' residents, (skin-reddening that does not disappear after pressure removed) and instructed to notify the nurse when this is observed.

Based on record review, interview, and policy review, the provider failed to ensure: *Seven of twelve (4, 6, 10, 21, 36, 93, and 142) sampled residents had received a copy of their baseline care plan. *Two of twelve (36 and 142) sampled residents had participated in a review of their baseline care plan. *Four of twelve (4, 10, 21, and 142) baseline care plans had been reviewed with the resident and/or representative within forty-eight hours. Findings include: 1. Review of resident 4's medical record revealed: *She had been admitted on [DATE]. *A multi-disciplinary care conference had been completed on 2/2/21 to review her baseline care plan. *There was no documentation she had been provided a copy of her baseline care plan. 2. Review of resident 6's medical record revealed: *She had been admitted on [DATE]. *There was no documentation she had been provided a copy of her baseline care plan. Surveyor: 3. Review of resident 10's medical record revealed: *She was admitted on [DATE]. *Her baseline care plan conference meeting date was 4/14/21. *Resident 10's family had attended the baseline care plan conference meeting. *There was no documentation that a copy of the baseline care plan had been provided to resident 10's family. 4. Review of resident 21's medical record revealed: *He had been admitted on [DATE]. *His baseline care plan conference meeting date was 5/11/21. *The baseline care plan conference meeting date was not within 48 hours of his admission. *Resident 21 had attended the baseline care plan conference meeting. *There was no documentation that a copy of the baseline care plan had been provided to resident 21. Surveyor: 5. Review of resident 36's medical record revealed: *She had been admitted on [DATE]. *No multi-disciplinary baseline care conference meeting had been held. *No documentation was found that the baseline care plan had been reviewed with her. *No documentation she had received a copy of the baseline care plan. Surveyor: 6. Review of resident 93's medical record revealed: *He was admitted on [DATE]. *His baseline care plan conference meeting date was 6/4/21. *Resident 93's family had attended the baseline care plan conference meeting. *There was no documentation that a copy of the baseline care plan had been provided to resident 93's family. Surveyor: 7. Review of resident 142's medical record revealed: *He had been admitted on [DATE]. *A multi-disciplinary baseline care plan meeting had been held on 6/14/21. *Resident 142 nor his representative had attended the meeting. There was no documentation that a copy of the baseline care plan had been provided to resident 142 nor his family. Interview on 6/16/21 at 10:44 a.m. with registered nurse/Minimum Data Set coordinator A revealed: *A copy of the baseline care plain was not given to the resident or their representative. *Agreed they were not always reviewed within 48 hours of admission. *Thought the forty-eight hours only was counted on business days. If a resident was admitted on a Friday, the care plan conference could be done the next week. *The care plan conference notes were written on a facility form and then the information was entered into the residents electronic medical record. Interview on 6/16/21 at 3:00 p.m. with director of nursing B revealed: *Was not aware a copy of the baseline care plan was to have been provided. *Agreed some of the care conferences to provide the information on the baseline care plan had not been completed within forty-eight hours. *There was no process that monitored if the baseline care plans had been completed on time. Review of the provider's September 2019 Care Planning policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. In doing so, the following considerations included: -The DON [director of nursing] will be responsible for holding the team accountable to initiating and completing the Admission care plan within 48 hours and the long term-care plan by day 21 and updated as necessary thereafter. *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 than 48 hours after admission. *Resident care conferences are held within the first 72 hours of admission. *There was no direction that a copy of the baseline care plan should have been given to the resident and/or representative.

