Every finding on record at Avantara North

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed regarding the residents' nasal cannulas being dated and stored in plastic bags when they were not in use for four of four sampled residents (1, 9, 11, and 15) who required the use of oxygen, and one of one sampled resident (11) who used a nebulizer (a device that converts liquid medication into an inhalable mist) machine that was not cleaned after each use by the nursing staff. Findings include:1. Observation and interview on 2/18/26 at 9:01 a.m. with resident 15 in his room revealed: *He was lying in his bed. *He had an oxygen concentrator in his room that was running, and it had oxygen tubing and a nasal canula (flexible tubing with prongs that deliver oxygen through the nose) connected to it. *The oxygen tubing and nasal canula were lying on the floor. *He said, I don't really need it [oxygen], but they're making me wear it. Further observation on 2/18/26 at 11:56 a.m. in resident 15's room revealed he was sitting in his wheelchair, with the oxygen tubing and nasal cannula attached to the portable oxygen tank. The part of the nasal cannula that would go into the resident's nose was touching the wheel of the wheelchair that had contact with the floor. Observation and interview on 2/20/26 at 10:55 a.m. with infection preventionist (IP) G in resident 15's room revealed: *The oxygen tubing and nasal canula connected to the concentrator were wrapped around the bedrail. *That did not meet her expectation of how the oxygen tubing and nasal canula should be stored. She would expect the oxygen tubing and nasal canula to be stored in a plastic bag while not in use by the resident according to the provider's policy. 2. Observation on 2/18/26 at 9:44 a.m. in resident 1's room revealed: *He was sitting in his wheelchair. *He had an oxygen concentrator in his room with oxygen tubing and a nasal canula connected to it. The oxygen tubing and nasal canula were draped across his bed and hanging off the side of it. Further observation on 2/18/26 at 4:06 p.m. in resident 1's room revealed that the oxygen tubing and nasal canula that were attached to the concentrator were lying on the floor. 3. Observation on 2/18/26 at 12:03 p.m. in resident 9's room revealed: *She had an oxygen concentrator with a nasal cannula attached to it. There was no date on the tubing of that nasal cannula to indicate when it was last changed. Review of resident 9's EMR revealed: *She had a physician's order for one to two liters as needed to keep oxygen saturation (percentage of oxygen in the blood) above 90% [percent]. The progress notes indicate that she would occasionally need oxygen after experiencing a seizure (a sudden, uncontrolled electrical activity in the brain that can cause temporary changes in behavior, movement, awareness, or sensation). *There was no physician's order to change the resident's nasal cannula tubing. 4 Observation on 2/18/26 at 12:09 p.m. with resident 11 in her room revealed: *She was sitting in her wheelchair that had a portable oxygen tank on the back. The oxygen tubing and nasal canula that were attached had a label dated 12/28. *There was an oxygen concentrator in her room that had oxygen tubing and a nasal canula connected to it dated 12/28. *There was a nebulizer machine on her nightstand that had the tubing and mask connected to it, and the medication chamber had liquid inside. The nebulizer mask was lying directly on the nightstand, uncovered. Further observation and interview on 2/19/26 at 11:02 a.m. with resident 11 in her room revealed: *The nebulizer machine was in the same condition as observed on 2/18/26. *She used the nebulizer machine three times per day. *She said some staff members do take the nebulizer mask off, rinse it, and let it dry between treatments, and others did not. Observation and interview on 2/20/26 at 10:53 a.m. with IP G in resident 11's room revealed: *The nebulizer machine was in the same condition as observed on 2/18/26 and 2/19/26. *She acknowledged that the nebulizer machine was not being cleaned and stored according to the provider's policy. She would expect staff to rinse the medication chamber and mask, then place them on a clean paper towel or cloth to dry. 5. Interview on 2/20/26 at 8:51 a.m. with registered nurse (RN) H revealed: *The residents who needed oxygen had a physician's order to change their nasal cannula and oxygen tubing weekly. Those orders generated a task for the staff to document when it was completed. That task was performed on Sunday nights by the overnight staff. *The staff were expected to discard the resident's soiled nasal cannulas and write the current date on the new nasal cannulas. *She confirmed that resident 9 did not have a physician's order to change her nasal cannula. *She confirmed that the nasal cannula in resident 9's room did not have a date written on it and confirmed that the nasal cannula change was not documented in her electronic medical record (EMR). She agreed that without a date or documentation of the nasal cannula change, it was unknown how old that nasal cannula was. 6. Interview on 2/20/26 at 10:13 a.m. with assistant director of nursing (DON) B and director of nursing (ADON) C revealed: *That if a resident did not have a physician's order to change their nasal cannula, then the staff would not be prompted to change it weekly per the provider's policy. They acknowledged that there was no indication of when resident 9's nasal cannula was last changed. 7. Interview on 2/20/26 at 11:02 a.m. with DON B and ADON C regarding the above observations of storage and cleaning of respiratory equipment revealed: *They agreed that the respiratory equipment was not being properly stored and cleaned following the provider's policy, which increased the risk of infection control issues. They expected the staff to follow the provider's cleaning policies for resident medical equipment. 8. Review of the provider's 11/18/25 Oxygen Administration policy revealed: *The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. The nasal cannula and tubing will be changed weekly and as needed. Change of tubing and cannula should be documented. When not in use, the nasal cannula should be stored in a plastic bag. 9. Review of the provider's 1/14/26 Nebulizer Cleaning policy revealed: After each use, the mask/reservoir will be cleaned. Rinse mask/reservoir with tap water and place upside down to dry on a paper towel or cloth towel. 10. Review of the provider's undated Guidelines for Legionella Control revealed: *Identify Areas Subject to Legionella, Colonization and Growth -5.) Respiratory therapy equipment *Control Measures & Corrective Action -.Nebulizers are cleaned after each use by nursing.

Based on observation, interview, record review, and policy review, the provider failed to ensure professional standards were met regarding one of one sampled resident (64) who was not prescribed a dose amount for his lidocaine (pain) medication by his physician, and two of two registered nurses (RN) (E and F) administered that medication without knowing the recommended amount. Findings include:1. Observation and interview on 2/19/26 at 5:37 p.m. with registered nurse (RN) E in the main dining room revealed:*RN E was preparing medications for resident 64. He had a physician's order on his medication administration record (MAR) to receive Lidocaine Viscous HCL Mouth/Throat Solution 2% [percent] with the instructions to apply one application [to the] mucous membrane (inside of the mouth) three times a day for oral pain, apply the medication directly to the affected area with a cotton swab, allow to sit TID (three times a day) before meals. The medication came in a bottle with those same instructions printed on the label. The lidocaine medication label and resident 64's MAR did not indicate the dose of lidocaine to be given per application.*RN E prepared resident 64's lidocaine medication. She stated that she usually poured about 5 mL (milliliters) of the medication into a clean medication cup. She would then use a clean cotton-tipped applicator to soak up the medication and apply the medication-soaked cotton-tipped applicator to resident 64's gums. She performed this process and administered the medication to resident 64. 2. Review of resident 64's electronic medical record (EMR) revealed:*His dentist removed the last six of his remaining teeth on 11/6/25. His goal was for his mouth to heal and then obtain dentures. *His primary care provider assessed him on 12/9/25 and noted that he had swelling along his top left gum line and a white pustule (a small blister or pimple containing pus) present in that area. The provider referred resident 64 back to the dentist and ordered Lidocaine ointment 5%: apply to affected oral mucosa TID PRN (as needed) before meals; adults may use up to 5 grams (250 mg [milligrams] lidocaine base) per application, with a maximum of 17-20 g [grams] (850-1000mg) per day.*A 12/10/26 nursing progress note indicated per Pharmerica [the resident's pharmacy], Lidocaine ointment 5% cannot be applied to oral mucosa. Pharmacy does have viscous lidocaine 2% that they can send which is a thick consistency and can be applied to that area. VERBAL ORDER RECEIVED TO CHANGE TO VISCOUS LIDOCAINE - see MAR.-The order got changed to the instructions in finding 1.*He had a dentist's appointment on 12/17/25. Upon return to the facility, the resident had two surgical incisions on his top left gums from the dentist draining the pustule.*Resident 64 continued to get lidocaine 2% viscous solution to his gum line until the order was discontinued on 2/20/26. His recorded pain levels from 12/10/25 through 2/20/26 ranged from zero to eight on the 10 point pain scale. 3. Interview and observation on 2/20/26 at 7:34 a.m. with RN F revealed:*She gave resident 64 his lidocaine dose that morning before he ate breakfast. She opened the medication cart upon request, and the lidocaine box that held the bottle of lidocaine medication indicated that the usual dosage for adults was 15 mL (one tablespoon).*She acknowledged that she did not measure the dose of lidocaine before she administered it to resident 64 earlier that day, and that she used less than the box's recommended amount.*She reported that resident 64 complained of occasional pain in his mouth while eating. 4. Interview on 2/20/26 at 10:13 a.m. with assistant director of nursing (ADON) C and director of nursing (DON) B revealed:*They acknowledged that resident 64 did not have a dosage amount for his lidocaine, and that this was one of the five rights of medication administration.*They felt resident 64 could have been underdosed or overdosed by not having a dosage amount listed on his MAR for the administration of that medication. 5. Interview on 2/20/26 at 10:22 a.m. with resident 64 revealed:*He communicated by using yes or no questions. When asked if he had pain, he held up nine fingers. When asked if he had pain in his gums, he was able to answer no. He could not answer where his pain was located to this surveyor. 6. Interview on 2/20/26 at 11:13 a.m. with administrator A revealed:*She acknowledged that resident 64 did not have a dosage amount for the lidocaine medication. She expected the residents to have complete orders for medication administration and the staff to reach out to the provider for clarification if a medication did not have a dosage amount to administer. 7. Review of the provider's September 2018 medication administration policy revealed:*Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. Compare the medication and dosage schedule on the resident's MAR with the medication label. If the label and MAR are different.or if there is any other reason to question dosage instructions, the prescriber's orders are checked for the correct dosage schedule.

Based on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to:Ensure there was a physician's order for one of one closed record sampled resident's (1) urinary catheter.Ensure there was a documented clinical indication for urinary catheter use by one of one closed record sampled resident (1) that included a physician's order for catheter removal when it was no longer clinically indicated.Identify and implement measures to mitigate of one of one closed record sampled resident (1) with a urinary catheter from developing a urinary tract infection.Findings include: Review of the 6/24/25 SD DOH complaint intake revealed:On 6/18/25, the provider discharged resident 1. She was transferred and admitted to a different nursing home later that same day with a urinary catheter.When resident 1 was admitted to the receiving nursing home, her catheter had a significant amount of sediment. It was not reported [to the receiving nursing home by the provider] that the resident had a UTI [urinary tract infection] or that a urine sample was obtained prior to transfer for possible UTI. She [resident 1] has had her catheter removed [by the receiving nursing home] as well as started an antibiotic to treat her UTI [after her admission to the receiving nursing home facility].Review of resident 1's closed electronic medical record (EMR) revealed:Neither her 6/3/25 hospital discharge orders nor her 6/3/25 nursing home admission orders had included a urinary catheter. Resident 1's 6/3/25 Nurse admission Assessment indicated that the resident had a urinary catheter. A question in that assessment, Is there a plan to discontinue [the catheter]? was answered no.Resident 1's 6/14/25 through 6/17/25 Nursing-Daily Evaluation assessments had included a checklist (Section A) that included Vital Signs/Devices and Treatments. There was space on that checklist to indicate if a resident had a urinary catheter and whether or not it was chronic or new. On that same assessment, Section B. Skilled Nursing, there was space (12 a.) to identify if a resident had an indwelling catheter. There was additional space in the Comments section (23.) to document nursing comments relevant to those resident care needs that were identified in Section A that applied to a resident.Resident 1's 6/14/25 through 6/17/25 Nursing-Daily Evaluation assessments failed to identify that she had a urinary catheter, and there was no documentation in the comment section of those assessments regarding resident 1 having signs or symptoms of a possible urinary tract infection. There was no Nursing-Daily Evaluation assessment completed on the date of resident 1's discharge, 6/18/25.A 6/16/25 progress note: Staff reported the resident's urine to be thick and yellowish in color. The resident's medical provider was notified, and a urine analysis (UA) was ordered. The results of that UA were not available on 6/18/25 when the resident was discharged . UA results were faxed to the receiving facility on 6/19/25. There was no documentation to support a hand-off communication between the provider's nursing staff and the receiving nursing home facility nurse had occurred on the day of resident 1's discharge. Interview on 8/7/25 at 9:55 a.m. with Minimum Data Set (MDS)/Care Plan Coordinator D revealed:She confirmed resident 1 had a urinary catheter during her 6/3/25 through 6/18/25 nursing home stay. Resident 1's hospital discharge orders and nursing home admission orders had not included resident 1's use of a urinary catheter. It was MDS/Care Plan Coordinator D's responsibility to ensure residents admitted to the facility with urinary catheters had a physician's order for that catheter, a diagnosis that supported its medical necessity, and a removal plan for the catheter if that was clinically indicated. Implementing those interventions would have decreased resident 1's risk of developing a UTI, but that had not occurred.Because resident 1's admission orders had not included a urinary catheter, MDS/Care Plan Coordinator D assumed the resident had no catheter, and her catheter follow-up referred to above had not occurred. Interview on 8/7/25 at 12:45 p.m. with director of nursing (DON) B revealed:A floor nurse was responsible for completing the Nurse admission Assessment, and a nurse manager was responsible for entering admission orders. DON B agreed that the nurse manager should have completed a visual assessment of resident 1 to have known she had a urinary catheter, and that the expected standards of practice for catheter use had been followed. Review of the provider's revised 5/15/25 Catheter Associated Urinary Tract Infection (CAUTI) Prevention Guidelines revealed:1) Verify that there is a physician's order for a catheter procedure.3) d) Do not use the indwelling catheter unless medically necessary: Appropriate indications for the continuation of use/justification of an indwelling urethral catheter beyond 14 days .

Based on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to ensure:During a June 2025 facility COVID-19 outbreak, all residents' COVID-19 testing and test results had been appropriately documented per the provider's policy.Prior to discharge of one of one closed record sampled resident (1) to another nursing home on 6/18/25, the receiving nursing home received disclosure of a COVID-19 outbreak at the provider's nursing home.Accurate and appropriate documentation of the administration of one of one closed record sampled resident's (1) second step of a 2-step tuberculosis (TB) test was conducted. Findings include: 1 Review of the 6/24/25 SD DOH complaint intake revealed:The provider had discharged resident 1 on 6/18/25. She was transported via public transportation and admitted to another nursing home approximately 100 miles away on that same day. The resident was wearing a face mask upon arriving at the receiving nursing home. The driver who transported the resident told staff at the receiving nursing home that the discharging provider had an active COVID-19 outbreak. The driver indicated the resident was coughing quite a bit on the way down [during the drive to the receiving facility]. We [the receiving nursing home] were not informed of the COVID [COVID-19] outbreak at their [the provider's] facility. The above information provided by the driver prompted the receiving nursing home to change the resident's initial room assignment from a semi-private room to a private room, and plans to ensure prevention of [a] COVID [COVID-19] outbreak were initiated.Upon arrival at the receiving nursing home, She [resident 1] stated she had chills, and she was assessed as having a productive cough. Resident 1 was tested at that time for COVID-19 test and the test result was positive.Review of resident 1's EMR revealed:Her admission date was 6/3/25.She was tested for COVID-19 during the provider's June 2025 COVID-19 outbreak on 6/13/25. That test was negative. There was no documentation in her EMR that indicated she had any other COVID-19 tests completed in June 2025.Review of her 6/15/25 through 6/17/25 Nursing Daily Evaluation assessments revealed that resident 1 was assessed and she was non-symptomatic (had no symptoms) for the following: her respirations, lung sounds, and respiratory virus monitoring (cough, running nose/sneezing, sore throat, headache, shortness of breath, temperature, and muscle aches). No Nursing Daily Evaluation assessment was documented on 6/18/25, the day of resident 1's discharge.Interview on 8/7/25 at 8:20 a.m. with Infection Preventionist (IP) E revealed:A symptomatic resident had tested positive for COVID-19 on 6/9/25. A second symptomatic resident had tested negative on 6/9/25, was retested again a short time later, and was positive for COVID-19. A nurse manager used a resident list with the residents' room numbers on it to ensure all residents were tested for COVID-19 on 6/9/25, 6/11/25, and 6/13/25. The test result for each resident's test was noted beside their name on those lists. The dates of all residents' COVID-19 testing and the results of all those tests were then expected to have been transferred from those lists to their EMR by the nurse manager who administered the COVID-19 test. The above resident lists had been discarded after test results had been transferred to a resident's EMR.IP E had only kept a spreadsheet that listed the names of those residents who had tested positive for COVID-19 during the June 2025 outbreak. There were progress notes in their EMRs regarding their COVID-19 testing and COVID-19 test results.Twenty-four residents had tested positive for COVID-19 during the June 2025 outbreak. The facility's census on 6/10/25 was 67 residents.Continued interview with IP E and review of resident 1's EMR revealed:There was documentation that resident 1 had only been tested for COVID-19 on 6/13/25. That COVID-19 test result was negative.There was no documentation to support that the provider had communicated to the receiving nursing home that they had a COVID-19 outbreak when resident 1 was transferred to their facility on 6/18/25. IP E agreed that communication failure had potentially placed the receiving nursing home at risk for its own COVID-19 outbreak.Interview on 8/7/25 at 11:15 a.m. with administrator A, director of nursing (DON) B, and assistant DON C revealed:Resident 1 was admitted to the facility on [DATE].All residents were tested for COVID-19 on 6/9/25, 6/11/25, and 6/13/25. ADON C had administered and read all residents' 6/13/25 COVID-19 tests. Documentation of those administered tests, and test results were entered in all residents' EMRs by ADON C. There was no similar documentation completed by other nurse managers for their 6/9/25 and 6/11/25 COVID-19 test administration and test results.Only the 6/13/25 COVID-19 test administration and negative test result was documented in resident 1's EMR. The nurse manager who had completed the 6/9/25 and 6/11/25 resident COVID-19 tests was expected to have documented the negative COVID-19 test results for all applicable residents, but that had not occurred. There was only documentation in the EMRs of residents who had tested positive for COVID-19 on 6/9/25 and 6/11/25. COVID-19 information was expected to have been communicated by the provider to the receiving nursing home before resident 1 was discharged to ensure a safe transition in care for her and all the residents and staff at the receiving nursing home, but that had not occurred.Reporting/Tracking: Administration will ensure records are maintained regarding the testing process; resident and staff consent for testing; test results; . 2. Upon identification of a new COVID-19 case in the facility (i.e., outbreak), document: b. The date that all other residents and staff are tested.c. The dates that staff and residents who tested negative are retested, .Review of the provider's 4/28/25 revised Discharge and Transfer of Residents/Bed Hold policy revealed: Policy: To ensure a safe transition is planned for any resident with a discharge or transfer to another setting.2 Review of resident 1's EMR revealed she was admitted on [DATE]. The first step of her two-step TB skin test was administered on 6/4/25. That test was read as negative on 6/6/25 and was documented in the immunization section of her EMR. There was no documentation in the EMR to support that the second step of her TB test was administered.Interview and review of resident 1's EMR with IP E on 8/7/25 at 9:35 a.m. revealed:A TB order set (orders grouped together for a specific condition or process) was entered on resident 1's medication administration record (MAR) at the time of her admission to the facility. That order set alerted nursing staff on what day to administer and what day to read the resident's first and second TB skin tests. That TB skin test information (the date of administration and results) was then to be transferred to the immunization section of her EMR by the nurse who administered the TB test and/or read the TB test. IP E reviewed residents' immunization records to ensure their TB skin tests were administered, read, and documented appropriately. IP E confirmed there was no documentation to support resident 1's second step TB skin test was administered. She stated, Maybe the check and balance didn't happen [for that test]. Interview and review of resident 1's June MAR with DON B on 8/7/25 at 11:30 a.m. revealed:Resident 1 was admitted on [DATE].On 6/4/25, she was scheduled to receive the first of her two-step TB skin test. The test was documented as having been administered intradermally (just below the top layer of skin) on the resident's left forearm on 6/4/25. On 6/6/25, the resident was scheduled to have that same TB test read. The test was documented as having been read on 6/6/25, and indicated there was no induration (raised, hardened area, or swelling at the injection site). The results of that skin test had been added to the immunization section of her EMR.On 6/13/25, she was scheduled to receive the second of her two-step TB skin test. There was no indication it had been administered on that date. On 6/15/25, she was scheduled to have the second TB test read. The test was documented as having been read on 6/15/25 by licensed practical nurse (LPN) I, but there was no indication of what the results of that test were. There was no information in the immunization section of her EMR regarding a second TB skin test having been completed.Telephone interview on 8/7/25 at 11:40 a.m. with LPN I revealed she thought she had read resident 1's second TB skin test, if that was what she had documented on her MAR. She presumed that the test result was negative because she had never read a positive TB test at the nursing home.Telephone interview on 8/7/25 at 11:50 a.m. with registered nurse (RN) J revealed she would have been responsible for administering resident 1's 6/13/25 scheduled TB skin test, but she was not able to remember whether she had administered it or not. Interview on 8/7/25 at 11:55 a.m. with ADON C revealed there were two different TB order sets available to add to a resident's MAR. The order set entered for resident 1's second TB skin test was different from the order set that was entered for her first TB skin test. The second order set was not as comprehensive as the first order set and she stated the second order set should not have been used. Review of the provider's revised 3/7/25 Tuberculosis Prevention and Control Program South Dakota policy revealed:TB Screening at admission: 1. A resident's clinical record must contain a report of a tuberculin test .8. All resident TB screening must be documented in the residents [resident's] medical record and be readily accessible to facilitate consideration of TB if the resident develops signs and symptoms of TB.

Based on a South Dakota Department of Health (SD DOH) complaint review, interview, record review, and policy review, the provider failed to follow their policy to ensure one of one closed record sampled resident's (1) discharge plan was documented and appropriate information was communicated to the nursing home that had accepted that resident for admission. Findings include: Review of the 6/24/25 SD DOH complaint intake revealed concerns that the nursing home where resident 1 was transferred and admitted to on 6/18/25 had not received the information needed to properly care for her before she was discharged on that same day by the provider. 1 Interview on 8/7/25 at 3:15 p.m. with Medical Records Director K revealed:She maintained a log of referral information that was sent to other healthcare providers on a resident's behalf. She had no documentation to support that she had sent any referral information to another healthcare provider on resident 1's behalf.Review of resident 1's closed electronic medical record (EMR) revealed:A 6/17/25 progress note: Medicare A last covered day 6/18[25] with daughter stating resident to be transferring to facility [in another town]. Arrangements are in place for transportation.There were no progress notes that indicated any communication had occurred between the provider and the nursing home that admitted resident 1 to their facility on 6/18/25. The 6/18/25 Instruction and Summary for Discharge UDA (user defined assessment) revealed:Section I of that assessment was a summary of the resident's status. That section included information regarding the resident's sensory impairments, mental and psychosocial status, cognitive status, attitude about discharge, and discharge status. A social services designee (SSD) was expected to have completed that section, but there was no SSD at the time of resident 1's discharge. No other staff had completed that section.Section II of that assessment was signed as having been completed by nurse supervisor/licensed practical nurse (LPN) F. That section included information regarding the resident's reason for admission, progress made and any complications the resident may have had, any assistive devices that were needed by the resident, and any pertinent antibiotic and laboratory information.Documentation in that section failed to include the following resident-specific information:The dates and results of resident 1's June 2025 COVID testing, and if there was a nurse assessment completed for signs and symptoms of COVID-19 on the day she was discharged . The documented vital signs in that section were dated 6/15/25. The resident had a Foley catheter. She also had shown signs and symptoms of a possible urinary tract infection (UTI) on 6/16/25. The results of a urine analysis (UA) test were pending.The resident had a physician's order for continuous oxygen to be worn.She had used a wheelchair cushion and a low air low-air-loss mattress at the facility. On 6/16/25, her medical provider was notified that her wounds had worsened. There were no new wound orders written at that time.The resident had completed a course of Vancomycin (an antibiotic) during her stay at the nursing home for treatment of C. difficile (a contagious bacterium that causes diarrhea).Section IV of that assessment was a summarization of the resident's rehabilitative services. A representative from the rehabilitation department was expected to have completed that section, but it was incomplete and unsigned. The medical provider was expected to have signed and dated Section V of that assessment, but it was incomplete and unsigned. Interview on 8/7/25 at 1:30 p.m. with director of nursing (DON) B confirmed:There was no documentation to support that discharge planning communication regarding resident 1 between the provider and the receiving nursing home facility had occurred.The above Instruction and Summary for Discharge documentation had not included resident-specific information that promoted a safe transition in care and assisted the receiving nursing home facility in providing resident 1's care needs.The SSD was the point of contact for resident discharges to other nursing home facilities. At the time of resident 1's discharge, there was no SSD to fulfill that responsibility, and another primary contact person was not identified to assume that responsibility.Review of the provider's revised 4/28/25 Discharge and Transfer of Residents/Bed Hold policy revealed:Policy: To ensure a safe transition is planned for any resident with a discharge or transfer to another setting.The LGHC [Legacy Healthcare] Instruction and Summary for Discharge UDA [User Defined Assessment] will be completed with all planned discharges. If proceeding with discharge, a copy of the UDA will be given to resident upon discharge. A copy will be signed by the physician for the summary of stay and will be scanned to electronic record or a copy maintained in closed medical record.

Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to ensure one of one closed record sampled resident (1) had documentation to support physician-ordered oxygen was arranged and provided for her to use while being transported from the provider's facility to another nursing facility where she had been accepted for admission. Findings include: Review of a 6/24/25 SD DOH complaint revealed:The provider discharged resident 1 on 6/18/25, and she was transferred that same day to another nursing home approximately 100 miles away. The resident was transported to the receiving nursing home via a public transportation service.The resident was not provided with continuous oxygen when she was transported between the two nursing homes. 1 Review of resident 1's closed electronic medical record (EMR) revealed:A 6/3/25 physician's order for the resident to receive three liters of continuous oxygen via nasal cannula (a flexible tube that goes around the head into the nose for oxygen delivery) for a diagnosis of chronic respiratory failure with hypoxia (absence of enough oxygen). There was no documentation regarding what arrangements had been made to ensure that resident 1 was safely transported to the receiving nursing home with continuous oxygen as ordered. Telephone interview on 8/7/25 at 11:50 a.m. with registered nurse (RN) J revealed:She was responsible for discharging resident 1 on 6/18/25. She thought she had given a hand-off report to the receiving facility, but confirmed there was no documentation to support that it had occurred. RN J had not known if arrangements were made for resident 1 to have oxygen while she was transported to the receiving nursing home. She had not known if resident 1 was wearing oxygen at the time she was discharged from the facility. Interview on 8/7/25 at 1:40 p.m. with director of nursing (DON) B and assistant DON (ADON) C revealed:It was RN J's responsibility to confirm that resident 1 had portable oxygen available to use while being transported to the receiving facility. If the receiving facility had not sent portable oxygen for resident 1 to use, the sending facility should have sent theirs. Review of the provider's revised 11/19/24 Oxygen Administration policy revealed 3. If portable oxygen is used, staff should ensure the tank has adequate volume to ensure oxygen does not run out.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and record review, the provider failed to validate the status of one of one social services designee's (SSD) (G) temporary nursing license while she was employed in that capacity between February 2025 and May 2025. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Interview on 8/6/25 at 8:30 a.m. with administrator A and director of nursing (DON) B and review of the provider's 5/7/25 SD DOH FRI final report regarding SSD G revealed:SSD G had been the facility's SSD since 2/1/21.She had completed her practical nursing degree in December 2024. Her temporary nursing license was issued on 1/2/25. She began training as a floor nurse at the facility shortly thereafter. SSD G had worked mostly evening shifts. There were two licensed nurses who worked those shifts with SSD G.SSD G was a certified nurse aide (CNA), but she was not a certified medication aide (CMA).She had told facility management staff that she had passed her National Council Licensure Examination (NCLEX-a standardized examination used to assess the knowledge, skills, and abilities of entry-level nurses) in February 2025. Upon passing the NCLEX, a permanent nursing license would have been issued to SSD G by the South Dakota Board of Nursing (SD BON).Human Resources (HR) director H requested from SSD G a copy of that permanent nursing license for her personnel file.On 5/5/25, HR director H had noticed there was still no copy of SSD G's permanent nursing license in her personnel file. On 5/5/25 and 5/6/25, she again requested a copy of that nursing license from SSD G. On 5/6/25, when SSD G failed to provide that copy, HR director H notified DON B.Referring to the SD BON website, DON B was unable to confirm SSD G had a valid nurse license.A 5/7/25 email sent to administrator A, DON B, and HR director H from SSD G attributed DON B's inability to find her nursing license on the website to a clerical error. On 5/7/25, DON B emailed the SD BON. Their 5/7/25 email response confirmed that SSD G had failed the NCLEX. Her temporary nursing license was invalid after she had failed that examination. That occurred on or about 2/10/25.SSD G was suspended from working on 5/7/25 pending a full investigation. On 5/8/25, SSD G sent a cropped screenshot of a temporary nursing license to administrator A. The effective and expiration dates on that license had been altered from the original temporary nursing license that was issued by the SD BON.SSD G was terminated from employment on 5/8/25. The provider's implemented actions to ensure the deficient practice does not recur were confirmed onsite on 8/6/25 after record review revealed the facility had followed their quality assurance process and:Local law enforcement, the SD BON, the SD Department of Social Services, the SD Department of Health (DOH), the facility's medical director, and the Office of the Inspector General were notified SSD G had falsified her temporary nursing license. An audit and review of SSD G's documentation between 1/18/25 and 5/7/25 in all residents' electronic medical records (EMR) was completed. An audit of medication administration variances for SSD G during that time frame was completed. A risk audit was completed to identify tasks SSD G had completed that would have been outside of her scope of practice. An audit was completed of skilled nursing care SSD G had provided for Medicare, managed care, and VA (Veterans Administration). An Ad Hoc QAPI (Quality Assurance and Process Improvement) meeting was held on 5/8/25 to identify a process for improving the tracking and management of staff's professional certifications and licenses. This resulted in a facility-wide audit of all applicable staff certifications and licenses. No additional staff were identified as having lapsed or absent certifications or licenses. Monthly audits will continue, and the findings will be discussed during QAPI meetings. HR director H was educated on 5/9/25 regarding professional certification and license verification, and background check expectations. Administrator A and DON B were educated on 5/13/25 regarding their responsibility for ensuring facility staff had completed their roles and responsibilities, certifications, and licenses of all applicable staff were verified, and the newly established process regarding licensed nurses working in the facility with a temporary nurse license was followed. Based on the above information, non-compliance at F726 occurred on 1/18/25, and based on the provider's implemented corrective actions beginning on 5/7/25, for the deficient practice confirmed on 8/6/25, the non-compliance is considered past non-compliance.

Based on observation, interview, and policy review, the provider failed to ensure residents' prepared food was served and distributed in a palatable manner during two of two observed meal services. Findings include: 1. Observation and interview on 1/12/25 from 5:00 p.m. through 6:00 p.m. with cook O and certified dietary manager (CDM) N in the kitchen during the evening meal service revealed: *Cook O removed pizza from the oven at 5:08 p.m., sliced it, and moved it onto a baking sheet. -The sheet was too large to fit inside the steam table well and too short to cover the well opening it was placed on. *A temperature probe was inserted into the pizza by cook O and read 132 degrees Fahrenheit (F) at 5:16 p.m. That temperature was too low CDM N returned the pizza to the oven. -It was expected the internal temperature of that pizza was to be 165 degrees F when it was served. *At 5:23 p.m. CDM N removed the pizza from the oven and it was re-temped by cook O -The internal temperature of that pizza was 158 degrees F and returned to the oven by CDM N. *At 530 p.m. CDM N removed the pizza from the oven and it was re-temped by cook O. -The internal temperature of that pizza was 162 degrees F and served to the residents. *At 5:55 p.m. two pieces of pizza remained on the baking sheet on the steam table. -The internal temperature of that pizza was 106 degrees F and the pizza appeared dry. *CDM N would have preferred the pizza was placed on a perforated pan that fit inside of the steam table well to have maintained its internal temperature. -He had not known why re-heating the pizza in the oven had not increased its internal temperature to the acceptable temperature of 165 degrees F. 2. Observation on 1/13/25 from 8:33 a.m. through 9:00 a.m. and interview with cook P in the kitchen during the breakfast meal service revealed: *She began serving breakfast at 7:30 a.m. that morning. *At 8:33 a.m. nine residents had not arrived to the dining room for breakfast. *The uncovered food on the steam table included Cream of Wheat cereal, sausage gravy, mechanical soft sausage, pureed sausage, and pureed cinnamon french toast. -That food remained uncovered until the last resident's breakfast was plated at 8:58 a.m. *Food on the steam table retained acceptable temperatures when it was temped at 9:00 a.m. but the uncovered food had developed a dry film over the top of it or appeared dry. *Cook P agreed covering the metal food containers on the steam table would have kept the food moist and decreased the likelihood of a crust forming over the top of the food. 3. Interview on 1/13/25 at 9:30 a.m. with CDM N regarding food service revealed: *Food left on the steam table for extended periods of time was expected to have been covered to retain moisture and heat and prevent potential cross-contamination. *He had determined during the 1/12/24 evening meal the oven had been switched to a cool down fan which circulated air inside the oven and was not heating the pizza to the acceptable temperature. Review of the provider's revised 3/19/20 Food Temperatures policy revealed: *5. If temperatures are not at acceptable levels and cannot be corrected in time for meal service, make an appropriate menu substitution. *8. Palatability of foods determines appropriate temperature at bedside or tableside food. Generally hot food is palatable between 110 degrees F and 120 degrees F or greater . *9. Reheating foods for hot holding either in the oven or microwave must reach 165 degrees F and hold for 15 seconds.

