Every finding on record at Avantara Milbank

Based on observation, interview, and record review, the provider failed to ensure the staff followed standard food service sanitation practices in one of one kitchen, where residents' meals were prepared and served, regarding the dishwashing machine not reaching the minimum temperature for the wash cycle, the crumbling wall behind the dishwasher, and the cleanliness of the food preparation areas, the two handwashing sinks, the clean dish areas, the dishwasher, and the light coverings. Findings include:1. Observation on 7/7/26 from 8:21 a.m. to 8:59 a.m. in the main kitchen revealed the wire shelving located above the handwashing sink to the right of the dishwashing area had a thick layer of dust covering most of the shelf. That handwashing sink had an unidentified reddish-brown stain in the drain and a buildup of limescale around the basin. The second handwashing sink near the back of the kitchen to the left of the door and across from the walk- in cooler had an unidentified reddish-brown stain in the drain and a buildup of limescale around the basin. The dishwasher had a buildup of scum on the inside back panel and the inside right panel. There was scum and limescale on the bottom outside of the door. There was dust, calcium buildup, and food on top of the dishwasher, including at the door seams. The wall behind the dishwasher was crumbling. Tiles had broken off the wall, creating holes and exposing the cement, brick, metal wiring, and plumbing. There was a buildup of dust, broken tiles, and cement particles on the floor near the crumbling parts of the wall. The wire shelving above the clean dish tray table had a thick layer of dust covering most of the shelf. Clean dishes in the dishwashing racks were beneath those wire shelves. The clean dish tray table had a layer of limescale, food crumbs, and hair on top of it, with the clean dishwashing racks sitting on the table. The vent above the clean dish area was dusty, and there were clean dishes that were drying in the dishwashing racks below the vent. The ventilation hood above the stove had dust hanging from a spider web, and hair blowing and dust buildup on the outer tract. There were dust and white seeds resembling dandelion seeds present on top of the oven. The light coverings had dead bugs in them, dust, and grease splatter buildup. There was a layer of dust on the wire rack holding the pots and pans located above a food preparation table. The wire shelving holding the spices and pans had a layer of dust. The plastic bins used for condiments had food crumbs in them. Observation and testing on 7/7/26 from 8:22 a.m. to 8:27 a.m., surveyors ran the dishwasher four times to test the wash cycle temperature. Those wash cycles reached temperatures ranging between 152 degrees Fahrenheit and 156 degrees Fahrenheit all four times. The instruction sticker on the dishwasher indicated that the hot water sanitizing wash cycle needed to reach a minimum temperature of 160 degrees Fahrenheit. 2. Interview on 7/9/26 at 11:04 a.m. with dietary aide G revealed her morning work routine included hooking the dishwasher up, cleaning out the drain if needed and then the dishwasher was ready to go. She did not run any dishwashing cycles to allow the water to heat up. She was not aware of the minimum wash or sanitation cycle temperature requirements. She was unaware of any manufacturer's guidelines for cleaning the dishwasher and stated that the cooks and other dietary staff members were responsible for cleaning the dishwasher. She would remove debris if needed from the dishwasher drain. 3. Interview on 7/9/26 at 11:11 a.m. with cook H revealed that there was a book with the dishwasher manufacturer's instructions located somewhere that they all had to sign off on for cleaning and temperature recommendations. She was not sure what the manufacturer's instructions were for the minimum wash cycle temperature. She thought 175 degrees Fahrenheit was the needed minimum temperature for the wash cycle. The load of dishes running during this interview had a wash cycle temperature of 156 degrees Fahrenheit. [NAME] H stated she wiped down the outside of the dishwasher with water and detergent daily and delimed it once a week. [NAME] H confirmed there was a buildup of limescale, dust, and food on top of and inside the dishwasher. [NAME] H stated she cleaned the clean tray table when she was done with it every day and that it should be cleaned in the morning. If it looked dirty, she wiped it down. She was unsure if anyone cleaned the wire shelves throughout the kitchen. [NAME] H acknowledged that there was dust buildup on the wire shelving units. [NAME] H stated that the sinks were used for handwashing and not for food or liquid disposal. She confirmed there was a buildup of limescale and a reddish-brown substance near the drain in the handwashing sink located to the right of the dishwasher, and in the handwashing sink located at the back of the kitchen to the left of the door and across from the walk-in cooler. 4. Interview on 7/9/26 at 11:32 a.m. with dietary manager E revealed that the staff were to follow the dishwasher manufacturer's operating instructions and used the temperature sticker on the front of the dishwasher for guidance that indicated a minimum wash cycle of 160 degrees Fahrenheit. She agreed that the dishwasher's wash cycle did not meet the minimum 160 degrees Fahrenheit as indicated on the sticker. Dietary manager E stated the staff should run the dishwasher through a couple of cycles first thing in the morning to get it up to temperature after sitting unused all night. The cleaning process for the dishwasher included washing it daily and de-liming it weekly. She confirmed there was limescale, dust, and food in and on top of the dishwasher. There was no process to clean the wire shelves throughout the kitchen. They were not included on the cleaning checklist. Dietary manager E confirmed there was dust buildup on those shelves. There was no process for cleaning around the ventilation hood over the stove. Dietary manager E cleaned it that week; however, it was not a task on the cleaning checklist. She confirmed there was dust and debris in the outside tract of the ventilation system. She also cleaned the top of the oven and was aware of the dust buildup and white seeds on top of it. Dietary manager E stated that no one in the kitchen had opened the light fixtures and cleaned the bugs out of them or cleaned the outside surfaces of those light fixtures. She believed the maintenance department staff performed that task. 5. Interview on 7/9/26 at 4:02 p.m. with dietary manager E revealed that she was aware of the crumbling wall behind the dishwasher. She thought that the maintenance department was also aware of the damage. The wall has been like that for at least five years. 6. Review of the 6/14/17 revised manufacturer's installation instructions for the dishwasher revealed on page 12 that the wash tank temperature should be 160 degrees Fahrenheit for hot water sanitizing. 7. Review of the provider's 2020 DiningRD.com Guideline & Procedure Manual for the Dishwashing: Machine Operation policy revealed that the dishwashing machine should be operated according to manufacturer recommendations. If the dishwashing machine has not been used for several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow the dishwashing machine to come up to proper function. Check the dishwashing machine for cleanliness before the start of each meal. Sanitize the clean worktable before starting dishes at each meal. Wipe down the dishwashing machine and clean per equipment cleaning procedure at the end of each workday. Remove any built-up debris, lime or scale as necessary or generally complete a thorough de-liming per cleaning schedule or one time weekly. Clean and sanitize the entire work area, both dirty and clean drain boards. 8. Review of the provider's 2020 DiningRD.com Guideline and Procedure Manual for the Sanitation of Dining and Food Service Areas revealed that the dining services staff will uphold sanitation of the dining areas according to a thorough, written schedule. The dining services manager will record the necessary cleaning and sanitation tasks for the department. All staff will be trained on the frequency of cleaning.