Based on record review, interview, and policy review, the provider failed to ensure steps had been completed to support appropriate self-administration of medication for one of one sampled resident (34) with a physician's orders [REDACTED]. Findings include: 1. Review of resident 34's electronic and paper medical records revealed: *She was admitted on [DATE]. *She resided on the Alzheimer's Care Unit (ACU) related to wandering and dementia. *[DIAGNOSES REDACTED]. *Her 3/22/19 Minimum Data Set assessment (MDS) indicated a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. *Review of resident 34's 4/3/19 physician's orders [REDACTED]. -A 3/29/19 order for continuous oxygen at 2 liters. -A 6/28/18 order for [MEDICATION NAME] sulfate nebulization solution to be inhaled orally using a nebulizer ever four hours as needed or shortness of breath. -A 1/4/17 order, (MONTH) self administer neb (nebulizer) treatments after nurse sets up. Review of monthly nursing progress summary notes revealed: 12/31/18: Resident continues to reside in ACU r/t (related to) dementia without any current behavioral disturbances. Needs encouragement to eat meals and keep o2 on. 1/15/19: Needs encouragement to eat meals and occasionally needs to be fed. Resident often takes oxygen off and needs to be reminded to keep it on. 2/13/19: Needs reminders to keep continuous oxygen on. Review of her revised 4/3/19 care plan revealed: *She had [MEDICAL CONDITION] and could not always make her needs known. *She was to have oxygen as ordered. *She was to be monitored frequently, because she removed her own oxygen at times. *Nothing in the care plan regarding self-administration of nebulizer medications. Interview on 4/24/19 at 9:00 a.m. with the certified dementia care manager regarding resident 34's nebulizer medication revealed:*She only used it as needed. *She had not needed to use it recently so there would probably be no opportunity to observe a nebulizer treatment. *She confirmed the resident had a physician's orders [REDACTED]. *The order for self-administration had been obtained, so the nurse could leave the room during a treatment if she was required elsewhere. Observations of resident 34 throughout the survey: *Had not revealed resident 34 removing her oxygen. *Had not included the use of nebulized medication. Review of resident 34's (MONTH) 2019 Medication Administration Record [REDACTED]. Review of Self Medication Administration nursing evaluations, section X completed 3/20/19, 12/15/18, 9/21/18, and 6/7/18 revealed: -A. Self Medication, question 1, Does the resident WANT to Self-Administer his/her own medications? had been answered with No - (STOP HERE). -Because the first question had been answered as no, the self-administration of nebulizer treatments had not been evaluated. -The evaluation review had not been completed for: --Any physical impairments such as visual or upper extremity that could prevent her from properly administering the medication. --A determination the resident was able to safely self-administer the medication after the nurse set-up. --Any cognitive impairment that would prevent her her from safely self-administering medication. Interview on 4/25/19 at 10:45 a.m. with the director of nursing (DON) regarding resident 34's self-administration nebulizer treatment order confirmed: *The self-administration order had been obtained, so the nurse could leave the room if she was called away during a nebulizer treatment. *The resident: -Required supervision to prevent her from removing her oxygen. -Should not have had a medication self-administration order. *The DON stated the nurse had completed the medication self-administration evaluations. But she had not evaluated the resident's ability to safely self-administer the nebulizer medication. The evaluation form would not allow the nurse to continue the evaluation when she had answered no to question one. Review of the provider's (MONTH) (YEAR) Self-Administration of Medications policy revealed: *Residents were permitted to self-administer medications if the interdisciplinary team determined the practice would be safe for the residents and other residents of the facility, and there was a physician's orders [REDACTED]. *If the resident indicated no desire to self-administer medications, that was to have been documented in the medical record, and the resident was then deemed to have deferred the right. *If the resident desired to self-administer medications an assessment was to have been conducted by the interdisciplinary team of the resident's cognitive, visual, physical abilities to carry out the responsibility. *The interdisciplinary team verified the resident's ability to self-administer medications with a skill assessment on a quarterly basis or with any significant change. *The results of the interdisciplinary team assessment of resident skills and the determination regarding storage were to have been recorded in the resident's medical record and on the care plan. Each medication was to have been recorded and contained a notation that it could be self-administered.

Based on record review, interview, and guideline review, the provider failed to ensure the South Dakota Department of Health (SD DOH) had been notified of a fall with reports of hip pain that had required an emergency assessment to rule out injury for one of one sampled resident (9). Findings include: 1. Review of resident 9's electronic and paper medical records revealed:*She was admitted on [DATE]. *A 4/16/19 at 8:04 p.m. progress note by licensed practical nurse (LPN) A indicated resident 9's daughter was notified regarding an incident, and the resident was on her way to the emergency room by ambulance. *A 4/16/19 at 9:01 p.m. Situation, Background, Assessment, Recommendation (SBAR) progress note by LPN A indicated: -The dietary aide Came and got this nurse from Unit. (Dietary aide B) reported that resident stood up and fell on to her back. -When the resident moved her left hip she complained of pain. -She had a background of abnormalities of gait and mobility. *A 4/17/19 at 12:30 a.m. progress note indicated the resident had returned to the facility at 12:20 a.m. after she was cleared of injury. Review of resident 9's fall event report information requested from the director of nursing (DON) and interview with the DON at that time on 4/25/19 at 10:30 a.m. revealed:*The DON provided an in-house fall report. That report had included documentation of the 4/16/19 incident and follow-up regarding the fall. *When the SD DOH event report and investigation was requested the DON stated: -The SD DOH had not been notified of the fall. -The provider had only been notifying the SD DOH of events with known injuries. -She was not aware falls requiring emergency assessments for possible severe injuries required notification and event reports to the SD DOH. -She had only been instructed of that SD DOH requirement by her supervisor the day before the survey had occurred. Review of the provider's (MONTH) (YEAR) Abuse, Neglect, and Exploitation guideline was provided a policy for reporting event injuries to the SD DOH had been requested revealed the following guidelines: *Were developed for the reporting of abuse, neglect, and exploitation to the state survey agency. *Had not included guidelines for falls with suspected severe injuries requiring assessments in emergency departments or hospitals.