Based on observation, interview, record review, and policy review, the provider failed to effectively implement and ensure appropriate and necessary infection prevention and control practices were followed: *When one of one observed licensed practical nurse (LPN) (F) did not wear a mask during a facility acknowledged respiratory outbreak. *When the use of appropriate enhanced barrier precautions (EBP) was not followed by one of one certified nurse aide (CNA) (H) during personal care for one of one sampled resident (7) on EBP. *When appropriate hand hygiene and glove use was not followed by one of one CNA (G) during personal care for one of one sampled resident (1). *For the cleaning of shared resident equipment by CNAs (H and I) after use by one of one sampled resident (45) on EBP. *When the use of EBP was not followed by one of one registered nurse (RN) (E) during the administration of nutritional formula through a tube for one of one sampled resident (17) who was on EBP. *When the use of EBP was not done when an unidentified CNA was obtaining vital signs on resident 31. *For resident 32 who's colostomy bag (a bag attached to the body that collects stool and needs to be emptied and rinsed periodically) rinse container was kept on his bedside table. Findings include: 1. Observation on 1/12/25 at 2:00 p.m. inside the enclosed entryway of the facility revealed: *A box of surgical masks was on a table against the wall. -An alcohol-based hand sanitizer dispenser was mounted above that table. *A type-written notice was taped on the door that led into the facility. -The facility was in respiratory outbreak status and mask use was required inside of the facility. 2. Continued observation inside of the facility revealed: *LPN F sat behind the nurses' station without a mask on her face. *She approached an unknown resident in front of the nurses' station and commented to that resident, I suppose I should be wearing a mask. *She walked towards the enclosed entry referred to above, entered a code on the wall-mounted key pad, pushed open the door, and without performing hand hygiene placed a mask over her face. 3. Interview on 1/12/25 at 2:15 p.m. with LPN F revealed the facility was in respiratory outbreak status related to an employee who had tested positive for COVID-19. 4. Observation and interview on 1/12/25 at 2:15 p.m. with certified nurse aide (CNA) H in resident 7's room revealed: *A notice on the room door for EBP (A set of infection control-measures that require the use of gowns and gloves to reduce the spread of multidrug-resistant organisms). *Without putting on a gown or gloves she placed her arms under the resident's armpits and lifted her up from her wheelchair to a standing position. -She transferred the resident to her bed. *She moved the resident's urine catheter bag from the wheelchair, attached it to her bed, and placed it inside a cloth bag. *CNA H stated resident 7 was on EBP because she had a catheter. She had not needed to put on a gown or gloves unless she was emptying the catheter bag. 5. Observation on 1/12/25 at 3:29 p.m. near resident 45's room revealed: *A notice was posted on the room door for EBP to have been followed. *CNA I exited the room with a mechanical lift that she had left along the wall near that room. -A bag was hung on the lift that contained disinfectant wipes. *CNA I returned to the resident's room before she exited again with CNA H. *The mechanical lift was not cleaned by either staff after they had left the room. 6. Interview on 1/12/25 at 4:30 p.m. with CNA H regarding the above observation revealed: *She and CNA I had used the mechanical lift to transfer resident 45 from his bed to his wheelchair. *The lift was expected to have been cleaned after it was used but neither she nor CNA I had cleaned it. 7. Observation on 1/13/25 and interview with CNA G at 4:15 p.m. while in resident 1's room revealed: *CNA G put on a gown and gloves to change the resident's soiled incontinence brief. -She used wet wipes to clean stool off of the resident's skin then discarded those wipes into a plastic bag. *With dirty gloves she: -Dispensed skin barrier cream onto the dirty glove and applied it onto the resident's skin. -Placed a clean incontinence brief on the resident. *She then removed her dirty gown and gloves, placed them in the plastic bag, and washed her hands. *She stated she was expected to have removed her dirty gloves, performed hand hygiene, and applied clean gloves before she had applied barrier cream and put a clean brief on the resident to prevent cross-contamination. 8. Interview on 1/14/25 at 1:45 p.m. with woundcare registered nurse (RN)/infection preventionist (IP) C revealed: *All staff were expected to wear masks while the facility was in respiratory outbreak status. -Hand hygiene was expected to have been performed before putting on a mask. *All shared resident equipment was expected to have been cleaned by staff after it was used. *Gown and glove use was expected during the care of any resident on EBP. *Gloves were expected to have been removed, hand hygiene performed, and new gloves put on after providing resident's personal care and before applying a barrier cream or a clean continence brief. Review of the provider's revised 6/21/24 Enhanced Barrier Precautions policy revealed: *2. a. Gowns and gloves should be used during high contact resident care activities that provide opportunities for transfer of MDROs [multi drug resistant organisms] to staff hands and clothing. -Transferring a resident was included in that list of resident care activities. Review of the provider's 2/20/24 Cleaning and Disinfection of Equipment policy revealed I. A. Supplies and equipment will be cleaned immediately after use. Review of the provider's revised 2/20/24 Standard Precautions policy revealed: *Personal Protective Equipment (PPE): -Gloves should be removed, hand hygiene performed, and a new pair of gloves applied before moving from a contaminated area to a clean area. 47780 9. Observation on 1/12/25 at 3:39 p.m. in resident 17's room revealed: *She had an EBP sign on her door. *Hanging on the resident's door were gloves, masks, and gowns. *An unknown staff member knocked on resident 17's door and asked if she was ready to take her after-dinner pill. Review of resident 17's electronic medical record (EMR) revealed: *She received nutritional formula through an Enteral tube two times a day. *Resident 17 had an order for Lansoprazole (medication) Capsule Delayed Release 30 MG once a day for GERD (a digestive disease in which stomach acid irritates the food lining). *Her diagnoses included: tubule-interstitial nephritis, moderate protein-calorie malnutrition, dementia, Alzheimer's, and dysphagia. Observation on 1/13/25 at 2:44 p.m. with RN E while in resident 17's room revealed: *Resident 17 was lying in bed with the head of the bed elevated. *RN E had hand sanitized her hands and then put gloves on both hands. She: -Had placed a clean barrier on the resident's bedside table and placed two cartons of Jevity 1.2 (the enteral nutrition formula), a measuring pitcher, three plastic cups, a pH tester strip in one of the plastic cups, and a sterile syringe. -She filled one of the plastic cups with tap water from the bathroom faucet. -She poured approximately 300 ml (milliliters) of Jevity 1.2 into the measuring pitcher. -She had informed the resident that it was time for her formula administration session and the resident assisted in removing the blankets. -RN E explained she needed to check the pH of the stomach contents. -She opened the sterile syringe and attached it to the PEG (percutaneous endoscopic gastrostomy) tube. -With the plunger, she injected air into the PEG tube. -She then pulled the plunger back and obtained residual stomach contents into the syringe. -She dripped some of the residuals onto the pH tester strip and reported that the pH was 4.5. -RN E then flushed the feeding tube with 50 CC (cubic centimeters) of water. -She then poured the liquid medication into the syringe. -After filling the syringe twice more with formula to reach the ordered amount to be given, she flushed the tube with water. -She replaced the cap on the PEG tub. -She then threw the Jevity cartons, syringe, plastic cups, measuring pitcher, and gloves into the trash can. -She went into the resident's bathroom and washed her hands. Continued interview on 1/13/25 at 3:00 p.m. with RN E regarding a resident on EBP precautions revealed she was unaware she was to be wearing a gown when she was with a resident with a feeding tube. Interview on 1/14/25 at 1:20 p.m. with DON B regarding the above observation revealed: *She stated all staff had received education regarding EBP in Relias (a learning platform that offers training for healthcare organizations) when hired. *She stated the nurses had a monthly meeting that discussed EBP. *Her expectation of staff was to follow all EBP. Review of the provider's revised March 2024 Enhanced Barrier Precautions policy revealed: Definition: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. ENHANCED BARRIER PRECAUTIONS should be used for all residents or for those residents colonized/infected with a novel or targeted MDRO [multi-drug resistant organism], when they no longer meet requirements for contact Precautions: 1. When a resident has any of the following: b. indwelling Medical Devices: .Feeding Tube 50915 1. Observation on 1/12/25 at 4:00 p.m. during the initial tour of the facility of an unidentified CNA revealed: *The CNA was obtaining vital signs on resident 31. *Resident 31 was on EBP. *There was a sign on his door indicating he was on EBP. *The CNA was not wearing a gown or gloves. 2. Random observations throughout the survey from 1/12/25 through 1/14/25 of resident 32's room revealed: *Resident 32 had a colostomy bag (a bag that collects stool and needs to be emptied and rinsed periodically). *Resident 32 would assist staff with rinsing his colostomy bag. *The container used to rinse the colostomy bag was kept on his bedside table. *On 1/13/25 at 8:00 a.m., resident 32 was eating his breakfast in his room with the colostomy rinsing container sitting next to his breakfast tray. *He said that he had never been asked to store the rinsing container elsewhere by staff. 3. Interview on 1/13/25 at 9:37 a.m. with licensed practical nurse (LPN) D revealed: *She was aware resident 32 kept his colostomy rinsing container on his bedside table. *She said, I think its gross. *She said staff have asked him to keep the rinsing container in the bathroom and he refuses. *She said that he was very particular about the way his possessions were situated in his room. 4. Interview on 1/14/25 at 2:30 p.m. with infection preventionist (IP) C revealed: *She was not aware resident 32 kept his colostomy rinsing container on his bedside table. *She said, That's disgusting. *She agreed that was an infection control issue. *Referring to personal protective equipment used for obtaining vital signs for a resident on EBP, she wanted to review her policy before answering questions on the topic. *She agreed staff should be following the policy. 5. Interview on 1/14/25 at 3:15 p.m. with director of nursing (DON) B revealed: *She was not aware resident 32 was keeping his colostomy rinsing container on his bedside table but agreed that this was an infection control issue, and she would talk to the resident and have it moved. *Referring to EBP, she said staff should be following the policy any time direct care was being provided to a resident on EBP, this included obtaining vital signs. 6. Review of the provider's February 2024 Infection Prevention Program policy revealed: *I. Goals The goals of the infection prevention and control program are to: A. Decrease the risk of infection to residents and personnel. B. Prevent, to the extent possible, the onset and spread of infection. D. Monitor for occurrence of infection and implement appropriate control measures. E. Identify and correct problems relating to infection prevention practices.

Based on a South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and personnel file review, the provider failed to ensure one of one sampled resident (35) was free from physical restraint by two of two certified nursing aides (CNA) (M and Q) and one of one licensed practical nurse (LPN) (R) who physically held down the resident's lower extremities while they provided his personal care. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's [DATE] SD DOH FRI revealed abuse and the physical restraint of resident 35 was identified by registered nurse (RN)/assistant director of nursing S during a review of the resident's progress notes. Review of resident 35's electronic medical record (EMR) revealed: *His admitted was [DATE] and his diagnoses included vascular dementia, anxiety, depression, and pain. *He had been on hospice services since [DATE]. *His Brief Interview for Mental Status (BIMS) assessment score was 12 which indicated he had moderate cognitive impairment. *An [DATE] progress note documented by LPN R indicated: -Behavior: resident refused to be changed since he went to bed. at 0400 [4:00 a.m.], this nurse was called to resident's room. when this nurse got there the resident was yelling and swearing at staff. i informed the resident that he needed to be changed. resident still refused. i informed resident that if he wasn't changed that his skin would start to break down. so we started to change the resident and he became combative. we [CNAs M and Q and LPN R] restrained him so that we could get him changed. once changed we left resident's room. Observation and interview with resident 35 on [DATE] at 3:40 p.m. in his room revealed he: *Sat in his recliner watching television. *Stated he was fine and had no concerns. -Declined any further conversation at that time or in the future. Continued review of resident 35's EMR revealed: *A skin assessment was completed on [DATE] and no new skin concerns had been identified following the [DATE] incident. *The resident's behavioral care plan was updated on [DATE] and again on [DATE] to reflect staff were to: -Approach and reapproach the resident when he refused personal care. -Educate the resident regarding the risks of refusing care. -Utilize staff who had a rapport with the resident to provide his personal care. -Use of an incontinent brief that was more absorbent and provided better skin protection. Interview on [DATE] at 6:15 p.m. with CNA M regarding the FRI revealed: *He confirmed the content of the FRI above was factual. *He complied with LPN R's instruction to physically restrain resident 35 when the resident had refused care knowing what he was asked to do was not right. -He failed to report the incident to his supervisor or any other member of management. *Resident 35 had a history of non-compliance with personal care that escalated after his spouse passed away in the fall of 2024. -They had resided together in the nursing home. *Resident 35's care refusals had been managed by leaving him alone for a short period of time and then reapproaching him. *Repeated care refusals had been reported to a nurse. -The resident sometimes accepted a nurse's explanation of the consequences of care refusal and then allowed staff to perform that care. *A new type of incontinent brief had been used since [DATE] that allowed brief changes to occur at a less frequent interval without compromising the resident's skin. *CNA M stated no other nursing staff had ever asked him to hold a resident's arms or legs in order to have completed their personal care. -He had not observed or known of any other instances of any staff who had been asked to or had physically restrained a resident. *He was suspended from work pending the outcome of the [DATE] incident investigation. -He was required to complete an abuse prevention training before he was allowed to return to work. Interview on [DATE] at 8:07 a.m. with RN E regarding resident 35's care refusals revealed: *He had a history of care refusal but the frequency had escalated after his spouse died . -He was moved to a private room across the hall and that seemed to have helped improve his behavior. *The resident verbally refused care by saying No, that type of thing which had indicated to staff he wanted to be left alone. -He was not usually physically aggressive. *The resident related better to some staff and they provided his care when possible or if he had refused care offered by another staff person. *Staff respected the resident's right to refuse care but reapproached him to offer that care again to ensure it had occurred. Review of CNAs M and Q and LPN R's personnel files revealed: *Their professional certifications or licenses were current and their pre-employment background checks identified no areas of concern. *Their mandatory resident rights, abuse/neglect, and restraint training was current. *CNA Q was terminated on [DATE] unrelated to the [DATE] incident. *LPN R was terminated on [DATE] related to the [DATE] incident. Interview on [DATE] at 9:45 a.m. with DON B and administrator A regarding the FRI revealed: *The incident was reported to the South Dakota Board of Nursing. *Audits of a sample of cognitively intact residents regarding their care and feelings of safety was completed. A review of those audits identified no concerns. *Audits of a sample of staff regarding resident care concerns was completed. A review of those audits identified no issues. *All staff were re-educated at the [DATE] All Staff meeting regarding resident abuse and neglect. -Training content was reviewed and included restraint use. The provider's implemented systemic actions to ensure the deficient practice does not reoccur was confirmed on [DATE] after: *Facility audits of sampled residents and staff identified no resident care or safety concerns. *Education was provided to all staff regarding resident abuse/neglect and restraint use. -Observations and interviews revealed staff understood that education regarding those topics. *Resident 35's care plan was revised to reflect modified behavioral interventions for the management of care refusal. -Interviews revealed staff understood the interventions for managing resident 35's care refusal according to his revised care plan. Based on the above information, non-compliance at F604 occurred on [DATE], and based on the provider's implemented corrective actions for the deficient practice confirmed on [DATE], the non-compliance is considered past non-compliance.

Based on observation, record review, interview, and policy review, the provider failed to document one of one sampled resident's (1) disrobing behavior that supported her continued need to have a dignity curtain placed inside of her room. Findings include: 1. Observation on 1/12/25 at 3:54 p.m. of resident 1 in her room revealed: *There was a corridor about five to six feet in length upon stepping inside the room. *At the end of the corridor was a piece of patterned material (a dignity curtain) velcroed between the two walls at the end of the corridor. -The curtain was about five to six feet wide and between four and five feet high. *The resident's living space was on the other side of the curtain. *The resident was able to be visualized after taking a few steps inside the corridor and looking over the curtain. *The resident was lying on her low bed, fully clothed, and watching television. -She was able to make eye contact but was not able to be understood when she tried to communicate. Interview on 1/13/25 at 8:10 a.m. with registered nurses (RN) E and T regarding resident 1's dignity curtain revealed: *It was used to prevent visitors and residents walking by her doorway from seeing her if she had removed her clothes. -Placement of the curtain allowed staff to step inside of the room and look over the curtain to monitor the resident. *The resident had a history of a brain injury that resulted in cognitive impairment. Additional observations of the resident on 1/12/25 (at 6:15 p.m.), 1/13/25 (at 8:03 a.m., 10:06 a.m., and 4:15 p.m.), and 1/14/25 (at 7:40 a.m., 10:00 a.m., and 2:00 p.m.) revealed: *She was in her room lying on her low bed, fully clothed, and watching television. -The dignity curtain was up. Interview on 1/13/25 at 4:40 p.m. with administrator A and director of nursing B regarding resident 1 revealed: *The dignity curtain was used to protect the resident's privacy due to her disrobing behavior. -Neither knew if the frequency of the resident's disrobing behavior was being tracked to support the continued use of the dignity curtain. Review of resident 1's care plan revealed: *A focus area revised on 7/26/24 related to the resident's use of antidepressant and anti-anxiety medication. -An intervention initiated on 7/30/19: Monitor/record occurrence of target behavior symptoms of pacing, wandering, disrobing, inappropriate response to verbal communicating, violence/aggression towards staff/others, etc, and document per facility protocol. *A focus area revised on 3/20/34 related to her behaviors which included disrobing. -An intervention revised on 7/30/19: Document behaviors and my response to interventions per facility protocol. -An intervention revised on 3/20/24: Ensure that Velcro-cloth barrier is placed to shield view of [resident 1] when lying in bed and disrobing/removing brief to promote her dignity. Review of resident 1's electronic medical record (EMR) revealed: *Her diagnoses included vascular dementia, seizure disorder, chronic pain, depression, anxiety, and an anoxic brain injury. *A behavioral symptom monitoring tool included areas to document the frequency of 13 different types of behavior on a daily basis. -Disrobing was not one of those 13 listed behaviors. *Her behavioral progress notes and interdisciplinary progress notes between 11/12/24 and 1/13/25 did not mention the resident's disrobing behavior. *An 11/5/24 Behavior/Psychotropic Interdisciplinary Team Review included a list of the resident's behaviors that have been present the last 2 weeks. -Disrobing was not present during that time. -Targeted behaviors included verbal behaviors, resisting care, but not disrobing. *An 11/6/24 care conference note did not include a disrobing behavior. *An 11/20/24 psychiatry progress note completed by the certified nurse practitioner: [Resident 1's] behavior includes yelling and getting out of her chair but she has maintained a minimal amount of agitation on current medications. *Resident 1's 11/1/24, 9/11/24, and 7/19/24 Minimum Data Set assessments (Section E-Behavior Symptoms/other behavior symptoms not directed toward others such as disrobing in public) indicated that behavior was not exhibited at the time of those assessments. Interview on 1/14/25 at 8:10 a.m. with restorative therapy aide (RTA) U and certified nurse aide (CNA) J regarding resident 1's disrobing behavior revealed: *RTA U stated the frequency of resident disrobing had improved. It had occurred maybe a couple times per day. *CNA J stated disrobing had occurred maybe a couple times per month which was a decrease from a few days a week. Interview on 1/14/25 at 2:15 p.m. and review of resident 1's 12/30/24 Siderail/Other Devices Evaluation form with administrator A revealed: *The Evaluation was to be completed quarterly to evaluate the use of the dignity curtain and to ensure it was not being used as a seclusionary device. *The Non-Physical Restraint Evaluation stated Barrier [dignity curtain] is being used to promote [resident 1's] dignity as chooses to remove her briefs when soiled with urine or BM [bowel movement], removes clothing, and lays naked on bed. *She agreed the lack of behavioral documentation had not supported the continued need for the dignity curtain. Review of the provider's revised 2/10/24 Psychotropic Medications policy revealed: 8. Residents receiving psychotropic medication will have adverse side effects and target behaviors addressed in the care plan and will be monitored, recorded, and summarized each quarter. Assessment (User Defined Assessment) will include resident specific behaviors, non-pharmacological interventions attempted and the resident's response to the interventions.

Based on observation, interview, record review, and policy review, the provider failed to protect the residents' right to be cared for with respect and dignity for: *One of one sampled resident (6) by one of one certified therapy assistant (COTA) (K). *One of one sampled resident (32) who had a container for rinsing his colostomy bag stored on his bedside table in full view of others. Findings include: 1. Observation on 1/13/24 at 8:33 a.m. of resident 6 in the dining room revealed: *She, three unidentified residents, and certified occupational therapy assistant (COTA) K were seated at a dining room table together. -COTA K was seated beside resident 6 to her left. *Resident 6's breakfast meal was in front of her and was mostly uneaten. *COTA K was looking at the cell phone in his lap. -He turned his attention to resident 6 after the surveyor walked by that table. 2. Continued observation between 8:35 a.m. and 9:18 a.m. of COTA K and resident 6 at the dining room table revealed: *The resident fed herself no more than three bites of food during that time. *COTA K physically assisted her in bringing a fork with food on it from her plate to her mouth one time. *COTA K either had one hand on his forehead while he looked down at a cell phone, held the phone with both hands while he looked down at it, or looked down towards the top of the table and wrote on a piece paper on the table during the observation. *He had a face mask on and it was not known if he had verbally interacted with the resident during that time. 3. Continued observation and interview with certified nurse aide (CNA) G at 9:25 a.m. revealed: *She sat next to resident 6 and assisted her with eating after COTA K had left the dining room. *Two full glasses of fluid, a full-serving of mechanically altered sausage and gravy, most of her Cream of Wheat cereal, and one piece of french toast remained on resident 6's plate. *She shook her head yes or no to CNA G's questions and responded to her verbal encouragement to eat. *CNA G had known resident 6 had sat in the dining room for about an hour before she had arrived. -She agreed the resident's food was cold and would no longer have been appetizing. 4. Interview on 1/13/25 at 9:40 a.m. with COTA K regarding the above dining room observation revealed: *Resident 6 was a feeder. -He had not known the use of that term was considered to have been derogatory. *The resident's occupational therapy goals had included improving her self-feeding abilities. -He had verbally interacted with the resident during the meal service but agreed it was disrespectful to have not made eye contact with her during those interactions. *He agreed the resident's food was likely cold and no longer tasteful after over an hour had passed. 5. Interview on 1/14/24 at 7:45 a.m. with COTA/therapy program director L regarding the above dining room observation revealed: *That is not our standard of care expectation. *Cell phone use was prohibited except in the case of an emergency. *Eye contact and conversation with the resident was expected of COTA K during that meal. Appropriate verbal and/or physical assistance should have been provided. Food should have remained at a palatable temperature during the meal service. *The use of terms such as feeder to describe a resident was unacceptable. 50915 6. Random observations on 1/12/25 and 1/14/25 revealed resident 32's container for rinsing his colostomy bag was stored on his bedside table in full view of anyone who may have passed by or entered his room. 7. Observation on 1/13/25 at 8:15 a.m. of resident 32 while in his room revealed the colostomy rinsing container was on his bedside table next to his breakfast tray while he was eating his breakfast. 8. Interview on 1/14/25 at 2:25 p.m. with infection preventionist (IP) C revealed it was her opinion that having resident 32's colostomy rinsing container exposed on his bedside table was a dignity issue. 9. Review of the provider's November 2024 Resident Dignity & Privacy policy revealed: *Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity, as well as, care for each resident in a manner and in an environment, that maintains resident privacy.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, and policy review, the provider failed to ensure the safety for: *One of one sampled resident (1) who staff assisted out of the building in the early afternoon hours, left the facility grounds without staff knowledge, was returned to the facility by an unknown individual, was not appropriately assessed for potential harm, and his physician was not notified timely of the incident. *One of one sampled resident (2) whose care plan was not followed by staff who were to provide her supervision while she was in her wheelchair with a safety belt around her lap. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incidents. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 1 revealed: *On 9/28/24 at an 1:30 p.m. the resident 1 was assisted out the front door by registered nurse (RN) D. -RN D got busy and was not able to monitor resident 1 while he was outside. *RN D heard the doorbell, and upon answering it, an unknown woman was observed with resident 1. -The woman asked if he lived here. -She stated she found him approximately 125 yards from the facility. --His face slightly flushed but returned to baseline with thickened fluids. -A full skin assessment, neuros, or vital signs were obtained upon his return to the facility. -An order for a Wanderguard (a wearable door alarming device) was obtained from his physician and the Wanderguard was placed on resident 1's wheelchair. *Interventions included: -Resident 1's identifying information was added to elopement binder. -Care staff were to supervise him when he was outside. -His care plan was updated with the new interventions. -The daily care sheet (a document that nursing staff references to identify individual care needs) was updated with the new interventions. -Provider reviewed all the residents for their current elopement risk. Review of resident 1's medical record revealed: *His 7/12/24 Brief Interview for Mental Status (BIMS) score was 0, which indicated he had severe cognitive impairment. *His diagnoses included: Alzheimer's disease, anxiety disorder, cerebral infarction (stroke), Aphasia (affects communication), history of falling, and hemiplegia (paralysis) affecting dominant right side. The provider implemented actions to ensure the deficient practice does not reoccur by having: *Followed their quality assurance process, and provided education all nursing care staff including: -Review of the provider's 2/20/24 Elopement Risk Evaluation policy. -Definition of an elopement. -Immediate notification of nurse manager or administrator when an elopement occurs. -Properly assessing a resident after an elopement. -Resident 1 was not to be outside unless there is always a staff member with his [him] to ensure his safety. *Re-assessed all residents for their elopement risk. *Held an Ad Hoc Quality Assurance Process Improvement meeting. *Initiated new interventions for resident 1 that included: -Obtained a physician's order that indicated he must not be left outside unattended or unsupervised do [due] to elopement risk. -Obtained and placed a Wanderguard on his wheelchair. *Implemented corrective actions for the nurse including: -Education on their abuse and neglect policy. -Reporting of incidents. *Observations and staff interviews on 10/7/24 revealed the staff understood the education that had been provided and the revised processes. Based on the above information, non compliance at F600 occurred on 9/28/24, and based on the provider's implemented corrective actions on 9/29/24 for the deficient practice it was confirmed on 10/7/24 that the non compliance is considered past non compliance. 2. Review of the provider's submitted SD DOH FRI regarding resident 2 revealed: *On 7/12/24 at 7:00 p.m. resident 2 was in her wheelchair at the nurses' station, unattended. -CNA F found resident 2 on the floor and alerted the nurse. --The nurse assessed her, and no injuries were identified. --Resident 2 was assisted back into her wheelchair. *The report identified CNA G as having been involved in the incident. *CNA G reported she was told by an unidentified CNA that resident 2 was known to unbuckle her seat belt when staff were not looking but did not know that resident 2 would put herself on the floor. Review of resident 2's medical record revealed: *Her 6/29/24 BIMS score was 9,which indicated she had severe cognitive impairment. *Her diagnoses included: epilepsy, unspecified psychosis, glaucoma, intellectual disabilities, anoxic brain damage, anxiety, restlessness, agitation, vascular dementia, and encephalopathy. *Her 7/12/24 care plan included the following: *A focus area that indicated, [Resident 2] is at risk for falls . [resident 2] will release her w/c [wheelchair] belt and slide/throw herself out of the w/c if upset or not being attended to quick enough. -Interventions for this focus area included: --On 11/29/21 is not to be left alone in her wheel chair [wheelchair]. [Resident 2] is to be in line of sight of staff while in w/c. --Revised on 10/19/23 Nursing monitors while up in w/c and should not be left out of line of sight of staff. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 10/7/24 after record review revealed: *LPN H provided immediate education on 7/12/24 to all CNAs on duty at the time of the incident regarding resident 2's need for continuous observation while in her wheelchair. *The facility had followed their quality assurance process, and education was provided to all nursing care staff on 7/18/24 regarding: -The provider's Abuse and Neglect policy. -Ensuring resident 2's person-centered care plan was followed. *Observations and staff interviews on 10/7/24 revealed the staff understood the education that had been provided. Based on the above information, non compliance at F600 occurred on 7/12/24, and based on the provider's implemented corrective actions on 7/18/24 for the deficient practice it was confirmed on 10/7/24 that the non compliance is considered past non complianc

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, policy review, the provider failed to ensure their policy related neglect reporting had been followed regarding an incident of elopement for one of one sampled resident (1). This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the managements knowledge of the elopement. Findings include: 1. Review of provider's SD DOH FRI for resident 1 revealed: *On 9/28/24 at approximately 1:30 p.m. registered nurse (RN) D assisted resident 1 outside. *RN D was busy and was not able to monitor resident 1 while he was outside. *Review of the footage from provider's cameras revealed that at 2:47 p.m. resident 1 was no longer in view of the facility cameras. *At 3:43 p.m. RN D heard the doorbell, answered it, and a woman was observed with resident 1. -The woman asked if he lived here. -The woman said she found him on the sidewalk on the other side of neighboring apartments, approximately 125 yards from the facility. -Time of submission from the provider to SD DOH for the initial FRI report was on 9/29/24 at 6:00 p.m. *The SD DOH initial FRI was not submitted within 24 hours of resident 1's elopement. Interview on 10/7/24 at 4:13 p.m. with RN D revealed: *She had not provided notification to any management staff of resident 1's elopement on 9/28/24. *On 9/29/24 she notified Minimum Data Set Nurse/Care Plan Coordinator/RN (MDS/CPC/RN) C, who was the manager on duty that day, of resident 1's elopement. *RN D confirmed she should have notified the director of nursing right away. *She stated, I didn't do it right. Interview on 10/7/24 at 4:30 p.m. with MDS/CPC/RN C revealed: *Resident 1's 9/28/24 elopement was reported to her by RN D on 9/29/24 at approximately 9:00 a.m. -MDS/CPC/RN C notified director of nursing (DON) B and administrator A immediately. -MDS/CPC/RN C initiated the investigation. *She stated the time frame for an elopement to be reported to the SD DOH was within two hours if there had been an injury and within 24 hours if there was no injury. -She stated the report to the SD DOH should have been completed as soon as possible. Interview on 10/7/24 at 5:40 p.m. with DON B revealed: *She was made aware of resident 1's elopement on 9/29/24. *She submitted the FRI to the SD DOH on 9/29/24 at 6:00 p.m. -The delay in reporting of the FRI was due to the information to be submitted needed to be reviewed by the Regional Nurse Consultant. -She submitted the FRI when she received notice that it was okay to submit. Review of the provider's Abuse and Neglect policy revealed: *Notify the appropriate/designated organization/authority that an investigation is being initiated immediately following intervention for the resident's safety. *All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. Review of the provider's 2/20/24 Elopement policy revealed: *Upon return of the resident to the facility, the Director of Nursing or charge nurse should: -Report to the DOH (SD DOH) per state requirements. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 10/7/24 after record review revealed: *The facility had followed their quality assurance process, and education was provided to all nursing care staff. -The nursing staff had been educated on their abuse and neglect policy, what an elopement was, and to immediately notify an elopement to a nursing manager or the administrator. *Corrective actions for RN D had included: education on their abuse and neglect policy, what an elopement was, and the process of reporting resident elopements to management immediately. Based on the above information, non-compliance at F609 occurred on 9/28/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 10/7/24, the non-compliance is considered past non-compliance. Based on the above information, non compliance at F609 occurred on 9/28/24, and based on the provider's implemented corrective actions on 9/29/24 for the deficient practice it was confirmed on 10/7/24 that the non compliance is considered past non compliance.

Based on observation, interview, and policy review, the provider failed to: *Maintain the cleanliness of the following kitchen equipment: -The dishwasher. -The microwave. -The reach-in ice machine. -The tabletop in which the beverage machines were located. -The flattop grill and stove backsplash. -The ovens underneath the flattop grill and stove. -The utensil drawers that were located underneath the kitchen prep table. -The convection ovens. -The reach-in beverage cooler. *Dispose of expired and visibly spoiled foods from one of two reach-in coolers in the kitchen, one of one shared resident refrigerator, one of one dry storage room, and two of two emergency food supply cabinets. *Properly cook unpasteurized eggs prior to serving to one of one sampled resident (34). Findings include: 1. Observation on [DATE] from 2:04 p.m. to 2:45 p.m. in the kitchen and dry storage room revealed: *The dishwasher had a layer of limescale buildup on the top and on the outside seams and edges of the machine. -There was a thick layer of grey slimy unidentified substance that was built up on the inside of the dishwasher doors. -Interview at that time with dietary aide U revealed that he cleaned the dishwasher each day by draining the dishwasher and rinsing out the food trap. He would delime the dishwasher once per week. *The reach-in ice machine had an orange-colored unidentified substance growing on the inside surfaces of the machine. *The microwave was dirty with burnt-on and crusty food particles. *There was a large black stain on the stainless-steel table where the beverage machines were kept. *The backsplash of the flattop grill and stove was caked with burnt-on black grease. There was a grease stain on the outside wall of the ovens too, that was located directly to the left of the stove. *The right oven located below the flattop grill had a large spill of an unidentified thick yellow substance. *The left oven located below the stovetop was covered in burnt-on black grease that was not able to have been opened without significant force. *The plastic utensil drawers located in the bottom shelf of a prep table had dust, food crumbs, and other unknown crumbs amongst the clean utensils. *Both convection oven interiors were covered in a sticky layer of brown and black burnt-on grease, which had the potential to affect how the oven cooked foods and could have led to uneven cooking. *There were lists on the cork-board labeled Deep Clean, however there were no assignments or checklists to document if a cleaning task had been completed. *The reach-in beverage cooler had crusty food crumbs and sticky liquid spills on the bottom surface of the cooler. *There was a bag of celery in the other reach-in cooler that had started to turn brown and felt mushy when picked up. -The producer's label on the bag indicated Best if used by [DATE]. -There was a handwritten note of Opened ,d+[DATE] on the bag. *There was an opened case of five cucumbers. The cucumbers had started to shrivel and became mushy, and had an unknown white fuzzy-looking mold-like substance growing on them. -The delivery label indicated the cucumbers were delivered on [DATE]. -There was a handwritten note of Opened [DATE] on the box. *There was another unopened case of cucumbers with a delivery date of [DATE]. -Upon looking in the case, those cucumbers had also started to shrivel and there was more of the unknown white fuzzy-looking mold-like substance on the cucumbers. *There was an unopened case of diced celery with a delivery date of [DATE]. The manufacturer's Best By date was [DATE]. *There were thirteen cans of sweetened condensed milk in the dry storage room with the manufacturer's label indicating Best used by 120321 [[DATE]]. Continued observation on [DATE] at 2:48 p.m. in the resident's dining room revealed there was a locked refrigerator for the resident's shared use. *There was a bottle of nondairy French vanilla coffee creamer in the door with a Best By date of 18 [DATE]. -That bottle of coffee creamer was not labeled with any resident's name, nor was it labeled with an open date. *There was a plastic bag of resident 24's food in the lower left drawer of the refrigerator. -The bag contained a bottle of water, a package of two hard-boiled eggs, three cups of yogurt, and a Styrofoam container with an unlabeled and undated unknown food item. --The unknown food item in the Styrofoam container was covered with an unknown mold-like substance that was colored with spots of brown, green, black, and white. --All the food, except for the bottle of water, was either visibly spoiled or past the expiration date. 2. Observation on [DATE] at 8:30 a.m. in the main dining room revealed: *Staff served over-easy eggs to resident 34. *A staff member assisted the resident with assembling an egg sandwich. -The egg yolk was runny when the sandwich was cut. Interview on [DATE] at 8:34 a.m. with cook V and dietary aide W about the shell eggs revealed: *They both thought the shelled eggs were pasteurized. *Cook V confirmed that the shelled eggs were not pasteurized. *They confirmed they often made eggs to order, such as over-easy eggs, for the residents. *Dietary aide W indicated that resident 34 requested over-easy eggs every morning. Interview on [DATE] at 9:06 a.m. with dietary manager (DM) C about the shell eggs revealed: *DM C confirmed the eggs were not pasteurized. *She indicated that resident 34 requested over-easy eggs every morning. *She was not aware that shell eggs needed to have been pasteurized if the eggs were to have been served undercooked, such as with over-easy eggs with runny yolk. 3. Interview on [DATE] at 12:03 p.m. with certified nurse assistant (CNA) P about the resident's shared refrigerator revealed: *He was unaware of the spoiled and expired food in that refrigerator. *It was everyone's responsibility to assist residents with labeling and dating their food and clearing out the old food from the refrigerator. 4. Observation on [DATE] from 4:23 p.m. to 4:49 p.m. in the emergency food cupboards revealed the following foods were past its expiration date: *One box of jelly packets with a delivery date of [DATE] and a Best by date of [DATE]. -The box was visibly damaged as if liquid had spilled on it at one point. *Five bags of powdered milk with a delivery date of [DATE]. *Three cans of tuna in water with a handwritten note of Received ,d+[DATE] and a Best by date of [DATE]. *One case of juice base with a delivery date of [DATE] and a Use by date of [DATE]. *Four cans of corned beef hash with a delivery date of [DATE] and a Use by date of ,d+[DATE]. *Two cans of beef ravioli with a delivery date of [DATE] and a Use by date of [DATE]. *Two cans of vanilla pudding with a manufactured date of 2018, a delivery date of [DATE], and a Use by date of [DATE]. *Three cans of pineapple chunks with a Use by date of ,d+[DATE]. *Twelve cans of diced peaches with a delivery date of [DATE] and a Use by date of [DATE]. *Three cans of diced carrots with a delivery date of [DATE] and a Use by date of ,d+[DATE]. Interview on [DATE] at 9:15 a.m. with DM C and regional culinary manager (RCM) G about kitchen cleanliness, the expired/spoiled foods, and the emergency food supply revealed: *They had no checklists or audit sheets for staff to utilize to ensure the cleaning tasks were completed. *They had no documentation when the last time the kitchen equipment was cleaned. *The dietary staff were responsible for checking for outdated and spoiled foods on a daily basis, and especially twice per week when they received the food shipments. *The dietary staff monitored the temperatures of the shared resident refrigerator, and the CNAs were responsible for assisting residents with labeling and dating their food. *RCM G explained that it was ultimately the dietary manager's responsibility to ensure the kitchen was cleaned, the food was rotated, and the spoiled/expired food was discarded. *When asked about the emergency food supply, DM C indicated that she rotated the foods into the regular menu to use up the supply and rotate new stock into place. She checked the [stock] once a year. -She was not aware that all the food in the emergency supply cupboards was past the manufacturer's Best by or Use by dates. 5. Review of the provider's [DATE] Cleaning Schedules policy revealed: *Policy statement: The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. *Procedure: -1. The Director of Food and Nutrition Services or other qualified nutrition professional shall record all cleaning and sanitation tasks for the Food and Nutrition Services Department. -2. A cleaning schedule shall be posted with tasks designated to specific positions in the department. -3. All tasks shall be addressed as to frequency of cleaning. Review of the provider's [DATE] Food from the Outside Policy revealed: *POLICY: The facility will comply with sanitary food practices in storing, handling, and consumption of food brought by family and visitors from the outside of the facility. *PROCEDURE: -1) All food brought by visitors and family members from the outside of the facility will be labelled with the date it was brought to the facility. -3) After 3 - 5 days, these food items will be discarded. -4) All undated food items will be discarded to ensure safety of the residents. Review of the provider's [DATE] Egg Cookery and Storage policy revealed: *POLICY: The Food and Nutrition or Dining Services department should ensure that eggs are prepared in a manner to preserve quality, maximize nutritional retention, and to be free of salmonella and acceptable to the resident. *PROCEDURE: -4. Do not use raw eggs as an ingredient in the preparation of uncooked, ready-to-eat menu items unless using pasteurized eggs. -5. Shell eggs must not be pooled. Pasteurized eggs should be substituted for shell eggs for such items as scrambled eggs, omelets, French toast, mousse, and meringue. -6. Individually prepared shell eggs that will be served immediately should be cooked to 145[degrees Fahrenheit] for 15 seconds. --The following cooking times are recommended: ---Fried, over easy - 3 minutes at 250[degrees Fahrenheit] on one side, turn over, fry 2 minutes on other side. -8. A soft egg should not be served unless the yolk and white are firm. -9. Pasteurized eggs in the shell may be cooked and served individually per resident's preference. Review of the provider's [DATE] Refrigerated Storage Chart policy revealed: *Following is a recommended outline of proper storage times for opened and unopened refrigerated items. Where different, follow manufacturer's directions and expiration dates. Expiration dates or manufacturer guidelines supersede these recommended storage times. *The chart recommended keeping fresh cucumbers and celery in the refrigerator for one week. *The recommendation for keeping Coffee Lightener, non-dairy creamer, mocha mix (liquid) was 3 weeks unopened, and 1 week from opening in the refrigerator. Review of the provider's [DATE] Dry Storage Chart policy revealed: *Following is a recommended outline of proper storage times for opened and unopened dry items. Where different, follow manufacturer's directions and expiration dates. Expiration dates supersede these guidelines. *The following recommendations were included on the chart: -Jellies and jams unopened for 12 months. -Juice bases unopened for 18 to 24 months. -Condensed milk for 12 months. -Canned pudding, ravioli, meats, fish, fruits, and vegetables for 12 months unopened. -Canned soups for 6 to 12 months.