Based on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that residents were free of significant medication errors for one of one sampled resident (3) who admitted to the facility following a hospitalization for surgical repair of a fractured left hip and did not receive Aspirin 81 milligrams (mg) twice daily as ordered from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose. Following that medication error, resident 3 experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention and developed Deep Vein Thrombosis (DVTs) (a blood clot that forms in a vein deep inside the body, most commonly in the lower leg or thigh) in both of her lower legs. Findings include:1. Review of the provider's 1/7/26 SD DOH FRI revealed that during the consultant pharmacist (CP) medication regimen review on 1/2/26, the CP identified the pharmacy's order entry error regarding resident 3's 12//17/25 physician-ordered 81 mg Aspirin, twice daily, to continue for 30 days after her admission to the nursing facility following a left hip surgical repair. The nursing facility utilized a pharmacy-initiated order system in which pharmacy personnel received all physicians' medication orders and entered those medication orders into the nursing facility's order system, which included residents' electronic medical records (EMRs) and their electronic medication administration records (EMARs). The pharmacy received a clarification order on 12/19/25 to decrease the 81 mg Aspirin administration frequency from twice daily to once daily after 30 days. The pharmacy entered the physician's order for Aspirin 81 mg once daily, to start on 1/19/26, into the electronic pharmacy-initiated order system for resident 3. On that same day, the pharmacy entered an incorrect end date for the 81 mg Aspirin twice daily order, which caused a discontinued medication message to be sent in the facility's electronic medical record (EMR) system for resident 3. The pharmacy corrected that discontinued date error immediately on 12/19/25; however, the facility's order system was unable to update the discontinuation date, and as a result, the 81 mg Aspirin twice daily order never reappeared in the EMR as a corrected or continued order for administration to resident 3. Resident 3 last received her 81 mg Aspirin twice daily dose on 12/19/25 at 8:00a.m. The order entry error resulted in resident 3 not receiving the scheduled Aspirin from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose. She experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention, and developed DVTs in both of her lower legs. 2. Review of resident 3's EMR revealed that she admitted to the facility on [DATE] for therapy services after being hospitalized for surgical repair of herleft hip fracture. While hospitalized , she developed a bowel obstruction (a blockage that prevents food, fluids, and gas from moving through the digestive tract) and required a second surgery on 12/6/25. Her diagnoses included hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). Her 12/23/25 Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated she had moderate cognitive impairment. She discharged from the facility and returned home in the care of a family member on 1/16/26. Resident 3's progress notes dated from 12/21/25 through 12/30/25 indicated that she began complaining of increased swelling in her left lower leg on12/21/25 at 9:04 p.m. On 12/24/25 at 10:53 a.m., a physical therapy (PT) progress note indicated that resident 3 complained of pain in both lower legs during her therapy session, which limited her activity, and she was unable to complete some of her exercises. Therapy staff documented that resident 3 had significant swelling in her bilateral lower extremities. The therapist did not document a pain level for resident 3 but assessed her pain based on her behaviors, including limited standing and walking, as well as difficulty lifting her feet off the floor. On 12/26/25 at 9:48 a.m., a PT progress note indicated that resident 3 had difficulty bearing weight on her legs due to increased weakness and pain in her lower left leg, and the therapy staff had to supervise all of her transfers. Resident 3 rated her pain 5/10 [five out of ten on a zero to ten level of pain scale] at rest and 7/10 [seven out of ten] with movement. She described her pain in the lower left leg at rest as an ache and with movement as sharp. Progress notes on 12/26/25 at 12:04 p.m. and again at 6:00 p.m. indicated that resident 3 described pain in her left leg as aching and informed nursing staff that her right leg was bothering her, was purple in color, and that the purple bruising was not present earlier in the day. Resident 3 told nursing staff that she had not bumped or hit her leg on anything to cause purple bruising. Nursing staff documented that resident 3 had 3+ (moderate-to-severe) pitting (temporary pit or indenting left in the skin after applying pressure) edema (fluid-related swelling) in the right lower extremity (leg). A progress note dated 12/27/25 at 5:46 a.m. revealed that resident 3 verbalized left leg pain to nursing staff and that a dark bruise was noted on her right leg. At 3:00 p.m. that same day, resident 3 requested that her physician be notified about her pain and to order a stronger pain medication to help her with pain control. A physician's order was received to monitor her bruising to the back of her left lower leg every day and night shift until the bruising healed. A progress note dated 12/28/25 at 2:57 p.m. indicated that resident 3 experienced intermittent pain in her right leg. At 5:12 p.m., a PT progress note indicated that an ice pack was applied to resident 3's left lower leg during her therapy session to help reduce her pain and swelling. Resident 3 rated her pain a 3 on a zero-to-ten pain scale at rest and described it as nagging and aching. A PT progress note dated 12/29/25 indicated that resident 3 attended a PT session. During the session, the physical therapist assistant/therapy coordinator (PTA/TC) U performed edema massage to resident 3's left lower leg to help reduce the tightness and swelling. Resident 3 arrived at that therapy session with a hematoma (a pool of clotted blood that forms outside of blood vessels, caused by injury or surgery) to her left medial (midline) gastrocnemius (two-part muscle located on the back of the lower leg that forms the calf muscle), with significant increased tenderness. There was no warmth or erythema (redness) to the area. Resident 3 had a positive Homans' sign ( a clinical exam of flexing the foot upward toward the shin. If that movement causes pain in the calf muscle, that is considered positive and suggests a possible DVT) in her left lower leg. PTA/TC U notified former DON MM and recommended contacting the physician for an order to complete a Doppler exam (a non-invasive test that uses sound waves to assess blood flow through blood vessels). Resident 3 rated her pain at rest as 3 and at 9 with movement on a zero-to-ten pain scale. The resident described the pain as intense and sharp with movement. On 12/29/25 at 2:09 p.m., a progress note indicated that a fax was sent to notify the physician of resident 3's bruising on her right leg and to request a Doppler exam. Another progress note on 12/29/25 at 7:23 p.m. indicated that resident 3 was experiencing intermittent pain in her right leg. Progress notes from 12/29/25 through 12/31/25 indicated that on 12/29/25, a physician's order was received for resident 3 to undergo a Doppler exam, and the appointment was scheduled for 12/31/25. While attending therapy sessions during those dates, resident 3 continued to experience increased pain and swelling in her lower left leg, which limited her ability to stand, walk, maintain her balance, and perform bed mobility without difficulty. The Doppler exam was completed on 12/31/25 and revealed that resident 3 had bilateral DVTs in both of her lower legs. A physician's order was received for resident 3 to take 5 mg of Eliquis, a blood-thinning medication, orally twice daily for seven days, for her diagnosis of acute thrombosis (a sudden blockage of a blood vessel by a blood clot) in unspecified deep veins of the lower extremities. 3. A drug regimen review for resident 3 was completed by consultant pharmacist (CP) W on 1/2/26 and revealed that Aspirin 81 mg twice daily for resident 3 had not been administered since 12/19/26 at 8:00 a.m. and had not been continued as the physician ordered for 30 days. Her findings were documented in her report, and former DON MM was notified of the finding on 1/2/26. A medication variance report was completed five days later, on 1/7/26, by former DON MM regarding resident 3's omitted Aspirin 81 mg doses she did not receive from 12/19/25 through 1/18/26. 4. On 1/7/26, a corrective action plan was initiated, and the interdisciplinary team (IDT) met to review resident 3's bruising on her right lower leg and to complete an interview process with resident 3 and the nursing staff. The pharmacy addressed the order error entered by the pharmacy, which resulted in a medication error involving the aspirin for resident 3. A late-entry nurse progress note on 1/7/26 documented that the physician was notified that resident 3's Aspirin order to be given twice daily, was inadvertently discontinued by the pharmacy, the nursing facility's medical record system was unable to update the original discontinuation date sent on 12/19/25, and that the order for resident 3's Aspirin twice daily never reappeared as a corrected or continued order. A call was held on 1/9/26 with the pharmacy, facility leadership, and corporate leadership to discuss the root cause analysis, the error, how it occurred, and the process and plan for correction moving forward. On 1/12/26, a letter from the director of pharmacy was sent to the facility leadership outlining the education and training to be provided to the pharmacy staff. Training on 1/13/26 and 1/14/26 provided the pharmacy staff with education for those involved in the ordering error on 12/19/25, as well as a review of training documentation for all order-entry technicians and pharmacists. Updated material on discontinued orders and the impact on the facility was included in the training. In addition, on 1/14/26, three facility nurses involved in resident 3's Aspirin and order confirmation reviews completed training in a course titled [Facility] LTC Pharmacy Initiated Orders. The pharmacy technology team attended an order entry meeting with the nursing facility's interface team (a specialized group that manages the software system) to review the process for discontinuing medication orders and future medication order start dates. The facility completed transitioning back to a facility-initiated order system rather than a pharmacy-initiated system on 1/28/26. 5. Interview on 5/5/26 at 2:06 p.m. and again at 3:30 p.m. with CP W revealed that pharmacy reviews were completed monthly with all residents. Resident medications and physician orders were reviewed. She would review progress notes and laboratory reports for changes to determine whether medications were contributing factors. She completed a comprehensive review of resident charts every month, and with any new resident admitted to the nursing facility. She indicated that the pharmacy has a team of nursing account managers who consult and provide education to nursing facilities. They can provide education as needed or upon request from the nursing facility. She acknowledged that a process improvement plan was implemented and completed regarding resident 3's pharmacy order error and that training was provided to the pharmacy team and to the nurses involved at the facility in January 2026. 6. Interview on 5/5/26 at 1:15 p.m. and again at 2:24 p.m. with the director of nursing (DON) B revealed that at the time the order entry error occurred with resident 3, the ordering system was pharmacy-initiated, and nurses were unable to enter physician orders into the facility's ordering system. However, she acknowledged that the facility nurses were responsible for confirming the orders that had been accurately entered by the pharmacy. She said that physician orders were sent to the pharmacy by e-fax or e-scribe at the time of resident 3's order-entry error, but that the facility now received the physician orders by e-fax, e-scribe, telephone, verbally, or in writing. 7. Interview on 5/6/26 at 10:21 a.m. with administrator A revealed that there were no medication errors related to order entries in the system since that incident. Nursing staff members now had the ability to put medication physician orders into the system. Administrator A acknowledged that when the error occurred regarding resident 3's medication, the pharmacy initiated the physician orders, the facility nurse confirmed the order, and an order error resulted in the discontinuation of her Aspirin, which was scheduled to be given twice daily. Administrator A said that she thought education on medication errors was provided to nurses regarding resident 3's ordering error. 8. On 5/6/26 at 11:44 a.m., interviews via phone call were attempted, and a voicemail message was left for resident 3 and resident 3's representative. No return calls were received during the survey. 9. Interview on 5/7/26 at 10:00 a.m. with PTA/TC U revealed that resident 3 admitted to the facility on [DATE] and had physician orders for physical and occupational therapy (OT). Resident 3 started PT on 12/17/25, started OT on 12/21/25, and experienced progressive pain, swelling, and bruising in her lower legs from admission until DVTs in both lower legs were discovered on 12/31/25. PTA/TC U stated that resident 3 continued her PT and OT therapy sessions five days a week, but at times, her pain and swelling limited her ability to stand, walk, and maintain her balance. She recalled the therapy session with resident 3, during which she identified a positive Homans' sign, notified former DON MM, and recommended that resident 3's physician be contacted to order a Doppler exam. She stated that she was happy with the timely response former DON MM provided by notifying the physician and obtaining an order for the Doppler exam for resident 3. PTA/TC felt that resident 3 not receiving the scheduled 81 mg of Aspirin twice daily could have been a contributing factor in the development of her bilateral lower leg DVTs. 10. Interview on 5/7/26 at 2:50 p.m. with RN/Minimum Data Set (MDS )coordinator J revealed that she received education regarding the incident involving resident 3's medication error. She reported that resident 3 had no further lower-leg pain or problems after starting Eliquis. 11. Interview on 5/7/26 at 5:30 p.m. with RN/Director of Electronic Health Records (EHR)/Point Click Care Implementation (PCCI) V stated that the facility transitioned to a facility-integrated system on 1/28/26 after a pharmacy order entry error involving resident 3 not receiving her medication as ordered was identified. That plan was adopted as the response to that incident. 12. Interview and record review on 5/7/26 at 5:43 p.m. with administrator A, regional nurse consultant (RNC) M (via phone), and RN/vice president of clinical services (VPCS) X revealed that on 1/9/26 a call was held with the pharmacy team, the nursing facilities leadership team, and corporate office personnel to discuss the root cause of resident 3's medication error, how it occurred, and the processes and plan for correction to move forward. Administrator A and RN/VPCS X acknowledged that the ordering error resulted in resident 3 not receiving the scheduled Aspirin for approximately two weeks. Resident 3 experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention and developed DVTs in both of her lower legs. RNC M acknowledged that since the facility-integrated order system was implemented on 1/28/26, the facility did not conduct any audits to verify whether any further medication order entry errors had occurred for all residents, and that no data about that was presented at the monthly Quality Assurance and Process Improvement (QAPI) meetings. 13. Review of the provider's Medication Errors policy dated 5/14/25 revealed that the Policy was to ensure medication errors are identified to prevent adverse resident effects. Errors will be documented, investigated, reported, and reviewed for the need of interventions and to prevent recurrence. Medication errors will be reviewed by the Medical Director and Consultant Pharmacist. The review may be done via telephone, during routine visits, or during QAPI discussions. The medication error will be entered into the Risk Management Section of [Facility System] for trending and tracking purposes. 14. Review of the provider's Following Physician Orders policy dated 11/18/25 revealed that the Policy was to correctly and safely receive and transcribe the physician's orders so the correct order is followed/administered. New admission/readmission physician orders and all transcription of orders should be transcribed by a HUC or a nurse and be double checked by a second nurse to ensure that all steps have been carried out to avoid errors.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure the staff followed the care planned interventions for one of one sampled resident (2) who expressed distress and reported allegations of abuse when one of one certified nursing assistant (CNA) (P) did not provide the resident's care with another staff member present, as identified in his care plan and the provider failed to provide necessary behavioral health care and services to support the resident's highest practicable mental, emotional, and psychosocial well-being. Findings include: 1. Review of the provider's 2/9/26 SD DOH FRI revealed that on 2/9/26, resident 2 posted a video on his Facebook page (social media site) that certified nursing assistant (CNA) P told him that if he called her a [curse word redacted] again, that she was going to pull his hair and punch him in the face. In that video, resident 2 stated he felt it was his First Amendment right to speak to staff disrespectfully and call them a [curse word redacted] if he wants to. The facility's investigation could not determine if CNA P stated that she was going to pull his hair or punch him in the face. Resident 2 was to have two staff members present when his care was provided (cares in pairs) at all times. CNA P did not follow resident 2's care plan for providing cares in pairs, was joking around with resident [2] during a conversation, and that resident 2 felt safe. 2. Review of resident 2's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His diagnoses included quadriplegia (a partial or total loss of function in all four limbs and the torso), anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression (a serious, common medical illness characterized by persistent sadness, loss of interest in activities, and low energy). His 4/19/26 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. Resident 2's 4/21/26 care plan included a 1/19/26 care plan intervention that indicated that resident 2 was to receive Cares in pairs (care provided with two caregivers present). The care plan had a 12/2/25 focus area that indicated that resident 2 was at risk for mood distress-signs and symptoms of anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). Interventions included encouraging him to reach out to the director of nursing (DON) or the assistant director of nursing (ADON), encouraging him to talk about anything that might be on his mind, evaluating the potential causal factors, and observing his psychosocial/emotional functioning. On 3/6/26, a focus area was added that indicated that he had a diagnosis of anxiety and depression, and that he had been offered and refused therapy services. A 4/25/26 focus area was added that indicated that resident 2 had a history of disruptive behaviors that interfered with his care and required additional staffing assistance, and that he posted things on Facebook and manipulated staff to do what he wanted. A 4/25/26 intervention was added that indicated to, Allow [resident 2] to express feelings. No other interventions were included for this focus area. There was no documentation in his EMR to support that resources such as cultural services, support groups for young adults with quadriplegia, mental health telehealth services, or religious services had been offered to resident 2 or that he had refused those services. 3. Observation and interview on 5/5/26 at 11:22 a.m. with resident 2, contacted travel certified nursing assistant (CNA) JJ, and CNA FF revealed that contracted travel CNA JJ and CNA FF assisted resident 2 to transfer from his wheelchair to his bed with the full body lift (a mechanical lift and sling used to lift a person's full body). Resident 2 kept his eyes closed and did not talk to the staff members while they assisted him from his wheelchair to his bed with the full body lift. When the two CNAs left the room, resident 2 asked the surveyor to return later so that he could share his concerns. When asked why he did not talk to the staff members and kept his eyes closed, resident 2 stated that he was tired of arguing with the staff members. 4. Observation and interview on 5/5/26 at 1:40 p.m. with resident 2 in his room revealed he had been awake most of the night and morning and was having difficulty staying awake that afternoon. He stated he had several concerns he wanted to discuss, including his rights and how the staff members treated him. He was afraid to ask for things because the facility had provided him a letter in January 2026 stating that they could not meet his needs and that they indicated they were going to make him leave when they found a facility that would accept him. He stated that the facility needed two staff members to provide his care because there had been multiple incidents when staff made smart remarks or he swore at them when he was frustrated or angry. He felt that staff made assumptions about him and the things he said, and it led to problems. He felt that having two staff members in the room helped him to feel safe most of the time, but not always. When he asked the staff members to leave his room, sometimes they argued with him, and he swore at them. He found it ridiculous that they would argue with a quadriplegic person. Resident 2 did not feel like there was anyone that he could go to when he needed help resolving a problem. He did not feel like he could bring his concerns to social services designee (SSD) HH, because he was not allowed to talk to her. He was a tribal member and did not have a tribal case worker after he admitted to the facility, and he did not receive any therapy services. He felt that he could only get angry and yell if the staff did not listen to him. He thought that there was nothing else he could do because he was paralyzed, depended on the staff members for all of his needs, and he felt like no one was listening to him. He stated that SSD HH had filed for a restraining order against him. She accused him of trashing her office four days after he arrived at the facility. That restraining order had not been upheld in court, but she had little to no involvement in his care at the facility, after that. He was then told that he needed to take all of his concerns to administrator A. Resident 2 stated he was tired, ended the interview, and asked the surveyor to return the next day. 5. Interview on 5/6/26 at 9:54 a.m. with resident 2 in his room revealed he had concerns about staff members taking his personal items out of his room without his knowledge, he felt like no one tells him anything, and He is sick of asking. Resident 2 did not think he had spoken with the Ombudsman about his concerns and was unsure how that would have helped. He did not think that he received information about his resident rights and felt he would have been better informed if he had. Administrator A told him that he had to take all of his concerns to her. Resident 2 took all of his concerns to administrator A until a complaint regarding resident 2 and administrator A was filed, and now he wasn't able to talk to administrator A either. He had an Indian Health Services (IHS) caseworker before he was admitted to the facility, but did not remember her name. Resident 2 did not know if anyone had filled out a grievance form for him when he voiced his concerns. He was physically unable to fill them out himself. Resident 2 stated that when he discussed his concerns with staff members, including administrator A, they said they would follow up, but then they did not. Resident 2 felt like the rules were changing all the time and that the staff members he spoke to made up rules as they went. He stated he has stopped asking for help even when he needs it because he felt the staff did not want to help him, they argue with him, and they told him in January 2026 that he would have to leave the facility. He was unsure if the facility was still looking for another facility for him to go to. He felt that his opinions were not heard, and that he was tired of it and was shutting down. He used to go out of his room more, but now he goes out to smoke and keeps his door closed. He stated that the staff members say they are joking around and sometimes say unkind things, but he felt vulnerable because he could not defend himself because of his medical condition, and he often yelled at or swore at the staff members. In February 2026, after he made a Facebook post about a staff member, DON B and CNA F came to his room to talk to him, and he felt very overwhelmed. He did not feel comfortable talking to DON B after that incident. He did not know who he could talk to about how he felt. 6. Multiple attempts were made on 5/6/26 and 5/7/26 to reach resident 2's resident representative by phone at the number listed in his EMR. These attempts were unsuccessful, and she was unable to be interviewed. 7. Interview on 5/6/26 at 2:25 p.m. with DON B regarding the letter resident 2 received in January 2026, revealed the facility had provided resident 2 a facility-initiated 30-day notice of discharge from the facility, that indicated they were unable to meet his needs and that he would be transferred to their sister facility. The sister facility reviewed his information and did not admit him. She was unsure if they were still looking for another facility to transfer him to. 8. Interview on 5/6/26 at 3:55 p.m. with SSD HH revealed that she had taken resident 2's vape out of his room about four days after he arrived at the facility because he was not allowed to have it until he was assessed by the nursing staff. Resident 2 became very upset and trashed her office by using his power wheelchair. She had filed for a restraining order against resident 2. That restraining order was not upheld in court, but she was told by administrator A not to have any contact with resident 2. SSD HH had been instructed by administrator A to only complete resident 2's social services paperwork, but administrator A talked to resident 2 and completed his social services assessments when they were due. SSD HH stated that about two months ago, a complaint was filed against administrator A regarding resident 2. At that time, DON B was put in charge of resident 2's social services needs by administrator A. Within the past month, SSD HH became more involved in resident 2's care because things were being missed, and SSD HH held resident 2's care conference in April 2026. Resident 2's representative attended his April 2026 care conference by phone and did not have any concerns. SSD HH stated that resident 2 did not talk or make eye contact during that care conference meeting. She stated that she offered resident 2 counseling services during that care conference and that resident 2 did not receive any mental health services because he had declined them. SSD HH stated that she had not been involved in issuing resident 2's facility-initiated 30-day notice of discharge from the facility, but thought that the facility was still looking for an alternative placement for him. She stated she felt uncomfortable around resident 2, and that administrator A was aware of this. 9. Phone interview on 5/7/26 at 10:26 a.m. with Indian Health Services Case Manager (IHS/CM) KK, revealed she assisted resident 2 and his family to find a long-term care (LTC) placement for him when he needed more assistance than he could receive in the community. She stated that her involvement with resident 2 ended when he admitted to the facility. Resident 2 knew he needed more care, accepted the need for LTC, and he agreed to come to the facility. She heard that once he got to the facility, things changed, and he was angry, but she was no longer involved in his care. She expected that there would be a period of adjustment as he transitioned to the facility. She thought that he might need mental health services or cultural services, but the facility had not reached out to her about any services that would be available to him through IHS, and she was unaware of the services that the facility was providing to resident 2. 10. Interview and review of resident 2's care plan and grievance forms on 5/7/26 at 3:44 p.m. with administrator A revealed that she was the grievance official and would complete the paperwork part of any grievance related to resident 2, but resident 2 was to bring all of his concerns to DON B. She stated that there had only been two grievances completed related to resident 2, and both were in regard to call lights. A complaint had been filed about and she was not allowed to be in a room alone with resident 2. SSD HH had limited interactions with resident 2 because she was uncomfortable around him. Administrator A stated she thought it was in resident 2's care plan that all of his concerns were to be brought to the ADON or the DON. She confirmed that at the time of the survey, there was no ADON working there. She expected that resident 2 would take all of his concerns to DON B and that DON B would complete a grievance form. Upon review of resident 2's care plan, administrator A confirmed that his 4/21/26 care plan indicated Resident need[s] to bring all concerns to Administrator. She stated this was inaccurate and needed to be updated. She was not aware that resident 2 did not feel comfortable talking to DON B. 11. Interview on 5/7/26 at 4:20 p.m. with administrator A and regional director of operations (RDO) LL regarding resident 2 revealed that administrator A thought that resident 2 did not participate in his admission paperwork process because he did not want to, and that he refused all offers of mental health and rehabilitation therapy services. Administrator A stated that resident 2 had never asked her for a copy of his resident rights or the facility rules. SSD HH was not allowed to be involved in resident 2's care, and she thought that SSD HH did not want to be involved. Administrator A put herself in charge of resident 2's social services needs until she was not allowed to be alone with him, and then administrator A had designated DON B to be responsible for his social service needs. When asked why the facility issued a 30-day notice of discharge to resident 2, administrator A stated it was because they could not meet his needs, and did not have people that he could talk to about his needs or concerns. When asked what social services were being provided to resident 2, administrator A stated that she did not know. 12. Interview on 5/7/26 at 6:27 p.m. with SSD HH revealed she offered resident 2 mental health services one time after he admitted to the facility, which included talk therapy with a counselor and telehealth psychiatry, and he declined. No tribal counseling services were offered. She did not think those services were available. She was then on leave from the facility for a period of time, and she was not sure if anyone else offered resident 2 mental health services during that time. SSD HH was unaware that a staff member threatened to punch resident 2. She thought that resident 2's care planned cares in pairs intervention was for the staff members protection. Resident 2 threatened that his family was going to come shoot up the facility, then he wrecked her office. In October 2025, he attempted to elope, the police were called, and he went to the hospital, had a psychiatric evaluation completed, and was brought back to the facility. His physician was aware of his behaviors and managed them with psychiatric medications. SSD HH stated that resident 2's family told him he had to stay in long-term care (nursing home) because they could not take care of him. She thought he wanted to be at a facility where there were other Native Americans. The facility made referrals to other nursing homes, but none accepted him for admission to their facilities. When SSD HH or administrator A was no longer allowed to talk to resident 2, she was not sure who he talked with to meet his mental health needs. In March 2026, she started to take over some of resident 2's social service needs. She did not ask him for his approval but just went in to talk to him, and he talked to her now. She thought that she could visit with him without other staff members present. SSD HH completed resident 2's facility admission paperwork with his representative and was unsure if his representative gave him the copies. She did not give him a copy of his resident rights or the facility rules. 13. Review of the provider's 2/4/22 Social Services Designee's job description revealed In keeping with our organization's goal of improving the lives of the Guests [residents] we serve, the Social Worker ensures that the medically related emotional and social needs of the Guests are met and maintained on an individual basis and in accordance with current federal, state, and local regulations. 14. Review of the provider's revised 5/14/25 Care Plans policy revealed Care plans are accessible to all direct-care staff, including the resident's physician/provider. It is the responsibility of all direct care members to familiarize themselves with the care plans and review them routinely for changes. 15. Review of the provider's November 2020 Resident Rights booklet revealed All nursing homes are required to provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to protect the resident's rights for one of one sampled resident (2) who was not provided a copy of his resident rights, or could exercise his rights without interference, when staff members took away his personal possessions (his tattoo gun, his vape, and his computer), and failed to honor his requests for privacy and staff boundaries as documented in his care plan. Findings include:1. Review of the provider's 2/9/26 SD DOH FRI revealed that on 2/9/26, resident 2 posted a video on his Facebook page (social media site) that certified nursing assistant (CNA) P told him that if he called her a [curse word redacted] again, that she was going to pull his hair and punch him in the face. In that video, resident 2 stated he felt it was his First Amendment right to speak to staff disrespectfully and call them a [curse word redacted] if he wants to. The facility's investigation could not determine if CNA P stated that she was going to pull his hair or punch him in the face. Resident 2 was to have two staff members present when his care was provided (cares in pairs) at all times. CNA P did not follow resident 2's care plan for providing cares in pairs, was joking around with resident [2] during a conversation, and that resident 2 felt safe. 2. Review of resident 2's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His diagnoses included quadriplegia (a partial or total loss of function in all four limbs and the torso), anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression. His 4/19/26 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. 3. Observation and interviews on 5/5/26 at 9:54 a.m., 11:22 a.m., and again at 1:40 p.m. with resident 2 in his room revealed that he wanted to know what his rights were. He stated that each time he got upset about something the facility had done, the staff members said it was because of the rules. He stated he had asked for a copy of the rules but was not provided with them. He stated he did not understand all the rules and that he would like to see the rules in writing. He asked administrator A and director of nursing (DON) B for a copy of the facility rules and policies, but they did not provide them to him. He was admitted to the facility in October 2025. Two family members were with him that day. He stated that he was not offered or provided a copy of his resident rights or the facility's rules when he was first admitted .He felt it was a violation of his rights that they took his vape and his tattoo gun out of his room while he was sleeping. He was allowed to use the vape now, but he did not know where his tattoo gun was located, and no one will tell me. He thought the tattoo gun was taken from his room in January 2026.He stated that two staff members were required to take care of him because he needed a significant amount of assistance with his care and because staff members were rude and disrespectful to him. He felt that having two staff members present during his care helped most of the time, but not always. He recalled the day, a couple of months ago, when he made a Facebook post about a staff member, and DON B and CNA F came to his room to talk to him. He did not want to listen to them and told them to get the [curse word] out of his room, but they would not leave. He was angry when DON B closed his computer and took it away. He said it made him angry because it was his personal property, and he could not take it back from her because he was paralyzed. He stated that DON B told him that he was not allowed to post about staff members on Facebook, because it was their right not to be recorded. He felt that it was his right to post on Facebook as long as he didn't videotape the staff. He stated he wanted to know what his rights were. 4. Interview on 5/6/26 at 11:19 a.m. with CNA F revealed resident 2 was very demanding with the staff, frequently swore, and she always had another staff person with her when she provided his care. She did not recall DON B taking resident 2's computer away from him, but resident 2 was told that he could not record the staff members in his room. When resident 2 requested the staff to leave his room, especially if he was upset, she was told to make sure he was safe and had his call light and then leave his room. 5. Multiple attempts were made on 5/6/26 and 5/7/26 to reach resident 2's resident representative by phone at the number listed in his EMR. These attempts were unsuccessful, and she was unable to be interviewed. 6. Interview on 5/6/26 at 3:55 p.m. with social services designee (SSD) HH revealed she had assisted resident 2's representative with completing the admission paperwork when resident 2 was admitted to the facility on [DATE]. She confirmed that resident 2 was not present when she discussed the admission paperwork and the resident rights with his representative. She stated staff members were getting him settled in his room. His representative was not his power of attorney (POA) (someone designated on a legal document to act on behalf of a resident), but at the time of his admission, resident 2 was not mobile, and his representative signed all of his paperwork for him. SSD HH did not think that resident 2 had wanted to be part of that admission process. She did not recall if she had asked him, and she did not provide him with a copy of his resident rights.She had taken resident 2's vape out of his room about four days after he arrived at the facility because he was not allowed to have it. Resident 2 became very upset and trashed her office with his power wheelchair. Resident 2 was allowed to have the vape during smoking times after nursing completed the necessary assessments and obtained a physician's order for it. She was unaware that resident 2 had a tattoo gun and had very minimal contact with resident 2 after she took his vape away. 7. Interview on 5/7/26 at 2:45 p.m. with DON B revealed she became the DON in April 2026, and she did not know who had removed resident 2's tattoo gun from his room or that it was removed from his room while he was sleeping. She expected that the staff member who removed it from his room would have told him that it was unsafe for him to use, removed it from his room with his knowledge, and stored it in a safe place. She found the tattoo gun in her office cabinet on 5/6/26.The facility did not have a policy regarding his use of the tattoo gun, but she thought that an assessment for his safety would need to be completed.After resident 2 posted on Facebook about a staff member, administrator A told DON B and CNA F to inform resident 2 that he was not allowed to videotape the staff or the residents. She went into resident 2's room on 12/21/24. He was in bed, and his computer was on his bedside table in front of him. She closed his computer and moved it away from him. Resident 2 was upset and did not want to listen, but she told him that he needed to listen and that administrator A told her that she needed to have that conversation with him. She stated that he swore at her several times, and then he closed his eyes. Resident 2 asked DON B to leave his room, and she did not. She stated she left his room when she had finished talking to him. She confirmed that his care plan stated that the staff was to leave his room and reapproach him regarding his behaviors. She did not provide resident 2 with a copy of his resident rights, but stated the resident rights booklet was in the admission packet he received on admission, and that there were posters on the wall. She did not think resident 2 had requested a copy of his resident rights from her. 8. Interview on 5/7/26 at 3:44 p.m. with administrator A revealed that resident 2's vape and tattoo gun were taken away from him for safety reasons. She was not aware that they were taken out of his room while he was asleep and expected that the staff would have explained why they were taken and where they would be stored. Resident 2 was allowed to use his vape during smoking times, but the provider did not have a policy about the use of his tattoo gun, and she was still looking into that.After resident 2 posted on Facebook about a staff member, administrator A told DON B to inform resident 2 that he was not allowed to videotape the staff or the residents. She was not aware that resident 2's computer was closed and moved out of his reach or that he became upset and requested that DON B leave his room.Administrator A expected all staff members to respect resident 2's wishes and leave his room when asked and reapproach him later, especially if he was upset. She was not aware that resident 2 wanted a copy of his resident rights and the facility rules, nor had she provided a copy of them to him. She thought that SSD HH would have provided that information when he was admitted to the facility. She was not aware that resident 2 did not participate in the admission process with SSD HH on the day of his admission. Resident 2 was to have all his care provided with two staff present for his safety and for the safety of the staff. 9. Review of the provider's November 2020 Resident Rights booklet revealed All nursing homes are required to provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. The right to be fully informed of Facility rules and regulations, including a written copy of resident rights. right to Dignity, Respect, and Freedom: Security of possessions. The resident has the right to be free from interference, coercion, discrimination, and reprisal when exercising their rights as a resident in long term care and as a citizen of the United States.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRIs), personnel files, record review, observation, interview, and policy review, the facility failed to protect the residents' property for one of one sampled resident (4) who had 13 Hydrocodone/APAP (acetaminophen) (a narcotic medication to treat moderate to severe pain) 5-325 milligram (mg) tablets go missing by one of one contracted travel registered nurse (RN) (N) and one of one sampled resident (5) who had one lorazepam (a medication to treat anxiety) 0.5 mg tablet found missing by licensed practical nurse (LPN) L and contracted travel LPN (T) and was not found. Findings include: 1. Review of the provider's 1/20/26 SD DOH FRI revealed that at approximately 8:30 a.m. on 1/20/26, contracted travel registered nurse (RN) N entered resident 4's room with his medication card, which contained his PRN (as needed) Hydrocodone/APAP 5-325 mg tablets, and the rest of his morning medications for administration to the resident. Approximately two hours later, RN N discovered she had misplaced the medication card of 13 tablets of Hydrocodone/APAP and reported that the medication card was missing to former director of nursing (DON) E between 12:45 p.m. and 1:00 p.m., and an investigation was started. Camera footage revealed that throughout the morning and early afternoon on 1/20/26, numerous staff members and resident 1 entered resident 4's room. Certified nursing assistant (CNA) P entered resident 4's room with his breakfast tray shortly after 8:30 a.m. and immediately exited the room. At 9:02 a.m., housekeeper K entered his room and exited at 9:08 a.m. Contracted travel CNA O entered his room at 9:09 a.m. to assist resident 4 in getting up and ready for the day, and she exited the room at 9:20 a.m. At 11:18 a.m., CNA Q entered resident 4's room and took him to lunch. At 12:03 p.m., resident 4 and resident 1 entered resident 4's room together. At 12:12 p.m., contracted travel RN N entered resident 4's room and then exited, and at 12:18 p.m., resident 1 exited. At 12:23 p.m., resident 4 left his room and attended therapy. The final report noted that contracted travel RN N stated she had taken the medication card containing 13 tablets of resident 4's Hydrocodone/APAP to his room that morning to save time, as she was in a hurry and the resident often requested a tablet of that medication in the mornings. A count of all the residents' controlled medications was completed by regional nurse consultant (RNC) M and contracted travel RN N, and all counts were accurate except for resident 4's known missing Hydrocodone/APAP. The medication card containing resident 4's Hydrocodone/APAP 5-325 mg tablets was never located after thorough searches of the facility during the investigation. Review of the personnel files for contracted travel RN N and contracted travel CNA O revealed that both had completed orientation training and education through their employing agency and received additional training and education through the facility. There were no prior disciplinary actions in their files. Their education included topics such as misappropriation of resident property and drug diversion (illegal transfer or use of prescription drugs). Contracted travel RN N's last working shift at the facility was on 1/20/26, when she was suspended from working at the facility pending the investigation, and her work contract with the facility was terminated on 1/21/26. Contracted travel CNA O remained on the facility's schedule and was allowed to work. Her last shift at the facility was on 3/31/26. 2. Review of resident 4's electronic medical record (EMR) revealed that he had a seizure and fell in his home on [DATE], which resulted in compression fractures (bones in the mid-back have collapsed or become crushed, causing back pain) of his T4, T5, and T6 vertebrae (the 4th, 5th, and 6th bones) and his admission to the hospital. He admitted to the facility on [DATE] and received therapy services. His diagnoses included seizure disorder (a condition with recurring, unpredictable seizures), cardiac arrest (the heart suddenly stops beating, cutting off blood flow to the brain and other vital organs), and lower extremity weakness. His 3/24/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. 3. Interview on 5/6/26 at 4:50 p.m. with resident 4 in his room revealed that he recalled the incident that involved his missing Hydrocodone/APAP medication card in January 2026. Resident 4 said he gave staff permission to search his room for the missing medication card, and he was questioned by the police. Resident 4 denied keeping the card and taking the medication himself, stating that he never saw a medication card left in his room and was unsure whether the nurse had even brought the Hydrocodone/APAP medication card into his room that day. Resident 4 stated that he had been taking that medication to help control his pain from the compression fractures in his back. He remembered eating breakfast in his room that morning, and that a CNA brought him his meal tray and another CNA later assisted him to get ready for the day, but he could not recall their names. Resident 4 said the nurse brought him his medications, but he could not recall her name. He did not see the nurse or CNA with a medication card when either left his room. Resident 4 was not sure what had happened to the missing medication card, but the pharmacy replaced the medication for him. Resident 4 said he requested one of his PRN Hydrocodone/APAP medication tablets for his pain that morning and that it was administered to him by contracted travel RN N. He stated that his missing Hydrocodone/APAP tablets were never found. 4. Interview on 5/7/26 at 11:15 a.m. with housekeeper K regarding the missing medication card of Hydrocodone/APAP revealed that she recalled the incident involving resident 4's missing medication card of Hydrocodone/APAP. She cleaned resident 4's room the morning that the medication card went missing and thought she entered his room between 9:00 a.m. and 9:30 a.m. Housekeeper K did not see a medication card in his room or in the trash. She indicated that checking resident trash was a daily task on their list to complete, to look for residents' personal items that may have been thrown away unintentionally, such as glasses, hearing aids, and dentures. 5. On 5/7/26 at 12:08 p.m., a call was placed to CNA P, which was unanswered. A voicemail message was left requesting a return call. No return call was received during the survey. 6. Interview on 5/7/26 at 12:23 p.m. with CNA Q revealed that she remembered contracted travel RN N looking for a missing medication card for resident 4 during a morning shift she worked. On the day that the resident's medication went missing, she entered resident 4's room just before lunch and assisted him to the dining room. She heard from other staff members that a medication card for resident 4 was left in his room by contracted travel RN N and was not found after the room was searched. Contracted travel RN N told CNA Q that she was asked to leave her shift and would be leaving the facility between 3:00 p.m. and 4:00 p.m. CNA Q was unsure whether resident 4's missing medication card was found. 7. A review of the educational material provided to the nursing staff regarding the 1/20/26 incident of resident 4's 13 missing Hydrocodone/APAP tablets revealed that the information was typed and titled Education. No date was typed or written on the 1-page document. The education document provided to the nursing staff stated, Do not take medication cards into resident rooms. Do not leave meds at bedside. If you notice any medications left in the room, notify the charge nurse or nursing administration immediately for removal. Sign below: 14 nurses signed that education document, but education was not provided to all nurses regarding the 1/20/26 incident of resident 4's missing medication card. 8. Review of the provider's 4/8/26 SD DOH FRI revealed that at approximately 6:00 a.m., during the shift change, licensed practical nurse (LPN) L and contracted travel LPN T were completing the routine change of shift controlled medication count of the controlled medications in one of the two facility's medication carts. During that count, it was discovered that one 0.5 mg lorazepam tablet was missing from resident 5's lorazepam morning dose medication card. The packaging on the back of that lorazepam medication card had a small hole, and no tablet was in it. On 4/8/26, the medication cart and surrounding areas were searched, but the missing 0.5 mg lorazepam tablet was not found. director of nursing (DON) B checked all other controlled medications and found no other discrepancies. It was discovered that the nurses were not fully removing the controlled medication cards from the narcotic (controlled pain medications) locked drawer to obtain a clear view of all the pills, and were not comparing the actual number of pills in each medication card with the controlled drug record forms to verify that those counts matched. The nursing staff was unsure how long resident 5's lorazepam tablet had been missing. The investigation concluded that resident 5's missing lorazepam 0.5 mg tablet was accidentally ejected from the medication card at some point, unnoticed, and potentially swept up by housekeeping staff. 9. Review of resident 5's EMR revealed that she admitted to the facility on [DATE]. Her diagnoses included weakness, repeated falls, abnormal gait (any waling pattern that deviates from the usual walk), delusional disorder (false beliefs and distorted views of reality), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and dementia ( a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbance. Her 4/4/26 BIMS assessment score was 07, which indicated her cognition was severely impaired. 10. Interview on 5/5/26 at 10:47 a.m. with resident 5 revealed that she did not recall that one 0.5 mg lorazepam tablet was missing on 4/8/26 or if the nursing staff reported it to her. 11. Phone interview on 5/5/26 at 11:50 a.m. with resident 5's representative revealed that the facility contacted her and discussed any changes in resident 5's care. The staff would contact her by phone and let her know if any new medications were ordered or if medications were changed. She stated, I talk to them all the time, and they are on top of it. She stated that she was probably notified of the missing 0.5 mg lorazepam tablet and had no concerns regarding that incident. 12. Interview on 5/6/26 at 4:35 p.m. with LPN L related to resident 5's missing 0.5 mg Lorazepam tablet revealed she could not recall that resident 5 was missing a 0.5 mg lorazepam tablet during the controlled medication count at shift change the morning of 4/8/26. She did not recall if she had completed a thorough search of the medication cart and the surrounding area to locate the missing medication, or if contracted travel LPN T had. She was not sure who had notified the nurse supervisor or the DON or whether the missing lorazepam tablet was found. 13. Interview on 5/7/26 at 11:50 a.m. with contracted travel LPN T revealed that she was the nurse going off duty the morning of 4/8/26. When she was completing the controlled medication count with LPN L, it was discovered that resident 5 was missing one 0.5 mg lorazepam tablet from her morning lorazepam dose medication card. She and LPN L searched the medication cart and the surrounding area but did not find the missing tablet. She stated, I am not sure how long it was missing. She said she did not report the missing medication to the nursing supervisor or the DON, but LPN L reported it to the unit manager, LPN I. She acknowledged that she received education to check both the controlled medication log and the medication card during the count to verify the accuracy of residents' controlled medications. 14. Review of the educational material provided to the nursing staff regarding resident 5's missing lorazepam tablet on 4/8/26 revealed that the information was typed and titled Attention Nurses:. No date was typed or written on the 1-page document. The education document stated, When counting narcotics during shift change, please be sure to pull the card all the way out, count the pills, and check the back of the card to ensure there are no tears or openings. It is also suggested that you look at the book and verify that the number that's being read to you is correct. If the count is off/wrong, DO NOT LEAVE THE BUILDING. Contact former DON NN, administrator A, AND DON B. If for any reason you cannot get in touch with one of them, call LPN I, whose number is listed in the numbers binder at the nurse's station. Narcotic audits will also be performed regularly moving forward. An in-service sign-in sheet indicated that RN R, LPN I, and LPN L received that education on 4/17/26 after it was identified that resident 5's lorazepam tablet was missing on 4/8/26. No other nurses at the facility received education. Weekly audits regarding accurate narcotic counts began on 4/10/26 following resident 5's missing lorazepam tablet. 15. Observation and interview on 5/5/26 at 1:30 p.m. with LPN I in the 200 hallway, of the controlled medications and the count sheets in cart one revealed that the medication cart contained controlled medication cards that were stored in a locked box in a locked drawer. Controlled medications were stored that way in all the facility's medication carts. LPN I stated that two nurses were to count the controlled medications at each shift change, which occurred twice daily or as needed based on staff schedules. She said that whenever possession of the keys changed, a count was completed. A controlled medication count for cart one was completed with LPN I and revealed that residents' controlled medication cards were stored in the locked narcotic box, and there were no medication count discrepancies. LPN I did not think that education was provided after resident 4's medication card of 13 tablets of Hydrocodone/APAP, was reported missing. 16. Interview on 5/5/26 at 2:06 p.m. and again at 3:30 p.m. with consultant pharmacist (CP) W revealed that pharmacy reviews were completed monthly for all residents. Resident medications and physician orders were reviewed, and gradual dose reduction (GDR) recommendations were provided to residents prescribed psychotropic medications (drugs that affect brain activities associated with mental processes and behavior). She would review progress notes, care plans, Minimum Data Set (MDS) assessments, and laboratory reports for changes to determine whether medications were contributing factors to residents' changes in condition. She completed a comprehensive review of resident charts every month, and for any new resident admitted to the facility. She stated that the pharmacy strongly encouraged facilities to report any missing medication to the pharmacy staff. 17. Observation and interview on 5/6/26 at 12:00 p.m. with contracted travel LPN S in the hall next to the nurse's station revealed that she had received education to check both the controlled medication log and the medication card during the count to verify the accuracy of residents' controlled medications. A controlled medication count for cart two was completed with contracted travel LPN S, and all controlled medications were securely stored in the locked box inside the locked cart with no medication count discrepancies. 18. Interview on 5/7/26 at 3:10 p.m. with DON B revealed that she expected nursing staff to be at their medication carts when punching medications out from the medication cards when preparing medications to administer to residents. Nurses were not to take medication cards into resident rooms. If a medication was missing, DON B expected nurses to search for it by checking cards stored around the missing medication to determine whether it was removed from the wrong medication card, checking whether it was signed out on the wrong narcotic drug sheet, checking the back of the medication card to see if it was stuck in the packaging, looking in the bottom of the medication cart drawer for it, and reviewing all narcotic drugsheets and medication administration records (MARs) for every entry. After the search, if the medication was not found, the nurses were to contact her as quickly as possible, and she would start an investigation. DON B stated that the physician and family were to be notified of missing medications, and residents were to be notified if they were responsible for themselves. She expected the information to be documented in a progress note. DON B stated that if medications were missing, the pharmacy needed to be notified so they could be replaced. DON B stated that she did not know what had happened to resident 4's Hydrocodone/APAP tablets and that contracted travel RN N, taking his medication card down to his room to administer it, was suspicious of drug diversion, as the 13 Hydrocodone/APAP tablets were never found. She said that the facility's camera footage was reviewed on 1/20/26 and confirmed that contracted travel RN N entered resident 4's room that morning with his Hydrocodone/APAP medication card in hand, but exited without it. Law enforcement was notified on 1/20/26 regarding the missing Hydrocodone/APAP tablets belonging to resident 4, and an officer came to the facility and interviewed him. Resident 4 refused to allow the facility nurse, whose name DON B could not recall, to search him for the missing medication card. DON B stated that she did not know what had happened to resident 5's lorazepam tablet on 4/8/26 and that she had checked all other controlled medications that morning and found no other discrepancies. DON B said that the nurses were not removing the controlled medication cards from the narcotic drawer to obtain a clear view of all the pills, and were not comparing the actual number of pills in each medication card with the controlled drug record forms to verify that those counts matched. She thought that resident 5's missing lorazepam tablet was accidentally ejected from the medication card, unnoticed, and swept up by the housekeeping staff. DON B said that all nursing staff were trained to remove the controlled medication cards from the medication carts, and both nurses were to verify that the medication card counts matched the counts on the controlled medication count sheets. She was not sure whether audits had been completed for the missing medications for residents 4 and 5, or whether incidents involving missing medications had been reported to the monthly QAPI meetings for tracking, recommendations, and process improvement plans. 19. Review of the provider's Quality Assurance and Process Improvement (QAPI) reports for 1/28/26, 3/25/26, and 4/21/26 revealed that medication variance reports were included as a section of the facility's QAPI document for review during the facility's monthly meetings.The incident investigation sections of the QAPI reports included one medication variance in the 1/28/26 report that occurred in December 2025. The 3/25/26 report had no medication variances from February 2026. The 4/21/26 report had one medication variance that occurred in March 2026. The Corrections Section for 1/28/26 and 3/25/26 indicated that staff education was provided and that the facility transitioned to a facility-initiated ordering system, which allowed the facility to enter physician orders, as planned after the order-entry error occurred with resident 3. No February 2026 QAPI report was provided during the survey for review to verify that resident 4's January 2026 medication variance was documented or to determine whether processes were in place to address his missing medication for tracking and trending, recommendations, and discussion. The medication errors section of the QAPI reports included one medication error in the 1/28/26 and 3/25/26 reports. No information was provided about the medication error in the 1/28/26 report. The 4/21/26 report indicated that Missing Norco (a brand name for Hydrocodone/APAP) was noted and that nursing education and audits were being completed two times weekly to ensure the accuracy of controlled medication counts. 20. Interview and record review on 5/7/26 at 5:43 p.m. with administrator A, regional nurse consultant (RNC) M (via phone), and RN/vice president of clinical services (VPCS) X revealed that DON B reported missing medication incidents to administrator A and, if determined to be reportable, administrator A completed a report to the SD DOH. Administrator A acknowledged that she reported the missing medications for residents 4 and 5 to the SD DOH. Administrator A stated that medication variances were reported at the monthly QAPI meetings. Administrator A expected that controlled medications be counted by the incoming and outgoing nurses at every shift change. After the controlled medications were counted, she expected both nurses to sign the narcotic drug sheet, which indicated that the controlled medication count was complete and accurate. If the count was inaccurate, a search for the medication was to be conducted, and DON B was to be notified immediately. *She acknowledged that staff not counting the controlled medications at every change of shift by the incoming and outgoing nurses could increase the risk of drug diversion and would make it difficult to determine when the controlled medication went missing. Administrator A, RN/VPCS X, and RNC M indicated that education was provided to all the nurses following the incidents involving resident 4 and resident 5's missing medications, which included the nurses not to take medication cards into resident rooms and to pull medication cards from the medication cart drawer to view all the pills and compare the pill counts to the controlled medication count sheets. Missing medication audits were being conducted, and the results were being reported at QAPI meetings. Resident 4 and resident 5's education documents and audits related to their missing medications were discussed. Administrator A, RN/VPCS X, and RNC M acknowledged that not all nurses received education related to resident 4 and resident 5's missing medication incidents and that audits had not been initiated after resident 4's missing medication was identified. RNC M acknowledged that audits began on 4/10/26 following the missing lorazepam tablet for resident 5, but not all nurses were educated after that incident. Administrator A, RN/VPCS X, and RNC M acknowledged that routine audits to monitor medication passes and controlled medication counts had not been conducted, including verifying that two nurses counted together at every shift change, monitoring the medication count process between nurses, and reviewing the narcotic count sheets for accuracy and nurse signatures. They acknowledged that audits related to missing medications and medication errors had not been tracked and monitored effectively through the facility's QAPI process, and that the QAPI reports provided limited information about the process improvement plan for those identified areas. 21. Review of the provider's revised January 2018 Discrepancies, Loss and/or Diversion Of Medications policy revealed, The DON investigates the discrepancy and researches all the records related to medication administration and the supply of the medication, including medication reconciliation. A thorough search in all drug storage areas, the resident's room, and other locations where medications may have been use/placed during the medication administration are made to locate any missing container or medication supply. Accountability of the medication in question should be checked several times in the following days to assure that accountability is being maintained. The DON investigates the suspected loss and researches all the records related to medication receipt, its use since receipt, all persons involved with medication administration, and the supply of the medication. The dispensing pharmacy should be notified, and the pharmacy should verify that the medication was actually dispensed. If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited. Appropriate agencies, required by state and federal law, will be notified. 22. Review of the provider's revised January 2018 Medication Storage In The Facility policy revealed, At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses and is documented. Any discrepancy in controlled substance counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. If a major discrepancy or a pattern of discrepancies occurs, the director of nursing notifies the administrator and consultant pharmacist immediately. 23. Review of the provider's revised January 2018 Consultant Pharmacist Services Provider Requirements policy revealed, The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. Assists in the identification and evaluation of medication-related issues, including the prevention and reporting of medication errors. Establishes a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and to determine that the drug records are in order and that an account of all controlled medications is maintained and periodically reconciled. Assists in establishing quality assurance and continuous quality improvement activities regarding the medication use process, prescribing, dispensing, storing, administering, and monitoring of medications in the facility. Assists nursing in reviewing medication administration records, treatment administration records, and physician orders quarterly within the QAPI process to ensure proper documentation of medication orders and administration of medications to residents.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure: residents received quality care when one of one certified nursing assistant (CNA) H applied Nair (chemical hair removal cream) cream to one of one sampled resident's (2) anal area and inner buttocks who did not have a physician's order for the use of that cream and subsequently sustained a chemical skin burn; and ensure call lights were answered timely for four of six sampled residents (1, 6, 11, and 13) who reported having to wait a long time for the staff to answer their call lights. Findings include: 1. Review of the provider's 4/24/26 SD DOH FRI revealed that on 4/23/26, CNA H applied Nair cream to resident 2's anal area and inner buttocks when she gave the resident his shower. On 4/22/26, administrator A has told resident 2 that Nair cream was not recommended for use on sensitive skin areas. Administrator A was unaware that resident 2 purchased the Nair Cream online. Despite the education provided, the resident insisted on its use. The provider determined that CNA H applied the Nair cream to resident 2's anal area and inner buttocks outside of her scope of practice and she should have first consulted with a licensed nurse. Resident 2 denied pain or discomfort. Nurse was notified after the shower. A barrier cream containing zinc and dimethicone was initiated to protect the affected skin. A nursing order was entered into the treatment administration record (TAR) on 4/23/26 to apply barrier cream twice daily to resident 2's buttocks. A skin evaluation was completed by licensed practical nurse (LPN) I on 4/29/26. No new skin alterations were noted to the areas. 2. Review of resident 2's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His diagnoses included quadriplegia (a partial or total loss of function in all four limbs and the torso). His 4/19/26 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. He had a 4/23/26 nursing order for Signature Moisture Barrier Cream with Zinc and Dimethicone- apply to rectum and buttocks excoriation (a raw, irritated sore caused by scratching, chemicals, or friction), every check and change every day and night shift for excoriation from hair removal, that was created by director of nursing (DON) B on 4/24/26 and documented as applied twice daily since 4/23/26. A skin alteration evaluation effective 4/23/26 indicated resident 2 had facility-acquired excoriation of the inner buttocks, which was signed by DON B on 4/29/26. A 4/29/26 skin evaluation indicated resident 2 had a pink area around the anus but is not open. Resident 2's physician was notified on 4/24/26 that resident 2 had requested to use the Nair hair remover, that on 4/23/26, resident 2's inner buttocks and anal area were superficially excoriated, and a treatment of Signature Moisture Barrier Cream with Zinc and Dimethicone [was] initiated. Resident 2 denied any discomfort. 3. Interview on 5/6/26 at 9:54 a.m. with resident 2 in his room revealed that he purchased the Nair cream online. He asked LPN I if the Nair cream could be used to remove hair from his inner buttocks to make it easier when the staff assisted him with hygiene after toileting when he had a bowel movement. He stated that LPN I told him she needed to look into it, and she never got back to him, so he assumed it was ok. He then asked CNA H to apply the Nair cream to his inner buttocks before his shower, and she did. CNA H told him that the Nair cream irritated his skin, and another staff member said it looked like a burn, and put another cream on it to protect the skin. He stated he could feel the staff touching him, but did not have pain in that area. He did not know if anyone discussed his request with his physician, but he wished that they would because he would like the hair removed. 4. A request was made to administrator A on 5/6/26 at 10:00 a.m. for an interview with CNA H. CNA H was unavailable throughout the survey. 5. Review of CNA H's written statement revealed that resident 2 asked me to put Nair on his anal area and groin area before [his] shower. I put it on. I asked him if he wanted it wiped off right away, but he told me no, it will come off in the bath. Then [CNA H] transferred [him] to [the] Whirlpool chair and [he] took a bath [for] maybe 20 minutes in the bath. Most [of] it [the Nair cream] came off, but some stayed on, then [the] rest [was] wiped off in the bed after the bath. 6. Observation and interview on 5/6/26 at 1:15 p.m. of registered nurse (RN)/minimum data set (MDS) coordinator J and RN/director of electronic health records (HER)/point click care implementation (PCCI) V changing resident 2's incontinence (involuntary urine or bowel leakage) product revealed he had a light pink area on his right and left buttocks that was intact. RN/MDS coordinator J applied a zinc barrier cream to the pink areas. She stated that was where the excoriation was. 7. Interview on 5/6/26 at 1:34 p.m. with LPN I regarding resident 2's Nair cream revealed that resident 2 asked her about the use of the Nair hair removal creams a couple of days before he used it. She asked DON B and administrator A if resident 2 could use the Nair cream for hair removal around his anus at his request. Administrator A said that she would take care of it, and by the time LPN I returned to work a couple of days later to follow up on resident 2's request, he already had a staff member assist him with using the Nair cream. She completed resident 2's skin assessment a few days after he used the Nair cream and stated the area was pink and excoriated, but there were no open areas. She was unsure if the area was a chemical burn. 8. Interview on 5/7/26 at 2:31 p.m. with DON B revealed she became the DON the day after the incident with resident 2 occurred, on 4/23/24. She was told that resident 2 insisted that the staff members use the Nair cream, and they followed his wishes. She thought that administrator A told resident 2 that he could not use the Nair cream. She was unaware that resident 2 had the Nair cream in his room until after it was used. She confirmed that resident 2 was unable to apply the Nair cream himself due to his quadriplegia and that a staff member assisted him by applying the cream. A request from a resident to use a hygiene product, such as Nair cream, would require a physician's order and that a chemical hygiene product would be required to be applied by a nurse, as that is not part of the delegated tasks and responsibilities of a CNA. Nair was a chemical hair remover intended for use on non-sensitive areas of the body. She stated everyone is different, but agreed that the Nair cream could cause a chemical burn if the directions were not followed and used on a resident's anal area and inner buttocks. 9. Interview on 5/7/26 at 3:44 p.m. with administrator A revealed she became aware that a staff member applied Nair hair removal cream to resident 2's anal area and inner buttocks the day after it happened (4/24/26). She stated that resident 2 asked her if he could use Nair hair removal cream the day before he used it on 4/22/26. She told resident 2 that he could not use it in sensitive areas because it could cause a chemical burn. She was unaware that resident 2 had already ordered the product online and had it in his room. LPN I was told by administrator A that resident 2 was not allowed to use the Nair cream. She expected that CNA H would have asked the licensed nurse before using the Nair cream, and that the nurse would have determined if the resident could use the cream and requested a physician's order. 10. Review of the provider's revised July 2018 Medication Ordering, Receiving, and Storage policy revealed: The Facility shall store all medications and biologicals in a safe, secure and orderly manner. 11. Review of the 12/2/25 SD DOH complaint report revealed that resident 6 indicated that it took the staff an hour at times to answer her call light while she resided at the facility from 7/25/25 through 8/19/25. 12. Review of resident 6's electronic medical record (EMR) revealed her 8/19/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her diagnoses included cellulitis (tissue infection) of the left lower limb, gait (walking) abnormality, weakness, and urge incontinence (involuntary urine or bowel leakage). Her 7/28/25 care plan indicated she had a wound vac (a medical treatment that applies controlled suction to a wound to accelerate healing) on her left foot, she required partial staff assistance with dressing, total staff assistance for moving in bed, and two staff members to assist her with transferring, using the bathroom, and walking. 13. Interview on 5/5/26 at 2:24 p.m. with resident 13 revealed that she had to sometimes wait 30-60 minutes for the staff to answer her call light and had called 911 a few times when the staff took too long to respond. No incidents had occurred when she had to wait for the staff to answer her call light, but it made her upset when she had to wait a long time. She talked to a nurse manager about it and who defended the staff. 14. Review of resident 13's EMR revealed her 5/5/25 BIMS assessment score was 15, which indicated her cognition was intact. Her diagnoses included neuromuscular bladder dysfunction (loss of bladder control caused by nerve damage), epileptic seizures (when brain cells misfire all at once), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), repeated falls, and weakness. Her 4/29/26 care plan indicated that the staff was to notify the nurse as soon as possible if she had a seizure, to educate her to use her call light, and to wait for the staff's assistance instead of calling out or yelling for help. She was at risk for falling, and the staff was to educate her on the importance of using her call light and waiting for help before transferring. She had a urinary catheter (flexible tubing placed in the bladder to drain urine). She required the assistance of two staff members and a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) for transferring, substantial staff assistance for moving in bed, dressing, and using the toilet. 15. Interview on 5/5/26 at 2:35 p.m. with resident 1 revealed he regularly had to wait, 15 minutes or more, for the staff to answer his call light. He reported that the staff sometimes came in and turned his call light off without assisting him, said they would be back, but they did not come back, and he had to turn it back on and wait another 15 minutes for the staff to answer his call light. No incidents occurred when he had to wait for the staff to answer his call light, but it made him mad when he had to wait for a long time. He reported that he talked to administrator A about it, and he felt that nothing was done to correct the issue. 16. Review of resident 1's EMR revealed his 4/6/26 BIMS assessment score was 15, which indicated his cognition was intact. His diagnoses included cerebrovascular disease affecting the left side (weakness or paralysis from a stroke on the left side of the body), anxiety, depression (a feeling of sadness and loss of interest in doing things, which stops you from doing normal activities), and abnormalities of gait and mobility. His 5/4/26 care plan indicated he was independent with transferring, and he needed two staff members to assist him with dressing and using the bathroom. He was at risk for falling, and the staff were to encourage him to use his call light for assistance. 17. Interview on 5/5/26 at 2:52 p.m. with resident 11 revealed she occasionally had to wait longer than 15 minutes for the staff to answer her call light. She stated that she was independent with most things and did not need a lot of help from the staff, but when she did, she expected the staff to help her because I am as important as everyone else. She stated, It ruins my sense of humor when she had to wait a long time for the staff to answer her call light. She stated that no incidents had occurred when she had to wait for the staff to answer her call light. 18. Review of resident 11's EMR revealed her 5/5/26 BIMS assessment score was 9, which indicated her cognition was moderately impaired. Her diagnoses included adjustment disorder (struggling to cope with changes or stress) with mixed anxiety and depression, repeated falls, abnormality of gait and mobility, and weakness. Her care plan indicated she needed partial staff assistance with dressing and personal hygiene. She was at risk for falling and was educated to call for staff assistance because she had a splint (a medical device used to immobilize a body part while it healed) on her left hand. 19. Interview on 5/6/26 at 1:45 p.m. with certified nursing assistant (CNA) FF revealed she was told she needed to answer the call lights as soon as possible. She wore a pager that alerted her when a resident used their call light, and there was a kiosk (a digital terminal placed in a high traffic area to provide information) in the hallway that indicated which resident had their call light on and what time it turned on. 20. Interview on 5/6/26 at 1:50 p.m. with licensed practical nurse (LPN) L revealed that resident call lights were to be answered within ten minutes, but in the mornings, it took a while longer. She would not turn the call light off until the resident was helped because the resident might get forgotten about. LPN L reported that the CNAs carried pagers to alert them of whose call lights were turned on, and some nurses carried them, but she did not think they had to. She monitored the call light kiosk to know which resident needed assistance. Everyone was responsible for answering the residents' call lights, and administrator A monitored the call light time reports. 21. Interview on 5/6/26 at 2:23 p.m. with registered nurse (RN)/minimum data set (MDS) coordinator J revealed that the residents' call lights were expected to be answered within five minutes and that all staff were responsible for answering the call lights. The CNAs wore a pager, and the nurses did not have to wear one. The nurses and the managers carried walkie radios. 22. Review of the call light report for resident 13's room from 4/5/26 through 5/5/26 revealed there were 40 instances where her call light was on for longer than 15 minutes, up to 59 minutes. 23. Review of the call light report for resident 1's room from 4/5/26 through 5/5/26 revealed there were 33 instances where his call light was on for longer than 15 minutes, up to 56 minutes. 24. Review of the call light report for resident 11's room from 4/5/26 through 5/5/26 revealed there were 10 instances where her call light was on for longer than 15 minutes, up to 45 minutes. 25. Resident 6's call light report was not available because she no longer resided in the facility. 26. Interview on 5/7/26 at 2:57 p.m. with administrator A revealed that the residents' call lights were to be answered within ten minutes, and everyone was responsible for answering the call lights. The staff were to leave the residents' call light on until the resident was helped. All staff were to carry the pagers, including CNAs, nurses, and managers. She then stated, I am not wearing mine. She or the manager on duty reviewed call light reports daily to monitor for long call light wait times. If the call light report indicated that a resident had a call light on for over 10 minutes, the manager on duty would talk with the resident. 27. Review of the provider's 11/28/25 Call Lights policy revealed the facility was to ensure that the resident's call for staff assistance was responded to promptly. It indicated that if immediate assistance could not be provided and there was not an emergent need, the call light could be turned off and the resident would be notified that the staff would be back to assist them shortly.