Based on observation, interview, record review, and vaccine manufacturer's instructions, the provider failed to maintain an acceptable temperature range for one of two (white) resident medication refrigerators located in the only medication room. Findings include: 1. Observation on 10/18/16 at 3:30 p.m. of the only medication room revealed: *Two dorm sized refrigerators used for medications: [REDACTED]. *Immediately upon opening the white one the thermometer read 50 degrees Fahrenheit (F). *Included inside that refrigerator were: -A single dose of antibiotic that had been discontinued. -Twenty-three single dose and six multi-dose vials of influenza vaccines. One multi-dose vial had been opened. -On the outside of the box of single dose vaccine the instructions said to keep the vaccine refrigerated between 35 to 46 degrees F. Review of the provider's October 2016 Monthly Refrigerator Monitor log for the white medication refrigerator revealed: *Range 36F to 46F at the top of the log. *Recordings were taken twice a day. *On the seventeenth the a.m. temperature was recorded at 48 degrees F, and the dial was adjusted down. -No time was recorded. -The temperature after adjustment was recorded as 46 degrees F. *On the seventeenth the p.m. temperature was recorded as 46 degrees F. -No time was recorded. *No temperature had been recorded for the eighteenth until checked at 3:30 p.m. *It was unclear how long the temperature for that refrigerator had been out of range. Interview on 10/18/16 at 3:40 p.m. with registered nurse C regarding their procedure for handling a refrigerator and medications outside of the temperature range revealed: *The temperature of the medication refrigerators had not been checked by staff today. *She would adjust the temperature. Interview on 10/18/16 at 3:45 p.m. with the director of nursing (DON) regarding the above revealed: *She would adjust the temperature of the refrigerator. *No further action was mentioned. *When asked about the influenza vaccines being outside of the recommended temperature range she stated she would check on it. *She then moved the medications from the white refrigerator into the brown one. Further interview on 10/19/16 at 8:35 a.m. with the DON regarding the medication refrigerator and the vaccines revealed: *No policy or procedure for the above existed. *Staff were just expected to know. *She spoke to the consultant pharmacist about the above and would be speaking to the vaccine manufacturer about what to do with the vaccine. *None of the vaccine had been given this past week. *She would have used this vaccine for staff and for new residents who had not received their flu shot yet. Interview on 10/19/16 at 11:25 a.m. with the consultant pharmacist regarding the medication refrigerator and the influenza vaccine revealed: *He agreed the refrigerator had been outside of the acceptable temperature range. *He thought the influenza vaccine was probably okay. Review of the provider's Monthly Refrigerator Monitor logs for the last six months for the white medication refrigerator revealed: *Recordings were made once a day. No times had been recorded. *August 2016 there were three days of temperatures outside of the acceptable range. *On the eighteenth the temperature was 48 degrees F. -In the adjust up or down column was an up arrow. -No temperature was recorded after the adjustment. *On the twenty-second the temperature was 60 degrees F. No adjustment had been made. *On the twenty-third the temperature was 56 degrees F. No adjustment had been made. Interview on 10/19/16 at 1:20 p.m. with the DON regarding the above temperature logs revealed she: *Agreed there were problems with the temperatures of the white medication refrigerator. *Agreed there were problems with the handling of the medications and vaccines. Interview on 10/19/16 at 1:30 p.m. with the administrator regarding the above medication refrigerator revealed: *She agreed it was hard to know how long it had been out of range without any times recorded. *She agreed there had been problems with the temperature. *According to the vaccine manufacturer's representative the open vaccine vial would need to be discarded. *She ordered a new refrigerator.