Based on observation, interview, record review, nursing textbook review, and policy review, the provider failed to: *Appropriately check for PEG (percutaneous endoscopic gastrostomy) tube placement prior to administering a liquid medication and enteral nutrition formula for one of one sampled resident (28). *Follow the provider's policy when the pH of the stomach contents was out of range. *Follow the manufacturer's guidelines for refrigerating the cartons of enteral nutrition formula after opening. *Follow professional standards by using cola to unclog one of one resident's (28) PEG tube without obtaining a physician's order. Findings include: 1. Observation and interview on 9/27/23 at 12:43 p.m. with registered nurse (RN) Q in resident 28's room revealed: *She brought the resident's liquid medication and obtained the enteral feeding supplies from the tray on top of the resident's dresser. -On the tray, there were two opened cans of cola, two cartons of Jevity 1.2 (the enteral nutrition formula), a used orange de-clogger tool, a box of sponge gauze, a measuring bottle, a measuring pitcher, and a syringe. -The supplies were sitting on a white towel with visible brown stains on it. *She filled the water bottle with approximately 150 mL (milliliters) of tap water from the bathroom faucet. *She poured approximately 270 mL of Jevity 1.2 into the pitcher. -She used one entire carton of the formula, and a partial amount from the second carton. She replaced the cap onto the carton and marked it with the date. *Prior to administering the medication or enteral nutrition formula, RN Q explained that she needed to check the pH of the stomach contents. -She attached the syringe to the PEG tube. -With the plunger, she injected air into the PEG tube. -She then pulled the plunger back but did not get any stomach contents into the PEG tube or syringe. -She removed the plunger from the syringe and poured about 50 mL of water into the syringe and waited for the water to enter the stomach through the PEG tube. -After all the water entered the stomach, she used the plunger to inject air into the PEG tube. -She drew the plunger back and obtained residual stomach contents into the syringe. -She dripped some of the residuals onto a pH tester strip and reported that the pH was 1.0. --She did not stop the procedure to notify the resident's physician. *To administer the resident's liquid medication, RN Q poured more water into the syringe to flush the tube. *She then poured the liquid medication into the syringe. *Without flushing the tube with water after administering the medication, she poured the Jevity 1.2 formula into the syringe. -After filling the syringe twice more with formula, she flushed the tube with water. *After flushing the tube with water, she poured the rest of the formula into the syringe. *To finish off the tube feeding session, she poured the last of the water into the syringe to flush the tube. *She replaced the cap on the PEG tube. *She rinsed out the water bottle, formula pitcher, and syringe in the bathroom sink and placed the items on the towel to dry. *RN Q confirmed that after she opened the carton of enteral formula, she wrote the opened date on the carton and stored it on the dresser with the rest of the tube feeding supplies. -She was not aware that the instructions on the carton indicated to Refrigerate after opening. *She said, Well it gets pretty cold in here. But if her room is hot that day then I will throw the rest of the formula away if I know it's been sitting out. Continued interview on 9/27/23 at 1:39 p.m. with RN Q about the tube feeding supplies revealed: *The night shift would replenish the tube feeding supplies each night. -They would put out a new tray, a clean towel, a water bottle, a formula pitcher, and a syringe. 2. Interview on 9/27/23 at 1:57 p.m. with director of nursing (DON) B about her expectations for proper tube feeding administration revealed: *She expected staff to set up the supplies prior to administering the tube feed. *She confirmed that RN Q should have followed the resident's physician's orders and the provider's policy for checking for PEG tube placement prior to administering water, medication, or formula into the tube. *She explained they used the cola to unclog the PEG tube. -She indicated that she had received an order from the resident's nurse practitioner to use the cola to unclog the tube. -They only used a small amount of cola. -Staff were supposed to change the cans of cola once per shift. *She expected staff to write the opened date on the Jevity 1.2 cartons and refrigerate them after opening. *The towels and equipment were changed daily. -Staff rinsed the equipment in between each procedure. *She explained that they recently had to change resident 28's PEG tube quite often because it kept getting plugged. -They were unable to determine why the PEG tube kept getting plugged. Continued interview on 9/27/23 at 2:30 p.m. with DON B about the resident's PEG tube revealed: *She confirmed she could not locate any documentation for a physician's order to use cola to unclog the resident's PEG tube. -She explained that it was a verbal order from the resident's nurse practitioner. *The nursing staff had recently been through competency training on tube feeding administration, but RN Q had been hired after the competency training. 3. Review of resident 28's electronic medical record revealed: *She had physician's orders for the following: -Enteral Feed Order three times a day 270 cc [mL] Jevity 1.2cal- via gravity. If PH greater than 5.5, alert MD [medical doctor] as tube may not be in place. If unable to withdraw contents for testing PH, Use a stethoscope, inject air listening over abdomen. After completed flush with 50 cc [mL] water. --That order was listed twice, indicating the resident was to receive 270 mL of formula six times per day. --Those physician's orders started on 9/2/23. -A verbal order of Send [to] interventional radiology for PEG tube eval/ exchange if needed, which was ordered on 9/15/23. -There were no orders or instructions for the use of cola to unclog the PEG tube. -There were no orders for how staff were to unclog the PEG tube. *Her current care plan included the following interventions: -Check GTube [gastric tube] placement prior to feeding to prevent aspiration pneumonia, that was initiated on 1/7/21. -Give GT tube [gastric tube] feeding and water flush as ordered, that was initiated on 1/7/21. *There were no interventions documented on her care plan about how staff were to unclog the PEG tube. *A nurse's progress note from 8/21/23 read, I attempted to flush the g-tube prior to medication administration and there was resistance. I added warm water to the tube and let sit for 20 mins and attempted to flush it again with no luck. I used the feeding tube declogger tool, then added soda (Coke) to the tube and let sit for 30 minutes. Myself and another nurse [name redacted] attempted to flush again with no luck. *Her PEG tube was replaced on 8/30/23 and again on 9/15/23 due to a complete blockage of the tube. *A nurse's progress note from 9/16/23 read, Went to give pt [patient] her morning feed with her meds and tried pouring water down the tube and it would not go. Attempted several times and even got another nurse to attempt with no luck. PT [Patient] will not swallow meds and meds were already crushed and mixed and it won't go down tube. On call Dr [doctor] called and talked with [nurse practitioner] and gave her the information. She states that [it is] not urgent to go in to get a tube change since she just got it done yesterday. We are to continue to give pt [patient] food tray and supplement with Ensure plus qid [four times a day]. Pt [Patient] did take a few sips of the [Ensure] but needs to be continually monitored and ask to continue to take sips. We are to do this through the weekend and then follow up on Monday. *Throughout 9/16/23, resident 28 refused all oral meds and oral nutritional intake. -The nurse practitioner gave an order to send the resident to the emergency room for PEG tube placement. -Resident 28 refused to go to the emergency room , but had agreed to go the next morning. *There was a nursing progress note from 9/17/23 that read, DON was able to get peg tube unplugged this AM [morning] with coke. *There was a nursing progress note from 9/20/23 that read., Feeding tube slow to flush to no flushing. Attempted to aspirate unable to aspirate fluid. Stylus/ DE clogger put down tube twisted several times. Continued to not flush or aspirate. Poured 30cc [mL] of coke down tube. slowly drained down tube. Flushed with water with pressure. Again, added 30cc [mL] of coke plugged tube and let set for 20 min. Flushed coke through tube. Noted air escaping from tube. flushed water through tube with little force. 4. Review of the provider's 3/23/23 Enteral Feeding (Tube Feeding) policy revealed: *Procedure: -4. Check for residual and placement by attaching a sixty (60) ml piston syringe to gastric tube and gently pulling back about 10 ml. If resistance is met as stomach contents are aspirated, stop procedure and notify MD. -5. If no resistance, aspirate 5-10 ml of gastric contents. The appearance of gastric content that the tube is patent and in the stomach. Use pH strips to confirm that aspirate is at a pH of 1.5 to 5.5. If outside of these parameters, stop procedure and notify MD. -6. If no gastric contents appear, the tube may be against the lining of the stomach or may be obstructed. Stop procedure and notify MD. *The policy had no instruction on what staff should have done if the feeding tube became clogged during administration. *The policy had no instruction for the use of cola as a means of unclogging a feeding tube. 5. Review of the provider's undated Medication / Tube Feeding (Observe) competency checklist revealed: *15. Check for residual and placement by attaching sixty (60) ml piston syringe to gastric tube and gently pulling back approximately 10 ml. *16. If resistance is met as stomach contents are aspirated, stop procedure and notify MD [medical doctor]. If no resistance, aspirate 5-10 ml of gastric contents and check pH. The appearance of gastric content implies that the tube is patent and in the stomach. Use pH strips to confirm that aspirate is at a pH of 1.5 to 5.5. If outside of these parameters, stop procedure and notify MD. If no gastric content appears, the tube may be against the lining of the stomach or may be obstructed. Stop procedure and notify MD. After establishing that the tube is patent and in correct position, clamp tube. 6. Review of the carton of Jevity 1.2 enteral nutrition formula indicated there were instructions which read, Once opened, reclose, refrigerate and use within 48 hours. 7. Review of the provider's 2021 copy of the tenth edition of Fundamentals of Nursing revealed: *Page 1125, Box 45.14, Procedural Guidelines, Obtaining Gastrointestinal Aspirate for pH Measurement . -1. Review agency policy and procedures for frequency of irrigation and frequency and method of checking tube placement. Do not insufflate air into tube to check placement. -11. Verify tube placement. --Clinical Decision: Listening for insufflated air instilled through tube to check tube tip position is unreliable . --a. Check tube placement at following times . ---(1) For patients receiving intermittent tube feedings, test placement immediately before each feeding (usually a period of at least 4 hours will have elapsed since previous feeding) and before medications. ---(3) Wait to verify placement at least 1 hour after medication administration by tube or mouth. --b.For intermittent feedings, remove plug at end of feeding tube. Draw up 30 mL of air into a 60-mL ENFit syringe. Place tip of syringe into end of gastric .tube. Flush with air before attempting to aspirate fluid. Repositioning patient from side to side is helpful. In some cases more than one bolus of air is necessary. --c. Draw back on syringe slowly and obtain 5 to 10 mL of gastric aspirate. Observe appearance of aspirate . -12. If after repeated attempts it is not possible to aspirate fluid from tube that was confirmed by x-ray film to be in desired position and if (1) there are no risk factors for tube dislocation, (2) tube has remained in original taped position, (3) patient is not in respiratory distress, assume that tube is correctly placed. Continue with irrigation. -13. Irrigate tube. --Clinical Decision: Do not use cola or fruit juices for flushing tubing as these liquids can club tube.

Based on observation, record review, interview, and hospice service review, the provider failed to develop a collaborative comprehensive care plan that defines hospice care for three of four sampled residents (12, 21, and 49) receiving hospice services. Findings include: 1. Observation on 9/26/23 at 12:45 p.m. of resident 12 in her room revealed she was laying in bed with her back to the door. Comparison review of resident 12's comprehensive care plan and revised 9/10/23 hospice care plan revealed: *She was admitted to hospice on 7/28/23 with diagnosis of protein calorie malnutrition. *While the comprehensive care plan reflected, the hospice aide visits were one to two days a week; no hospice aide visits were reflected on the hospice care plan. *While the hospice care plan reflected, the medical social worker was one visit every week; no medical social worker vists were reflected on the comprehensive care plan. 2. Observation on 9/26/23 at 8:30 a.m. of resident 21 in her room revealed she was resting with eyes closed and her oxygen was on per nasal cannula. Comparison review of resident 21's comprehensive care plan and revised 9/17/23 hospice care plan revealed: *She was admitted to hospice on 7/27/23 with diagnosis of acute on chronic respiratory failure. *While the hospice care plan reflected, medical scial worker visits were one visit every two weeks; no medical social worker visits were reflected on the comprehensive care plan. 3. Observation on 9/25/23 at 3:00 p.m. of resident 49 in his room revealed he was tossing a ball back and forth with guest service aide I. Comparison review of resident 49's comprehensive care plan and revised 9/20/23 hospice care plan revealed: *He was admitted to hospice on 11/7/22 with diagnosis of dysphagia causing pulmonary aspiration with swallowing. *While the comprehensive care plan reflected hospice aide visits were one day a week; hospice care plan reflected no visits. *While the comprehensive care plan reflected medical social worker once every three weeks; hospice care plan reflected one visit every two weeks. While the comprehensive care plan reflected skilled nursing visits every week; hospice care plan reflected two visits every week. 4. Interview on 9/27/23 at 2:45 p.m. with nurse supervisor D revealed: *She had no knowledge of when hospice staff planned to come to the facility or how many days a week each resident was seen by each hospice staff member. *Resident hospice binders had no up-to-date calendar with the times of upcoming visits. -No recent documentation from hospice staff on their visits. 5. Interview on 9/27/23 at 3:00 p.m. with director of nursing (DON) B revealed: *Hospice had its own schedule and the staff do not know what days of the week or what time the hospice staff would come visit the residents. *We do not have hospice aides come visit because we have our own certified nurse aides (CNAs). *It should have been documented in the chart when the hospice staff had visited. 6. Interview on 9/27/23 at 3:30 with licensed practical nurse (LPN) K revealed: *She had no schedule for the residents hospice visits. *Hospice would stop at the nurse's station and give a verbal report to the staff. -Hospice nurse visits are not in the residents chart. *All hospice residents would have hospice aide visits. *Hospice aides would call before coming to the facility for their visits. *She would call the hospice phone number to talk to the nurse, if she would have a question or concern about a hospice resident. 7. Interview on 9/28/23 at 7:55 a.m. with CNA T revealed: *Hospice aide's give bed baths. *Hospice aides usually call before their visits and the bath aide will reschedule their regular bath around hospice aide visits. 8. Interview on 9/28/23 at 8:10 with DON and assistant administrator S revealed hospice visits should have been posted to communicate with staff. 9. Review of the provider's revised May 18, 2021 Hospice Services revealed: 3. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status.

Based on observation, interview, record review, and policy review the provider failed to ensure: *One of one sampled resident (22) received appropriate medical professional psychiatric monitoring of psychiatric medications and accurately documented fall risk evaluation. *One of one sampled resident (45) received a timely assessment and documented assessment of a reported skin injury. 1. Review of resident 22's medical record revealed: *She was admitted on [DATE]. *Her 7/13/22 Brief Interview of Mental Status (BIMS) score was a three, indicating she had severe cognitive impairment. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 10 mg once a day for [CONDITION(S)]. -[MEDICATION(S)] 5 mg once a day for [CONDITION(S)]. -[MEDICATION(S)] 75 mg once a day for [CONDITION(S)]. --This had been decreased from 150 mg on 9/1/22. *Her care plan included: -A revised 6/2/20 focus of potential alterations to mood/psychosocial well-being related to: repeated accidents and falls, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . --Revised 6/17/22 interventions included: Psychiatric support with a psychiatrist, with an attempt to switch providers to a local psychiatric provider so resident would not need to travel. -A revised 7/27/20 focus of aggressive/inappropriate behavior including yelling, cussing, threatening behavior, hitting, grabbing, and mimicking staff related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . --Revised 6/17/22 interventions included: give psychoactive medication as ordered and refer to mental health provider as needed or indicated. -A revised 6/15/22 focus of using psychoactive medications for [CONDITION(S)] and to be followed by psychiatrist but currently trying to get switched to local psychiatry group that can come see her in facility. *Her progress notes included: -*A 3/1/22 behavior and [CONDITION(S)] interdisciplinary team (IDT) review indicated she had been seeing a psychiatrist. -There was no documentation to support when she had last seen a psychiatrist. *A facsimile had been sent to her psychiatrists office on 3/21/22 regarding her [CONDITION(S)] medications. -A 4/9/22 facsimile was returned from her psychiatrists office indicated she had been last seen on 10/13/20 and should follow up with her primary care provider or to schedule an appointment with the psychiatrists office. *A 4/13/22 facsimile to her primary care provider had been sent requesting further advise on pharmaceutical therapy. -A 4/14/22 facsimile response was provided by her primary care provider stating she should be followed by a psychiatrist. *A 5/23/22 progress note that an attempt to contact her psychiatrist had been made and the provider was waiting on a call back. *A 5/24/22 behavior and [CONDITION(S)] IDT review indicated she had been seeing a psychiatrist with attempts to change over to a new one. -There was no documentation to support when she had seen a psychiatrist. *Documentation of her behaviors from 8/25/22 through 8/30/22 included: -Eight episodes of inappropriate behavior including one or more of the following: yelling, screaming, kicking, hitting, pushing, grabbing, pinching, scratching, spitting, wandering, abusive language, threatening behavior, rejection of care. *Documentation of her behaviors from 9/1/22 through 9/14/22 included: -Twelve episodes of inappropriate behaving including one or more of the following: yelling, screaming, wandering, grabbing, abusive language, and rejection of care. Interview on 9/15/22 at 1:50 p.m. with social service designee (SSD) E regarding psychiatric care for resident 22 revealed: *SSD did not always document care provided. *SSD was responsible to coordinate psychiatric care, including filling out paperwork for referrals and contacting physicians for assistance in obtaining referrals. *Her psychiatrist had not provided care recently. -SSD was not certain when she last seen a psychiatrist. *SSD had been working on getting a different psychiatric provider but had not always documented this. *SSD had contacted the current psychiatrist and had been told they had not seen in her a while. *The certified nurse practitioner provider had been adjusting her psychiatric medications, including [MEDICATION(S)]. *There had been a decrease in the [MEDICATION(S)] on 9/1/22. -She had been really snippy lately but had not been abusive or mean. -She had been having inappropriate behavior prior to the decrease of the [MEDICATION(S)]. Interview on 9/15/22 at 4:09 p.m. with administrator A regarding resident 22's psychiatric care revealed she was unaware she was not receiving care from a psychiatrist and would have benefited from seeing one. Psychiatric visit notes for resident 22 were requested from the administrator on 9/15/22 at 1:25 p.m. the only notes provided were from 8/22/19 which was prior to resident 22's admission on 5/1/20. A policy for psychiatric care was requested from the administrator on 9/15/22 at 1:25 p.m. Regional Nurse Consultant C stated there was no policy for this. 2. Observation on 9/13/22 at 3:10 p.m. of resident 22 revealed: *She was in the hallway. *She attempted to stand up from her wheelchair. *A CNA assisted her in sitting back down and put her feet on the wheelchair pedals. Review of resident 22's medical record revealed: *She was admitted on [DATE]. *Her 7/13/22 Brief Interview of Mental Status (BIMS) score was a three, indicating she had severe cognitive impairment. *Fall risk evaluations had been completed for her falls on 5/27/22, 5/29/22, and 6/23/22. *She had a fall on 7/2/22 at 5:45 a.m. -This fall resulted in a left tibia fracture. *On 7/2/22 her fall risk evaluation with an effective date of 5:45 a.m. indicated: -She had not just had a fall. -She did not have a fall incident in the last three months. *She did have three falls within the last three months as indicated by the fall risk evaluations being completed on 5/27/22, 5/29/22, and 6/23/22. Continued interview and record review on 9/15/22 at 3:17 p.m. with ADON B regarding documentation revealed: *Resident 22 fell often. *He had not been aware of any issues with documentation. *His expectation would have been for the documentation to be accurate. *Agreed the 7/2/22 fall risk evaluation was incorrect as resident 22 did have a fall that resulted in the fall risk evaluation being completed on that date. Interview on 9/15/22 at 4:12 p.m. with administrator A regarding accuracy of assessments revealed she would have expected the documentation to always be accurate. Review of the provider's falls management policy revealed: *POLICY 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. -Fall injury prevention - Post Fall. --4. Complete Fall Risk evaluation. 3. Review of resident 45's electronic medical record revealed: *A 6/21/22 skin alteration evaluation that showed she had an abrasion on her lower back. -There was no description or measurements of the abrasion. *A 6/23/22 progress note that a certified nursing assistant reported she had a large bruise on her shoulder. *A 6/23/22 skin evaluation that showed no skin issues. Observation on 9/13/22 at 9:27 a.m. of resident 45 in her room revealed: *She was lying in her bed that was in the lowest position. -Next to the bed there was a mattress. -Next to that mattress there was a fall mat that extended to the dresser against the opposite wall. Review of resident 45's record revealed: *A 6/21/22 skin alteration evaluation that showed she had an abrasion on her lower back. -There was no description or measurements of the abrasion. *A 6/23/22 progress note that a certified nursing assistant reported she had a large bruise on her shoulder. *A 6/23/22 skin evaluation that showed no skin issues. Interview on 9/15/22 at 11:29 a.m. with certified nursing assistant (CNA) R regarding resident 45's bruise revealed: *She confirmed she had reported the bruise to a nurse. -The bruise was large about the size of an orange or apple. -She was not certain if a nurse had evaluated the bruise. Interview on 9/15/22 at 11:40 a.m. with MDS Nurse F regarding the bruise on resident 45 revealed she: *Remembered talking to the director of nursing about the bruise. -Had not documented this conversation. *Confirmed the bruise should have been documented on the 6/23/22 skin evaluation, and investigated. Interview on 9/15/22 at 11:03 a.m. with assistant director of nursing B regarding the bruise on resident 45 revealed: *The bruise had not been evaluated and documented, and should have been. *Had provided skin program training to the professional nurses on 6/30/22. Interview on 9/15/22 at 11:29 a.m. with certified nursing assistant (CNA) R regarding resident 45's bruise revealed: *She confirmed she had reported the bruise to a nurse. -The bruise was large about the size of an orange or apple. -The nurse did not evaluate the bruise at the time of it being reported, to her knowledge. Interview on 9/15/22 at 11:40 a.m. with MDS Nurse F regarding the bruise on resident 45 revealed she: *Remembered talking to the director of nursing about the bruise. -Had not documented this conversation. *Confirmed the bruise should have been documented on the 6/23/22 skin evaluation, and investigated. Interview on 9/15/22 at 11:03 a.m. with assistant director of nursing B regarding the bruise on resident 45 revealed: *The bruise had not been evaluated and documented, and should have been. *Had provided skin program training to the professional nurses on 6/30/22. The director of nursing was not available for an interview. Review of the provider's revised April 2021 Skin Program policy revealed: *6. When a pressure injury, bruise or skin tear is noted, a Skin Evaluation UDA [user defined assessment] should be completed, and the injury entered into Risk Management in PCC [electronic medical record]. These areas will be monitored on Treatment Administration Record (TAR) until healed. Following identification of a skin issue, the Skin Alteration Evaluation UDA will be completed weekly until resolved.

Based on observation, interview, record review, and policy review the provider failed to ensure: *One of one sampled resident (27) received a continuously working pressure reduction alternating air mattress to promote the healing of a pressure ulcer. *One of one sampled resident (50) received a continuously working pressure reduction alternating air mattress to prevent a pressure ulcer. Findings include: 1. Observation and interview on 9/13/22 at 9:40 a.m. with resident 27 revealed: *She was sitting up in her bed, dressed and groomed. *She had a pressure ulcer on her right buttocks. *She had the pressure ulcer at home before she moved into the facility. *She was supposed to have a pressure reduction mattress. -Her current mattress was hard, and her bottom was sore. -She had been on the hard mattress for 2 days. *The only time she was got out of bed was to use the bedside commode. *Dressings for her pressure ulcer were done daily in the mornings before 6 a.m., they do it after I get off the commode. *She ate her meals in bed with the use of her overbed table. *She stated, they are short of help, last night was the worst night. -At 8:00 p.m. she activated her call light to get assistance in getting on the commode. --It was almost 9 p.m. when someone came and assisted her with getting on the commode, they did not return and assist her off of it until 10:00 p.m. Interview on 9/14/22 at 1:02 p.m. with registered nurse (RN) G regarding resident 27's pressure ulcer revealed: *She was admitted with a stage three pressure ulcer to her right buttock and still had that stage three pressure ulcer. *She previously had a pressure reduction alternating air mattress to promote healing of the pressure ulcer. -That pressure reduction alternating air mattress had stopped inflating and was replaced with a different mattress that was not a pressure reduction alternating air mattress. Observation and interview on 9/14/22 at 1:14 p.m. with resident 27 revealed: *She was sitting up in bed crying and was refusing to eat her lunch. *The facility had placed a different pressure reduction alternating air mattress on her bed. *The air mattress was under inflated and sagging in the middle. -She was laying on the underinflated sagging portion of the air mattress and was crying. *She stated her buttocks hurt and she had wanted to sit on her commode. *Her call light was placed on. *The assistant director of nursing (ADON) B answered her call light. -He stated they were having issues with some of their air mattresses. -They were in the process of getting a different air mattress to replace the one that was not inflating. *The resident was transferred onto her bedside commode per her request. Review of resident 27's medical record revealed: *She was admitted to the facility on [DATE]. *A 7/13/21 admission Minimum Data Set (MDS) assessment documented a stage three pressure ulcer. *Her most recent Brief Interview for Mental Status (BIMS) dated 7/15/22, had a score of 15 which means she was cognitively intact. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Severe Pain related to [CONDITION(S)] OF BUTTOCK; PRESSURE-INDUCED DEEP TISSUE DAMAGE OF RIGHT-BUTTOCK. -Check air mattress if functioning properly as needed. *Care plan intervention initiated on 8/24/21 for I will use an air mattress on bed and cushion in w/c [wheelchair]for pressure relief and comfort. Interview on 9/15/22 at 1:05 p.m. with certified nursing assistant (CNA) J regarding resident 27 revealed: *The resident had a pressure ulcer to her right buttock. *She had come to the facility with the pressure ulcer. *She stated, She has a different air mattress; the previous mattress broke. Interview on 9/15/22 at 2:36 p.m. with nurse supervisor licensed practical nurse (LPN) and ADON B regarding resident 27 revealed: *She had a stage 3 pressure ulcer on admission to the facility. -That pressure ulcer was not healed. -That pressure ulcer was due to immobility. *She does not get out of bed, except to use the bedside commode. *Her air pressure reduction mattress had not been working correctly. *She now had an air pressure reduction mattress that was working. 2. Observation on 9/13/22 at 1:07 p.m. and 4:42 p.m. of resident 50 revealed: *With his door open, resident 50 was lying in bed sleeping. -He was wearing an incontinent brief and no pants. *The door to his room was open. *He had a urinal on his bedside table and a bedside commode in the corner of his room. *There was a walker next to his closet. *There was no alternating air pressure reduction mattress on his bed. *His mattress he did have was firm to the touch. Observation and interview on 9/14/22 at 1:32 p.m. with RN G revealed: *With his door open, resident 50 was lying in bed sleeping. -He was wearing an incontinent brief and no pants. *The door to his room was open. *He had a urinal on his bedside table and a bedside commode in the corner of his room. *There was a walker next to his closet. *There was no alternating air pressure reduction mattress on his bed. -The mattress he did have was firm to the touch. *He had a stage three facility acquired pressure ulcer to his coccyx. -He did not have this pressure ulcer when he was admitted on [DATE]. *His reluctance to reposition caused the pressure ulcer. *He slept a lot. *He did not walk, was weak and stayed in bed. *She agreed the mattress he was laying on was not a pressure reducing alternating air mattress nor a pressure reduction mattress. *His alternating air mattress had stopped working correctly and they were in the process of getting him a different one. *Following wound care and interview, ADON B presented to resident 50's room with a pressure reducing alternating air mattress and placed it on his bed. Observation on 9/14/22 at 4:00 p.m. of resident 50 revealed: *An alternating air mattress was on his bed. *The air mattress was not inflated and was on the bed. -He was laying on top of this un-inflated air mattress. *ADON B agreed the mattress was not inflated and stated he would replace that one with a different air mattress. Observation and interview on 9/15/22 at 1:12 p.m. with resident 50 revealed: *With his door open, resident 50 was lying in bed. -He was wearing an incontinent brief and no pants. *The door to his room was open. *He moved to the facility because of his rheumatism. *His pressure ulcer was on his coccyx, and it had developed in the facility. -I think I was laying on all this wet stuff. -They put me in a wheelchair when I go to medical appointments, otherwise I stay in bed, I am too weak to walk. -I could walk before I came in here. -I told one of the ladies to tell the therapy people to put me on their list and she said they only work half a day. -No one was helping him with exercises in bed. *He had an air mattress and then it broke. -He was unsure of how long it took to get the new air mattress. -The staff had come and helped turn him. -He was rolled over to his right side and laid there for half of the day. *He had a urinal and bedside commode for going to the bathroom. Review of resident 50's medical record revealed: *He was admitted on [DATE]. *His current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *His most recent BIMS dated 8/17/22 had score of 14 indicating he was cognitively intact. *His 7/5/22 admission MDS had documented that he: -Had no current pressure ulcer. -Was at risk for the development of a pressure ulcer. *Braden Scale and Clinical Evaluations were completed on: -On 7/5/22 and 7/12/22 that revealed he was at low risk for pressure ulcer development and that: --His skin was rarely moist: skin was usually dry. --He walked occasionally. --He had no mobility limitations. --Nutrition was excellent and ate most every meal. --Friction and sheer were no apparent problem. -On 7/22/22, 8/11/22, and 8/19/22 that revealed he was at high risk for pressure ulcer development and that: --His skin was occasionally moist: Skin is occasionally moist. --He was chairfast: ability to walk severely limited or nonexistent. --Nutrition was probably inadequate. --Friction and shear were a potential problem. *Skin Evaluations were completed: -Weekly from 7/5/22 to 7/26/22 with no skin alterations identified. -The 7/27/22 skin assessment indicated he had a skin alteration but did not have a description of what or where the alteration was. -The weekly skin assessment dated [DATE] had no alteration in skin integrity documented. -The weekly skin assessment dated [DATE] had documentation of an unstageable pressure ulcer to the coccyx. *Skin alteration evaluations were documented: -On 8/29/22 indicating he had an unstageable pressure ulcer. -On 9/12/22 indicating he had a stage three pressure ulcer. *Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Alternating air mattress on bed check Q [every]shift for proper functioning and settings. *Care Plan focus was documented as: -Resident is at risk for impairment to skin integrity r/t [related to]poor appetite with weight loss, occasional incontinence of bladder, limiting mobility d/t [due to]pain in hip. Date Initiated: 06/28/2022 Revision on: 08/24/2022. -Resident has an actual impairment to skin integrity Open area. Unstageable on coccyx area Date Initiated: 08/26/2022 Revision on: 08/26/2022. *Care plan goal was documented as: -Resident will continue to have intact skin through next review. Date Initiated: 06/28/2022 Revision on: 09/01/2022. -Resident will not develop signs and symptoms of infection on the wound site Date Initiated: 08/26/2022 Revision on: 09/01/2022. *Care Plan interventions included: -Maxi float mattress [pressure reduction air mattress] and w/c [wheelchair] cushion in place. -LOW RISK -Skin weekly. Report abnormalities to the nurse. -Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] failure to heal, signs and symptoms of infection, maceration etc. to MD. -Alternating air mattress on bed date initiated: 08/26/2022. -Wound care to Coccyx. *Physical therapy treatment notes included: -6/30/22 Physical therapy started walking using a four wheeled walker, patient ambulated approximately 80 feet today with cues on upright standing with minimum assist, one time, and was followed closely by wheelchair. -7/4/22 He had performed NuStep four minutes and two minutes with a rest break. Therapeutic exercises to increase bilateral lower extremity endurance, cardiovascular endurance, and cardiopulmonary endurance. He had ambulated 50 feet and 80 feet with a four wheeled walker with minimum assist to improve functional capacity and endurance. *Physical Therapy discharge summary was documented as: -A baseline on 6/29/22 of having been able to ambulate 40 feet with a four wheeled walker and with caregiver assistance. -A discharge on 8/2/22 of having been able to ambulate 250 feet with a four wheeled walker, with caregiver assistance, and one rest break due to fatigue. Interview on 09/15/22 at 12:54 p.m. with CNA J regarding resident 50 revealed: *The CNA's observed residents' skin during cares. *Changes in skin condition were reported to the charge nurse on duty. *Staff were made aware of the resident's daily care needs by the resident call light, care sheets, shift report and the morning huddle. *He had a pressure ulcer to his coccyx. -He did not have that pressure ulcer when he was admitted to the facility. *She was unsure if his pressure ulcer had improved or gotten worse stating I haven't seen it for a few days, so I don't know. *Pressure ulcer interventions had included: *An air mattress on his bed. -She stated, He had one prior to yesterday but it had not worked so we had taken it off until they got one that worked. Interview on 9/15/22 at 2:32 p.m. with nurse supervisor LPN H and ADON B regarding resident 50 revealed: *Nurse supervisor LPN H was the facility's wound care nurse. -She was not wound care certified. -She had completed: -- A webinar regarding wound care. --A wound care seminar in another town. -She worked with a wound care company that assisted with treatment recommendations and provided education regarding the proper utilization of wound care products. -That company employed a nurse who came to the facility to do this. -She could call that nurse with specific wound care concerns. *That nurse visited the facility monthly but had not visited in the last month. *Resident 50 was at risk for the development of a pressure ulcer. *He had a facility acquired stage three pressure ulcer to his coccyx. *He did not have an alternating air mattress prior to the development of his pressure ulcer. *Interventions in place once he had developed a pressure ulcer had included: -An alternating air mattress, but it had quit working so they had put him back on a regular mattress until they could get a different air mattress. *Nurse supervisor LPN H completed a weekly wound assessment that included measurements to monitor the wound progress and the effectiveness of the interventions. *The wound measurements had not improved. *The depth of the wound had increased. *Staff were monitored to ensure they were implementing care plan interventions by her completing observation rounds twice a day. *There had been a concern identified regarding the development and management of pressure ulcers in the spring of 2022. *The facility's policies and procedures regarding care, treatment, prevention, and interventions for pressure ulcers had included the use of pressure reduction alternating air mattresses. Interview on 9/15/22 at 4:30 p.m. with administrator A regarding the facilities Quality Assurance Plan Improvement (QAPI) process revealed: *Pressure ulcers were identified as a facility systemic failure concern during a MOCK survey conducted in the spring of 2022. -This systematic failure concern had been reviewed to the QAPI committee. -A nurses meeting was held on 6/30/22 to discuss the skin program with education provided. -Audits had been started in June 2022. *There was no documentation to support the audits had continued. Review of the facility's 12/1/2019 Treatment Nurse job description revealed: *Summary/Objective -The Treatment Nurse is responsible for performing skin treatments for all guests under their care. This position will obtain treatment orders for attending physicians and assist with modifying the treatment regimen in accordance with established policies and procedures. The Treatment Nurse will provide supervision of staff and will safeguard the health, safety and welfare of all guests under their care by following applicable laws, regulations, and established nursing policies and procedures. *Essential Functions -8. Ensure that guest care plans are being followed and assess each guest's status in accordance with their care plan. -10. Must be knowledgeable of individual care plans and support the care planning process by reporting specific information and observations of the guest's needs, preferences and report any behavioral changes. -15. Reports all hazardous conditions, damaged equipment, accidents/incidents and supply issues to appropriate person. -16. Maintains the comfort, privacy and dignity of guests and interacts with them in a manner that displays warmth, respect and promotes a caring environment. -17. Ensure each guest receives person centered care. Review of facility's 4/2021 Skin Program policy revealed: *Policy: -To ensure a resident who enters the facility without pressure injuries does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable. -To provide care and services to prevent pressure injury development, to promote the healing of pressure injuries/wounds that are present and prevent development of additional pressure injuries/wounds. *Procedure: -5. A comprehensive wound assessment will be completed: --c) A review of the resident's current POC [plan of care] and medical status-any other possible risk factors, impaired healing due to diagnoses; -7. Nursing personnel will develop a plan of care (POC) with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident's adherence to the pressure injury prevention/treatment plan. POC to include Impaired mobility, Pressure relief, nutritional status and interventions, Incontinence, skin condition checks, Treatment, Pain Infection, Education of resident and family, Possible causes for pressure injury and what interventions have been put in place to prevent.