Based on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), record review, interview, observation, and document review, the provider failed to ensure the safety for one of one resident (10) who spilled coffee on his hand and leg that was not at safe temperature, two of seven observed residents (11 and 12) who were drinking hot liquids and did not have identified safety inventions followed, and for one of one sampled resident (8) who fell in the shower when certified nursing assistant (CNA) (AA) did not follow his care plan (personalized plan that addresses a resident's care needs, goals, and interventions). Findings include: 1. Review of the provider's 1/5/26 SD DOH FRI report revealed that on 1/4/26 at 8:26 a.m., registered nurse (RN)/former director of nursing (DON) MM witnessed resident 10 spill his coffee. The video camera footage indicated that resident 10's coffee was served to him at 7:29 a.m. He went to wave at the staff while drinking his coffee and bumped his coffee cup, spilling it on his left hand and pant leg. His initial 1/4/26 skin assessment found that the skin areas where the coffee spilled were pink, and his 1/5/26 and 1/6/26 skin assessments determined that there were no injuries. The coffee's temperature from the kitchen's coffee pot on 1/4/26 at 7:00 a.m. was 170 degrees. The kitchen filled a carafe with coffee for meals. The coffee's temperature was not checked after being placed in the carafe on 1/4/26. Resident 10 had a new hot liquid safety evaluation completed, and his tray card and care plan were updated. 2. Review of resident 10's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His 5/5/26 Brief Interview of Mental Status assessment score was a 15, which indicated his cognition was intact. His 12/20/25 hot liquid safety evaluation indicated he was not at risk, and interventions were to fill the cup/mug half to three-fourths full. His 1/5/26 hot liquid safety evaluation indicated he was not at risk for burning himself, and the interventions in place were to use a lid on the cup/mug. His 3/9/26 hot liquid safety evaluation indicated he was not at risk of burning himself and that he was to drink hot liquids in a sitting position due to his unsteady walk and balance. Resident 10's January 2026 treatment administration record (TAR) indicated his skin was monitored for three days after the incident on 1/4/26. His care plan and dietary card were updated with the intervention to use a lid on his cup/mug on 1/5/26, and were updated after his newest hot liquid safety evaluation on 3/9/26. 3. Interview on 5/7/26 at 10:35 a.m. with resident 10 revealed that he recalled spilling his coffee on his hand and leg in January 2026, and he did not have any injuries. 4. Interview on 5/5/26 at 9:35 a.m. with dietary aide EE revealed that hot water and coffee were available in the dining room for the residents to serve themselves during the day between meals, and the staff served the residents their drinks at meal times. 5. Observation on 5/5/26 from 11:18 a.m. through 11:32 a.m. in the dining room revealed that residents 11 and 12 were drinking coffee from a coffee cup without a lid. 6. Interview on 5/6/26 at 1:45 p.m. with CNA FF revealed she thought that if a resident had interventions related to drinking hot liquids safely, they would be on the resident's care plan or kardex (a report of the resident's care needs and interventions). 7. Review of resident 11's 2/26/26 hot liquid evaluation score was 4, which indicated she was at risk of burning herself and that she was to use a lid on her cup/mug. Her care plan did not include her hot liquid safety interventions. 8. Review of resident 12's 2/21/26 hot liquid evaluation indicated he was not at risk for burning himself, but he was to use a lid on his cup/mug. His care plan did not include his hot liquid safety interventions. 9. Interview and review of the January 2026 through May 2026 coffee temperature monitoring logs on 5/6/26 at 8:40 a.m. with dietary manager (DM) Y revealed that the coffee temperature documented on 1/4/26 was 170 degrees Fahrenheit (F), and it was to be at 155 degrees F before serving to the residents. All other temperatures after 1/4/26 were documented before meals and were at acceptable serving temperatures. There were three residents who were required to use coffee cups with a lid. Those three residents were written on the whiteboard in the kitchen and did not include residents 11 and 12. She stated that whoever completed their hot liquid safety evaluation was to let her know if they were at risk of burning themselves and if they required safety interventions. She would then update the whiteboard in the kitchen and the resident's diet card. The dietary aide served the drinks to the residents. 10. Interview on 5/6/26 at 3:08 p.m. with registered nurse (RN)/minimum data set (MDS) coordinator J revealed that hot liquid safety interventions should be on the residents' care plans. Director of nursing (DON) B and regional nurse consultant (RNC) M completed the residents' care plans. DM Y was notified of changes to residents' hot liquid evaluations during the daily interdisciplinary team (IDT) meeting, and she was to update her dietary staff. 11. Interview on 5/7/26 at 2:57 p.m. with administrator A revealed she expected the dietary staff to follow their policy regarding temping and serving the coffee to residents. She expected residents 11 and 12 to use cups/mugs with lids as indicated on their hot liquid safety evaluation, and for that information to be updated on the white board in the kitchen, on their diet cards, and in their care plans. The IDT was to discuss resident hot safety evaluation interventions in the daily morning meeting. Administrator A acknowledged that not following residents' 11 and 12 hot liquid safety interventions put them at risk for burning themselves. 12. Interview on 5/7/26 at 3:43 p.m. with DON B revealed she expected the hot liquid safety evaluation interventions to be on the residents' care plan and that they were to be updated by the DM or the nurse who completed the hot liquid safety evaluation. The evaluations were completed by the scheduled nurse or the MDS coordinator. 13. Review of the provider's 11/18/25 Hot Liquids Safety Evaluation policy revealed that the temperatures that hot beverages should be served at are governed by the palatability and by the risk for a burn. The Hot Liquid Safety Evaluation will be completed on all residents. Follow these safety precautions for hot liquid safety: Serve the hot beverages between 140 and 155 degrees. Hot liquid temperatures should be taken and recorded at every meal and/or when prepared to ensure the temperature is within the above parameters before being served. Hot beverage dispensers should be removed from the dining rooms or other areas where residents have accessibility without supervision. It indicated that if the resident scored 3 or greater, then they were to implement interventions for safe handling of hot liquids and add them to the resident's care plan. 14. Review of the provider's 9/9/25 SD DOH FRI report revealed that on 9/8/25, resident 8 was left in the shower unsupervised by CNA AA, and he fell on his knees, which bruised. His care plan indicated he required supervision/touching assistance in the shower. All staff were educated to follow resident care plans. 15. Review of resident 8's EMR revealed he was admitted to the facility on [DATE] and discharged on 11/20/25. His diagnoses included hepatic failure (when the liver shuts down), cirrhosis of the liver (severe, permanent scarring of the liver caused by long-term damage or disease), kidney failure (when the kidneys shut down), hypotension (low blood pressure), hepatic encephalopathy (a decline in brain function caused by severe liver disease), and hemiplegia (a form of paralysis that causes weakness or the complete inability to move just one side of the body) affecting the left side. Resident 8 had an 8/21/25 physician's order for midodrine (a medication to raise the blood pressure) and furosemide (a diuretic [medication to flush extra fluid from the body]). He had an 8/23/25 physician's orders for occupational therapy (OT), and physical therapy (PT). His 8/21/25 fall risk evaluation indicated he was at high risk for falling due to diagnoses of hypotension-currently being treated for with medication, cognitive impairment, [and] left sided hemiparesis. His 8/29/25 care plan indicated he was at risk for falling related to diuretic use, cirrhosis of the liver, renal failure, hemiparesis to his left side. He was to use assistive devices during ambulation to prevent falling, and the staff were to assist him with showering or bathing, by providing supervision/touching assistance with bathing, and to be present when he showered. Resident 8 had a 9/8/25 progress note that indicated he was found on the floor in the shower room lying on his stomach. The CNA was in the room when the nurse arrived, but the resident was in the shower by himself when he fell. He had bruising to his knees and required two staff members to help him off the floor. 16. Interview on 5/7/26 at 11:50 a.m. with administrator A revealed that she expected CNA AA to follow resident 8's care plan and stay with him in the shower. She acknowledged that not all staff were educated to follow the residents' care plans following the incident on 9/8/25as indicated in the SD DOH FRI report. 17. Review of the provider's 5/14/25 Falls Management policy revealed it is the policy of the facility to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. 18. Review of the provider's 5/14/25 Care Plans policy revealed it is the responsibility of direct care members to familiarize themselves with the care plans and review them routinely for changes.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRIs), personnel files, record review, observation, interview, and policy review, the facility failed to ensure safe and secure storage of controlled medications (medications with risk for abuse and addiction) for one of one sampled resident (4) with 13 missing Hydrocodone /APAP (acetaminophen) (a medication to treat moderate to severe pain) 5-325 milligram (mg) tablets and one of one sampled resident (5) missing one lorazepam (a medication to treat anxiety) 0.5 mg tablet.Findings include: 1. Review of the provider's 1/20/26 SD DOH FRI revealed that at approximately 8:30 a.m. on 1/20/26, contracted travel registered nurse (RN) N entered resident 4's room with his medication card, which contained his PRN (as needed) Hydrocodone/APAP 5-325 mg tablets, and the rest of his morning medications for administration to the resident. Approximately two hours later, RN N discovered she had misplaced the medication card of 13 tablets of Hydrocodone/APAP and reported that the medication card was missing to former director of nursing (DON) E between 12:45 p.m. and 1:00 p.m., and an investigation was started. Camera footage revealed that throughout the morning and early afternoon on 1/20/26, numerous staff members and resident 1 entered resident 4's room. Certified nursing assistant (CNA) P entered resident 4's room with his breakfast tray shortly after 8:30 a.m. and immediately exited the room. At 9:02 a.m., housekeeper K entered his room and exited at 9:08 a.m. Contracted travel CNA O entered his room at 9:09 a.m. to assist resident 4 in getting up and ready for the day, and she exited the room at 9:20 a.m. At 11:18 a.m., CNA Q entered resident 4's room and took him to lunch. At 12:03 p.m., resident 4 and resident 1 entered resident 4's room together. At 12:12 p.m., contracted travel RN N entered resident 4's room and then exited, and at 12:18 p.m., resident 1 exited. At 12:23 p.m., resident 4 left his room and attended therapy. The final report noted that contracted travel RN N stated she had taken the medication card containing 13 tablets of resident 4's Hydrocodone/APAP to his room that morning to save time, as she was in a hurry and the resident often requested a tablet of that medication in the mornings. A count of all the residents' controlled medications was completed by regional nurse consultant (RNC) M and contracted travel RN N, and all counts were accurate except for resident 4's known missing Hydrocodone/APAP. The medication card containing resident 4's Hydrocodone/APAP 5-325 mg tablets was never located after thorough searches of the facility during the investigation. Review of the personnel files for contracted travel RN N and contracted travel CNA O revealed that both had completed orientation training and education through their employing agency and received additional training and education through the facility. There were no prior disciplinary actions in their files. Their education included topics such as misappropriation of resident property and drug diversion (illegal transfer or use of prescription drugs). Contracted travel RN N's last working shift at the facility was on 1/20/26, when she was suspended from working at the facility pending the investigation, and her work contract with the facility was terminated on 1/21/26. Contracted travel CNA O remained on the facility's schedule and was allowed to work. Her last shift at the facility was on 3/31/26. 2. Review of resident 4's electronic medical record (EMR) revealed that he had a seizure and fell in his home on [DATE], which resulted in compression fractures (bones in the mid-back have collapsed or become crushed, causing back pain) of his T4, T5, and T6 vertebrae (the 4th, 5th, and 6th bones) and his admission to the hospital. He admitted to the facility on [DATE] and received therapy services. His diagnoses included seizure disorder (a condition with recurring, unpredictable seizures), cardiac arrest (the heart suddenly stops beating, cutting off blood flow to the brain and other vital organs), and lower extremity weakness. His 3/24/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. 3. Interview on 5/6/26 at 4:50 p.m. with resident 4 in his room revealed that he recalled the incident that involved his missing Hydrocodone/APAP medication card in January 2026. Resident 4 said he gave staff permission to search his room for the missing medication card, and he was questioned by the police. Resident 4 denied keeping the card and taking the medication himself, stating that he never saw a medication card left in his room and was unsure whether the nurse had even brought the Hydrocodone/APAP medication card into his room that day. Resident 4 stated that he had been taking that medication to help control his pain from the compression fractures in his back. He remembered eating breakfast in his room that morning, and that a CNA brought him his meal tray and another CNA later assisted him to get ready for the day, but he could not recall their names. Resident 4 said the nurse brought him his medications, but he could not recall her name. He did not see the nurse or CNA with a medication card when either left his room. Resident 4 was not sure what had happened to the missing medication card, but the pharmacy replaced the medication for him. Resident 4 said he requested one of his PRN Hydrocodone/APAP medication tablets for his pain that morning and that it was administered to him by contracted travel RN N. He stated that his missing Hydrocodone/APAP tablets were never found. 4. Interview on 5/7/26 at 11:15 a.m. with housekeeper K regarding the missing medication card of Hydrocodone/APAP revealed that she recalled the incident involving resident 4's missing medication card of Hydrocodone/APAP. She cleaned resident 4's room the morning that the medication card went missing and thought she entered his room between 9:00 a.m. and 9:30 a.m. Housekeeper K did not see a medication card in his room or in the trash. She indicated that checking resident trash was a daily task on their list to complete, to look for residents' personal items that may have been thrown away unintentionally, such as glasses, hearing aids, and dentures. 5. On 5/7/26 at 12:08 p.m., a call was placed to CNA P, which was unanswered. A voicemail message was left requesting a return call. No return call was received during the survey. 6. Interview on 5/7/26 at 12:23 p.m. with CNA Q revealed that she remembered contracted travel RN N looking for a missing medication card for resident 4 during a morning shift she worked. On the day that the resident's medication went missing, she entered resident 4's room just before lunch and assisted him to the dining room. She heard from other staff members that a medication card for resident 4 was left in his room by contracted travel RN N and was not found after the room was searched. Contracted travel RN N told CNA Q that she was asked to leave her shift and would be leaving the facility between 3:00 p.m. and 4:00 p.m. CNA Q was unsure whether resident 4's missing medication card was found. 7. A review of the educational material provided to the nursing staff regarding the 1/20/26 incident of resident 4's 13 missing Hydrocodone/APAP tablets revealed that the information was typed and titled Education. No date was typed or written on the 1-page document. The education document provided to the nursing staff stated, Do not take medication cards into resident rooms. Do not leave meds at bedside. If you notice any medications left in the room, notify the charge nurse or nursing administration immediately for removal. Sign below: 14 nurses signed that education document, but education was not provided to all nurses regarding the 1/20/26 incident of resident 4's missing medication card. 8. Review of the provider's 4/8/26 SD DOH FRI revealed that at approximately 6:00 a.m., during the shift change, licensed practical nurse (LPN) L and contracted travel LPN T were completing the routine change of shift controlled medication count of the controlled medications in one of the two facility's medication carts. During that count, it was discovered that one 0.5 mg lorazepam tablet was missing from resident 5's lorazepam morning dose medication card. The packaging on the back of that lorazepam medication card had a small hole, and no tablet was in it. On 4/8/26, the medication cart and surrounding areas were searched, but the missing 0.5 mg lorazepam tablet was not found. Director of nursing (DON) B checked all other controlled medications and found no other discrepancies. It was discovered that the nurses were not fully removing the controlled medication cards from the narcotic (controlled pain medications) locked drawer to obtain a clear view of all the pills, and were not comparing the actual number of pills in each medication card with the controlled drug record forms to verify that those counts matched. The nursing staff was unsure how long resident 5's lorazepam tablet had been missing. The investigation concluded that resident 5's missing lorazepam 0.5 mg tablet was accidentally ejected from the medication card at some point, unnoticed, and potentially swept up by housekeeping staff. 9. Review of resident 5's EMR revealed that she admitted to the facility on [DATE]. Her diagnoses included weakness, repeated falls, abnormal gait (any waling pattern that deviates from the usual walk), delusional disorder (false beliefs and distorted views of reality), bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and dementia ( a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbance. Her 4/4/26 BIMS assessment score was 07, which indicated her cognition was severely impaired. 10. Interview on 5/5/26 at 10:47 a.m. with resident 5 revealed that she did not recall that one 0.5 mg lorazepam tablet was missing on 4/8/26 or if the nursing staff reported it to her. 11. Phone interview on 5/5/26 at 11:50 a.m. with resident 5's representative revealed that the facility contacted her and discussed any changes in resident 5's care. The staff would contact her by phone and let her know if any new medications were ordered or if medications were changed. She stated, I talk to them all the time, and they are on top of it. She stated that she was probably notified of the missing 0.5 mg lorazepam tablet and had no concerns regarding that incident. 12. Interview on 5/6/26 at 4:35 p.m. with LPN L related to resident 5's missing 0.5 mg Lorazepam tablet revealed she could not recall that resident 5 was missing a 0.5 mg lorazepam tablet during the controlled medication count at shift change the morning of 4/8/26. She did not recall if she had completed a thorough search of the medication cart and the surrounding area to locate the missing medication, or if contracted travel LPN T had. She was not sure who had notified the nurse supervisor or the DON or whether the missing lorazepam tablet was found. 13. Interview on 5/7/26 at 11:50 a.m. with contracted travel LPN T revealed that she was the nurse going off duty the morning of 4/8/26. When she was completing the controlled medication count with LPN L, it was discovered that resident 5 was missing one 0.5 mg lorazepam tablet from her morning lorazepam dose medication card. She and LPN L searched the medication cart and the surrounding area but did not find the missing tablet. She stated, I am not sure how long it was missing. She said she did not report the missing medication to the nursing supervisor or the DON, but LPN L reported it to the unit manager, LPN I. She acknowledged that she received education to check both the controlled medication log and the medication card during the count to verify the accuracy of residents' controlled medications. 14. Review of the educational material provided to the nursing staff regarding resident 5's missing lorazepam tablet on 4/8/26 revealed that the information was typed and titled Attention Nurses:. No date was typed or written on the 1-page document. The education document stated, When counting narcotics during shift change, please be sure to pull the card all the way out, count the pills, and check the back of the card to ensure there are no tears or openings. It is also suggested that you look at the book and verify that the number that's being read to you is correct. If the count is off/wrong, DO NOT LEAVE THE BUILDING. Contact former DON NN, administrator A, AND DON B. If for any reason you cannot get in touch with one of them, call LPN I, whose number is listed in the numbers binder at the nurse's station. Narcotic audits will also be performed regularly moving forward. An in-service sign-in sheet indicated that RN R, LPN I, and LPN L received that education on 4/17/26 after it was identified that resident 5's lorazepam tablet was missing on 4/8/26. No other nurses at the facility received education. Weekly audits regarding accurate narcotic counts began on 4/10/26 following resident 5's missing lorazepam tablet. 15. Observation and interview on 5/5/26 at 1:30 p.m. with LPN I in the 200 hallway, of the controlled medications and the count sheets in cart one revealed that the medication cart contained controlled medication cards that were stored in a locked box in a locked drawer. Controlled medications were stored that way in all the facility's medication carts. LPN I stated that two nurses were to count the controlled medications at each shift change, which occurred twice daily or as needed based on staff schedules. She said that whenever possession of the keys changed, a count was completed. A controlled medication count for cart one was completed with LPN I and revealed that residents' controlled medication cards were stored in the locked narcotic box, and there were no medication count discrepancies. LPN I did not think that education was provided after resident 4's medication card of 13 tablets of Hydrocodone/APAP, was reported missing. 16. Interview on 5/5/26 at 2:06 p.m. and again at 3:30 p.m. with consultant pharmacist (CP) W revealed that pharmacy reviews were completed monthly for all residents. Resident medications and physician orders were reviewed, and gradual dose reduction (GDR) recommendations were provided to residents prescribed psychotropic medications (drugs that affect brain activities associated with mental processes and behavior). She would review progress notes, care plans, Minimum Data Set (MDS) assessments, and laboratory reports for changes to determine whether medications were contributing factors to residents' changes in condition. She completed a comprehensive review of resident charts every month, and for any new resident admitted to the facility. She stated that the pharmacy strongly encouraged facilities to report any missing medication to the pharmacy staff. 17. Observation and interview on 5/6/26 at 12:00 p.m. with contracted travel LPN S in the hall next to the nurse's station revealed that she had received education to check both the controlled medication log and the medication card during the count to verify the accuracy of residents' controlled medications. A controlled medication count for cart two was completed with contracted travel LPN S, and all controlled medications were securely stored in the locked box inside the locked cart with no medication count discrepancies. 18. Interview on 5/7/26 at 3:10 p.m. with DON B revealed that she expected nursing staff to be at their medication carts when punching medications out from the medication cards when preparing medications to administer to residents. Nurses were not to take medication cards into resident rooms. If a medication was missing, DON B expected nurses to search for it by checking cards stored around the missing medication to determine whether it was removed from the wrong medication card, checking whether it was signed out on the wrong narcotic drug sheet, checking the back of the medication card to see if it was stuck in the packaging, looking in the bottom of the medication cart drawer for it, and reviewing all narcotic drugsheets and medication administration records (MARs) for every entry. After the search, if the medication was not found, the nurses were to contact her as quickly as possible, and she would start an investigation. DON B stated that the physician and family were to be notified of missing medications, and residents were to be notified if they were responsible for themselves. She expected the information to be documented in a progress note. DON B stated that if medications were missing, the pharmacy needed to be notified so they could be replaced. DON B stated that she did not know what had happened to resident 4's Hydrocodone/APAP tablets and that contracted travel RN N, taking his medication card down to his room to administer it, was suspicious of drug diversion, as the 13 Hydrocodone/APAP tablets were never found. She said that the facility's camera footage was reviewed on 1/20/26 and confirmed that contracted travel RN N entered resident 4's room that morning with his Hydrocodone/APAP medication card in hand, but exited without it. Law enforcement was notified on 1/20/26 regarding the missing Hydrocodone/APAP tablets belonging to resident 4, and an officer came to the facility and interviewed him. Resident 4 refused to allow the facility nurse, whose name DON B could not recall, to search him for the missing medication card. DON B stated that she did not know what had happened to resident 5's lorazepam tablet on 4/8/26 and that she had checked all other controlled medications that morning and found no other discrepancies. DON B said that the nurses were not removing the controlled medication cards from the narcotic drawer to obtain a clear view of all the pills, and were not comparing the actual number of pills in each medication card with the controlled drug record forms to verify that those counts matched. She thought that resident 5's missing lorazepam tablet was accidentally ejected from the medication card, unnoticed, and swept up by the housekeeping staff. DON B said that all nursing staff were trained to remove the controlled medication cards from the medication carts, and both nurses were to verify that the medication card counts matched the counts on the controlled medication count sheets. She was not sure whether audits had been completed for the missing medications for residents 4 and 5, or whether incidents involving missing medications had been reported to the monthly QAPI meetings for tracking, recommendations, and process improvement plans. 19. Review of the provider's Quality Assurance and Process Improvement (QAPI) reports for 1/28/26, 3/25/26, and 4/21/26 revealed that medication variance reports were included as a section of the facility's QAPI document for review during the facility's monthly meetings.The incident investigation sections of the QAPI reports included one medication variance in the 1/28/26 report that occurred in December 2025. The 3/25/26 report had no medication variances from February 2026. The 4/21/26 report had one medication variance that occurred in March 2026. The Corrections Section for 1/28/26 and 3/25/26 indicated that staff education was provided and that the facility transitioned to a facility-initiated ordering system, which allowed the facility to enter physician orders, as planned after the order-entry error occurred with resident 3. No February 2026 QAPI report was provided during the survey for review to verify that resident 4's January 2026 medication variance was documented or to determine whether processes were in place to address his missing medication for tracking and trending, recommendations, and discussion. The medication errors section of the QAPI reports included one medication error in the 1/28/26 and 3/25/26 reports. No information was provided about the medication error in the 1/28/26 report. The 4/21/26 report indicated that Missing Norco (a brand name for Hydrocodone/APAP) was noted and that nursing education and audits were being completed two times weekly to ensure the accuracy of controlled medication counts. 20. Interview and record review on 5/7/26 at 5:43 p.m. with administrator A, regional nurse consultant (RNC) M (via phone), and RN/vice president of clinical services (VPCS) X revealed that DON B reported missing medication incidents to administrator A and, if determined to be reportable, administrator A completed a report to the SD DOH. Administrator A acknowledged that she reported the missing medications for residents 4 and 5 to the SD DOH. Administrator A stated that medication variances were reported at the monthly QAPI meetings. Administrator A expected that controlled medications be counted by the incoming and outgoing nurses at every shift change. After the controlled medications were counted, she expected both nurses to sign the narcotic drug sheet, which indicated that the controlled medication count was complete and accurate. If the count was inaccurate, a search for the medication was to be conducted, and DON B was to be notified immediately. *She acknowledged that staff not counting the controlled medications at every change of shift by the incoming and outgoing nurses could increase the risk of drug diversion and would make it difficult to determine when the controlled medication went missing. Administrator A, RN/VPCS X, and RNC M indicated that education was provided to all the nurses following the incidents involving resident 4 and resident 5's missing medications, which included the nurses not to take medication cards into resident rooms and to pull medication cards from the medication cart drawer to view all the pills and compare the pill counts to the controlled medication count sheets. Missing medication audits were being conducted, and the results were being reported at QAPI meetings. Resident 4 and resident 5's education documents and audits related to their missing medications were discussed. Administrator A, RN/VPCS X, and RNC M acknowledged that not all nurses received education related to resident 4 and resident 5's missing medication incidents and that audits had not been initiated after resident 4's missing medication was identified. RNC M acknowledged that audits began on 4/10/26 following the missing lorazepam tablet for resident 5, but not all nurses were educated after that incident. Administrator A, RN/VPCS X, and RNC M acknowledged that routine audits to monitor medication passes and controlled medication counts had not been conducted, including verifying that two nurses counted together at every shift change, monitoring the medication count process between nurses, and reviewing the narcotic count sheets for accuracy and nurse signatures. They acknowledged that audits related to missing medications and medication errors had not been tracked and monitored effectively through the facility's QAPI process, and that the QAPI reports provided limited information about the process improvement plan for those identified areas. 21. Review of the provider's revised January 2018 Discrepancies, Loss and/or Diversion Of Medications policy revealed, The DON investigates the discrepancy and researches all the records related to medication administration and the supply of the medication, including medication reconciliation. A thorough search in all drug storage areas, the resident's room, and other locations where medications may have been use/placed during the medication administration are made to locate any missing container or medication supply. Accountability of the medication in question should be checked several times in the following days to assure that accountability is being maintained. The DON investigates the suspected loss and researches all the records related to medication receipt, its use since receipt, all persons involved with medication administration, and the supply of the medication. The dispensing pharmacy should be notified, and the pharmacy should verify that the medication was actually dispensed. If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited. Appropriate agencies, required by state and federal law, will be notified. 22. Review of the provider's revised January 2018 Medication Storage In The Facility policy revealed, At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses and is documented. Any discrepancy in controlled substance counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. If a major discrepancy or a pattern of discrepancies occurs, the director of nursing notifies the administrator and consultant pharmacist immediately. 23. Review of the provider's revised January 2018 Consultant Pharmacist Services Provider Requirements policy revealed, The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. Assists in the identification and evaluation of medication-related issues, including the prevention and reporting of medication errors. Establishes a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and to determine that the drug records are in order and that an account of all controlled medications is maintained and periodically reconciled. Assists in establishing quality assurance and continuous quality improvement activities regarding the medication use process, prescribing, dispensing, storing, administering, and monitoring of medications in the facility. Assists nursing in reviewing medication administration records, treatment administration records, and physician orders quarterly within the QAPI process to ensure proper documentation of medication orders and administration of medications to residents.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, document review, record review, and policy review, the provider failed to report within the required time frame for one of one sampled resident (1) who eloped (left the facility without staff knowledge) from the facility's front door.Findings include: 1. Review of the provider's 11/3/25 SD DOH FRI revealed that on 10/30/25 at 5:40 p.m., certified nursing assistant (CNA) F observed that resident 1 was outside. He had eloped from the facility's front door and indicated he was going to a wake (visitation before a funeral) for a friend who had passed away. He was easily redirected back into the facility by the staff. Previous administrator C was notified of resident 1's elopement immediately following the incident on 10/30/25 by registered nurse (RN) G. On 11/3/25, administrator A, who was in training at the time, filed an initial report regarding resident 1's elopement to the SD DOH. 2. Previous administrator C was no longer at the facility and was not available for an interview during the survey. 3. Interview on 5/7/26 at 9:16 a.m. with administrator A regarding the provider's 11/3/25 SD FRI of resident 1's elopement revealed she was aware of the elopement. It was reported to her on 10/30/25 that he went out the lobby door and not the following front door, which would have been the exit door of the facility. On 11/3/25, after she read the notes and watched the video of resident 1's, she realized it was an elopement. She was aware of the required reporting time of 2 hours for incidents involving serious harm and 24-hour reporting for all other incidents to the SD DOH. Administrator A indicated she had reported the incident within 24 hours, after she determined it was an elopement. Administrator A was the only staff member who had electronic access to report incidents to the SD DOH. She confirmed that the reporting of resident 1's 10/30/25 incident was not reported to SD DOH within the required time frame. 4. Review of the provider's 5/14/25 Abuse and Neglect policy revealed: All allegations and/or suspicions of abuse must be reported to the Administrator immediately .All allegations of abuse will be reported to your state agency immediately (within 2 hours) after the initial allegation is received.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the staff followed the resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) for:*One of one sampled resident (14) who was transferred from his wheelchair to the commode (portable toilet) by one of one certified nursing assistant (CNA) GG when he required the assistance of two staff members.*One of one sampled resident (2) who required two staff members present during all of his cares and was assisted by one of one CNA (P), and an accusation of resident abuse was made. Findings include:1. Review of the provider's 10/14/25 SD DOH FRI revealed that on 10/14/25, resident 14's family member reported to the assistant director of nursing that CNA GG was using inappropriate words in front of the family and resident 14 and stood the resident up from his wheelchair without assistance from another staff member at the counter in his room. He was to be assisted by two staff members during transfers with a slide board (a smooth, rigid board, usually made of plastic or wood, used to move a person between two seated surfaces) or a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position). The facility's investigation found that CNA GG transferred [resident 14] alone with one person at the sink. CNA GG confirmed that this was true. 2. Review of resident 14's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His diagnoses included hemiparesis (paralysis of one side of the body) following cerebral infarction (stroke) affecting his left side and weakness. His 9/24/25 care plan interventions indicated that therapy was working with resident 14 on transfers to the commode. His 10/1/25 revised care plan indicated [One] 1 person slide board transfer from recliner/wheelchair/bed. If toileting 1 [one] person and [an] additional person [to] remove [the] wheelchair and place [the] commode. May use Hoyer [a mechanical lift and sling used to lift a person's full body] as needed for transfers. 3. Interview on 5/6/26 at 9:28 a.m. with resident 14's power of attorney (POA) (someone designated on a legal document to act on behalf of a resident), who participated by phone, revealed that this incident had occurred a long time ago, and that resident 14 no longer lived at the nursing home. He knew that resident 14's family member was pretty upset about this incident. Resident 14 did not fall that day but stated, he could have. He stated he would ask resident 14 and his family member if they had additional information they wanted to provide related to this situation, and call back if he had any additional information to share. No return call was made. 4. Interview on 5/6/26 at 2:00 p.m. with CNA GG revealed that resident 14 had muscle weakness on one side of his body from a stroke. She felt that resident 14's transfer status had changed several times and that there was a lack of communication on how she was expected to transfer resident 14 that day. She stated that she would review the resident's care plan to determine how to transfer the resident, but she was unsure where the resident's care plan was located. There was a whiteboard in the staff break room that contained resident transfer status, and there was an assignment worksheet that CNAs used that contained a resident transfer status. She stated that they all said something different. She thought resident 14 could stand at the sink while she moved his wheelchair and placed a commode behind him. 5. Interview on 5/7/26 at 9:55 a.m. at the nurses' station with contract travel CNA JJ and CNA FF revealed they both started working at the facility about four days ago. Contract travel CNA JJ stated that the information on how to transfer residents was located in the residents' care plan, but he relied on other staff members to tell him how a resident would transfer. He would ask the nurse or another CNA if he was unsure. He was unaware whether there was a whiteboard in the staff breakroom with resident transfer statuses on it.The assignment worksheet he was provided did not have the resident transfer statuses on it. CNA FF stated she used the Kardex (an abbreviated version of the care plan) located in the resident's EMR. She was shown a paper worksheet on 5/6/26 that had resident transfer information on it. It was located in the nurses' report room. She was unsure if she was to use that sheet or if it was something they were still working on. 6. Interview and review of the paper worksheets on 5/7/26 at 10:06 a.m. with director of nursing (DON) B revealed that the paper worksheets located in the nurses' report room were implemented during the week of 5/1/26. In October 2025, they had a similar worksheet that contained a resident's transfer status, but the previous version did not have as much information on it. The worksheets from 10/14/25 were no longer available to review. She was not the DON in October 2025, but she expected the CNAs to use the paper worksheets or the resident's care plan in the EMR to know the correct way to transfer a resident. Registered nurse (RN)/ minimum data set (MDS) coordinator J updated those worksheets every time there was a change in the residents' care plan or weekly at the leadership meeting. 7. Interview and review of physical therapy documentation on 5/7/26 at 10:44 a.m. with physical therapist assistant/ therapy coordinator (PTA/TC) U revealed she communicated resident 14's transfer status changes to the nursing staff through an email and documented it in a binder in the report room each time there was a change in a resident's transfer status. The nursing staff updated the resident's care plan in the EMR, the whiteboard, and the CNA worksheets.On 10/14/25, resident 14 required the use of a slide board and one staff member to transfer between his bed and chair. He required two staff members if he needed to stand to use the commode. She expected that one staff member would have stood with resident 14 and another staff member would have moved the wheelchair and placed a commode behind him. She stated it would have been unsafe for one staff member to have done that alone because resident 14 had a one-sided weakness and was at risk of falling.She had spoken with CNA GG on 9/30/25 about not following resident 14's care plan for transfers and provided education on the level of assistance and the devices needed to assist him when transferring. She expected the CNAs to transfer resident 14 according to his care plan. She felt that the information provided to the CNAs may not have been updated on a regular basis, depending on where they looked for that information. 8. Interview on 5/7/26 at 11:36 a.m. with administrator A revealed resident 14's family member had filed a complaint on 10/14/25 about CNA GG and how she had transferred resident 14 that day. Administrator A conducted an investigation and determined that CNA GG did not follow resident 14's care plan when she transferred him alone on 10/14/25. She expected that CNA GG would have had a second person assisting with his transfer for his safety and to reduce the risk that he would fall. 9. Review of the provider's 2/9/26 SD DOH FRI revealed that on 2/9/25, resident 2 posted a video on Facebook that certified nursing assistant (CNA) P told him that if he called her a [curse word] again, that she was going to pull his hair and punch him in the face. In the video, resident 2 stated that he feels it's his First Amendment right to speak to staff disrespectfully and call them a [curse word] if he wants to.The facility's investigation could not determine if CNA P stated that she was going to pull his hair or punch him in the face. Resident 2 should have had two staff members present when care was provided at all times. It was determined that CNA P had not been following resident 2's care plan, and the staff member had been joking around with resident [2] during a conversation. [Resident 2] feels safe. 10. Review of resident 2's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His diagnoses included quadriplegia (a partial or total loss of function in all four limbs and the torso), anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and depression. His 4/19/26 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated his cognition was intact. His care plan indicated he would refuse to talk to the staff or ignore the staff if he got mad. His 10/28/25 intervention indicated staff will allow [resident 2] time and reapproach at another time. A 1/19/26 intervention indicated that resident 2 was to receive Cares in pairs [two staff members]. 11. Interview on 5/6/26 at 9:54 a.m. with resident 2 in his room revealed that he recalled the day, a couple of months ago, when he made a Facebook post about a staff member. That staff member was in his room without another staff member present, and he stated that they were talking and he asked her what she would do if he called her a (swear word) and she said she would punch him and pull his hair. He was unsure if she was joking, and he did not know what happened to her, but he never saw her again. He was upset becauseafter that, DON B and CNA F came to his room to talk to him. He did not want to listen to them and told them to get the [curse word] out of his room, but they would not leave. He stated that DON B told him that he was not allowed to post about staff members on Facebook, but that he did not want to listen to her, had asked her to leave several times, and she would not leave his room. 12. A request was made to administrator A on 5/6/26 at 10:00 a.m. for an interview with CNA P. CNA P was unavailable throughout the survey. 13. Review of CNA P's 2/10/26 written statement revealed, I never said that I would pull his hair and punch him. I was in [the] room by myself, and I know he is cares in pairs. I know I didn't follow the care plan. 14. Interview on 5/6/26 at 11:19 a.m. with CNA F revealed that resident 2 was very demanding with the staff, frequently swore, and she always had another staff person with her when she provided his care. When resident 2 requested the staff to leave his room, especially if he was upset, she was told to make sure he was safe and had his call light and then to leave his room. 15. Interview on 5/7/26 at 2:45 p.m. with DON B revealed she became the DON in April 2026. After resident 2 posted on Facebook about a staff member, administrator A told DON B and CNA F to inform resident 2 that he was not allowed to videotape the staff or the residents. She went into resident 2's room that day. He was in bed, and his computer was on his bedside table in front of him. She closed his computer and moved it away from him. Resident 2 was upset and did not want to listen, but she told him that he needed to listen and that administrator A told her that she needed to have that conversation with him. She stated that he swore at her several times, and then he closed his eyes. Resident 2 asked DON B to leave his room, and she did not. She stated she left his room when she had finished talking to him. She confirmed that his care plan stated that the staff was to leave his room and reapproach him regarding his behaviors. Staff members were to have two people in the room when they provided care to resident 2. She was not the DON when the incident with CNA P occurred, but she expected that all staff would follow the resident's care plan, and resident 2 was to have two staff members present for their safety and his. 16. Interview on 5/7/26 at 3:44 p.m. with administrator A revealed that after resident 2 posted on Facebook about a staff member, administrator A told DON B to inform resident 2 that he was not allowed to videotape the staff or the residents. She was not aware that resident 2's computer was closed and moved out of his reach or that he became upset and requested that DON B leave his room. She expected all staff members to respect resident 2's wishes and leave his room when asked and reapproach him later, especially if he was upset. CNA H did not follow resident 2's care plan when she was in his room alone when the accusations were made. CNA P denied making the comments, and resident 2 was unwilling to talk to administrator A or the police at the time. 17. Review of the provider's revised 5/14/25 Care Plans policy revealed Care plans are accessible to all direct-care staff, including the resident's physician/provider. It is the responsibility of all direct care members to familiarize themselves with the care plans and review them routinely for changes.