Based on observation, interview, record review, and hospice contract review, revealed the provider failed to have a combined care plan for hospice and the facility for 2 of 12 sampled residents (5 and 8). Findings include: 1. Observation and interview on 11/2/15 at 4:30 p.m. with registered nurse (RN) A regarding resident 5 revealed he: *Had a [DIAGNOSES REDACTED]. *Would remain in his room unless he was participating in smoking breaks. *Would often refuse care. *Was placed on hospice care on 9/9/15. Review of the current undated care plan for resident 5 revealed no mention of what the facility or hospice's responsibilities were in caring for the resident. Interview on 11/3/15 at 4:00 p.m. with RN A revealed: *When asked how anyone would know what care to provide for resident 5 she replied I just know. *She agreed there was no clear delegation of responsibilities of what care hospice provided and what care the provider was responsible for. Interview on 11/3/15 at 4:15 p.m. with the director of nursing (DON) revealed she agreed there was no clear responsibility of care assigned between hospice or the provider. 2. Review of resident 8's complete medical record revealed: *He was placed on hospice on 9/18/15. *The facility care plan dated 7/14/15 had admitted to hospice 9/18/15 handwritten under each focus area. *No specific information regarding when hospice personnel were coming, which hospice personnel were coming, or what hospice personnel would be doing for the resident. *The hospice care plan dated 9/18/15 stated: -Ongoing updates would be communicated by hospice to the long term care facility. -The long term care facility would integrate the changes into their care planning system. 3. Interview with the DON on 11/4/15 at 11:20 a.m. regarding the above revealed: *She agreed the two care plans were not integrated. *They had no policy or procedure on care plans. Surveyor Review of the 9/11/15 contracted hospice program's plan of care revealed no assigned duties that would direct who was to provide the care given to resident 5 and 8 between hospice or the provider. Review of the 9/17/13 contract between hospice and the provider revealed: *Hospice was to have assigned an RN to coordinate care. *The plan of care shall be developed in full consultation of both Hospice and the Facility. The parties agree each shall maintain its portion of the Plan of Care in accordance with laws and regulations .

Based on observation, interview, record review, and policy review, the provider failed to ensure sanitary conditions were maintained for the following: *Two of two broken floor tiles in the kitchen next to the steam table and food production table with a moderate accumulation of black and brown spots and grease. *One of two floors in the kitchen (refrigeration and storage area) had a moderate accumulation of chipped and peeling paint. *The dishes and silverware being transported from the central kitchen to the memory care unit dining room were uncovered for two of two observed meals for all residents served there. Findings include: 1. Observation on 11/2/15 in the kitchen from 1:05 p.m. through 1:25 p.m. revealed: *An accumulation of black and brown spots and grease on two of two broken tiles located next to an electrical outlet box in the floor. -The above tiles had an exposed area of approximately six inches long and one-half to one inches deep on two sides of each of the tiles. -Those tiles were located next to the steam table and food preparation table that contained resident food. *The floor in the kitchen's refrigerator and storage area had a moderate accumulation of chipped and peeling paint exposing the cement. Interview on 11/3/15 at 8:20 a.m. with the maintenance director regarding the above broken tiles and flooring revealed: *He agreed the tiles were broken and no longer were cleanable. *He agreed the floor had a moderate amount of peeling and chipped paint with multiple areas of exposed cement. -That flooring was no longer a cleanable surface. *He stated he was responsible for the tiles and the flooring in the kitchen. *He stated he checked those areas at least monthly. Interview on 11/4/15 at 8:45 a.m. with the dietary manager (DM) regarding the above broken tiles and flooring revealed she agreed: *The tiles were broken and no longer cleanable. *The floor had a moderate amount of peeling and chipped paint with multiple areas of exposed cement. -That floor was no longer a cleanable area. *Dietary was responsible for sweeping and mopping the floors daily. *Housekeeping was responsible for floor care quarterly. *Maintenance was responsible for any floor repair. Interview on 11/4/15 at 9:45 a.m. with the administrator regarding the above broken tiles and flooring revealed she agreed: *The tiles were broken and no longer cleanable. -Those tiles had been broken for at least two years. *The floor had a moderate amount of peeling and chipped paint with multiple areas of exposed cement. -That floor was no longer a cleanable area. Review of the provider's November 2015 Preventative Maintenance Schedule revealed: *Daily interior (inside the building) rounds and inspections were to have been completed. *There was no specific task listed for the tiles and floor in the kitchen on that schedule. Review of the provider's 2011 Floor Safety policy revealed the floors were to have been clean, free of grease and chemical build-up, and dry at all times. Review of the provider's 2011 Cleaning Kitchen Areas policy revealed the following guidelines for quarterly maintenance of floors: *Check floors for chipped and/or peeling paint. *Keep in good repair. 