Based on observation, interview, record review, and policy review the provider failed to ensure one of one resident (17) had received physician ordered treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Observation and interview on 9/13/22 at 11:29 a.m. of wound care for resident 17 by registered nurse (RN) I revealed: *A a dressing on her lower back with a date of 9/9 written on it. -That was the date of the last dressing she had placed on the wound. *The dressing was to have been changed daily. *She confirmed the dressing with the 9/9 date written on it indicated the dressing had not been changed since 9/9. -That was four days the dressing had not been changed. *There was small amount of thick, gray matter that came out of the wound when she had pressed around the edges of it. *She stated the wound may be infected and would need an antibiotic, and she was going to notify the doctor. Review of resident 17's medical record revealed: *Her 8/13/22 Brief Interview of Mental Status was a score of 2, meaning the she had severe cognitive impairment. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her care plan included she: -Had the potential for impairment to skin integrity related to incontinence and difficulty understanding due to developmental delays. -Required assistance for getting dressed, assistance with cleaning up after using the toilet, and with personal hygiene. *A skin evaluation on dated 8/19/22 revealed on her left lower back she had a small red bump with a center head showing, and moderate drainage from the center. *A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *A skin evaluation dated 8/26/22 revealed a wound of a small red raised bump on lower back area that was to be cleansed daily. *The TAR revealed the wound care treatment had been documented seven consecutive time, from the evening of 9/9/22 through the evening of 9/12/22, as having been completed when it had not been. Interview on 9/15/22 at 1:46 p.m. with nurse supervisor H regarding wound care for resident 17 revealed she: *Did wound rounds and evaluated wounds once per week. *Had completed wound rounds on 9/11/22. *Had forgotten resident 17 had a wound and had not looked at on 9/11/22. -She had not looked at the wound since the previous week. Interview on 9/15/22 at 3:04 p.m. with nurse supervisor H and assistant director of nursing (ADON) B regarding wound of resident 17 revealed: *The wound was a boil and nurse supervisor H thought the dressing had been a dry dressing, but was not certain. *The TAR would have shown the correct order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] *If a treatment had not been completed the documentation should have reflected that in the TAR. Continued interview and record review on 9/15/22 at 3:12 p.m. with ADON B regarding 17's wound revealed: *His expectation would have been for the documentation to be accurate. *He confirmed he had worked as the charge nurse on 9/10/22 and 9/11/22. -He had documented the wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . -He agreed that the dressing dated 9/9/22 indicated the treatment had not been provided for that wound since that date. -He confirmed that: --The wound care documentation indicated the wound dressing had been completed, although it had not been done. --He had not completed the wound dressing on 9/10/22 and 9/11/22. --He had documented the wound dressing as being done. --He confirmed other nurses had documented that they had completed the wound dressing for the evening of 9/9/22 through the evening of 9/12/22. ---He confirmed that not having the dressing changed during that time period may have resulted in the gray, thick matter the wound had developed. Interview on 9/15/22 at 4:12 p.m. with administrator A regarding wound documentation revealed: *Her expectation was for documentation to be accurate. -When a treatment had not been completed as ordered, the nurse should have documented why it was not done. -The nurse should have notified the next shift so that they could have completed the treatment. *She stated I think it is neglect and should be reported [to the South Dakota Department of Health]. Review of nurse supervisor H's signed job descriptions revealed she was: *To complete Wound Care Rounds. *12. Administer or supervise all treatments prescribed by physicians including but not limited to pressure ulcer care, Foley catheter care, and hot and cold compounds. *15. Provide wound care when needed. Review of ADON B's signed job description revealed: *Essential Functions. -1. Assists the D.O.N. [director of nursing services] with planning, directing, and supervising the activities of the nursing staff. -2. Ensure the Nursing Department is in compliance with federal, state, and local regulations. Review of the provider's revised May 2021 following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Policy: to correctly and safely receive and transcribe physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -If the order is for a medication or treatment, it should be entered in the MAR/TAR [medication administration record/treatment administration record]. *The policy did not cover documentation of administering or not administering medications or treatments. Review of the provider's abuse and neglect policy revealed: *Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, . neglect, or mistreatment. -Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware or should have been aware of the service the resident requires, but fails to provide that service.

Based on observation, record review, interview, and policy review, the provider failed to complete weekly skin assessments, follow physician's orders, and implement interventions for three of six sampled residents (1, 3, and 8) who had acquired multiple pressure ulcers while in the facility. Findings include: 1. Observation on 6/6/17 at 8:10 a.m. of resident 8 revealed she had been walking with a walker from the dining room to her room. Observation and interview on 6/6/17 at 9:45 a.m. with resident 8 in her room revealed: *She was sitting in her recliner. *She had not been sleeping in her bed at night, because the mattress was hard, and it hurt her back. *She would usually sleep a few hours in her bed then move to the recliner. *She had requested a different mattress. *She currently had a pressure ulcer on her bottom. *She stated they were going to start her on a nutritional supplement, but that had not happened yet. *She was able to stand up with the use of her walker. *She had a black cushion on the seat of her recliner. Review of resident 8's 4/17/17 Minimum Data Set (MDS) assessment revealed: *She had a Brief Interview for Mental Status score of fifteen that meant her cognition was intact. *She required extensive assistance of one staff person to transfer from one location to another. Review of resident 8's medical record revealed: *She had been admitted on [DATE]. *She had developed a pressure ulcer to her bottom on 4/23/17 and on 5/29/17. *The documentation regarding the staging for the 4/23/17 pressure ulcer had stated it was a stage one open area. -For a stage one pressure ulcer the skin would be intact and not open. *There had been documentation regarding the 4/23/17 pressure ulcer stating it was on her left buttock, but the note to the physician stated it was on her right buttock. *There had been no wound data sheets for the 4/23/17 pressure ulcer. -The 4/24/17 weekly skin assessment stated there was on opened area to her left buttock. -There had been no other documentation regarding the measurements for that wound. -On 5/8/17 there had been a physician's order to discontinue the dressing due to the wound being healed. *On the 5/29/17 physician's notification they had staged the pressure ulcer as Unstageable - dark purple in color and nonblanchable with small opening at bottom of wound. -Measurements had been 2.0 x 1.8 x 0.1. -On 5/30/17 the measurements had been 3.0 centimeters (cm) by 0.6 cm and 0.2 cm. Review of resident 8's 4/26/17 physician's order revealed the staff were to check her chair/recliner and cushion for possible cause of opened area on right buttock. There had been no documentation that had occurred until 5/29/17 after she had developed another pressure ulcer to her bottom. Review of the weekly skin assessment reports from 1/5/17 through 6/5/17 revealed there were nine out of twenty-five missing skin assessments during that timeframe. Review of resident 8's registered dietician and dietary manager notes revealed they had not addressed the pressure ulcers to her bottom that had developed on 4/23/17 or 5/29/17. Interview on 6/6/17 at 2:50 p.m. with interim director of nursing (DON) N regarding resident 8 revealed:*She stated she was uncomfortable answering the questions related to the resident's pressure ulcers. *She deferred the questions to the interim assistant director of nursing (ADON) as she was responsible for their quality assurance plan for pressure ulcers. Interview on 6/6/17 at 2:55 p.m. and again at 5:45 p.m. with interim ADON H and ADON F regarding resident 8 revealed: *Interim ADON H had started on 4/10/17. *There had been a performance improvement plan for pressure ulcers developed on 3/30/17. -She had taken it over when she started. -She was unsure of what to put as target dates and how to implement the plan. *The document had been blank except for the listed tasks. *She had no documentation of audits having been completed. *She had not attended any of the quality assurance meetings up to this point in time. *The resident had acquired the two pressure ulcers in the facility. *Interim ADON H had known the resident had not slept in her bed and had requested a different mattress. -She was unsure of when they were getting it for her but thought they had notified the physician last week. -At 5:45 p.m. they had provided documentation that the physician had been notified on 5/30/17 requesting an order for [REDACTED].>-They had refaxed the physician after the conversation earlier today and received an order for [REDACTED].>*The interventions had included the cushion in her chair and reminding her to offload often when she was sitting in her recliner. Interview on 6/7/17 at 10:15 a.m. with resident 8 revealed she had gotten a new mattress last night. She stated she had slept great, and her back did not hurt. She slept in the bed all night and had not moved to the recliner. Interview on 6/7/17 at 11:30 a.m. with certified dietary manager A revealed they had not started resident 8 on any supplements or implemented any interventions to help with wound healing and prevention. Interview on 6/7/17 at 2:15 p.m. with director of rehabilitation B regarding resident 8 revealed: *She had started to work with the resident on 5/2/17. -That had been nine days after the pressure ulcer had developed on 4/23/17. *The resident should have had a gel cushion in her recliner. -She had no documentation regarding when she would have gotten the gel cushion. -Upon examination of the black cushion in the resident's recliner it was determined it was not the correct cushion for her. During interview on 6/7/17 at 2:30 p.m. with certified nursing assistant P regarding resident 8 revealed due to a language barrier he was unable to provide an answer about how he assists her with her activities of daily living. 2. Observation on 6/6/17 at 8:00 a.m. and again at 11:10 a.m. of resident 3 revealed she was laying in bed on her back with the head of the bed raised to a sitting position. She was hard of hearing and could not answer questions. Review of resident 3's medical record revealed: *She had been admitted on [DATE]. *She had developed a stage two pressure ulcer to her bottom on 2/25/17. -It had healed on 4/28/17. *On 5/2/17 that pressure ulcer had re-opened. Review of resident 3's 3/31/17 MDS assessment revealed: *She had a Brief Interview for Mental Status score of fourteen that meant her cognition was intact. *She required total assistance from two staff members to transfer from one location to another. Review of resident 3's current undated care plan revealed: *They had identified skin alterations as a focus area. *The interventions had been: -Administer the medications as ordered. -Administer treatments as ordered. -Assess, record, and monitor for wound healing. -Educate the resident and family as to causes of skin breakdown. -Follow policies and protocols for prevention and treatment of [REDACTED]. -Inform the resident and family of any new skin breakdown. -Instruct and educate resident on need for compliance with repositioning and turning. -Obtain and monitor laboratory tests as ordered. -She required pressure relieving devices on her bed and in her wheelchair. -Turn and reposition resident every two hours. Review of the weekly skin assessment reports from 2/4/17 through 6/2/17 revealed there were three out of eighteen missing skin assessments during that timeframe. Review of resident 3's weekly wound data assessments revealed: *The measurements were: -On 2/25/17 0.8 cm by 0.5 cm by 0.1 cm. -On 2/28/17 0.7 cm by 0.4 cm by 0.1 cm. -On 3/6/17 0.8 cm by 0.4 cm by 0.1 cm. -On 3/14/17 0.3 cm by 0.2 cm by 0.1 cm. -On 3/21/17 0.3 cm by 0.3 cm by 0.1 cm. -On 3/29/17 0.3 cm by 0.4 cm by 0.2 cm. -On 4/4/17 1.0 cm by 0.7 cm by 0.1 cm. -On 4/11/17 0.6 cm by 0.4 cm by 0.1 cm. -On 4/18/17 0.2 cm by 0.2 cm by 0.1 cm. -There had been no assessment done the week of 4/24/17. -On 5/2/17 0.5 cm by 0.3 cm by 0.1 cm. -On 5/9/17 or 5/16/17 there had been no measurements. Interview on 6/7/17 at 2:15 p.m. with director of rehabilitation B regarding resident 3 revealed she had screened the resident on 3/1/17 for rehabilitation services. She had been referred by staff due to having a stage two pressure ulcer on her bottom. They had not implemented any interventions at that time. They were to re-screen her in thirty days if there had been no improvement, but that had not happened. She was unsure why. 3. Interview on 6/7/17 at 2:40 p.m. with interim director of nursing N regarding residents 3 and 8 revealed: *They had no physician's notes or documentation regarding the pressure ulcers for either resident. *Resident 3 liked to stay in her room and in her bed. -She took all three meals in her room. -She used to come out of her room more, but now she did not like to come out. *She agreed the wound documentation had not been completed properly for both residents. *They had not followed their policy for assessing, implementing interventions, or preventing pressure ulcers. 4. Review of resident 1's 4/17/17 Minimum Data Set (MDS) assessment revealed she: *Required total assistance with her activities of daily living including transfers, dressing, bathing, and range of motion movements. *Had contractures of her feet. *Had no pressure ulcers at that time but was at risk for them. Observation of resident 1 on 6/5/17 at 4:45 p.m. revealed: *She had cushioned boots on both of her feet while she laid in bed. *The boots rested directly on her bed. Review of resident 1's 6/5/17 physician's orders revealed: *An order to complete weekly skin assessments every evening shift and every Tuesday. -That order had been started on 1/2/17. Review of resident 1's wound consultant reports revealed: *On 5/8/17 she had a stage three pressure ulcer that measured 2.8 cm (length) by 1.0 cm (wide) and 0.1 cm (deep). -Wound debridement had been performed. -The plan: Will continue the same plan of care with foam boots on at all times, with position check of contracted foot in boot. Also further offload with pillow under calf to float heel. *On 5/25/17 the wound measured 1.0 cm x 0.4 cm x 0.1 cm. -The plan: Cleanse with saline; [MEDICATION NAME]; [MEDICATION NAME] Flex change every 3-4 days and prn; foam boots to offload heel, please check position in boot; dangle foot off pillow to further offload. Interview and observation on 6/6/17 at 10:15 a.m. with RN L during the pressure ulcer dressing change and assessment of resident 1 revealed: *She had a facility acquired pressure ulcer on her left heel. *Her feet were significantly contracted. *The resident was lying in her bed with the cushioned boots on both feet. -Her feet rested directly on her bed with nothing supporting her legs. --They were not floating her feet with pillows. *The resident had an opened area on her left heel that measured 1.1 cm by .8 cm. A later interview on 6/6/17 at 11:25 a.m. with RN L confirmed there was no pillow under resident 1's legs to offload the pressure on her foot or float her feet. Review of the weekly skin assessment reports from 1/2/17 through 6/5/17 revealed they were documented as completed ten out of twenty-one weeks during that time frame. Interview on 6/7/17 at 10:00 a.m. with the director of nursing confirmed there were not skin assessments documented as completed weekly during that above time frame. Surveyor 5. Review of the provider's 7/1/13 Prevention and Management of Wounds policy revealed: *Residents who had wounds should have had weekly documentation completed. *Pressure redistribution mattresses were in-place as indicated by the individualized plan of care. *If there was a decline in skin pressure redistribution surfaces they should have been reviewed. *Nursing should have notified dietary, and a nutritional assessment should have been completed. *Documentation should have been completed by the dining services manager or registered dietician on initial notification of a new pressure ulcer. *Tracking and analysis of pressure ulcer trends should have been completed monthly through the quality assurance committee.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the overall well-being of all sixty-two residents. NOTICE: Notice of immediate jeopardy was given verbally on 2/8/17 at 10:30 a.m. to the administrator, the interim director of nursing (DON), and the assistant director of nursing (ADON). They were asked for an immediate plan of correction to ensure the overall well-being of all sixty-two residents. PLAN: On 2/8/17 at 4:08 p.m. the administrator and the regional director of operations (RDO) provided the surveyors with an immediate written plan of correction (POC). After that POC dated 2/8/17 had been reviewed it was then accepted on 2/9/17 at 9:10 a.m. by the surveyors and included: *Administration: No correction can be make for past non-compliance. *Residents residing in the facility have the potential to be affected in a similar manner. *The administrator will direct, monitor and supervise all department heads, activities and quality of care issues to progress and sustainability in the Plan of Correction. *The Regional Director of Operations will provide immediate education on the importance of the Immediate Jeopardy, the removal plan and the process and accountability of all staff to achieve compliance and sustainability. The RD (registered dietician) and DON will begin immediate education of dietary and nursing staff on dietary and nutrition issues for residents. Contract services will be onsite to assist in cleaning and all food handling preparation, hygiene, food storage, and serving guidelines. *The Administrator or designee will ensure QAPI (quality assurance performance improvement) Committee minutes include copies of the audits required in this plan of correction. *On 2/9/17 at 9:10 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Interviews, observations, record reviews, and policy reviews, throughout the course of the survey 2/6/17 through 2/9/17 revealed the administrator had not ensured the safe management and overall well-being of the sixty-two residents residing in the facility. Interview on on 2/6/17 at 4:30 p.m. and 2/7/17 at 3:10 p.m. with the DM revealed he: *He had started about three months ago right after Thanksgiving. *Had worked at a seasonal restaurant for sixteen years. The last few years he had been the kitchen manager at that seasonal restaurant. *He was not a certified dietary manager. *Had taken the ServSafe course several years ago. *Had no background in healthcare, healthcare food service, or serving the elderly population. *Was not aware of the recommended serving sizes for food. *Thought they used the food guide pyramid for the recommended daily servings of food. *Was aware the cleaning schedule had not been followed. *He thought he had a copy of a dietary manual on-line on his home computer. *He had to re-establish all the provider food service accounts after the change of ownership on January 1, 2017. *He had no time to be the dietary manager as he spent all his time in the kitchen helping staff. *No one from the corporate office had offered any assistance or training. *Had provided on-the-job training to staff but had not documented any of that training. *Agreed the RD had tried to schedule training for all kitchen staff. But the staff had been busy, staff had been ill, and another time he could not make it to work. *Confirmed the RD had walked through the kitchen with him and expressed her concerns. *Had not had time to correct those concerns, as he was always busy in the kitchen and was not able to fulfill his DM duties. *Had expressed his concerns about training for himself to the administrator several times but nothing had been done. *Was not aware residents had unplanned weight loss since the fall of 2016. Interview on 2/6/17 at 4:55 p.m. with the administrator revealed: *Since the past certified DM (CDM) left before Labor Day, he had gone through two to three DMs and had also used the corporation's contracted temporary employee service (360) for DMs. *The past CDM from 360 had tried to clean out the staff and hire all new people. The administrator told him that would not work, so the 360 CDM left. *The 360 employee service also sent certified nursing assistants (CNA) to help in the kitchen. That did not work as they also had to be trained by someone, and the current staff did not have the time to train the new CNAs for the kitchen. *He and the maintenance supervisor had worked in the kitchen and cooked breakfast and lunch for over two weeks. He was happy the residents had gotten fed. *Was not aware there was an overall 25% weight loss among the residents. *Had not conducted any audits nor had the DM conducted any in-services. *Could not find any employees or had not been able to hire any employees in the kitchen due to failure of background checks. *Confirmed he and the maintenance supervisor had cooked breakfast and lunch for three weeks. They followed the menus for what foods to cook and serve. They had not followed the physicians' ordered diets for each resident. He stated I was just happy to get the residents fed. *Was aware the DM did not have any experience in the healthcare industry. *Had enrolled him in the CDM program 2/8/17 to get more experience. *Had requested help from the corporate office but all they sent was certified nurse assistants to help in the kitchen. They had no experience in food service. *Was aware the RD had scheduled trainings. Interview on 2/7/17 at 9:00 a.m. with the RD/LN revealed: *She had been the RD/LN for close to two years. *Administration does not ask her to attend nutrition at-risk meetings or QAPI. *She was not aware 25% of the residents had a weight loss. *The dietary department had started to go downhill after the past DM had left in September 2016. *She had spoken to the administrator about past retired experienced staff to come to work but nothing had happened. *She had tried and tried to put together staff trainings and meetings but there always seemed to be some excuse why they could not be done. *The administrator and the maintenance supervisor had cooked breakfast and dinner for about three weeks until she requested a 360 (corporate temporary staffing agency) person. *The administrator had called her one week-end to work in the kitchen as the regular dietary staff did not show up to work. Interview on 2/8/17 at 2:25 p.m. with the regional director of operations revealed: *She was aware of the dietary concerns back in September 2017 when she was vice-president with the former owners. *She was aware the temporary employee agency had sent at least two DMs to help. The agency had also sent CNAs to help. *The executive director of the facility had not requested additional resources (training and staff) for the dietary department since the former CDM had left in September. Review of the undated CEO (chief operating officer) job description revealed: *The CEO is responsible for the day to day operations and direction of the facility, and ensures that the facility complies with all policies and procedures set forth by the company, as well as those required by regulatory agencies. *Ensures the provision of quality of services through design and implementation of facility wide quality assurance and program evaluation plans. *Ensures that all work is completed with optimal efficiency and effectiveness. *Displays initiative to act independently by taking effective action before being directed by supervisor or being forced to by events. *Maintains effective and appropriate staffing levels. *Ensures facility specific orientation to all new employees and ensures ongoing educational training as required by the company policy to meet the facility's needs. Refer to tags: F244, F281, F309, F325, F360, F361, F362, F363, F364, F365, F366, F367, F368, F371, F490, F492, F493, F500, and F520.

Based on record review, interview, and policy review, the provider failed to ensure an effective quality assurance performance improvement (QAPI) program had been implemented and followed through for resolution of identified deficiencies and to develop and implement corrective actions for all sixty-two residents. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 2/8/17 at 10:30 a.m. to the administrator, the interim director of nursing (DON), and the assistant director of nursing (ADON). They were asked for an immediate plan of correction to ensure PLAN: On 2/8/17 at 4:08 p.m. the administrator and the regional director of operations (RDO) provided the surveyors with an immediate written plan of correction (POC). After that POC dated 2/8/17 had been reviewed it was then accepted on 2/9/17 at 9:10 a.m. by the surveyors and included: *QAPI (quality assurance performance improvement): The facility is unable to correct past administrative processes. *Residents residing in the facility have the potential to be affected in a similar manner. *Administrator, Director of Nursing, Medical Director and Interdisciplinary team will review the Quality Assurance and Performance Improvement policy by February 17, 2017. *The QAPI members and facility staff members will be educated on the QAPI process by the Regional Director of Operations by February 17, 2017. *The Quality Assurance Performance Improvement (QAPI) program will include review of the deficiencies, the plan of correction and the ongoing audits for review and recommendations for sustainability. *QAPI committee meetings will be held monthly consisting of the Administrator, Director of Nursing, Medical Director and at least 3 other members of the facility staff. *The Regional Director of Operations or designee will audit QAPI minutes for 6 months to ensure the facility is meeting the expectations of the prepared plan of correction, making necessary recommendations and continuing to work with staff to ensure regulatory compliance. *On 2/9/17 at 9:10 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1a. Review of the provider's August 2014 QAPI committee guidelines revealed: *The facility would conduct Performance Improvement Plans (PIP) to examine and improve care or services in areas identified as opportunities for improvement. *A PIP was a concentrated effort on a particular opportunity for improvement, and prioritized based on high risk, high volume, and problem prone areas. *PIPs were selected in areas that were important and meaningful for the specific type and scope of services unique to each facility. *The administrator was the process owner of committee content, facilitated meetings, developed the agenda, coordinated the QAPI calendar, provided/coordinated training and resources for process improvement initiatives. *The following elements were in place for the facility to demonstrate satisfactory compliance with the guideline: -Monthly meetings were held and documented. -Designated core members attended QAPI meetings. -PIPs were developed and implemented for identified opportunities for improvement. -Special QAPI meetings were conducted as needed to address and improve identified opportunities for improvement in between monthly meetings. b. Review of the provider's QAPI minutes from March 2016 through November 2016 revealed:*March 2016: Performance Improvement Plan (PIP) log had a goal for the reduction of pain by 10% by 4/30/16 and the use of antipsychotic medications as ongoing. *April 2016: PIP log continued with the same PIPs from March 2016. There was no change in the plans. *June 2016: PIP log continued with the same PIPs from March 2016. There was no change in the plans. *July 2016: PIP log continued with the same PIPs from March 2016. There was no change in the plans. *August 2016: PIP log continued with the same PIPs from March 2016. There was no change in the plans. *September 2016: PIP log continued with the same PIPs from March 2016. The goal for the reduction of pain by 10% by 4/30/16 had been extended to 12/30/16. *October 2016: PIP log continued with the same PIPs from March 2016. There was no change in the plans. *November: 2016: PIP log continued with the same PIPs from March 2016. There was no change in the plans. c. Review of the same QAPI minutes from March 2016 through November 2016 regarding weight loss revealed: *March 2016: Review of February 2016 quality measures indicated 1.5% weight loss. The national average was 7.8%. *April 2016: Review of March 2016 quality measures indicated 8.3% weight loss. No analysis of the increased weight loss percentage had been completed. The national average was 6.8%. *June 2016: Review of May 2016 quality measures indicated 16.9% weight loss. No analysis of the increased weight loss percentage had been completed. The national average was 16.1%. *July 2016: Review of June 2016 quality measures indicated 16.9% weight loss. No analysis of the increased weight loss percentage had been completed. The national average was 16.1%. *August 2016: Review of July 2016 quality measures indicated 11.5% weight loss. No analysis of the increased weight loss percentage had been completed. The national average was 8%. *September 2016: Review of August 2016 quality measures indicated 12.1% weight loss. No analysis of the increased weight loss percentage had been completed. The national average was 7.8%. *October 2016: Review of September 2016 quality measures indicated 4.9% weight loss. No analysis of the increased weight loss percentage had been completed. The national average was 7.8%. *November: 2016: No review of the October 2016 quality measures had been completed. Interview on 2/6/17 at 3:30 p.m. with the administrator and the staff development coordinator/assistant director of nursing (SDC/ADON) revealed: *The SDC/ADON had the minutes from the QAPI meetings. *She was not the QAPI coordinator but had put in the information for minutes. *The previous DON had been the QAPI coordinator. She had left on 11/11/16. *The administrator stated he was not the QAPI coordinator. No person had been assigned as the coordinator yet. *He stated all issues were brought up in the clinical meetings with all department heads. *The SDC/ADON agreed the QAPI program was not effective in monitoring critical areas including weight loss. *The quality measures that fell above the national average had not been reviewed other than falls, pain, antipsychotic medication use, and decreased activities of daily living. *The January 2017 QAPI meeting had focused on a quality of life issue regarding stabilizing staffing in the dietary department, insurance issues for residents, and nursing staff retention.

Based on observation, interview, record review, job description review, and policy review, the governing body failed to make certain: *The facility was managed in a manner that ensured the overall well-being for all 62 current residents in the facility. *Residents' concerns identified in the resident council meetings were adequately addressed. *Physicians' orders had been followed: -For 4 of 4 sampled residents (1, 3, 27, and 33) with fluid restrictions. -For 29 of 62 residents with therapeutic diets. *The necessary care and treatment had been provided for: *Seventeen of seventeen sampled residents (3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 22) who had weight loss. *Physicians' ordered fluid restrictions had been followed, monitored, and documented for 4 of 4 sampled residents (1, 3, 27, and 33). *Twenty-eight randomly reviewed residents (1, 3, 4, 12, 16, 19, 24, 29, 30, 32, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, and 52) with physician ordered therapeutic diets. *Nutrient dense foods had been made available for all residents recommended by the registered dietician/licensed nutritionist (RD/LN). *Supervision had been provided for 9 of 10 observed residents (1, 5, 20, 23, 24, 25, 26, 27, and 29) in the restorative dining room. *Supervision had been provided for 1 of 6 residents (2) who received a room tray for all meals. *Three week cycled menus had been followed from September 2016 through 12/31/16. *Four week cycled menus had been followed from 1/1/7 through the last day of the survey on 2/9/17. *All food required for the menus was purchased, planned with staff, and compared with the menus for that week. *Substitute food had been of the same nutritive value. *Employ sufficient staff to carry out the daily needs of one of one dietary department including the kitchen and three of three dining rooms. *Employ a qualified food service manager. *Daily bedtime snacks were offered to all residents. *The Food and Drug Administration food service guidelines and South Dakota Department of Health Food Service Code had been followed. *Qualified, trained, and experienced dietary manager (DM) was employed or contracted to provide: -Proper procedure, guidelines, and practices were implemented and maintained for food safety. -A balanced diet for a highly susceptible population for compliance with federal guidelines for menu planning and substitutions. -A nutritional diet with emphasis on physicians' orders for 28 of 62 residents. *To comply with proper procedures, practices, and guidelines for food safety as evidenced by: -No dietary staff had a current ServSafe certification. -Random observations of improper handwashing and glove use. -Three of three handwashing sinks were dirty, held dirty cloths, or a bucket of sanitizer. -One of one, two compartment sink was used for handwashing. -One of two handwashing sinks had no paper towels. -Two of two buckets of sanitizer had readings less than 100 parts per million (ppm). -No probe thermometers with a range of 0 to 220 degrees Fahrenheit (F) were available for use. -Two of three products (chicken noodle soup and leftover turkey) were cooled inappropriately. -Reheated foods and soups were not heated to 165 degrees F for service. -Raw meat products (chicken and hamburger) were stored with cooked meatballs on one of one cookie sheet in the reach-in cooler. -The entire kitchen floors, walls, food contact and non-food contact surfaces, equipment, cupboards, coolers, freezers, and storage shelves needed a deep cleaning and sanitizing. -Two of four sinks had leaking faucets. -Canned drink supplements were stored on the floor in the dietary manager's office. -Two of two ready-to-eat roast beef sandwiches were not dated in the reach-in cooler. -Daily temperature logs for five of five weeks had inaccurate and improper hot and cold food temperatures. -One of one wall mounted plastic storage unit for storing clean linens was dirty and broken. -Two of two plastic lids and two of two plastic food bins were cracked and broken. Three of five rubber spatulas had ripped or ragged edges. -Two of four light bulbs in two of two freezers were neither shielded nor shatterproof. -Two of twelve light shields in the kitchen were cracked and broken. -A diet manual, guidelines for extended diets, or a list of residents' physicians' ordered diets were not available for staff use in the kitchen. *Ensure the facility was operated and administered in a manner that ensured the overall well-being of all sixty-two residents. *An effective quality assurance performance improvement (QAPI) program had been implemented and followed through for resolution for identified deficiencies and to develop and implement corrective actions for all residents. *Necessary resources had been made available to provide for and meet the needs of the individual residents. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 2/8/17 at 10:30 a.m. to the administrator, the interim director of nursing (DON), and the assistant director of nursing (ADON). They were asked for an immediate plan of correction to ensure the facility was managed for the overall well-being of all sixty-two residents. PLAN: On 2/8/17 at 4:08 p.m. the administrator and the regional director of operations (RDO) provided the surveyors with an immediate written plan of correction (POC). After that POC dated 2/8/17 had been reviewed it was then accepted on 2/9/17 at 9:10 a.m. by the surveyors and included: *Governing Body: No correction can be made for past non-compliance. *Residents in the facility have the potential to be affected in a similar manner. *The Governing Body consists of the Regional Director of Operations or Regional Clinical Manager, The Administrator, Director of Nursing and the Medical Director. The Governing Body will meet following each monthly QAPI (quality assurance performance improvement) meeting to review progress of the plan of correction and implement any correction actions. *The Regional Clinical Manager or Regional Director of Operations will attend monthly QAPI committee meetings for a minimum of 6 months to provide further guidance as necessary to ensure continued improvement in the highest quality of care for each resident. *The Administrator or designee will ensure QAPI committee minutes include copies of the audits required in this plan of correction. *On 2/9/17 at 9:10 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. The governing body had not ensured the facilities dietary services had provided the necessary care and services to attain or maintain the highest practicable physical well-being. Refer to tags: F244, F281, F309, F325, F360, F361, F362, F363, F364, F365, F366, F367, F368, F371, F490, F492, F493, F500, and F520.