Based on observation, interview, record review, and policy review, the provider failed to provide wound care as ordered by the physician for one of one sampled resident (9) who had a wound vac (a device that uses negative pressure to remove excess fluid and debris from a wound to promote wound healing) dressing that was not changed as prescribed by the physician by one of one registered nurse (RN) (R) and needed emergent medical attention. Findings include:1. Observation on 5/5/26 at 9:50 a.m. and at 10:57 a.m. of resident 9 in her room revealed she was sleeping and positioned on her left side. There was a wound vac tube under her blanket that connected to the wound vac device on her nightstand. She had intravenous (IV) (used to deliver medication to a person's bloodstream through a needle or tube (catheter) inserted into a vein), and she declined an interview. 2. Interview on 5/5 at 10:50 a.m. with licensed practical nurse (LPN) I revealed that resident 9 went to the emergency room (ER) on 5/4/26 to have her wound assessed by a physician because it was worsening. She had a Kennedy ulcer (a skin wound that appears suddenly, often in the final days or weeks of life) on her sacrum (area at the base of the spine between the hip bones); she was on IV antibiotics for it, and it took three people to change the wound vac dressing. Nurses were to monitor the wound vac daily and empty the drainage canister when it was full. At first, a wound nurse was coming in to do the wound vac dressing change, but now the nursing staff changed it at the facility. She did not change resident 9's wound vac dressing on her own, but had assisted other staff members with it. 3. Interview on 5/6/26 at 2:23 p.m. with RN/minimum data set (MDS) coordinator J revealed she was the wound nurse. Resident 9's wound vac dressing change was not completed by RN R on 5/3/26 as prescribed by the physician. RN R was instructed to call LPN I, who was the manager on-call (a manager who was available to come in if help was needed), or RN/MDS coordinator J to help with changing resident 9's dressing if RN R needed help. RN/MDS coordinator J changed the dressing on 5/4/26 and found her wound had worsened. She notified resident 9's primary care physician and the infectious disease physician, and they wanted resident 9 to be sent to the ER because she had a lower blood pressure, an elevated temperature on 5/1/26, and her wound worsened. RN/MDS coordinator J stated that the black foam dressing for the wound vac was to be changed every three days due to bacteria build-up, and if it was not changed every three days, then that increased the resident's risk for infection. She felt the infection was not worse, but that there was more skin breakdown because the dressing was not changed on 5/3/26. 4. Review of resident 9's electronic medical record (EMR) revealed her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She admitted to the facility on [DATE], was admitted to the hospital on [DATE] for a sacrum wound, and re-admitted to the facility on [DATE]. Resident 9's 4/2/26 primary physician's progress note indicated her pressure ulcer was a Kennedy ulcer. Her diagnoses included osteomyelitis (a serious bone infection) of the vertebrae (backbone), sacral, and sacrococcygeal (vertebrae at the base of the sacral area and tailbone) region, abnormalities of gait (walking) and mobility, mononeuropathy (damage to nerves causing pain, numbness, and muscle weakness) of bilateral (both) lower limbs, and weakness. Her 4/28/26 Braden Scale (a tool used to assess a person's risk of developing pressure injuries) risk assessment score was 8, which indicated she had a high risk for developing pressure injuries. Resident 9's 4/17/26 care plan indicated she was at risk for altered skin integrity, had pressure ulcer preventative interventions in place, such as frequent repositing, air mattress, and heel protective boots, had a Kennedy ulcer to her sacrum, and her wound treatments were to be completed as ordered by the physician. Resident 9 was dependent on the staff's assistance with eating, dressing, completing personal hygiene care, moving in bed, and transferring. Resident 9 had physician's orders on 4/10/26 for the wound vac and to change the wound vacs dressing three times per week until the wound was healed. A 4/14/26 physician's order to review RN/MDS coordinator J's wound note on 4/14/26 on how to apply and troubleshoot the wound vac, and a 4/24/26 physician's order for ceftriaxone (IV antibiotic) for osteomyelitis of the vertebra, sacral, and sacrococcygeal regions. On 4/30/26, resident 9 had a physician's note that indicated her lab work had improved, to continue IV antibiotics, to see wound care again, and to have the facility send pictures of the wound. On 5/1/26, a progress note by LPN II indicated that resident 9 had a temperature of 100.2 that resolved to 97.0 during her shift. On 5/4/26 her ER physician notes indicated she was seen for a sacral wound. A computed tomography (CT) scan (a painless procedure imaging test) of her abdomen was completed and compared to her previous abdominal CT on 4/2/26. The findings indicated she had a left-sided sacral wound seen with erosion (destruction of tissue) to the level of the bone. The ER physicians' orders were to discharge resident 9 back to the nursing home, continue using the wound vac, to gently clean the wound when the wound vac dressing was changed, and to continue her IV antibiotics. Her diagnoses listed on the ER visit report were cellulitis (bacterial infection of the skin and underlying tissue) and a non-pressure chronic ulcer of the back with unspecified severity.A progress note on 5/4/26 at 3:46 p.m. by RN/MDS coordinator J revealed that she changed resident 9's wound vac dressing because the dressing was not changed on 5/3/26. When she removed the dressing, the wound was odorous. There was a reddish-brown and gray drainage in the wound vac canister. She described the wound as she indicated in the 5/4/26 weekly wound assessment. She updated the resident's infectious disease physician and primary care physician. Both physicians directed her to send the resident to the ER to be evaluated due to resident 9 having a fever, low blood pressure, and a change of [her] wound. On 5/4/26 at 4:17 p.m. by RN/MDS coordinator J, revealed that resident 9's blood pressure was 92/46 and her other vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were within normal limits. A progress note on 5/5/26 at 5:42 a.m. by LPN T indicated that the resident came back from the ER on [DATE] at 9:30 p.m. no new medication orders, and her vital signs were within normal limits. At the ER, the staff cleaned her Kennedy ulcer and applied betadine (antiseptic) to the wound. LPN T applied the wound vac when the resident returned. On 4/21/26, resident 9's weekly wound assessment for her Kennedy ulcer, completed by RN/MDS coordinator J, revealed she changed resident 9's wound vac dressing, and her wound length was 8.2 centimeters (cm), width was 16.4 cm, depth was 5 cm, and it was a stage IV (4; open wound with full-thickness skin and tissue loss. Bone, tendon, or muscle may be visible) pressure ulcer (skin and/or underlying tissue injury from prolonged pressure). It did not indicate what the wound bed (the moist base or deepest open area of a wound) assessment was. The edges of the wound were red, there was a moderate amount of bloody red drainage, the resident experienced pain, and the wound was unchanged from the previous assessment. There was undermining (when tissue under the skin was destroyed, creating a hidden pocket beneath the wound edges) of the wound at 10 o'clock (describing a wound using a clock to create a standardized picture of a wound's location, shape, and size) that measured 6.5 cm, and at 11 o'clock it measured 6.9 cm. The assessment indicated that the resident was to see a surgeon to evaluate the undermining of the pressure ulcer. On 4/28/26, her weekly wound assessment for her Kennedy ulcer, completed by RN/MDS coordinator J, revealed her wound developed on 3/7/26. The length was 8.6 cm, the width was 13.7 cm, the depth was 4.5 cm, and it was a stage IV pressure ulcer. The wound bed had 60% (percent) of granulation tissue (healthy tissue), 38% slough (a soft, moist, yellow or white slimy material that forms on top of a wound, consisting of dead tissue and bacteria), 2% necrosis (dead tissue that may be black, brown, tan or green), and the edges of the wound were red. There was undermining from 10:30 to 1 o'clock, and at 12 o'clock it measured 6 cm deep. There was a large amount of drainage that was pink in color, the resident had pain, and the wound had improved. On 5/4/26, her weekly wound assessment for her Kennedy ulcer, completed by RN/MDS coordinator J, revealed her wound length was 9 cm, width was 15 cm, depth was 3.3 cm, and it was a stage IV pressure ulcer. It did not indicate what the wound bed assessment was. The edges of the wound were red. She had undermining of the wound at 10 o'clock to 1 o'clock that was 6 cm. There was black and gray tissue seen at 12 o'clock-3 o'clock within the wound bed, and scattered darker areas with grey slough. The wound was odorous. She had moderate drainage that was red blood, the resident had pain, the wound had worsened and the physician was notified. Her treatment administration record (TAR) indicated her wound vac dressing change on 5/3/26 was not signed off as completed by RN R, and RN R indicated to see the nurse's notes. There were no nurse's notes made by RN R regarding the wound vac dressing change not being done. 5. Interview on 5/7/26 at 8:43 a.m. with RN R revealed she did not change resident 9's wound vac dressing on 5/3/36 as ordered by the physician. She stated she only changed the suction canister and that it took two people to change the dressing. She did not receive education on how to change the wound vac dressing and had only assisted with it, and was scared to do it by herself. She did not want to bother LPN I, who was on-call, or RN/MDS J that day, so she passed it on to the next shift to have RN/MDS J do it on 5/4/26. She acknowledged that not changing her dressing as ordered by the physician increased resident 9's risk for her infection worsening. 6. Interview on 5/7/26 at 3:43 p.m. with director of nursing (DON) B revealed she expected RN R to change resident 9's wound vac dressing when it was ordered by the physician, and that she should have called for help if she did not know how to do it. She stated that RN R had a competency checklist completed with her nursing agency on 2/12/26 that indicated she was proficient and highly skilled at wound care, wounds, and drains. She acknowledged that not changing the dressing as ordered by the physician put resident 9 at risk for her wound deteriorating and her infection worsening. 7. Interview on 5/7/26 at 4:30 p.m. with RN/MDS coordinator J revealed that she provided hands-on education to RN R in December 2025 related to wound vacs and their dressing changes. She did not have written documentation that she provided her with this education. RN R did not indicate to her that she was uncomfortable changing the dressing. 8. On 5/7/26 at 8:45 a.m. and 2:57 p.m., administrator A stated they did not have a wound vac policy. She expected that RN R would have completed the wound vac dressing change on 5/3/26 and to call for help if she did not know how to. 9. Review of the provider's 11/18/25 Following Physician Orders policy revealed that all physician orders should be followed as written. The physician should be notified when an order is not followed for any reason.