2. Observation on 11/2/15 at 5:05 p.m. with certified nursing assistant G revealed: *She had left the kitchen with a three-tiered cart with a tablecloth over the top. *That cart had contained: -Dishes on the second shelf and silverware on the third shelf that had been left uncovered. *She took the above cart down a service hallway, through a dining room, and a resident hallway to the memory care unit dining room. Observation and interview on 11/2/15 at 5:45 p.m. with dietary assistant (DA) F revealed: *She returned the same above cart from the memory care unit dining room back to the kitchen. *That cart's second shelf contained: -Twenty-five uncovered bowls turned upright. -Four uncovered small plates. -Six plastic glasses turned on their sides and two spoons in an opened container. *That cart's third shelf contained one dozen knives in an opened container. *She stated the dishes and silverware on the second and third shelf were considered clean as they had not been used by the residents. *She stated the same cart containing those items would be used at the next meal for the memory care unit dining room. Observation on 11/3/15 at 11:30 a.m. with both cook E and DA F revealed: *Cook E left the kitchen with a steam table that had contained six uncovered plates on the second shelf. *DA F left the kitchen with the same cart as the above with a tablecloth over the top. -That cart had contained: -Multiple uncovered bowls, plates, glasses, and silverware. *Cook E took the above steam table and DA F took the above cart down a service hallway, through a dining room, and a resident hallway to the memory care unit dining room. *DA F placed the cart next to an unoccupied resident couch in the memory care unit dining room during meal service. Interview on 11/3/15 at 11:50 a.m. with the director of the memory care unit revealed she agreed: *The above dishes and silverware had not been covered when transported from the kitchen to the memory care unit. *Those items needed to have been covered during transport due to the possibility of contamination. *The cart that contained uncovered and cleaned dishes should not have been placed next to a resident couch. Interview on 11/4/15 at 8:45 a.m. with the DM regarding the above revealed she agreed: *The above dishes and silverware had not being covered when transported from the kitchen to the memory care unit. *Those items needed to have been covered during transport due to the possibility of contamination. Interview on 11/4/15 at 9:45 a.m. with the administrator revealed she agreed: *The above dishes and silverware had not being covered when transported from the kitchen to the memory care unit. *Those items needed to have been covered during transport due to the possibility of contamination. Review of the provider's 2011 Food Service Distribution policy revealed the dining room service silverware should have been covered, so it had not been exposed. Review of the provider's 2011 Handling Clean Equipment and Utensils revealed: *Store clean and sanitized portable (moveable) equipment and utensils so that food contact surfaces were protected from splash, dust, and other contaminants. *Tableware should have been protected from contamination by being covered. *All tableware would have been removed, washed, and sanitized between seatings even if not used.

Based on record review, interview, and policy review, the provider failed to accurately revise the care plan regarding advance directives (written instructions for health care decisions if a resident was unable to act or respond for themselves) for one of one sampled resident (3). Findings include: 1. Review of resident 3's complete medical record revealed: *She had been admitted on [DATE]. *On [DATE] her physician had signed a Resuscitation (revive) Orders form for: -In the event of a cardiac (heart) and/or respiratory (lungs and breathing), initiate CPR (Cardiopulmonary Resuscitation). *CPR means that if she had suffered a cardiac or respiratory arrest (the heart suddenly stops beating or breathing stops) efforts were to have been made to resuscitate (revive) her. Review of resident 3's revised [DATE] care plan revealed: *She had an advance directive for a full code (all life-saving measures were to have been done). *That had been changed to DNR (do not resuscitate) on [DATE]. *CPR to have been performed as ordered had been discontinued on [DATE]. *Her wishes were to have been honored as written on the care plan. Interview on [DATE] at 9:40 a.m. with registered nurse (RN) A and on [DATE] at 8:40 a.m. with RN D regarding resident 3's advance directives revealed: *They would have both checked the provider's Twenty-four Hour Report Nurse Communication form. -That form contained documentation she was a DNR. Interview on [DATE] at 9:00 a.m. with the director of nursing regarding resident 3 and her advance directives revealed: *She confirmed the resident had a physician's orders [REDACTED]. *The current care plan had not matched the physician's orders [REDACTED].>*The care plan had not been accurately revised and updated. *The charge nurse upon each resident's admission and the care team after admission were responsible for updating and revising the care plan as needed. Review of the provider's [DATE] Interdisciplinary Care Plan policy revealed the interdisciplinary care plan was to have been revised/updated as necessary to address resident needs.