Based on observation, testing, record review, interview, and policy review, the provider failed to: *Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. *Follow proper sanitation and food handling practices for the prevention of foodborne illnesses. NOTICE: Notice of immediate jeopardy was given verbally on 2/8/17 at 10:30 a.m. to the administrator, the interim director of nursing (DON), and the assistant director of nursing (ADON). They were asked for an immediate plan of correction to amend and remedy nutritional diets and food safety standards. PLAN: On 2/8/17 at 4:08 p.m. the administrator and the regional director of operations (RDO) provided the surveyors with an immediate written plan of correction (POC). After that POC dated 2/8/17 had been reviewed it was then accepted on 2/9/17 at 9:10 a.m. by the surveyors and included: *Dietary Sanitation: Process to be in place to begin tonight 2/8/17 cleaning Kitchen and storage areas and completed by end of day 2/10/17. Contract Dietary Manager (DM) will be onsite to help with direction and process of cleaning kitchen, equipment, and dietary storage areas. *RD (registered dietician) and contract Dietary Services Manager from another facility will educate dietary staff members on dietary sanitation F371 immediately and to be completed before end of day 2/10/17. *Facility DM will conduct end of day dietary observation and checklists 5 x's (times) per week. *RD to inspect sanitation in dietary with each visit. *Administrator will conduct end of week rounds and checklist x's 12 weeks. *Administrator/Facility DM will report compliance to QAPI (quality assurance performance improvement) monthly x's 3 months. *Administrator scheduled the dietary manager and dietary cooks 2/8/17, on the Serve Safe Certification course in February and March. *Administrator to conduct education with dietary manager on 2/8/17 regarding Serve Safe Certification requirement for all dietary cooks. *On 2/9/17 at 9:10 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: Surveyor: 1a. Observation, testing, document review, and interview on 2/6/17 from 3:45 p.m. to 5:15 p.m. and on 2/7/17 from 10:00 a.m. to 11:15 a.m. and at 3:10 p.m. of the kitchen, pantry, and serving area in the dining room failed to ensure: *Gloves were worn while handling dirty and clean dishes in the dishwashing room. *Hands had not been washed between changes of gloves. *Gloves had been worn between entering the dining room and re-entering the kitchen. *Cook A asked the DM to make her two peanut butter and jelly sandwiches and dish up two bowls of fruit. Observation on 2/6/17 from 4:45 p.m. through 5:15 p.m. revealed: -The DM removed the gloves he had on and put on new gloves without washing his hands. -He used one package of peanut butter and two packages of jelly per sandwich. -Review of the manufacturer's directions revealed two packages of peanut butter must have been used to provide two tablespoons of peanut butter for a serving of protein. -He dished out two bowls of fruit and filled them full without measuring one half cup for each serving. -Neither time did the DM question cook A to see if the sandwiches or fruit would meet the resident's diet. *Interview on 2/6/17 at 5:00 p.m. with the DM regarding the above finding confirmed there had been improper glove use. -He had tried to train the staff while working in the kitchen but had not had any proper in-services. -He stated when he was busy he did not have time to measure food quantities. b. The handwashing sink in the: -Dishwashing room was dirty and had dirty rags in the basin. -Kitchen was blocked for use by the sanitizer bucket. -Main dining room was used as a dump sink for leftover beverages from meal times. *Interview with the DM confirmed those observations. He had tried to train staff while working in the kitchen but had not had any proper in-services. He and the staff had tried to keep things clean in the kitchen but had not had time to do a deep cleaning. c. Dietary Aide (DA) C was noted returning from the outside through the back door and washed her hands in the two compartment sink. Interview with the DM revealed DA C was new. He had not had time to train all the new employees in proper handwashing. d. The handwashing sink in the kitchen: *Had no paper towels. -Interview with cook A revealed she had not had time to refill the dispenser. *Dishwashing room had a stack of paper towels next to the sink, as the dispenser was empty. -Interview with DA D revealed he did not know how to fill the dispenser in the dishwashing room. -Interview with the DM confirmed the paper towel dispensers were empty at times as he had ordered the wrong paper towels. He stated he did not have a key to the dispensers and would let housekeeping know when they were empty. e. A bucket of sanitizer sat inside a basin of the three compartment sink in the dishwashing room. Another bucket of sanitizer sat in the basin of the handwashing sink in the kitchen. Interview with DA D revealed those buckets of sanitizer had been made up early in the morning and had not been changed or tested since before 7:00 a.m. He revealed they had sanitizer test strips above the three compartment sink. Using those test strips both buckets of sanitizer solution tested below 100 parts per million (ppm). Review of the sanitizer's directions revealed the sanitizer must have been between 150-400 ppm. Interview with the DM revealed staff should have changed the sanitizer buckets after each meal service. He had just ordered test strips to check the sanitizer, as the kitchen did not have any to check the sanitizer. f. Interview with cook A revealed they only had meat thermometers and did not have a probe thermometer with a range of 0 to 220 degrees Fahrenheit (F). She stated she brought her own from home to use. Interview with the DM revealed he had probe thermometers in his office. He returned with a packaged probe thermometer and handed it to the surveyor. The surveyor questioned if the thermometer was calibrated. The DM then questioned cook A how to calibrate a thermometer, and she replied they used the ice bath method. g. Two containers of soup (tomato and chicken noodle) and a container of cooked turkey pieces sat in the west reach-in cooler. The surveyor used the calibrated probe thermometer provided by the DM. The surveyor asked if the kitchen had alcohol pads to clean the probe of the thermometer. The DM stated they did not have alcohol pads and provided the surveyor with clean sanitizer solution to clean the probe between food testing. Observation at that same time revealed a plastic bin on the counter with alcohol pads. Testing of those products with a clean calibrated probe thermometer revealed the tomato soup was 38 degrees F, the chicken noodle soup was 130 degrees F, and the cooked turkey was 78 degrees F. *Interview with cook B revealed those products had been used the previous night for supper. The hot containers of food had been placed directly in the cooler from the steam table to cool after supper. Cook B stated that was how she was taught when she was a DM about thirty years ago. Interview with the DM and cook B revealed they were not aware of the four-step cooling method. The DM stated he would have used an ice bath to cool foods. But neither he nor cook B were aware what the temperatures guidelines were for the four step cooling method. The surveyor had the DM dispose of the improperly cooled foods. h. The surveyor questioned Cook B and the DM how the leftover containers of soup were reheated for service. They stated the soup would be individually heated in a bowl to serving temperature. They did not know what temperature was to have been the serving temperature. Neither the DM nor cook B were aware leftover foods must have been reheated to 165 degrees F. i. Packages of raw chicken and five pound packages of raw hamburger were stored on the same cookie sheet as an opened package of undated cooked meat balls. That cookie sheet had dried and pooled blood on it. Interview with the DM confirmed those findings. He stated he was unaware the raw meat was stored with the cooked meatballs. He stated they had served the meat balls last week, and they should have been discarded after three days. The DM was unaware the raw chicken and raw packages of hamburger could not be thawed on the same cookie sheet as the two products required different cooking temperatures. j. The entire kitchen, dishwashing room, and dry food storage room including floors, walls, equipment, reach-in freezers and shelves, reach-in coolers and shelves, stove range, the two convection ovens, the two regular ovens, the microwave, the can opener, the steamer, the knife rack, food tray carts, hot chocolate machine, the dishwasher, plate lowerator, all sinks, the outside of the ice machine, all food preparation surfaces, the steam table, and all cupboards, drawers, and shelves were in immediate need of a deep cleaning. Those surfaces were embedded with both dried food debris, old grease, and other grime. Interview with the DM revealed he had tried to train staff about cleanliness while working in the kitchen but had not had any proper in-services. He and the staff had tried to keep things clean in the kitchen, but since they were short on staff they had not had time to do a deep cleaning. The DM stated he had a cleaning schedule. Review of that daily cleaning schedule from 1/5/17 through 2/4/17 revealed only sixteen of twenty-eight days had initials to show cleaning had been done on those days. k. The two reach-in coolers and two reach-in freezers had every type of food and food containers stored intermingled with other food supplies. There was no organization or logical approach to storage of food. Food containers such as frozen sausage were stored with pre-cooked lasagna and garlic bread was stored with five pound packages of frozen hamburger. Interview with the DM confirmed that finding. He stated he had not had time to sort the products in the freezers or coolers. l. The two compartment sink and the handwashing sink in the kitchen had leaking faucets. Interview with the DM confirmed that finding. He stated he had not put in a work order for the leaking faucets. m. Three boxes of canned drink supplements were stored on the floor in the DM's office. Interview with the DM revealed he was aware some of the canned and boxed goods were stored inappropriately. He had not had time to go through the kitchen and dry food storage room to organize the boxes and packages of food and get them off the floor. n. Two undated and unlabeled what appeared to be roast beef sandwiches were stored in a cooler. Interview with cook B revealed those sandwiches had been made up earlier for a resident's choice. She stated she had forgotten to label and date the sandwiches. Interview with the DM revealed he and his staff were aware all prepared food and leftover food must label and dated. o. Review of a grimy and dirty binder in the kitchen revealed it held food temperature logs for the previous five weeks 1/1/7 to 2/4/17. Review of those temperature logs revealed: *There were empty slots for Monday through Friday. *No recorded temperatures on any week-end. *Improper recorded hot and cold temperatures. Interview with the DM revealed staff were aware they must record daily food temperatures of all food at all meals. He was unaware some of the recorded hot and cold temperatures were improper for heating and holding. He confirmed those findings but stated he had not done any audits on the temperature charts. p. The gray plastic enclosed storage shelf for clean linens revealed it: *Hung loose from the wall. *Was dirty on the inside and the outside of the unit. *Had aprons and clean cloths spilled out of the unit that would not allow the door to close. Interview with the DM confirmed those findings. He stated he had not put in a work order to have the shelving unit repaired. Nor had he or his staff had time to clean and organize the unit. q. Two plastic lids used to cover food and two plastic bins used to hold food were cracked and broken. Three rubber spatulas had ripped or ragged edges. The lids, bins, and spatulas were no longer cleanable and could not be used in the kitchen. That was confirmed by cook B. r. Two of two light bulbs in the north reach-in freezer were neither covered nor shatterproof. Interview with the DM revealed he was not aware those light bulbs needed to be covered or shatterproof. s. Two plastic light shields in the kitchen were cracked and broken. They no longer provided adequate shielding of the light bulbs. Interview with the DM revealed he had not put in a work order to have those light shields replaced. t. Interview on 2/9/17 at 10:00 a.m. with cook B revealed: *She had asked the DM for a list of current residents and their diets a few weeks ago. *But had never received one. *Neither a diet manual, guidelines for extended diets, or a list of residents' physicians' ordered diets was posted and available for the staff use in the kitchen. *She had tried to use the meal cards, but might have missed a few diet orders or restrictions. Interview with the DM revealed he had a dietary manual on-line on his computer at home, and staff would call him with questions. He did not know the name of the manual. He would also approve substitutions for menu items. u. Interview with cook A revealed neither she nor any other dietary staff were certified in ServSafe. The DM confirmed the interview above with cook A. He stated he was not certified in ServSafe either but had taken the course several years ago. v. Interviews with the RD, activity assistant F, DM, and administrator confirmed the above findings. Refer to F361. w. Review of the provider's 3/14/14 Food Deliveries policy revealed to ensure that all food prepared is of good quality the facility would follow the current Food Code as stated by Federal and State guidelines for receiving foods. Review of the provider's 3/14/14 Food Storage policy revealed: *To ensure that all food served by the facility was of excellent quality and safe for consumption all food would have been stored according to the current Federal and State Food Code. *Dry storage rooms: -Date packages and place new items behind existing supplies so the older items were used first. -All items should have been stored on clean racks or shelves and protected from contamination. *Refrigerators: -All refrigerated food would be stored per the current Food Code. -Date, label, and tightly seal all refrigerated foods. All items should include name of item and a use-by date. -To avoid cross-contamination store raw or uncooked food and produce away from and below prepared or ready-to-eat food. *Freezers: --Store meat, fish, and poultry below fruits, vegetables, juices, and breads. Review of the provider's 3/14/14 Food Preparation and Handling policy revealed: *To ensure that all food served by the facility was of good quality and safe for consumption all food would have been prepared and handled according to the current Federal and State Food Codes. *Guidelines: -Use clean, sanitized surfaces, equipment, and utensils. -Wash hands properly before beginning food preparation. -Do not let surfaces, equipment, or utensils that have been in contact with raw meat come into contact with other food unless the surfaces, equipment, or utensils have been cleaned and sanitized first. *Food Preparation: -Treat all raw products with methods to reduce existing contamination or prevent cross-contamination. -Keep raw and cooked foods separated. -Take temperatures throughout the preparation process to ensure the food was safe. *Hot Food Temperatures: -Cook ground meat, such as hamburger products, thoroughly to heat all parts of the meat to a minimum temperature of 155 degrees Fahrenheit (F) for at least 15 seconds. -Heat poultry throughout to a minimum temperature of 165 degrees F for at least 15 seconds. *Cold Food Temperatures: -Maintain all cold prepared items to a temperature of 40 F or below until ready-to-serve. Review of the provider's 5/19/14 Tray Line Service policy revealed: *Adequate portion sizes were essential to the patient's/resident's well-being and safety. The facility would ensure diets were served accurately and in the correct portions and patient/resident preferences were met. -A dated copy of the daily menu extensions with any changes would be posted in the kitchen near the tray line, so servers could use the extension to correctly serve the diets. -The trays would be prepared by the server using the diet extensions and the portion sizes list on the extensions. -Staff on the tray line would check each patients/residents tray card to ensure dietary preferences and dislikes were honored and appropriate substitutions were provided. -Each tray was checked against the Optima solutions tray care by the tray line personnel that would ensure the diet was served accurately, the portion size of each item was correct, and preferences were met. -The food service director would conduct a tray line audit twice per week to ensure diets were served correctly and to identify any training needs. Review of the provider's 5/19/14 Portion Control policy revealed: *The facility would use standard portion control procedures and utensils to ensure adequate portions were served to patients/residents. -A dated copy of the daily menu extension with portion sizes would be posted in the kitchen near the tray line. -Follow the specific portion sizes listed on the menus for each food item. Review of the provider's 5/19/14 Cooling and Reheating Foods policy revealed: *All food would be cooled and reheated according to the current Federal and State Food Codes. -Rapidly cool all potentially hazardous food requiring refrigeration after preparation to an internal temperature of 41 degrees F or below within six hours or less. The total cooling time should not exceeded six hours. -Rapidly reheat potentially hazardous foods that had been cooked and then refrigerated to a minimum of 165 degrees F for 15 seconds throughout all parts of the food. Review of the provider's 5/19/14 Employee Sanitation policy revealed: *The kitchen employees of the facility would practice good sanitization practices in accordance with the state and Federal Food Codes in order to minimize the risk of infection and food borne illness. *Handwashing: -Employees must wash their hands and exposed portions of their arms at designated the handwashing facility at the following times: --Immediately before engaging in food preparation including: --Working with exposed food, clean equipment and utensils, unwrapped single-service, and single-use articles. --After engaging in other activities that contaminated the hands. *Use of Gloves: -When using gloves always wash hands before touching or putting on new gloves. -Use single-use gloves for one task. -Change gloves: --When leaving the food preparation area for any reason. --Every hour for all tasks taking longer than one hour. Review of the provider's 5/19/14 Hand Washing policy revealed: *All dietary employees would practice good hand washing practices in order to minimize the risk of infection and food borne illness. -Handwashing Stations: --Make sure all handwashing stations were equipped with individual, disposable towels, or a continuous towel system that supplies the user with a clean towel. -Sinks used for food preparation or washing utensils could not be used as a handwashing station. Review of the provider's 7/23/14 General Kitchen Sanitation policy revealed: *All dietary employees would maintain a clean, sanitary kitchen in accordance with the current Federal and State food codes that would minimize the risk of infection and food borne illness. -Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities, and equipment. -After each use clean and sanitize all tableware, kitchenware, and food-contact surfaces of equipment. -Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated debris. -Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation of storage of potentially hazardous food prior to each use. -Cloths used for wiping food spills on kitchenware, food-contact surfaces, and equipment should be cleaned and sanitized prior to reuse. When not in-use hold in a sanitizing solution of the proper concentration. Review of the provider's July 2014 Cleaning Schedule policy revealed: *The cleaning list would be posted weekly, initialed off, and dated by each employee upon completion of the task. *The food service director or designee would verify the tasks were completed as assigned. Review of the provider's 7/23/14 Sanitizing Equipment in Place policy revealed: *The facility would follow the cleaning and sanitizing requirements of the current Federal and State Food Codes for cleaning equipment in place in order to ensure that all equipment was thoroughly cleaned and sanitized to minimize the risk of food hazards. Review of provider's 7/23/14 Cabinets, Drawers, and Shelving policy revealed: *The facility would maintain cabinets, drawers, and shelving free of food particles and dirt to minimize the risk of food hazards. *Cabinets, drawers, and shelving would be cleaned as needed. Review of the provider's 7/23/14 Can Opener policy revealed: *The facility would maintain can openers free of food particles and dirt to minimize the risk of food hazards. *Can openers would be cleaned after each use. Review of the provider's 7/23/14 Coffee and Juice Machines policy revealed: *The facility would maintain coffee machines and juice machines in a clean and sanitized condition to minimize the risk of food hazards. *Coffee and juice machines would be cleaned daily. Review of the provider's 7/23/14 Counter and Tabletops policy revealed: *The facility would maintain counters and tabletops in a clean and sanitary condition to minimize the risk of food hazards. *Counters and tabletops would be cleaned before and after food preparation. Review of the provider's 7/23/14 Floors, Tables, and Chairs policy revealed: *Sweep kitchen floors of food and debris after each meal. *Move major appliances as necessary when cleaning kitchen floors. Review of the provider's 7/23/14 Food Dish Carts policy revealed: *The facility would maintain food and dish carts in a clean and sanitary condition. *Food carts would be cleaned after each meal. *Dish carts would be cleaned once a day or more often as needed. Review of the provider's 9/11/14 Garbage Disposal Dish Machine policy revealed the facility would maintain dish machines in a clean condition to minimize the risk of food hazards. Review of the provider's 9/12/14 Ice Machine policy revealed: *The ice machine would be cleaned once quarterly or more often as needed. -Clean the exterior with detergent solution and rinse. -Clean underneath and around the machine. Review of the provider's 9/12/14 Ingredient Bins policy revealed the facility would maintain the ingredient bins in a sanitary manner to minimize the risk of food hazards. Review of the provider's 9/12/14 Knife Rack policy revealed the facility would maintain the knife rack in a sanitary manner to minimize the risk of food hazards. Review of the provider's 9/12/14 Microwave policy revealed the microwave would be wiped out after each use and thoroughly cleaned and sanitized as needed. Review of the provider's 9/12/14 Oven policy revealed: *Minor spills would be cleaned on a daily basis. *Thorough cleaning would be done weekly and as needed. Review of the provider's 9/12/14 Plate Lowerator policy revealed the plate lowerator would be cleaned daily. Review of the provider's 9/12/14 Range and Grill policy revealed the range would be cleaned once each day and the grill would be cleaned after each use. Review of the provider's 9/12/14 Refrigerators, Coolers, and Freezers policy revealed: *Refrigerators, coolers and freezers would be kept clean on a daily basis. *They would be thoroughly cleaned as needed. Review of the provider's 3/9/15 Sinks policy revealed the facility would maintain sinks in a clean and sanitary manner to minimize the risk of food hazards. Review of the provider's 3/9/15 Kitchen Steamers policy revealed the steamers would be cleaned after each use. Review of the provider's 3/9/15 Steam Table policy revealed the steam table would be cleaned after each meal. Review of the provider's November 2015 Floor Safety policy revealed: *Keep all floors clean and dry. *Clean all spills immediately. Review of the provider's November 2015 Fire and Burn Safety policy revealed: *Keep all hoods, fans, vents, grills, oven, and burners free of grease accumulation. *Keep all equipment clean, functional, and maintained. Review of the provider's 3/9/15 Diet Manual policy revealed: *The facility would adopt a currently accepted up-to-date diet manual that supports the diets served in order to ensure that all diets were served according to nutrition best practices. -A copy of the diet manual would be kept in the dietary department. -A copy of commonly ordered diets might be posted for use. Review of the provider's 3/9/15 Menu Planning policy revealed: *Prior to roll-out of the new menu cycle the food service director and the dietician would review the menus. *Menu changes must comply with product specifications and cost control practices. *Dated current menus would be posted in all dining areas. Review of the provider's 3/9/15 Diets Offered by Facility policy revealed: *All patients/residents would receive diets as ordered by the attending physicians. *All diets must be ordered by the attending physician and recorded in the resident's medical record. Review of the provider's 3/9/15 Menu Substitutions policy revealed: *The facility recommended a well-balanced menu and served as posted was important to the well-being of its patents/residents. The menus would be served as planned except for emergency situations when a food item was unavailable. -If a specified item was not available the cook would consult with the food service director or dietician. -All substitutions would be made in accordance with the menu substitution guide to ensure that the meal was well-balanced and adequate. -All changes to the menu would be recorded on the menu substitution form. -The food service director would review the menu substitution approval form with the dietician on each visit to determine trends in substitutions and accuracy of substitutions. -The dietician would review and validate the menu substitutions and sign as evidence of acceptance. Review of the provider's 3/9/15 Diet Order Accuracy policy revealed: *The facility would conduct monthly audits of the diet orders to ensure residents received the diet as ordered by the physician. -The food service director would obtain a diet roster as needed. -A diet census would be printed out from the tray card system once a month. -The physicians' diet order forms and the roster would be compared to the tray card system. Review of the provider's 3/9/15 Alternate Food Choices and Substitutions and Honoring Preferences policy revealed: *An alternate entree would be offered at each meal. Other substitutions such as always available items would also be available. *The dietician would monitor for menu compliance. *Nursing staff would observe the residents at meal time. Any resident not eating would be offered the alternate or a substitute from the items available. The items offered must be compatible with any dietary restrictions or texture modifications. Review of the provider's 3/9/15 Nutrition Supplementation policy revealed: *The facility was committed to assisting residents in maintaining and maximizing nutritional status. *When oral diet intake alone was insufficient, supplemental nutrition would be added in a stepwise manner to achieve the maximum result. Review of the provider's 3/9/15 Alternate Food Choices and Substitutions and Honoring Preferences policy revealed: *An alternate entree would be offered at each meal. Other substitutions, such as always available items would also be available. *The dietician would monitor for menu compliance. *Nursing staff would observe the residents at meal time. Any resident not eating would be offered the alternate or a substitute from the items available. The items offered must be compatible with any dietary restrictions or texture modifications.

Based on observation, interview, record review, and policy review, the provider failed to ensure the necessary care and treatment had been provided for the following: *Seventeen of seventeen sampled residents (3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 22) who had weight loss. *Twenty-eight randomly reviewed residents (1, 3, 4, 12, 16, 19, 24, 29, 30, 32, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, and 52) with physician ordered therapeutic diets. *Nutrient dense foods recommended by the registered dietician/licensed nutritionist (RD/LN) had been made available for all residents. *Supervision had been provided for 9 of 10 observed residents (1, 5, 20, 23, 24, 25, 26, 27, and 29) in the restorative dining room. *Supervision had been provided for 1 of 6 residents (2) who received a room tray for all meals. *Physician ordered fluid restrictions had been followed, monitored, and documented for 4 of 4 sampled residents (1, 3, 27, and 33). Findings include: 1. The provider had not ensured all residents had received the proper physicians' ordered and care planned nutritional support to maintain their highest practicable physical well-being. Refer to F281 and F309.

Based on observation, interview, and record review, the provider failed to ensure the necessary care and treatment had been provided for: *Seventeen of seventeen sampled residents (3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 22) with weight loss. *Physicians' ordered fluid restrictions for four of four sampled residents (1, 3, 27, and 33). *Physician ordered diets and diet textures for sixty-two residents. *Nutrient dense foods for all residents recommended by the registered dietician/licensed nutritionist (RD/LN). *Supervision for nine of ten observed residents (1, 5, 20, 23, 24, 25, 26, 27, and 29) in the restorative dining room. *Supervision for one of six observed residents (2) who received a room tray for all meals. NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 2/8/17 at 10:30 a.m. to the administrator, the interim director of nursing (DON), and the assistant director of nursing (ADON). They were asked for an immediate plan of correction to ensure all residents, including residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 27, and 33 would receive the proper nutritional support to maintain their highest practicable physical well-being. PLAN: On 2/8/17 at 4:08 p.m. the administrator and the regional director of operations (RDO) provided the surveyors with an immediate written plan of correction (POC). After that POC dated 2/8/17 had been reviewed it was then accepted on 2/9/17 at 9:10 a.m. by the surveyors and included: Dietary Services: *All residents in sample will be assessed head to toe, including skin by licensed nurse. All negative findings will be immediately addressed. *All residents in sample will be reviewed for weight loss by RD before end of day 2/10/17. Medical record on all sampled residents with weight loss will be reviewed for proper interventions by RD before end of day 2/10/17, with updated recommendations as applicable. MD (medical doctor) and family will be notified of any resident on sample with weight loss by licensed nurse before end of day 2/10/17. *Licensed nurses will receive education by Director of Clinical Education on Clinical Guideline regarding weight management before 2/10/17. *RD will conduct in-service training with the dietary staff by end of day 2/10/17 regarding: -Meal preparation. -Food portions. -Following menus. -Monitoring of the dining room. -Fortified foods. -Adaptive equipment. *IDT (interdisciplinary team) members to begin weekly Weight Meeting on 2/10/17. All residents to be reviewed for weight loss and weight gain, develop interventions for weight loss/gain, care plan interventions as indicated and notify MD and family. *Administrator to develop monitoring system for each mealtime before end of day 2/10/17. To be included in the monitoring will be department heads and support personnel. RD will educate Department Heads and support personnel before end of day 2/10/17 on monitoring for proper equipment, proper diet, proper fluids, meal intake, offering replacements, and quality of food. *Administrator and/or DON will monitor dining room and room service during 5 meals per week, X's (times) 4 weeks. All negative findings will be immediately corrected. *Administrator and/or DON will report compliance to QAPI (quality assurance performance improvement) monthly X's 3 months. *On 2/9/17 at 9:10 a.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1a. Review of the weights and vitals exceptions document received from the interim DON on 2/6/17 at 3:00 p.m. revealed: *Seventeen residents had a recorded weight loss from 8/1/16 through 1/31/17. Of those sixteen residents: -Resident 18 had a 17.7% weight loss in the past 180 days. -Resident 8 had a 16.6% weight loss in the past 180 days. -Resident 3 had a 14.1% weight loss in the past 180 days. -Resident 9 had a 14.2% weight loss in the past 180 days. -Resident 20 had an 11.1% weight loss in the past 180 days. -Resident 7 had a 10.9% weight loss in the past 180 days. -Resident 5 had a 10.7 % weight loss in the past 180 days. -Resident 11 had a 10.6% weight loss in the past 180 days. -Resident 22 had a 9% weight loss in the past 90 days. -Resident 10 had a 6.3% weight loss in the past 30 days. -Resident 16 had an 11.5% weight loss in the past 30 days. -Resident 12 had a 6.4% weight loss in the past 30 days. -Resident 13 had an 11.1% weight loss in the past 180 days, and 6.3% in the past 30 days. -Resident 14 had a 6.6% weight loss in the past 30 days. -Resident 19 had a 5.2% weight loss in the past 30 days. -Resident 17 had a 5.1% weight loss in the past 30 days. -Resident 15 had a 5% weight loss in the past 30 days. b. Review of resident 1, 3, 27, and 33's medical records revealed they had physician ordered fluid restrictions. There had been no monitoring in place to ensure they had received the correct amount of fluids. The dietary services department was not aware of what amount of fluids those residents were to have received. Refer to F281. c. Twenty-eight residents had not received their physicians' ordered therapeutic diets. Those diets also included altered textures other than regular texture. Refer to F281. 2a. Observation on 2/6/17 from 4:55 p.m. through 5:45 p.m. in the restorative dining room revealed: *Ten residents were seated at four different tables. *Certified nursing assistant (CNA) G was the only CNA who was present to deliver their meals, supervise, cue, and assist those ten residents. *After she delivered all the residents their meals she sat with resident 18 to assist and cue him to eat. *She did not cue or assist any other residents in the restorative dining room. *The residents in the restorative dining room took their meals there due to their requirement of needing additional supervision. b. Review of resident 1's 1/27/17 nutritional assessment revealed she should have received a mechanical soft diet due to a previous speech therapy evaluation. She should have been cued to empty her oral cavity, and to swallow prior to taking additional bites. Review of her updated 12/14/16 care plan revealed no restorative dining program for her. c. Review of resident 5's 1/4/17 updated care plan revealed: *Focus: Resident is having a decline in feeding self. *Goal: Resident will have no weight loss and will feed self 75% of all meals. *Interventions: Restorative nursing program 7 times wkly (weekly). Eats in Restorative dining room. Provide set up and cueing to stay on task. d. Review of resident 20's 11/23/16 care plan revealed: *Focus: Restorative dining eating/swallowing. *Goal: Resident to eat at least 75% of all meals. *Interventions: Restorative aid to set up and cue resident to feed self at least 75% of all meals. 3. Observation on 2/7/16 at 10:20 a.m. of resident 2 revealed: *She was sitting in a wheelchair in her room. *There was a meal tray on the overbed table. *She stated It was breakfast and I've been done for a long time. *Of the items on the breakfast tray she had eaten approximately 75% of the cold cereal, and none of the scrambled egg, sausage, juice, or the biscuit. She also had what appeared to be a nutritional supplement in a four ounce plastic cup on the tray that was half-full. *Observation again at 10:50 a.m. revealed resident 2's breakfast tray was still in her room. She had not consumed any more of the food or fluids. Review of resident 2's medical record revealed: *A weight loss of 9.2% in six months. *Her January 2017 food acceptance record revealed: -No recorded meal acceptance for one breakfast, one lunch, and fourteen suppers. -Refusals documented for two breakfasts, one lunch, and one supper. -She ate 64% of breakfast, 60% of lunch, and 30% of supper. *Her 2/6/17 updated care plan revealed: -Focus: Potential for inadequate oral food/beverage intake due to dementia. -Goals included: Improve nutritional status and/or body weight and will consume more than 50% to 75% of her meals. -Interventions included: Monitor meal consumption daily. Resident eats in Main dining room. Requires supervision and set up with meals. 4. Interview on 2/6/17 at 4:55 p.m. with the administrator revealed: *He was not aware of the 25.3% weight loss of all residents. *Since the past certified DM (CDM) left before Labor Day. *He had gone through two to three DMs and had also used the corporation's contracted temporary employee service (360) for DMs. *The past CDM from 360 had tried to clean out the staff and hire all new people. The administrator told him that would not work, so the 360 CDM left. *The 360 employee service also sent CNAs to help in the kitchen. That did not work as they also had to be trained by someone. The current staff did not have the time to train the new CNAs for the kitchen. *He and the maintenance supervisor had cooked breakfast and lunch for over three weeks. I'm just happy we got them all fed. Interview on 2/7/17 at 9:00 a.m. with the RD revealed: *She had been the RD for close to two years. *She was not aware 25.3% of the residents had a weight loss. *Due to the cooks not having training they had not been able to provide nutrient dense foods. *Administration had not asked her to attend nutrition at-risk meetings or quality assurance performance improvement. *Tray line cards with the residents' physicians' ordered diets had not been in place for over three weeks. The tray cards had just started again a few days ago. *The dietary department had started to go downhill after the past dietary manager had left in September 2016. *She had spoken to the administrator about past retired experienced staff to come to work, but nothing had happened. *The ED and the maintenance supervisor had cooked breakfast and dinner for about two weeks until she requested a 360 staff person. Interview on 2/7/17 at 9:55 a.m. with the activities director revealed: *She had worked at the facility for over fifteen years and had been activity director for six of those years. *When asked if the residents ever had any concerns she responded they complained about late meal service; food being cold; inadequate food; poor food quality; no choices for food; menu choices were not what was served; alternate choices were chicken or tomato soup and sandwich; and not having enough staff to help in the dining rooms. *She revealed the administrator and maintenance director had cooked for about three weeks when they had very few dietary staff. The residents did not receive meal tickets, diet restrictions were not followed, and the residents just ate what was placed in front of them. *She had done a weight comparison on the residents about a month ago and was aware of weight loss among the residents. She was not aware of who needed supplements or who received snacks. Interview on 2/7/16 at 2:20 p.m. with activity assistant F revealed:*They had a ticket based system with the residents' diets and choices on meal lists. *The tickets had not been used from 1/21/17 until 2/4/17. *Without the tickets the dietary staff had to guess what diets the residents were supposed to have received. Interview on 2/8/17 at 10:00 a.m. with the DON and ADON confirmed: *The residents in the therapeutic dining room had been placed there due to their requirement of extensive assistance with meals. *The residents in the restorative dining room took their meals there due to their requirement of needing additional supervision. *Only one CNA was in the restorative dining room during meals. *One CNA was unable to cue and supervise the ten residents in the restorative dining room. *Resident 2 was to have been supervised on a more consistent basis when eating. Interview on 2/8/17 at 2:25 p.m. with the regional director of operations revealed: *She was aware of the dietary concerns back in September when she was vice-president with the former facility owners. *She had not been informed of the weight loss. *She was aware the temporary employee agency had sent at least two DMs to help. The agency had also sent CNAs to help. *The administrator of the facility had not requested additional resources (training and staff) for the dietary department since the former CDM had left in September.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the necessary care and treatment had been provided for: *Seventeen of seventeen sampled residents (3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 22) with weight loss. *Twenty-eight randomly reviewed residents (1, 3, 4, 12, 16, 19, 24, 29, 30, 32, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, and 52) with physician ordered therapeutic diets. *Nutrient dense foods recommended by the registered dietician/licensed nutritionist (RD/LN) had been made available for all residents. *Supervision had been provided for nine of ten observed residents (1, 5, 20, 23, 24, 25, 26, 27, and 29) in the restorative dining room. *Supervision had been provided for one of six residents (2) who received a room tray for all meals. *Physicians' ordered fluid restrictions had been followed, monitored, and documented for four of four sampled residents (1, 3, 27, and 33). Findings include: 1. The below listed resident reviews and employee interviews indicated a failure for the provider to achieve acceptable parameters and guidelines for nutrition, assisted nutrition, hydration, and physician prescribed therapeutic diets for twenty-eight of twenty-eight sampled residents. Refer to F309 and all job descriptions and and refer to F371 for policies. 3a. Review of the weights and vitals exceptions document received from the interim DON on 2/6/17 at 3:00 p.m. revealed: *Seventeen residents 3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 22 had a recorded weight loss from 8/1/16 through 1/31/17. Within that time period weight loss was recorded at 180 days, 90 days, and 30 days. *Refer to F309, finding 4 for interviews with the administrator, RD/LN, and the activity director. *Review of those seventeen residents documentation revealed the following: b. Resident 18 had a 17.7% weight loss in the past 180 days. *Review of a 7/22/16 nutrition assessment revealed: -He had inadequate oral intake related to his age, chronic medical conditions, chronic pain, and depression. Had a low BMI of 18.7. Average meal intake in past two weeks was only 44%. No recent significant weight changes noted. *Nutrition interventions included: -2oz Med Plus 2.0 TID. -Multivitamin with meals. -Therapeutic Dining -[MEDICATION NAME] for depression. -Regular diet. *Review his 1/11/17 updated care plan revealed: -Focus: Resident is on a Regular diet. Wt loss due to poor appetite. -Goals: No significant weight loss of 5% in 30 days or 10% in 180 days and Resident will maintain intake at or above 50-75.%. -Interventions included: Resident is eating in Restorative DR (dining room) and Will monitor daily intake. c. Resident 8 had a 16.6% weight loss in the past 180 days. *Review of nutrition assessments completed on 10/7/16, 10/13/16, 12/8/16, and 1/27/17 revealed: -10/7/16: 8# (6.4%) wt. loss over the last 30 days. Recommend 2 oz. Med Plus 2.0 TID with meds. -10/13/16: 8# (6.4%) wt. loss over the last 30 days. Offer Magic cup as requested by resident. -12/8/16: Triggered for a 13#(10.2%) wt. loss since 8/25/16 and a 15.5#(12%) wt. loss since 8/11. She actually gained a couple of pounds last month, no new wt. yet for Dec. Decreased po (oral intake) the last couple months with average meal and HS (bedtime) intake the last 2 weeks. No new interventions were initiated. -1/27/17: 15.5#(12.5%) wt. loss over the last 180 days, 3.5#(3%) wt. loss over the last 3 months. Order for Ensure daily, will request change to 2oz Med Plus 2.0 TID with med pass. *Review of her 12/21/16 updated care plan revealed: -Focus: Resident on regular diet. Risk for weight loss. -Goals: No significant weight change of 5% in 30 days or 10% in 180 days. Will maintain intake of 50-75%. Those goals had been initiated on 9/22/16. -Interventions included: Ensure 1 can shift were initiated on 9/22/16 and Magic cup had no initiation date. d. Resident 9 had a 14.2% weight loss in the past 180 days. *Review of nutrition assessments completed on 8/12/16, 9/23/16, 10/28/16, and 12/8/16 revealed: -8/12/16: Malnutrition related to chronic illness, dementia, and advanced age as evidenced by BMI of 15.1- severely low for age. Average meal intake the last 2 weeks only 36%. --Interventions included: Regular diet, order for supplement per RD but refuses all including Magic Cup, Mighty shakes, Ensure, and Med Plus 2.0, may eat up to 5 servings of vanilla ice cream a day. -9/23/16: Only change in assessment from 8/12/16 was Average meal intake the last 2 weeks only 25%. -10/28/16: Triggered for a 5.5#(5.2%) wt. loss since 9/29. Average meal intake the last 2 weeks around 35%. -12/8/16: Triggered for a 5.5#(5.5%) wt. loss since 10/20/16 and a 11.5#(10.8%) wt. loss since 6/2/16. No changes in any interventions. *Review of a 1/24/17 physician's note and order revealed Cachexia-diet/boost ad lib (as wants). *Review of a 10/23/16 updated care plan revealed: -Focus: Initiated on 3/8/16. Altered nutrition related to laboratory values as related to: [MEDICAL CONDITION] dysfunction, Shortness of Breath. Weight loss had been added with no date of when it had been added. -Goals initiated on 3/8/16 included: Improve nutritional status and/or body weight. A handwritten goal of Will eat 50-75% of meals with no date of when it had been added. -Interventions initiated on 3/8/16 included: Monitoring through Weight Management Committee. e. Resident 3 had a 14.1% weight loss in the past 180 days. *Review of a 12/8/16 nutrition assessment revealed she had Triggered for a 43.5 # (pound) (17.2%) wt. (weight loss) since 6/5/16 and a 19# (8.3%) wt. loss since 9/6/16, loss likely related to fluid issues but some could be true loss which is desirable. -During that time she had been hospitalized for [REDACTED]. *Review of her 1/13/17 updated care plan revealed: -Focus: She is above her BMI (body mass index) and has a NAS (no added salt) w (with)/1/2 sweets diet. -Goal: Resident will have no significant weight gain of 5% in 30 days or 10% in 180 days. -Interventions included: Will monitor daily intake. f. Resident 16 had an 11.5% weight loss in the past 30 days. *Review of a 1/20/17 nutrition assessment revealed: -She was to have had Ensure BID (twice a day) but had not been drinking it, because it caused diarrhea. -Eats in room or MDR (main dining room), able to feed self, no adaptive devices used. -Nutrition interventions included: --Cardiac diet, mech.soft diet, recommend D/C (discontinue) cardiac diet due to poor po (orally). Ensure BID (says causes diarrhea), recommend change order to house suppl. BID, Consider appetite stimulant. *A 1/9/17 physician's orders [REDACTED]. *A 1/27/17 physician's orders [REDACTED]. There was no mention of her weight loss. *Review of her 1/6/17 care plan revealed: -Focus: Inadequate oral intake related to advanced age and chronic illness. -Goals: Meal intake at least 70%. and Wt. Stable. -Interventions included: -Cardiac, mechanical soft diet, recommend D/C cardiac diet. -Consider appetite stimulant if no improvement in po. g. Resident 13 had a 11.1% weight loss in the past 180 days and 6.3% in the past 30 days. *Review of nutrition assessments completed on 10/28/16, 12/2/16, and 1/27/17 revealed: -10/28/16: Unintentional wt. loss related to chronic illness with recent decline, is a very slow eater, and possible dysphagia as evidenced by a 10#(6%) wt. loss over the last 30 days, noted to be pocketing food with order for ST (speech therapy) to see and evaluate, and recently has needed more assistance and cueing to eat. -12/2/16: --After having wt. loss now stabilizing, on [MEDICATION NAME] so some wt. fluctuations to be expected. --Has own teeth, still pockets food, this was passed on to ST, she did not feel diet needed to be downgraded at this time. Therapeutic dining, able to eat/drink by self but very slow and needs more cueing and assistance. -Nutrition interventions included: --*Dysphagia (altered texture) diet, --*House supplement TID, nursing give him 2oz Med Plus 2.0 TID. -1/27/17: Resident is on hospice. Continues to come to Therapeutic Dining Room for meals, minimal oral intake, wt. loss unavoidable. *Review of his 1/27/17 care plan revealed: -Focus: Resident is a nutritional risk due to decline in status, now on Hospice. Residents appetite has decreased, risk for aspiration, choking, wt. loss, pocketing foods and cognition. Resident is dependent on staff for oral intake. Resident is on Hospice. -Goals include: Resident will have intake at least 50%. and Wt. will remain stable. -Interventions included: --Provide verbal cues and reminders, give ample time to respond. --Staff to assist with meal intake. h. Resident 20 had a 11.1% weight loss in the past 180 days. *Review of a 10/8/16 nutrition assessment revealed: -Eats in the Therapeutic dining, able to feed self, no adaptive devices used and Adequate nutrition at this time. *Review of his 11/23/16 care plan for restorative dining revealed: -Focus included: Restorative dining eating/swallowing. -Goals included: Resident to eat at least 75% of all meals. -Interventions included: Restorative aide to set up and cue resident to feed self at least 75% of all meals. *Review of his 11/23/16 care plan for nutrition revealed: -Focus: Resident intake is between 40-50% and may affect weight. -Goals: Resident will work to a stable weight of his UBW (upper body weight) of 160-170# and Will have a PO (orally) > (greater than) 65%. -Interventions included: Ensure BID, fortify foods and BID snack cart, help with meal selection, meals in restorative dining room to help encourage intake, monitor daily intake will have a regular diet. i. Resident 7 had a 10.9% weight loss in the past 180 days. *Review of nutrition assessments completed on 8/12/16, 9/23/16,10/28/16, and 11/25/16 revealed: -8/12/16: Has had some wt. loss over the last couple months but not triggering as significant. -hospitalized [DATE] through 9/6/16 and again on 9/19/16 through 9/21/16 for [MEDICAL CONDITION] infection with pneumonia and ,[MEDICAL CONDITION]. [MEDICAL CONDITION]. -9/23/16: 10.5#(6.7%) wt. loss over the last 30 days. Consider appetite stimulant if no improvement. -10/28/16: 6.6#(4.5%) wt. loss over the last 30 days. Consider moving from Restorative dining to TDR (therapeutic dining room) so gets more assistance. -11/25/16: Has had a sig. (significant) wt. loss of 22.5#(14.3%) since 6/2 eats in Restorative Dining. *Review of a 1/27/17 nutrition assessment revealed he had a 22#(14.3%) wt. loss over the last 180 days. -Resident 7's assessment and comments included: --Daughter says 'Resident is very fatigued at mealtime but does not want help. L (left) handed but unable to use that hand for eating, R (right) hand is very shaky, does best with liquids.' -Her nutrition prescription included: Mech. soft diet. Ensure TID (three times daily). Faxed Dr. for order for 2 oz Med Plus 2.0 with med pass and consider addition of appetite stimulant per daughters request and if appropriate. *A 1/30/17 physician's orders [REDACTED]. *Review of his 12/16/16 updated care plan revealed an addition on 2/1/17 to have been moved to the therapeutic dining room. j. Resident 5 had a 10.7% weight loss in the past 180 days. *Review of a 1/7/17 nutrition assessment revealed she had a 11.5# (10.6%) wt. loss since 7/8/16, 3.5#(3.5%) wt. loss since 12/9/16. -Her assessment and comments included: --Had very few teeth, received and tolerated a mechanical soft diet, ate in the restorative dining room, and was able to feed herself with cues. *Her nutrition prescription included: -Change her Ensure Plus twice daily to three ounces of Med Plus 2.0 three times daily with medication passes, offer 206 (brand name) juice or Mighty shake at breakfast, and fortified foods. *Her 1/4/17 revised care plan included: -Focus: Resident is having a decline in feeding self and a decline in ADL (activities of daily living) function. -Goals included: Resident will have no weight loss and feed self 75% of all meals. -Interventions included: Restorative nursing program 7 times wkly . Eats in Restorative dining room. Provide set up and cueing to stay on task. k. Resident 11 had a 10.6% weight loss from 8/24/16 through 1/2/17. *Review of nutritional assessments completed on 9/2/16 and 11/10/16 revealed: -9/2/16: --Condition improved and no longer on hospice. --Triggering for wt. loss but fluctuations to be expected. --Average meal intake the last 2 weeks ~ (approximately) 80%, average intake of HS snack ~40%, needs to eat at least 60% to meet needs. --No with overall improvement diet has changed to regular, order for 1-2 cans Ensure/day, resident says not getting regularly and would like a PM snack. -11/10/16: --Triggered for a 14.5#(10.3%) wt. loss since 8/22/16, had 3+[MEDICAL CONDITION] (large amount of extra fluid) to legs and feet when admitted and has been on diuretics so some fluid related, also initially was on comfort care and had wt. loss due to poor po. Average meal intake the last 2 weeks ~68%, average intake of HS snack ~40%, needs to eat at least 60% to meet needs. No new recommendations had been made. *Review of her 11/17/16 updated care plan revealed: -A focus area initiated on 8/12/16 Resident on Mech soft diet. At risk for wt loss. -Goals initiated on 8/12/16: --Resident will not have significant wt loss of 5% in 30 days time or 10% in 180 days time. --Resident will maintain intake of 50-75% or above. -Interventions included: --Monitor wt as ordered. Wts. now 3 times wkly. --Update MD. initiated on 8/12/16. --Upgrade diet to regular consistency initiated on 9/12/16. Surveyor: l. Resident 22 had a 9% weight loss from 10/6/16 through 2/6/17. *Observation on 2/8/17 at 1:10 p.m. of resident 22 revealed she had eaten her cake, a few bites of mixed vegetables, and none of her chicken. Interview with the resident at that time revealed: -I can't eat the corn or chicken, because I need mechanical soft or I will choke. -She could not eat the food unless it was cut into small pieces or soft. -It was easier for her to eat more of the breakfast meals than lunch and dinner, as the breakfast meals were softer. *Observation on 2/8/17 at 5:30 p.m. revealed she had not eaten her grilled ham and cheese sandwich but had eaten her soup. *Observation on 2/9/17 at 9:00 a.m. revealed she had not eaten her piece of ham or her toast. Interview with an unidentified aide revealed she did not know why resident 22 ate better for breakfast, and did not eat very much for lunch and dinner. *Review of resident 22's meal cards on her serving tray at the time of the above observations revealed an order for [REDACTED].>*Review of the January 2017 food acceptance record for resident 22 revealed she ate mostly: -75% to 100% of her breakfast. -25% to 50% of her lunch. -25% to 50% of her supper. Surveyor: m. Resident 14 had a 6.6% weight loss in the past 30 days. *Review of a 1/26/17 nutrition assessment revealed: Recent hospitalization for persistent N/V (nausea/vomiting) and diarrhea, now resolved, typically constipated and on [MEDICATION NAME] (used for constipation). Eats in main dining room, able to feed self. No recommendations were made. *Review of resident 14's 1/21/17 care plan revealed: -Focus: Resident is at risk for alterations in nutritional status related to a Dx (diagnosis) of DM (diabetes mellitus), hx of CA (cancer) and abnormal lab values. Resident is receiving a regular diet. -Goals included: Resident will have no significant wt. changes of 5% in 30 days or 10% in 180 days. -Interventions included: --Diet as ordered --Monitor daily intake --Offer food and beverages of residents choice --Offer milk and juice at all meals t her request. n. Resident 12 had a 6.4% weight loss in the past 30 days. *Review of a 1/27/17 nutrition assessment revealed: -Visited with (resident) and staff regarding 11.5#(6.4%) wt. loss over the last 30 days, (resident) states appetite was down the last 1 month but getting better, also on [MEDICATION NAME] (diuretic) so some could (be) fld. (fluid) related, had 1+ [MEDICAL CONDITION] bilaterally per Dr. visit 12/9/16 and no [MEDICAL CONDITION] visit 1/6/17. No new interventions noted. *Review of initiated 8/29/16 care plan revealed: -Focus: Resident has a high BMI and on a therapeutic diet. -Goals included: Resident will have no significant weight gain of 5% in 30 days or 10% in 180 days. and Will maintain intake at or above 75%. -Interventions included Will monitor weight per facility protocol. o. Resident 10 had a 6.3% weight loss in the past 30 days. *Review of a nutrition assessment completed on 9/10/16 revealed. -Increased nutrient needs related to chronic illness, Hx (history) ETOH (alcohol), and [MEDICAL CONDITION] as evidenced by a BMI of 19.3-low for age. Declined nutritional supplements. -No further nutrition assessments had been completed. *Review of his 12/31/16 updated care plan revealed: -Focus area initiated on 9/3/16 Resident is below his IBW (ideal body weight) of 171-209. -Goals initiated on 9/3/16 Resident will not have a significant weight loss of 5% in 30 days or 10% in 180 days. and Resident will maintain intake of 75% or above. -Interventions initiated on 9/3/16 included Will monitor his daily intake. p. Resident 19 had a 5.2% weight loss in the past 30 days. *Review of a 10/4/16 nutrition assessment revealed: -She had no recent significant wt. changes. -Had regular texture diet ordered, ate in the MDR, and was able to feed self. *Review of her 12/12/16 updated care plan revealed; -Focus: Resident receives a therapeutic diet. -Goals: Resident will not experience a significant weight change of 5% or more in 30 days time or 10% or more in 180 days time and Resident will eat 75-100% of meals. -Interventions included: Monitor meal consumption daily. Diet as ordered. q. Resident 17 had a 5.1% weight loss in the past 30 days. *Review of a 12/16/16 nutrition assessment revealed Con CHO (concentrated carbohydrate) diet resident requests 1 scoop PRO powder daily. *Review of her 1/5/17 care plan revealed: -Focus: Resident is at nutritional risk due to [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]) on [MEDICAL TREATMENT], IDDM (insulin dependent diabetes mellitus), and is receiving therapeutic diet. -Goals: Lab values will be WNL (within normal limits) and Resident will have no s/s (signs or symptoms) of altered blood sugars. -Interventions included: Monitor daily intake and Refer to RD for further recommendations. r. Resident 15 had a 5% weight loss in the past 30 days. *Review of a 2/3/17 nutrition assessment revealed: -She received two ounces Med Plus 2.0 four times daily (QID) and one scoop of PRO powder in hot cereal. -Eats in TDR (therapeutic dining room), able to feed self but needs staff to assist, drinks fluids from straw. -Nutrition intervention: to also receive fortified hot cereal, a pureed diet, and to ensure she received adequate assistance in TDR. *Review of her 12/26/16 care plan revealed: -Focus: Resident receives a Mechanically altered diet. Resident eats less than 75% at majority of meals. Resident is at risk for wt. loss due to poor intake. -Goals: Resident will not experience sig wt change of 5% or more in 30 days time or 10% or more in 180 days time. and Resident will eat 50% of meals. -Interventions included: --Eats all meals in the TDR at an assisted table. --Fortified cereal and fortified foods. --[MEDICATION NAME] in fortified cereal. Surveyor: s. Interview on 2/7/17 at 2:20 p.m. with activity assistant F revealed: *She had been asked to help in the dietary department by the administrator for approximately six weeks prior to 1/21/17. *In that six weeks she had done the scheduling, ordering, created the meal tickets, and helped in the kitchen. She had put the deliveries away and had started to clean. But when she had started to wash the coolers out and discovered mold, she had quit cleaning. *The residents had a ticket based system with the resident diets and choices for meals during the six weeks. *The tickets had not been handed out since 1/21/17. The staff would guess what the residents' diets were without the tickets. During that time period there had been a choking incident, because an unidentified resident had received the wrong diet. *_______( resident 34) was listed as a mechanical soft but was getting a pureed diet. That is just one sample of wrong diets. *The residents' tickets and menu orders had just stated again on Saturday 2/4/17.