Based on the South Dakota Department of Health (SD DOH) Facility Reported Event (FRI), SD DOH complaint report, record review, interview, professional reference review, and policy review, the provider failed to provide appropriate enteral (passing through the digestive tract) feeding care regarding using a new enteral feeding bag for administering formula and safely storing nutritional formula for one of one sampled resident (7) who received nutritional formula through a feeding tube (a tube surgically placed through the abdomen into the stomach to administer liquid nutrition, fluids and medications) when an enteral feeding bag was not replaced with a new bag for administration of nutritional formula to the resident when a new bag was not found by the director of nursing (DON) B.Findings include: 1. Review of the provider's 8/23/25 SD DOH Facility FRI report stated that licensed practical nurse (LPN) BB put a tube feeding nutritional formula bag on resident 7 on 8/20/25 at 5:00 a.m. She had two days off and returned to work on 8/22/25 to find the bag she dated on 8/20/25 was still hanging with nutritional formula in it. The administrator interviewed staff. Director of nursing (DON), B, who was a charge nurse at the time of the report, stated she cleaned and reused the feeding bag because there were no more feeding bags available. There was an order placed for more supplies, and they received the wrong bags. Staff were educated on reporting when the supplies were low.2. Review of the 8/25/26 SD DOH complaint report revealed it referenced the event that occurred in the 8/23/25 SD DOH FRI report. The report complaint indicated that there was about 300 mls [milliliters of formula] left in the bag, but it was chunky and curdled and pretty solid. Former DON D was notified and gave direction to rinse the bag out and reuse it, and she (former DON D) would get more supplies in the morning. The report indicated that administrator A was also notified.3. Review of resident 7's electronic medical record (EMR) revealed he was admitted to the facility on [DATE] and discharged on 8/28/25. He had diagnoses of a stroke affecting his left side, altered mental status, and dysphagia (difficulty swallowing). He had 8/3/26 physician orders for enteral feeding formula Compleat 1.4 calorie, to be given at a continuous rate of 50 ml (milliliters) per hour by a feeding pump, twenty-four hours per day.Review of resident 7's August 2025 medication administration record (MAR) and treatment administration record (TAR) revealed that his feeding formula was signed off as administered during the night shifts on 8/19/25 by LPN BB, on 8/20/25 and 8/21/25 by DON B, and on 8/22/25 by registered nurse (RN) DD.4. Interview on 5/6/26 at 11:53 a.m. with DON B revealed that she worked the nights of 8/20/25 and 8/21/25 and noticed they did not have any more formula feeding bags. She had to rinse resident 7's formula bag out with clear water and reuse the bag to administer his nutritional formula. They were to change the bag every twenty-four hours. She felt someone should have reported when the formula bag supply was low so more could have been ordered, because he was to receive the formula continuously. She filled the feeding tube bag full of formula. The formula did not all fit in the bag, so before the day shift staff came on duty, she added the rest of the formula to the bag, and the formula would run until the night shift staff came back on duty to change the bag. The feeding bag was not insulated. The facility used the [NAME] and [NAME] Fundamentals of Nursing, 10th edition, as a reference of professional standards.5. Interview on 5/7/26 at 8:54 a.m. with registered dietitian Z revealed that once opened, the Compleat formula was good for eight to twelve hours at room temperature. She expected the formula in the feeding tube bag to be hung for a maximum of twelve hours, and felt that going over that time increased the risk for bacterial growth. 6. Interview on 5/7/26 at 3:43 p.m. with DON B revealed she was unsure of who was responsible for ensuring there were feeding tube supplies available to use. She hoped the nursing staff would notify someone to order more when the supply was low. She acknowledged that rinsing the feeding tube bag and having formula in the bag for administering to a resident for over eight hours, increased the risk of infection.7. Review of the provider's 11/19/24 Enteral Feeding (Tube Feeding) policy revealed it stated, change formula bags daily and PRN [as needed]. Use new enteral tubing daily and each time a new formula bag is started.8. Interview on 5/7/26 at 11:50 a.m. with administrator A revealed that education was not completed for all staff as indicated in the SD DOH report. She was unsure of what the ordering process was for the feeding tube bags. She expected the staff to follow the facilities.9. Review of the [NAME] Fundamentals of Nursing, 10th edition book revealed it stated to refer to manufacturer guidelines to determine hang time for enteral feedings. The maximum hang time for formula is 8 hours in an open system. There is increased risk of bacterial growth in feedings that exceed the recommended hang time.10. Review of the Compleat formula manufacturer's directions for use did not indicate what the maximum hang time was. It stated, Once opened, reclose, refrigerate and use within 24 hours.

Based on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure that procedures were implemented to process medication orders to ensure medications were administered accurately for one of one sampled resident (3) who admitted to the facility following a hospitalization for surgical repair of a fractured left hip and did not receive Aspirin 81 milligrams (mg) twice daily as ordered from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose after the order was incorrectly entered into the provider's electronic order system (PCC) by the pharmacy. Resident 3 experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention and developed Deep Vein Thrombosis (DVTs) (a blood clot that forms in a vein deep inside the body, most commonly in the lower leg or thigh) in both of her lower legs. Findings include:1. Review of the provider's 1/7/26 SD DOH FRI revealed that during the consultant pharmacist (CP) medication regimen review on 1/2/26, the CP identified the pharmacy's order entry error regarding resident 3's 12//17/25 physician-ordered 81 mg Aspirin, twice daily, to continue for 30 days after her admission to the nursing facility following a left hip surgical repair. The nursing facility utilized a pharmacy-initiated order system in which pharmacy personnel received all physicians' medication orders and entered those medication orders into the nursing facility's order system, which included residents' electronic medical records (EMRs) and their electronic medication administration records (EMARs). The pharmacy received a clarification order on 12/19/25 to decrease the 81 mg Aspirin administration frequency from twice daily to once daily after 30 days. The pharmacy entered the physician's order for Aspirin 81 mg once daily, to start on 1/19/26, into the electronic pharmacy-initiated order system for resident 3. On that same day, the pharmacy entered an incorrect end date for the 81 mg Aspirin twice daily order, which caused a discontinued medication message to be sent in the facility's electronic medical record (EMR) system for resident 3. The pharmacy corrected that discontinued date error immediately on 12/19/25; however, the facility's order system was unable to update the discontinuation date, and as a result, the 81 mg Aspirin twice daily order never reappeared in the EMR as a corrected or continued order for administration to resident 3. Resident 3 last received her 81 mg Aspirin twice daily dose on 12/19/25 at 8:00a.m. The order entry error resulted in resident 3 not receiving the scheduled Aspirin from the 12/19/25 p.m. dose through the 1/18/26 p.m. dose. She experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention, and developed DVTs in both of her lower legs. 2. Review of resident 3's EMR revealed that she admitted to the facility on [DATE] for therapy services after being hospitalized for surgical repair of her left hip fracture. While hospitalized , she developed a bowel obstruction (a blockage that prevents food, fluids, and gas from moving through the digestive tract) and required a second surgery on 12/6/25. Her diagnoses included hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). Her Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated she had moderate cognitive impairment. She discharged from the facility and returned home in the care of a family member on 1/16/26. Resident 3's progress notes dated from 12/21/25 through 12/30/25 indicated that she began complaining of increased swelling in her left lower leg on 12/21/25 at 9:04 p.m. On 12/24/25 at 10:53 a.m., a physical therapy (PT) progress note indicated that resident 3 complained of pain in both lower legs during her therapy session, which limited her activity, and she was unable to complete some of her exercises. Therapy staff documented that resident 3 had significant swelling in her bilateral lower extremities. The therapist did not document a pain level for resident 3 but assessed her pain based on her behaviors, including limited standing and walking, as well as difficulty lifting her feet off the floor. On 12/26/25 at 9:48 a.m., a PT progress note indicated that resident 3 had difficulty bearing weight on her legs due to increased weakness and pain in her lower left leg, and the therapy staff had to supervise all of her transfers. Resident 3 rated her pain 5/10 [five out of ten on a zero to ten level of pain scale] at rest and 7/10 [seven out of ten] with movement. She described her pain in the lower left leg at rest as an ache and with movement as sharp. Progress notes on 12/26/25 at 12:04 p.m. and again at 6:00 p.m. indicated that resident 3 described pain in her left leg as aching and informed nursing staff that her right leg was bothering her, was purple in color, and that the purple bruising was not present earlier in the day. Resident 3 told nursing staff that she had not bumped or hit her leg on anything to cause purple bruising. Nursing staff documented that resident 3 had 3+ (moderate-to-severe) pitting (temporary pit or indenting left in the skin after applying pressure) edema (fluid-related swelling) in the right lower extremity (leg). A progress note dated 12/27/25 at 5:46 a.m. revealed that resident 3 verbalized left leg pain to nursing staff and that a dark bruise was noted on her right leg. At 3:00 p.m. that same day, resident 3 requested that her physician be notified about her pain and to order a stronger pain medication to help her with pain control. A physician's order was received to monitor her bruising to the back of her left lower leg every day and night shift until the bruising healed. A progress note dated 12/28/25 at 2:57 p.m. indicated that resident 3 experienced intermittent pain in her right leg. At 5:12 p.m., a PT progress note indicated that an ice pack was applied to resident 3's left lower leg during her therapy session to help reduce her pain and swelling. Resident 3 rated her pain a 3 on a zero-to-ten pain scale at rest and described it as nagging and aching. A PT progress note dated 12/29/25 indicated that resident 3 attended a PT session. During the session, the physical therapist assistant/therapy coordinator (PTA/TC) U performed edema massage to resident 3's left lower leg to help reduce the tightness and swelling. Resident 3 arrived at that therapy session with a hematoma (a pool of clotted blood that forms outside of blood vessels, caused by injury or surgery) to her left medial (midline) gastrocnemius (two-part muscle located on the back of the lower leg that forms the calf muscle), with significant increased tenderness. There was no warmth or erythema (redness) to the area. Resident 3 had a positive Homans' sign ( a clinical exam of flexing the foot upward toward the shin. If that movement causes pain in the calf muscle, that is considered positive and suggests a possible DVT) in her left lower leg. PTA/TC U notified former DON MM and recommended contacting the physician for an order to complete a Doppler exam (a non-invasive test that uses sound waves to assess blood flow through blood vessels). Resident 3 rated her pain at rest as 3 and at 9 with movement on a zero-to-ten pain scale. The resident described the pain as intense and sharp with movement. On 12/29/25 at 2:09 p.m., a progress note indicated that a fax was sent to notify the physician of resident 3's bruising on her right leg and to request a Doppler exam. Another progress note on 12/29/25 at 7:23 p.m. indicated that resident 3 was experiencing intermittent pain in her right leg. Progress notes from 12/29/25 through 12/31/25 indicated that on 12/29/25, a physician's order was received for resident 3 to undergo a Doppler exam, and the appointment was scheduled for 12/31/25. While attending therapy sessions during those dates, resident 3 continued to experience increased pain and swelling in her lower left leg, which limited her ability to stand, walk, maintain her balance, and perform bed mobility without difficulty. The Doppler exam was completed on 12/31/25 and revealed that resident 3 had bilateral DVTs in both of her lower legs. A physician's order was received for resident 3 to take 5 mg of Eliquis, a blood-thinning medication, orally twice daily for seven days, for her diagnosis of acute thrombosis (a sudden blockage of a blood vessel by a blood clot) in unspecified deep veins of the lower extremities. 3. A drug regimen review for resident 3 was completed by consultant pharmacist (CP) W on 1/2/26 and revealed that Aspirin 81 mg twice daily for resident 3 had not been administered since 12/19/26 at 8:00 a.m. and had not been continued as the physician ordered for 30 days. Her findings were documented in her report, and former DON MM was notified of the finding on 1/2/26. A medication variance report was completed five days later, on 1/7/26, by former DON MM regarding resident 3's omitted Aspirin 81 mg doses she did not receive from 12/19/25 through 1/18/26. 4. On 1/7/26, a corrective action plan was initiated, and the interdisciplinary team (IDT) met to review resident 3's bruising on her right lower leg and to complete an interview process with resident 3 and the nursing staff. The pharmacy addressed the order error entered by the pharmacy, which resulted in a medication error involving the aspirin for resident 3. A late-entry nurse progress note on 1/7/26 documented that the physician was notified that resident 3's Aspirin order to be given twice daily, was inadvertently discontinued by the pharmacy, the nursing facility's medical record system was unable to update the original discontinuation date sent on 12/19/25, and that the order for resident 3's Aspirin twice daily never reappeared as a corrected or continued order. A call was held on 1/9/26 with the pharmacy, facility leadership, and corporate leadership to discuss the root cause analysis, the error, how it occurred, and the process and plan for correction moving forward. On 1/12/26, a letter from the director of pharmacy was sent to the facility leadership outlining the education and training to be provided to the pharmacy staff. Training on 1/13/26 and 1/14/26 provided the pharmacy staff with education for those involved in the ordering error on 12/19/25, as well as a review of training documentation for all order-entry technicians and pharmacists. Updated material on discontinued orders and the impact on the facility was included in the training. In addition, on 1/14/26, three facility nurses involved in resident 3's Aspirin and order confirmation reviews completed training in a course titled [Facility] LTC Pharmacy Initiated Orders. The pharmacy technology team attended an order entry meeting with the nursing facility's interface team (a specialized group that manages the software system) to review the process for discontinuing medication orders and future medication order start dates. The facility completed transitioning back to a facility-initiated order system rather than a pharmacy-initiated system on 1/28/26. 5. Interview on 5/5/26 at 2:06 p.m. and again at 3:30 p.m. with CP W revealed that pharmacy reviews were completed monthly with all residents. Resident medications and physician orders were reviewed. She would review progress notes and laboratory reports for changes to determine whether medications were contributing factors. She completed a comprehensive review of resident charts every month, and with any new resident admitted to the nursing facility. She indicated that the pharmacy has a team of nursing account managers who consult and provide education to nursing facilities. They can provide education as needed or upon request from the nursing facility. She acknowledged that a process improvement plan was implemented and completed regarding resident 3's pharmacy order error and that training was provided to the pharmacy team and to the nurses involved at the facility in January 2026. 6. Interview on 5/5/26 at 1:15 p.m. and again at 2:24 p.m. with the director of nursing (DON) B revealed that at the time the order entry error occurred with resident 3, the ordering system was pharmacy-initiated, and nurses were unable to enter physician orders into the facility's ordering system. However, she acknowledged that the facility nurses were responsible for confirming the orders that had been accurately entered by the pharmacy. She said that physician orders were sent to the pharmacy by e-fax or e-scribe at the time of resident 3's order-entry error, but that the facility now received the physician orders by e-fax, e-scribe, telephone, verbally, or in writing. 7. Interview on 5/6/26 at 10:21 a.m. with administrator A revealed that there were no medication errors related to order entries in the system since that incident. Nursing staff members now had the ability to put medication physician orders into the system. Administrator A acknowledged that when the error occurred regarding resident 3's medication, the pharmacy initiated the physician orders, the facility nurse confirmed the order, and an order error resulted in the discontinuation of her Aspirin, which was scheduled to be given twice daily. Administrator A said that she thought education on medication errors was provided to nurses regarding resident 3's ordering error. 8. On 5/6/26 at 11:44 a.m., interviews via phone call were attempted, and a voicemail message was left for resident 3 and resident 3's representative. No return calls were received during the survey. 9. Interview on 5/7/26 at 10:00 a.m. with PTA/TC U revealed that resident 3 admitted to the facility on [DATE] and had physician orders for physical and occupational therapy (OT). Resident 3 started PT on 12/17/25, started OT on 12/21/25, and experienced progressive pain, swelling, and bruising in her lower legs from admission until DVTs in both lower legs were discovered on 12/31/25. PTA/TC U stated that resident 3 continued her PT and OT therapy sessions five days a week, but at times, her pain and swelling limited her ability to stand, walk, and maintain her balance. She recalled the therapy session with resident 3, during which she identified a positive Homans' sign, notified former DON MM, and recommended that resident 3's physician be contacted to order a Doppler exam. She stated that she was happy with the timely response former DON MM provided by notifying the physician and obtaining an order for the Doppler exam for resident 3. PTA/TC felt that resident 3 not receiving the scheduled 81 mg of Aspirin twice daily could have been a contributing factor in the development of her bilateral lower leg DVTs. 10. Interview on 5/7/26 at 2:50 p.m. with RN/Minimum Data Set (MDS )coordinator J revealed that she received education regarding the incident involving resident 3's medication error. She reported that resident 3 had no further lower-leg pain or problems after starting Eliquis. 11. Interview on 5/7/26 at 5:30 p.m. with RN/Director of Electronic Health Records (EHR)/Point Click Care Implementation (PCCI) V stated that the facility transitioned to a facility-integrated system on 1/28/26 after a pharmacy order entry error involving resident 3 not receiving her medication as ordered was identified. That plan was adopted as the response to that incident. 12. Interview and record review on 5/7/26 at 5:43 p.m. with administrator A, regional nurse consultant (RNC) M (via phone), and RN/vice president of clinical services (VPCS) X revealed that on 1/9/26 a call was held with the pharmacy team, the nursing facilities leadership team, and corporate office personnel to discuss the root cause of resident 3's medication error, how it occurred, and the processes and plan for correction to move forward. Administrator A and RN/VPCS X acknowledged that the ordering error resulted in resident 3 not receiving the scheduled Aspirin for approximately two weeks. Resident 3 experienced increased pain, spontaneous bruising, and increased swelling in her lower legs, which required medical intervention and developed DVTs in both of her lower legs. RNC M acknowledged that since the facility-integrated order system was implemented on 1/28/26, the facility did not conduct any audits to verify whether any further medication order entry errors had occurred for all residents, and that no data about that was presented at the monthly Quality Assurance and Process Improvement (QAPI) meetings. 13. Review of the provider's revised January 2018 Provider Pharmacy Requirements policy revealed that The [Facility] Long Term Care Pharmacy agrees to perform the following pharmaceutical services, including but not limited to: Accurately dispensing prescriptions based on authorized prescriber orders. 14. Review of the provider's Medication Errors policy dated 5/14/25 revealed that the Policy was to ensure medication errors are identified to prevent adverse resident effects. Errors will be documented, investigated, reported, and reviewed for need of interventions and to prevent recurrence. Medication errors will be reviewed by the Medical Director and Consultant Pharmacist. The review may be done via telephone, during routine visits, or during QAPI discussions. The medication error will be entered into the Risk Management Section of [Facility System] for trending and tracking purposes. 15. Review of the provider's Following Physician Orders policy dated 11/18/25 revealed that the Policy was to correctly and safely receive and transcribe the physician's orders so the correct order is followed/administered. New admission/readmission physician orders and all transcription of orders should be transcribed by a HUC or a nurse and be double checked by a second nurse to ensure that all steps have been carried out to avoid errors. 16. Review of the provider's revised January 2018 Consultant Pharmacist Services Provider Requirements policy revealed, The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. Assists in the identification and evaluation of medication-related issues, including the prevention and reporting of medication errors. Establishes a system of records for receipt and disposition of all controlled medications to enable an accurate reconciliation, and to determine that the drug records are in order and that an account of all controlled medications is maintained and periodically reconciled. Assists in establishing quality assurance and continuous quality improvement activities regarding the medication use process, prescribing, dispensing, storing, administering, and monitoring of medications in the facility. Assists nursing in reviewing medication administration records, treatment administration records, and physician orders quarterly within the QAPI process to ensure proper documentation of medication orders and administration of medications to residents.