Based on observation, interview, record review, and guidelines review, the provider failed to: *Verify the correct dosage of a medication (med) prior to administration during 1 of 33 random resident (8) medication administration observations during 1 of 33 medication passes by 1 of 2 (RN A) nurses. *Ensure the physician's orders [REDACTED]. Findings include: 1. Observation and record review on 11/3/15 at 10:15 a.m. with registered nurse (RN) A during a medication administration to resident 8 revealed: *The medication administration record (MAR) in the electronic medical record said to give thirty milligrams (mg) of [MEDICATION NAME] (stomach med) daily. *The label on the plastic bag containing the medication said to give one tablet every day. The tablets were labeled as fifteen mg. *RN A gave resident 8 fifteen mg of [MEDICATION NAME]. Interview with RN A on 11/3/15 at 2:00 p.m. regarding the above medication administration revealed: *She had not noticed the difference in milligrams between the MAR and the label on the medication container. *She had been administering only one fifteen mg tablet. Further interview with RN A on 11/3/15 at 4:00 p.m. revealed: *She found the hospice orders dated 9/18/15 were for only fifteen mg of [MEDICATION NAME] daily instead of the thirty mg the physician had previously ordered and she notified hospice. *Hospice had contacted the physician on 11/3/15 at 3:20 p.m. *On 11/3/15 at 3:27 p.m. the physician ordered the resident was to be on thirty mg of [MEDICATION NAME] given daily. Interview with the director of nursing on 11/4/15 at 11:20 a.m. revealed:*She had not been made aware of the medication error described above. *She agreed it was a medication error. Review of the provider's May 2012 Medication Administration-Preparation and General Guidelines revealed there were four medication checks to have been done before giving a medication: *First check should have been with the medication container label and the MAR. *Second check should have been done after the medication was removed from the container and checked with the MAR again. *Third check was to have been after the medication was prepared to administer and was to verify the medication label with the MAR again. *Final check of the medication dosage on the label and in the MAR was to have happened prior to administration. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo, 2013, p. 583, revealed the steps to take to prevent medication errors included to read labels at least three times, comparing the medication administration record (MAR) and the label before administering the medication. 2. Review of resident 8's complete medical record revealed: *He had been placed on hospice care on 9/18/15. *The physician's 10/13/15 summary order sheet had not included an order to continue hospice care. Interview with the DON on 11/4/15 at 11:20 a.m. revealed she agreed the physician's orders [REDACTED]. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo, 2013, p. 305, revealed the nurse was responsible for transcribing physician's orders [REDACTED].

Based on record review, interview, and policy review, the provider failed to have in place and to follow a consistent policy for completing neurological (nervous system) assessments for three of three fall incidents for one of one resident (4) who had fallen and hit her head in the memory support unit. Findings include: 1. Review of resident 4's neurological assessments and verification of investigation reports revealed: *On 7/9/14 at 1:00 a.m. she had "slid out of bed and hit her head." *A neurological assessment was started on 7/9/14 at 1:00 a.m. -Neurological documentation was completed again on 7/9/14 at 1:00 p.m., 7/10/14 at 1:00 p.m., and 7/11/14 at 2:30 p.m. -There were no other neurological assessments completed for that fall. *On 7/13/14 at 1:42 p.m. she had "lost balance and fell to bottom, then back onto floor, bumping occipital (back of head) on floor." *A neurological assessment was started on 7/13/14 at 1:30 p.m. -Neurological documentation was completed every fifteen minutes the first hour, every thirty minutes the next two hours, and one time in the following hour. -The next entry had no date and the time entered was 8:00 p.m. -The following entry was on 7/13/14 at 1830 (6:30 p.m.) which would have been earlier then the previous entry. -There was no neurological documentation completed for 7/14/14 on the neurological assessment. *On 7/24/14 at 9:00 p.m. she was found on the floor. Another resident had informed staff she had "hit her head on the wall." *A neurological assessment had been started on 7/25/14 at 11:00 a.m. -The next assessment was done on 7/26/14 at 8:00 a.m. and again at 4:00 p.m. -On 7/27/14 there was one entry but no time had been documented. *None of the above neurological assessments followed any consistent policy or procedure. Interview on 10/1/14 at 1:15 p.m. and again at 2:20 p.m. with the director of nursing services revealed: *They had no policy on completing neurological assessments for when a resident hit their head after a fall. *They used a standard of practice that was to document every shift for seventy-two hours. *She had no reference book in the facility to verify that standard of practice. *The shifts in the unit included: -One nurse working ten hours in the unit. -The other fourteen hours were covered by the charge nurse working