A. Based on record review, interview, and observation, the provider failed to meet the daily nutritional needs for 28 of 28 sampled residents as evidenced by: *Seventeen of seventeen sampled residents (3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 22) who had significant weight losses. *Twenty-eight randomly reviewed residents (1, 3, 4, 12, 16, 19, 24, 29, 30, 32, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, and 52) with physician ordered therapeutic diets. *Nutrient dense foods had not been made available for all residents recommended by the registered dietician/licensed nutritionist (RD/LN). *Supervision had not been provided to nine of ten observed residents (1, 5, 20, 23, 24, 25, 26, 27, and 29) in the restorative dining room. *Supervision had not been provided to one of six observed resident (2) who received a room tray for all meals. *Physician ordered fluid restrictions had not been followed, monitored, and documented for four of four sampled residents (1, 3, 27, and 33). Findings include: 1. The provider had not ensured all residents would have received the proper nutritional support to maintain their highest practicable physical well-being. Refer to F309. B. Based on observation, document review, and interview, the provider failed to ensure meal tickets with residents' diet restrictions, and ready-to-eat food was prepared according to residents' diets. Findings include: 1. Observation on 2/6/17 from 3:45 p.m. to 5:15 p.m. and on 2/7/17 from 10:00 a.m. to 11:15 a.m. and at 3:10 p.m. revealed: 1. Random observations throughout the above three time periods revealed: *Several meals had been sent out on trays that did not match the residents' diet cards. *Cook A asked the dietary manager (DM) to make her two peanut butter and jelly sandwiches and dish up two bowls of fruit. The DM removed the gloves he had on, and put on new gloves without washing his hands. He used one package of peanut butter and two packages of jelly per sandwich. Review of the manufacturer's directions revealed two packages of peanut butter must have been used to provide two tablespoons of peanut butter for a serving of protein. He dished out two bowls of fruit and filled them full without measuring one half cup for each serving. At neither time did the DM question cook A to see if the sandwiches or fruit would meet the residents' diets. He stated when he was busy he did not have time to measure food quantities or check residents' diets and just focused on feeding the residents. C. Based on observation, interview, and record review, the provider failed to follow a physician's orders [REDACTED]. Findings include: 1. The provider had not ensured resident 22 had been provided with the physician's orders [REDACTED]. Refer to F325, finding 3l. D. Based on observation, interview, and policy review, the provider failed to ensure: *Three week cycled menus had been followed from September 2016 through 12/31/16. *Four week cycled menus had been followed from 1/1/7 through the day of survey on 2/9/17. *All food required for the menus was purchased, planned with staff, and compared with the menus for that week. Findings include: 1. The provider had not ensured a menu system had been provided to meet the nutritional needs of all residents. Refer to F363. E. Based on menu review for two of three months, observation, and interview, the provider failed to substitute food of the same nutritive value. Findings include: 1. Review of the December 2016 and February 1 through 9, 2017 menus revealed the dietary manager (DM) had made substitutions without the approval of the registered dietician (RD). The DM did not provide the January 2017 menus upon several requests from the surveyor. Refer to F366. F. Based on observation, interview, and record review, the provider failed to employ sufficient staff to carry out the daily needs of one of one dietary department to include the kitchen and three of three dining rooms. Findings include: 1. The provider had not ensured the necessary care and treatment had been provided for all residents that required assistance with eating. Refer to F362. Review of a 3/9/15 Meal Service policy revealed: *Residents who require assistance with feeding will not have their trays delivered until a staff member was available to assist with feeding. *A record of all residents' diet orders and a list of those residents on thickened liquids or fluid restrictions would be kept in each dining area. *All residents eating less than 50% of a meal would be offered a substitute. *Room service trays would be delivered promptly upon reaching the floor. *Residents eating in their rooms would be provided assistance as needed. Dependent diner (resident) and diner needing assistance would be provided required assistance and supervision as appropriate consistent with their plan of care.

Based on interview and job description reviews, the provider failed to employ a qualified food service manager for approximately five months. Findings include: 1. Interview on 2/7/17 at 9:00 a.m. with the registered dietician (RD) revealed: *She had been the RD for close to two years. *She gave training and tips when she came every Friday, but nothing got changed. *She had never approved any substitutions for the menus nor was she aware substitutions had been made for the approved menus. *Administration had not asked her to attend nutrition at-risk meetings or quality assurance meetings. *She was not aware 25% of the residents had a weight loss. *The dietary department had started to go downhill after the past dietary manager had left in September 2016. *Tray line cards with the residents' physicians' ordered diets had not been in place for over two weeks. The tray cards had just started again a few days ago. *The administrator and the maintenance supervisor had cooked breakfast and dinner for about three weeks until she requested a 360 (corporate temporary staffing agency) person. The resident diets and tray line cards had not been followed at that time. *She had tried to schedule training and in-services. Those had been canceled by the DM as he had not been available to attend the training. *She had conducted walk-throughs of the kitchen on: -1/6/17: She had listed eighteen items out of compliance (the same items were found by the surveyor during the survey) and in need of correction. The DM had walked with the RD and he was aware of the identified items that had been out of compliance. -1/6/17: After the walk-through with the DM she had sent an email to the administrator stating her concerns and the dire need for in-house training and in-services. -1/10/17: She had the administrator do a walk-through of the kitchen with her. She found the same items as listed on the 1/6/17 walk-though. No changes had been made. *She had completed a Supreme Care Dietary Department Review-Score Care on 1/20/17, and the kitchen had scored 30 points out of 100 points. -1/24/17: She had sent an email to the administrator, DM, and vice-president of operations in regards to the walk-throughs, need for training, and for those issues to be added the next all staff meeting. -She had received no responses from the two 1/6/17 emails nor the 1/24/17 email. Interview on 2/7/17 at 2:20 p.m. with activity assistant F revealed: *She had been asked to help in the dietary department by the administrator for approximately six weeks prior to 1/21/17. *In that six weeks she had done the scheduling, ordering, created the meal tickets, and helped in the kitchen. *She had put the deliveries away and had started to clean. When she started to wash the coolers out and discovered mold she had quit cleaning. *At one time the DM had not been there for about a week. The administrator stated he did not know where the DM was. *There was not enough staff in the kitchen. *At least twice a week the residents ate off of paper plates, as the kitchen staff were tired of doing dishes or having no dishwasher staff person. *The dietary department had deteriorated, and the kitchen was filthy. *Employees and residents had complained to management and nothing ot done. Interview on 2/7/17 at 3:10 p.m. with the DM revealed he: *Had worked at a seasonal restaurant for sixteen years. The last few years he had been the kitchen manager at that seasonal restaurant. *Had taken the ServSafe course several years ago. *Had no background in healthcare or healthcare food service. *Was not aware of the recommended serving sizes for food. *Thought they used the food guide pyramid for the recommended daily servings of food. *Was aware the cleaning schedule had not been followed. *Had provided on-the-job training to staff but had not documented any of that training. *Agreed the RD had tried to schedule training for all kitchen staff. But the staff had been busy, staff had been ill, and another time he could not make it to work. *Confirmed the RD had walked through the kitchen with him and expressed her concerns. *Had not had time to correct those concerns, as he was always busy in the kitchen and was not able to fulfill his DM duties. *Had expressed his concerns about training for himself to the administrator several times but nothing had been done. *Was not aware residents had unplanned weight loss since the fall of 2016. Interview on 2/7/17 at 4:55 p.m. with the administrator revealed he: *Was aware of all the concerns in the dietary program. It was discussed daily in the stand-up meetings. *Agreed the kitchen had gone downhill since the past certified dietary manager (CDM) had left in September 2016. *Was aware of the concerns from the resident council regarding the food service and had addressed those concerns at the council meetings. *Was not aware there was an overall 25% weight loss among the residents. *Had not conducted any audits nor had the DM conducted any in-services. *Could not find any employees or had not been able to hire any employees in the kitchen due to failure of background checks. *Confirmed he and the maintenance supervisor had cooked breakfast and lunch for three weeks. They followed the menus for what foods to cook and serve. They had not followed the physicians' ordered diets for each resident. He stated I was just happy to get the residents fed. *Had gone through two or three DMs before he had hired the current DM. The DM seemed like the logical choice, as he had a food service background. *Was aware the DM did not have any experience in the healthcare industry. *Had enrolled him in the CDM program 2/8/17 to get more experience. *Had requested help from the corporate office but all they sent was certified nurse assistants to help in the kitchen. They had no experience in food service. *Was aware the RD had scheduled trainings. *Stated the only emails he had received from the RD was about a week ago. That email concerned improper food temperatures and lack of recording temperatures for the coolers and freezers. Review of the provider's undated Director of Dietary Job description revealed: *The director of dietary services was responsible for planning, preparing, and serving regular, modified consistency, and therapeutic diets using the corporate menu program. He supervised preparation service and delivery of food. *Job Duties included: -Identify nutrition concerns and make appropriate referrals. -Implement diet plan and physicians' ordered diets using appropriate modifications. -Specify standards and procedures for food preparation. -Supervise preparation and serving of modified consistency and therapeutic diets and supplemental foods. -Manage sanitary food service environment by protecting food in all phases of preparation, handling, service, cooling, storage, and transportation. -Purchase, receive, and store food following established sanitation and quality guidelines. -Purchase, store, and ensure safe use of chemicals and cleaning agents. -Manage equipment and maintenance of equipment. -Develop work schedules, cleaning schedules, and work assignments. -Prepare, plan, and conduct departmental meetings and in-service programs. *Qualifications were: -Certified dietary manager (CDM)/Certified food protection professional (CFPP) certification. -ServSafe certification was desired. -Prior work experience in healthcare environment sufficient enough to meet position requirements. -Knowledge of state and federal regulations. -Experience with healthcare menu planning software. Review of the undated Registered Dietician job description revealed: *Responsible for ensuring the nutritional needs of the residents had been met based on physicians' orders. *Consulted with physicians and staff to determine the nutritional needs and diet restrictions of the residents. -Developed and prepared the curriculum, diet manual, visual aids, course outlines, and other material for use in teaching. -Monitored sanitation standards, food temperatures, and food quality at the point of service in the dining rooms and resident rooms by use of a test tray per standards in conjunction with the DM. -Planed and reviewed the therapeutic, regular diet plans, and menus. Ensured they were in compliance with physicians' orders. -Provided education to departments in the healthcare center regarding nutritional services.

A. Based on observation, interview, and policy review, the provider failed to ensure: *Three week cycled menus had been followed from September 2016 through 12/31/16. *Four week cycled menus had been followed from 1/1/7 through the last day of the survey on 2/9/17. *All food required for the menus was purchased, planned with staff, and compared with the menus for that week. Findings include: 1.Residents' physicians' ordered diets and portion control had been followed and maintained. Refer to F364 finding D1. B. Based on observation, interview, and record review, the provider failed to follow a physician's orders [REDACTED]. Findings include: 1. A physician's orders [REDACTED]. Refer to F325, finding 3l. C. Based on observation, interview, record review, and policy review, the provider failed to ensure the necessary care and treatment had been provided for: *Seventeen of seventeen sampled residents (3, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 22) with weight loss. *Physicians' ordered fluid restrictions for four of four sampled residents (1, 3, 27, and 33). *Twenty-eight randomly reviewed residents (1, 3, 4, 12, 16, 19, 24, 29, 30, 32, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, and 52) with physician ordered therapeutic diets. *Nutrient dense foods for all residents recommended by the registered dietician/licensed nutritionist. *Supervision for 9 of 10 observed residents (1, 5, 20, 23, 24, 25, 26, 27, and 29) in the restorative dining room. *Supervision for 1 of 6 residents (2) who received a room tray for all meals. 1. The provider had not ensured all residents would have received the proper nutritional support to maintain their highest practicable physical well-being. Refer to F309.

Based on interview, record review, and policy review, the provider failed to have an appropriate [DIAGNOSES REDACTED]. Findings include: Surveyor: 1. Observation and interview on [DATE] at 10:00 a.m. with resident 10 revealed: *Everything had gone pretty good here until recently. She got mad a little while back and was upset, because her brother-in-law had died . So you know how that can stress you out? *She used to be able to go outside and have a cigarette. Now she needed a supervisor with her if she wanted to go out and have a cigarette. That was new. *She just wanted to go out and talk with people the way she used to. *She was stressed and could not get a supervisor to go out with her. She got angry. Talk about acting like a [AGE] year old. I was real angry. -So she went out and was in the parking lot, then when she had to come back in, she got so mad she pulled the fire alarm. *That was when they stuck me. They gave me a shot and told me it was to make me sleep. I don't take meds (medications) that I don't know what they are for. -They did that to me four or five times. It didn't make me sleep. It made me angry. -They should put a picture of a dog on my door that says Beware of Dog. That is how I feel. *She thought a couple of the nurses are bull dogs. They were the ones that gave her the shots. They said I was combative. I was not combative. *Now they wanted her to move to another facility because I am combative. *She relayed that one certified nursing assistant (CNA) who was holding her when they gave her the shot, the resident used her long fingernails to get the CNA and pointed to her neck were she had gotten the CNA. *A new resident had come in on [DATE], and that resident also smoked. When the staff saw her warning this new resident about not being able to smoke they moved resident 10 to a different table away from the new resident. Surveyor: Review of resident 10's interdisciplinary progress notes from [DATE] through [DATE] revealed: *On [DATE] at 6:45 a.m. Resident is alert with confusion and able to make all needs know to staff using call light. *On [DATE] at 6:55 p.m. Resident is alert and oriented with confusion at times. Always ask staff to go out and smoke. *On [DATE] at 9:16 a.m. Resident is alert and can be confused at times. She requires assistance to go out to smoke. She cannot pass the smoking assessment. *On [DATE] at 9:39 p.m. the following documentation revealed: -Situation: At about 1900, (7:00 p.m.) resident was reported to be in the middle of the facility parking lot and stating she was going to leave. Resident hit a parked car of another family member's and scratching it with her WC (wheelchair) and attempting to leave. -Background: History of UTI (urinary tract infection), altered mental status (not thinking clearly), dementia (decreased thought process). -Assessment: Resident refused any and all cares and vital signs (blood pressure, pulse, and breathing per minute) but is noted to be confused and combative towards staff. Resident trying to stand and get out of chair while WC is being pushed by staff and grabbing staff's hands. -Response: Resident was assisted by staff back onto the sidewalk and back into facility. Resident's sister called as requested. Once sister arrive, resident was assisted down to her room. At 1955 (7:55 p.m.) on call MD (medical doctor) was paged. At 2030 (8:30 p.m.) MD paged again. At 2120, (9:20 p.m.) call from ______(MDs name) received with orders noted. *On [DATE] at 2:54 a.m. St. (straight) cath (catheterization (tube to drain urine) of urinary bladder) done as ordered. Resident tolerated well. Results pending. *On [DATE] at 1:38 p.m. Received UA (urinalysis) (urine test results) and faxed to ______ (MDs name). *On [DATE] at 8:25 p.m. a note by the social services (SS) worker revealed: Earlier a mood assessment was completed with resident. She scored 5 for mild depression. She answered yes to thoughts that she would be better off dead and that she has had thoughts in the past of hurting herself but not at the time. As SS was leaving for home this evening found resident in the street trying to leave. Brought her back to facility and she refused to come in. She continued to try to leave and 4 times almost tipped chair over going down the sloping drive and off the curb. She made comments that hurting her self would be ok and being better off dead. These comments were made a few times. She is refusing to come into facility. She states that her behavior is ok and disagrees that being in the road is a safety risk. *On [DATE] at 9:00 p.m. the following documentation revealed: -Situation: At 1900, (7:00 p.m.) facility SS worker found resident in the street trying to leave facility. SS brought her back to facility and resident refused to come in. Resident continue to try and leave 4 times and almost tipped her w/c (wheelchair) over while going down the sloping driveway and off the curb. -Background: Hx (history) of altered mental status, UTI. -Assessment: Resident apparently disoriented and confused. Resident is not thinking clearly and cognitive (thinking; reasoning) status is severely altered. Resident refuses any care from any and all staff. -Response: Resident was brought back several times for safety purposes. One on one and at times two staff to 1 for safety and monitoring. PRN (as needed) medication administration attempted and refused. Call to her niece made. Niece arrived to assist in reassuring resident but resident continued to be agitated and attempt to elope. Call to MD at 2025 (8:25 p.m.) with order to send to _____ (name of hospital) for psych (psychiatric) eval (evaluation) via (by) ambulance. Ambulance on scene and here to transport resident at 2035 (8:35 p.m.). At 2040, (8:40 p.m.) report called to _____(name of registered nurse at hospital). Awaiting update at this time. *On [DATE] at 1:44 a.m. At 2330, (11:30 p.m.) call received from _______ (name of hospital) ER (emergency room ) that resident is being sent back to facility. Resident verbalized no intentions to harm self in ER and displayed no behaviors while in the ER. Resident returned at 0030, (12:30 a.m.) with new orders for antibiotics for present UTI as well as progress notes regarding medications administered while in the ER. Resident assisted to bed with no concerns noted at this time. Will continue to monitor. *On [DATE] at 6:43 p.m. Received orders for [MEDICATION NAME] (anti-anxiety medication) solution 2 mg (milligram) per ml (milliter) injection et (and) for a wanderguard (personal alarm device) R/T (related to) recent attempts to leave. *On [DATE] at 9:30 p.m. Medication administration of 1 mg of [MEDICATION NAME] (antipsychotic medication) intramuscularly (IM). Resident is exit seeking and combative to staff. *On [DATE] at 10: 43 p.m. the following documentation revealed: -Situation: Resident is repeatedly attempting to elope from facility. Has opened exit doors at least x (times) 3 starting at 1930 (7:30 p.m.) exiting x 2. Resident hitting at staff and grabbing door handles and side rails and attempting to stand when wheel chair is in motion. -Background: Present UTI-currently on antibiotics therapy. Eloping and combative behaviors noted previous two days. -Assessment: Resident is noted to be confused, combative, and danger to self at this time. -Response: Earlier this shift, order was received for IM [MEDICATION NAME]. Pharmacy called for medication. Medication unavailable at this time and not in our medication dispensing unit. Pharmacy continued with communications with MD for alternative medication. New order received. During this time, resident was supervised 1 on 1 (one staff person for one resident) at nurse's station by staff to prevent elopement. PRN oral medication administration attempted without success. IM injection of [MEDICATION NAME] given as ordered. Family was notified and came to facility to help facilitate ADLs (activities of daily living that includes dressing, toileting, eating and personal care) with success. Family appreciative towards staff. Will continue to monitor and assess. *On [DATE] at 4:58 p.m. [MEDICATION NAME] 2 mg IM given. Resident left building three times. On third time, resident became combative with staff, attempting to hit staff, swinging at CNA (certified nursing assistant), nurse, et management. Resident re-directed for brief time et (and) brought into the hallway, where she then pulled the fire-alarm. *On [DATE] at 5:19 p.m. Resident left building three times, stating that she was 'leaving this damn place'. Resident was stopped by nurse et CNA and explained to her why she needs to stay here for her safety. Resident re-directed back into building. A different resident left the building to leave with her son et this resident attempted to leave with the other resident. Nursing was able to re-direct resident, but she became combative, swinging to hit staff et kicking at nurse. Resident brought back into building et re-directed for a short time. Resident went down the hallway et pulled the fire-alarm, after being asked not to by nurse. Nurse assigned CNA to do one-on-one with resident; PRN dose of IM [MEDICATION NAME] given per MAR (medication administration record). *On [DATE] at 8:44 p.m. a late entry Resident was trying to get out of the facility, and telling everyone that she will pull the fire alarm. Resident was stopped by nurse et CNA and explained to her why she needs to stay here for her safety. Nursing was able to re-direct but she's trying to hit staff. Given PRN dose of IM [MEDICATION NAME] given per eMAR (electronic medication administration record). She tries to kick staff while given the injection. After that she pours water on the laptop and still mad because she wants to go out. *On [DATE] at 8:19 p.m. [MEDICATION NAME] 2 mg IM given. Resident was trying to go out of the facility, and was very agitated. *On [DATE] at 9:49 p.m. Resident was trying to get out the facility again at 2000, (8:00 p.m.) and she want (wanted) to go out and smoke. She was confused, she stated that she want to talk to the doctor on what's going on. Explained to the resident that she's living here and needs to stay here for her safety. Give PRN dose of IM [MEDICATION NAME] given per eMAR. Resident is still agitated called her sister and they came to help calm her down. Resident sister help her to bed and finally goes to sleep. *On [DATE] at 9:09 p.m. [MEDICATION NAME] 2 mg IM given. *On [DATE] at 10:03 p.m. Resident with increased agitation, admin (administered) one IM shot of [MEDICATION NAME] and called family to come up to see res.(resident) Res. then called 911 and police officer showed up, explained situation to police without any issues. res is resting in bed at this time, family just left. will cont (continue) to monitor. *On [DATE] at 12:43 p.m. a note by the SS worker. Faxed _____ (MD) regarding resident behaviors. Family member is concerned about the behavior and said they have a Dr appt (appointment) schedule with _____(MD) on [DATE]. Discussed that we have request bed on 2nd fl (floor) ______(another facility) for her safety. Interview on [DATE] at 5:30 p.m. with registered nurse O and licensed practical nurse N revealed:*Resident 10 had been having multiple episodes of trying to elope from the building. *She had been combative towards staff and had required one-on-one staff supervision. *They had not known why she had kept on trying to leave. *Agreed she was a smoker and had been assessed as unsafe to smoke alone on [DATE]. *The provider's policy was only residents that did not have to be supervised to smoke could smoke. *Agreed staff had been supervising her since then for smoking. *Had not thought the [MEDICATION NAME] she had received was a chemical restraint. *It had only been used to control her behaviors. 2. Review of resident 14's [DATE] physician's orders [REDACTED].>*He was admitted on [DATE] and discharged on [DATE]. *His [DIAGNOSES REDACTED].>-A [MEDICAL CONDITION] (TBI). -Mild cognitive impairment. *The following [MEDICAL CONDITION] (medications effecting mood and behavior) had been ordered: -[MEDICATION NAME] (treatment for [REDACTED]. Start date [DATE]. There was no time limit on the use of that medication. -Resperidone (treatment for [REDACTED]. Start date [DATE]. -[MEDICATION NAME] (for [MEDICAL CONDITION]) tablet 25 mg per PEG tube every four hours as needed for severe agitation. -[MEDICATION NAME] (depression) HCL ([MEDICATION NAME]) tablet 25 mg every six hours as needed for ABS (agitated behavior scale) greater than 27. Start date [DATE]. -[MEDICATION NAME] HCL tablet 50 mg every 6 hours as needed for ABS greater than 27. Start date [DATE]. Review of resident 14's [DATE] physician's orders [REDACTED].>*His [DIAGNOSES REDACTED]. *The following [MEDICAL CONDITION] had been ordered: -[MEDICATION NAME] inject 2 milligram (mg) intramuscularly every eight hours for severe agitation. Start date [DATE]. -Resperidone - 0.25 mg by mouth three times a day related to mild cognitive impairment. Start date [DATE] -[MEDICATION NAME] tablet 25 mg by mouth every four hours as needed for severe agitation. -[MEDICATION NAME] HCL 25 mg every six hours as needed for ABS greater than 27. Start date [DATE]. -[MEDICATION NAME] HCL 50 mg every six hours as needed for ABS greater than 27. Start date [DATE]. Review of nurses progress notes and the Medication Administration Record [REDACTED]. Review of resident 14's behavior log revealed: *On [DATE] he exhibited verbal behavior one time. *From [DATE] through [DATE] he exhibited behaviors thirteen times. *Those behaviors included: -Rejecting care four times. -Wandering four times, -Verbal behavior twice. -Physical behavior twice. -Other behavior once. Interview on [DATE] at 10:40 a.m. with the director of nurses regarding resident 14 revealed: *He was very confused and restless. *He was assigned a one-on-one staffing ratio to monitor him. *He was constantly wanting to leave the building and was a fall risk. *The ABS scale (measured agitation) was a scale the TBI unit he had come from used. -They did not have a copy of that scale and had not used it. -The nurses should have addressed that when they got the order for the medication using the ABS scale. *She agreed the [DIAGNOSES REDACTED]. *Not all behaviors had been documented. *She confirmed the nurses should have addressed those [DIAGNOSES REDACTED]. Review of the provider's [DATE] Antipsychotic Medication Review policy revealed: *The procedure was to Ensure that the Medical Record of any Resident who receives antipsychotic medication contains documentation supporting the appropriateness and necessity for the use of the drug. *Antipsychotics are a class of psychiatric medication primarily used to manage [MEDICAL CONDITION] (including delusions, hallucinations, or disordered thought) particularly in [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, and is increasingly being used in the management of non-[MEDICAL CONDITION]. *The Assessment of [MEDICAL CONDITION] medications was a part of the policy. -That document was not found completed in resident 14's medical records. *Review to ensure that a consent form or documentation noting the risks and benefits for the use of an antipsychotic medication had been discussed with the resident and/or responsible party. -That had not been noted for resident 10. Review of the provider's [DATE] Behavior Management Guideline policy revealed: *The use of any medication to control behaviors should always be considered a last resort to assist with managing a patient's/resident's behavior. *Antipsychotic drugs would not be used unless the clinical record documents that the patient/resident has one or more of the following specific conditions, as dictated and documented by the physician: *A. Conditions other than Dementia- This included a list of twelve [DIAGNOSES REDACTED]. -Mild Cognitive Impairment. -Severe agitation. *Criteria: All of the above highlight conditions/[DIAGNOSES REDACTED]. -The behavioral symptoms present a danger to the patient/resident or others AND one or both of the following: -The symptoms are identified as being due [MEDICAL CONDITIONS] (such as auditory, visual or other hallucinations; delusions, paranoia, or grandiosity); OR -Behavioral interventions have been attempted and included in the plan of care, except in an emergency. *When an antipsychotic medication is being initiated or used to treat an emergency situation related to one or more of the aforementioned conditions/diagnosis, the use must meet the above criteria and all of the following additional requirements: -1. The acute treatment period is limited to seven days or less; -2. A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days to identify and address and contributing and underlying causes of the acute condition and verify the continuing need for an antipsychotic medications.