Based on observation, interview, and policy review, the provider failed to follow acceptable food service standards and their policies to ensure one of one kitchen was maintained in a clean and sanitary condition, and proper glove use by cook/dietary aide (J) while preparing and serving residents' food during one observed meal service. Findings include: 1. Observation on 3/11/25 at 5:05 p.m. of serving pans under the steam table in the kitchen revealed: *Food debris and a yellow film on some of the serving pans. *Food debris and a yellow film on three of the pan lids. *Food spatter and a yellow film on the side windows of the steam table. *Food spatter on the undersurface of the top of the steam table where plate covers had been located. 2. Observation on 3/11/25 at 5:15 p.m. of the storage racks next to the stove in the kitchen revealed: *A moderate amount of dust was hanging from the first three racks. *One knife was on the floor under the storage rack. 3. Observation on 3/11/25 at 5:20 p.m. of cook/dietary aide J while serving food revealed: *With his gloved hands he: -Retrieved buttered bread from a bowl and placed it on the resident's plate. -Retrieved a plate from the warming cabinet. -Dished beets and tuna noodle hotdish onto a plate. -Touched a resident's menu slip. -Repeated that same entire process for another resident. *He then removed his gloves, washed his hands, and put on a new pair of gloves. With those gloved hands he: -Retrieved coleslaw from the refrigerator. -Opened a drawer, retrieved a serving spoon, and dished coleslaw into a bowl, and placed a lid on top of that bowl. -Touched a resident's menu slip and then, with those same gloved hands, he repeated the above-observed process of retrieving a slice of buttered bread, dishing food, serving food, and touching resident's menu slips. *Removed his gloves and washed his hands. *He then buttered toasted bread with his bare washed hands. *Cook/dietary aide J put on a pair of gloves. With those gloved hands he: -Opened the refrigerator to retrieve ketchup packets, opened the foil wrapper for a resident's cheeseburger and placed all of those items onto a plate to be served to a resident. 4. Interview with cook/dietary aide J following the above observations revealed: *He agreed that he should not have touched the resident's menu slips and resident food items with the same gloved hands. *He agreed he should not have opened the refrigerator, retrieved ketchup packets, opened the foil, and handled the resident's cheeseburger with the same gloves on. That was not a clean food service. 5. Observation and interview on 3/12/25 at 10:20 a.m. with dietary manager D in the kitchen revealed: *The carts in the kitchen were to be cleaned daily but sometimes that did not happen. *She agreed a cart had food debris and food spatter on the shelves. *Dietary staff had a cleaning list that should have been completed daily. *She would have reminded staff to clean equipment if the cleaning task had not been completed. *The floors in the kitchen should have been mopped every day. *A knife that was observed under a storage rack on 3/11/25 was still present. -She said that the floor may not have been mopped yesterday (3/11/25). *She agreed that the steam table was not clean. 6. Interview on 3/12/25 at 10:45 a.m. with dietary manager D regarding glove use and food service revealed: *Cook/dietary aide J should have used tongs to retrieve the buttered bread instead of wearing gloves. *Wearing gloves to open the refrigerator door and then touching food items and touching resident's menu slips was not an acceptable food service practice. 7. Interview and observation on 3/12/25 at 2:30 p.m. with administrator A in the kitchen revealed: *Dietary manager D had been sweeping the kitchen floor. *She agreed that there was an observable yellow residue on the convection oven and the steam table. 8. Interview on 3/13/25 at 8:30 a.m. with administrator A regarding dietary manager certification revealed: *Dietary manager D was taking classes for her dietary manager certification. *The facility did not have a certified dietary manager. Review of the provider's April 2020 handwashing and glove use policy revealed: *Gloves may be used when working with food to avoid contact with hands. Gloves must be worn when touching any ready-to-eat food. *When gloves are used, handwashing must occur prior to putting on gloves and whenever gloves are changed. *It is important to remember that gloves can often give a false sense of security and can carry germs the same as our hands. Review of the provider's August 2018 Tray Carts, Dish Carts, Utility Carts policy revealed: *Wash inside (sides, top, bottom, tray guides, and inside of door). Use sanitizing solution and clean cloth. *Rinse with clean, warm water and clean cloth. *Allow to air dry. *Frequency: Weekly.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, observation, manufacturer's manual review, and policy review, the provider failed to ensure resident safety by improper use of lift equipment as directed in the residents' care plans and/or the lift manufacturer's manual for: *One of two sampled resident (9) who required the assistance of two staff for transfers with a lift, who was lowered to the floor while being transferred with the use of a mechanical sit-to-stand lift (a mechanical lift that requires the person to partially bear weight on at least one leg when assisted from a seated position to a standing position) by one certified nursing assistant (CNA) (K) without the assistance of another qualified staff person. *One of two sampled resident (14) who required the assistance of two staff for transfers with a lift, who was lowered to the floor while being transferred with the use of a non-mechanical (manual) sit-to-stand lift by CNA (M) without the assistance of another qualified staff person. 1. Review of the provider's 1/28/25 SD DOH FRI regarding resident 9 revealed: *On 1/28/25 at 4:00 p.m. while certified nursing assistant (CNA) K was attempting to transfer resident 9 to the commode with the sit-to-stand lift she assisted her to the floor when the right side of the sling came off the lift. *CNA K did not follow manufacturer guidelines when securing the sling to the lift. *Resident 9 was evaluated by the nursing staff and had no injury. *Resident 9's physician and power of attorney (POA) were notified. *CNA K was suspended and reinstated after she was provided education and demonstrated competency with proper sling use and securement. *The resident's care plan was reviewed and noted to have appropriate interventions in place. 2. Review of resident 9's electronic medical record (EMR) revealed: *Her diagnoses included acquired absence of right leg above the knee, morbid obesity, and Epilepsy. *Her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *The care plan indicated: -Stand lift for transfers unless [resident 9] is uncomfortable with the CNA and wants the Hoyer lift [a mechanical lift and sling used to lift a person's full body] used. -She required the assistance of two staff when she was feeling weak or tired when transferring in [the] stand lift. -Allow [resident 9] to choose what stand lift to use when transferring. -Resident 9 had a right lower leg prosthesis. Do not don [put on] before using [the] mechanical lift. Refusing use at present time. *A 1/28/25 incident progress note indicated, CNA called [the] nurse to [the] resident room for an assisted fall .[The] right strap became separated from [the] lift suggestive of sling placement misalignment . pain medication given for stump [residual limb] pain. 3. Observation and interview on 3/12/25 at 1:46 p.m. with resident 9 regarding the 1/28/25 incident involving the mechanical sit-to-stand lift revealed: *She had an above-the-knee amputation of her right leg and did not wear a prosthesis. *She stated the lift sling came unattached from the right side of the lift when CNA K raised the lift from a sitting position to a standing position. *She fell to the floor and bumped her right leg. *She had two medium size sit-to-stand lift slings hanging from her bedroom door. *The CNAs were trained on a new way to hook the sit-to-stand lift sling strap so that it did not come unhooked. -She always checked now that the lift sling was attached correctly. 4. Observation and interview on 3/13/25 at 9:38 a.m. with CNA H and resident 9 revealed: *She received education and had to demonstrate how to use the mechanical sit-to-stand lift and attach the sling correctly to transfer a resident three to four times in a row about a month ago. *She knew how to transfer resident 9 because it was on her care plan. *She transferred resident 9 from the commode to her wheelchair and applied the sling correctly. 5. Interview on 3/13/25 at 8:35 a.m. and again at 9:04 p.m. with administrator A regarding the incident with resident 9 on 1/28/25 revealed: *CNA K had not correctly attached the sling to the mechanical sit-to-stand lift, and resident 9 was lowered to the floor when that sling came unhooked from the lift. *Education on how to attach the mechanical sit-to-stand lift sling was completed on 1/28/25. -Staff competencies (demonstration of proper technique) on the sit-to-stand lifts had been started after the incident on 1/28/25. *She expected staff to use the lift slings per the manufacturer's guidelines. *No audits had been completed for the correct use of the slings and lifts since that incident. 6. Interview on 3/13/25 at 11:03 a.m. with human resources coordinator L revealed that CNA K no longer worked at the facility and was unavailable for interview. 7. Review of the provider's 1/28/25 How to apply [the] sling for [the] sit-to-stand lift correctly staff education revealed: *The education sheet contained three pictures of how to attach the lift sling. *There were nine steps listed for the process of Transferring to a Commode Chair with the mechanical sit-to stand-lift. *Handwritten information was added, Sling should be pulled around the outside of the bar and hooked that way. 8. Review of the (Name) manufacturer's undated mechanical sit-to-stand manual revealed: *Ensure the following .the loops of the sling are completely on the hooks of the lift arms. -There was a reference to a picture labeled Sling Attachment. 50915 9. Review of the provider's 2/24/25 SD DOH FRI regarding resident 14 revealed: *On 2/22/25, CNA M was using a nonmechanical sit-to-stand lift to transfer resident 14. *While in the nonmechanical sit-to-stand lift, resident 14 sat down prematurely. -He was safely lowered to the floor and was unharmed. *Resident 14 was to have cares in pairs (the assistance of two staff when providing residents' care) due to his cognitive impairment. *CNA M was suspended until she had completed the education on cares in pairs. 10. Review of resident 14's electronic medical record (EMR) revealed: *He had a BIMS assessment score of 3, which indicated he was severely cognitively impaired. *His diagnoses included Alzheimer's Dementia, anxiety, congestive heart failure, and chronic kidney disease. *His care plan indicated: -A focus area of I require assistance with ADLs [activities of daily living] (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). -A goal of I will be assisted with ADL's as needed. -Interventions of Provide Cares in Pairs. All cares should be done with 2 care givers [caregivers] present. -Date initiated: 01/17/25. 11. Phone interview on 3/13/25 at 10:55 a.m. with CNA M revealed: *She had been a CNA for about eight months. *She was not aware resident 14 was to have two staff assisting during all resident care. *She reported the resident was standing on the nonmechanical sit-to-stand lift, and he started to sit down before the lift's padded seat could be positioned into place. 12. Interview on 3/13/25 at 11:30 a.m. with CNA E revealed: *The facility had two types of lifts; mechanical and non-mechanical. *All lifts should have been operated with two staff members and never operated with just one staff. 13. Review of the provider's 9/30/24 Care Plans policy revealed: *Policy: Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. In doing so, the following considerations are made: 1. Each resident is an individual. The personal history, habits, like and dislikes, life pattens and routines, and personality facets must be addressed in addition to medical/diagnosis-based care considerations. *The Resident-Centered Care Plan Format: 3. Goal for care is directly related to the resident's discharge plan (short-term stay focuses on rehabilitation and return to community placement, while long-term stay focuses on helping the resident feel at home and maintain/improve ADL abilities, physical and mental wellness, socialization, and overall quality of life). *4. Goal date correlates directly to anticipated goal completion or re-evaluation, and/or care conference review. For short-term care residents, goal dates related directly to the discharge plan time frame. Goal dates are set in conjunction with the next quarterly care conference. *5. Interventions act as the means to meet the individual's needs. The recipe for care requires active problem solving and creative thinking to attain, and clearly delineates who, what, where, when, and how the individual goals are being addressed and met.

Based on observation, interview, record review, resident council review, and policy review, the provider failed to ensure prompt response to call lights and necessary care and services were provided for six of six residents (5, 8, 9, 15, 23, and 285) and one of six additional resident council meeting residents (18) to maintain their physical, mental, and emotional well-being. Those residents expressed frustration related to the delay in staff response to their call lights and requests for assistance. Findings include: 1. Observation and interview on 3/11/25 at 12:25 p.m. with resident 5 in her room regarding call light response times revealed: *Sometimes it would have taken staff an hour to answer her call light and it had frustrated her. *Resident 5's daughter stated she had witnessed 30-45 minutes. 50915 2. Interview on 3/11/25 at 1:00 p.m. with resident 285 revealed: *Staff would take a long time to answer call lights, especially around meal times. *Sometimes it would take staff 20 to 30 minutes for staff to answer her call light. *She felt they were short on staff who could help residents sometimes. 3. Interview on 3/11/25 at 1:05 p.m. with resident 8 revealed she felt staff took a long time to answer her call light. 4. Interview on 3/11/25 at 3:19 p.m. with resident 15 revealed: *He said staff wanted him to use his call light for assistance. -When he used it, he felt it took them a long time to answer it. -He has fallen in the past. -This was frustrating to him. *He stated he had witnessed CNAs gathered at the nurses' station ignoring call lights. 5. Interview on 3/12/25 at 2:30 with resident 23 revealed: *Call light response wait times were very long, sometimes as long as one hour. *Resident 23 said, When I have to go to the bathroom, I don't have an hour [to wait for help]. -This was frustrating to the resident. 6. Interview on 3/12/25 at 10:40 a.m. with licensed practical nurse (LPN) I revealed: *The facility had a new call light system, less than six months old. -There was a central monitor at the nurse's station that showed activated call lights until they were answered. *All caregiver staff (such as certified nursing assistants (CNAs) and nurses) carried a pager to notify them when a call light was activated. *The pager would remind them of an activated call light at five-minute intervals until the call light was answered. *The facilities' proccess was nurses usually would not answer call lights until after the first five minutes had passed. *She expected staff to answer residents' call lights within ten minutes. 7. Interview on 3/12/25 at 11:20 a.m. with registered nurse (RN) G revealed: *She did not feel staff time for answering call lights was an issue. *She expected staff to answer residents' call lights within five to ten minutes. *She felt a wait longer than 15 minutes was unacceptable. 8. Interview on 3/12/25 at 11:30 with CNA E revealed: *The provider's expectation to answer call lights was five minutes. *That was regularly reminded to staff during daily huddles (a team meeting daily to give staff updates). 9. Review of call light logs for resident 285 revealed: *She had pressed her call light 44 times between 2/10/25 and 3/1/25. *Eight times the response time was over ten minutes. *Four times the response time was over 20 minutes. *Four times the response time was over 30 minutes. 10. Review of call light logs for resident 9 revealed: *She had pressed her call light 178 times between 2/10/25 and 3/1/25. *Thirty-five times the response time was over ten minutes. *Ten times the response time was over 20 minutes. *Six times the response time was over 30 minutes. *Three times the response time was over 40 minutes. 11. Review of call light logs for resident 23 revealed: *She had pressed her call light 236 times between 2/10/25 and 3/1/25. *Fourty-four times the response time was over ten minutes. *Twenty-two times the response time was over 20 minutes. *Three times the response time was over 30 minutes. *Seven times the response time was over 40 minutes. *One time the response time was over 50 minutes. *One time the response time was over 90 minutes. 12. Review of call light log for resident 8 revealed: *She had pressed her call light 28 times between 2/10/25 and 3/1/25. *6 times the response time was over ten minutes. *1 time the response time was over 20 minutes. *3 times the response time was over 30 minutes. *2 times the response time was over 40 minutes. *1 time the response time was over 60 minutes. 13. Review of call light logs for resident 5 revealed: *She had pressed her call light six times between 2/10/25 and 3/1/25. *Three times the response time was over ten minutes. *One time the response time was over 20 minutes. 14. Review of the provider's 2/25/25 resident council (a meeting where residents can discuss concerns with staff) minutes revealed: *Three of the six residents in attendance shared the concern that their call lights were not being answered timely. -Specifically, during morning hours, medication passes, and at bedtime. *Call light audits from 2/28/25 revealed: -One call light was answered in seven minutes. -Six call lights were answered in less than five minutes. 15. Review of provider's 2/7/25, 2/10/25, and 2/11/25 Daily Shift Huddle sheet revealed: *Expectation for call light is to respond within 5 minutes. 16. Review of the provider's 3/3/25 daily shift huddle sheet revealed: *2. Call bells [call lights] concern-remember to answer promptly. 17. Interview on 3/12/25 at 12:20 p.m. with interim director of nursing (IDON) B revealed: *She expected staff to answer residents' call lights as soon as possible, and stated within five to ten minutes was reasonable. *She said taking longer than 15 to 20 minutes to answer call lights was unacceptable. 18. Review of the provider's 9/30/24 call lights policy revealed: *Policy-It is the policy of the facility to ensure that there is prompt response to the resident's call for assistance. *Procedures 1. Facility shall answer call light in a timely manner. If immediate assistance cannot be provided and there is not an emergent need, call light may be turned off and resident informed that staff member will be back to assist them shortly.

Based on interview, record review, and policy review, the provider failed to provide bed-hold notices to the resident or the resident's responsible party at the time of transfer to a hospital for three of three sampled residents (2, 9, and 186) who were hospitalized after admitting to the facility. Findings include: 1. Interview on 3/11/25 at 12:24 p.m. with resident 9 revealed she: *Had been hospitalized since she was admitted to the facility but did not remember why. *Did not recall having been given a bed hold notice but was allowed to return to the facility after that hospital admission. 2. Review of resident 9's electronic medical record (EMR) revealed: *She admitted to the facility on [DATE]. *She was transferred and admitted to the hospital on [DATE]. -Her power of attorney (POA) was notified of that transfer. -There was no documentation that indicated the bed hold information was given to the resident or her POA. 3. Interview on 3/11/25 at 12:35 p.m. with resident 186 revealed she: *Had been hospitalized recently but could not recall the date of that hospitalization. *Did not recall having been given a bed hold notice but was allowed to return to the facility after that hospital admission. 4. Review of resident186's EMR revealed: *She admitted to the facility on [DATE]. *She was admitted to the hospital on [DATE] after a clinic appointment. *She was her own responsible party. *There was no documentation that indicated the bed hold information was given to the resident. 5. Review of resident 2's EMR revealed: *She admitted to the facility on [DATE]. *She had been hospitalized on [DATE] and returned to the facility on 5/28/24. *She was her own responsible party. *There was no documentation that indicated the bed hold information was given to the resident. 6. Interview on 3/12/25 at 4:25 p.m. with licensed practical nurse (LPN) I regarding bed hold notices revealed: *If a resident went to the hospital the nurse would have notified the POA of that hospitalization and documented that notification in the EMR progress note. *The social worker was responsible for completing and providing the bed hold notices. 7. Interview on 3/13/25 at 8:36 a.m. with administrator A regarding bed hold notices revealed: *She expected the business office manager would have provided the bed hold to resident 9 when she was admitted to the hospital after her clinic appointment because she was her own responsible party. -That business office manager no longer worked at the facility. *The bed hold notice for resident 9 had not been provided for the above hospitalization. *There had been recent staffing changes, and she now expected the social services designee to provide the bed hold notices when a resident transferred to the hospital. 8. Interview on 3/13/25 at 10:48 a.m. with assistant administrator C revealed bed hold notices were not provided to resident 186 or resident 2 for the above hospitalizations. 9. Review of the provider's undated Bed Reserve Policy Notification revealed: *This Bed Reserve Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. *Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. Under certain conditions, we can reserve your existing bed for you at your request, so when you return to the facility, you will have the same bed and room as before. *My signature below acknowledges that I have been provided with a copy of the South Dakota Bed Hold Policy.

Based on record review and interview, the provider failed to notify or provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for three of three sampled residents (2, 9, and 186) who were hospitalized after admission to the facility. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *She admitted to the facility on [DATE]. *She was admitted to the hospital on [DATE] and returned to the facility on 5/28/24. *There was no documentation that indicated the ombudsman was notified of that transfer. 2. Review of resident 9's EMR revealed: *She admitted to the facility on [DATE]. *She was transferred to the hospital and admitted on [DATE]. *There was no documentation that indicated the ombudsman was notified of that transfer. 3. Review of resident186's EMR revealed: *She admitted to the facility on [DATE]. *She was admitted to the hospital on [DATE]. *There was no documentation that indicated the ombudsman was notified of that transfer. 4. Interview on 3/13/25 at 8:36 a.m. with administrator A regarding providing notice to the ombudsman of resident transfers to the hospital revealed: *She expected the business office manager to have completed the notification to the ombudsman of resident 9's transfer to the hospital. -That business office manager no longer worked at the facility. *There was no documentation that indicated the ombudsman had been notified of resident 9's transfer to the hospital. *There had been recent staffing changes, and she now expected the social services designee to provide the notification to the ombudsman when a resident transferred to the hospital. 5. Interview on 3/13/25 at 10:48 a.m. with assistant administrator C revealed there was no documentation that indicated the ombudsman had been notified of resident 2 or resident 186's transfers to the hospital. 6. Interview with the facility's local ombudsman by email on 3/13/25 at 1:06 p.m. regarding notification of resident transfers to the hospital revealed she had not received notifications of resident 2, 9, or 186's above hospital transfers. 7. Review of the document shared by the Ombudsman revealed: *Notice before transfer. *Before a facility transfers or discharges a resident, the facility must - (i) *Notify the resident and the resident representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. *That facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Based on South Dakota Department of Health (SD DOH) complaint online report, interviews, records review, and policy review, the provider failed to ensure one of one resident (1) had been free from a significant medication error when he was administered two long-action insulins at the same time for four consecutive days. Findings include: 1. Review of the SD DOH 12/12/24 intake information revealed: *I am writing to file a complaint regarding [long-term care provider's name]. There was a sentinel event [not anticipated] that could have ended a resident's life. *[Resident 1] (4/5/1956) was transported to [name of hospital] on 12/12/24 for complaints of hypoglycemia and altered mental status. It was reported by [registered nurse (RN) K] (nursing home staff) that the patient's blood sugar was 24 at their facility. No interventions were completed by the nursing home staff at that time, only waiting for [ambulance name] to arrive. [RN K] reported that the patient has been having hypoglycemic episodes for the past 5 days. *Upon inspection of the MAR [medication administration record] sent with the patient to our facility, it was discovered that the patient was getting dosed with two different types of long-acting insulin types. The insulins that were administered were Touje [Toujeo] SoloStar 44 IU [international units] daily and Tresiba Flex INJ [injection] 40 IU daily. *The pharmacist at [hospital's name], [pharmacist's name], spoke with [provider's pharmacy name] regarding the two prescriptions for long-acting insulin. It was made to light that the brand of insulin was changed due to insurance funding issues. The patient was to change from Touje [Toujeo] to Tresiba because his insurance did not cover Touje [Toujeo]. There was a delay from when the Tresiba order was signed and when the medication arrived at the facility. Per [provider's pharmacy name], the facility was supposed to non-administer the Tresiba until the entirety of the Touje [Toujeo] insulin pen was administered. On 12/6/24 and 12/7/24 the Tresiba was non-administered by their pharmacy's directions. However, on 12/8/24 the patient started to receive both the Tresiba and Touje [Toujeo] every day until 12/12/24 when the Touje [Toujeo] order was discontinued per the estimated length of time for the pen to run out per [provider's pharmacy name]. Patient received both the insulins from 12/8-12/11/24. *The facility was updated when the patient was admitted for his hypoglycemia and blood sugar monitoring. A nursing report was given to [RN K] at [provider's name] and she stated she had no idea the patient was receiving two types of long-acting insulin. However, upon inspection of their MAR it seems that she potentially gave the does on 12/9/24 and 12/10/24 per their MAR user abbreviations. Review of resident 1's 12/12/24 ED note revealed: *[AGE] year-old male with type 2 diabetes on insulin presented to [hospital's ED name] via EMS [emergency medical services] due to being unresponsive secondary to hypoglycemia. Blood sugar was initially reported by nursing home staff to be 24. Blood sugar increased to 73 after receiving D10 [dextrose] by EMS. Patient was responsive and answering questions. He ate toast without difficulty. Serum blood sugar reading was 41. Suspected that patient may be receiving multiple long-acting insulin medications unintentionally which occurred related to insurance requesting changing insulin options and having to re-order new medication, apparently both Toujeo and Tresiba were administered for 4 days. *He last received double coverage of insulin yesterday morning. Concerned that he may have persistent hypoglycemia until insulin wears off. Recommended admission to [hospital's name] for observation to ensure his blood sugar levels return to baseline and adjust his diabetes medication. Review of resident 1's electronic medical record (EMR) revealed he: *Had an admitted [DATE]. *Had a diagnosis of Type 2 diabetes and was dependent upon the use of insulin to maintain his blood sugar levels. *Had a Brief Interview for Mental Status (BIMS) score of 11 that indicated he had mild cognitive impairment. *Was dependent upon the staff to: -Assist him with medication administration and ensure he received the right medication and the right dose. -Ensure they followed-up with the physician and pharmacy department regarding any medication order discrepancies and clarification of those orders. -Communicate with each other on order changes received from the pharmacy department or physician to ensure his safety from medication administration errors. Continued review of resident 1's electronic medical record (EMR) from 12/6/24 through 12/12/24 revealed: *On 12/6/24 at 2:57 p.m. there was a nurse progress note (PN) that indicated the resident to be given Tresiba Flex [insulin] 40 units once a day starting the next morning. -There was no documentation that supported the Tresiba should not have been given until the Toujeo insulin supply was all gone. *On 12/7/24 at 8:36 a.m. RN E documented that she had administered only the Toujeo. -There was no documentation that supported why she only administered the Toujeo. -There was no documentation that she had contacted the physician or the pharmacy department for clarification of the two long-acting insulin orders. *On 12/9/24 at 7:49 a.m. RN K gave the resident 6 ounces (oz) of orange juice. -There was no documentation that supported why she had given him orange juice. -The MAR documentation indicated that: --His blood sugar level had been checked and was low at 62. --She administered both the Toujeo and Tresiba insulins shortly after she had given him orange juice for a low blood sugar level. *On 12/10/24 the physician had seen the resident and decreased the Toujeo by 2 units. -There was no documentation that those two long-acting insulins had been clarified with the physician. *On 12/12/24 at 3:30 a.m. a certified nursing assistant (CNA) had observed the resident in the doorway of a shared bathroom. Another resident had been attempting to hold him up and telling him to hang on. The CNA attempted to direct the resident to sit down on the toilet but he could not follow directions. He was alert but unable to speak. The nurse and CNA were able to assist him to sit down in the wheelchair (w/c). -His blood sugar level had been checked and was low at 45. -The nurse administered a glucose injection into his abdomen per physician orders. -His blood sugar continued to drop to 40 and remained low at 44. -The nurse administered another glucose injection. He was able to drink a glass of orange juice and eat 1/2 a cup of ice cream. -His blood sugar level continued to rise from 49, 57, and 73. By 4:45 a.m. his blood sugar level had risen to 101. -A note regarding the resident's hypoglycemic episode was sent to the physician. *On 12/12/24 at 8:51 a.m. social services designee L had written a PN that the wife of the resident was called and informed he was sent to the ED due to being nonresponsive and a low blood sugar. *On 12/12/24 at 9:03 a.m. RN K documented: -This RN went into this resident room after being notified by [nurse consultant A], [director of nursing (DON) B] instructed me to call the ED to give report, this RN left the room to call the [local ED] to give report on this resident being sent to ER for hypoglycemia, this RN updated this resident's name, birthdate, & is having hypoglycemia episodes to the ER nurse, [DON B] was in the room with this resident until the ambulance arrived, this resident's blood sugar was taking [taken] by the [DON B], [DON B] stated this resident blood sugar was 24, the blood sugar was stated to the ER nurse that it was 24, the ER nurse state you need to recheck the blood sugar & if it is still low give him some honey or glucose, or something, you can't send him here with a low blood sugar, so they need to recheck the blood sugar, this RN let the ER nurse know that a call back will be given, resident is in & out of consciousness & is not able to swallow at this time, the ambulance is here for transport, resident left by ambulance, resident's spouse was phone called, no answer left a voice mail on her phone message to call facility for update & this resident is being transferred to the [hospital's ED]. -At 12:40 p.m. the ED had called to inform RN K that the resident was admitted for observation due to hypoglycemia and a urinary tract infection. Review of resident 1's 12/6/24 through 12/12/24 MAR revealed he had been given both the Tresiba and Toujeo insulins every day at the same time on 12/8/24, 12/9/24, 12/10/24, and 12/11/24. There was no documentation that supported those nurses had contacted the physician or the provider's pharmacy for clarification of the insulin orders. Review of resident 1's 12/12/24 medication variance report revealed: *An internal report had been completed he had an hypoglycemic episode and required the activation of the EMS system. *He was found cool, clammy, unresponsive, eyes open, and he was grunting. *His blood sugar was tested and had been below the typical range of 80 to 130 milligrams (mg)/deciliter (dl). -The blood sugar level was 24. Review of the provider's 12/13/24 Safety Huddle meeting notes revealed that there was to be education on insulin administration and pharmacy training. 3. Interview on 12/17/24 at 4:10 p.m. with RN E revealed: *She was aware of the insulin medication errors that had been found the prior week regarding the resident 1. *She had worked during that time frame that he had two orders on his MAR for both of the long-acting insulins. *She only administered the Toujeo insulin to the resident and did not administer the Tresiba insulin. *She stated: -I thought it was strange that he had two long-acting insulins and just gave the one that we always had. -I charted that too. -The Tresiba was there, I just didn't remove it and give it to him. *The provider had a new pharmacy and a new process for entering the medication orders onto the resident's MAR. -The staff faxed the medication orders to the pharmacy and they would update the resident's MAR with the new or changed orders. *The Toujeo was not going to be covered by the resident's insurance and it was going to be replaced with Tresiba. *The pharmacy had expected there to be a delay with the delivery of the new insulin and the staff were to continue giving resident 1 the Toujeo until it was gone. -That information had not been communicated amongst the staff or from shift-to-shift. -The pharmacy had entered the new order on the resident's MAR but had not added to hold it until the Toujeo was completed. -There were two orders on the resident's MAR to administer both of those long-acting insulins at the same time every day. -The Tresiba had been delivered to the facility the next day and was available to be administered. *She had not: -Contacted the pharmacy or the physician to clarify those orders that were entered in the MAR for resident 1 to receive two long-acting insulins at the same time. -Communicated that discrepancy to the next nurse coming on shift. *She stated: -I got busy and forgot about it. -Besides common sense would tell you not to give two long-acting insulins. *The nursing staff had been educated to: -Not assume that another nurse would have known not to administer two long-acting insulins at the same time. -Make sure to report off to the next nurse coming on shift. Interview on 12/18/24 at 8:00 a.m. with resident 1 regarding the incident on 12/12/24 revealed he: *Was alert and oriented to self. *Remembered being sent to the hospital and that his insulin had to be adjusted. *Was not able to recall why he had been hospitalized . *Stated: My memory is poor. Interview on 12/18/24 at 9:25 a.m. with RN H revealed she: *Had been employed with the facility approximately three weeks. *Had been educated that morning on: -Not administering two long-acting insulins. -The importance of clarifying with the doctor if there were two orders to administer long-acting insulins. *Had worked the morning of 12/11/24 but could not recall if she had administered both of the insulins to resident 1. Interview on 12/18/24 at 9:45 a.m. with DON B revealed: *She had been the DON since November 2024. *Prior to November she had been the assistant DON from April 2024. *She did not recall if the prior DON had completed medication administration competencies for the nursing staff. *She was not able to find any medication administration competencies for the nursing staff. *They should have completed medication administration competencies yearly. -She knew that because they had just been placed on her desk. *They had not completed any recent medication administration competencies. Interview on 12/18/24 at 9:50 a.m. and again at 2:35 p.m. with licensed practical nurse (LPN) D revealed: *She filled-in as needed at this facility. *She had received education yesterday on: -The importance of contacting the physician or pharmacy on any orders that do not look correct. -An overview for insulin administration. -There was a double check verification process for new orders to make sure they were entered correctly. *To her knowledge there was no other education or competencies on medication administration initiated since this incident to ensure residents safety. Interview on 12/18/24 at 5:10 p.m. with administrator C, DON B, and nurse consultant A revealed: *They had recently changed pharmacies and the new process was implemented on 12/2/24. *The pharmacy was in charge of changing and updating all the physician orders in the residents' MARs. *The staff would have faxed any order changes to the pharmacy and they would make the changes. *The staff should have checked to make sure the orders had been implemented correctly. *The order change for resident 1 regarding the two long-acting insulins had come from the pharmacy because insurance was no longer going to pay for the Toujeo. *The pharmacy had called to speak with the nurse in charge on 12/6/24 regarding the insulin medication change. -The staff were to continue giving the Toujeo until it was completed and the new Tresiba insulin arrived. -The Tresiba had come in right away and was placed in the medication compartment with the Toujeo for resident 1. -The charge nurse who had spoken with the pharmacy had failed to pass on the process to the on-coming nurse. *The pharmacy had put the order for resident 1's new insulin in the MAR to be started right away and did not delete the old insulin order. *RN E had caught the discrepancy with the duplicate order the next day but she had not: -Called the pharmacy or the physician to clarify the order. -Communicated this discrepancy with the other nurses to ensure a significant medication error had not occurred. *They would have expected RN E to have completed the above process and RN E was re-educated on that. *They initiated education with the nursing staff on 12/13/24. -They had educated the staff when they worked their next shift. -The education included recognizing duplicate orders and contacting the pharmacy and the physician to clarify the orders. -The 5 rights of medication administration. -Pharmacy training on the new process of verifying the orders in the resident's MAR had been entered correctly. *They could not locate or recall the last time medication administration competencies had been completed on the staff who administered residents' medications. *The only audit they had initiated to ensure the residents were safe from significant medication errors was a daily audit to compare the new orders with the resident's MAR to ensure the pharmacy had entered it correctly. *They had not initiated any other audits or medication administration competencies since the occurrence with resident 1 to ensure: -The staff had understood the process changes and implemented them correctly. -All residents who were dependent upon the staff to administer their medications had done so safely, correctly, and according to the 5 rights of medication administration. *They had not considered implementing those audits on medication administration for the safety of the residents. Review of the provider's December 2019 Medication Administration - General Guidelines policy revealed: *Medications are administered as prescribed in accordance with good nursing principles and practices *FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and policy review, the provider failed to follow their grievance policy regarding a complaint filed by a family member on behalf of resident 2 who had received services from the facility. Findings revealed: 1. Review of the provider's 8/14/24 SD DOH FRI revealed: *On 8/14/24 the daughter of resident 2 had voiced concerns regarding services provided to her mother (resident 2) which included the following: -Potential staff improper use of mechanical lifts with resident transfers which may have resulted in resident 2 having a dislocated hip that was later discovered while she was hospitalized . -Short staffing. -Long call light wait times. -A COVID-19 positive resident wandering the facility and possibly infecting others. -Resident 2 had symptoms of black/tarry bowel movements. *The report had not indicated nursing followed-up with the physician in response to resident 2's black/tarry bowel movement symptoms. Review of resident 2's electronic medical record revealed: *On 7/7/24 at 8:37 p.m. there was a nurse progress note that indicated: -Resident continued to complain of stomach pain. -She had a poor appetite and ate very little at meals. -She had needed more assistance from staff with transfers. -She was noted to have dark/tarry bowel movement. -When the on-call physician was notified, the nurse was advised to continue to monitor resident 2, to call with any changes of resident's condition, and set up an appointment with resident 2's primary physician for the next morning. *There had been no documentation resident 2 had been seen by her primary physician on 7/8/24. *On 7/9/24 at 6:13 p.m. there was a nurse progress note that indicated resident 2 had been transferred to the emergency room due to a suspected gastrointestinal bleed. Interview on 12/18/24 at 3:54 p.m. with administrator C regarding resident 2 and review of the provider's 8/14/24 SD DOH FRI regarding resident 2 revealed: *The surveyor requested a copy of the grievance investigation and response to the family of resident 2 that was filed with the facility. *The requested grievance and investigation was not available. *They had no documentation that indicated an investigation had been conducted regarding resident 2's daughter's concerns. *Administrator C had filed an incident report with the SD DOH after the daughter's concerns were brought to her attention. -The daughter felt there had been poor communication between the facility nurses and a lack of follow through from facility nursing with resident 2's physician. -Resident 2 had continued stomach discomfort leading up to her transfer to the emergency department on 7/9/24 where she was diagnosed with a gastrointestinal bleed. *Administrator C could not remember if she had spoken with resident 2's family about their concerns. *The former director of nursing (DON) and administrator C had been responsible for following their grievance process for any grievances filed with the facility. *That DON had left their employment recently and had been replaced about a month ago by DON B who previously had been the assistant DON. *The facility's human resources representative had been recently appointed to address resident grievances and was following through with their grievance policy. *She thought the former DON had been addressing the grievances but there was no documentation to prove investigations had been completed and their grievance process had been followed. *They had not been following their grievance policy. *Administrator C confirmed she was responsible for ensuring any facility grievances were addressed in a timely manner and that had not happened for resident 2. Review of the provider's revised September 30, 2024 Grievances policy revealed: *It is the policy of this facility to investigate all grievances registered by, or on behalf of a resident, without the threat of reprisal in any form. Residents are encouraged to express grievances on behalf of themselves or others to the facility's Administrator, the Resident Council, State or Government Agencies, or other persons. The Administrator shall provide all residents or their representatives with the name, address and telephone number of the appropriate state government office where complaints may be lodged. Procedure: 1. The facility will establish a Grievance Policy that will be made available to the resident upon request. 2. The facility Administrator has been designated to receive all grievances. 3. The facility will notify the resident individually or through postings in prominent location of the facility the right to file grievance orally, in writing or anonymously. a. The notification will include the name, address, and phone number of the grievance official, a reasonable time frame to investigate the grievance, and the resident's right to obtain a written copy of the grievance investigation if requested. b. The notification will also include the contact information for agencies where the grievance can also be reported to appropriate state agencies. 4. Any resident or representative or member of the resident's family or the resident council may present a grievance to the Administrator or designee orally or in writing. 5. The Administrator or designee shall confer with persons involved in the incident and other relevant persons and within three [3] days of receiving the grievance shall provide a written explanation, upon request, of findings and proposed remedies to the complainant and the aggrieved party, if other than the complainant and legal representative, if any. Where appropriate, due to the mental or physical condition of the complainant or aggrieved party, an oral explanation shall accompany the written one. 6. During the investigation, the facility will put in place immediate action to prevent potential violation of resident's rights. 7. If the grievance involves suspected abuse, neglect, injury of unknown source, or misappropriation of property, abuse protocol will be followed. [See Abuse and Neglect Policy] 8. All written grievance decisions will include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings, or conclusions regarding the resident's concerns [s], a statement as to whether the grievance was confirmed or not confirmed, any corrective action to be taken by the facility as a result of the grievance, and the date the written decision was issued. 9. If grievance is confirmed, the facility will take appropriate corrective action. 10. The facility will maintain results for 3 years.