in the main area of the facility. *Based on her standard of practice neurological assessments would have been done two times per day for 72 hours. Review of the provider's January 2011 Falls Management policy revealed: *After a fall the nurse should have assessed the resident for injuries including neuro (neurological) checks if indicated. *"Ongoing assessments including neurological, pain and alert charting documentation shall occur per center policy." *There were no specific guidelines for when a resident hit their head after a fall. Review of Sharon L. Lewis et al., Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th Ed., Mosby Elsevier, St. Louis, Mo., 2007, p. 1481, revealed: *"Head injury includes any trauma to the scalp, skull, or brain. *Deaths occurring within a few hours of the trauma are caused by progressive worsening of the head injury or internal bleeding. *Immediately recognizing changes in neurologic status and rapid surgical interventions are critical in the prevention of deaths at this point. *Deaths occurring 3 weeks or more after injury result from multisystem failure. *Expert nursing care in the weeks following the injury is crucial in decreasing mortality and in optimizing patient outcome." Review of Sharon L. Lewis et al., Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 7th Ed., Mosby Elsevier, St. Louis, Mo., 2007, p. 1486, revealed "The nurse should perform neurologic assessments at intervals based on the patient's condition."

Based on record review, observation, testing, and interview, the provider failed to ensure sanitation practices were maintained for the dishmachine and for stored food leftovers for the protection of all residents. Findings include: 1. Observation of the dishmachine operation on 5/29/12 at 6:10 p.m. revealed:*The provider had a low temperature dishmachine operation. *The sanitizer used was Ecolab's Ultra San. Review of the manufacturer's label on the side of the Ultra San revealed: *It was a chlorine-based sanitizer. *Manufacturer's recommendation was a sanitizing concentration of 100 parts per million (ppm) available chlorine. *The sanitizer was not to exceed 200 ppm or to go below 50 ppm available chlorine sanitizing concentration. Interview with the dietary manager (DM) and the consultant registered dietitian (RD) at that time revealed the sanitizer was not tested at each meal. The RD stated it was tested on ce a month and recorded on a clipboard. They stated the Ecolab chemical representative also came once a month. He checked all the chemicals and made sure the machine was functioning properly. The RD checked the clipboard next to the three compartment sink. The documented sanitizer concentrations were for the three compartment sink that used a quaternary sanitizer not the chlorine-based sanitizer for the dishmachine. She and the DM checked the clipboard in the dishmachine and the documented numbers were for the temperatures of the water. The columns on the form had spaces for the concentration of the sanitizer to be recorded for each meal for each day. Testing on 5/29/12 at 6:15 p.m. by the DM and the RD of the sanitizing solution in the rinse water of the dishmachine with a chlorine test strip revealed a reading of approximately 50 ppm. The test strip was compared to the colors on the test grid of the sanitizing test strips. The sanitizing solution was tested a second and third time with the same results. The DM stated the Ecolab representative had been there in the middle of the month and when he tested the sanitizer it was stronger. She was not sure what the concentration number had been. The last two months reports were requested. Testing on 5/30/12 at 11:15 a.m. of the sanitizing solution in the dishmachine revealed the concentration to be a weak 50 ppm. The DM stated she had called the Ecolab representative, and he was coming to fix the machine. Again the last two months reports of the Ecolab representative's testing of the sanitizing solution was requested. The DM was unable to find them. Testing at 2:30 p.m. on 5/30/12 by the Ecolab representative of the sanitizer concentration in the dishmachine with a chlorine test strip confirmed it was a weak 50 ppm. After he checked the dishmachine he stated the squeeze tube that was timed and squeezed out the amount of sanitizer solution had gone bad. It was letting more air through the line that came from the sanitizer pail into the dishmachine. He stated the corrosive nature of the chlorine sanitizer wore out the squeeze tube faster than the detergent or rinse dry chemicals. He stated it could have collapsed overnight. Testing with a chlorine test strip of the sanitizer solution after he replaced the squeeze tube and adjusted it revealed a 100 ppm of available chlorine. Testing at 8:10 a.m. on 5/31/12 of the sanitizing solution in the dishmachine by the DM and this surveyor revealed the test strip had not shown any chlorine concentration. Observation with the maintenance supervisor and the DM revealed no chlorine sanitizer solution was moving through the line. The maintenance supervisor adjusted the machine. The Ecolab representative came again later that morning and checked over the machine. He found the line from the sanitizer pail to the dishmachine had a crack in it. He stated only air was being let through the line. He replaced the line with a new one and set the concentration at 100 ppm.