Based on record review, policy review, and interview, the provider failed to ensure an as needed (PRN) antipsychotic (mind-altering) medication ([MEDICATION NAME]) had not been used for staff convenience and to chemically restrain two of seven sampled residents (10 and 14) with a PRN antipsychotic medication. Findings include: 1. Review of resident 10's entire medical record revealed: *She had been admitted on [DATE]. *She had [DIAGNOSES REDACTED]. Review of resident 10's [DATE] admission clinical health status assessment revealed she: *Was alert and her short and long-term memory were good. *Was independent with decision making. *Was able to make her self understood and understood others. *Had no indicators of depression, anxiety (nervousness), sad mood, or adjustment of new conditions. *Had no behavioral symptoms. *Had a risk for elopement (leaving the facility without staff knowing) assessment that had indicated she was physically able to leave the building on her own and was a recent admission.Those answers had triggered a prevention plan of care for elopement should have been considered. *Smoked and a separate provider assessment had been completed on [DATE] indicateing she was able to smoke independently. Review of resident 10's [DATE] re-admission clinical health status assessment revealed she: *Was alert and her short-term memory was good. *Had a problem with her long-term memory. *Required assistance with decision making. *Was able to make her self understood and understood others. *Had no indicators of depression, anxiety, sad mood, or adjustment of new conditions. *Had no behavioral symptoms. *Had a risk for elopement assessment that had indicated she was physically able to leave the building on her own and was a recent admission.Those answers had triggered a prevention plan of care for elopement should have been considered. *Smoked and a separate provider assessment had been completed on [DATE] and was unclear on whether she was safe with smoking or not. Review of resident 10's interdisciplinary progress notes from [DATE] through [DATE] revealed: *On [DATE] at 6:45 a.m. Resident is alert with confusion and able to make all needs know to staff using call light. *On [DATE] at 6:55 p.m. Resident is alert and oriented with confusion at times. Always ask staff to go out and smoke. *On [DATE] at 9:16 a.m. Resident is alert and can be confused at times. She requires assistance to go out to smoke. She cannot pass the smoking assessment. *On [DATE] at 9:39 p.m. the following documentation revealed: -Situation: At about 1900, (7:00 p.m.) resident was reported to be in the middle of the facility parking lot and stating she was going to leave. Resident hit a parked car of another family member's and scratching it with her WC (wheelchair) and attempting to leave. -Background: History of UTI (urinary tract infection), altered mental status (not thinking clearly), dementia (decreased thought process). -Assessment: Resident refused any and all cares and vital signs (blood pressure, pulse, and breathing per minute) but is noted to be confused and combative towards staff. Resident trying to stand and get out of chair while WC is being pushed by staff and grabbing staff's hands. -Response: Resident was assisted by staff back onto the sidewalk and back into facility. Resident's sister called as requested. Once sister arrive, resident was assisted down to her room. At 1955 (7:55 p.m.) on call MD (medical doctor) was paged. At 2030 (8:30 p.m.) MD paged again. At 2120, (9:20 p.m.) call from ______(MDs name) received with orders noted. *On [DATE] at 2:54 a.m. St. (straight) cath (catheterization (tube to drain urine) of urinary bladder) done as ordered. Resident tolerated well. Results pending. *On [DATE] at 1:38 p.m. Received UA (urinalysis) (urine test results) and faxed to ______ (MDs name). *On [DATE] at 8:25 p.m. a note by the social services (SS) worker revealed: Earlier a mood assessment was completed with resident. She scored 5 for mild depression. She answered yes to thoughts that she would be better off dead and that she has had thoughts in the past of hurting herself but not at the time. As SS was leaving for home this evening found resident in the street trying to leave. Brought her back to facility and she refused to come in. She continued to try to leave and 4 times almost tipped chair over going down the sloping drive and off the curb. She made comments that hurting her self would be ok and being better off dead. These comments were made a few times. She is refusing to come into facility. She states that her behavior is ok and disagrees that being in the road is a safety risk. *On [DATE] at 9:00 p.m. the following documentation revealed: -Situation: At 1900, (7:00 p.m.) facility SS worker found resident in the street trying to leave facility. SS brought her back to facility and resident refused to come in. Resident continue to try and leave 4 times and almost tipped her w/c (wheelchair) over while going down the sloping driveway and off the curb. -Background: Hx (history) of altered mental status, UTI. -Assessment: Resident apparently disoriented and confused. Resident is not thinking clearly and cognitive (thinking; reasoning) status is severely altered. Resident refuses any care from any and all staff. -Response: Resident was brought back several times for safety purposes. One on one and at times two staff to 1 for safety and monitoring. PRN (as needed) medication administration attempted and refused. Call to her niece made. Niece arrived to assist in reassuring resident but resident continued to be agitated and attempt to elope. Call to MD at 2025 (8:25 p.m.) with order to send to _____ (name of hospital) for psych (psychiatric) eval (evaluation) via (by) ambulance. Ambulance on scene and here to transport resident at 2035 (8:35 p.m.). At 2040, (8:40 p.m.) report called to _____(name of registered nurse at hospital). Awaiting update at this time. *On [DATE] at 1:44 a.m. At 2330, (11:30 p.m.) call received from _______ (name of hospital) ER (emergency room ) that resident is being sent back to facility. Resident verbalized no intentions to harm self in ER and displayed no behaviors while in the ER. Resident returned at 0030, (12:30 a.m.) with new orders for antibiotics for present UTI as well as progress notes regarding medications administered while in the ER. Resident assisted to bed with no concerns noted at this time. Will continue to monitor. *On [DATE] at 6:43 p.m. Received orders for [MEDICATION NAME] (anti-anxiety medication) solution 2 mg (milligram) per ml (milliter) injection et (and) for a wanderguard (personal alarm device) R/T (related to) recent attempts to leave. *On [DATE] at 9:30 p.m. Medication administration of 1 mg of [MEDICATION NAME] (antipsychotic medication) intramuscularly (IM). Resident is exit seeking and combative to staff. *On [DATE] at 10: 43 p.m. the following documentation revealed: -Situation: Resident is repeatedly attempting to elope from facility. Has opened exit doors at least x (times) 3 starting at 1930 (7:30 p.m.) exiting x 2. Resident hitting at staff and grabbing door handles and side rails and attempting to stand when wheel chair is in motion. -Background: Present UTI-currently on antibiotics therapy. Eloping and combative behaviors noted previous two days. -Assessment: Resident is noted to be confused, combative, and danger to self at this time. -Response: Earlier this shift, order was received for IM [MEDICATION NAME]. Pharmacy called for medication. Medication unavailable at this time and not in our medication dispensing unit. Pharmacy continued with communications with MD for alternative medication. New order received. During this time, resident was supervised 1 on 1 (one staff person for one resident) at nurse's station by staff to prevent elopement. PRN oral medication administration attempted without success. IM injection of [MEDICATION NAME] given as ordered. Family was notified and came to facility to help facilitate ADLs (activities of daily living that includes dressing, toileting, eating and personal care) with success. Family appreciative towards staff. Will continue to monitor and assess. *On [DATE] at 4:58 p.m. [MEDICATION NAME] 2 mg IM given. Resident left building three times. On third time, resident became combative with staff, attempting to hit staff, swinging at CNA (certified nursing assistant), nurse, et management. Resident re-directed for brief time et (and) brought into the hallway, where she then pulled the fire-alarm. *On [DATE] at 5:19 p.m. Resident left building three times, stating that she was 'leaving this damn place'. Resident was stopped by nurse et CNA and explained to her why she needs to stay here for her safety. Resident re-directed back into building. A different resident left the building to leave with her son et this resident attempted to leave with the other resident. Nursing was able to re-direct resident, but she became combative, swinging to hit staff et kicking at nurse. Resident brought back into building et re-directed for a short time. Resident went down the hallway et pulled the fire-alarm, after being asked not to by nurse. Nurse assigned CNA to do one-on-one with resident; PRN dose of IM [MEDICATION NAME] given per MAR (medication administration record). *On [DATE] at 8:44 p.m. a late entry Resident was trying to get out of the facility, and telling everyone that she will pull the fire alarm. Resident was stopped by nurse et CNA and explained to her why she needs to stay here for her safety. Nursing was able to re-direct but she's trying to hit staff. Given PRN dose of IM [MEDICATION NAME] given per eMAR (electronic medication administration record). She tries to kick staff while given the injection. After that she pours water on the laptop and still mad because she wants to go out. *On [DATE] at 8:19 p.m. [MEDICATION NAME] 2 mg IM given. Resident was trying to go out of the facility, and was very agitated. *On [DATE] at 9:49 p.m. Resident was trying to get out the facility again at 2000, (8:00 p.m.) and she want (wanted) to go out and smoke. She was confused, she stated that she want to talk to the doctor on what's going on. Explained to the resident that she's living here and needs to stay here for her safety. Give PRN dose of IM [MEDICATION NAME] given per eMAR. Resident is still agitated called her sister and they came to help calm her down. Resident sister help her to bed and finally goes to sleep. *On [DATE] at 9:09 p.m. [MEDICATION NAME] 2 mg IM given. *On [DATE] at 10:03 p.m. Resident with increased agitation, admin (administered) one IM shot of [MEDICATION NAME] and called family to come up to see res.(resident) Res. then called 911 and police officer showed up, explained situation to police without any issues. res is resting in bed at this time, family just left. will cont (continue) to monitor. *On [DATE] at 12:43 p.m. a note by the SS worker. Faxed _____ (MD) regarding resident behaviors. Family member is concerned about the behavior and said they have a Dr appt (appointment) schedule with _____(MD) on [DATE]. Discussed that we have request bed on 2nd fl (floor) ______(another facility) for her safety. Review of a [DATE] facsimile note sent to resident 10's primary physician by the SS worker included: *Resident begins behaviors around 2:30 - 3:30 (p.m.). *She is agitated not easily redirected, combative, verbally abusive. *Calls the police and pulls the fire alarm, dumped water on computer. *See notes and med (medication) list. *Please review and provide direction. Surveyor: Observation and interview on [DATE] at 10:00 a.m. with resident 10 revealed: *Everything had gone pretty good here until recently. She got mad a little while back and was upset, because her brother-in-law had died . So you know how that can stress you out? *She used to be able to go outside and have a cigarette. Now she needed a supervisor with her if she wanted to go out and have a cigarette. That was new. *She just wanted to go out and talk with people the way she used to. *She was stressed and could not get a supervisor to go out with her. She got angry. Talk about acting like a [AGE] year old. I was real angry. -So she went out and was in the parking lot, then when she had to come back in, she got so mad she pulled the fire alarm. *That was when they stuck me. They gave me a shot and told me it was to make me sleep. I don't take meds (medications) that I don't know what they are for. -They did that to me four or five times. It didn't make me sleep. It made me angry. -They should put a picture of a dog on my door that says Beware of Dog. That is how I feel. *She thought a couple of the nurses are bull dogs. They were the ones that gave her the shots. They said I was combative. I was not combative. *Now they wanted her to move to another facility because I am combative. *She relayed that one certified nursing assistant (CNA) who was holding her when they gave her the shot, the resident used her long fingernails to get the CNA and pointed to her neck were she had gotten the CNA. *A new resident had come in on [DATE], and that resident also smoked. When the staff saw her warning this new resident about not being able to smoke they moved resident 10 to a different table away from the new resident. Surveyor: Review of a [DATE] psychosocial history and assessment for resident 10 by the social services (SS) worker revealed: *A history of depression and anxiety. *An active smoker and required supervision to smoke for safety as she had failed the smoking assessment. Due to her history of falls she required supervision. *Was alert and oriented to person, place, time, and self. She was limited regarding safety awareness. *Was able to make herself known and was able to understand others well. *Was pretty upbeat and usually did not trigger for any mood indicators. *Would have rather lived on her own but understood she was not able to do that due to her medical limitations. Review of resident 10's physician's orders [REDACTED]. *A [DATE] 1:40 p.m. order to await a culture from her urinalysis results. *A [DATE] 1:00 a.m. order from the ER physician for Keflex 250 mg for her UTI. *A [DATE] untimed order for [MEDICATION NAME] one mg for one time and for a Wanderguard due to her elopement risk. *A [DATE] at 12:08 p.m. order for [MEDICATION NAME] 1 mg IM every six hours as needed for combativeness and anxiety related to UTI and anxiety. *A [DATE] at 9:15 p.m. order for [MEDICATION NAME] one to two mg IM every six hours as needed. *A [DATE] untimed order for a urinalysis and to make an appointment with her primary physician. Review of resident 10's [DATE] alterations in ADLs related to a recent hospitalization included an intervention that had been initiated on [DATE]. Those interventions included: *Resident will be safe when smoking and staff to assist with removing O2 (oxygen) prior to going outside to smoke. Resident will follow smoking policy and pass smoking assessment. She is to wear smoking apron. *Handwritten addendums (additions) on [DATE] were supervised smoking and cigarettes kept at nurses station/medication room. An immediate plan of care for the risk of elopement was initiated on [DATE]. That plan included: *Problems of resident stated I'm leaving and active exit seeking. *Interventions included: -Evaluate need for wandering management program. -Check resident every two hours and as needed. -Involve resident in activities of her liking. -Accutech bracelet (personal alarm). -Communicate with resident to determine reason for the behavior. -Involve the resident in decision making regarding daily choices. 2. Review of resident 14's [DATE] physician's orders [REDACTED].>*He was admitted on [DATE] and discharged on [DATE]. *His [DIAGNOSES REDACTED].>-A [MEDICAL CONDITION] (TBI). -Mild cognitive impairment. *The following [MEDICAL CONDITION] (medications effecting mood and behavior) had been ordered: -[MEDICATION NAME] (treatment for [REDACTED]. Start date [DATE]. There was no time limit on the use of that medication. -Resperidone (treatment for [REDACTED]. Start date [DATE]. -[MEDICATION NAME] (for [MEDICAL CONDITION]) tablet 25 mg per PEG tube every four hours as needed for severe agitation. -[MEDICATION NAME] (depression) HCL ([MEDICATION NAME]) tablet 25 mg every six hours as needed for ABS (agitated behavior scale) greater than 27. Start date [DATE]. -[MEDICATION NAME] HCL tablet 50 mg every 6 hours as needed for ABS greater than 27. Start date [DATE]. Review of resident 14's [DATE] physician's orders [REDACTED].>*His [DIAGNOSES REDACTED]. *The following [MEDICAL CONDITION] had been ordered: -[MEDICATION NAME] inject 2 milligram (mg) intramuscularly every eight hours for severe agitation. Start date [DATE]. -Resperidone - 0.25 mg by mouth three times a day related to mild cognitive impairment. Start date [DATE] -[MEDICATION NAME] tablet 25 mg by mouth every four hours as needed for severe agitation. -[MEDICATION NAME] HCL 25 mg every six hours as needed for ABS greater than 27. Start date [DATE]. -[MEDICATION NAME] HCL 50 mg every six hours as needed for ABS greater than 27. Start date [DATE]. Review of nurses progress notes and the Medication Administration Records for May and [DATE] revealed: *He received the [MEDICATION NAME] 2 mg IM [DATE] for severe agitation. *He received the [MEDICATION NAME] 25 mg on [DATE] for severe agitation. *The nurses had documented he had: -Attempted to leave the building. -Fallen. -Attempted to stand up and required assistance. -Become agitated. -A Wanderguard on. -A fall mat by his bed (to prevent injury if he fell ). Review of resident 14's [DATE] care plan revealed there were no resident specific interventions to reduce agitation other than medications. Review of resident 14's behavior log revealed: *From [DATE] through [DATE] he exhibited behaviors thirteen times. *Those behaviors included: -Rejecting care four times. -Wandering four times, -Verbal behavior twice. -Physical behavior twice. -Other behavior once. *On [DATE] he exhibited verbal behavior one time. *On [DATE] he wandered one time. Interview on [DATE] at 10:40 a.m. with the director of nurses regarding resident 14 revealed: *He was very confused and restless. *He was assigned a one-on-one staffing ratio to monitor him when he first came in, because he was constantly trying to leave the building and was a fall risk. *The ABS scale was a scale the TBI unit used that he came from. -They did not have a copy of that scale and had not used it. -The nurses should have addressed that when they got the order for using a medication based on an assessment (scale) they did not have. *She agreed the [DIAGNOSES REDACTED]. -Those were [DIAGNOSES REDACTED]. *She acknowledged the behavior documentation had not reflected the extent of his behaviors. *She confirmed the nurses should have addressed those [DIAGNOSES REDACTED]. Review of the provider's [DATE] antipsychotic medication review policy revealed: *The Procedure was to Ensure that the Medical Record of any Resident who receives antipsychotic medication contains documentation supporting the appropriateness and necessity for the use of the drug. *Antipsychotics are a class of psychiatric medication primarily used to manage [MEDICAL CONDITION] (including delusions, hallucinations, or disordered thought) particularly in [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, and is increasingly being used in the management of non-[MEDICAL CONDITION]. *The Assessment of [MEDICAL CONDITION] medications was a part of the policy. Review of the provider's [DATE] Behavior Management Guideline policy revealed: *The use of any medication to control behaviors should always have been considered a last resort to assist with managing a patient's/resident's behavior. *Antipsychotic drugs would not be used unless the clinical record documented the patient/resident has one or more of the following specific conditions as dictated and documented by the physician: *A. Conditions other than Dementia included a list of twelve [DIAGNOSES REDACTED]. -Mild cognitive impairment. -Severe agitation. *Criteria: All of the above highlight conditions/[DIAGNOSES REDACTED]. -The behavioral symptoms present a danger to the patient/resident or others AND one or both of the following: -The symptoms are identified as being due [MEDICAL CONDITION](hyperactive thinking) or [MEDICAL CONDITION] (such as auditory, visual or other hallucinations; delusions, paranoia, or grandiosity); OR -Behavioral interventions have been attempted and included in the plan of care, except in an emergency.

Based on record review, policy review, and interview, the provider failed to ensure an as needed (PRN) antipsychotic (mind-altering) medication ([MEDICATION NAME]) had not been used for staff convenience and to chemically restrain two of seven sampled residents (10 and 14) with a PRN antipsychotic medication. Findings include: 1. Review of resident 10's entire medical record revealed: *She had been admitted on [DATE]. *She had [DIAGNOSES REDACTED]. Review of resident 10's [DATE] admission clinical health status assessment revealed she: *Was alert and her short and long-term memory were good. *Was independent with decision making. *Was able to make her self understood and understood others. *Had no indicators of depression, anxiety (nervousness), sad mood, or adjustment of new conditions. *Had no behavioral symptoms. *Had a risk for elopement (leaving the facility without staff knowing) assessment that had indicated she was physically able to leave the building on her own and was a recent admission. -Those answers had triggered a prevention plan of care for elopement should have been considered. *Smoked and a separate provider assessment had been completed on [DATE] indicateing she was able to smoke independently. Review of resident 10's [DATE] re-admission clinical health status assessment revealed she: *Was alert and her short-term memory was good. *Had a problem with her long-term memory. *Required assistance with decision making. *Was able to make her self understood and understood others. *Had no indicators of depression, anxiety, sad mood, or adjustment of new conditions. *Had no behavioral symptoms. *Had a risk for elopement assessment that had indicated she was physically able to leave the building on her own and was a recent admission. -Those answers had triggered a prevention plan of care for elopement should have been considered. *Smoked and a separate provider assessment had been completed on [DATE] and was unclear on whether she was safe with smoking or not. Review of resident 10's interdisciplinary progress notes from [DATE] through [DATE] revealed: *On [DATE] at 6:45 a.m. Resident is alert with confusion and able to make all needs know to staff using call light. *On [DATE] at 6:55 p.m. Resident is alert and oriented with confusion at times. Always ask staff to go out and smoke. *On [DATE] at 9:16 a.m. Resident is alert and can be confused at times. She requires assistance to go out to smoke. She cannot pass the smoking assessment. *On [DATE] at 9:39 p.m. the following documentation revealed: -Situation: At about 1900, (7:00 p.m.) resident was reported to be in the middle of the facility parking lot and stating she was going to leave. Resident hit a parked car of another family member's and scratching it with her WC (wheelchair) and attempting to leave. -Background: History of UTI (urinary tract infection), altered mental status (not thinking clearly), dementia (decreased thought process). -Assessment: Resident refused any and all cares and vital signs (blood pressure, pulse, and breathing per minute) but is noted to be confused and combative towards staff. Resident trying to stand and get out of chair while WC is being pushed by staff and grabbing staff's hands. -Response: Resident was assisted by staff back onto the sidewalk and back into facility. Resident's sister called as requested. Once sister arrive, resident was assisted down to her room. At 1955 (7:55 p.m.) on call MD (medical doctor) was paged. At 2030 (8:30 p.m.) MD paged again. At 2120, (9:20 p.m.) call from ______(MDs name) received with orders noted. *On [DATE] at 2:54 a.m. St. (straight) cath (catheterization (tube to drain urine) of urinary bladder) done as ordered. Resident tolerated well. Results pending. *On [DATE] at 1:38 p.m. Received UA (urinalysis) (urine test results) and faxed to ______ (MDs name). *On [DATE] at 8:25 p.m. a note by the social services (SS) worker revealed: Earlier a mood assessment was completed with resident. She scored 5 for mild depression. She answered yes to thoughts that she would be better off dead and that she has had thoughts in the past of hurting herself but not at the time. As SS was leaving for home this evening found resident in the street trying to leave. Brought her back to facility and she refused to come in. She continued to try to leave and 4 times almost tipped chair over going down the sloping drive and off the curb. She made comments that hurting her self would be ok and being better off dead. These comments were made a few times. She is refusing to come into facility. She states that her behavior is ok and disagrees that being in the road is a safety risk. *On [DATE] at 9:00 p.m. the following documentation revealed: -Situation: At 1900, (7:00 p.m.) facility SS worker found resident in the street trying to leave facility. SS brought her back to facility and resident refused to come in. Resident continue to try and leave 4 times and almost tipped her w/c (wheelchair) over while going down the sloping driveway and off the curb. -Background: Hx (history) of altered mental status, UTI. -Assessment: Resident apparently disoriented and confused. Resident is not thinking clearly and cognitive (thinking; reasoning) status is severely altered. Resident refuses any care from any and all staff. -Response: Resident was brought back several times for safety purposes. One on one and at times two staff to 1 for safety and monitoring. PRN (as needed) medication administration attempted and refused. Call to her niece made. Niece arrived to assist in reassuring resident but resident continued to be agitated and attempt to elope. Call to MD at 2025 (8:25 p.m.) with order to send to _____ (name of hospital) for psych (psychiatric) eval (evaluation) via (by) ambulance. Ambulance on scene and here to transport resident at 2035 (8:35 p.m.). At 2040, (8:40 p.m.) report called to _____(name of registered nurse at hospital). Awaiting update at this time. *On [DATE] at 1:44 a.m. At 2330, (11:30 p.m.) call received from _______ (name of hospital) ER (emergency room ) that resident is being sent back to facility. Resident verbalized no intentions to harm self in ER and displayed no behaviors while in the ER. Resident returned at 0030, (12:30 a.m.) with new orders for antibiotics for present UTI as well as progress notes regarding medications administered while in the ER. Resident assisted to bed with no concerns noted at this time. Will continue to monitor. *On [DATE] at 6:43 p.m. Received orders for [MEDICATION NAME] (anti-anxiety medication) solution 2 mg (milligram) per ml (milliter) injection et (and) for a wanderguard (personal alarm device) R/T (related to) recent attempts to leave. *On [DATE] at 9:30 p.m. Medication administration of 1 mg of [MEDICATION NAME] (antipsychotic medication) intramuscularly (IM). Resident is exit seeking and combative to staff. *On [DATE] at 10: 43 p.m. the following documentation revealed: -Situation: Resident is repeatedly attempting to elope from facility. Has opened exit doors at least x (times) 3 starting at 1930 (7:30 p.m.) exiting x 2. Resident hitting at staff and grabbing door handles and side rails and attempting to stand when wheel chair is in motion. -Background: Present UTI-currently on antibiotics therapy. Eloping and combative behaviors noted previous two days. -Assessment: Resident is noted to be confused, combative, and danger to self at this time. -Response: Earlier this shift, order was received for IM [MEDICATION NAME]. Pharmacy called for medication. Medication unavailable at this time and not in our medication dispensing unit. Pharmacy continued with communications with MD for alternative medication. New order received. During this time, resident was supervised 1 on 1 (one staff person for one resident) at nurse's station by staff to prevent elopement. PRN oral medication administration attempted without success. IM injection of [MEDICATION NAME] given as ordered. Family was notified and came to facility to help facilitate ADLs (activities of daily living that includes dressing, toileting, eating and personal care) with success. Family appreciative towards staff. Will continue to monitor and assess. *On [DATE] at 4:58 p.m. [MEDICATION NAME] 2 mg IM given. Resident left building three times. On third time, resident became combative with staff, attempting to hit staff, swinging at CNA (certified nursing assistant), nurse, et management. Resident re-directed for brief time et (and) brought into the hallway, where she then pulled the fire-alarm. *On [DATE] at 5:19 p.m. Resident left building three times, stating that she was 'leaving this damn place'. Resident was stopped by nurse et CNA and explained to her why she needs to stay here for her safety. Resident re-directed back into building. A different resident left the building to leave with her son et this resident attempted to leave with the other resident. Nursing was able to re-direct resident, but she became combative, swinging to hit staff et kicking at nurse. Resident brought back into building et re-directed for a short time. Resident went down the hallway et pulled the fire-alarm, after being asked not to by nurse. Nurse assigned CNA to do one-on-one with resident; PRN dose of IM [MEDICATION NAME] given per MAR (medication administration record). *On [DATE] at 8:44 p.m. a late entry Resident was trying to get out of the facility, and telling everyone that she will pull the fire alarm. Resident was stopped by nurse et CNA and explained to her why she needs to stay here for her safety. Nursing was able to re-direct but she's trying to hit staff. Given PRN dose of IM [MEDICATION NAME] given per eMAR (electronic medication administration record). She tries to kick staff while given the injection. After that she pours water on the laptop and still mad because she wants to go out. *On [DATE] at 8:19 p.m. [MEDICATION NAME] 2 mg IM given. Resident was trying to go out of the facility, and was very agitated. *On [DATE] at 9:49 p.m. Resident was trying to get out the facility again at 2000, (8:00 p.m.) and she want (wanted) to go out and smoke. She was confused, she stated that she want to talk to the doctor on what's going on. Explained to the resident that she's living here and needs to stay here for her safety. Give PRN dose of IM [MEDICATION NAME] given per eMAR. Resident is still agitated called her sister and they came to help calm her down. Resident sister help her to bed and finally goes to sleep. *On [DATE] at 9:09 p.m. [MEDICATION NAME] 2 mg IM given. *On [DATE] at 10:03 p.m. Resident with increased agitation, admin (administered) one IM shot of [MEDICATION NAME] and called family to come up to see res.(resident) Res. then called 911 and police officer showed up, explained situation to police without any issues. res is resting in bed at this time, family just left. will cont (continue) to monitor. *On [DATE] at 12:43 p.m. a note by the SS worker. Faxed _____ (MD) regarding resident behaviors. Family member is concerned about the behavior and said they have a Dr appt (appointment) schedule with _____(MD) on [DATE]. Discussed that we have request bed on 2nd fl (floor) ______(another facility) for her safety. Review of a [DATE] facsimile note sent to resident 10's primary physician by the SS worker included: *Resident begins behaviors around 2:30 - 3:30 (p.m.). *She is agitated not easily redirected, combative, verbally abusive. *Calls the police and pulls the fire alarm, dumped water on computer. *See notes and med (medication) list. *Please review and provide direction. Surveyor: Observation and interview on [DATE] at 10:00 a.m. with resident 10 revealed: *Everything had gone pretty good here until recently. She got mad a little while back and was upset, because her brother-in-law had died . So you know how that can stress you out? *She used to be able to go outside and have a cigarette. Now she needed a supervisor with her if she wanted to go out and have a cigarette. That was new. *She just wanted to go out and talk with people the way she used to. *She was stressed and could not get a supervisor to go out with her. She got angry. Talk about acting like a [AGE] year old. I was real angry. -So she went out and was in the parking lot, then when she had to come back in, she got so mad she pulled the fire alarm. *That was when they stuck me. They gave me a shot and told me it was to make me sleep. I don't take meds (medications) that I don't know what they are for. -They did that to me four or five times. It didn't make me sleep. It made me angry. -They should put a picture of a dog on my door that said Beware of Dog. That is how I feel. *She thought a couple of the nurses are bull dogs. They were the ones that gave her the shots. They said I was combative. I was not combative. *Now they wanted her to move to another facility because I am combative. *She relayed that one certified nursing assistant (CNA) who was holding her when they gave her the shot, the resident used her long fingernails to get the CNA and pointed to her neck were she had gotten the CNA. *A new resident had come in on [DATE], and that resident also smoked. When the staff saw her warning this new resident about not being able to smoke they moved resident 10 to a different table away from the new resident. Surveyor: Review of a [DATE] psychosocial history and assessment for resident 10 by the social services (SS) worker revealed: *A history of depression and anxiety. *An active smoker and required supervision to smoke for safety as she had failed the smoking assessment. Due to her history of falls she required supervision. *Was alert and oriented to person, place, time, and self. She was limited regarding safety awareness. *Was able to make herself known and was able to understand others well. *Was pretty upbeat and usually did not trigger for any mood indicators. *Would have rather lived on her own but understood she was not able to do that due to her medical limitations. Review of resident 10's physician's orders [REDACTED]. *A [DATE] 1:40 p.m. order to await a culture from her urinalysis results. *A [DATE] 1:00 a.m. order from the ER physician for Keflex 250 mg for her UTI. *A [DATE] untimed order for [MEDICATION NAME] one mg for one time and for a Wanderguard due to her elopement risk. *A [DATE] at 12:08 p.m. order for [MEDICATION NAME] 1 mg IM every six hours as needed for combativeness and anxiety related to UTI and anxiety. *A [DATE] at 9:15 p.m. order for [MEDICATION NAME] one to two mg IM every six hours as needed. *A [DATE] untimed order for a urinalysis and to make an appointment with her primary physician. Review of resident 10's [DATE] alterations in ADLs related to a recent hospitalization included an intervention that had been initiated on [DATE]. Those interventions included: *Resident will be safe when smoking and staff to assist with removing O2 (oxygen) prior to going outside to smoke. Resident will follow smoking policy and pass smoking assessment. She is to wear smoking apron. *Handwritten addendums (additions) on [DATE] were supervised smoking and cigarettes kept at nurses station/medication room. An immediate plan of care for the risk of elopement was initiated on [DATE]. That plan included: *Problems of resident stated I'm leaving and active exit seeking. *Interventions included: -Evaluate need for wandering management program. -Check resident every two hours and as needed. -Involve resident in activities of her liking. -Accutech bracelet (personal alarm). -Communicate with resident to determine reason for the behavior. -Involve the resident in decision making regarding daily choices. 2. Review of resident 14's [DATE] physician's orders [REDACTED].>*He was admitted on [DATE] and discharged on [DATE]. *His [DIAGNOSES REDACTED].>-A [MEDICAL CONDITION] (TBI). -Mild cognitive impairment. *The following [MEDICAL CONDITION] (medications effecting mood and behavior) had been ordered: -[MEDICATION NAME] (treatment for [REDACTED]. Start date [DATE]. There was no time limit on the use of that medication. -Resperidone (treatment for [REDACTED]. Start date [DATE]. -[MEDICATION NAME] (for [MEDICAL CONDITION]) tablet 25 mg per PEG tube every four hours as needed for severe agitation. -[MEDICATION NAME] (depression) HCL ([MEDICATION NAME]) tablet 25 mg every six hours as needed for ABS (agitated behavior scale) greater than 27. Start date [DATE]. -[MEDICATION NAME] HCL tablet 50 mg every 6 hours as needed for ABS greater than 27. Start date [DATE]. Review of resident 14's [DATE] physician's orders [REDACTED].>*His [DIAGNOSES REDACTED]. *The following [MEDICAL CONDITION] had been ordered: -[MEDICATION NAME] inject 2 milligram (mg) intramuscularly every eight hours for severe agitation. Start date [DATE]. -Resperidone - 0.25 mg by mouth three times a day related to mild cognitive impairment. Start date [DATE] -[MEDICATION NAME] tablet 25 mg by mouth every four hours as needed for severe agitation. -[MEDICATION NAME] HCL 25 mg every six hours as needed for ABS greater than 27. Start date [DATE]. -[MEDICATION NAME] HCL 50 mg every six hours as needed for ABS greater than 27. Start date [DATE]. Review of nurses progress notes and the Medication Administration Records for (MONTH) and (MONTH) (YEAR) revealed: *He received the [MEDICATION NAME] 2 mg IM [DATE] for severe agitation. *He received the [MEDICATION NAME] 25 mg on [DATE] for severe agitation. *The nurses had documented he had: -Attempted to leave the building. -Fallen. -Attempted to stand up and required assistance. -Become agitated. -A Wanderguard on. -A fall mat by his bed (to prevent injury if he fell ). Review of resident 14's [DATE] care plan revealed there were no resident specific interventions to reduce agitation other than medications. Review of resident 14's behavior log revealed: *From [DATE] through [DATE] he exhibited behaviors thirteen times. *Those behaviors included: -Rejecting care four times. -Wandering four times, -Verbal behavior twice. -Physical behavior twice. -Other behavior once. *On [DATE] he exhibited verbal behavior one time. *On [DATE] he wandered one time. Interview on [DATE] at 10:40 a.m. with the director of nurses regarding resident 14 revealed: *He was very confused and restless. *He was assigned a one-on-one staffing ratio to monitor him when he first came in, because he was constantly trying to leave the building and was a fall risk. *The ABS scale was a scale the TBI unit used that he came from. -They did not have a copy of that scale and had not used it. -The nurses should have addressed that when they got the order for using a medication based on an assessment (scale) they did not have. *She agreed the [DIAGNOSES REDACTED]. -Those were [DIAGNOSES REDACTED]. *She acknowledged the behavior documentation had not reflected the extent of his behaviors. *She confirmed the nurses should have addressed those [DIAGNOSES REDACTED]. Review of the provider's [DATE] antipsychotic medication review policy revealed: *The Procedure was to Ensure that the Medical Record of any Resident who receives antipsychotic medication contains documentation supporting the appropriateness and necessity for the use of the drug. *Antipsychotics are a class of psychiatric medication primarily used to manage [MEDICAL CONDITION] (including delusions, hallucinations, or disordered thought) particularly in [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, and is increasingly being used in the management of non-[MEDICAL CONDITION]. *The Assessment of [MEDICAL CONDITION] medications was a part of the policy. Review of the provider's [DATE] Behavior Management Guideline policy revealed: *The use of any medication to control behaviors should always have been considered a last resort to assist with managing a patient's/resident's behavior. *Antipsychotic drugs would not be used unless the clinical record documented the patient/resident has one or more of the following specific conditions as dictated and documented by the physician: *A. Conditions other than Dementia included a list of twelve [DIAGNOSES REDACTED]. -Mild cognitive impairment. -Severe agitation. *Criteria: All of the above highlight conditions/[DIAGNOSES REDACTED]. -The behavioral symptoms present a danger to the patient/resident or others AND one or both of the following: -The symptoms are identified as being due [MEDICAL CONDITION](hyperactive thinking) or [MEDICAL CONDITION] (such as auditory, visual or other hallucinations; delusions, paranoia, or grandiosity); OR -Behavioral interventions have been attempted and included in the plan of care, except in an emergency.