Based on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. * On 9/29/24, staff was notified by family that resident 1's right wrist was swollen. Nursing was unaware of the swelling, assessed the wrist, and notified the physician. The staff thought the swelling may have been caused by the sling during a transfer. It was also reported that resident 1 had a small bruise on his penis. Review of resident 1's 9/30/24 hospitalization medical records revealed: * Discharge plan had noted Additionally he [resident 1] fell a few weeks ago and hasn't been using his right hand. Nobody has evaluated his right hand and wrist in the clinic or emergency department [ED]. * Resident one was diagnosed with a right scapholunate ligament tear (tissue that connects the scaphoid and lunate bones in the wrist and most common cause is a fall on the wrist). * The assessment and plan on 10/1/24 indicated a right scapholunate ligament tear that required a splint. The resident was not a candidate for surgery. 2. Interview on 10/8/24 at 11:30 a.m. with certified nurse aide (CNA) H revealed: * On or around 9/27/24 she reported to the nursing staff an incident of possible abuse regarding two other CNAs. She reported that the CNA came out of resident 1's room and had stated, that motherfucker. When CNA H had asked the other CNA what had happened, the CNA stated that resident 1 had started fighting with them during a transfer so instead of using a total body mechanical lift as it was care planned, they decided to use a two-assist (two staff) transfer to get him on the toilet. CNA H reported the incident to an unidentified nurse. She was unsure if it was investigated. * On 9/29/24, she reported to the nursing staff a sore on resident 1's scrotum and a bruise on his penis. CNA H felt that the bruising may have been caused by the two-assist transfer a few days prior. * She was not sure if the bruising was investigated. No one had followed up with her regarding the incident. 3. Record review of nursing progress notes for resident 1 revealed: *A 9/15/24 nursing progress note indicated that the resident was complaining of left knee pain. Evaluation of the knee indicated that the left knee appeared swollen and tender to the touch. The resident had denied any injury that he could remember. A CNA had reported to the nurse that transferring the resident was difficult that day. It was noted that his left knee was wrapped, elevated, and ice was applied. An appointment would be considered for evaluation the next day. * A 9/29/24 nursing progress note indicated that resident 1's family was visiting during supper and had brought to the attention of the staff that resident 1's right wrist was swollen. It was noted that there were no reports of falls that day and the cause of the swelling was unclear. The physician was notified, and staff were instructed to apply ice to the area and to monitor overnight. If the condition had worsened, an x-ray would have been considered. 4. Interview on 10/8/24 at 12:45 p.m. through 1:00 p.m. with CNA K and director of nursing (DON) B revealed: *If CNA K had witnessed an incident of abuse or neglect, she would report it to the nurse on duty. * DON B stated that all reports to the nurses regarding abuse and neglect would have been taken very seriously and the administrator would have been notified immediately. Interview on 10/8/24 at 1:15 p.m. with administrator A revealed: * She had not been notified of the allegations of abuse regarding resident 1. * She was not able to provide documentation of any investigations to rule out abuse and neglect regarding the injuries of unknown origin related to resident 1's left knee and right wrist. * She stated that it was determined that the localized swelling in resident 1's left knee and right wrist was due to the resident 1's disease process. 5. Review of the SD DOH facility incident reporting database revealed: * No report was made regarding staff reporting to family that resident 1 had fallen on or around 8/21/24. * No report was made regarding the resident's swollen left knee and the cause was undetermined on 9/22/24. * No report was made regarding the report to staff of resident 1's swollen wrist and the cause was noted to be unclear. * No report was made regarding the bruise on resident 1's penis that was identified on 9/29/24. 6. Review of the provider's 7/31/24 Incident reporting policy revealed: * The provider would report any serious injury sustained by a resident that was not an expected outcome of the disease process would have been reported. * An incident that does not result in serious injury will not be reported. * The policy defined that physical harm did not include skin tear or bruise or something that could be covered with a band-aid. But that physical harm included a fracture or blood flow not stopped by a band- aid or hospital treatment that involves more than diagnostic evaluation only with subsequent finding of no injury do not need to be reported. Review of the provider's 7/12/24 abuse and neglect policy revealed: * Injury of unknown origin were injuries that met all three criteria according to the SOM [State Operations Manual]: - The source of injury was not observed by any person. - The source of injury could not be explained by the resident. - The injury was suspicious because of the extent of the injury or the location of the injury (the injury was in an area not generally vulnerable to trauma) or the number of injuries at one particular point in time or the incident of injuries over time. * Examples of possible reportable injuries that may fall under the definition of injuries of unknown origin included: - Unobserved/unexplained fractures, sprains, or dislocations. - Unobserved/unexplained scratches or bruises found in suspicious locations such as the head, neck, upper chest, and back. - Unobserved/unexplained swelling that was not linked to a medical condition. - Unobserved/unexplained bruising or other injuries in the genital area, inner thighs, or breasts. - Unobserved/unexplained injury requiring transfer to the hospital for examination and/or treatment. - Any injury that was explained and appeared to be a result of abuse must be reported. * If abuse was suspected the provider would have: - Took immediate steps to assure the protection of the residents. - Notified the appropriate/designated authorities or organization. - Conducted a careful and deliberate investigation centering on facts, observations, and statements from the alleged victim and witnesses. - Notified authorities if the abuse was also a case of a crime. - Report investigation findings to the state health department.

Based on complaint intake report review, record review, observation, interview, and policy review. The provider failed to ensure adequate fluid intake, monitoring, and interventions for 6 of 6 sampled residents [1, 2, 3, 4, 5, & 6] resulting in dehydration and hospitalization for one of six sampled residents [1]. Findings include: 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake report revealed: *On 7/29/24, it was observed by resident 1's family member that he was having difficulty eating and was asking for more water. He had already had his liquid limitation for supper. Resident 1's family member asked for additional fluids for resident 1 and was denied additional fluids due to resident's fluid restriction. *On 8/29/24, it was observed by a family member that resident 1's water pitcher was out of reach for the resident, it was unmarked and sitting next to his roommate's urinal. The straw wrapper was still on the straw that was placed in the water pitcher. *On 9/30/24, Resident 1's family requested reports on resident 1's vital signs, weights, and intake and output records. The provider was unable to locate the intake and output in the records. Review of resident 1's 9/30/24 hospitalization medical records revealed: * Resident was hospitalized on [DATE] * History and physical on 9/30/24 reported weakness that was multifactorial due to acute dehydration and malnutrition. * Resident had drank three liters of fluid on the day of admission to the hospital. * Discharge plan on 9/30/24 reported dehydration and weakness. * Laboratory findings included: - Potassium was low at 3.4. - BUN (blood urea nitrogen) was high at 27. - Albumin was low at 3.2 and is an indicator of poor nutrition. 2. Observation on 10/7/24 at 11:21 a.m. revealed: * Resident 2's water pitcher was out of reach. * Resident 3 did not have a water pitcher. * Residents 4 and 5 both had a full water pitcher sitting on their nightstands. The pitchers were not cold and there was no visible ice in the water. 3. Interview on 10/7/24 at 1:15 p.m. with dietary aide I revealed: * She would document the resident's fluid intake on the daily nutrition intake form and enter it into the residents Electronic Medical Record (EMR). * The daily fluid intake forms would have been filed at the nurse's station. Interview on 10/7/24 at 1:30 p.m. with certified nurse aide (CNA) H revealed: *Resident 3 should have had a water pitcher and should have been offered water between meals and during care. *Residents who were to have their liquids thickened would not normally have fluids offered to them between meals. Interview and observation on 10/7/24 at 2:00 p.m. with CNA E revealed: * She had been employed with the provider for [AGE] years. * Resident 3 required thickened liquids and residents with thickened liquids would sometimes not have water available at their bedside. * There would have been thickened liquids in the fridge to offer resident 3. * There was no thickened liquid in the fridge where CNA E stated it would be. * She thought resident 3 should have had water or liquids offered to her during resident checks and when providing her care. * Resident 3 would need assistance to drink and could not communicate her needs to staff. Interview on 10/7/24 at 2:10 p.m. with CNA F revealed: * The resident's water pitchers were filled with water and ice twice during the day shift. * It was not in her normal procedure to encourage residents to drink water between meals. Interview on 10/7/24 at 3:30 p.m. with Administrator A revealed: * Resident 1 was on a 2000 milliliter (mL) a day fluid restriction related to heart failure. * Dietary staff were to provide Resident 1 with 960 mL per day. * Nursing staff were to provide Resident 1 with 1040 mL per day. * Resident 1's fluid intake should have been documented in two places in the resident's EMR. * Administrator A stated that Resident 1's EMR fluid intake report was not an accurate account of the resident's actual fluid intake. * There was no process in place to accurately document resident's fluid intakes. Interview on 10/7/24 at 4:00 p.m. with registered nurse (RN) G revealed: * If a resident was on a fluid restriction, the CNAs would have given him the fluid intake report at the end of the shift. He would have noted the amount left in the resident's water pitcher and then documented in the treatment administration record (TAR). Interview on 10/8/24 at 9:00 a.m. with dietary aide J revealed: * She would document the resident's fluid intake on the daily nutrition intake form and enter it into the resident's EMR. * If she noticed a resident had not drunk any fluids all day, she would only record this in the EMR but not report it to the nursing staff because she is not part of the medical staff. Interview 10/8/24 at 9:44 a.m. with director of nursing (DON) B and (DON) D revealed: * On 10/7/24 Resident 5 had not consumed any fluids for breakfast, lunch, or supper. * On 10/7/24 Resident 6 had not consumed any fluids for breakfast, lunch, or supper. * The resident's recorded fluid intakes from the daily nutrition intake form that would have been entered into the EMR would have not alerted nursing staff if a resident was not drinking fluids. 4. Review of residents 1's 7/17/24 care plan revealed: * He had impaired skin integrity. * Interventions included: - Staff were to encourage good nutrition and hydration. Review of Resident 2's 8/28/24 care plan revealed: * Resident 2 was at risk for alteration in nutritional status related to: recent admission, poor PO [oral] intake and a skin wound. * She required assistance with [ADLs] activities of daily living. This included eating. * She had impaired skin integrity. * Interventions included: - Staff were to encourage good nutrition and hydration in order to promote healthier skin. - Staff were to monitor for signs and symptoms of dehydration and weight loss. - She would sit at the assisted table for meals for eating assistance. Review of Resident 3's 5/1/24 care plan revealed: * She was at risk for impaired skin integrity. * She was at risk for alteration in nutritional status. * Interventions included: - Staff were to offer extra fluids. - Staff were to encourage good nutrition and hydration in order to promote healthier skin. - Staff were to encourage fluid intake to help liquefy secretions. - She was dependent on staff for all care needs. - She was dependent on staff for assistance with meals. Review of resident 4's 7/18/24 care plan revealed: * He had required assistance with ADLs including eating. * He was at risk for altered skin integrity. * Interventions included: - He was dependent on staff for eating and drinking. - Staff were to encourage good nutrition and hydration. Review of resident 6's 7/18/24 care plan revealed: * He had the potential for impaired skin integrity. * He was at risk for dehydration due to use of a diuretic. * Resident took Lasix related to edema (fluid retention). * Interventions included: -Staff were to assess for signs of dehydration. -Staff were to encourage good nutrition and hydration in order to promote healthier skin. -Staff were to monitor for any sign and symptoms of fluid deficit. Review of the provider's 7/30/24 Hydration policy revealed: * The purpose of the policy was to ensure that residents are adequately hydrated. * Staff were to encourage fluid intake unless contraindicated. * Staff were to ensure that during meals, residents have fluids with their food. * Staff were to ensure that during meals, there is an available source of hydration when a resident asks for it. * Staff were to ensure that residents who are able to drink and pour themselves water have water pitchers *Those residents with physician orders for strict intake and output (I & O) will have their intake and output strictly measured and recorded in their I & O record.

Based on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. * On 9/29/24, staff was notified by family that resident 1's right wrist was swollen. Nursing was unaware of the swelling, assessed the wrist, and notified the physician. The staff thought the swelling may have been caused by the sling during a transfer. It was also reported that resident 1 had a small bruise on his penis. Review of resident 1's 9/30/24 hospitalization medical records revealed: * Discharge plan had noted Additionally he [resident 1] fell a few weeks ago and hasn't been using his right hand. Nobody has evaluated his right hand and wrist in the clinic or emergency department [ED]. * Resident one was diagnosed with a right scapholunate ligament tear (tissue that connects the scaphoid and lunate bones in the wrist and most common cause is a fall on the wrist). * The assessment and plan on 10/1/24 indicated a right scapholunate ligament tear that required a splint. The resident was not a candidate for surgery. 2. Interview on 10/8/24 at 11:30 a.m. with certified nurse aide (CNA) H revealed: * On or around 9/27/24 she reported to the nursing staff an incident of possible abuse regarding two other CNAs. She reported that the CNA came out of resident 1's room and had stated, that motherfucker. When CNA H had asked the other CNA what had happened, the CNA stated that resident 1 had started fighting with them during a transfer so instead of using a total body mechanical lift as it was care planned, they decided to use a two-assist (two staff) transfer to get him on the toilet. CNA H reported the incident to an unidentified nurse. She was unsure if it was investigated. * On 9/29/24, she reported to the nursing staff a sore on resident 1's scrotum and a bruise on his penis. CNA H felt that the bruising may have been caused by the two-assist transfer a few days prior. * She was not sure if the bruising was investigated. No one had followed up with her regarding the incident. 3. Record review of nursing progress notes for resident 1 revealed: *A 9/15/24 nursing progress note indicated that the resident was complaining of left knee pain. Evaluation of the knee indicated that the left knee appeared swollen and tender to the touch. The resident had denied any injury that he could remember. A CNA had reported to the nurse that transferring the resident was difficult that day. It was noted that his left knee was wrapped, elevated, and ice was applied. An appointment would be considered for evaluation the next day. * A 9/29/24 nursing progress note indicated that resident 1's family was visiting during supper and had brought to the attention of the staff that resident 1's right wrist was swollen. It was noted that there were no reports of falls that day and the cause of the swelling was unclear. The physician was notified, and staff were instructed to apply ice to the area and to monitor overnight. If the condition had worsened, an x-ray would have been considered. 4. Interview on 10/8/24 at 12:45 p.m. through 1:00 p.m. with CNA K and director of nursing (DON) B revealed: *If CNA K had witnessed an incident of abuse or neglect, she would report it to the nurse on duty. * DON B stated that all reports to the nurses regarding abuse and neglect would have been taken very seriously and the administrator would have been notified immediately. Interview on 10/8/24 at 1:15 p.m. with administrator A revealed: * She had not been notified of the allegations of abuse regarding resident 1. * She was not able to provide documentation of any investigations to rule out abuse and neglect regarding the injuries of unknown origin related to resident 1's left knee and right wrist. * She stated that it was determined that the localized swelling in resident 1's left knee and right wrist was due to the resident 1's disease process. 5. Review of the SD DOH facility incident reporting database revealed: * No report was made regarding staff reporting to family that resident 1 had fallen on or around 8/21/24. * No report was made regarding the resident's swollen left knee and the cause was undetermined on 9/22/24. * No report was made regarding the report to staff of resident 1's swollen wrist and the cause was noted to be unclear. * No report was made regarding the bruise on resident 1's penis that was identified on 9/29/24. 6. Review of the provider's 7/31/24 Incident reporting policy revealed: * The provider would report any serious injury sustained by a resident that was not an expected outcome of the disease process would have been reported. * An incident that does not result in serious injury will not be reported. * The policy defined that physical harm did not include skin tear or bruise or something that could be covered with a band-aid. But that physical harm included a fracture or blood flow not stopped by a band- aid or hospital treatment that involves more than diagnostic evaluation only with subsequent finding of no injury do not need to be reported. Review of the provider's 7/12/24 abuse and neglect policy revealed: * Injury of unknown origin were injuries that met all three criteria according to the SOM [State Operations Manual]: - The source of injury was not observed by any person. - The source of injury could not be explained by the resident. - The injury was suspicious because of the extent of the injury or the location of the injury (the injury was in an area not generally vulnerable to trauma) or the number of injuries at one particular point in time or the incident of injuries over time. * Examples of possible reportable injuries that may fall under the definition of injuries of unknown origin included: - Unobserved/unexplained fractures, sprains, or dislocations. - Unobserved/unexplained scratches or bruises found in suspicious locations such as the head, neck, upper chest, and back. - Unobserved/unexplained swelling that was not linked to a medical condition. - Unobserved/unexplained bruising or other injuries in the genital area, inner thighs, or breasts. - Unobserved/unexplained injury requiring transfer to the hospital for examination and/or treatment. - Any injury that was explained and appeared to be a result of abuse must be reported. * If abuse was suspected the provider would have: - Took immediate steps to assure the protection of the residents. - Notified the appropriate/designated authorities or organization. - Conducted a careful and deliberate investigation centering on facts, observations, and statements from the alleged victim and witnesses. - Notified authorities if the abuse was also a case of a crime. - Report investigation findings to the state health department.

Based on interview, observation, record review, and policy review, the provider failed to adequately assess one of four resident's (43) ability to safely smoke unsupervised that resulted in the resident falling outside on two separate occasions and sustaining head injuries. Findings include: 1. Interview on 11/7/23 at 3:56 p.m. with registered nurse (RN) V about the residents who smoked revealed: *None of the residents who chose to smoke were supervised while they were outside. -They had been evaluated and determined to be safe to smoke independently. *It was the expectation that the residents were responsible for notifying staff when they wanted to be let back inside via the doorbell on the wall outside. *The doorbell was out of the resident's reach if they were to have fallen outside. Interview on 11/8/23 at 8:58 a.m. with licensed practical nurse (LPN) F about the residents who smoked revealed: *Resident 43 had fallen at least twice while outside smoking in the courtyard. *She said, We don't have enough staff to have someone sit out there to supervise. 2. Observation on 11/8/23 at 9:59 a.m. revealed that resident 43 was outside in the courtyard smoking without any supervision. Observation on 11/8/23 at 10:10 a.m. in the courtyard revealed: *There was a doorbell on the wall to the left of the door. -When pressed, a doorbell sound was audible inside. *There was one glass ashtray available with several cigarette butts and ashes in the tray. *There were two lawn chairs and one bench just outside the patio door. *A white plastic garbage can with a lid and a plastic liner was to the left of the door. -The garbage can was filled with empty cigarette cartons and visibly burnt, used cigarette butts. *A red metal bucket with a lid was to the left of the corner of the building. -Inside the bucket, there were several visibly burnt, used cigarette butts and cigarette ashes. 3. Interview on 11/8/23 at 10:19 a.m. with regional nurse consultant (RNC) D about the provider's smoking rules and resident 43's falls revealed: *She explained that resident 43 had fallen because directly before going outside to smoke, the resident had been given her bedtime medications. -Resident 43 became dizzy due to her medications. As a result, she fell and hit her head. *She confirmed that staff now give the resident her bedtime medications after her final cigarette for the day. *Resident 43 was assessed for smoking safety and was determined to not need supervision while smoking outside. *They had discussed with the residents previously about establishing a smoking schedule to provide more supervision; however, the residents were not in favor of a schedule. *She was not aware that residents had been placing their burnt and used cigarette butts in the white garbage can. She confirmed that was an unsafe practice due to the risk of a fire. 4. Review of the resident's electronic medical record revealed that she was hospitalized overnight from 9/29/23 to 9/30/23, and again on 10/1/23 to 10/2/23 due to her falls. Review of a nurse's progress note on 9/29/23 at 11:21 p.m. revealed: *Resident left the facility per ambulance at 2315 [11:15 p.m.]. Dr. [name redacted] [gave order] to have a scan completed due to resident's complaint of severe [head pain] and she is currently taking Eliquis [an anticoagulant medication]. *There were no other progress notes with a description of the fall from 9/29/23. *She returned to the facility on [DATE] at 2:30 a.m. Review of the resident's hospital discharge paperwork that was sent to the facility on [DATE] at 1:24 a.m. revealed the clinical impressions included contusion of head and acute hip pain. Review of the resident's September 2023 medication administration record (MAR) revealed she received the following medications at 8:00 p.m. per physician's orders on 9/29/23: *tiZANidine HCl Oral Tablet [a muscle relaxant] 4 MG [milligrams] Give 1 tablet by mouth at bedtime for muscle spasms. *traZODone HCl Oral Tablet [an antidepressant and sedative] 50 MG Give 0.5 tablet by mouth at bedtime for Insomnia. *Zolpidem Tartrate Oral Tablet [a sedative] 5 MG Give 2 tablet by mouth at bedtime for Insomnia. -Only one tablet was administered. Review of the resident's October 2023 MAR revealed she received the following medications at 8:00 p.m. per physician's orders on 10/1/23: *tiZANidine HCl Oral Tablet 4 MG Give 1 tablet by mouth at bedtime for muscle spasms. *traZODone HCl Oral Tablet 50 MG Give 0.5 tablet by mouth at bedtime for Insomnia. *Zolpidem Tartrate Oral Tablet 5 MG Give 2 tablet by mouth at bedtime for Insomnia. Review of a medication administration note on 10/1/23 at 7:41 p.m. revealed: *Note Text: LORazepam Oral Tablet 0.5 MG. Give 1 tablet by mouth every 4 hours as needed for anxiety and agitation for 14 Days. resident request for anxiety. Review of an incident note on 10/1/23 at 11:30 p.m. revealed: *Incident Summary: Called to patio outside facility where resident had been [to go] out for a cigarette. Resident is observed lying on the concrete on her [right side] propped up by her elbow. Her seated walker is behind her. *Resident reports that she hit her head and has [a headache]. She said she got 'dizzy' and fell . *Resident is observed for injury. Lump to back right side of her head is noted. *Small amount of blood with bruising is seen. Resident is [sic] staff assisted to her walker and brought back into the facility. VS [vital signs] are obtained and neuro checks are initiated. *Calls placed to [name redacted] POA [power of attorney] at 2119 [9:19 p.m.] and resident's [ex-spouse] to inform her of resident's fall. *Resident was declining to be seen and was showing signs of confusion, agitation and hypotension. With some encouragement resident did agree to go to [the hospital] to be evaluated. *DON [director of nursing], ADON [assistant director of nursing], Administrator and Regional Nurse consultant were notified at 2056 [8:56 p.m.] of fall. Notified again at 2203 [10:03 p.m.] of resident being sent to [the hospital] for evaluation. Resident was sent via EMS [emergency medical service] at 2215 [10:15 p.m.]. Review of the resident's hospital discharge paperwork that was sent to the facility on [DATE] at 12:24 a.m. revealed: *The clinical impressions included contusion of head and concussions. *The patient specific instructions read, Do not give zolpidem, [A]tivan, tizanidine, trazodone or any other sedating medications before patient is in bed for the evening and had her final trip outdoors for the night. Patient appears to have concussion from multiple falls. Headache, confusion are to be expected . Review of resident 43's undated care plan revealed: *She was admitted on [DATE]. *Relevant diagnoses included absence epileptic syndrome, not intractable, without status epilepticus [a seizure condition in which the person stops all activity, and appears to be staring into space, may affect the person's situational awareness, does not last longer than five minutes, and is able to be controlled by medications]; nicotine dependence; vitamin D deficiency; hypothyroidism; essential hypertension; depression; chronic obstructive pulmonary disease; immune thrombocytopenic purpura; anxiety disorder; type 1 diabetes mellitus with diabetic neuropathy; insomnia; unspecified severe protein-calorie malnutrition; portal hypertension. *There was the following intervention: The resident has been assessed according to facility policy and has been determined to be a safe smoker, capable of following the applicable rules. That was initiated on 9/22/23. *There was no documentation in her care plan that she had sustained falls with injury while smoking or any additional precautions staff should have taken regarding safe smoking, such as administering her bedtime medications after her final cigarette for the day. Review of the resident's assessments titled Smoking Program (Evaluation for Risk) - V 2 completed on 9/22/23 and again on 10/4/23 revealed: *The following statement was check-marked with both assessments: Resident is considered a safe smoker and May use/access smoking materials consistent with facility policy. Staff is not required to remain in attendance while resident is smoking. RESIDENT AGREES TO FOLLOW SMOKING RULES. *The assessments had not taken into consideration contributing factors to smoking safety such as risk for falls, diagnoses, or medications that might have put the resident at risk for accidents while smoking. 5. Review of the provider's September 2019 Smoking policy revealed: *Policy: This facility shall establish and maintain safe resident smoking practices while protecting the rights of the individual resident. *Facilities, at their discretion, may not allow smoking on their premises or may allow smoking only when the resident requires no supervision to smoke, or may offer smoking times and supervised smoking only. *Procedures: .If the facility allows smoking, all residents who smoke will be assessed for their ability to safely smoke with or without assistance or supervision and such will be included on the care plan. The Smoking Assessment will be completed at admission, readmission quarterly, annually, and with a change in condition. -a. Facility will provide staff, family or volunteer supervision when assessment determines supervision is required . -b. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. *Designated smoking areas include: - .e. A suitable number of noncombustible ashtrays will be provided in smoking areas. --1. To reduce the potential for a burning cigarette to fall out of the ashtray and onto nearby combustibles, only ashtrays designed with holders inside the ashtray will be used. --2. Cigarettes or other smoking materials will not be left unattended in ashtrays. -g. Smoking areas will be provided with metal containers equipped with self-closing covers to be used solely for the disposal of cigarette butts and ashes. --1. A sign to that effect will be posted on the containers. --2. All cigarettes and other smoking materials will be promptly disposed of in these containers and are not allowed to be discarded elsewhere. *The staff shall consult with the Attending Physician and the Director of Nursing to determine any restrictions on a resident's smoking privileges. *Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's individual care plan.