Based on observation, interview, and policy review, the provider failed to store and secure all employee and resident records in a manner to prohibit access by unauthorized persons. Findings include: 1. Observation on 5/29/12, 5/30/12, and 5/31/12 at random times throughout those three days revealed: *The door to the dietary manager's office was frequently left open when there was not anyone in the office. *The dietary manager's office was located behind swinging doors labeled "employees only." Those doors opened into a hallway that led to an outside door. *Numerous kitchen and laundry employees passed by that office frequently each day as they went to and from their work areas behind the swinging doors. *The swinging doors were not secured and any resident or visitor could have entered that area. *File cabinets and boxes were stacked almost to the ceiling, and were stored in a closet that had no door in the dietary manager's office (photos 1 and 2). *Examples of labeled boxes included: -"Terminated employees 2009-2011 Payroll 5/10-6/10." -"Medical records past employees." -"2010 Accounts payables Resident lost receipts 2010-2011." -"Accounts payable 2009." -"Past employees" from A-Z (three file drawers). -"Pharmerica invoices 2010-2011." -"discharged residents 2008." -"Medicare RA, Medicaid RA Resident Trust, Receipt books, deposit tickets, census, medical review." -"2008 Deposit records." -"2009 Deposit records." -"Billing reports." -"Terminated employees 2010-2011." Interview at 8:30 a.m. on 5/31/12 with the director of nurses revealed: *Resident and employee records should have been confidential. *Resident and employee records were kept in the dietary manager's office, and she believed that had always been locked. The provider's Health Information Management Manual dated February 2012 stated: "PURPOSE: To retain Health Information in an organized manner for ease of retrieval by appropriate individuals and agencies. Ensure protection of records from loss, destruction, and unauthorized use in compliance with federal and state retention requirements." In the manual under "DISCHARGE RESIDENT MEDICAL RECORDS 3. To ensure that information contained in the Resident's Medical Record is confidential, keep cabinets or areas containing the thinned and discharge Medical Records locked at all times."

A. Based on record review, interview, and policy review, the provider failed to ensure proper documentation was done on the medication administration record (MAR) and on the Pain Monitoring Tool form for three of three residents (13, 14, and 15) reviewed for the use of [MEDICATION NAME] for pain. Findings include: 1. Review of resident 13's January 2011 MAR and Pain Monitoring Tool revealed: -Four doses of [MEDICATION NAME] were initialed as given on the MAR. -Seven doses of [MEDICATION NAME] were noted as given on the Pain Monitoring Tool. 2. Review of resident 14's April 2011 MAR and Pain Monitoring Tool revealed: -Twelve doses of [MEDICATION NAME] were initialed as given on the MAR. -Five doses of [MEDICATION NAME] were noted as given on the Pain Monitoring Tool. -Four of the five doses noted as given on the Pain Monitoring Tool had no follow-up documentation. 3. Review of resident 15's October, November, and December 2010 and February 2011 MAR and Pain Monitoring Tool revealed: -Twenty-three doses of [MEDICATION NAME] were initialed as given on the MAR. -Sixteen doses of [MEDICATION NAME] were noted as given on the Pain Monitoring Tool. -Four of the sixteen doses noted as given on the Pain Monitoring Tool had no follow-up documentation. 5. Interview on 5/4/11 at 11:20 a.m. with the DON revealed her expectation was for any PRN pain medication to be documented on the MAR and on the Pain Monitoring Tool. Follow-up documentation was to be done for evaluating the effectiveness of the pain medication on that same form. Review of the provider's March 2000 Medication Administration policy revealed: -The patient's MAR was to be initialed in the space provided under the date and on the line for that specific medication dose administration. -The following documentation should have been provided when PRN medications were administered: "A) Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. B) Complaints or symptoms for which the medication was given. C) Results achieved from giving the dose and the time results were noted. D) Signature or initials of person recording administration and signature of initials of person recording effects, if different from person administering." B. Based on record review, policy review, and interview, the provider failed to receive and dispose of medications appropriately following professional standards occurred for one of one sampled closed resident record (11). Findings include: 1. Refer to F425.