Based on record review, interview, and policy review, the provider failed to ensure two of three residents (1 and 8) with pressure ulcers (injury to skin usually from pressure and frequently over a boney area) had received effective preventative care to ensure pressure ulcers had not occurred and/or worsened while a resident in the facility. Findings include: 1. Review of resident 8's June 2015 treatment administration record (TAR) revealed: *A right ischial (area on the bottom where all the weight is when sitting) wound that was to have been cleansed, ointment applied, and a dressing applied every day and evening. *It had not been described as a pressure ulcer. *Prevalon (special padded boots) boots were to have been on when the resident was in bed every shift. *It had not stated why the boots were to have been worn. Review of resident 8's nursing progress notes from 12/22/15 through 6/30/15 revealed: *On 12/1/14 in the weekly wound documentation the resident had: -A wound on his right ischial that measured 1.0 centimeters (cm) by 1.0 cm by less than 0.1 cm. -No drainage, odor, pain, or signs of infection were noted. -The tissue was described as [MEDICATION NAME] tissue (tissue that covers an area) . -The wound bed had been dry and pink. -A deep tissue injury identified to his right outer heel. -An area on his left heel was measured and described as the appearance of a donut with a dry pink to white center and 50% of dark smooth coloration to the skin tissue. -Both heels had no drainage, odor, pain, or signs of infection noted. *On 12/22/15 the wound care nurse documented the right ischial wound was healed. *On 1/2/15 in the Minimum Data Set (MDS) assessment for 12/31/14 revealed the resident had deep tissue injuries to both of his heels. -It had not adressed how it had occurred. -It had not addressed any concerns with his ischial area. -Interventions listed were a redistribution mattress for the resident's bed and a cushion in his wheelchair. -Heel protectors were to be used while he had been in bed. *On 1/5/15 the wound care nurse documented there were no concerns with the resident's right heel. -The left heel deep tissue injury had been intact (no open area) and dark in color. *On 1/19/15 the wound care nurse documented the left heel deep tissue injury was clear from signs of breakdown or irritation. -The resident was to have worn Prevalon heel boots when in bed. *On 1/26/15 the wound care nurse documented the resident had a stage 2 (partial loss of the top skin layers without slough (dead, off-colored skin) or a serum filled blister) on residents right ischial. -(This would be a re-occurrence of the one healed on 12/22/15, the previous month) -It had measured 3.0 (no unit of measurement noted) by 1.6 by less than 0.1 cm. -The wound was red and moist. -A dressing was applied to the area. -The resident was positioned on his right side between meals. -He had a cushion (not specified what kind) in his wheelchair. *On 2/16/15 the wound care nurse documented the resident continued to have a stage two on resident right ischial. -It had measured 1.0 cm by 0.5 cm by less than 0.1 cm. -He had a cushion (not specified what kind) in his wheelchair. -Wore Prevalon boots when in bed. *On 3/16/15 the wound care nurse documented the stage two on his right ischial had measured 0.4 cm by 0.7 cm by 0.1 cm. -The wound bed had been red and moist. *On 3/23/15 the wound care nurse had documented the stage 2 on his right ischial had measured 1.7 by 0.8 by less than 0.1 cm. (This was larger than on 2/16/15.) *On 4/13/15 the wound care nurse documented the resident had an unstageable (unable to determine how deep the open area was) area on his right ischial area. -It had measured 0.5 cm by 0.4 cm by 0.1 cm. -It had been 90 percent dark smooth tissue. *On 4/20/15 the wound care nurse had documented the resident's area on his right ischial had gotten larger. -It had measured 1.4 cm by 1.2 cm by 0.1 cm. -Ten percent of the wound had been slough. -The previous red area had broken down and had added to the size of the wound. *On 4/27/15 the area on his right ischial had improved from last week. -It then measured 0.8 cm by 0.5 cm by less than 0.1 cm. *On 6/2/15 the wound care nurse documented the ischial area was a stage 2 and measured 0.6 cm by 0.5 cm by 0.1 cm. -The wound bed had been 40 percent yellow slough. *On 6/16/15 the weekly wound assessment measurements for the right ischial had been 0.3 cm by 0.5 cm by 0.1 cm. -The wound bed was 100 percent slough. *On 6/23/15 the wound care nurse documented the resident had a stage 2 on his ischial area. -It had measured 0.7 by 0.5 by 0.1 cm (an increase from the week before). -The wound bed had been 80 percent yellow slough. *On 6/25/15 the MDS assessment for the 6/23/15 time period revealed a stage 2 pressure ulcer on his right ischium. *On 6/30/15 the wound care nurse documented the resident had a stage 2 pressure ulcer to his right ischium. -It had measured 1.1 cm by 0.7 cm by 0.1 cm. (an increase from the week before). -It had 40 percent white to light yellow slough present. -He was to have a pressure relieving cushion in his wheelchair. *He was to have worn Prevalon boots at all times. Review of the resident's care plan that was in use from 7/2/14 until 6/30/15 revealed: *He had a focus of At risk for skin breakdown related to mobility deficit (difficulty moving) and incontinence (loss of bladder and/or bowel control). *Resident has stage 2 to right ischial bone. *The goals had been: -Resident will have no further skin breakdown. -Stage 2 will heal. *Some of the interventions had been: -Pressure redistribution w/c (wheelchair) cushion and pressure redistribution mattress. *A focus area of deep tissue injury noted to each heel. *The goals had been to heal those. *On 11/26/14 the interventions had been Prevalon boots and a foam foot board over the wheelchair pedals for protection. -It had not stated when the boots were to be on. *On 12/1/14 it was added the Prevalon boots were to be on while in bed. Review of the resident's care plan that was instituted on 6/30/15 revealed: *He still had as a focus of a stage 2 to his right ischial bone. *He was to have no further skin breakdown for a goal through 9/23/15. -Stage 2 will heal. *Interventions had included a pressure redistribution w/c cushion and mattress. *The Prevalon boots were no longer on the care plan for prevention of breakdown to the resident's heels. *The foam board was no longer included to be used on the w/c pedals. Interview on 6/30/15 at 4:35 p.m. with the MDS nurse confirmed she had missed putting the Prevalon boots on the new care plan. Observation on 6/30/15 from 12:45 p.m. through 2:30 p.m. revealed: *Resident 8 was transferred to his bed from his wheelchair at 12:45 p.m. by certified nursing assistant (CNA) G. *His Prevalon boots were not put on his feet to protect his heels. *At 2:30 p.m. CNA H had assisted with a dressing change with registered nurse (RN) M for resident 8. *He was in bed at that time. *He still did not have his Prevalon boots on his feet for heel protection. *RN M and CNA H had not placed them on his feet before they had left his room. *His heels had been unprotected for one hour and forty-five minutes. Interview on 6/30/15 at 4:25 p.m. with CNA H confirmed he had forgotten to put the Prevalon boots on resident 8 before he had left the room. He agreed they should have been on the resident for protection. Observation and interview with the physical therapist aide (PTA) J on 6/30/15 at 4:25 p.m. revealed: *Resident 8's wheelchair had a cushion in the seat. *Upon inspection by PTA J she confirmed it had not been a pressure relieving cushion. *It had not been the correct cushion for resident 8 and would not help prevent breakdown or healing of a pressure ulcer. *She had not known what had happened to the cushion that was to have been in his wheelchair or when it had been removed. *She stated it could have happened when his wheelchair had been washed but she had not known for sure. Observation and interview on 7/1/15 at 8:03 a.m. with the director of nursing (DON) confirmed the cushion on resident 8's w/c pedals was not thick enough to be effective in preventing pressure to the resident's heels. The w/c pedals were sharp and easily felt through the pad. Interview on 7/1/15 with the DON confirmed staff used the 2007 Pressure Ulcer Staging Guide to stage a pressure ulcer. She further stated training was provided yearly to the nursing staff for documentation of pressure ulcers/skin concerns by the centralized training nurse for all of the Golden Living Centers in Rapid City. Review of that material revealed it had not addressed how to stage a pressure ulcer. It had contained a wound evaluation flow sheet, a risk identification/prevention sheet, and the revised 2013 Skin Integrity Guidelines. A sign in sheet to identify who had attended the training and what date it had been held was requested from the DON and the administrator on 7/1/15 and again on 7/2/15 at 8:03 a.m. It had not been received by the survey exit on 7/2/15 at 2:05 p.m. Thus it was unknown who had attended that training. Review of the provider's 2007 Pressure Ulcer Staging Guide for an unstageable pressure ulcer revealed: *It was a full thickness tissue loss. *The base of the ulcer was covered by yellow, tan, grey, green, or brown slough. *Until enough eschar (dark, dead tissue) was removed to expose the base of the wound the true depth could not be determined. *If the depth could not be determined it can not be staged. Review of the provider's revised 2013 Skin Integrity Guidelines revealed: *The interdisciplinary plan of care would address problems, goals, and interventions to prevent pressure ulcers. *Pressure reducing cushions would be used in wheelchairs of residents who used it as a primary mode of transportation. *Weekly skin evaluation and observations were to determine if care plans were consistently implemented, evaluated, and revised to meet the resident's needs. Review of the provider's RN assesment coordinator job description revealed the essential job duties for that position had been accurate and thorough completion of the MDS, Care Area Assessments, and the Care Plans. 2. Review of resident 1's medical record revealed: *She had been admitted on [DATE] from the hospital. *She had a stage three (subcutaneious fat may be visible, slough may be present) pressure ulcer to her coccyx (tailbone). *That pressure ulcer had closed on 5/19/14. *On 12/28/14 a stage two (partial thickness loss of tissue, a shallow open wound with a red pink wound bed) pressure ulcer had been noted. *That stage 2 pressure ulcer measured 4.0 centimeters (cm) in length, 2.0 cm in width, and less than 0.1 cm in depth to the top of her sacrum (upper tailbone). No drainage had been noted. *Her Braden pressure ulcer development risk assessments on: -12/10/14 was 12 that indicated high risk for developing a pressure ulcer. -1/22/15 and 2/25/15 was 11 that indicated high risk. -5/26/15 was 9 that indicated severe risk. Continued review of the documentation of the sacrum pressure ulcer revealed measurements and condition of the pressure ulcer included: *1/5/15, Stage two 2.9 cm length, 0.4 cm width, and less than 0.1 cm in depth with no drainage. [MEDICATION NAME] border dressing (type of absorbent soft silicone dressing). *1/12/15, Stage two 0.5 cm length, 0.1 cm width, and less than 0.1 cm in depth with no drainage. [MEDICATION NAME] border dressing. *No measurements noted for the week of 1/19/15. *1/26/15, Stage two 1.2 cm length, 0.5 cm width, and less than 0.1 cm in depth with no drainage. [MEDICATION NAME] border dressing. *2/2/15, Unstageable (slough (yellow, tan, gray, green, or brown tissue) that covers the base of the ulcer) 1.3 cm length, 1.0 cm width, and less than 0.1 cm in depth with no drainage but 100 percent (%) slough described as black moist. [MEDICATION NAME] border dressing. *No measurements noted for the week of 2/9/15. *2/16/15, Stage two 3.5 cm length, 3.0 cm width, 1.3 cm depth and tunneling (open area underneath edges of wound) noted. Brown, thin, large amount of drainage. 100% odorous black, green, and gray slough. Complaints of pain. [MEDICATION NAME] border dressing with Santyl (removes dead tissue) ointment. Physical therapy doing E-Stim (electrical stimulation of tissue for healing) and debridement (removing dead tissue). *2/23/15, No stage noted. 3.5 cm length, 3.0 cm width and no depth on form. Brown, thin, large amount of drainage. Slough present with no description or amount. Turning schedule initiated and to be kept up minimal amount of time for meals. *3/3/15, Staging and measurements with new treatment orders by outpatient wound care (OPWC). Was being seen by OPWC. Unstageable sacral ulceration. 3.0 cm length, 0.7 cm width, and 2.0 cm depth. Undermining (open area under edges of wound) present. *3/12/15, Unstageable sacral ulceration. 3.0 cm length, 0.8 cm width, and 2.0 cm depth. Undermining present. Was seen by OPWC. *3/19/15, Unstageable sacral ulceration. 3.0 cm length, 2.7 cm width, and 1.7 cm depth. Undermining present. Negative pressure wound treatment initiated. Was seen by OPWC. *3/25/15, Did not go to outpatient wound care. *4/2/15 Unstageable sacral ulceration. 2.5 cm length, 0.1 cm width, and 2.9 cm depth. No undermining present. Negative pressure wound treatment continued. Was seen by OPWC. *4/15/15, Unstageable sacral ulceration. 2.0 cm length, 2.0 cm width, and 1.9 cm depth. No undermining present. Negative pressure wound treatment continued. Was seen by OPWC. *4/20/15, Stage four sacral pressure ulcer. 2.2 cm length, 1.4 cm width, and 1.7 cm depth. Undermining present. Measured by provider wound care nurse. *4/26/15, Stage four sacral pressure ulcer. 2.3 cm length, 1.8 cm width, and 1.5 cm depth. Undermining present. Measured by provider wound care nurse. *5/4/15 Stage four sacral pressure ulcer. 2.0 cm length, 1.6 cm width, and 2.2 cm depth. Undermining present. Measured by provider wound care nurse. *5/11/15, Stage four sacral pressure ulcer. 1.9 cm length, 1.4 cm width, and 1.1 cm depth. Undermining present. Measured by provider wound care nurse. *5/20/15, Unstageable sacral ulceration. 1.9 cm length, 1.3 cm width, and 2.0 cm depth. Undermining present. Negative pressure wound treatment continues. Was seen by OPWC. *6/4/15, Unstageable sacral ulceration. 1.5 cm length, 1.5 cm width, and 2.0 cm depth. Undermining present. Negative pressure wound treatment discontinued due to insufficient decrease in measurement and development of a blister to the edge of the wound. Was seen by OPWC. *6/11/15, Unstageable sacral ulceration. 1.3 cm length, 1.3 cm width, and 2.3 cm depth. Undermining present. Was seen by OPWC. *6/16/15, Stage four sacral pressure ulcer. 1.0 cm length, 0.6 cm width, and 1.7 cm depth. Undermining present. Measured by provider wound care nurse. *6/23/15, Stage four sacral pressure ulcer. 1.2 cm length, 0.8 cm width, and 0.8 cm depth. Undermining present. Measured by provider wound care nurse. Review of resident 1's interdisciplinary progress notes revealed on: *12/12/14 Her skin was intact (no open areas). *2/15/15 Resident stage II (two) pressure sore of her sacrum is getting worse and it has a really bad smell. Fax _____ (physician name) if we can order a wound culture. *2/16/15 Resident does C/O (complain of) pain at site, mostly at edges. Staff educated on proper turning techniques and to keep resident off her bottom as much as possible. Observation of the dressing change for resident 1 on 6/30/15 at 10:20 a.m. with licensed practical nurse/wound care nurse P revealed measurements of 1.2 cm in length from top to bottom, 0.6 cm in width from left to right, 1.1 cm in depth, and undermining present that at the deepest measured 2.2 cm. Refer to F281, finding 2. Review of the weekly head-to-toe skin checks from 7/1/14 through 1/31/15 revealed: *Two weeks had no documentation a skin check had been completed in July 2014. *Two weeks had no documentation a skin check had been completed in September 2014. *The entire month of October 2014 had no documentation a skin check had been completed. *One week had no documentation a skin check had been completed in November 2014. *One week had no documentation a skin check had been completed in December 2014. Interview on 7/2/15 at 7:45 a.m. with the director of nursing (DON) revealed she: *Was aware resident 1 had developed a pressure ulcer, had acquired an infection of that pressure ulcer, and was on continuous bedrest to assist with healing the pressure ulcer. *Thought the admitted pressure ulcer from 4/16/14 had not totally healed, and there had been undermining that eventually surfaced. *Had not realized the OPWC orders had not been followed. *Had initiated documentation of the turning and repositioning schedule for resident 1 on 6/24/15. *Had initiated that turning schedule, so resident 1 was positioned on her right when she ate her meals. 3. Review of the provider's undated Skin Integrity Guideline policy included: *To promote healing of wounds of any type whether there when admitted or acquired after admission. *A routine schedule was to be developed to review residents with wounds or at risk for developing wounds on a weekly basis and document those findings. *The DON or designee would be responsible to implement and monitor the skin integrity program. *The interdisciplinary plan of care would address problems, goals, and interventions directed toward the prevention of pressure ulcers and/or identified skin integrity concerns. *If there was a decline in skin integrity pressure redistribution surfaces would be reviewed for appropriateness. *Reposition every two hours or as needed and tolerated. Indicate frequency in the plan of care. *Treatment protocols included: -For stage two pressure ulcers use of dressings included: non-adherent composite dressings and foam dressings. -For stage three pressure ulcers use of dressings included: those indicated for stage two pressure ulcers and negative pressure wound therapy. -For stage four pressure ulcers use of dressing included: both those indicated for stage two and three pressure ulcers. Review of the provider's 2007 Pressure Ulcer Staging Guide revealed: *An unstageable pressure ulcer was a full thickness tissue loss. *The base of the ulcer was covered by yellow, tan, gray, green, or brown slough. *Until enough eschar was removed to expose the base of the wound the true depth could not be determined. *If the depth could not be determined it could not be staged. Review of the provider's 2008 Wound Bed Interventions Guideline to decrease the incidence of infection interventions included: *Effective wound cleansing to remove debris. *Topical antiseptics such as Dakin's solution. *Oral antibiotics used only if the infection extends beyond the ulcer margin.

Based on observation, record review, interview, and professional standard review, the provider failed to ensure one of one sampled residents ( 2) at nutritional risk received care to ensure no further weight loss or nutritional concerns. Findings include: 1. Review of resident 2's entire medical record revealed he had several [DIAGNOSES REDACTED]. *He was an insulin dependent diabetic. *Had a [DIAGNOSES REDACTED].>-Depression (mood was feeling down). -[MEDICAL CONDITION]. -High blood pressure. -High cholesterol. Review of resident 2's weight record revealed: *On 3/5/15 he weighed 157.5 pounds (lb). *One month later on 4/2/15 he weighed 140.5 lb. -This was a 17 lb (or 10.7%) weight loss in one month. *His weight on 6/3/15 was 145.5 lb. Review of resident 2's progress notes revealed his physician was not notified of the above 17 lb weight loss. Review of resident 2's June 2015 blood sugar (BS) record revealed: *His BS was below 100 three times. *His BS was between 101-199 thirty-one times. *His BS was between 200-299 forty-one times. *His BS was between 300-399 thirty-four times. *His BS was over 400 six times. Random observation of resident 2 from 6/29/15 in the afternoon through 7/2/15 revealed: *He came out to the dining room very early every morning. *He liked hot chocolate and peanut butter. *After meals he returned to his room and laid down on his bed. *Staff had to encourage him to come out to the dining room for breakfast. *He had a big container of cheese balls in his room. Interview on 6/1/15 at 11:50 a.m. with his daughter revealed he: *He liked Mexican food as that was part of his culture and ethnic background -She tried to bring him Mexican food whenever she could. -She was unaware he had lost any weight. *He had recently been to the dentist and needed to have a lot of dental work done. Interview on 6/30/15 at 11:20 a.m. with the dietary services manager (DSM) revealed: *He had a significant weight loss. *They had reviewed him at their monthly weight meeting for a month at the time he lost the weight. -His weight had stabilized now. *They encouraged his family to bring Mexican food for him because he liked that kind of food. *He came out to the dining room very early in the morning and always ate two packets of peanut butter and a cup of hot chocolate. -He then returned to his room. -It was sometimes difficult to get him to come back out to the dining room. *When he selected his own meals, he circled everything on the menu. -When the food came he had four or five glasses of juice and milk, plus all the food. -He would not eat very much of any of it. -Their plan was to assist him in ordering a more reasonable meal, so he might eat more. *They had also started him on a daily nutritional drink supplement. *She was unaware of any dental concerns. Review of resident 2's 4/14/15 nutrition assessment revealed : *___(name of resident) with weight loss over that past 2 months. Stating he just doesn't feel like eating. PO (per oral/eating) approximately 25% daily. RSD (resident) has been taking snacks. discussed the importance of eating more at meals. RSD is open to fortified foods. stating no new issues with chew or swallow. DM (diabetic mellitus) with glucometers in fair control (150-250's) . *Interventions: -ConCHO diet order (diet for diabetics). -Offering/encouraging TID (three times per day) snacks. Begin to fortify (boost nutritional value of food served) all meals. Review of the nutrition care team meeting minutes revealed his weekly meal intake from 4/20/15 through 5/12 15 was 40% or less. Telephone interview on 6/30/15 at 4:00 p.m. with the registered dietitian on 6/30/15 revealed he confirmed the above interview with the DSM. Interview on 6/30/15 at 4:15 p.m. with the social services designee regarding resident 2 revealed: *He denied he was depressed when she had assessed him. *She had not seen any indicators of depression with him. -He slept a lot and was a loner. -When she had spoke earlier in the day with his daughter about his weight loss, the daughter said a family member had commented to him about gaining weight. He had always been very concerned about his weight - so he probably quit eating when that comment was made. Interview on 7/2/15 at 8:15 a.m. with the Minimum Data Set (MDS) assessment coordinator regarding resident 2 revealed: *He had not indicated he had any dental concerns when she did the Dental portion of the MDS. *He would not always talk to her when she went to do the assessment - if he will not talk to you there is nothing more that I could do. *They had not received any information back from the dentist regarding his dental concerns. -They had two referral forms from the dentist from his last visits but there was no information on them. Review of resident 2's 5/18/15 care plan revealed activity interventions included invite to food related activities. Review of his activity participation records revealed he had not been invited to any food related activities. Review of resident 2's 5/18/15 care plan revealed: *It had not addressed: -His significant weight loss. -His daily average meal intake was currently between 35-40%. -How they ensured a staff person sat with him to select his meals. -The nutritional supplement. -How the provider accommodated his preference for Mexican food if the family was unable to do so. -His high BS. -How they addressed the high BS nutritionally. -How they fortified his food. -Any dental issues.

Based on observation, record review, interview, and professional standard review, the provider failed to ensure one of one sampled resident (2) at nutritional risk received the necessary care to ensure no further weight loss or nutritional concerns occurred. Findings include: 1. Review of resident 2's entire medical record revealed he had several [DIAGNOSES REDACTED]. *He was an insulin dependent diabetic (loss of blood sugar (BS) control). *Had [DIAGNOSES REDACTED].>-Depression (mood was feeling down). -[MEDICAL CONDITION] (poor heart function). -High blood pressure. -High cholesterol. Review of resident 2's weight record revealed: *On 3/5/15 he weighed 157.5 pounds (lb). *On 4/2/15 he weighed 140.5 lb. -That was a 17 lb or 10.7% weight loss in one month. *His weight on 6/3/15 was 145.5 lb. Review of resident 2's progress notes revealed his physician was not notified of the above 17 lb weight loss. Review of resident 2's (MONTH) (YEAR) BS record revealed: *His BS was below 100 three times. *His BS was between 101-199 thirty-one times. *His BS was between 200-299 forty-one times. *His BS was between 300-399 thirty-four times. *His BS was over 400 six times. *The normal range for BS was 70 - 100. Random observation of resident 2 from 6/29/15 in the afternoon through 7/2/15 revealed: *He came out to the dining room very early every morning. *He liked hot chocolate and peanut butter. *After meals he returned to his room and laid down on his bed. *Staff had to encourage him to come out to the dining room for breakfast. *He had a big container of cheese balls in his room. Interview on 6/1/15 at 11:50 a.m. with resident 2's daughter revealed: *He liked his ethnic food as that was part of his culture and background. -She tried to bring that food to him whenever she could. *He had recently been to the dentist and needed to have a lot of dental work done. *She was unaware he had lost any weight. Interview on 6/30/15 at 11:20 a.m. with the dietary services manager (DSM) revealed: *He had a significant weight loss. *They had reviewed him at their monthly weight meeting for a month. -His weight had stabilized now. *They encouraged his family to bring ethnic food for him because he liked that kind of food. *He came out to the dining room very early in the morning and always ate two packets of peanut butter and a cup of hot chocolate. -He then returned to his room. -It was sometimes difficult to get him to come back out. *When he selected his own meals he circled everything on the menu. -When the food came he had four or five glasses of juice and milk plus all the food. -He would not eat very much of any of it. -Their plan was to assist him in ordering a more reasonable meal, so he might eat more. *They had also started him on a daily nutritional supplement drink. Review of resident 2's 4/14/15 nutrition assessment by the registered dietitian (RD) revealed: *___(name of resident) with weight loss over that past 2 months. Stating he just doesn't feel like eating. PO (per oral/eating) approximately 25% daily. RSD (resident) has been taking snacks. discussed the importance of eating more at meals. RSD is open to fortified foods. stating no new issues with chew or swallow. DM (diabetic mellitus) with glucometers (BS tests) in fair control (150-250's) . *Interventions: -ConCHO (concentrated carbohydrate) diet order (diet for diabetics). -Offering/encouraging TID (three times per day) snacks. Begin to fortify (boost nutritional value of food served) all meals. Review of the nutrition care team meeting minutes revealed his weekly meal intake from 4/20/15 through 5/12/15 was 40% or less. Telephone interview on 6/30/15 at 4:30 p.m. with the RD on 6/30/15 revealed he confirmed the above interview with the DSM. Interview on 6/30/15 at 4:15 p.m. with the social services designee regarding resident 2 revealed: *He denied he was depressed when she had assessed him. *She had not seen any indicators of depression with him. -He slept a lot and was a loner. -When she had spoken earlier in the day with his daughter about his weight loss the daughter said a family member had commented to him about gaining weight. He had always been very concerned about his weight, so he probably quit eating when that comment was made. Interview on 7/2/15 at 8:15 a.m. with the Minimum Data Set (MDS) assessment coordinator regarding resident 2 revealed: *He had not indicated he had any dental concerns when she did the dental portion of the MDS. *He would not always talk to her when she went to do the assessment, if he would not talk to you there was nothing more that she could do. *They had not received any information back from the dentist regarding his dental concerns. -They had two referral forms from the dentist from his last visits, but there was no information on them. Review of resident 2's 5/18/15 care plan revealed activity interventions included invite to food related activities. Review of resident 2's (MONTH) (YEAR) activity participation records revealed he had not been invited to any food related activities. Review of resident 2's 5/18/15 care plan revealed: *It had not addressed: -His significant weight loss. -His daily average meal intake was currently between 35-40%. -How they ensured a staff person sat with him to select his meals. -The nutritional supplement. -How the provider accommodated his preference for ethnic food if the family was unable to do so. -His high BS readings. -How they addressed the high BS nutritionally. -How they fortified his food. -Any dental issues.

Based on interview, record review, and policy review, the provider failed to have an appropriate [DIAGNOSES REDACTED]. Findings include: Surveyor: 1. Observation and interview on [DATE] at 10:00 a.m. with resident 10 revealed: *Everything had gone pretty good here until recently. She got mad a little while back and was upset, because her brother-in-law had died . So you know how that can stress you out? *She used to be able to go outside and have a cigarette. Now she needed a supervisor with her if she wanted to go out and have a cigarette. That was new. *She just wanted to go out and talk with people the way she used to. *She was stressed and could not get a supervisor to go out with her. She got angry. Talk about acting like a [AGE] year old. I was real angry. -So she went out and was in the parking lot, then when she had to come back in, she got so mad she pulled the fire alarm. *That was when they stuck me. They gave me a shot and told me it was to make me sleep. I don't take meds (medications) that I don't know what they are for. -They did that to me four or five times. It didn't make me sleep. It made me angry. -They should put a picture of a dog on my door that says Beware of Dog. That is how I feel. *She thought a couple of the nurses are bull dogs. They were the ones that gave her the shots. They said I was combative. I was not combative. *Now they wanted her to move to another facility because I am combative. *She relayed that one certified nursing assistant (CNA) who was holding her when they gave her the shot, the resident used her long fingernails to get the CNA and pointed to her neck were she had gotten the CNA. *A new resident had come in on [DATE], and that resident also smoked. When the staff saw her warning this new resident about not being able to smoke they moved resident 10 to a different table away from the new resident. Surveyor: Review of resident 10's interdisciplinary progress notes from [DATE] through [DATE] revealed: *On [DATE] at 6:45 a.m. Resident is alert with confusion and able to make all needs know to staff using call light. *On [DATE] at 6:55 p.m. Resident is alert and oriented with confusion at times. Always ask staff to go out and smoke. *On [DATE] at 9:16 a.m. Resident is alert and can be confused at times. She requires assistance to go out to smoke. She cannot pass the smoking assessment. *On [DATE] at 9:39 p.m. the following documentation revealed: -Situation: At about 1900, (7:00 p.m.) resident was reported to be in the middle of the facility parking lot and stating she was going to leave. Resident hit a parked car of another family member's and scratching it with her WC (wheelchair) and attempting to leave. -Background: History of UTI (urinary tract infection), altered mental status (not thinking clearly), dementia (decreased thought process). -Assessment: Resident refused any and all cares and vital signs (blood pressure, pulse, and breathing per minute) but is noted to be confused and combative towards staff. Resident trying to stand and get out of chair while WC is being pushed by staff and grabbing staff's hands. -Response: Resident was assisted by staff back onto the sidewalk and back into facility. Resident's sister called as requested. Once sister arrive, resident was assisted down to her room. At 1955 (7:55 p.m.) on call MD (medical doctor) was paged. At 2030 (8:30 p.m.) MD paged again. At 2120, (9:20 p.m.) call from ______(MDs name) received with orders noted. *On [DATE] at 2:54 a.m. St. (straight) cath (catheterization (tube to drain urine) of urinary bladder) done as ordered. Resident tolerated well. Results pending. *On [DATE] at 1:38 p.m. Received UA (urinalysis) (urine test results) and faxed to ______ (MDs name). *On [DATE] at 8:25 p.m. a note by the social services (SS) worker revealed: Earlier a mood assessment was completed with resident. She scored 5 for mild depression. She answered yes to thoughts that she would be better off dead and that she has had thoughts in the past of hurting herself but not at the time. As SS was leaving for home this evening found resident in the street trying to leave. Brought her back to facility and she refused to come in. She continued to try to leave and 4 times almost tipped chair over going down the sloping drive and off the curb. She made comments that hurting her self would be ok and being better off dead. These comments were made a few times. She is refusing to come into facility. She states that her behavior is ok and disagrees that being in the road is a safety risk. *On [DATE] at 9:00 p.m. the following documentation revealed: -Situation: At 1900, (7:00 p.m.) facility SS worker found resident in the street trying to leave facility. SS brought her back to facility and resident refused to come in. Resident continue to try and leave 4 times and almost tipped her w/c (wheelchair) over while going down the sloping driveway and off the curb. -Background: Hx (history) of altered mental status, UTI. -Assessment: Resident apparently disoriented and confused. Resident is not thinking clearly and cognitive (thinking; reasoning) status is severely altered. Resident refuses any care from any and all staff. -Response: Resident was brought back several times for safety purposes. One on one and at times two staff to 1 for safety and monitoring. PRN (as needed) medication administration attempted and refused. Call to her niece made. Niece arrived to assist in reassuring resident but resident continued to be agitated and attempt to elope. Call to MD at 2025 (8:25 p.m.) with order to send to _____ (name of hospital) for psych (psychiatric) eval (evaluation) via (by) ambulance. Ambulance on scene and here to transport resident at 2035 (8:35 p.m.). At 2040, (8:40 p.m.) report called to _____(name of registered nurse at hospital). Awaiting update at this time. *On [DATE] at 1:44 a.m. At 2330, (11:30 p.m.) call received from _______ (name of hospital) ER (emergency room ) that resident is being sent back to facility. Resident verbalized no intentions to harm self in ER and displayed no behaviors while in the ER. Resident returned at 0030, (12:30 a.m.) with new orders for antibiotics for present UTI as well as progress notes regarding medications administered while in the ER. Resident assisted to bed with no concerns noted at this time. Will continue to monitor. *On [DATE] at 6:43 p.m. Received orders for [MEDICATION NAME] (anti-anxiety medication) solution 2 mg (milligram) per ml (milliter) injection et (and) for a wanderguard (personal alarm device) R/T (related to) recent attempts to leave. *On [DATE] at 9:30 p.m. Medication administration of 1 mg of [MEDICATION NAME] (antipsychotic medication) intramuscularly (IM). Resident is exit seeking and combative to staff. *On [DATE] at 10: 43 p.m. the following documentation revealed: -Situation: Resident is repeatedly attempting to elope from facility. Has opened exit doors at least x (times) 3 starting at 1930 (7:30 p.m.) exiting x 2. Resident hitting at staff and grabbing door handles and side rails and attempting to stand when wheel chair is in motion. -Background: Present UTI-currently on antibiotics therapy. Eloping and combative behaviors noted previous two days. -Assessment: Resident is noted to be confused, combative, and danger to self at this time. -Response: Earlier this shift, order was received for IM [MEDICATION NAME]. Pharmacy called for medication. Medication unavailable at this time and not in our medication dispensing unit. Pharmacy continued with communications with MD for alternative medication. New order received. During this time, resident was supervised 1 on 1 (one staff person for one resident) at nurse's station by staff to prevent elopement. PRN oral medication administration attempted without success. IM injection of [MEDICATION NAME] given as ordered. Family was notified and came to facility to help facilitate ADLs (activities of daily living that includes dressing, toileting, eating and personal care) with success. Family appreciative towards staff. Will continue to monitor and assess. *On [DATE] at 4:58 p.m. [MEDICATION NAME] 2 mg IM given. Resident left building three times. On third time, resident became combative with staff, attempting to hit staff, swinging at CNA (certified nursing assistant), nurse, et management. Resident re-directed for brief time et (and) brought into the hallway, where she then pulled the fire-alarm. *On [DATE] at 5:19 p.m. Resident left building three times, stating that she was 'leaving this damn place'. Resident was stopped by nurse et CNA and explained to her why she needs to stay here for her safety. Resident re-directed back into building. A different resident left the building to leave with her son et this resident attempted to leave with the other resident. Nursing was able to re-direct resident, but she became combative, swinging to hit staff et kicking at nurse. Resident brought back into building et re-directed for a short time. Resident went down the hallway et pulled the fire-alarm, after being asked not to by nurse. Nurse assigned CNA to do one-on-one with resident; PRN dose of IM [MEDICATION NAME] given per MAR (medication administration record). *On [DATE] at 8:44 p.m. a late entry Resident was trying to get out of the facility, and telling everyone that she will pull the fire alarm. Resident was stopped by nurse et CNA and explained to her why she needs to stay here for her safety. Nursing was able to re-direct but she's trying to hit staff. Given PRN dose of IM [MEDICATION NAME] given per eMAR (electronic medication administration record). She tries to kick staff while given the injection. After that she pours water on the laptop and still mad because she wants to go out. *On [DATE] at 8:19 p.m. [MEDICATION NAME] 2 mg IM given. Resident was trying to go out of the facility, and was very agitated. *On [DATE] at 9:49 p.m. Resident was trying to get out the facility again at 2000, (8:00 p.m.) and she want (wanted) to go out and smoke. She was confused, she stated that she want to talk to the doctor on what's going on. Explained to the resident that she's living here and needs to stay here for her safety. Give PRN dose of IM [MEDICATION NAME] given per eMAR. Resident is still agitated called her sister and they came to help calm her down. Resident sister help her to bed and finally goes to sleep. *On [DATE] at 9:09 p.m. [MEDICATION NAME] 2 mg IM given. *On [DATE] at 10:03 p.m. Resident with increased agitation, admin (administered) one IM shot of [MEDICATION NAME] and called family to come up to see res.(resident) Res. then called 911 and police officer showed up, explained situation to police without any issues. res is resting in bed at this time, family just left. will cont (continue) to monitor. *On [DATE] at 12:43 p.m. a note by the SS worker. Faxed _____ (MD) regarding resident behaviors. Family member is concerned about the behavior and said they have a Dr appt (appointment) schedule with _____(MD) on [DATE]. Discussed that we have request bed on 2nd fl (floor) ______(another facility) for her safety. Interview on [DATE] at 5:30 p.m. with registered nurse O and licensed practical nurse N revealed:*Resident 10 had been having multiple episodes of trying to elope from the building. *She had been combative towards staff and had required one-on-one staff supervision. *They had not known why she had kept on trying to leave. *Agreed she was a smoker and had been assessed as unsafe to smoke alone on [DATE]. *The provider's policy was only residents that did not have to be supervised to smoke could smoke. *Agreed staff had been supervising her since then for smoking. *Had not thought the [MEDICATION NAME] she had received was a chemical restraint. *It had only been used to control her behaviors. 2. Review of resident 14's [DATE] physician's orders [REDACTED].>*He was admitted on [DATE] and discharged on [DATE]. *His [DIAGNOSES REDACTED].>-A [MEDICAL CONDITION] (TBI). -Mild cognitive impairment. *The following [MEDICAL CONDITION] (medications effecting mood and behavior) had been ordered: -[MEDICATION NAME] (treatment for [REDACTED]. Start date [DATE]. There was no time limit on the use of that medication. -Resperidone (treatment for [REDACTED]. Start date [DATE]. -[MEDICATION NAME] (for [MEDICAL CONDITION]) tablet 25 mg per PEG tube every four hours as needed for severe agitation. -[MEDICATION NAME] (depression) HCL ([MEDICATION NAME]) tablet 25 mg every six hours as needed for ABS (agitated behavior scale) greater than 27. Start date [DATE]. -[MEDICATION NAME] HCL tablet 50 mg every 6 hours as needed for ABS greater than 27. Start date [DATE]. Review of resident 14's [DATE] physician's orders [REDACTED].>*His [DIAGNOSES REDACTED]. *The following [MEDICAL CONDITION] had been ordered: -[MEDICATION NAME] inject 2 milligram (mg) intramuscularly every eight hours for severe agitation. Start date [DATE]. -Resperidone - 0.25 mg by mouth three times a day related to mild cognitive impairment. Start date [DATE] -[MEDICATION NAME] tablet 25 mg by mouth every four hours as needed for severe agitation. -[MEDICATION NAME] HCL 25 mg every six hours as needed for ABS greater than 27. Start date [DATE]. -[MEDICATION NAME] HCL 50 mg every six hours as needed for ABS greater than 27. Start date [DATE]. Review of nurses progress notes and the Medication Administration Record [REDACTED]. Review of resident 14's behavior log revealed: *On [DATE] he exhibited verbal behavior one time. *From [DATE] through [DATE] he exhibited behaviors thirteen times. *Those behaviors included: -Rejecting care four times. -Wandering four times, -Verbal behavior twice. -Physical behavior twice. -Other behavior once. Interview on [DATE] at 10:40 a.m. with the director of nurses regarding resident 14 revealed: *He was very confused and restless. *He was assigned a one-on-one staffing ratio to monitor him. *He was constantly wanting to leave the building and was a fall risk. *The ABS scale (measured agitation) was a scale the TBI unit he had come from used. -They did not have a copy of that scale and had not used it. -The nurses should have addressed that when they got the order for the medication using the ABS scale. *She agreed the [DIAGNOSES REDACTED]. *Not all behaviors had been documented. *She confirmed the nurses should have addressed those [DIAGNOSES REDACTED]. Review of the provider's [DATE] Antipsychotic Medication Review policy revealed: *The procedure was to Ensure that the Medical Record of any Resident who receives antipsychotic medication contains documentation supporting the appropriateness and necessity for the use of the drug. *Antipsychotics are a class of psychiatric medication primarily used to manage [MEDICAL CONDITION] (including delusions, hallucinations, or disordered thought) particularly in [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder, and is increasingly being used in the management of non-[MEDICAL CONDITION]. *The Assessment of [MEDICAL CONDITION] medications was a part of the policy. -That document was not found completed in resident 14's medical records. *Review to ensure that a consent form or documentation noting the risks and benefits for the use of an antipsychotic medication had been discussed with the resident and/or responsible party. -That had not been noted for resident 10. Review of the provider's [DATE] Behavior Management Guideline policy revealed: *The use of any medication to control behaviors should always be considered a last resort to assist with managing a patient's/resident's behavior. *Antipsychotic drugs would not be used unless the clinical record documents that the patient/resident has one or more of the following specific conditions, as dictated and documented by the physician: *A. Conditions other than Dementia- This included a list of twelve [DIAGNOSES REDACTED]. -Mild Cognitive Impairment. -Severe agitation. *Criteria: All of the above highlight conditions/[DIAGNOSES REDACTED]. -The behavioral symptoms present a danger to the patient/resident or others AND one or both of the following: -The symptoms are identified as being due [MEDICAL CONDITIONS] (such as auditory, visual or other hallucinations; delusions, paranoia, or grandiosity); OR -Behavioral interventions have been attempted and included in the plan of care, except in an emergency. *When an antipsychotic medication is being initiated or used to treat an emergency situation related to one or more of the aforementioned conditions/diagnosis, the use must meet the above criteria and all of the following additional requirements: -1. The acute treatment period is limited to seven days or less; -2. A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days to identify and address and contributing and underlying causes of the acute condition and verify the continuing need for an antipsychotic medications.

Based on interview, record review, and policy review, the provider failed to ensure one of one resident (1) that smoked had been accurately assessed for safety. Findings include: 1. Review of resident 1's 2/5/14 safe smoking evaluation revealed it had been documented the resident did not smoke. Review of resident 1's 4/1/14 progress notes revealed: *He had a sore on his right upper thigh. *The area was circular, and it had appeared to be a cigarette burn. *His wife took him out to smoke and assisted him when he smoked. Review of resident 1's careplan revealed no mention of the resident smoking. Interview on 5/14/14 at 1:30 p.m. with the director of nursing regarding resident 1 revealed: *The resident smoked when his wife came to visit. *He was not considered a smoker, because he only smoked when his wife came to visit. *They had not assessed if the resident's wife was safe to take him out to smoke. *She thought some days the wife was safe to take him out and some days she was not safe to assist him. *The facility had bought a smoking apron, but she could not remember when. *They had let the resident's wife take the smoking apron home with her. *The resident did not have the smoking apron on when he had burned himself. *There had been nothing on the careplan regarding the resident smoking. Review of the provider's undated Smoking policy revealed: *Every resident who desired to smoke was permitted to do so if the facility's interdisciplinary team had determined the practice would be safe for the resident. *"The accomodation of the desires of residents with a desire to smoke but who has not been assessed as unable to safely smoke independently, will be careplanned."