A. Based on observation, interview, and record review, the provider failed to clarify one of one sampled resident's (35) medication dosage from a physician's order which resulted in the resident receiving 8 times the intended prescribed dose of an antipsychotic medication for 14 days, which potentially contributed to his increased lethargy during that time. Findings include: 1. Observation and interview on 11/6/23 at 2:19 p.m. with resident 35 revealed: *He was hard of hearing and could not answer questions. *He was sitting in a Broda chair. *He appeared very thin, his eyes and temples were sunken, and was calling for his mother and father. 2. Review of resident 35's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *Relevant diagnoses included unspecified dementia, diffuse traumatic brain injury, and bilateral hearing loss. *A 9/14/23 physician's fax order for Start Zyprexa 205 mg [milligrams] po [orally] BID [twice daily] from a hospital in Sioux Falls. *The physician's order that was entered into the resident's EMR on 9/14/23 was for 20 mg, not 205 mg as the faxed physician's order had read. *He received 20 mg of Zyprexa twice daily from 9/14/23 to 9/28/23. *He experienced increased episodes of lethargy between 9/14/23 when the Zyprexa was started, to 9/28/23 when the Zyprexa order was decreased. *A nurse's progress note from 9/28/23 at 4:21 p.m. indicated, Writer had phone conference today with the [hospital] team. During conference writer was informed that on the notes that we received 2 weeks ago .there was a typo. Order was supposed to be for [Zyprexa] 2.5mg BID. [Hospital team] stated this is why he is having so many episode[s] of lethargy. Orders received today was to decrease [Zyprexa] to 2.5mg TID [three times daily]. *A 9/28/23 physician's order for Reduce olanzapine [Zyprexa] to 2.5 mg po TID from the same hospital in Sioux Falls. *The resident had received eight times the intended prescribed dose of Zyprexa from 9/14/23 to 9/28/23. 3. Interview on 11/8/23 at 10:22 a.m. and again at 3:28 p.m. with assistant director of nursing (ADON) E revealed she: *Confirmed she had entered the order for Zyprexa as 20 mg BID on 9/14/23. *Should have clarified the physician's order from 9/14/23 as the initial faxed physician's order for 205 mg was out of the ordinary. *Confirmed she had not called the physician to clarify the order. Interview on 11/8/23 at 2:51 p.m. with Administrators A and B revealed their expectation was that all medication orders that were out of the normal dosage for a medication should have been clarified prior to administration of that medication. 4. A policy for resident prescription verification was verbally requested on 11/8/23 at 3:30 p.m. from ADON E. She indicated there was no such policy. 48058 B. Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident's (12) medicated topical cream had a physician's order. Findings include: 1. Observation on 11/7/23 at 8:30 a.m. of licensed practical nurse (LPN) F during the medication administration revealed: *Certified nursing assistant (CNA) staff had approached LPN F and explained that resident 12 had requested BioFreeze cream to her right hip and upper right thigh. *LPN F had stated that the resident had a different cream that she preferred to use in the resident's room. *Upon entering resident 12's room, LPN F searched and eventually found a tube of Arthritis Relief Pain Relieving Cream with Aloe on the resident's bedside table. *After confirming with resident 12 that the tube of cream was hers, LPN F administered the topical cream. 2. Review of resident 12's EMR revealed: *She had a physician's order for the BioFreeze. *There was no order for the Arthritis Relief Pain Relieving Cream with Aloe that LPN F had administered. *There was no documentation on the treatment administration record (TAR) or medication administration record (MAR) that the Arthritis Relief Pain Relieving Cream with Aloe was to have been administered to the resident. 3. Observation on 11/8/23 at 8:53 a.m. in resident 12's room revealed: *A basket was sitting next to the sink that contained a tube of cream stacked on top of various lotions. *The label on the tube of cream identified it as Arthritis Relief Pain Relieving Cream with Aloe 10% trolamine salicylate. *There was no label on the tube indicating whose cream it was. *There was no date written on the tube indicating when the cream had been opened. 4. Interview on 11/8/23 at 10:09 a.m. with LPN F revealed: *Resident 12 had a physician's order for the BioFreeze but the resident did not like the cold sensation or the smell of the BioFreeze. *She would make a note in the resident's medical record that the cream had been administered. *She agreed that there was no physician's order for the Arthritis Relief Pain Relieving Cream with Aloe. *She agreed that the Arthritis Relief Pain Relieving Cream with Aloe should not have been stored in the resident's room. Interview on 11/8/23 at 2:44 p.m. with ADON E and regional nurse consultant D revealed they agreed that there should have been a physician's order for the arthritis cream found in resident 12's room and that it should not have been kept in her room. 5. Review of the providers undated MEDICATION STORAGE IN THE FACILITY policy revealed: *B. Administration *1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. *2. Medications are administered in accordance with written orders of the prescriber. *D. Documentation (including electronic) *3. Topical medications used in treatments are listed on the treatment administration record (TAR/e[electronic]TAR). *4. The resident's MAR/e[electronic]MAR is initialed by the person administering the medication . *5. When PRN [as needed] medications are administered, the following documentation is provided: *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 [the] person recording administration and signature or initials of person recording effects, if different from the person administering the medication.

Based on closed record review, interview, and policy review, the provider failed to appropriately assess, monitor, and make timely arrangements for transfer to a higher level of care for one of one sampled resident (4) who had a change in his medical condition after a fall. Findings include: 1. Review of resident 4's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He was alert and oriented (memory okay). *He had been participating in physical and occupational therapies to regain strength. *A physician's orders [REDACTED]. -Oxygen at 2 liters per minute (lpm) per nasal cannula. Up to 4 lpm with activity. He had required the use of that oxygen continuously at 2 lpm. -[MEDICATION NAME] (pain medication) 5/325 milligrams (mg) 1 tablet orally (po) twice a day. He took those pills at 8:00 a.m. and 8:00 p.m. everyday. -[MEDICATION NAME] 5/325 mg 1-2 tablets po every 4 hours as needed (prn) for pain. *He had been able to walk short distances with the use of a wheeled walker (w/w). Attached to that w/w had been an oxygen tank. *On 12/20/15 at 12:40 p.m. he had been walking on his own and had fallen. Review of resident 4's 12/20/15 Post Fall Analysis/Plan revealed: *Fall details: Lost strength. *Subjective or resident states: -Headache. -Dizziness/Faint. -Discomfort in area of trauma. -Resident had been ambulating in halls for exercise. *Physical assessment after fall: -Anxious/irritable. -Skin tear to his left shoulder, left side of face, left eyebrow. -Redness/swelling/bruise, to left side of face, eye. -Range of motion to both arms and legs had been normal. -He had denied any pain. *The interdisciplinary care team had: -Reviewed the fall on 12/21/15 at the stand-up meeting. -Recommended to monitor and assess any further events of dizziness. *His wife had been notified of the fall. *The certified nurse practitioner (CNP) had not been notified of the fall until 12/21/15. No time of day had been documented. Review of resident 4's nursing progress notes from 12/20/15 through 12/23/15 revealed on: *12/20/15: -He had fallen while walking on his own. -At 2:56 p.m. he had requested a [MEDICATION NAME] for a pain level of ten (excruciating pain). That pain pill had been effective. -At 9:40 p.m. Scheduled [MEDICATION NAME] (pain medication) given at HS (hour of sleep) muscle pain all over, especially his upper chest area. No documentation to support the nurse had assessed his chest area for increased bruising, tenderness from touch, swelling, or abnormal lung sounds. *12/21/15: -1:15 a.m. Resident c/o (complaining of) pain in the right side of his chest when he takes deep breaths. His O2 (oxygen) sats (saturation) were 88% (normal 90% or greater), so turn his O2 up to 4 lpm, and his sats went up to 92%. Lungs have ronchi (abnormal lung sounds) throughout on expiration. He stated he didn't know what to rate his pain at, but when I watched him take deep breaths his facial scale would be seven out of ten. He states he is still using the incentive spirometry (device to help keep lung airways open), but he can't get his lung volume as high as he could prior to the fall. Resident also states that it really hurt on the right side when he coughed. The resident is definitely weaker now than he was prior to his fall. Requesting pain medication, he stated I don't know what the pain rating would be he stated his right upper chest hurt on inspiration (inhaling) since he fell . -1:15 a.m. [MEDICATION NAME] 1 tablet given. Requesting pain medication, he stated I don't know what the pain rating would be he stated his R (right) upper chest hurt on inspiration since he fell . By facial scale he is seven out of ten. -1:55 a.m. [MEDICATION NAME] DM (cough syrup) requested for cough. He has a wet productive cough, have not seen what he is coughing up. -3:30 a.m. PRN administration was ineffective. Resident stated his right side of his chest still hurt really bad, so I gave him another [MEDICATION NAME]. His pain scale he now rates at seven out of ten. -11:46 a.m. O2 at 2 lpm up to 4 lpm with activity. -12:52 p.m. [MEDICATION NAME] 2 tabs given prior to whirlpool for c/o right sided chest pain. -1:33 p.m. (name of CNP) notified of resident fall and laceration. O2 small tanks have been ordered. -There was no documentation to support the CNP was notified of the resident's significant change in medical status. Those areas of change had been an increase in pain to his right side, productive cough with abnormal lung sounds, and a need for his oxygen level to have been increased from 2 lpm to 4 lpm. -2:35 p.m. He had continued to c/o right chest pain and was tender to the touch. The nurse had observed no bruising to that area. -8:48 p.m. O2 90% with O2 on continuous at 4 lpm per nasal cannula. Resident complaining that chest and ribs hurt when coughing, PRN cough syrup given with some relief. -11:13 p.m. prn [MEDICATION NAME] 1 tablet had been given for c/o rib pain from his fall. *12/22/15: -1:47 a.m. the prn [MEDICATION NAME] given at 11:13 p.m. was ineffective and another pain pill had been administered. The resident has continued to be in pain. Follow-up pain scale was 7. -5:01 a.m. Resident had wanted to see a doctor during the night because his ribs hurt, also wanting the ambulance called. Informed resident that writer would report pain in ribs to AM shift, so they can call doctor during clinic hours. Resident had [MEDICATION NAME] 2 tabs at 3:38 a.m., and was c/o no relief at 4:15 a.m. Resident does rest at intervals, but says has not rested at all. -2:58 p.m. Resident is currently at clinic seeing on call doctor for c/o rib and chest discomfort. O2 sats 85% today with oxygen at 4.5 liters, attempted to use incentive spirometer but unable to take very deep breaths. Faint bruise noted to left side of chest. There was no documentation to support the family had been notified of the physician visit. -There was no documentation to support the resident had received any pain medication after 4:15 a.m. or had been assessed for an increase in pain. -3:25 p.m. Call received from clinic. Res (resident) being admitted to hospital with pneumonia. *12/23/15 at 12:05 p.m. Res passed away at hospital this a.m. *There was no documentation to support the physician had been notified of the resident's change in his medical condition until 12/22/15 when he had been assessed in the clinic. Review of resident 4's December 2015 Medication Administration Record [REDACTED] *12/1/15 through 12/19/15 he had received only two extra doses of hyrdrocodone for complaints of pain. *12/20/15 through 12/23/15 after his fall he had requested six extra doses of [MEDICATION NAME] for complaints of pain. Interview on 3/29/16 at 1:40 p.m. with licensed practice nurse (LPN) A regarding resident 4 revealed: *She confirmed he had an intact memory, and his requests to the staff were appropriate. *She had taken care of the resident on 12/22/15, two days after his fall. *He had complained of rib pain that day but not shortness of breath. *She could not recall: -Giving him any extra pain medication to help decrease that pain. -Increasing the resident's O2 from 4 lpm to 4.5 lpm. -If she had notified the family but had called to set-up the clinic appointment for him. -Much about his condition that day or if his condition had worsened from the fall. Interview on 3/29/16 at 2:00 p.m. with the administrator revealed the director of nurses was not available, and questions should be directed to the Minimum Data Set (MDS) assessment coordinator. Interview on 3/29/16 at 2:40 p.m. with the MDS assessment coordinator regarding resident 4 revealed: *She had been working on 12/20/15, the day of the resident's fall, and been part of the initial post-fall assessment of him. *She confirmed the resident had a change in medical condition after his fall. *The resident's wife was aware he had fallen, because she came to visit while they were doing the post-fall assessment. *The CNP had: -Been in the facility seeing other residents on 12/21/15 per her usual schedule. -Not seen the resident or assessed his condition after the fall. -Not been informed of the resident's change in condition on 12/21/15 when she had been in the facility. *The nursing staff should have contacted the physician on 12/21/15 after the nurse noted a change in his medical condition or he should have been seen by the CNP when she was in the facility. *She was not aware if the family had been notified of the resident's change in condition or of his physician's appointment on 12/22/15. *She agreed the nurses had failed to: -Appropriately assess the resident after his fall with his complaints of increased pain, productive cough, and increase in O2 needs. -Monitor and notify the physician and family in a timely manner of the resident's change in condition. -Notify the physician for an order to increase his O2 beyond 4 lpm. Interview on 3/30/16 at 7:00 a.m. with LPN B revealed: *She had worked the night shift after resident 4's fall. *She confirmed the resident had appeared to be in more pain after the fall. *Resident 4: -Had complained of increased rib pain and had requested to go to the hospital. -Had been assessed, and she had noted a bruised area on the left side of his chest. -Had not been assessed for any increase in pain from touch or increased congestion in his lungs. *She did not feel based on her observations and assessments he required hospitalization . *During the night they try to wait until the next day for the residents to see their physicians. *She stated (resident name) wanted to go to the hospital many times during his care here. She had not always documented those requests to go to the hospital. As a nurse she should have assessed his pain and chest better. *The expectation of the nursing staff was they were to notify the physician and family with a fall or change in condition. *She agreed if the documentation was not there the assessment or task would had not have been considered completed. Interview on 3/30/16 at 7:30 a.m. with the administrator revealed: *He had arranged for all of the transportation in the facility. *He had arranged for resident 4 to be transported by their facility van on 12/22/15. *The maintenance supervisor drove the resident to his physician's appointment that day. *No staff or family had gone along with the resident in the van. That had not been an uncommon occurrence. *The families had not always been notified of all physicians' visits. *If the resident had been their own power-of-attorney (POA) they were not required to notify the families. *He was not surprised the family had not been notified of the clinic appointment, because he did not have a POA and could act on his own behalf. *When he arranged the transportation for resident 4 he had not been aware the resident had: -A change in condition since his fall on 12/20/15. -Increased pain. -The need for his O2 to be increased significantly. -Requested an ambulance during the night. Interview on 3/30/16 at 8:30 a.m. with registered nurse (RN) C regarding resident 4 revealed: *She confirmed the resident had an intact memory and could make his needs known to the staff. *The resident would become impatient with his requests, but his requests were accurate and justifiable. *She had been working the day he fell . *He had complained of right-sided rib pain after the fall. That area had been tender to the touch. *She had reported the fall and change in condition to the director of nursing. *She had not reported the fall or any change in condition of the resident to the family or physician. *She stated: Well it was probably my responsibility to report to the physician. I didn't feel that he was that critical. I don't know why they did not notify the physician. I don't know when the physician was actually notified. *The nursing staff should have notified the physician when the resident had an increase in pain and increase in O2 needs. *She confirmed If a resident requested an ambulance to be called they should have honored that request. Interview on 3/30/16 at 10:15 a.m. with the clinic physician who had seen resident 4 on 12/22/15 revealed: *He could not remember all of the details on the day the resident had visited the clinic. *He had been concerned the resident had a: -Change in status. -Combination of not getting enough air and pain. *The x-ray had revealed significant pneumonia. *He had referred the surveyors to review his clinic assessment documentation. Review of resident 4's 12/22/15 physician's clinic report revealed: *History of present illness: He is brought to the clinic today with increasing shortness of breath, cough, and rib pain after a fall at the nursing home on 12/20/15. He was a little light-headed, and he fell over and knocked the anterior chest wall against his oxygen tank. He is on supplemental O2 for his [MEDICAL CONDITION] with increased O2 requirement over the last two days. *Pain: 10/10 worst/intolerable. *Chest: Lungs have diminished breath sounds with poor air movement. *Impression: Pneumonia, right lung. Interview on 3/30/16 at 10:23 a.m. with the licensed social worker revealed: *The family and physician should have been notified when the resident had a change in condition. *Families should be notified with any physician visits/appointments. *It was a resident right to request an ambulance. Review of the provider's undated Long-Term Care Facilities Resident's Bill of Rights pamphlet revealed: *A long-term care facility must notify you when your condition changes. *A facility must inform you, consult with your physician, and, if known, notify your legal representative or interested family member when any of the following occurs: -You were injured in an accident and may potentially require a physician. -Your physical, mental or psychosocial status changes significantly. -Your treatment needs altered significantly. -The facility decides to transfer or discharge you. Review of the provider's undated Deciding About Going to the Hospital policy revealed: *A copy of the policy was provided to the resident/family member upon admission to the facility. *Whether hospitalization can be prevented depends on the resident's condition, the ability of the staff to provide the care necessary in the nursing home, and the preferences of the resident and her or his family. The provider had no policy or procedure for post fall assessments when requested from this surveyor, and none were provided prior to exit. Review of the provider's 11/12/14 Notification of Change in Resident Health Status policy revealed: *The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's interested family member when there is: -Notification: within 24 hours from the time an assessment has been made indicating there may be a potential for physician intervention. -Acute illness or a significant change in the resident's physical, mental, or psychosocial status. -A need to alter treatment significantly. -A decision to transfer or discharge the resident from the center. Review of the provider's 2/10/15 Pain Management Guideline policy revealed: *Guideline statement: To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life, in concert with the patient's/resident's plan of care and goals for pain management. *Following an acute change in condition when pain is suspected, and after any fall, the licensed nurse assesses the patient/resident for pain, using the appropriate pain scale and documents assessment findings. Discusses the findings with the patient's/resident's physician or provider, and receives any new orders for evaluation and treatment of [REDACTED]. Review of the provider's 9/10/14 Charge Nurse RN job description revealed: *Responsible for the independent supervision of the delivery of care to a group of residents in a nursing unit. Assess resident needs, develop individual care plans, administer nursing care, evaluate nursing care. *Assure that effective quality nursing care is delivered which is outcome focused through utilization of the nursing process. *Identify needs and provide input for discharge planning and follow-up throughout length of stay. *Work in collaboration with the physician and/or other health care professionals by sharing information relevant to changing plan of care. *Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices. Review of the provider's 3/29/13 Charge Nurse LPN job description revealed: *Responsible for the independent supervision of the delivery of care to a group of resident in a nursing unit. Assess resident needs, develop individual care plans, administer nursing care, evaluate nursing care. *Assure that effective quality nursing care is delivered which is outcome focused through utilization of the nursing process. *Identify needs and provide input for discharge planning and follow-up throughout length of stay. *Work in collaboration with the physician and/or other health care professionals by sharing information relevant to changing plan of care. *Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.

Based on observation, interview, record review, and policy review the provider failed to continually assess, monitor, document, and report the acute pain of one of one sampled cognitively impaired resident (2) in the Alzheimer's care unit (ACU) with acute pain. Findings include: 1. Review of resident 2's medical record revealed: *He had been diagnosed with [REDACTED]. *He had been placed in the ACU to ensure his safety and well-being due to his mental impairment. *On 4/26/12 nursing noted he was having pain with ambulation, and he was complaining of pain in his right hip. He was subsequently sent to the physician's office on 4/27/12 to have his hip evaluated. X-rays from that visit were negative for a fracture. The physician had ordered continued use of Tylenol three times a day, and okay for weight bearing and physical therapy. *The resident had received a total of eight as needed doses of Tylenol for pain level ratings ranging from five to ten in May 2012. *On 5/1/12 he had fell at 10:35 a.m. and at 10:40 p.m. Fall reports from those times indicated: -He had been found on the ACU kitchen floor at 10:35 a.m. Passive range of motion evaluation was performed by the ACU director and was found difficult to perform on the right leg. The physician was notified of the fall, and no new orders were received. -He had been found on the floor next to his bed at 10:40 p.m. by his roommate. He was noted to have a skin tear to his left hand. No nursing documentation of the evaluation of his hips was in that report. The nurse had documented "Has had back and hip pain and has not been able to get around as well in the past. "No documentation of physician notification regarding the second fall was noted in the fall report or in the nurses notes. *The ACU director contacted the resident's physician on 5/3/12 regarding pain, and the physician had no new orders. *A significant change Minimum Data Set was initiated on 5/10/12 due to his decline in bed mobility, transferring, locomotion, and toileting related to hip and sacral area pain. *On 5/15/12 he was seen by his physician at the facility for follow-up related to right hip injury. His dictation from that time indicated the resident was "Still not ambulating well on his hip." He also noted the resident had no new complaints. No documentation was noted related to pain. *No nursing documentation of the resident's pain was noted in the progress notes until 5/21/12 at 2:20 p.m. when the secure unit director had written the resident continued to complain of pain and pinching in his hip, and he was not making progress in physical therapy. The physician was then notified of the above and had ordered a computed tomography (CT) scan. *The 5/22/12 CT scan showed the resident had a comminuted impaction-type right femoral neck fracture. Interview on 5/22/12 at 10:05 a.m. with physical therapy (PT) aide H regarding resident 2 revealed: *She had worked with the resident the majority of the times he had come to the rehabilitation department for therapy. *He had frequent severe pain when moving or standing and was frequently upset with her when she performed therapy. *She was concerned something more was wrong with him due to the amount of pain he had with therapy. She had the physical therapist evaluate him on 5/10/12 but was informed it was okay to continue therapy. *She recently only performed electronic stimulation of his right hip as he would have too much pain otherwise. *She had informed the ACU director about her concerns related to his pain level with therapy on 5/4/12, the director of nursing (DON) on 5/17/12, and the DON and social worker on 5/21/12 as she still believed something was wrong with his leg. *He was unable to express his pain level due to his cognitive status. He would not demonstrate a pain response unless he was moved, stood, or made to do range of motion with his right extremity. *She was not aware the orders for physical therapy had been made prior to his two falls on 5/1/12. *She was not aware the X-rays performed on him that cleared his hip for physical therapy were prior to the two falls he had on 5/1/12. *She was unsure as to what pain medications he was receiving prior to therapy but again confirmed he had little pain relief during therapy. Interview on 5/22/12 at 10:30 a.m. with the ACU director regarding resident 2 revealed: *He had been having significant pain in his right hip since late April 2012, but the provider had not been able to identify the cause of that pain. That pain had significantly affected the resident's activities of daily living that had resulted in her completing the significant change MDS noted above. Prior to the time of his hip pain he could walk on his own and perform many of the activities of daily living. *He only complained of pain when he was moved. If he was in his wheelchair or in bed he had not complained of pain. *She had contacted the physician related to his hip pain on 5/3/12. The physician had ordered the same dose of Tylenol he was already on, so no new order was received. She stated she had not contacted the physician for further orders after that until the order for a CT scan had been received. *She was on vacation on 5/15/12 when his physician came for a follow-up visit and was unsure of the findings of that visit as it had not yet been dictated. However she was able to show this surveyor that no new orders had been received to help address the resident's pain. *No daily documentation of the resident's pain level was in his medical record since his acute pain had started. The last formal documentation of his pain had been on 5/10/12 when the significant change MDS had been completed. Review of resident 2's 5/10/12 care plan revealed: *He should have been assessed for pain, and the medical doctor should have been contacted if the pain was not controlled. *The characteristics and frequency/pattern of his pain should have been evaluated. *The need for pain medications prior to treatments or therapies should have been evaluated. *His pain level should have been established using a numeric scale/evaluation. Observation and interview on 5/22/12 at 11:20 a.m. of resident 2 revealed: *When staff transferred him to his wheel chair per the stand aide he grimaced with pain. When asked by this surveyor where his pain was he explained he was hit by a truck. He could not describe his pain level or the location of his pain at that time. However he stated his eye bothered him. Further evaluation of his ability to describe his pain revealed he was not cognitively able to describe his pain. *The ACU director stated that transfer had gone a lot better than most of his recent transfers, as he usually had more pain than that. *The ACU director confirmed he had never been able to use a pain scale to describe his pain. Interviews on 5/22/12 at 2:45 p.m. and at 4:00 p.m. with the DON, ACU director, and nurse consultant regarding resident 2 revealed: *They agreed no continual assessment of his pain had been completed. *They agreed regular documentation of the frequency, intensity, and cause of his pain had not been completed. *They confirmed his physician had not been contacted to request stronger pain medications since 5/3/12. *The DON was with his physician on 5/15/12 when he had seen the resident. She had not informed the physician about the significant pain he was having with physical therapy and with ambulation and moving, as she had not been aware of it. *They agreed if continual monitoring and assessment of his acute pain by all departments had been completed it would have been easier to ensure proper, early intervention of pain management was completed. Review of the provider's revised January 2011 pain management guideline revealed: *Pain was the residents fifth vital sign. *Pain intervention should have occurred prior to the pain becoming severe. *Documentation of the pain assessment, interventions, and evaluations should had been documented in a clear and concise manner per the plan of care. *Resident 2's pain should have been documented using the advanced dementia pain scale. *Acute pain documentation should have been in the resident's nurses' progress notes until the resident's pain had been stabilized. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO. pp. 477 and 1239 - 1249 revealed: *Complete and appropriate documentation was a vital aspect of nursing practice. *"Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice." *"Nurses need to approach pain management systematically to understand a client's pain and to provide appropriate intervention." *Acute pain should have been monitored and documented on a daily and on an as needed basis to ensure proper pain intervention.